Rey Complex Figure Test Professional Manual

Rey Complex Figure ure Tes Rec ognition Trial J ohn E. Meyers, PsyD Jo Ke lly R. Meyer Meyers Professiona ionall M Ma anua nuall Psychological Assessment Assessmen Resources, tInc. Rey C omp mple lex x Figur igure e Test and Rec ognition ion Tria iall Professional Manual J ohn E. Meye Meyer rs, PsyD Kelly R. Me Mey yers PAR PA R Psychologic yc hological al Assessment ment Resourc ourc es, Inc. Inc. ^ s. —' N/ Ac knowledgments Development of this manual and all the research sparked my interest in clinical neuropsychology and that encompassed it was performed over a 5-year gave me an opportunity to work in his neuropsychol pe riod ri od . Ne ed le less ss to say, m any an y ho urs ur s o f wo rk w en t ogy laboratory. into its development. The purpose was to provide a A special word of thanks goes to Travis White, reliable and valid scoring and administration proce PhD, and the staff of PA PAR. R. Their patience and know l d u re fo r t h e R C F T b a se d o n a w e l l -re se a rc h e d edgeable assistance were most helpful in developing approach. Many individuals had a hand in the devel this work. opment of this work, some directly and some indi Finally, to my coauthor, Kelly R. Meyers, who rectly, but in all cases their contributions are greatly has been involved with the development of this man appreciated. ual and approach from its beginnings, my deepest Thanks also go to Don Lange, PhD, from whose thanks and appreciation. N Neu eu ro ps yc ho lo gy and an d St ati stic st icss co urse ur se I de ve lope lo pe d my interest in this work. Additional thanks go to William de Bosch Kemper, PhD, my internship super visor, who encouraged me to pursue my clinical inter John E. Meyers, PsyD ests and to William McMordie, PhD, who originally October, 1995 iii k_ Table of C ontents Acknowledgments .................................. ..................................................................... ...................................................................... ...................................................................... ................................................. .............. iii k_ Chap Ch apter ter 1: In trod tr od uc ti tion on .............. ............................. .............................. .............................. .............................. .............................. ....................... ........ ? 1 ................... Hist oric al Bac kgr kgroun oun d and O ve rv iew ..... .......... ........... ........... ........... ............ ............ ............ ............ ............ ........... ........... ............ ............ ............ ............ ............ ........... ........... ............ ............1 ......1 The Rey Com plex Figu re T Test est and Reco gniti on Tr ial ..... .......... ........... ............ ............ ............ ............ ........... ........... ............ ............ ............ ............ ............ ........... ........... ........2 ..2 Chapter 2: 2: Test Test Materials and and U s e ................................... ....................................................................... ....................................................................... ................................................ ............. 5 Testt M at er ia ls ............................... Tes .................................................................. ...................................................................... ....................................................................... ............................................................5 ........................5 RC FT Stimu Sti mu lus F ig ur e............................................................. e................................................................................................ ...................................................................... ............................................. .......... 5 RCFT Test Booklet...................................................................................................................................................5 Appropriate Populations............................................................................................................................................... 5 Professional Requirements...........................................................................................................................................6 Administration................................................................................................................................................................6 General Guidelines....................................................................................................................................................6 Use o f Co lor ed M arke ar ke rs .............................. ................................................................. ....................................................................... ....................................................................... ...................................... ... 7 Administration Directions........................................................................................................................................7 Chapter 3: Scoring and Profiling Procedures ............................................................................... 11 11 Gene ral Sco ring Crit eria for RCF T Dr aw ing s....... s............ .......... ........... ............ ............ ............ ............ ........... ........... ............ ............ ............ ............ ............ ........... ........... ............ ...... 1 11 1 Scoring Examples.........................................................................................................................................................13 Specific Scoring Criteria.............................................................................................................................................14 Sc Scori oring ng Uni Unitt 1: 1: Verti Vertical cal Cr o s s ............................... .................................................................. ...................................................................... ............................................................ ......................... 14 Sc Scori oring ng Un it 2: Lar Large ge Re ctan ct an gl e.................................................. e..................................................................................... ...................................................................... ...................................... ... 15 Scoring Unit 3: Diagonal Cross of the Large Rectangle (2).............................................................................16 Scor ing Un it 4: Horiz onta l Mid line o f the Large Rec tang le ( 2 ).......... )................ ............ ............ ............ ........... ........... ............ ............ ............ ............ ........ 17 Scor ing U nit 5: Vertical M idlin e o f the L arge Rec tang le (2 )........ )............. .......... ........... ............ ........... ........... ............ ............ ............ ............ ............ ...........1 .....18 8 Scoring Unit 6: Small Rectangle Within the Large Rectangle (2)...................................................................19 Scoring Unit 7: Small Horizontal Line Above the Small Rectangle (6).........................................................20 Scor ing Un it 8 : Fou r Paral lel Li nes W ithin the L arge R ecta ngle (2) ..... .......... .......... .......... ........... ............ ............ ............ ............ ........... ........... ........ 21 Scoring Unit 9: Small Triangle Above the Large Rectangle (2)......................................................................22 Scoring Unit 10: Small Vertical Line Within the Large Rectangle (2), Below the Small Triangle (9) ...... 23 Sco ring Uni t 11 11:: Circle With Thr Three ee D ot s........ s............. ........... ............ ............ ............ ............ ............ ........... ........... ............ ............ ............ ............ ............ ........... ........... ............ ........ 24 Scoring Unit 12: Five Parallel Lines Inters Intersecting ecting the Diagonal Cross ( 3 ) .................................................... 25 Scoring Unit 13: 13: Sides o f the Large T riangle Attached to the Large Recta ngle ( 2 ) ...... ......... ...... ...... ...... ...... ...... ...... ...... ...... ...... ....26 .26 Scoring Unit 14: Diamond Attached to the Large Triangle (13)......................................................................27 Scoring Unit 15: Vertical Line Within the Sides of the Large Triangle (13).................................................28 Scoring Unit 16: Horizontal Line Within the Sides of the Large Triangle (13).............................................29 Scoring Unit 17: Horizontal Cross....................................................................................................................... 30 v Scoring Unit 18: Square Attached to the Large Rectangle (2) .31 Scoring the Recognition Trial ......................................................... .32 Obtaining Normative Scores and Profiling ................................... .32 Chapter 4: Normative and Descriptive Statistics ........... .33 No rm ati ative ve Sa m pl e............................................................................. .33 Influence of Demographic Variables .............................................. .33 Demographically Corrected Normative Data ................................ .36 Co ntin uou s N o rm s.......... s................ ............ ............ ........... ........... ............ ........... ........... ............ ........... .......... ..... .36 Cat ego rical N o rm s ..... ........... ........... ........... ............ ........... ........... ............ ........... ........... ............ ........... .......... ..... .38 U.S. Census Age-Matched Normative Data .................................. .38 Chapte Ch apterr 5: Inte In terp rp re retat tat ion .......... ............... .......... .......... .......... ......... ......... .......... .......... ......... .... .39 No rm ati ve Co m pa ris on s................................................................... .39 Interpreta Inter pretation tion of RCFT Perform ance ............................................. .40 Performance on Single RCFT Measures .................................... .40 Memory Profile Profile Pattern s .............................................................. .40 Qualitative Aspects of Performance............................................ .40 Casee Ill us tra tio ns ..... Cas ........... ............ ............ ............ ........... ........... ............ ........... ........... ............ ........... ........... ........... ..... . .42 Case Illustration 1: Brain Injury ................................................. .42 Case Illustration 2: Depression ................................................... .49 Case Illustration 3: Questionable Motivation ........................... .56 Chapter 6: 6: De velopment, R eliability, eliability, and Validity ......... .63 D ev el op m en t....... t............. ............ ........... ........... ............ ........... ........... ........... ........... ............ ........... ........... ............ ........... ....... .63 Orientation of the Stimulus Figure and Drawings.................... .63 Deve lopm ent of the Scoring C rit er ia..... ia........ ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ..... .64 Development of the Recognition Trial ....................................... .65 Reliability............................................................................................ .65 Interrater Reliability ...................................................................... .65 Tem poral St ab ilit y......... y............... ............ ........... ........... ............ ........... ........... ............ ............ ............ ........... ....... .. .65 Validity................................................................................................. .66 Convergent and Discriminant Validity ....................................... .66 Factorial Validity............................................................................ .71 .71 Gro up Di ffe ren tiat ion ...... ............ ........... ........... ............ ............ ............ ........... ........... ............ ........... .......... ..... .72 Profile Analys is of Mem ory Pa tter ns ...... ......... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ... Basee Rate In fo rm at io n.......... Bas n............... ........... ............ ........... ........... ............ ........... ........... ............ ........... ..... .73 .77 Spec ial Validity To pic s........ s.............. ........... ........... ............ ............ ............ ........... ........... ............ ........... ....... .79 Summary of Validity Studies....................................................... .81 .81 References ................................................................................ .83 Appendix A: Scoring Examples.......................................... Scoring Example 1: Scoring Sheet .................................................. ,87 Scoring Example 1: Copy trial......................................................... .89 Scoring Example 1: Immediate Recall trial ................................... ,90 Scoring Example 1: Delayed Recall trial ....................................... ,91 ,91 vi ,88 Scoring Example 1: Recognition trial......... ..92 Scoring Example 2: Scoring Sheet .............. ..93 Scoring Example 2: Copy trial..................... ..94 Scoring Example 2: Immediate Recall trial ..95 Scoring Example 2: Delayed Recall trial.... ..96 Scoring Example 2: Recognition trial......... ..97 Scoring Example 3: Scoring Sheet .............. ..98 Scoring Example 3: Copy trial..................... ..99 Scoring Example 3: Immediate Recall trial 100 10 101 1 Scoring Example 3: Delayed Recall trial.... Scoring Example 3: Recognition trial ......... 102 Appendix B: Normative Data for U.S. Census Age-Matched Sample 103 103 Appendix C: Demographically Corrected Normative Data.... 10 105 5 Age: 18 Years 0 Months 0 Days Thro ugh ugh19 19 Years 11 Months 31 Days 106 Age: 20 Year Yearss 0 Months 0 Days Throu gh24 gh 24 Years 1 11 1M Mont ont hs 3 31 1 D ays 107 Age: 25 Year Yearss 0 Months 0 Days Throu gh29 gh 29 Years 1 11 1 Mo nths nth s 31 31 D ays 108 Age: 30 Year Yearss 0 Months 0 Days Throu gh34 gh 34 Years 1 11 1M Mont ont hs 3 31 1D Days ays 109 Age: 35 35 Year Yearss 0 Mon ths 0 Days Throu gh39 gh 39 Years 1 11 1M Mont ont hs 3 31 1 Day Dayss 11 110 0 Age: 40 Years 0 Mon ths 0 Days Throu gh44 gh 44 Years 1 11 1 M onth s 3 31 1 Days 111 Age: 45 Year Yearss 0 Months 0 Days Throu gh49 gh 49 Yea Years rs 11 Mo nth s 31 Day s 11 112 2 Age: 50 Years 0 Months Age: 55 55 Year Yearss 0 Months 0 Days Throu gh54 gh 54 Years 11 M ont hs 3 31 1 D ays 0 Days Throu gh59 gh 59 Years 1 11 1 Mo nths nth s 31 Day s 11 113 3 114 Age: 60 Year Yearss 0 Months 0 Days Throu gh64 gh 64 Years 11 Months 31 Days 11 115 5 Age: 65 65 Year Yearss 0 Mon ths 0 Days Throu gh69 gh 69 Years 1 11 1M Mont ont hs 3 31 1D Days ays 116 Age: 70 70 Year Yearss 0 Mon ths 0 Days Through 74 Years 1 11 1 M onths 31 D ays 11 117 7 Age: 75 Year Yearss 0 Months 0 Days Through 79 Years 1 11 1 Mo nth s 31 Day Dayss 11 118 8 Age: 80 80 Year Yearss 0 Months 0 Days Throu gh89 gh 89 Years 11 M ont hs 31 Day Dayss 119 VII 1 Introduct uc tion ion HISTORIC ICA AL BAC KGROUND AND O OVER VERVIEW A “complex figure” was originally derived by Rey in 1941 (Corwin & Bylsma, 1993) to investigate visuospatial constructional constructional ability and visual memory in brain-injured persons (Lezak, 1995). In more recent times, the Complex Figure Test (CFT) has } copy trial to assess visuospatial constructional ability, followed by immediate recall and delayed recall trials t o a sse ss v i su o sp a t i a l m e m o ry , w h e re a s o t h e rs employed copy and delayed recall trials but no imme diate recall trial. Still others reported using copy and immediate recall trials, but no delayed recall trial. The presence or absence of an immediate recall trial seems to impact performance on a delayed recall trial (Lezak, 1995; Meyers & Meyers, 1995). be en freq fr eq ue nt ly em pl oy ed as a ne urop ur op sy ch ol og ical ic al test of visuospatial constructional ability and visuo spatial memory (Butler, Retzlaff, & Vanderploeg, 1991; Lezak, 1995). The intervals of time between the copy and immediate recall trials varied from immediately after (the copy) to 3 minutes, and the intervals between the copy and the delayed recall trials ranged from 15 Rey (1941) advocated using a copy trial, fol minutes to 1 hour. These intervals are consisten t with with lowed by a recall trial that was administered 3 min those employed in empirical studies of the CFT utes after the copy trial. Osterrieth (1944; Corwin & (Brooks, 1972; Corwin & Bylsma, 1993; Delaney, Bylsma, 1993) standardized Rey’s administration Prevey, Cramer, & Mattson, 1988; Lezak, 1995; pr proce oce du dure re and pro vid ed initial init ial no norm rmati ative ve data da ta on 230 Odgen, Growdon, & Corkin, 1990, Spreen & Strauss, children (4 to 15 years of age) and 60 adults (16 to 60 1991; Taylor, 1979). Overall, Knight and colleagues years of age). Rey’s original complex figure stimulus (Knight et al., 1994) found the most frequently used and paradigm have, at times, been referred to as the CFT administration paradigm involves a copy trial, “Rey-Osterrieth Complex Figure,” which acknowl followed by an immediate recall trial that is adminis edges both Rey’s and Osterrieth’s contributions. A variety of administration procedures and scor tered 20 to 30 seconds after the copy trial, followed by a de delay lay ed recall rec all trial tria l th that at is adm ini ste red 30 to 45 ing systems have been developed for the CFT. In minutes after the immediate recall trial. In addition to addition to Rey’s original stimulus figure, other com these administration parameters, some researchers pl plex ex stimu sti mu lus fig ure s hav e bee n desig de sig ne ned d to acc om  suggest using felt-tip pens (Binder, 1991, cited in modate the need for equivalent forms for repeated Lezak, 1995) and having the examiner keep a detailed testing (MCG Complex Figures; Lee, Loring, & re c o rd o f e a c h re sp o n d e n t ’s d ra w i n g se q u e n c e Thompson, 1989; Taylor Complex Figure; Taylor, (Milberg, Hebben, & Kaplan, 1986). 1979). Knight, Kaplan, and Ireland (1994) surveyed Various scoring systems that yield both quantita clinicians and researchers about their current use of tive and qualitative indices of CFT performance have the CFT. A variety of administration procedures were appeared in the literature. Perhaps the most frequently used scoring system in clinical use is the 36-point reported by professionals. Some reported using a 1 system that was originally developed by Osterrieth lobe epilepsy; Loring, Lee, Martin, & Meador, 1988). (1944), adapted by Taylor Taylor (1959), and widely dissem  In fact, it is the inherent complexity of the stimulus inated in Lezak (1983, 1995). Eighteen scoring units figure that supports the wide variety of scoring that refer to specific areas of details of the stimulus approaches. figure are numbered for scoring convenience. Scores As a measure of visuospatial constructional abil range from 2 (full credit) to 0 (no credit) for each ity, research has shown that the CFT is sensitive to unit. The unit scores are summed to obtain a raw traumatic brain injury (Osterrieth, 1944), cerebrovas score for each administration trial. However, the cular disease (Binder, 1982), HIV serpositivity implementation of this 36-point system is character (Hamby et al., 1993), Alzheimer’s disease (Brouwers, ized by variability among different laboratories and Cox, Martin, Chase, & Fedio, 1984), Huntington’s clinicians. For example, Lezak (1995) recommends strict adherence to the scoring criteria for the copy d i se a s e (B ro u w e rs e t a l . , 1 9 8 4 ; . F e d i o , C o x , N e o p h y ti d e s , C a n a l- F r e d e r ic k , & C h a s e, 19 79 ), trial, but somewhat more lenient application of the Parkinson’s disease (Ogden et al., 1990), temporal scoring rules for the recall trials. Other variants of the lobe epilepsy (O’Callaghan, 1985), and undifferenti 36-point system are presented by Bennett-Levy ated brain damage (Schorr et al., 1992). As a measure (1984), Guyot and Rigault (1965), Loring, Martin, of visuospatial memory, the CFT has been shown to Meador, and Lee (1990), and Duley et al. (1993). be sen siti sitive ve to late ral ity of cereb cer ebral ral les lesion ion (Os (Oster terrie rieth, th, Denman (1984, 1987) provides a more complex 1944), especially right hemisphere involvement quantitative scoring system with 72 points. (Loring, Lee, & Meador, 1988), frontal lobe damage Loring, Lee, and Meador (1988) developed an 11- (Le Gall et al., 1990), traumatic brain injury (Brooks, po point int sys tem fo forr sco rin ring g qu alitat ali tat ive errors err ors mo st co m  1972; Leininger, Gramling, Farrell, Kreutzer, & Peck, monly made by patients with right-hemisphere dam 1990), Huntington’s disease (Fedio et al., 1979), and a g e , w h e re a s W a b e r a n d H o l m e s (1 9 8 5 , 1 9 8 6 ) Parkinson’s disease (Ogden et al., 1990). Perform employ three indices to capture the qualitative fea tures of children’s CFT reproductions. By dividing ance on the CFT may also be useful in differentiat i n g a m o n g d i ffe re n t fo rm s o f m e m o ry d i so rd e r the scoring units into configural, fragmented, and (Bigler, 1988). missing units, Binder (1982) demonstrated that stroke pa tie nts nt s made ma de di ffer ff eren en t ty type pe s o f err ors or s tha n nor mal ma l subjects. Hamby, Wilkins, and Barry (1993), Schorr, THE REY C OMPLEX FIG GU URE TEST Delis, and Massman (1992), and Bennett-Levy (1984) AND REC OG NITIO ION N TRIA IAL L are other examples of qualitative approaches to scor ing CFT drawings. drawings. The testing procedures and materials presented in Several other instruments may be employed to this manual involve Rey’s original complex figure, assess visuospatial constructional ability, including bu t not Os te terri rri et eth’s h’s n orm ati ative ve data. Th e pro ced ure ur e is, the Bender-Gestalt test (Bender, 1938) and the Canter therefore, referred to as the Rey Complex Figure Test Background Interference Procedure (Canter, 1966, (RCFT) to avoid confusion with other paradigms that 1976). In addition, other instruments contain visual memory components similar to the CFT, including involve different administration procedures, scoring criteria, or complex figure stimuli. The RCFT will the Visual Reproduction subtests of the Wechsler serve the important function of standardizing the Memory Scale—Revised (WMS-R; Wechsler, 1987) complex figure testing materials and procedures. and the Benton Visual Retention Test (BVRT; Sivan, Administration of the RCFT involves a Copy trial, a 1992). Although research has demonstrated that these 3-minute Immediate Recall trial, a 30-minute measures are sensitive to a variety of neurobehavioral Delayed Recall trial, and a newly developed syndromes (Heaton, Baade, & Johnson, 1978; Sivan, Recognition trial (Meyers & Lange, 1994), which is 1992), it is felt that the CFT, by virtue of the inherent administered immediately after the Delayed Recall complexity of the stimulus figure and task demands, trial. The Recognition trial presents 12 of the 18 scor yields more clinical information and is more sensitive ing elements of the complex figure stimulus, along to certain forms of brain dysfunction (e.g., temporal with 12 designs that serve as foils. The respondent 2 indicates which items are recognized from the earlier ambiguities in scoring the accuracy and placement Copy trial. The Recognition trial measures the of each of the 18 scoring units. Normative data are respondent’s recognition memory for the elements of now provided for adults 18 through 89 years of age. the complex figure stimulus and assesses the respon Where appropriate, normalized scores and percentile dent’s ability to use cues to retrieve information, thus scores are presented for the major RCFT memory evaluating the relative contributions of encoding, variables to assist in interpretation and in making storage, and retrieval processes to memory perfor comparisons among individuals and various patient mance. Initial research has shown that scores derived groups. Results of reliability and validity studies are from the RCFT, including the Recognition trial, dis also presented. The chapters that follow provide criminate mildly brain-injured patients from normal information on the RCFT materials, administration subjects, discriminate brain-damaged patients with documented memory impairment who were able to and scoring procedures, characteristics of the norma tive sample, procedures used for generating the nor live independently from brain-damaged patients who mative tables, guidelines for interpretation, and were not, and distinguish deficient RCFT perfor results of the reliability and validity studies. To aid mance due to motor impairment from that due to the examiner in scoring the RCFT, Appendix A pre memory impairment (Meyers & Lange, 1994). sents three complete RCFT protocols and the scores In addition to the newly developed Recognition that correspond with each drawing. Appendixes B and trial, this manual also presents empirically derived C present the norm ative data for the U.S. census age- scoring criteria that improve the clarity and objectiv matched sample and the normative sample grouped ity of the 36-point scoring system. Specifically, according to age, respectively. more precise rules have been developed to resolve 3 2 Test Materia ials ls and Use TEST MATERIALS ERIALS r RC FT Test B Bo ooklet klet The RCFT Test Booklet is a 16-page booklet that The Rey Complex Figure Test materials consist prov pr ov ide s all forms for ms nec ess ary to ad admi mi nis ter and sco score re of the Professional Manual, the laminated RCFT the RCFT. The first page of the test booklet provides Stimulus Card, and the 16-page RCFT Test Booklet. blank bl ank s to rec or ord d the res po nd en t’s de demo mo gr graph aph ic inf or or  mation, to record the obtained raw scores and associ RCF RC FT Stim imulu ulus s Figure ated standardized scores, and to profile selected Many variati variations ons o f Rey’s ori original ginal complex figure RCFT scores. Page 2 provides spaces to record perti have appeared in the literature. Lezak printed the nent background, referral, and behavioral informa stimulus figure in both her 1983 and 1995 texts. It is tion. Page 3 is used for scoring the respondent’s not uncommon for investigators and journal publish Copy, Immediate Recall, and Delayed Recall repro ers to publish the stimulus figure that was used to col ductions, as well as the Recognition trial. Pages 4, 5, lect research data. Prior to this publication, Rey’s and 6 provide spaces for the administrator to draw original complex figure has not been available com along simultaneously with the respondent and to mercially. Given this, professionals who wished to make notes during the Copy, Immediate Recall, and use Rey’s stimulus figure had to rely on photocopies Delayed Recall trials, respectively. Pages 7 through of an “original,” with successive generations of 10 are perforated and contain the 24 items of the copies exhibiting increasing distortion from the origi Recognition trial. Pages 11 through 16 are perforated nal. Some professionals have generated professional- and are used to record the respondent’s reproductions quality reproductions of Rey’s original figure (Stem for each of the drawing trials. et al., 1994; Waber & Holmes, 1985, 1986), but an inspection of these figures reveals slight differences in size and line quality. Th e st i m u l u s fi g u re u se d i n t h i s m a n u a l i s APPROPRIA IAT TE PO POPULATIONS IONS intended to be a computer-rendered replica of Rey’s The RCFT has been standardized and normed for original publication (1941). The normative data pre use with adults ranging from 18 through 89 years of sented in this manual were collected using the RCFT age. Caution should be used when interpreting RCFT Stimulus Card. Use of a different complex figure p er fo rm an ce fo r re sp o n d en ts ag ed 80 th ro u g h 89 stimulus may render normative comparisons invalid years, because of the small number of individuals in and may affect the validity and utility of the obtained the normative sample in this age range. Respondents results. The complex figure is presented in portrait should have normal or corrected visual acuity to see orientation on an 8'/2 by 11 inch sheet. The figure is the stimulus figure and hearing sufficient to compre prin pr inted ted on thi ck car card d sto ck and is lam ina ted to ens ure hend the test instructions. The administration proce durability. dure may be altered slightly to accommodate the 5 needs of a specific situation. Among clinical popula she completes the Delayed Recall trial by again draw  tions with known or suspected brain dysfunction, ing the figure from memory. The respondent com these requirements may not be fully met. In such plet pl etes es the Re co gn iti on tr tria iall im m ed ia iatel tel y af afte terr co m  cases, the reliability and validity of the RCFT data ple tin g the De lay ed Rec all tri trial. al. The Re co gniti gn ition on tria l will depend on the clinical skill and expertise of the consists of 24 geometric figures, 12 of which are indi examiner. vidual scoring elements o f the stimulus figure and 12 of which are distractors. The respondent indicates which of the 24 recognition items he or she recog PROFESSIO IONA NAL L REQ EQUIRE UIREMENT MENTS nizes as being from the stimulus figure. In addition to the RCFT materials, the examiner will need a #2 pen Any trained person with a background in psycho logical testing may serve as an examiner. However, cil with an eraser for the respondent’s use and a stop watch or digital watch to record the length of time the administration, recording, and scoring procedures required to copy the stimulus figure. detailed in this manual should be carefully studied and mastered by the examiner before the RCFT is used in a clinical setting. Training and supervision in these procedures should be provided by a qualified doctoral-level psychologist. As was noted in chapter 1, administration proce dures that use different delay intervals between copy and immediate recall trials and between copy and delayed recall trials have appeared in the literature as well as in clinical practice (Knight et ah, 1994; C o n si st e n t w i t h t h e g u i d e l i n e s g i v e n i n t h e Lezak, 1995; Meyers & Meyers, 1995). Some admin Standards fo r Edu cational an d Psychological Testin Testing g istration protocols omit an immediate recall trial. (American Educational Research Association, Previous research has indicated that different admin American Psychological Association, & National istration procedures affect RCFT performance Council on Measurement in Education, 1985), clini (Loring et ah, 1990). It should be emphasized that the cal interpretation of the RCFT requires professional training and expertise in clinical psychology, neu normative data for the RCFT were collected using a 3-minute delay interval between Copy and Immediate ropsychology, or both. The utility and validity of the Recall, and a 30-minute delay interval between Copy RCFT as a clinical measure of cognitive ability are and Delayed Recall. Deviation from this procedure directly related to the professional’s background and may affect the validity and utility of the obtained knowledge, as well as to the mastery of the informa results. tion contained in this manual. Interpretation of RCFT scores for clinical or diagnostic purposes should not be -atte -a ttem m pte d wi witho tho ut a cle ar un de ders rstan tan din g o f brainbra inbe ha vi or rela re latio tio ns hi hips ps and the m edic ed ical al and an d ps yc ho  logical factors that affect them. General Guidelines Administration should take place in a quiet room with illumination adequate for viewing the RCFT Stimulus Card. The testing environment should be comfortable and free from distraction. A table or desk ADMINISTRATION and two chairs—one for the examiner and one for the The RCFT consists of four separate tasks. First, respondent—are required. The table or desk should prov pr ovide ide am ple sp space ace fo forr arr arran angin gin g the sti mu lus fig figure ure the respondent views the complex figure stimulus and the reproduction sheets and should be free of card and copies the figure onto a blank sheet o f pa paper. per. extraneous materials. Ideally, the examiner should sit After the respondent indicates he or she has com directly across from the respondent so that the exam ple ted the Copy Co py draw dr awing ing , the stimu sti mu lus fig ure ur e and the iner can accurately follow along with the respondent’s drawing are immediately removed from view. Three drawing. A clipboard to hold the test booklet is also minutes of unrelated verbal activity follow. The desirable in order to shield the test booklet from the Immediate Recall trial is administered next. This respondent’s view. It is im imper per ative ati ve that tha t the t he respond resp ond ent involves the respondent drawing the figure from never glimpses any RCFT materials that contain the memory on a blank sheet of paper. Then, 30 minutes stimulus figure, pa rts o f the stimulus figure, or his or after the respondent completed the Copy trial, he or her own previous drawings o f the the figure. 6 Prior to administration, the examiner should testing in the spaces provided on each sheet. Pages 7 develop appropriate rapport with the respondent. This through 16 should be kept out of the respondent’s is especially necessary when testing older subjects. view. Seat the respondent at the table so that he or she The subject should not be interrupted or disturbed is across from and directly facing the examiner. Enter during the administration. Some respondents, espe the respondent’s demographic information in the cially those with brain dysfunction, may find the spaces provided on page page 1 of the ttest est bookle booklet. t. Obtain RCFT especially challenging and frustrating. and record any referral and background information Respondents may be encouraged and praised for their on page 2. efforts, but not for their drawings. The respondent is pe rm itt ed to era se, bu t he or she shou sh ould ld ne ver ve r trac e the figure or be given a straight edge or ruler to use in drawing. C opy Trial Locate page 15 and 16 of the test booklet, labeled Copy trial. Center this sheet in front of the respondent in portrait orientation (i.e., with the long side of the Use o of f C olored Ma Mar rkers Many professionals use colored pencils, pens, or felt-tip markers when administering the RCFT in order to capture organizational and sequential aspect aspectss of performance. Most suggest that the color of the marker should be changed when the respondent com p l e te s a s e c ti o n o f th e d r a w in g ( L e z a k , 1 99 5) . However, it is felt that several disadvantages are asso ciated with this practice. First, clinical experience suggests that some respondents, especially those with moderate-to-severe brain dysfunction, are overly dis tracted by the requirement to switch markers. The ability to switch markers easily may also be influ pa pe r run nin g ve vertic rtical al to the res respo pond nden ent), t), bla nk side (page 15) facing up. Next, locate the laminated RCFT Stimulus Card and place this directly above the Copy trial response sheet, also positioned in portrait orien tation. Locate page 4 of the test booklet and position it so that no part of the test booklet can be viewed by the respondent. Hand a #2 pencil to the respondent, then point to the stimulus card and say, “Look at this figure.” Nex Next, t, po in t to the bla nk res po ns nsee she et and say, “I would like you to copy that figure onto this sheet of paper.” Point back to the stimulus card and say, “Copy it so that I would know that this is the figure you drew. Do a good job.” enced by impaired fine-motor control, depth percep After the respondent indicates that he or she tion, and so forth. Second, it is very difficult to vali understands the nature of the task, begin timing the date guidelines adequately for when markers should drawing as the respondent starts copying the figure. be sw switch itch ed. Sw itc itchin hin g ma rkers rk ers als also o tak es add itio nal The instructions may be repeated or paraphrased as administration time, making it problematic given the often as necessary to ensure that the respondent finding that the time it takes to copy the stimulus fig understands the task. The respondent’s effort may be ure discriminates between brain-injured patients and encouraged, should he or she have difficulty with the normal subjects (Meyers & Lange, 1994). task. However, no additional hints or cues about the Based on these considerations, the procedure of figure may be given. The respondent is permitted to alternating colored markers is not used in the RCFT. erase, but he or she may never trace the figure or be given a straight edge or ruler to use in drawing. Rather, a #2 black lead pencil with a sharp point is used. Clinicians who wish to record the organiza Page 4 o f the test booklet provide providess an area for the tional and sequential aspects of the respondent’s examiner to draw along with the respondent, record reproductions may follow along with the respondent ing an exact duplicate of the respondent’s drawing, and simultaneously draw the figure on the separate noting the sequence and organization of the reproduc sheet of paper provided in the test booklet. tion. As this process-oriented and qualitative informa tion is not formally included in the RCFT, the Adminis dministration Direc tions specifics specifi cs o f this procedure are left to individual exam Prior to beginning the testing session, detach iners based on personal preference and prior training. pag es 7 throu thr ough gh 16 fro m the RC FT Tes Testt Bo oklet ok let by Some examiners use a system of numbers and arrows tearing along the perforations. Record the respon to indicate the exact sequence and drawing strokes dent’s name, identification number, and the date of employed by the respondent. v_ 7 The respondent may rearrange the Copy trial Some examiners may wish to record timing the response sheet and the stimulus card according to per length of time the respondent requires to produce the sonal preference. However, the respondent should not Immediate Recall drawing. Unlike the Copy trial, rotate either the response sheet or the stimulus card this is an optional procedure, and this time interval is more than 25 degrees from the portrait orientation. If not a formal score in the RCFT. The directions may this occurs, correct the respondent by placing the be re repe peate ate d and sim plifi pl ifi ed as ne ces sary sar y to ensu en sure re that th at response sheet, stimulus card, or both back in the the respondent understands the nature of the task. prop pr op er orien or ientati tation on.. If the res po nd ent en t rot ate s eit he r the The respondent’s effort may be encouraged, should response sheet or stimulus card a second time, do not he or she have difficulty with the task. However, no correct him or her, but do note this rotation in the test additional cues or hints about the stimulus figure book bo oklet let for fo r l ate r re fer ferenc enc e. When the respondent is finished copying the fig may be given. Page 5 of the test booklet provides an area for the examiner to draw along with the respon ure, immediately remove both the stimulus card and dent in a similar manner as was discussed above for the response sheet from view. Note the length of time the Copy trial. Again, this procedure is optional and (in seconds) required to copy the figure and record information derived from it is not formally scored in this in the space provided on page 4. Record the time the RCFT. of day that the Copy trial was completed in the space prov pr ovid ided ed on pa ge 4. As the Im m ed iate iat e and De lay ed Recall trials are measures of incidental visuospatial memory, the respondent should not be told this is a memory test or that he or she will be asked later to draw the figur e from memory. When the respondent is finished drawing the fig ure, immediately remove the response sheet from view. If desired, note the length of time (in seconds) required to draw the figure, and record this in the space provided on page 5. The respondent should not be told that he or she will be asked later to draw the Imm ed iat iate e Rec all Tri rial al figu fi gu re fro m mem ory. ory . The Immediate Recall trial is administered 3 min utes after the Copy trial is completed. Administer a De lay ed Re c a ll Tri rial al verbal task to the respondent in the intervening 3 min utes, such as time estimation, controlled verbal flu ency, temporal orientation, or even a clinical inter view. Tasks involving visuospatial stimuli, such as the Benton Judgment of Line Orientation (BJLO; Benton, Hannay, & Varney, 1975) or the Visual Reproduction subtest of the WMS-R, should no t be administered be tw ee een n th thee Co py an and d the Re co gn iti on tri als. al s. It is The Delayed Recall trial is administered 30 min utes after the Copy trial (not the Immediate Recall trial) is completed. Administer verbal tasks to the respondent during the interval interval between com pletion of the Immediate Recall trial and the Delayed Recall trial. Tasks involving visuospatial stimuli should no t be a d m in is te re d b et w e en th e C op y tr ia l an d the th e Delayed Recall trial. It is important that the respon important that the subject is engaged and actively per dent is engaged and actively performing a verbal task forming a verbal task during the delay interval. during the delay interval. Locate page 13 and 14 of the test booklet, labeled Locate page 11 and 12 of the test booklet, Immediate Recall Trial. Center this sheet in front of the respondent in portrait orientation, blank side labeled Delayed Recall Trial. Center this sheet directly in front of the respondent in a portrait orien (page 13) facing up. Next, locate page 5 of the test tation, blank side (page 11) facing up. Next, locate book bo oklet let and po sit ion it so tthat hat no part of the tes testt b oo k pag e 6 o f the tes t bo ok let and po posit sit ion it so tha t no let may be viewed by the respondent. After handing handing a pa rt of the th e tes t bo ok let ma y be vie we d by the th e re resp sp on  #2 pencil to the respondent, say, “A short time ago I dent. Hand a #2 pencil to the respondent and say, “A had you copy a figure. I would like you to draw short time ago, I had you copy a figure. I would that figure again, but this time from memory.” Point to the blank response sheet and say, “Draw that figure here.” R e c o rd t h e t i m e o f d a y t h a t t h e like you to draw that figure again, but this time from memory.” Point to the blank response sheet Immediate Recall trial commenced in the space pro of day that the Delayed Recall trial commenced in vided on page 5. the space provided on page 6. 8 and say, “Draw that figure here.” Record the time Some examiners may w ant to record th thee length of time the respondent requires to produce the delayed recall drawing. Unlike the Copy trial, this is an optional procedure, and this time interval is not a formal score in the RCFT. The directions may be repeated and simplified as necessary to ensure that the respondent understands the nature of the task, and the respondent may be encouraged, should he or she have difficulty with the task. However, no additional cues or hints about the stimulus figure may be given. Page 6 of the test booklet provides an area for the examiner to draw along with the respondent in the manner discussed previously for the Copy trial. Again, this procedure is optional, and information derived from it is not formally scored in the RCFT. When the respondent is finished drawing the figure, immediately remove the response sheet from view. If desired, note the length of time (in seconds) required to draw the figure, and record this in the space provided on page 6. Rec og nit nition ion Tri Trial al The Recognition trial is administered immediately after the Delayed Recall trial with no intervening task. Locate pages 7 through 10 of the test booklet. Place the Recognition trial response sheets and the pencil in front of the respondent and say, “Some of the designs that are printed on these pages were part of the larger figure that I asked you to copy earlier. Circle the figures that were part of the larger design you copied. Each figure on these pages is facing the same direction as in the original, com plete design. There are four pages, and the designs are numbered 1 to 24. Go ahead and begin.” If the respondent hesitates or does not appear to understand the nature of the task say, “Circle the fig ures you recognize that were part of the larger drawing that was shown to you, the one you copied earlier.” If the respondent still does not understand the nature of the task, additional explanation may be given, as long as no specific hints or cues about the stimulus figure are given. , 9 k_/ Sc oring a an nd Profil ilin ing g Proc edures G ENERAL SC ORING C RITERIA FOR RCFT DRAWING INGS This manual presents a standardized approach to if the unit was drawn inaccurately and was placed incorrectly, but is still recognizable. A score of 0.5 is assigned if the unit was duplicated in the drawing, and both units were drawn inaccurately and were developed by Rey (1941; Corwin & Bylsma, 1993) place pl ace d inco rrec tly, bu butt bot h we were re still rec recog ogniz niz abl e. A and presented in Lezak (1995). Rey’s scoring system score of 0 is assigned if the unit was omitted alto- divides the complex figure into 18 units; each unit is gether or was drawn inaccurately and placed incor- scored separately for both accuracy and placement. The Rey Complex Figure, with the 18 scoring units rectly, and was not recognizable. were developed for scoring the accuracy and placement of units units of drawings. Table 1 presents the gen- w rately and placed correctly. A score of 0.5 is assigned the scoring of the RCFT, based on the scoring criteria numbered, is illustrated in Figure 1. Specific criteria V, bu t at leas le as t on e o f the th e du plic pl icat ates es wa wass dr draw aw n ac cu - eral scoring criteria for RCFT drawings. A general scoring rule and specific criteria for rating accuracy For each scoring uni unit, t, both a general scoring principle and specific scoring criteria are presented. The specific scoring criteria specify accuracy and placement ratings in terms of precise distance measurements. These specific scoring criteria were intended to serve several purposes, including (a) to provide and placement of the units of drawings are presented additional guidance and training for inexperienced, in this chapter for each scoring unit. The empirical beg inn ing sco scorer rers; s; and (b) to pro vid e rul es to res resolv olv e ba sis an and d de ve lo lopm pm en t o f the se scor sc orin ing g cri teria te ria are ambiguous and unclear drawings. After a scorer has pres pr esen ented ted in chap ch apter ter 6 . learned the scoring rules and gained experience scor- A score of 0, 0.5, 1, or 2 is assigned to each unit ing actual RCFT protocols, he or she should be able of the figure based on accuracy and placement crite- to score drawings by relying mainly on the general ria. Unit scores are then summed to obtain the raw score for that drawing. The same scoring criteria scoring principles. The specific scoring criteria that inv olv e ’’/4 /4 and V s inch measurements were n o t apply to all three drawing trials. Thus, raw scores intended to require experienced scorers to measure ranging from 0.0 to 36.0 may be obtained for the every unit with a ruler. An experienced scorer should Copy, Immediate Recall, and Delayed Recall trials. use the specific scoring criteria to clarify units of the For each unit of the figure, a score of 2 is assigned if drawings that may not be readily scored using the the unit was drawn accurately an d placed correctly. A general scoring principle. score of 1 is assigned if tthe he unit wa wass drawn accu- Units of drawings that deviate in size from accurately, but was placed incorrectly. A score of 1 is rate reproduction by Vs inch (3 millimeters) or less assigned if the unit was drawn inaccurately, but was are scored as accurate. Units of drawings that deviate place pl ace d corr correctl ectly. y. A sco score re of 1 is also assig as sig ne ned d if the from correct placement by Va inch (6 millimeters) or unit was duplicated (i.e., drawn twice) in the drawing, less are scored as correctly placed. In sc or in g the 11 O' Figure 1. The Rey Complex Figure with numbered scoring units. Table 1 Scoring Criteria for RCFT Drawings O Scoring criteria Score 2 1 1 0.5 0 o A ccu ra cy P l a cem ent O' Accurately drawn Accurately drawn Inaccurately drawn Inaccurately drawn, but recognizable Inaccurately drawn and unrecognizable, or omitted Correctly placed Incorrectly placed Correctly placed Incorrectly placed Incorrectly placed o o G units, it is important not to penalize a drawing twice crooked lines and minor distortions) are ignored. In ffo o r the sam e error. If a part of tthe he figure is not drawn many instances, the endpoints of a line, rather than its and, thus, does not provide a reference point for the straightness, are used to score the accuracy of the accuracy or proper placement of some other unit, the unit. The rotation of either the RCFT Stimulus Card, second unit should not be scored as misplaced if it is a response sheet, or both does not affect the scoring po sitio si tio ne d in the co rrec rr ectt ge ne ral ra l area . Th is scor sc oring ing assigned to individual units. was developed from the perspective of the RCFT as a Page 3 of the RCFT Test Booklet, titled Scoring memory test. As such, slight inaccuracies (e.g., Sheet, is used to score the RCFT drawings. Using the 12 scoring criteria that follow, determine scores for each U SC ORING EXA XAMP MPLES unit of the Copy trial and circle the appropriate score. U The Rey Complex Figure is reproduced on page 3 of A p p e n d i x A c o n t a i n s t h re e R C F T p ro t o c o l s o the test booklet to aid the examiner in scoring draw- (Copy, Immediate Recall, and Delayed Recall trial ings. Sum the unit scores to obtain the Copy raw score drawings, and the Recognition trial sheets) and the and record this in the space provided. Repeat this corresponding scoring sheets, which provide the unit proc pr oces esss fo r th thee Im me dia te Re Recal calll and De lay ed Recal Re calll scores and total raw scores for the drawings. It is rec- drawings. Transfer the raw scores to the spaces pro- ommended that new users practice scoring several vided beneath the the profil profilee grid on page 1 of the RCFT RCFT protocols prior to scoring protocols of actual Test Booklet. respondents. O o O O c 13 SPEC IFIC SC ORING C RITERIA SC ORIN ING G UNIT 1: VERTIC AL C ROSS Scoring Criteria for RCFT Drawings Score Accuracy Placement 2 1 Accurately drawn Accurately drawn Correctly placed Incorrectly placed 1 Inaccurately d drrawn Correctly placed 0.5 Inaccurately drawn, but recognizable recognizable Incorrectly placed 0 Inaccurately drawn and unrecognizable, or omitted Incorrectly placed G eneral Sc oring oring Principl Principle e A vertical cross should be drawn to the upper left of the Large Rectangle (2). Sp e c ific Sc o ring C rite rite ria Accu Ac cura racy. cy. The vertical segment of the Vertical Cross (1) should be parallel to the left vertical segment of the Large Rectangle (2). The horizontal segment of the Vertical Cross (1) should be short and should intersect the vertical segment near the top. The length of the horizontal and vertical segments of the Vertical Cross (1) should be proportional to those of the complex figure stimulus. Placement. The short horizontal line that connects the Vertical Cross (1) to the Large Rectangle (2) should be positioned within */4 inch of the correct position above the Small Rectangle (6) and the Small Horizontal Line (7), very near but below the upper left corner of the Large Rectangle (2). The height of the Vertical Cross (1) should not extend more than */4 inch above the top point of the Small Triangle (9), or more than */2 inch above or X A inch below the Horizontal Midline (4). The cross should not be rotated or drawn upside down. C SC O RING UNIT 2: LARG E REC TANG NGL LE C Scoring Criteria for for RCFT D rawings Accuracy Placement 2 Accurately drawn Correctly placed 1 Accurately drawn Incorrectly Incorrect ly placed 1 Inaccurately drawn Correctly placed 0.5 Inaccurately dr drawn, but recognizable recognizable Incorrectly placed 0 Inaccurately drawn and unrecognizable, or omitted Incorrectly placed Score G ene ral Sc oring oring Rule Rule A large rectangle should be drawn with four distinct corners. The width should be greater than the height and roughly proportional to the complex figure stimulus. Sp e c ific Sc o ring C riteria Ac cu racy ra cy.. A large large rectangle composed o f four line segments should be drawn. These lines may be drawn discontinuously and still receive full credit for accuracy. The line segments should form four right angles at the comers. The lines should extend past the comer intersections no more than Vs inch. The lines should fail to intersect at a corner by no more than Vs inch. The width of the Large Rectangle (2) should be greater than the height and generally proportional to the complex figure stimulus. Placement. The Large Rectangle (2) should be drawn in the approximate center of the page. An edge of the page should not be used as a side. 15 SC O RING UNIT 3: DIA DIAG O NA NAL L C RO SS O F THE LARG E REC RECT TANG LE (2) (2) cy Vy Scoring Criteria Criteria for RCFT Drawings Score Accuracy Placement 2 Accurately drawn Correctly placed 1 Accurately drawn Incorrectly placed Vy 1 Inaccurately drawn Correctly placed O 0.5 Inaccurately drawn, but recognizable recognizable Incorrectly placed Cy 0 Inaccurately d drrawn and unrecognizable, or omitted Incorrectly placed Cy Cy O \y 'V y yy G ene ral Sc oring oring Rul Rule e Two diagonal lines should be drawn from adjacent corners of the Large Rectangle (2), passing through the midpoint o f the Large Rectangle (2) (2).. Sp e c ific Sc o ring C rite rite ria Acc ur urac acy. y. Two diagonal lines should be drawn from adjacent corners of the Large Rectangle (2). Cy vy Ay Vy The lines should extend past the corners of the Large Rectangle (2) no more than */8 inch. The lines Vy should be no more than Vs inch from intersecting the comers of the Large Rectangle (2). The two lines Vy that form the Diagonal Cross (3) should be approximately straight. These line segments may be drawn Cy discontinuously and still receive full credit for accuracy. If only one diagonal line segment in one quadrant is drawn, a score of 0 is assigned. Placement. The two diagonal lines that form the Diagonal Cross (3) should intersect no more than l/4 inch from the midpoint of the Large Rectangle (2). The midpoint of the Large Rectangle (2) \y may be defined as the intersection of imaginary lines drawn from opposite corners of the Large o Rectangle (2). A 0.5 is scored if only two quadrants have a diagonal. Vy Vy Cy Sy vy Vy O' 16 Vy "O SC O RING UNIT 4: HOR HO RIZO NTAL MIDLINE O F THE LARG E REC RECT TANG LE (2) Scoring Criteria for RCFT Drawings Score Placement Accuracy 2 Correctly placed 1 Accurately drawn Accurately drawn Incorrectly placed 1 Inaccurately drawn Correctly placed 0.5 Inaccurately dr drawn, but recognizable recognizable Incorrectly placed 0 Inaccurately drawn and unrecognizable, or omitted Incorrectly placed G eneral Scoring Scoring Ru Rulle A horizontal line should be drawn perpendicular to each vertical segment of the Large Rectangle (2), crossing through the midpoint. » Sp e c ific Sc o ring C riteria Ac cura cu racy cy.. A horizontal line should be drawn between the vertical segments of the Large Rectangle (2). It should not overshoot or undershoot the vertical segments of the Large Rectangle (2) more than l/8 inch. The line segment should be approximately straight. Placement. The Horizontal Midline (4) should be positioned no further than lA inch from the intersection of the two lines that form the Diagonal Cross (3) and should be within XA inch of bisecting the vertical sides of the Large Rectangle (2). If the Diagonal Cross (3) is not present, the Horizontal Midline (4) should be no further than lA inch from the midpoint of the Large Rectangle (2). 17 SC O RING UNIT 5: VER VERTIC A L MIDLINE MIDLINE O F THE LARG E REC RECT TANG LE (2) Scoring Criteria for RCFT Drawings Score Accuracy Placement 2 1 Accurately drawn Accurately drawn Correctly placed Incorrectly placed 1 In Inaaccurately drawn Corr rreectly p pllaced 0.5 Inaccurately drawn, but recognizable Incorrectly placed 0 Inaccurately drawn and unrecognizable unrecognizable,, or omitted Incorrectly placed G ene ral Sc oring oring Rul Rule e A vertical line should be drawn perpendicular to each horizontal segment of the Large Rectangle (2), crossing through the midpoint. Sp e c ific Sc o ring C rite rite ria Ac Accu cura racy. cy. The Vertical Midline (5) should be drawn perpendicular to each horizontal segment of the Large Rectangle (2). It should not overshoot the horizontal segments of the Large Rectangle (2) more than Vs inch. The line segment should be approximately straight. Placement. The Vertical Vertical M idline (5) should be pos itioned no further than l/4 inch from the intersection of the two lines that form the Diagonal Cross (3). If the Diagonal Cross (3) is not present, the Vertical Midline (5) should be positioned no further than X A inch from the midpoint of the Large Rectangle (2). The Vertical Midline (5) should be within */4 inch of bisecting the horizontal segments of the Large Rectangle (2). It should connect with the vertical segment of the Small Triangle (9) and the vertical connecting line of the Horizontal Cross (17), but it may be drawn discontinuously, within ’/4 inch, and still receive full credit for placement. SC O RING UNIT 6: SM SMALL REC TANG NGL LE WITHIN THE LARG E RECT EC TANG LE (2) (2) Scoring Criteria for RCFT Drawings Accuracy Placement 2 Accurately drawn Correctly placed 1 1 Accurately drawn Inaccurately drawn Incorrectly placed Correctly placed 0.5 Inaccurately drawn, but recognizable recognizable Incorrectly placed 0 Inaccurately drawn and unrecognizable, or omitted Incorrectly placed Score G eneral Sco rin ingg Ru Rulle A small rectangle should be drawn within the area defined by the left vertical side of the Large Rectangle (2) and the two lines that form the Diagonal Cross (3). The Small Rectangle (6) should have two diagonal lines that connect adjacent corners and intersect at its midpoint. Sp e c ific Sc o ring C riteria Ac Accu cu racy ra cy.. A small rectangle should be drawn within the area defined by the left vertical side of the Large Rectangle (2) and the two lines that form the Diagonal Cross (3). The small rectangle should be composed of four line segments. The line segments should form four right angles at the comers. The lines should extend past an intersection no more than Vs inch. The lines should fail to intersect at a corner by no more than Vs inch. The height of the Small Rectangle (6) should be greater than its width and generally proportional to the complex figure stimulus. Within the Small Rectangle (6) are two diagonal lines that connect adjacent corners of the Small Rectangle (6). These lines should not overshoot or undershoot the corners by more than Vs inch. Placement. The midpoint of the Small Rectangle (6) should not deviate from the Horizontal Midline (4) by more than */4 inch. The intersection of the two small diagonals within the Small Rectangle (6) should not deviate from the Horizontal Midline (4) by more than Vt inch. The corners of the Small Rectangle (6) should not deviate from the area defined by the left vertical side of the Large Rectangle (2) and the Diagonal Cross (3) more than */4 inch at any point. SC O RING ING UNIT 7: SMALL HOR HORIZO NTAL LINE ABOV BOVE THE SMALL RECT EC TANG LE (6) (6) Scoring Criteria for RCFT Drawings Score Accuracy Placement 2 Accurately d drrawn Correctly p pllaced 1 Accurately drawn Incorrectly placed 1 Inaccurately drawn Correctly placed 0.5 Inaccurately drawn, but recognizable Incorrectly placed 0 Inaccurately drawn and unrecognizable, or omitted Incorrectly placed G ene ral Sc oring oring Rul Rule e A horizontal line should be drawn parallel to and directly above the Small Rectangle (6), crossing from the left vertical segment of the Large Rectangle (2) to the proximal D iagonal Cross (3) segment. Sp e c ific Sc o ring C rite rite ria Ac Accu cura racy cy.. The Small Horizontal Line (7) should be drawn parallel to and directly above the Small Rectangle (6), crossing from the left vertical segment of the Large Rectangle (2) to the proximal Diagonal Cross (3) segment. It should not overshoot the endpoints on the Large Rectangle (2) and the prox pr oxim im al Di agon ag on al Cr Cros osss (3) mo re tha n Vs inch inch.. Placement. The line should deviate no more than V4 inch from the proper location, defined as the area above the Small Rectangle (2) and below the short vertical line that connects the Vertical Cross (1) to the Large Rectangle (2). The line should be discontinuous with any segment of the Four Parallèl Lines ( 8). 8). SC O RING RING UNIT 8: FO UR PA PARALLEL LINES INES WITHIN THE LARGE RGE REC RECT TANG LE (2) Scoring Criteria for RCFT Drawings Score Accuracy Placement 2 Accurately drawn Correctly placed 1 Accurately drawn Incprrectly placed 1 Inaccurately d drrawn Correctly placed 0.5 Inaccurately d drrawn, but recognizable recognizable Incorrectly placed 0 Inaccurately drawn and unrecognizable, or omitted Incorrectly placed G ene ral Sc oring oring Rul Rule e Four evenly spaced horizontal lines should be drawn in the area defined by the upper left segment of the Diagonal Cross (3), the upper segment of the Vertical Midline (5), and the left portion of the top horizontal segment of the Large Rectangle (2). Sp e c ific Sc o ring C rite rite ria Ac cu cura racy cy.. Four lines must be present, with no fewer and no extra lines. The lines should not be rotated more than 30 degrees from the horizontal plane. Each line should be horizontal and drawn parallel to the other three lines. The spacing between each line is scored liberally but should be generally prop pr op ortio or tio na l to the co m plex pl ex fig ure ur e stimu sti mu lus lus.. No erro er ro r is sc or ored ed if disp di sp ro po rti on ate dista di sta nc e is left lef t betw be tween een the top line and the top ho riz on ontal tal segm se gm ent of tthe he Lar Large ge Recta Re cta ng ngle le (2). T he lin lines es sh shoul ould d exte e xtend nd no more than Vs inch past the boundary of the Vertical Midline (5) or the upper left portion of the Diagonal Cross (3). Placement. Four evenly spaced horizontal lines should be drawn in the area defined by the upper left segment of the Diagonal Cross (3), the upper segment of the Vertical Midline (5), and the left portion of the top horizontal segment of the Large Rectangle (2). The lines should be contained in the upper left quadrant of the Large Rectangle (2). SC O RING ING UNIT 9: SM SMA LL TRIANG IA NG LE ABO VE THE LARG E RECT EC TANG LE (2) (2) Scoring Criteria for RCFT Drawings Accuracy Placement 2 1 Accurately drawn Accurately drawn Correctly placed Incorrectly placed 1 Inaccurately drawn Correctly placed 0.5 Inaccurately drawn, but recognizable recognizable Incorrectly placed 0 Inaccurately dr drawn and unrecognizable, or omitted Incorrectly placed Score - w - v G ene ral Sc oring oring Rul Rule e A right triangle should be drawn above the Large Rectangle (2) with the base of the triangle extending from the upper right corner of the Large Rectangle (2) to the Vertical Midline (5). Sp e c ific Sc o ring C rite rite ria Ac cura cu ra cy . The Small Triangle (9) should be a right triangle, with the 90-degree angle to the bottom left, the 60-degree angle at the top, and the 30-degree angle on the right. The hypotenuse should not be a continuation of the upper side of the Large Triangle (13). The lines that form the top (60 degree) cor ner of the Small Triangle (9) should extend past the point of intersection no more than Vs inch. The V_' lines should be within V s inch of intersecting at a corner. Placement. The Small Triangle (9) should be drawn immediately above the right portion of the top horizontal segment of the Large Rectangle (2). The horizontal segment of the Large Rectangle forms the bottom segment of the Small Triangle (9). The left vertical side of the Small Triangle should be within Va inch of connecting with the Vertical Midline (5). If the left vertical side of the Small Triangle (9) is correctly connected to the Vertical Midline (5), but the Vertical Midline (5) is itself misplaced (thereby distorting the Small Triangle [9]), score the Small Triangle (9) as correctly placed and score the Vertical Midline (5) as incorrectly placed. The hypotenuse of the Small Triangle (9) should connect with the upper right com er of the Large Rectangle (2) (2).. 22 — / ° SC O RIN ING G UNIT 10: SMALL VER ERT TIC AL LINE WITHIN THE LARG RGE E REC ECT TANG LE (2), BELO W THE SMALL TRIA RIAN NG LE (9) Scoring Criteria for RCFT Drawings Score V Accuracy Placement 2 1 Accurately drawn Accurately drawn Correctly placed Incorrectly placed 1 Inaccurately d drrawn Correctly placed 0.5 Inaccurately drawn, but recognizable recognizable Incorrectly placed 0 Inaccurately drawn and unrecognizable, or omitted Incorrectly placed O' G ene ral Sc oring oring Rul Rule e A vertical vertical line should be drawn within the area defined by the upp er right segment o f the Diagona Diagonall Cross (3), the upper portion of the Vertical Midline (5), and the top right horizontal segment of the Large Rectangle (2). Sp e c ific Sc o ring C rite rite ria Accu Ac curac rac y. One, and only one, vertical line should be drawn. The line should not be rotated more than 30 degrees. The Small Vertical Line (10) should extend past the points of intersection no more than Vs inch. Placement. A vertical line should be drawn within the area defined by the upper right segment of the Diagonal Cross (3), the upper portion of the Vertical Midline (5), and the top right horizontal segment of the Large Rectangle (2). The Small Vertical Line (10) should be positioned within */4 inch of the center point of the designated area with the Small Vertical Line (10) to the left of the center point. Vw 23 SC O RING UNIT 11: C CIRC IRC LE WITH THREE DOT DOTS Scoring Criteria for RCFT Drawings Accuracy Placement 2 1 Accurately drawn Accurately drawn Correctly placed Incorrectly placed gG 1 Inaccurately dr drawn Correctly pl placed G 0.5 Inaccurately drawn, but recognizable recognizable Incorrectly placed 0 Inaccurately drawn and unrecognizable, or omitted Incorrectly placed Score G G G G G G ene ral Sc oring oring Rul Rule e A circle with three dots should be drawn in the area defined by the upper right segment of the g Diagonal Cross (3), (3), the proximal segment of the Horizontal M idline (4), and the top right vertical segment o f the Large Rectangle (2) (2).. Sp e c ific Sc o ring C rite rite ria Accu Ac cura racy cy.. The circle should have three, and only three, dots. The dots must be oriented properly to G G G be sco red as acc accura ura te. The cir circle cle shou sh ould ld be ge gene neral rally ly prop pr op ort ion al to the comp co mp lex fig ur uree sti mu lus lus.. The Th e dots should be dark (i.e., not overly light), but this may be scored somewhat liberally. A “smiley face” is scored as inaccurate. Placement. The Circle With Three Dots (11) must be placed within the area defined by the upper right segment of the Diagonal Cross (3), the proximal segment of the Horizontal Midline (4), and the top right vertical vertical segm ent of the Large Rectangle (2). If any portion of the circle crosses these bound- G G aries, it is scored as misplaced. G G G G G G G w 24 G SC ORIN RING G UNI UNIT T 12: FIV IVE E PARALLEL LIN INES ES INT IN TERSEC TIN ING G THE DIA DIAG GONA NAL L C ROSS (3) L. Scoring Criteria Criteria for RCFT Drawings Accuracy Placement 2 1 Accurately drawn Accurately drawn Correctly placed Incorrectly placed 1 Inaccurately drawn Correctly placed 0.5 Inaccurately drawn, but recognizable recognizable Incorrectly placed 0 Inaccurately drawn and unrecognizable, or omitted Incorrectly placed Score G ene ral Sc oring oring Rul Rule e Five parallel lines should be drawn along the lower right segment o f the Diagonal Cross (3), within the lower right quadrant of the Large Rectangle (2). Sp e c ific Sc o ring C rite rite ria Accu Ac curac rac y. Five lines of roughly equal length must be present along the lower right segment of the Diagonal Cross (3). They should form right angles with the Diagonal Cross (3). The lines should be evenly spaced and parallel to each other and generally proportional to the complex figure stimulus. Spacing and parallelism are scored libe liberall rally. y. In the event that the lower right segm ent of the Diagonal Cross (3) is not present, but the Five Parallel Lines (12) are drawn, the lines are scored as accurate if they meet the above criteria. Placement. The lines should be positioned on the lower right segment of the Diagonal Cross (3), within the lower right quadrant of the Large Rectangle (2). In the event that the lower right segment of the Diagonal Cross (3) is not present, the line liness are scored as correctly placed i f they meet the above criteria. 25 SC O RING UNIT 13: SIDES O F THE LARG E TRIAN IA NG LE ATTAC HED HED TO THE LARG E REC RECT TANG LE (2) Scoring Criteria for RCFT Drawings Accuracy Placement 2 1 Accurately drawn Accurately drawn Correctly placed Incorrectly placed 1 Inaccurately dr drawn Correctly pl plaaced 0.5 Inaccurately drawn, but recognizable recognizable Incorrectly placed 0 Inaccurately drawn and unrecognizable, or omitted Incorrectly placed Score - G ene ral Sc oring oring Rul Rule e Two diagonal lines that form the sides of a triangle should extend from the right two comers of the Large Rectangle (2) to the point defined by the right end of the Horizontal Line in the Triangle (16). The right vertical segment of the Large Rectangle (2) serves as the base of the Sides of the Large ( . Triangle (13). Sp e c ific Sc o ring C rite rite ria Ac Accu cu ra cy . Two line segments should originate from the two right comers of the Large Rectangle (2) and converge at a point to the right of the right vertical segment of the Large Rectangle (2). The size of the Sides o f the Large Triang Triangle le should be g enerally proportional to the complex figure stimulus. The lines should not overshoot or undershoo t the termination points by more than V s inch. In the event that the right vertical segment of the Large Rectangle (2) is not drawn, the Sides of the Large Triangle (13) is scored as accurate if all other accuracy criteria are met. G G Placement. The lines should converge at a point no more than Vs inch from the endpoint of the Horizontal Line within the Triangle (16). (16). The vertex of the triangle should be drawn opposite the m id poi nt o f th thee righ t ver vertic tical al seg me nt o f the t he Lar Large ge Rectan Re ctan gle (2) and sh shou ould ld no nott d evi ate fro m this thi s pos itio n by mor moree than tha n V4 inch. The base of the triangle should incorporate the right vertical segment of the Vy G Large Rectangle (2). g G G o G 26 G SC O RING UNIT 14: DIAMO DIAMOND ND ATTAC HED TO THE LARG E TRIAN RIANG LE (13) Scoring Criteria for RCFT Drawings Accuracy Placement 2 1 Accurately d drrawn Accurately drawn Correctly pl placed Incorrectly placed 1 Inaccurately drawn Correctly placed 0.5 Inaccurately drawn, but recognizable recognizable Incorrectly placed 0 Inaccurately drawn and unrecognizable, or omitted Incorrectly placed Score G ene ral Sc oring oring Rul Rule e A diamond-shaped figure should be drawn with the top vertex o f tthe he diamond co nnecting with the vertex of the Large Triangle (13). _ Sp e c ific Sc o ring C rite rite ria Ac cu cura racy cy.. This elem ent must be a diamond shape with four sides of equal lengt length. h. A round or trian gle shape is scored as inaccurate. Although the shape of the diamond is scored somewhat liberally, the widest portion of the figure must be in the middle, and the width must taper at the top and bottom ver tices. tice s. All lines of the Diamond (14) must be distinct from the segments that form the Sides of the Large Triangle (13). The Diamond (14) must not be attached to the Sides of the Large Triangle (13) with another line segment (i.e., “stem”). The lines should extend past an intersection no more than Vs inch. The lines should be within Vs inch of intersecting at a comer. The vertical axis of the Diamond (14) should not be rotated more than 30 degrees from vertic vertical. al. Placement. The top vertex of the Diamond (14) should connect with the vertex of the Sides of the Large Triangle (13). The bottom vertex of the Diamond (14) should not extend below the horizontal line of the Large Rectangle (2). 27 ■V, / SC O RING UNIT 15: VERTIC AL LINE WITHIN THE SIDES IDES O F THE LARGE RGE TRIAN RIANG LE (13) (13) Scoring Criteria for RCFT Drawings Score Accuracy Placement 2 1 Accurately drawn Accurately drawn Correctly placed Incorrectly placed 1 Inaccurately Inaccuratel y drawn Correctly placed 0.5 Inaccurately d drrawn, but recognizable recognizable Incorrectly placed 0 Inaccurately drawn and unrecognizable, or omitted Incorrectly placed G ene ral Sc oring oring Rul Rule e A vertical line should be drawn within the Sides of the Large Triangle (13) to the right of the base of the Sides of the Large Triangle (13) and connecting with the two line segments that form the Sides of the Large Triangle (13). Sp e c ific Sc o ring C rite rite ria Accu Ac curac rac y. A vertical line should be drawn that connects with the two line segments that form the Sides of the Large Triangle (13). The line should be rotated no more than 30 degrees. The line should extend past an intersection no more than Vs inch. The line should be within Vs inch o f intersecting the Sides of the Large Triangle (9). Placement. The vertical line should be positioned to the left of the midpoint of the Horizontal Line within the Triangle (16). SC O RING UNIT 16: HO HOR RIZO NTAL LINE W WIT ITHIN THE SID IDES ES O F THE LARG E TRIA RIAN NG LE ( (13) 13) Scoring Criteria Criteria for RCF T Drawings Accuracy Placement 2 1 Accurately Accurately drawn A c c u ra te ly d raw n Correctly placed Incorrectly placed 1 I n a c c u r a t e ly d r a w n Correctly placed 0.5 Inaccurately drawn, bu t re co gn iz ab le Incorrectly placed 0 Inaccurately drawn and unrecognizable, or omitted Incorrectly placed Score G ene ral Sc ori oring ng Rule Rule A horizontal line should be drawn within the Sides of the Large Triangle (13), extending from the intersection of the Horizontal Midline (4) and the right vertical side of the Large Rectangle (2) to the apex of the Sides of the Large Triangle (13). Sp e c ific Sc o ring C rite rite ria Ac Accu cura racy cy.. The Horizontal Line in Triangle (16) should be within V s inch of connecting with the Horizontal Midline (4). It should not overshoot the apex of the Sides of the Large Triangle (13) by more than Vs inch. Placement. The horizontal line should bisect the apex of the Large Triangle Triangle (13), and the endpoint should not fall more than '/4 inch above or below the appropriate intersection points. 29 SC O RING ING UNIT 17: HOR HORIZO NTAL C RO SS Scoring Scorin g Criter Criteria ia for RCFT Drawings Accuracy Placement 2 1 A c c u r a te l y d ra w n A cc cc u r a t e l y dr dr a w n C o r r e c tl y p la c e d I n c o r r e c t l y pl pla c e d 1 I n a c c u r a te l y d r a w n C o r r e c tl y p l a c e d 0.5 Inaccurately drawn, but b ut re co gn iz ab le Incorrectly placed 0 Inaccurately drawn and unrecognizable, or om itted itted Incorrectly placed Score G ene ral Sc ori oring ng Rul Rule e A horizontal cross should be drawn below the Large Rectangle (2), attached on the left to both the Square (18) and the Large Rectangle (2) by a short vertical line that also connects with the Vertical Midline (5). Sp e c ific Sc o ring C rite rite ria Accu Ac cura racy cy.. A horizontal cross with its vertical cross-piece should be present on the right side of the figure. A short vertical line should connect the horizontal cross to the Large Rectangle (2). The length of the lines that form the Horizontal Cross (17) should be generally proportional to the complex figure stimulus. The short vertical line that connects the Horizontal Cross (17) to the Large Rectangle (2) should also connect with the Vertical Midline (5). If the Vertical Midline (5) is not drawn, then this small vertical line should connect at the approximate center of the bottom horizontal segment of the Large Rectangle (2). The */8 inch tolerance rule is used to score the accuracy of all closures. Placement. The cross should be within lA inch of connecting to the midpoint of the right side of the Square (18) ( if dr drawn). awn). The right end o f the Horizontal Cross (17) should not extend m ore than lA inch past the right vertical side of the Large Rectangle (2). If the Vertical Midline (5) is drawn, then the small vertical line that connects the cross must be within lA inch of the Vertical Midline (5). w L/ 30 y SC O RING UNIT 18: SQ UA UAR RE ATTAC HED TO THE LARG E R REC ECT TANG LE (2) Scoring Criteria for RCFT Drawings Accuracy Placement 2 A c c u ra te ly dra w n Correctly placed 1 A c c u ra te ly dra w n Incorrectly placed 1 I n a c c u r a te l y d r a w n Correctly placed 0.5 Inaccurately drawn, bu b u t r ec og n iz ab le Incorrectly placed 0 Inaccurately drawn and unrecognizable, or omitted Incorrectly placed Score G ene ral Sc ori oring ng Rule Rule A small square should be drawn below the low er left comer of the Large Rectangle (2). (2). The Square (18) should contain a diagonal line that extends from the upper left to the lower right corners of the Square (18). Sp e c ific Sc o ring C rite rite ria Ac Accu cura racy. cy. A small square should be drawn that contains a diagonal line that extends from the upper left comer to the lower right comer of the square. The width of the Square (18) should be within X A inch of the approximate width of the Small Rectangle (6). The four lines of the Square (18) should meet to form right angles at the comers. These lines should extend past an intersection no more than Vs inch. The lines should be within Vs inch of intersecting at a corner. The end points of the diagonal line in the Square (18) should not overshoot or undershoot the adjacent com ers by more than Vs inch. Placement. The Square (18) should be positioned below the lower left corner of the Large Rectangle (2). The top of the Square (18) should be within Vt inch inch of connecting with the lower horizontal segment o f the Large Rectangle (2), (2), and the left vert vertical ical segment o f the Square should be within */4 inch of connecting with the left vertical segment of the Large Rectangle (2). SC ORING THE OBTAININ INING G NO NOR RMA MAT TIVE REC OG NITIO ION N TRIA IAL L SC ORES AND PROFILING Page 3 of the RCFT Test Booklet, titled Scoring After the raw scores for the RCFT have been cal Sheet, is used to score the RCFT Recognition trial. A culated and entered into their respective spaces on true positive response on the Recognition trial occurs pag e 1 o f the tes testt bo ok let, let , co corr rres espo po nd ing no norm rm ati ve when a respondent indicate indicatess that he or she recognizes scores may be recorded. Locate the appropriate nor an element that is part of the Rey Complex Figure mative table in Appendix C based on the respond ent’s (i.e., circles a target item). Recognition trial Items 2, age. Normative data in Appendix B may also be used 5, 7, 8, 9, 12, 13, 15, 19, 20, 22, and 24 are target items. Sum the number of these items that were cir for making comparisons with the general population of adults (18 through 89 years of age). Record the cled, and enter this value as the raw score for table number (or the age grouping of the table) in the Recognition True Positives. A false positive response space provided on page 1 of the ttest est bookle booklet. t. on the Recognition trial occurs when a respondent Within the column of the normative table labeled indicates that he or she recognizes an element that is Immediate Recall, locate the numb er that corresponds part of the figure (i.e., circles a distractor item). to the respondent’s Immediate Recall raw score. Recognition trial Items 1, 3, 4, 6, 10, 11, 14, 16, 17, Staying within that row, move to the left of the table 18, 21, and 23 are distractor items. Sum the number and find the corresponding 7-score and percentile of these items that were circled, and enter this value score values. Enter these values in their respective as the raw score for Recognition False Positives. spaces on page 1 of th thee test booklet. Use an analo no t A true negative response on the Recognition trial gous procedure to locate and transcribe the normative occurs when a respondent indicates that he or she score values for Delayed Recall and Recognition does not recognize an item that is not part of the figure (i.e., does not circle a distractor item). The Total Correct. Recognition True Negatives raw score is the inverse mative table, locate the column labeled Copy. Within of the Recognition False Positives raw score. that column, find the range of numbers that corre Therefore, subtract the Recognition False Positives sponds to the respondent’s Copy raw score. Move to raw score from 12, and record this value as the raw the left or right of the box and find the corresponding score for Recognition True Negatives. A false nega p e rc e n ti le ra n g e s co re . T ra n sc ri b e th is p e rc e n ti le tive response on the Recognition trial occurs when a range sco re to its respective space on page 1 of the respondent indicates that he or she does not recognize test booklet. Use an analogous procedure to locate an item that is part of the figure. The Recognition and transcribe the percentile ranges for Time to Cop Copy, y, False Negatives raw score is the inverse of the R e c o g n i t i o n Tru e P o si t i v e s, R e c o g n i t i o n F a l se Recognition True Positives raw score. Therefore, sub Positives, Recognition True Negatives, and Recog tract the Recognition True Positives raw score from nition False N egatives egatives.. 12, and record this value as the raw score for Recognition False Negatives. In the Raw scores box at the bottom of the nor To plot the respondent’s performance on the RCFT, locate the Profile of Selected Scores area on The Recognition Total Correct raw score is the pag e 1 of the test tes t bo book oklet. let. Fo r eac h va ria ble lis listed ted at sum of the Recognition True Positives and Recognition True Negatives raw scores. Sum these the bottom of the profile (i.e., Immediate Recall, Delayed Recall, and Recognition Total Correct), two scores and record this value as the Recognition locate the tick mark in the respective column that cor Total Correct raw score. Transfer the raw scores to the responds to the 7 score and mark it with an “X.” 7 spaces provided on page 1 of the RCFT Te Test st Bookl Booklet. et. scores are located at the extreme left of the profile area. After all 7 scores have been marked on the pro file, connect the “Xs” with a line. Chapter 5 presents criteria and rules to assist the professional in rating and interpreting the configural pattern of the 7-score profi pr ofi le of the these se three thr ee sco scores. res. 4 Nor No rmat mative and Des Desc ript iptive Statist istics ic s NOR NO RMA MAT TIVE IVE S SA AMPLE States population. Census data middle-series projec tions of the U.S. population for the year 2000 were RCFT normative data were derived from a total u se d i n d e t e rm i n i n g t h e a g e d i st ri b u t i o n (U . S . group of 601 normal subjects aggregated from several Department of Commerce, 1994). Middle-series pro distinct samples. Prior to testing, all subjects were je ct io n s fo forr 20 2000 00 we were re th ou gh t to pr ov ide id e the bes t screened for a history of neurological dysfunction, current and near-future representations representations of this popula psyc ps ychia hia tri c disor dis order der,, lea rni ng disabi dis ability lity , and alc alcoho oho l tion characteristic. Table 3 presents the percentages of or drug abuse or dependence. In addition, subjects the U.S. population and the RCFT U.S. census age- that obtained a Beck Depression Inventory (BDI; Beck & Steer, 1987) score of 11 or greater were matched sample by age group. As seen from these data, the RCFT U.S. census age-matched sample excluded from participation. closely corresponds to the 2000 middle-seri middle-series es projec The first sample consisted of 134 students drawn from various university settings. These subjects received course credit for their participation. The tions for age. RCFT raw score means and standard deviations for the U.S. census age-matched subsam ple are pre se sente nte d in Tab Table le 4. second sample consisted of 74 friends or family The average education level of this subsample members o f patient patientss in a residential head injury treat (M = 13.91; SD = 2.48) was found to be slightly ment facility. The third sample of subjects (n = 393) higher than that of the U.S. population in 1993 (U.S. was drawn from various suburban communities in Department of Commerce, 1994). The 1993 data rep the western and midwestern United States and resent the most current descriptive information on British Columbia, Canada. Subjects were recruited educational attainment available at the present time. via word of mouth, flyers, bulk mailings, and news Therefore, the subsample could not be equated for years of education. However, as will be shown later, pa pe r adv ert ise me nts . Ni ne netyty- six sub jec jects ts wer weree pa paid id a nominal fee to secure their participation. Urban and years of education has an insignificant relationship to rural residents were represented approximately RCFT performanc performance. e. evenly in the normative sample. The majority of the normative sample was recruited from the north cen tral and western areas of the United States; however, all regions of the country were represented. Table 2 prese pr ese nt ntss nu m ber be r o f su bje cts cts,, de demo mo grap gr ap hic info in fo rm a INFLUENCE INFL ENCE OF OF DEMO DE MOG GRAPHIC VAR VARIA IAB BLES tion, means, and standard deviations for all RCFT Analyses were conducted on RCFT data obtained raw scores by age group for the complete normative from the normative sample to examine the potential effects of age, gender, and education. Hierarchical sample. A subset of the normative sample (n = 394) was selected to reflect the age distribution of the United pol yn ynom om ial reg res sio n ana lyses lys es wer weree use d to inves in ves ti gate these relationships. 33 Table 2 RCFT Raw Score Descriptive Statistics for the Normative Sample Age group Copy Time to Immediate Delayed Copy Recall Recall Recognition Total Correct Recognition True Positives Recognition False Positives Recognition True Negative s Recognition False Negativ es 35. 1 10 0 1.81 244.16 71.21 24.84 4.70 25.11 4.69 21.74 1.48 10.13 1..45 1 0.39 0.65 11.61 0.65 1.88 1.45 35.23 1.46 199.61 72.74 25.65 3.89 25.85 3.89 21.30 1.35 9.82 1.28 0.52 0.85 11.48 0.85 2.18 1.28 35.38 0.88 181.59 71.80 24.73 4.14 24.85 4.23 21.53 1.65 9.91 1.57 0.38 0.66 11.62 0.66 2.09 1.57 35.37 1.44 187.95 73.28 23.67 4.25 23.86 4.58 21.58 1.27 10.05 10 1.54 0.47 0.89 11.53 0..89 0 1.95 1.54 34 34.9 .90 0 2.54 18 189 9.9 .98 8 57.40 20.95 4.37 21.35 4.11 21.44 1.32 9.84 9. 1..43 1 0.40 0.58 11.61 0.58 2.16 1.43 33.52 3.86 211.86 72.14 20.13 4.77 19.70 5.06 20.10 1.76 8.86 8. 1.79 0.76 0.93 11.24 0..93 0 3.14 1.79 34.44 2.44 204.34 79.17 21.03 5.44 20.54 5.53 20.86 2.03 9.49 2.13 0.63 0.84 11.37 0.84 2.51 2.13 18-19 years (n = 88) M SD 20-24 years (n = 87) M SD 25-29 years (,n = 53) M SD 30-34 years (n = 38) M SD 35-39 years (« = 43) M SD 40-44 years (n = 42) M SD 45-49 years (n = 35) M SD « c ( ( < ( ( ( ( ( C ( ( ( ( ( ( < ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( c c c c c c c c c c c c c e e e e e e e e e e e e e e e e r e ( ( ( ( ( ( ( ( e ec ce ec e _ Time to Immediate Delayed Recognition Recognition Recognition Recognition Recognition Copy Copy Recall Recall Total Correct True Positives False Positives True Negatives False Negatives 35.15 1. 1.26 26 225.65 11 112. 2.12 12 20.29 4..49 4 20.47 4.05 20.47 1.69 9.59 9. 1..54 1 1.12 1.39 10.88 1.39 2.41 1.54 34.57 1.46 222.97 97.00 17.97 5.26 17.98 4.82 20.03 1.50 8.67 1.52 1. 0.63 0.96 11.37 11 0.96 3.33 1.52 33 33.4 .42 2 2.62 20 201. 1.90 90 109.27 17.65 17 4.61 17.29 3.97 20.23 1.54 8.87 8. 1.69 0.65 0.95 11.36 11 0.95 3.13 1.69 33.73 2. 2.35 35 319.24 10 107. 7.50 50 14.59 4.83 14.61 4.55 19.42 1.66 8.73 1..88 1 1.30 1. 1.31 10.70 1..31 1 3.27 1.88 32 32.9 .97 7 3.79 29 293. 3.08 08 90.51 15.50 5.35 14.14 5.64 20.14 1.49 8.76 1.65 0.61 0.91 11.39 11 0.91 3.25 1.65 32.91 3.99 294.65 127.71 10.48 3.30 10.83 3.02 20.04 1.43 9.35 1..19 1 1.30 1. 1.19 10.70 1..19 1 2.65 1.19 29.6 29.63 3 343. 343.13 13 9.00 8.60 19.33 8.93 1.60 10.40 3.07 50-54 years (n = 34) M SD 55-59 years (n = 30) M SD 60-64 years (n = 31) M SD 65-69 years (,n = 33) M SD 70-74 years (n = 49) M SD 75-79 years (« = 23) M SD 80-89 years 15) (n = 15) M ( e ere Table 2 (continued) RCFT Raw Score Descriptive Statistics for the Normative Sample Age group ( ( 4.86 SD 150.02 4.39 4.15 1.45 1.28 1.06 1.06 1.28 L/ l Table 3 Percentagee o f U.S. Census Percentag Age-Matched Age-Matche d RCFT Sample by Age Age group 18-24 25-34 35-44 45-54 55-64 65-74 75-85 85 85+ + RCFT sample ( % ) U.S. census (%) 12.90 19.00 21.60 17.50 11.70 9.10 6.10 2.00 12.67 18.70 22.07 17.69 11.59 9.07 6.09 2.12 Note. N = 394. Proportions for age were based on middleseries projected data for 2000 as given in Table 16, Statistical abstract o f the the United States: States: 1994 (114th ed.), U.S. Department of Commerce, Bureau of Census, 1994, Washington, DC: U.S. Government Printing Office. greater than the selected component, incremental increases in proportion of variance accounted for by these components were not meaningful. Gender and the interactions interactions between gender and age were not sig nificantly related to RCFT scores after the effects of age were removed. The relationship between years of education (and its various powers) and age-adjusted RCFT scores was then examined. No significant relationship be tw ee n yea rs o f ed educ uc ati on an and d ag e-a dju st sted ed RC FT scores was found for any RCFT variable. The propor tion of variance in age-adjusted RCFT scores accounted for by years of education ranged from 0% to 5%, with an average of 2%. Overall, the results of the polynomial regression analyses revealed a substantia substantiall cu rvilinear (quadrati (quadratic) c) relationship between RCFT copy scores (Copy and Time to Copy) and age, and a substantial linear rela Table 4 Means and S tandard Deviations of CFT Scores for the U.S. Census-Matched Normative Sample RCFT variable Copy Time to Copy Immediate Recall Delayed Recall Recognition Total Correct Recognition True Positives Recognition F Faalse P Po ositives Recognition True Negatives Recognition False Negatives tionship between RCFT memory scores (Immediate Recall, Delayed Recall, Recognition Total Correct, R e c o g n i t i o n Tru e P o si t i v e s, R e c o g n i t i o n F a l se Positives, Recognition True Negatives, and Recog nition False Negatives) and age. Examination of the M SD 34.29 222.87 19.90 19.85 20.77 9.48 0.71 11.29 2.52 2.75 96.74 6.22 6.28 1.78 1.72 0.98 0.98 1.72 Note. N = 394. quadratic regression curves for age showed RCFT copy performance was fairly stable through the 20-, 30-, and 40-year age decides. Beyond 50 years of age, an accelerated decrease in copy proficiency was noted, as was an accelerated increase in the time required to copy the figure. Exam ination of the linear regression lines for age indicated a gradual, but sig nificant, decrease in RCFT recall and recognition p e rf o rm a n c e a c ro s s th e ag e ra n g e. B as ed on th e obtained relationships, normative tables were grouped into a 2-year age span for 18 and 19 yearolds and 5-year age spans for 20 through 79 years of Age (and its various powers), gender, and the var ious interactions of these variables were entered as pr ed ic to rs , in th at re la lati tive ve ord er. R esul es ul ts sh ow ed a age. Subjects 80 through 89 years of age were grouped into one table becaus e o f tthe he relatively small number of these subjects. significant quadratic effect for age on Copy (p < .001) and Time to Copy {p < .001). The proportion of vari ance in RCFT copy scores accounted for by the qua dratic relationships ranged from 15% to 17%. Results showed a significant linear effect for age on all remaining RCFT variables (p < .001 in all cases). The DEMOG MOGRAPHICA IC ALLY C ORRECT EC TED NOR NORMAT MATIVE IVE DATA C ontinuous ontinuous Norms p r o p o r ti o n o f v a ri a n c e in R C F T m em o ry s co re s The method of continuous norming was used to accounted for by the linear relationships ranged from derive separate normative data for the RCFT U.S. 6% to 50%, with an average of 19%. Although signif census age-matched sample and for the entire RCFT icant effects were also found for powers of age n o rm a t i v e sa m p l e g ro u p e d b y a g e . C o n t i n u o u s 36 O norming has been recommended to correct for irregu various powers were used as predictors. Results from larities in (a) the distributions of scores within group these analyses found the quadratic component to ings of the normative variable, and (b) trends in the yield the best fitting curves for the means. Visual means and standard deviations across groupings when inspection of the quadratic curves derived from the group sample sizes are 200 or smaller (Angoff & group means and the lines derived previously from Robertson, 1987). Calculation of normative scores by the individual subjects’ raw scores showed consider the method of continuous norming involves the fol able congruence. The quadratic trend com ponent was lowing sequence o f four steps: steps: found to describe best the progression of standard 1. 2. 3. \ 4. Determ ining the lines or curves of best fit for deviations across age subgroups. the progression of means and standard devia tions across groupings of the norming vari ables, using polynomial regression. Step 2 Means and standard deviations .were then calcu lated for each normative age group. For each table, Estim ating the mean, standard deviation , mean RCFT scores and standard deviations were pre skewness, and kurtosis of the distribution of dicted using the derived quadratic equations. These scores for each normative variable group. calculations used the mean age of each normative Calculating the percen tile and standard scores group as the value for age in the regression equa ba sed se d on th thee es tim ti m at es ob tain ta in ed in Ste ps 1 tions. Standard deviations were calculated in the and 2. same manner. Eva luating tthe he accuracy of the comp uted norms. These four steps are implemented for each test The procedure of continuous norming assumes that the best estimate of distribution shape is derived from the composite skewness and kurtosis aggregated across groupings of the normative variables (Angoff score that requires normative transformation. Angoff and Robertson (1987), Gorsuch (1983), Roid (1983), and Zachary and Gorsuch (1985) present detailed dis cussions of the m ethod of continuous norming. Step 1 The method of continuous norming uses group descriptive statistics, rather than the data of the indi vidual subjects comprising the groups, as the unit of analysis when modeling the line or curves of best fit. To estimate the shape of the distribution of scores, the total normative sample was divided into 14 subgroups ba se d on age. Insp In sp ectio ec tio n of the ag agee-gr grou ou p di stri st ribu bu  tions indicated that Immediate Recall, Delayed Recall, and Recognition Total Correct were suffi ciently normally distributed to allow for normalized transformations of the data. Therefore, these scores were selected for continuous norming. Distributions of scores for Copy, Time to Copy, Recognition True Positives, Recognition False Positives, Recognition True Negatives, and Recognition False Negatives were too highly skewed to warrant normalized trans & Robertson, 1987). Composite estimates of skew ness and kurtosis were thus calculated from the weighted averages of these respective values in the 14 age subgroups. The size of each subgroup was used as the weight. Step 3 Percentile and normalized standardized scores corresponding to raw scores were derived according to the Johnson-curve method (Hill, Hill, & Holder, 1976) for every normative group, using the respective mean, standard deviation, skew, and kurtosis values described in Step 2. The Johnson-curve method esti mates the cumulative probability of a distribution with a given mean and standard deviation based on prob pr ob ab ili ty va value lue s of the th e nor ma mall curve cu rve ad jus ted for the skewness and kurtosis of the distribution. T scores were derived to have a mean of 50 and a standard deviation of 10. All RCFT variables were scaled such that higher standardized scores (i.e., T scor scores es and per centile scores) reflect better test performance. formations and were, therefore, treated with categori Step 4 cal methods. Means and standard deviations of the selected Accuracy of the derived normative values was evaluated by comparing the percentile values derived scores for the 14 subgroups were analyzed separately according to the Johnson-curve method with those by polyn po lyn om ial reg res ressio sion. n. M ean ea n subgr su bgroup oup age and an d its derived from the raw frequency distribution of scores 37 for each age group. These distributions matched (b) scores within the 16th through the 11th per closely at each age group even with the differences centiles, (c) scores within the 10th through the 6th expected because of the fitting of means and minor perc pe rcen en tiles, til es, (d) sco res wi with thin in the th e 5th thr ou gh the 2nd fluctuations o f skew skew.. perc pe rcen en tiles, til es, and an d (e) sco res les lesss tha than n or equ al to the 1st per cen tile. til e. C ategoric ategorical al Norms Norms N o r m a t iv e d a ta f o r C o p y , T im e to C o p y , R e c o g n i t i o n Tru e P o si t i v e s, R e c o g n i t i o n F a l se U.S. C CENS ENSUS AGE-MA E-MAT TC HED HED Positives, Recognition True Negatives, and Recog NOR NO RMAT MATIVE IVE DATA nition False Negatives were determined for each nor mative group (see Appendix C). It was decided that N o rm at iv e da ta w er e al so g e n er at ed fr from om the th e categorical presentation would reflect more accu RCFT scores of the U.S. census age-matched subsam  rately the skewed nature of the distributions of these ple of adu lts (N = 394). Means, standard deviations, scores. The raw score means and standard deviations skewness, and kurtosis statistics were calculated for required smoothing to correct for slight inconsisten Immediate Recall, Delayed Recall, and Recognition cies in the progression of scores across age groups. Total Correct from the RCFT scores of this subsam This was accomplished using the polynomial regres ple. Th e Jo hn so sonn-cu curv rvee me tho d (Hil (Hill, l, Hill, Hil l, & Hol Holder, der, sion techniques discussed previously. Means and 1976)) was used to derive percentile and norm alized T 1976 standard deviations of the selected scores for the 14 scores for each of these RCFT scores, using the age subgroups were analyzed separately by polyno respective mean, standard deviation, skew, and kurto mial regression. Mean subgroup age and its various sis values. These normative data are presented in po w er erss we re us ed as pr ed ic to rs . U sing si ng th e de riv ed Appendix B. regression equations, the mean and standard deviati deviation on No rm ati ve da ta fo r Copy, Co py, Time Ti me to Copy, Co py, Re co g of each score were predicted for each age group. nition True Positives, Recognition False Positives, Visual inspection revealed a close fit between the Recognition True Negatives, and Recognition False means and standard deviations and the smoothed Neg N eg ati ve s we re calcu ca lcu late la ted d by ra rank nk or orde deri ring ng the raw means and standard deviations. Within each age score values and calculating the associated percentile group, linear T scores were computed for each raw values. Raw score ranges were then determined for score using the smoothed means and standard devia five categories: (a) scores greater than the 16th per tions. Percentile equivalents were assigned to the centile, (b) scores within the 16th through the 11th obtained T scores. All RCFT variables were scaled pe rce ntile nt ile s, (c) sc score ore s wi thi n the 10th th ro roug ug h the 6th such that higher standardized scores (i.e., percentile pe rce ntile nt ile s, (d) sco res wi th in the 5th thro th roug ug h the 2nd score ranges) reflect better test performance. Raw pe rcen rc en til es es,, an and d (e) sc score ore s les s th an or eq equa ua l to the score ranges were then determined for five cate 1st percentile. These normative data are also pre gories: (a) scores greater than the 16th percentile, sented in Appendix B. 38 5 Interpretation This chapter presents guidelines and case illustra sample. For example, a T score of 60 would indicate tions for clinical interpretation of the RCFT. The that the respondent’s scores exceed those of 84% of RCFT is only one of a number of psychological tests the responden t’ t’ss peers within the normative sample. sample. that provide information on important areas of neu Inferences regarding the adequacy of a respon ropsychological functioning. As seen in the following dent’s abilities for everyday functioning can be quite case illustrations, illustrations, results o f the RCFT should be inter complex, because they require the clinician to esti pr prete ete d wi withi thin n the co conte nte xt o f a lar larger ger cli nica ni call as asse se ss  mate how important the particular ability is to the ment battery, as well as collateral clinical and histori everyday functioning of the particular respondent. cal information. The U.S. census age-matched normative data pre sented in Appendix B may be useful in addressing questions of everyday functioning for adults. Heaton NOR NO RMA MAT TIVE C OMPA MPARISO ISONS and colleagues (Heaton et al., 1991; 1993) have developed a classification system, based on their clin Two major goals o f neuropsychological test inter ical experience, for interpreting normative scores. pr etat et atio io n rela re late te to di ag no st ic infe in fere renc nc es (e.g ., Do Does es These guidelines for clinical interpretation, presented the person have a cerebral disorder?) and to infer in Table 5, can be used with the normative tables in ences regarding the adequacy of the tested ability in Appendix B or C, depending on which norms are absolute terms (e.g., How good or poor is this per considered appropriate for the particular interpreta son’s functioning compared with the general popula tion being made. tion?). Different normative standards may be appro p ri a te fo r th es e tw o a sp ec ts o f te s t in te rp re ta ti o n Table 5 (Heaton, Chelune, Talley, Kay, & Curtiss, 1993; Heaton, Grant, & Matthews, 1991) and are presented Suggested Guidelines for the Clinical Interpretation of T-Scor T-Scoree Values in separate appendixes of this manual. For diagnostic purposes, we recommend the use of demographically corrected normative scores. These data, presented in Appendix C, allow the trans formation of various RCFT raw scores to normalized T scores and associated percentile scores. T scores have been constructed to have a mean of 50 and a standard deviation of 10. Appendix C provides infor mation about the responde nt’ nt’ss performance relative to that of the respondent’s age peers in the normative T- score range >5 5 45 to 54 40 to 44 35 to 39 30 to 34 25 to 29 20 to 24 < 19 Suggested clinical interpretation Above average Average Below average Mildly impaired Mildly-to-moderately impaired Moderately impaired Moderately-to-severely Moderately-to-severe ly impaire impaired d Severely impaired 39 When considering the categories associated with the normative score ranges, the professional should raw scores should be converted to age-corrected T scores using the norm ative tables in Appendix C. keep in mind that the focus of interpretation is the Profiles are judged to reflect a normal pattern of respondent’s performance; that is, it is the respon p e rf o rm a n c e i f s c o re s on Im m e d ia te R e c a ll an d dent’s performance on the RCFT, rather than the Delayed Recall are above a T scor scoree o f 40 and exhibit respondent per se, that may be deficient or impaired. little or no slope. In normal memory patterns, the This distinction is especially important when evaluat Delayed Recall score may be slightly higher than the ing older adults because of the greater variability in Immediate Recall. A profile is judged to reflect dis RCFT performance found among neurologically rupted attention if all three T scores are below 25 and intact subjects in this age range. exhibit little or no slope. The attention profile repre sents very impaired performance on ^11 three RCFT memory measures. An encoding pattern is inferred if INTERPRETATION OF OF RCF RCFT PERFORMANC MANCE E Performa manc nce eo on n Single RC FT Mea Measures Results of validity analyses indicate that the Copy score measures visuospatial constructional skills. Lower Copy scores indicate reduced visualpe rc ep tu al and vi su om ot or in tegr te grat atio ion n sk ills. ill s. In the the Immediate and De layed Recall T scores are below a T score of 25 for respondents 75 years and older or a T scor scoree of 23 fo r respondents you nger than 75 years and are generally equivalent (i.e., within 3 T-score poi nts nts). ). Re co cogn gn ition iti on Tota Totall Co rre ct sh shou ou ld be no mo re than 10 7-score points higher than the recall scores. The encoding pattern reflects negligible improvement in memory w hen given retrieval cues. factor analyses with both normal subjects and brain A profile is judged to reflect disrupted storage damaged patients, Time to Copy and Copy loaded on proc pr oc es esse se s wh en the pr prof ofile ile slo pes do wn w ar ard d and an d to different factors, suggesting that these two variables the right, with Immediate Recall higher than Delayed measure different constructs. In the absence of per Recall and Delayed Recall higher than Recognition ceptual or motor difficulties, higher Time to Copy Total Correct. A retrieval pattern is inferred if the scores indicate reduced speed of cognitive process Immediate Recall and Recognition Total Correct ing. Reduced Immediate and Delayed Recall scores scores are generally eq uivalent, .often in the normal suggest reduced visuospatial recall ability, while range, and the Delayed Recall score is less than either Recognition Total Correct measures the ability to t h e Im m e d i a t e R e c a l l o r t h e R e c o g n i t i o n To t a l retrieve visuospatial material when given retrieval Correct score, forming a “V” shape. A retrieval pat c u e s. Me y e rs a n d La n g e (1 9 9 4 ) fo u n d t h a t t h e tern is also inferred when the Immediate Recall and Recognition trial measures a unique dimension of Delayed Recall T scores are generally equivalent, the visuospatial memory functioning that was not tapped Recognition Total Correct T score is higher than both by the Im m ediat ed iatee and De lay ed Recal Re calll trial trials. s. the Immediate Recall and Delayed Recall T scores, and the pattern does not qualify as an encoding pro Memory Profile Patterns One interpretive approach to RCFT scores is to file. The memory profile patterns for a sample of 100 b ra in -d a m a g e d p a ti e n ts w er e ra te d by th e s en io r evaluate the profile or pattern of scores on Immediate author. Figure 2 illustrates the mean RCFT score for R e c a l l , D e l a y e d R e c a l l , a n d R e c o g n i t i o n To t a l each profile pattern in this sample. Refer to chapter 6 Correct. Chapter 6 discusses the results of research for additional information about the derivation and conducted with brain-damaged patients on the diag empirical validation of the m emory profile patterns. nostic utility of these memory profile patterns. This interpretive approach is similar to the codetype Q ualit ualitative Aspe Aspec c ts of Performanc erformanc e approach used to interpret multiscale personality In both normal and brain-damaged samples, sev inventories (Greene, 1991) and is based on the theo eral items from the Recognition trial (Items 1, 4, 6, retical discussion of memory performance by 10, 11, 18, and 21) are rarely answered incorrectly. Sohlberg and Mateer (1989). Prior to profiling, RCFT An incorrect answ er on these items is referred to as an 40 Attention Encoding Storage Retrieval _ _ _ _ _ _ _ _ _A. ■ No rmal rma l k^ k_ k_// k^ k^ Figure 2. Typical RCFT memory profile patterns. k^ k_ Atypical Recognition Error (Knight & Meyers, 1995). do not pr oduc e A t ypi c a l R e c ogni t i on E r r or s or In both normal and brain-damaged samples, the Recognition Failure Errors (Knight & Meyers, 1995). a c c ur a t e dr a w i ng of a n i ndi vi dua l s c or i ng uni t For respondents at a Rancho Los Amigos Level of (although not necessarily correctly placed) at the VIII, a cutoff score of 2 for Atypical Recognition Delayed Recall trial is highly predictive of a correct Errors and Recognition Failure Errors is cautiously answer to the corresponding Recognition trial item. suggested to identify cases of questionable motivation Stated differently, differently, a respondent is highly likely to rec needing further investigation for possible response ognize a scoring unit if he or she correctly recalled it styles. As these cutoff scores have not been ade at the Delayed Recall trial. A Recognition Failure quately cross validated with independent samples of Error refers to the situation where a respondent cor pa tie nt ntss wi th co nf irm ed ne ur ob eh av io iora rall an and d co gn i rectly recalls (i.e., draws) a scoring unit at the tive impairment, appropriate caution should be exer Delayed Recall trial but subsequently fails to recog cised in interpreting elevations on these scores. For nize the unit during the Recognition tri trial. al. example, an individual who is functioning below an N o r m a l s u b je c ts r a r e ly p r o d u c e e v e n o n e independent level of daily living skills may achieve a Atypical Recognition Error. However, both brain score that suggests questionable motivation or dissim damaged patients functioning below Rancho Los ulation, which may, in fact, be the result of confusion Amigos Level VII (Hagan, Malkmus, Durham, & and disorientation. However, for an individual who is Bowman, 1979) and experimental dissimulators (nor functioning independently, the presence of two or mal subjects instructed to malinger) produce a similar more Atypical Recognition Errors or two or more number of Atypical Recognition Errors, ranging from Recognition Failure Errors would raise a question zero to five or more. Patients with mild head injury regarding m otivation (Knight & Meyers, 1995). 1995). 41 C ASE ILLUSTRATIONS C ase IIllust llustration 1: Brain Injury J. N. was a 57-year-old, right-handed White male with 13 years of education. He had suffered a trau matic brain injury in a fall from a scaffold. An initial CT scan showed basilar cistern and parenchymal hematoma involving the right and left temporal Benton & Hamsher, 1989) was impaired. His scores on Trials Trials 1 through 9 of the Re Rey y Auditory Ve Verba rball Learning Test (RAVLT; cf. Lezak, 1995) were: 7, 7, 8, 8, 11, 4, 0, 3, 13. He showed adequate performance on the Trail Making Test (TMT; Reitan & Wolfson, 1993), Sentence Repetition (Benton & Hamsher, 1989), Three Dimensional Block Construction (Benton, Hamsher, Varney, & Spreen, 1983), Visual regions, with extensive subarachnoid hemorrhage. A Form Discrimination (VFD; Benton, Hamsher, large hemorrhagic contusion of the right temporal Varney, & Spreen, 1983), Hooper Visual Organization Test (VOT; Hooper, 1983), Tinker Toy Test (Lezak, lobe was also observed. J. N. was unconscious for 2 weeks following the injury, after which he showed 1995), Booklet Category Test (DeFilippis & po sttr st trau au m at atic ic co nfus nf us io n fo r 2 m on ths. th s. He rece re ce iv ed McCamp bell, 199 1991), 1), and the Benton Visual Retent Retention ion acute and postacute rehabilitation services. His psy Test (BVRT; Sivan, 1992). chosocial history was not significant for birth or Figure 3 presents the profile of RCFT scores for developmental difficulties. He obtained above aver this case, and Figure 4 presents the RCFT Scoring age grades in high school. He had no history of psy Sheet. Figures 5 through 8 present J. N.’s drawings chiatric disorder or chemical abuse. He had a stable for the Copy, Immediate Recall, and Delayed Recall work record prior to the in injur jury. y. He was tested 1 year trials, and for the Reco gnition trial. J. N .’ .’ss RCFT after his injury, injury, and he dem onstrated good motivation scores were compared to subjects in his same age and consistent behavior during testing. During the group using Table C9 (Appendix C). He obtained a evaluation, he was noted to be “chatty” and, at times, Copy raw score of 29.0, which corresponded to the tangential. His speech was pressured, and, occasion ally, he was impulsive in his responses. He was func 2-5 percentile range. This score indicated low visuospatial constructional skills. His Time to Copy raw tioning independently in the community and was score of 187 seconds, which fell in the >16 percentile driving a car, but he had not returned to full-time range, indicated adequate cognitive pro cessing speed. employment. J. N. obtained an Immediate Recall raw score of 10.5 He achieved a WAIS-R (Wechsler, 1981) Full (347) and a Delayed Recall raw score of 10.0 (327). Scale IQ of 121 (Verbal IQ = 120, Performance IQ = These scores indicate mildly-to-moderately impaired 117). These scores had increased from prior testings. visual memory skills and suggest impairment in right Current neuropsychological test results indicated hemisphere functions. He obtained a Recognition impaired performance on the word and color-word Total Correct raw score of 18 (377). This score was trials of the Stroop Color and Word Test (Golden, interpreted as mildly impaired. The profde configura 1978). On the Finger Tapping Test (FTT; Reitan & tion of J. N.’s memory scores was judged to be a Wolfson, 1993), the dominant hand was average but retrieval pattern, which suggested that he might be the nondominant hand was low. His score on the Controlled Oral Word Association Test (COWAT; able to function independently and that he might ben efit from the use o f a memory book. 42 c_ c_// RC Ff Rey Complex Figure Test and Recognition Trial Test Booklet J. N. Case Illustration 1 White Male Race Name_ Nam e_ I D# Gender Test Date Birth Date. Handedness. Education Occupation. RIAh t ____ RI ______ A ge . 13 ye a rs 57 Examiner Vw/ Raw score T score %ile score Raw score %ile range 10.0 10.5 34 5 Copy _____ 2 9.0 2-5 1&7_ >16 Normative Normati ve Table. 37 32 4 Time to Copy Vw 1 b 10 Recognition True Positives Recognition False Positives Recognition True Negatives Recognition False Negatives 6 5 12 6 2 -5 >16 >1 6 >16 2 -5 C9 F i g u r e 3 . Case Illustration 1: Profile of Selected Scores. Memory Profile Pattern. Retri Re triev eval al 43 Scoring Sheet Scoring Criteria for RCFT Drawings S co r e Scoring Element 1. Vertica l Cro ss 2. Large Rectang le 3. Diagonal Cross 4. Horizontal Midline of Large Rectangle (2) 5. Vertica Verticall Midline of Large Rectangle (2) (2) 6. Small Rectang le 7. Small Horizon tal Line aabove bove Small Rectang le (6) 8. Four Parallel Lines 9. Small Triangle above Large Rectang le (2) 10 10.. Small Vertical Vertical Line within Large Rectangle (2) A cc uracy 2 Accurately drawn Correctly placed 1 1 Accurately drawn Incorrectly placed Inaccurately drawn Correctly placed 0.5 Inaccurately drawn, but recognizable Incorrectly placed 0 Inaccurately drawn and unrecognizable, or omitted Incorrectly placed Imm edia te Recall Delayed Recall ( 9 i 0.5 0 © \ 0.5 0 0.5 0 2 1 0 .5 ( 9 © 1 0 .5 0 2 1 0.5 0.5(9 (9 2 1 0 .5 ( 9 2 ( 9 0.5 0 2 1 0.5 0.5(9 (9 © 1 0 .5 0 © 1 0.5 0 2 1 0.5( 0.5(9 9 2 1 0.5( 0.5(9 9 2 1 0 . 5( 5( 9 2(9 0.5 0 15(9 © « 0.5 0 0.5 0 © 1\ 0.5 0 © 0.5 0 12 12.. Five Parallel Lines 13. Sides of Large Triangle attached to Large Rectangle (2) 14. Diamond © 1 0.5 0 2 1 0 ..5 5 ((9 9 2 © 0.5 0 (2) (2) 1 0.5 0 2 © 0.5 0 © 1 0 .5 0 15. 15. Vertical Vertical Line within Sides of Large Triangle (13) (13) 2 1 0 .5 ( 9 16 16.. Horizonta l Line within Sides of Large Triangle (13) (7) (7) 1 0. 5 0 © 1 0.5 0 2 ( 9 0.5 0 17. Horizontal Cross 18. 18. Square attached to Large Rectangle (2) f Copy 0.5 0 11. Circle with Three Dots Placement 2 (9 0 0..5 0 © 1 0.5 0 2 1 0.5(9 2 1 0.5 0.5(9 (9 2 l 0.5(9 2(9 0.5 0 2 1 0 ..5 5 ((9 9 2 ( 9 0 ..5 5 0 © 0 2 1 0 ..5 5(9 2 1 15(9 2 ( 9 0 ..5 5 0 ).5 0 2 1 0 . 5 (9 (9 2 1 0.5(9 0.5(9 2 1 0 ..5 5 ((9 9 ( 9 1 0. 5 0 2 1 ^ 0 2 1 0 .5 ( 9 ))-5 5( 9 © l 0.5 0 2 1<53 o 2 1 0 .5 (9 2 9 .0 10 10.5 10.0 Raw score R a w sc o r e Raw score Recognition Trial Worksheet 6 Recognition True Positives = Sum of items 2, 5, 7. 8, 9, 12, 13, 15, 19, 20, 22, and 24 that were circled. 9 Recogniti Reco gniti on False Po Positives sitives = Sum o f items 1, 3, 4, 6, 10, 10, 11, 14, 14, 16, 17, 18, 21, and 23 that were circled. 12 Recognition Recogniti on True Negatives =1 2 minus Recognition False Positi Positives. ves. 9 Recognition False Negatives = 12 minus Recognition True Positives. 7<3 Recognition Total Correct = Recognition True Positives plus Recognition True Negatives. Figure 4. Case Illustration 1: Scoring Sheet. 44 w F i g u r e 5 . Case Illustration 1: Copy trial. 45 / Figure 6. Case Illustration 1: Immediate Recall trial. 46 F i g u r e 7. Case Illustration 1: Delayed Recall trial. 4 Figure 8. Case Illustration 1: Recognition trial. 48 C ase Illustration 2: Dep Depr ressi ession on C. N. was a 44-year-old, right-handed White female with 15 years of education. She was referred for outpatient neuropsychological evaluation of mem ory problems. She had been complaining of memory loss for several months. She had a history of Bipolar Disorder and was in the depressed phase at the time of the evaluation. She was taking an antidepressant medication. At the time of testing, she was an inpa tient in a psychiatric unit. C. N. was administered a battery of neuropsycho logical tests. tests. She demonstrated impaired performance on Part A (207) and Part B (357 ) of the Trai Traill Making Test. She had normal performance on the Three percen per cen tile rang e. Th is sco score re indic in dic ate ated d intact int act visuos vis uospapatial constructional skills. Her approach to copying the fi g u re w a s c h a ra c t e ri z e d b y d ra w i n g t h e o u t e r per im ete r of the Large La rge Re cta ng le (2) fir first, st, and then the n adding the internal internal details. Her approach was c onsid ered normal. The retracing and dark lines may be an indication of her anxiety and rumination, which were consistent with her clinical presentation. Her Time to Copy raw score of 225 seconds, which also fell in the >16 percentile range, indicated adequate cognitive proc pr ocess ess ing speed speed.. C. N. obtained an Immediate Recall raw score of 15.0 (367) and a Delayed Recall raw score of 14.0 (337). These scores indicate a mild-to-moderate level of impairment of visual memory skills. She Dimensional Block Construction, the Hooper VOT, obtained a Recognition Total Correct raw score of 18 the COWAT, the BVRT (8 correct, 4 errors), and the (337). This score was also interpreted as mildly-to- RAVLT (raw scores on Trials 1-9 = 7, 8, 11, 12, 13, 6, moderately impaired. The configuration of C. N.’s 10, 13, and 15, respectively). Her MMPI-2 Welch memory score scoress was judged to be a normal profile pat code was 87*26"410'3-9:5# F*L:K:. She obtained an tern, even though her scores were low, indicating that MMP I-2 D score of 887 and a Beck Depression the configuration of scores is not usually one found in Inventory raw score of 20, indicating a significant patien pat ien ts who hav e br brain ain dam age. He Herr p ro rofile file o f sc scores ores level of depression. Figure 9 presents the profile of scores for this failed to meet the criteria for the attention, encoding, storage, or retrieval patterns. case, and Figure 10 presents the RCFT Scoring Sheet. C. N. presented a pattern of neuropsychological Figures 11 through 14 present C. N.’s drawings for and RCFT performance characteristic of depression. the Copy, Immediate Recall, and Delayed Recall tri Given that her cognitive processing was within the als, and for the Recognition trial. Her RCFT scores normal range and her memory pattern was judged to were compared to subjects in her same age group be nor norma mal, l, it is mo st lik likely ely that th at he r d epr epress ess ion , rat he r using Table C6 (Appendix C). She obtained a Copy than primary brain damage, significantly contributed raw score of 36.0, which corresponded to the >16 to her reduced memory skills. 49 r c fT Rey Complex Figure Test and Recognition Trial Test Booklet 2. N N.. Na me Caee Illustration 2 Race White Female ID # Gender O c c upa t i on Test Date / / Birth Date / / Handedness r \ l f i f i Ts E duc a t i on 15 yyea ea re 44 Age Examiner 3 T score %ile score Raw score %ile range 14.0 33 4 15.0 Raw score 6 3 13 33 4 Copy Time to Copy Recognition True Positives Recognition False Positives Recognition True Negatives Recognition False Negatives 36.0 >16 225 >16 <3 2 10 4 >16 >16 >16 >1 6 >16 Normative Table 2 6 Figure 9. Case Illustration 2: Profile of S elected Scores. Scores. Memory Profile Pattern Normal Nor mal 50 Scoring Sheet Scoring Criteria for RCFT Drawings Sco re 2 Accurately drawn Correctly placed 1 Accurately drawn Incorrectly placed 1 Inaccurately drawn Correctly placed 0.5 Inaccurately drawn drawn,, but recognizable Incorrectly placed 0 Inaccurately drawn and unrecognizable unrecognizable,, or omitted Incorrectly placed Copy Scoring Element 4. Horizontal Midline of Large Rectangle (2) © 1 0.5 0 © 1 0 .5 0 © 1 0 .5 0 © 1 0 .5 0 Vertical Midline of Large Rectangle (2) (2 ) 1 0.5 0 6. Small Rectangle 7. 8. 9. Small Horizontal Line above Small Rectangle (6) 10. Small Vertical Line within Large Rectangle (2) 11. 11. Circle with Three Dots 12. Fiv Fivee Para Parall llel el Li Lines nes 13. Sides of Large Triangle Triangle att attached ached to Large R ectangle (2) 14. Diamond 15. 15. Vertical Line within Sides of Large Triangle (13) © 1 0.5 0 © 1 0.5 0 © 1 0 .5 0 © 1 0.5 0 © 1 0 .5 0 © 1 0 .5 0 © 1 0 .5 0 © 1 0 .5 0 © 1 0 .5 0 © 1 0.5 0 1. Vertical Cross 2. Large Rectangle 3. Diagonal Cross 5. Four Parallel Lines Small Triangle above Large Rectangle (2) H H 16. Horizontal Line within Sides of Large Triangle (13) — 17. Horizontal Cross 18. Square attached to Large Rectangle (2) Placement A c c u ra cy Immediate Recall Delayed Recall 2 © 0.5 0 2 \0 © 1 0 .5 0 © 1 0 .5 0 2 © 0.5 0 © 1 0 .5 0 © 1 0 .5 0 2 1 0 .5 © 2 © 0.5 0 2 1 0.5© 2 1 0.5 © © 1 0 .5 0 2 1 fê© 0 2 1 0 .5 © 2 1 0.5© 2 1 0.5© 01 05 0 © 1 0.5 0 2© 0.5 0 © 1 0.5 0 © 1 0 .5 0 2 1 0 ..5 5© 2 \0 0 2 1 0 .5 © 2 1 0 .5 © (2) l 0 ..55 0 2 10 0 2 1 0 .5 © 2 I 0 .5 @ 2 1 0.5© 2 © 0.5 0 2 1 0 .5 © 2 (i) o . 5 0 2 1 0 0 3 6 .0 15.0 14.0 Raw score Ra w s c o r e Raw score ^ 1 0 .5 0 © 1 0 .5 0 © 1 0 .5 0 2 1 0.5© 2 10 0 Recognition Trial Worksheet _8 l Reco gnition True P ositives = Sum o f items 2, 5, 7, 8, 9, 12, 13, 15, 19, 20, 22, and 24 that were circled . JZ 10 Recognitio Rec ognitio n False Po sitive sitivess = Sum of items 1, 3, 3, 4, 6, 10, 11, 14, 14, 16, 17, 18, 21, and 23 that were we re circled. _4 Recognition False Negatives = 12 minus Recognition True Positives. 1Ô Recognition Total Correct = Recognition True Positives plus Recognition True Negatives. Recognition True Negatives = 12 minus Recognition False Positives. Figure 10. Case Illustration 2: Scoring Sheet. 0 51 Figure 11. 11. Case Illustration 2: Copy trial. 52 Figure 12. Case Illustration 2: Immediate Recall trial. 53 f Figure 13. Case Illustration 2: Delayed Recall trial. 54 Figure 14. Case Illustration 2: Recognition trial. C ase Illustration 3: Questionable Motivation C. S. was a 45-year-old, right-handed White male with 12 years of education. He was referred for neu ropsychological evaluation by his physician because of “extreme cognitive problems.” He had worked for many years in a semiskilled position. His medical his tory was significant for bleeding ulcers, hernias, foot injuries, a back injury, and allergies. He had fallen approximately 8 feet in an industrial accident. He reported injury to his right orbital area, lower back, and shoulder. There was no loss of consciousness, bu t he re po rt ed be in ing g co nf us ed fo r se ve vera rall secon se con ds after the fall. He was hospitalized for 5 days. A CT scan taken immediately after the injury was nega tive, as was was one taken 1 week after tthe he inj injury. ury. He reported problems with balance, headaches, confu sion, short term memory, word finding and expres sive language, and chronic pain. He was taking Zoloft for depression. His speech therapist, occupational therapist, and phys ph ysica ica l the rapi ra pist st all rep orted or ted som e inc on sis ten cy in his symptoms. He typically presented in an extreme manner, suggesting a great deal of difficulty in all cognitive and physical activities. His caregivers all noted that his symptoms became most noticeable when his attention was drawn to his difficulties. Upon formal examination, he had problems initiating and stopping walking, but in informal settings he was able to ambulate freely. During the clinical interviews, he gave detailed accounts of the “terrible experiences” caused by his severe memory problems. However, he was independent in his ADLs. He drove to the evalua tion and had no difficulty remembering his appoint ment, driving routes, or names of his therapists. He claimed he could handle his own financial affai affairs. rs. He was seeking disability compensation. C. S. was evaluated evaluated 1 month after his iinjur njury. y. He obtained a WAIS-R Full Scale IQ of 90 (Verbal IQ = 93, Performance IQ = 88). His behavior during sev eral Performance subtests was unusual and was char acterized by almost completing a task, but eventually pr od uc in g a “n ea r- m is s” an sw er by m ispl is pl ac in g the last block or piece. He often commented on the great effort he was putting into the tasks. His severe stutter ing would often come and go during testing, particu larly if it was ignored by the evaluator. He obtained a deficient score on Part A of the TMT and a borderline impaired score on Part B. His scores on FTT were impaired for both hands. Deficient performance was also obtained on the COWAT, a dichotic listening task (left, right, and both ears), the BVRT, and the BCT. His RAVLT performance (scores on Trials 1-9 = 5, 7, 8, 11, 11, 6, 6, 9, and 12, respectively) was unusual in that he recalled more words at the long delay recall than at the immediate recall. Also, his recognition scores were considered to be low. He showed average perfo pe rfo rm an ance ce on the Tok en Tes Testt and the pers pe rsev evera era tiv e errors score of the Wisconsin Card Sorting Test (WCST; Heaton et ah, 1993). He had low average perfo pe rfo rm an ance ce on VFD. VF D. His RAVLT RAVLT perfo rm ance was' sug gestive o f malingering because of the recency-primacy effect (Bernard, 1991) and his low score on the recognition trial. On the Rey Fifteen Item Test (cf. Lezak, 1995), he obtained a score of 9 (total points = 15), which raises the question of his motivation (Bernard & Fowler, 1990; Lezak, 1983). His MMPI-2 Welch code was 2 1*78"3’ 1*78"3’4'-6059/F'K/L?. 4'-6059/F'K/L?. Figure 15 presents the profile of scores for this case and Figure 16 presents the RCFT Scoring Sheet. Figures 17 through 20 present C. S.’s drawings for the Copy, Immediate Recall, and Delayed Recall tri als and for the Recognition trial. His RCFT scores were compared to subjects in his same age group using Table C7 (Appendix C). C. S. obtained a Copy raw score of 35.0, which corresponded to the >16 perc pe rc en til e ran ge ge.. This Th is sc score ore in dica di cated ted no rm al visuo vi suo spatial constructional skills. His Time to Copy raw score of 244 seconds also fell in the normal (>16 per centile) range, indicating adequate speed of cognitive proc pr oces essin sin g. He obtained an Immediate Recall raw score of 9.5 (25 T) and a Delayed Recall raw score of 7.5 (< 20 T) . These scores indicate moderately-to-severely impaired visuospatial recall skills. His Recognition Total Correct raw score of 15 (<20 T ) also fell in this range. The configuration of his profile of memory scores was judg ed to be an attention pattern, which is associated with severe impairment in functional memory skills. In brain-damaged patients, an atten tion profile pattern is associated with severe impair ment in functional cognitive skills, as measured by the Rancho Los Amigos Scale of Cognition (Levels IV to VI). Clearly, this individual was functioning at a much higher level than his test scores suggested. When his RCFT performance is combined with other test results, behavioral observations, and the reports of his rehabilitation therapists, his motivation and po ss ssibl ibl e m ali aling ng eri ng are calle ca lled d int into o que stion. sti on. 56 Rey Complex Figure Test and Recognition Trial Test Booklet r c fT C. 5. Name_ Nam e_ Test Date Case Illustration 3 Male Race_ White ID # Gender_ Birth Date_ Handedness^ Education _ ___ Occupation^ R ight Rig ht ____ ______ Age_ Î2 ye years 45 Examiner__ __ Raw score T score %ile score Raw score %ile range w w <2 0 <20 <1 1 Copy __ 3_ 5__.0_ >16 15 7.5 9 .5 25 toTime Copy Recognition True Positives 244 24 4 >16 <1 Normative Tab Table le Figure 15. Case Illustration 3: Profile of Selected Scores. <2 <20 0 <1 Recognition False Positives Recognition True Negatives Recognition False Negatives 5 12 2 >166 >1 >16 < 1 57 Scoring Sheet Scoring Criteria for RCFT Drawings A c c u ra c y Placement 2 Accurately drawn Correctly placed 1 Accurately drawn Incorrectly placed 1 Inaccurately drawn Correctly placed 0.5 Inaccurately drawn, Incorrectly placed S co r e but recognizable Inaccurately drawn and unrecognizable unrecognizable,, or omitted 0 Incorrectly Incorrect ly placed f Copy Im media te Recall Delayed Recall © 1 0.5 0 2 1 ^ 0 2 1 0 .5 © Scoring Element 1. Vertical Cro ss 2. Large Rectangle 3. Diagonal Cross 4. Horizonta l Midline of Large Rectang le (2) 5. 6. Vertical Vertical Midline of Large Rectangle (2) (2) Small Rectangle 7. Small Horizontal Line Line above Small Rectangle (6) 8. Fou r Parallel Lines 9. Small Triangle above above Large Rectangle (2) (2) 10. 10. Small Vertical Vertical Line within Large Rectan gle (2) 11. 11. Circ le with Thre e Dots 12. Fiv e Parallel Lines 13. 13. Sides of Large Triangle attached to to Large Rectangle ((2) 2) © © © © © © © © © 14. Diamond g ) l 0 .5 .5 0 15. 15. Vert Vertical ical Line within Sides of Large Large Triangle (13) 16. 16. Horizontal Line within Sides of Large Triangle (13) 17. 17. Horizontal Cross 18. Square attached to Large Rectan gle (2) © 1 0.5 0 © 1 0.5 0 © 1 0.5 0 © i 0.5 0 2 1 0.5© © I 0.5 0 © 1 0.5 0 © Ì 0.5 0 © I 0.5 0 2 1 0.5 © j 1 0.5 0 1 0.5 0 2 1 0.5© 2 1 0 .5 © 2 1 0.5 © I 0.5 0 2 1 0.5 0 2 1 0.5 © 2 I 0.5 0 I 0.5 0 © 1 0.5 0 © l 0.5 0 2 1 0 .5 .5 © 2 1 0 .5 © 2 I 0 . 2 1 (o) 0 2 1 0 .5 .5 © 2 1 0.5 © 3 5 .0 9.5 9 .5 7.5 Raw score Raw score Raw score Recognition True Positives = Sum of items 2, 5, 7, 8, 9, 12, 13, 15, 19, 20, 22. and 24 that were circled. 0_ 12 Recognition False Positives = Sum of items 1, 3, 4, 6, 10, 11, 14, 16, 17, 18, 21, and 23 that were circled. 9_ 15 Recognition Recognitio n False Negatives = 1 2 minus Recognition Tr True ue Positives. Positives. Recognition True Negatives = 12 minus Recognition False Positives. Recognition Total Correct = Recognition True Positives plus Recognition True Negatives. Figure 16. Case Illustration 3: Scoring Sheet. 1 0.5 © 2 © 0 .5 0 2 1 0.5© 2 1 0.5 © 2 1 0.5 © Recognition Trial Worksheet 3 1 0.5 0 1 0.5 © I 0.5 0 1 0.5 0 58 Vw >w Fig u re 1 7 . Case Illustration 3: Copy trial. 59 Figure 18. Case «lustration 60 3. Immediate Recall trial. O w Figure 19. Case Illustration 3: Delayed Recall trial. 61 Fi g u r e 2 0 . Case Illustration 3: Recognition trial. 62 Development, Reliability, and Validity DEVELOPMENT Orientation of the Stimulus Figure and Drawings length of the entire drawing, but no significant differ ences for the height of the Large Rectangle (2). The landscape group drew the length of the entire figure and the length of the Large Rectangle (2) signifi There are many different methods for administer cantly larger than the portrait group and the actual ing the Rey complex figure. Some researchers advo stimulus figure. The landscape and portrait groups cate using a landscape orientation (cf. Lezak, 1995). drew the height of the Large Rectangle (2) similarly. In keeping with the goal of this project to design an Thus, subjects who copied the figure in the landscape orientation elongated their drawings, but without a empirically based approach to administering, scoring, and interpreting the RCFT, a study was conducted to corresponding increase in the height of the drawings, evaluate the effect of page orientation (portrait vs. pro du cin g a draw dr aw ing th at wa wass di spro sp ropo po rti on al to the landscape) on the copy drawings. Two groups of nor actual stimulus figure. This suggests that subjects mal subjects (n = 13 in each group) were matched for who draw the figure in landscape orientation elon age, education level, and gender. One group com g a t e t h e i r d ra w i n g s, p o ssi b l y t o fi l l t h e p a g e . ple ted the Co Copy py trial tria l with wi th bot h the Rey Re y stim ulu s fig  Drawings made in portrait orientation did not have ure and the drawing sheets in landscape orientation, this characteristic. while the second group completed the Copy trial with Based on these findings, it was judged that the the materials in portrait orientation. Only the Copy po rt rtra ra it or ien tat ion wa wass th thee m ost os t em pi piric ric all y so und un d trial was used to control for differences in drawings method to use. Clinical observation suggests that due to memory recall. The portrait group had a mean some respondents have a desire to turn the page to the age of 35.15 years (SD = 6.37 years) and a mean edu landscape orientation. This is often observed in psy cation level of 14.84 years (SD = 1.67 years). The chiatric and demented patients. It is suggested that landscape group had a mean age of 35.15 years (SD = use of the portrait orientation forces the respondent to 6.37 years) and a mean education level of 14.23 years impose a certain degree of organization onto the task, (SD = 1.83 years). There were nine males and four bu t wi tho ut any ten de dency ncy to exp an and d the figu re. It is females in each group. After administration of the our clinical belief that the use of the portrait orienta Copy trial, measurements using mechanical drawing tion provides a rich opportunity to observe the effects tools were made of the length of the figure and the of poor organization and “true” expansion character length and height of the Large Rectangle (2). In addi istics in the respondent’s performance. For example, a tion, a score to reflect the number of drawing errors respondent, drawing in portrait orientation, who (e.g., closure errors, misplaced units) was calculated. draws the point of the Sides of the Large Triangle A one-way analysis of variance revealed a signifi cant difference (p < .001) between drawing orienta (13) or the Diamond (14) off the page may be exhibit tion for the length of the Large Rectangle (2) and the pa patho tho log ica l) ten den cy to exp an and d the figure. figu re. ing poor organizational skills and an abnormal (i.e., 63 As a result, it was decided that the RCFT would be de ve lo lope ped d using us ing po rtr ait orien or ien tation tat ion . Th Thee no rm a memory associated with using immediate and delayed recall drawings. tive, reliability, and validity data were collected using The copy drawings of 100 subjects were selected this method. In the normative sample of 601 subjects, from the normative sample for inclusion in this study. only four subjects spontaneously rotated the paper to These subjects had an average age of 25.9 years (SD landscape orientation. This orientation was corrected and their drawings com pleted in portrait mode. Developm Deve lopment ent of the Sc Scorin oring g C rit iteria eria - 13.5 years), ranging from 16 to 74 years. The mean level of education was 12.7 years (SD (S D =1.7 years). Fifty-three of the subjects were male, and 93 were right-handed. The mean level of intelligence, esti This manual presents a standardized approach to scoring the RCFT, based on the scoring criteria devel m a t e d fro m d e m o g ra p h i c i n fo rm a t i o n (B a ro n a , Reynolds, & Chastain, 1984), was average (Verbal IQ oped by Rey (1941; Corwin & Bylsma, 1993) and estimate = 102; Performance IQ estimate = 102; Full pre p re se n te d in L ez ak (1 99 5) . R e y ’s sc o ri n g sy st em Scale IQ estimate = 102). divides the complex figure into 18 units that are scored separately for both accuracy and placement. A score of 0, 0.5, 1, or 2 is assigned to each u nit of the figure based on accuracy and placement criteria. The same scoring criteria apply to the Copy, Immediate Recall, and Delayed Recall drawings. Thus, raw scores ranging from 0.0 to 36.0 may be obtained for Some degree of variability in the accuracy and place pl ace m en t of the copy co py dra wi wing ng s was obser ob serva vable ble in all subjects. This variability included minor displace ments of lines and scoring units, failure to enclose corners, overshooting corners, and angles that devi ated from those of the original stimulus figure. each of the three trials. However, clinicians and Measurements using mechanical drawing tools were research labs may interpret these scoring criteria dif made of the distance of error (i.e., the distance from ferently (cf. Lezak, 1995). correct accuracy or placement) of the drawings. Two The RCFT requires respondents to produce copy and recall reproductions using only a freehand draw ing technique. The use of straight edges and rulers is not permitted. Even in normal subjects, there is some degree of error variance associated with the freehand types of measurement were made: the first reflected accuracy (i.e., line inaccuracies, “overshoots,” and closure errors), and the second reflected plac pl ac em ent. en t. Error scores that reflected the distance from correct accuracy or distance from correct placement were drawing process that is independent of true variance computed for each scoring element for each subject. associated with visuospatial constructional skills and Averaged across subjects and scoring elements, the visuospatial memory. distance of error for accuracy criteria was 1.89 mil Loring and colleagues (Loring et al., 1990) pro vided explicit scoring criteria based on Rey’s original scoring system, but they permit scorers to exercise a limeters (SD = 1.40 millimeters), and the distance of error for placement criteria was 3.73 millimeters (SD = 2.40 millimeter millimeters). s). certain degree of latitude in rating RCFT protocols. Ne xt, xt , the th e cu m ul at iv e fr eq ue nc y di st ri bu tion ti on o f Spreen and Strauss (1991) state that slight inaccura these error scores was computed. A cutof f score of 1.5 cies in drawings should not be penalized. In her own standard deviations below the m ean, corresponding to clinical practice, Lezak (1995) scores the Copy trial a z score of -1.5, was used to classify error scores as strictly and the recall trials more leniently. either within normal limits or exceeding normal lim The authors set out to build upon Rey’s 36-point its. Distance of error scores were considered within scoring system by conducting an empirical study of normal limits if their corresponding z score was the variability in the accuracy and placement of greater than -1.5. Distance of error scores were con RCFT drawings of normal healthy subjects. Normal sidered to exceed normal limits if their corresponding subjects, rather than brain-damaged patients, were z score was less than or equal to -1.5. Measurements selected for study because of the research goals to in millimeters were rounded to the closest whole unit quantify the so-called “normal variance” associated and converted to inches for convenience. These cut with freehand drawing. Only copy drawings were off scores corresponded to distance of errors of 3 used in this study, which avoided the confound of millimeters (approximately V s inch) for the accuracy 64 criterion and 6 millimeters (approximately lA inch) raters consisted of one bachelor’s level psychometri for the placement criterion. cian with 1 year of eexperience, xperience, one m aster’s lev level el Therefore, units of drawings that deviate from ps ycho yc ho m etr etrici ici an with 1 year ye ar of expe ex perie rie nce, nc e, and the accurate reproduction by Vs inch (3 millimeters) or senior author. Training was conducted by the senior less are considered within normal limits and are scored as accurate. Units of drawings that deviate author and consisted o f having each psychometrician score a protocol consisting of the Copy, Immediate from correct placement by */4 inch (6 millimeters) or Recall, and Delayed Recall trials. Each rater was less are considered within normal limits and are given feedback from the senior author on scoring scored as correctly placed. Thus, these scoring rules accuracy, and all scoring questions were answered. pres pr esen entt ob jec tiv e de fin ition iti on s o f ina ccur cc urate ate and mis mi s This procedure was repeated four m ore times for each pla ced scori sc oring ng elem ent entss bas ed on distan dis tan ce m eas ure ur e psy cho me tric ian . ments, rather than on subjective estimation. Fifteen protocols were randomly selected from a mixed group of 300 drawings of brain-damaged, psy Develop Deve lopme ment nt of the Rec og ognit nition ion Trial chiatric, learning-disabled, and demented patients, as The Recognition trial for the RCFT was devel well as normal subjects. Each rater was blind both to oped in the following manner. Each of the 18 separate the scores generated by the other raters and to any scoring units (including the details within each scor identifying or diagnostic information associated with ing unit) defined by Rey (1941) was printed sepa the protocols. Interrater reliability coefficients rately on a blank sheet of white paper. This formed (Pearson product-moment correlations) ranged from the pool of target items. The same procedure was .93 to .99 for total raw scores, with a median inter employed to assemble the pool of distractor (foil) rater reliability coefficient of .94. These results indi items, drawing on each of the 18 scoring elements of cate excellent interrater reliability for this scoring the Taylor complex figure (Taylor, 1979). A pool of method. These results are consistent with others who 36 total elements was generated. Fourteen of these elements were excluded from the item pool. Seven have established acceptable interrater reliability using similar scoring methods (Bennett-Levy, 1984; Loring were excluded from each target and distractor item et al., 1990; Strauss & Spreen, 1991). po ol s be ca u se th they ey sh ared ar ed co m po ne nt s wi th ot he r e l e m e n t s. A ft e r t h e n o n u n i q u e e l e m e n t s w e re Temporal Stability excluded, a total of 22 unique figures was retained. The reliability of the RCFT was determined in a Two gestalt figures, one from each of the Rey and sample of normal subject subjectss (n = 12) selected from the Taylor complex figures, were also added. The gestalt normative sample. These subjects had an average age figures consisted of the configural outline of the large of 33.9 years (SD =10.1 years) and an average level units of each figure. The final item pool consisted of of education of 15.2 years (SD = 3.2 years). Seventy- 12 target items and 12 distractor items. The 24 recog five percent were male. The average retest interval nition items were then randomly placed on four was 184.0 days (SD = 6.2 days). pag es, formi for ming ng app rox im ate ately ly two tw o col colum um ns of item s per pe r page page.. The item s wer weree print pr inted ed in the sam e size and orientation as in the original complex figures. Initial research (Meyers & Lange, 1994), presented later in this chapter, supports the construct and factorial validity and the clinical utility of the Recognition trial of the RCFT. From a theoretical perspective, the psychometric definition of a test’s temporal stability is the correla tion coefficient between the scores obtained at the first and second testings. However, often this may not be the mo st us usefu efu l info in form rm ati on abou ab ou t the rel iab ility ili ty from a clinical perspective. For a neuropsychological test, the clinician is more often concerned about diag nostic reliability or the ability of the test to produce RELIABILIT LIABILITY consistent conclusions or classifications rather than ju st co ns is iste te nc y o f sc or ores es (L acks ac ks,, 198 4). Th is has Inte Int errater Relia Reliability bility Three independent raters were trained using the scoring system that was previously described. The been be en ref referr erred ed to as tthe he dis distin tin ctio n betw be tween een ps psyc ycho ho m e tric and clinical reliability (Matarazzo, Matarazzo, Wiens, Gallo, & Klonoff, 1976). 65 Several RCFT scores present problems for com second testings. The results of these analyses indi putin pu tin g tra dit io ional nal co corre rre lat ion co coeff effici ici ents en ts be tw een the cated no significant differences in mean scores for first and second testings. The ranges of the Copy any RCFT variable across the retest interval. As can score and the Recognition scores are restricted due to be se seen en fro m Tab Table le 7, sco res res,, on ave rag e, are hig hly the maximum or near maximum level of performance stable from the first to second testing. For these attained by most normal subjects. This artificially scores, the percentile range associated with the raw reduces the magnitude of the reliability coefficients. Second, the Copy, Recognition True Positives, and score (i.e., >16, 11-16, 6-10, 2-5, <1) was used to classify raw scores into clinical interpretive ranges Recognition True Negatives variables also have sig using the age-corrected normative tables in Appendix nificant ceiling effects in healthy normal subjects. For C. The percentage of agreement in the clinical inter example, 70.7% of subjects in the normative sample preta pr eta tio n b etw een ee n the fir first st and sec on ond d testin tes tin g sessio ses sio ns obtained Copy raw scores of 35.0 or greater (maxi was calculated for these m easures. Copy, Recognition mum score = 36.0); 51.2% obtained R ecognition Tru Truee True Positives, and Recognition False Negatives all Positives raw scores of 10 or greater (maximum score had 100% agreement in the clinical interpretation = 1 2 ); a n d 9 4 . 1 % o b t a i n e d R e c o g n i t i o n Tru e b e tw e e n th e te s ti n g s e s s io n s . R e c o g n it io n F al s e N eg at iv es ra w sc or es o f 10 or g re a te r (m ax im um Positives and Recognition True Negatives demon score = 12). Any variability at the second testing ses strated less accurate, though still acceptable, agree sion is likely to result in a lower score relative to the ment rates (83.3%). Time to Copy demonstrated the first session score, thus attenuating a traditional relia largest practice effect, though this was not statistically bil ity coe ffic ien ient. t. In add itio n, the in cid ental en tal lear learnin nin g significant due to the high variance, and had a 66.6% pa ra di gm em pl oy ed by th e R CF T is co nt am in at ed agreement rate. when a subject is retested after the original testing. That is, subjects at retesting may have been aware of the upcoming Recall and Recognition trials that fol low the Copy trial and may have spontaneously engaged in explicit encoding strategies during the Copy trial to improve performance. Table 6 Temporal Stability of the Immediate Recall, Delayed Recall, and Recognition Total Correct Measures Based on these considerations, it was decided that test-retest reliability coefficients (Pearson correla tions) would be presented only for the RCFT scores RCFT variable r tt with a sufficient range and distribution of scores Percentage agreement of clinical interpretation (Immediate Recall, Delayed Recall, and Recognition I m m e d ia t e R e c a ll .7 5 9 9 1 .7 Total Correct). Table 6 presents the test-retest correla Delayed R ecall ecall .888 91.7 R e c o g n i t i o n T o ta l C o r r e c t .8 7 4 9 1 .7 tions for these three scores. To measure the temporal stability of the clinical interpretation, age-corrected T Note. ra = test-retest reliability coefficient (Pearson corre scores for these measures were classified according to lation). the clinical interpretation based on the Heaton et al. (1991) 7-score classification system that is presented in Table 5. The percentage of agreement in the clinical VALIDITY interpretation between the first and second testing ses sions was calculated for these three RCFT measures. These percentages are also presented in Table 6. C onver onve rgent ge nt and Disc Discr riminant Va Validi liditty The convergent and discriminant validity of the The temporal stability of the remaining RCFT RCFT was examined by correlating RCFT raw scores measures that do not have a sufficient range and from the 601 normative subjects. The effects of age distribution of scores to permit calculation of tradi were partialed from these correlations. These correla tional test-retest reliability was established in the tions are presented in Table 8. As can be seen from following manner. Paired-samples t tests were cal t h i s t a b l e , t h e l a rg e st c o rre l a t i o n w a s b e t w e e n culated between the mean scores for the first and Immediate Recall and Delayed Recall. The recall 66 Table 7 Temporal Stability of the Copy and Recognition Measures First testing Second testing / (11) (11) P Percentage agreement of clinical interpretation M SD 35.5 35.0 1.11 .293 100.0 1 .0 0 .8 Time to Copy M SD 1 9 9.3 57.0 1 8 1 .7 61.4 0.91 .3 8 3 66.6 Recognition True Positives M SD 10.3 1.4 10.5 - 0 .6 2 .5 5 1 100.0 Recognition False Positives M SD 0. 7 0 .7 0.3 0 .7 1.0 8 .3 0 5 8 3 .3 Recognition True Negatives M SD 1 1 .3 0 .7 1 1 .7 0 .7 - 1 .0 8 .3 05 8 3 .3 Recognition False Negatives M SD 1 .7 1.4 1.5 0 .6 2 .55 1 100.0 1. 1 Raw scores RCFT variable Copy 1 .1 measures demonstrated lower, though still significant, As can be seen from this table, the Copy score correlations with Recognition Total Correct. Time to Copy had minimal statistical relationships to the w a s si g n i fi c a n t l y re l a t e d t o p e rfo rm a n c e o n Immediate Recall, Delayed Recall, and Recognition accuracy of the copy drawing (Copy), as well as Total Correct. The Immediate Recall and Delayed Immediate Recall and Delayed Recall. Interestingly, Recall scores were highly correlated with each other, moderate correlations were noted between the Copy as well as with the Recognition Total Correct. The raw score and the Immediate Recall and Delayed pa patter ttern n of int erc orrela orr elatio tions ns o f RCFT RC FT sco res of brain br ain  Recall raw scores, suggesting a relationship between damaged patients was generally comparable to that the ability to copy the complex figure and the ability found in the normative sample. to later recall and draw the figure from memory. Construct validity was also evaluated by studying The convergent and discriminant validity of the the pattern of intercorrelations among RCFT RCFT was examined by correlating RCFT scores measures and performance on the WAIS-R. For the from a heterogeneous sample of patients with docu br brai ainn-da da m ag ed sam ple de sc rib ed previ pr evi ou sly , RC FT mented brain dysfunction dysfunction (n - 100). Age-corrected T age-corrected T scores were correlated with WAIS-R scores, rather than raw scores, were analyzed to con trol for the effects of age. This sample was composed age-corrected scaled scores to correct for the effects of age. Table 10 presents this correlation matrix. In of patients with the following diagnoses: traumatic general, RCFT measures correlated more strongly br brain ain inj ury (n = 35), cerebrovascular accident and with Performance subtests than with Verbal subtests. aneurysm repair (n = 34), cerebral tumor (n = 5), cerebral anoxia (n = 4), multiple sclerosis (n = 5), Copy had highly significant correlations with Picture Arrangement and Block Design. Time to Copy was Alzheim er’ er’ss disease (n - 3), epilepsy (n = 3), general not significantly related to WAIS-R performance, ized encephalopathy (n = 1), electrical injury (n - 1), having the highest correlation with Block Design. and indeterminate or unknown diagnosis (n = 9). This Immediate Recall and Delayed Recall were signifi (SD D = 19.3 sample had a mean age of 53.2 years (S years) and a mean education level of 12.3 years (SD = cantly related to Picture Arrangement, Block Design, and Digit Symbol. Recognition Total Correct had sta 2.8 years). Fifty-seven of the patients were male. t i st i c a l l y si g n i fi c a n t c o rre l a t i o n s w i t h P i c t u re These correlations are presented in Table 9. Completion and Digit Symbol. 67 Table 8 RCFT Intercorrelations Intercorrelations for the Normative Sample Adjusted for Age Effects Time to Immediate Delayed Copy Recall Recall Recognition Total Correct Recognition True Positives Recognition False Positives Recognition True Negatives — — — — Recognition False Negatives R CF T v a r i a b l e Copy Copy 1.000 — Time to Copy -.092* 1.000 — — — — — — — Immediate Recall .329*** -.130** 1.000 — — — — — — Delayed Recall 3 7 g * * * -.127** .8 .881 81** *** * 1. 1.00 000 0 — — — — — Recognition Total Correct .150** .150*** * -.077 .236*** 270*** 1.000 — — — — Recognition True Positives .1 .107 07** ** -.064 .158*** 1.000 — — — Recognition False Positives -.071 .022 --.1 .12 28 8* ** — — Recognition True Ne ga tiv es .071 - ..0 02 22 2 .128** .129** .274*** -.315*** -1.000*** 1.000 — Recognition False Ne ga tiv es -. -.10 107* 7** * .0 .06 64 -.158*** _191*** -.827*** -1.000*** -.315*** .315*** 1.000 — — g27*** - ..1 12 29 9* ** * —274*** .315*** — 1.000 Note. N =601. * p < .05. ** p < .01. *** p < .001. C C C T C C C K C C C ( C ( C C C C C C ( f ( ( ( ( ( ( ( ( C C ( ( ( ( ( ( ( ( ( Table 9 RCFT Intercorrelations for the Brain-Damaged Sample Adjusted for Age Effects Immediate Recall Delayed Recall Recognition Total Correct Recognition False Positives Recognition False Negatives RCFT v va a ri a b l e Copy Time to Copy Copy 1.000 — — — — — — Time to Copy ..0 045 1.000 — — — — — Immediate Recall .584*** .186 1.000 — — — — Delayed Recall .581*** ..1 199* .961*** 1.000 — — — Recognition Total Correct 437*** -.042 47g*** 479*** 1.000 --- Recognition False Positives .319** .171 .36 .363*** .376*** 491*** 1.000 — Recognition False Negatives .185 -.237* .172 .161 .485*** -.262** 1.000 Note, n = 100. * p < .05. ** p < .01. *** p < .001. Table 10 Intercorrelations Among RCFT Measures and WAIS-R Subtests and Quotients for the Brain-Damaged Sample f — ( ( ( ( RCFT variable s. Immediate Recall Delayed Recall Recognition Total Correct Recognition False Positives Recognition False Negatives WAIS-R score Copy Time to Copy In f o r m a tio n .2 1 7 .1 3 5 .407* .424* .285 ..2 29 4 - .1 8 3 Digit Span .4 3 6 * * .113 .22 4 .1 5 2 .09 5 .3 5 4 * - .2 0 8 Vocabulary .1 2 7 .0 3 0 .27 4 .2 8 7 .13 6 .317 - .267 Arithmetic .4 2 8 * * .1 0 8 .25 0 .2 3 3 .274* ..4 4 12 * * .0 1 8 C o m p re h e n s io n .5 1 6 * * . 1 51 ..3 37 3* .3 6 3 * .3 7 2 * .4 6 3 * * - .1 2 0 Similarities .4 3 6 * * .0 0 7 .2 4 6 .2 0 8 ..2 27 2* .3 5 6 * * .033 Picture Com pleti pletion on .402** .053 ..3 37 5* .3 2 3 * .4 8 6 * * .4 0 3 * * .195 P i c tu r e A r r a n g e m e n t .5 .5 7 2 * * .0 5 8 .4 5 2 * .4 5 8 * .32 6 .4 3 9 * .082 Block Design .5 8 0 * * * .2 0 7 .4 5 5 * * ..4 451** .17 0 .467** - .068 Object Assembly ..5 561** .1 4 3 .3 3 4 .3 7 0 .2 6 2 .4 2 0 * - .250 Digit Symbol .5 1 3 * * * .0 9 9 .5 2 2 * * * .5 3 3 * * * .530*** .178 Verbal IQ .5 0 5 * * .0 6 0 .302 .2 9 2 .31 0 .5 1 8 * * - .097 P er er f o rm rm an a n ce ce I Q .5 8 5 * * * .233 .487** .490** 4 7 7 ** .534** .047 Full Scale IQ .455** .138 .3 7 4 * * .2 8 7 * .285* .290* .161 Note. Overall n = 100. 100. Due to m issing values, sample sizes in each cell vary. vary. * p < .05. ** p < .01. *** p < .001. 69 Construct validity was also evaluated by studying (COWAT). Age-corrected T scores were used to the pattern of intercorrelations among RCFT vari control for the effects of age. Table 11 presents these ables and measures of related and unrelated neu intercorrelations. ropsychological constructs in the heterogeneous s a m p l e o f b r a i n - d a m a g e d p a t i e n t s ( n = 100). As can be seen from Table 11, Copy was most highly correlated with BVRT Total Correct but also Ne ur urop op sych sy cholo olo gic al me asu res we were re de deriv riv ed fro m the demonstrated significant correlations with other Benton Visual Retention Test (BVRT), the Rey BVRT measures, as well as with the Hooper VOT and Auditory Verbal Learning Test (RAVLT), the Benton TMT Part B. Time to Copy was significantly corre Judgment of Line Orientation test (JLO), the Benton l a t e d w i t h P a rt s A a n d B o f t h e TMT. R C F T Visual Form Discrimination test (VFD), the Hooper Immediate Recall and Delayed Recall were signifi Visual Organization Test (VOT), Parts A and B of the cantly correlated with BVRT and RAVLT memory Trail Making Test (TMT), the Token Test (DeRenzi & measures. Lower, but still significant, correlations Vignolo, 1962), the Benton Sentence Repetition Test, b et w e en R C F T R e ca ll v ar ia b le s an d m ea s u re s o f a n d t h e C o n t ro l l e d O ra l W o rd A sso c i a t i o n Te st visuospatial ability were found. Recognition Total Table 11 Intercorrelations Among RCFT Measures and Neuropsychological Measures for the Brain-Damaged Sample RCFT variable Neuropsychological Time to Immediate Delayed Recognition Total Recognition False Recognition False measure Copy Copy Recall Recall Correct Positives Negatives BVRT Total Correct .614*** .094 .493*** 491*** .590*** 514*** .126 BV R T E rro r .553*** .14 4 .562*** .5 6 1 * * * .3 6 5 * * .3 0 1 * * .113 RA V L T T ria l 5 .396*** .1 4 8 .548*** .532*** .338** .255* * .121 RA V LT S h o rt D e la y .26 4 * .1 8 4 .470*** .4 9 2 * * * .3 5 4 * * * .2 7 2 * * .121 RA V LT L o n g D Dee l a y Free Recall .1 6 7 .180 .4 5 8 * * * .2 4 0 * .1 4 5 .104 B e n to n J u d g m e n t o f Line Orientation .54 1 * .43 0 .42 3 .4 3 4 .3 7 0 .0 4 0 .2 9 5 B en en t o n V iiss u a l F or or m Discrimination .23 5 * - .234* .1 6 0 .1 4 2 .4 6 5 * * * .2 9 7 * * .278* Hooper Visual Organization Test 4g4*** - .0 8 7 .3 4 5 * .3 8 1 * * .4 3 5 * * .220 .378** T M T P a rt A .2 6 5 * .3 7 7 * * .32 1* * .3 4 1 * * .201 .3 2 4 * * -.1 1 7 TMT Part B 432*** .3 6 0 * * .486*** 4 9 4 *** ** * .3 4 7 * * .2 8 4 * .0 6 7 Token Test 332*** .024 .313** .324** 4 7 9 *** .361** .217 Free Recall B e n t o n S e n te n c e Repetition C o n tr o lle d O r a l W o rd Fluency (FAS) 4 4 5 *** - .1 3 3 .122 - .0 6 9 - .0 6 2 - .0 4 6 .1 6 8 - .169 .0 1 3 .14 0 .1 5 0 .102 .160 .002 .205 Note. Overall n = 100. Due to missing valu es, samp le sizes in each cell var vary. y. BVR T = Benton V isual Retention Test; RAVLT = Rey Auditory Verbal Learning Test Test;; TMT = T rail Making Test. * p < .05. ** p < .01. *** p < .001. 70 Correct was significantly correlated with BVRT Total the normative sample. The resulting factor structure, Correct and Benton VFD. Language measures along with the eigenvalues and percentage of vari (Benton Sentence Repetition and COWAT) had no ance accounted for by each factor, are presented in statistically significant relationships with any RCFT measure. Overall, the intercorrelational data among Table 12. RCFT variables and measures derived from the factor due to the high loadings of Immediate Recall WAIS-R and from neuropsychological tests support and Delayed Recall. Factor 2 was interpreted as a the construct validity of the RCFT as a measure of Visuospatial Recognition factor due to the high load visuoconstructional ability (Copy) and visuospatial ing of Recognition Total Correct and the high nega memory (RCFT Recall and Recognition measures). tive loading of Recognition False Negatives. Factor 3, Factor 1 was interpret interpreted ed as a Visu Visuospatia ospatiall Recall tentatively labeled a Response Bias factor, demon Fac torial Va Validit lidity y strated a high loading of Recognition False Positives. Principal components factor analysis was con Factor 4 was interpreted as a Processing Speed factor ducted to determine the factor structure of the RCFT becau be cau se of the high hi gh loa loadin din g o f Ti Time me to Copy. Fina Finally, lly, in normal respondents. Age-residualized RCFT raw Factor 5 is thought to reflect Visuospatial Construc scores from the normative sample (N = 601) were tional Ability due to the high loading of the Copy entered into a principal components factor analysis. Two RCFT variables, Recognition True Positives and score. Principal components factor analysis was also Recognition True Negatives, were excluded from the conducted to determine the factor structure of the analysis because of redundancy with Recognition RCFT in a heterogeneous sample of brain-damaged Total Correct. An examination of the scree plot sug patie pa tients nts (n = 100). Age-corrected T scores, rather than gested that a five-factor solution was the most appro raw scores, were used to control for the effects of age. pria te. Fiv e fac tor torss we were re ex extra tra cte d and subje su bjecte cted d to a Two RCFT variabl variables, es, Recognition True Positives and Varimax rotation. The five-factor solution accounted True Negatives, were excluded from the analysis for 98.4% of the variance in RCFT performance for b e c a u s e o f r e d u n d a n c y w it h R e c o g n it io n T o ta l Table 12 Varimax Factor Loadings of RCFT Variables for the Normative Sample 1 2 Factors 3 Visuospatial recall Visuospatial recognition Response bias Processing speed .2 0 1 3 2 .0 6 8 4 3 - .0 2 4 8 2 -.0 1 5 7 1 .97658 - .0 5 3 5 2 - .0 4 5 9 5 .00272 .99739 - .01497 Immediate R ecall ecall .96111 .0 8 3 9 6 - .0 5 1 1 9 - .0 3 8 4 0 .10154 Delayed Recal Recalll .94768 . 11 9 4 1 - .0 5 3 2 7 - .0 3 6 2 7 .15862 R e c o g n i t i o n T o ta l C o r r e c t .1 34 5 1 .94905 - .2 7 6 4 4 - .0 3 6 3 4 .0 58 8 1 R e c o g n i t i o n F a ls e P o s i tiv e s - .0 7 9 5 4 .0 1 4 4 5 .99640 .0 0 3 2 1 - .0 2 5 4 0 Recognition False Negatives - .08624 -.94521 - .31000 .0 3 3 9 9 - .0 4 3 1 9 Eigenvalue 2.47464 1.53585 1.09788 0.97716 0.80108 Percent variance accounted for 35.4 15.7 14.0 11.4 RCFT variable Copy Time to Copy 21.9 4 5 Visuospatial constructional ability Note. N = 601. Scores were residualized for the effects of age. Significant factor loadings are printed in bold. 71 Correct. An examination of the scree plot suggested that involved more than one cerebral hemisphere, that a five-factor solution was the most appropriate. subcortical structures, or both. F i v e fa c t o rs w e re e x t ra c t e d a n d su b j e c t e d t o a The group of chronic psychiatric patients was Varimax rotation. The five-factor solution accounted for 97% o f the variance in RCFT performance for the gathered from two inpatient treatment facilities for brain br ain -dam -d am ag ed sam ple. ple . Th e res ultin ult ing g fac tor to r structu str uctu re, along with the eigenvalues and percentage of vari ance accounted for by each factor, are presented in Table 13. The factor structure and the interpretation of the factors were virtually identical to those of the normative sample sample.. G roup Dif Different ferentia iattion Meyers and Lange (1994) evaluated the ability ability of t h e R C F T t o d i sc ri m i n a t e a m o n g b ra i n -i n j u re d pat p atie ie nt s w ith do cu m en te d ne ur ob eh av io ra l im p ai r ment (n = 30), patients with chronic psychiatric disor der (n = 30), and healthy normal subjects (n = 30). the chronically mentally ill. Psychiatric patients with a history of brain injury or loss of consciousness were excluded. The diagnoses of these patients included schizophrenia (n = 18), bipolar disorder (n = 4), major depression (« = 7), and atypical psychosis (n = 1). The healthy normal subjects were randomly sampled from the normative data set. None had a history of mental illness, brain injury, learning disability, or developmental delay, and none were taking pre scribed medication at the time of testing. Descriptive information about these samples is presented in Table 14. G roup Diff Differenc es The three groups were equated for age, level of edu Table 15 presents means and standard deviations cation, and gender. All brain-injured patients were of RCFT scores for these samples, as well as the rated as a Rancho Los Amigos Scale of Cognition results of one-way analyses of variance. Analyses of level of VII or higher at the time of testing. The mean variance indicated significant differences among the time since the injury was 5.6 years (SD = 4.2 years). groups for all RCFT measures (p < .001). Post hoc All brain-injured patients had diffuse cerebral damage Scheffe tests of group differences in RCFT variables Table 13 Varimax Factor Loadings of RCFT Variables for the Brain-Damaged Sample 1 2 Factors 3 4 5 Visuospatial recall Visuospatial recognition Response bias Processing speed Visuospatial constructional ability C opy .3 6 1 6 0 .1 2 2 9 0 .1 6 6 3 3 .00431 .90909 Time to Copy .11522 -.1 1 7 8 9 .0 5 2 2 1 .98492 .00538 Immediate Recall .93891 .1 1 7 4 2 .1 7 2 4 4 .0820 4 .22096 Delayed Recall .93703 .10959 .1 8 5 0 3 .0 95 2 1 .2 1 7 0 2 R e c o g n i t i o n T o tal C o rr e c t .2 7 5 1 0 ..6 64922 .63669 - .0 3 0 6 1 .1 6 6 5 9 Recognition False Positives .2 0 1 3 9 - .1 7 6 8 4 .92619 .0 7 8 3 4 .1 2 5 2 2 R ec ec o g n i t i o n F Faa l s e N eeg g aatt i v e s .0 9 1 5 0 .94364 - .17358 - .1 2 9 9 2 .0 7 2 7 0 Eigenvalue 3.15863 1.48892 0.91891 0.72430 0.50404 Percent variance accounted for 45.1 13.1 10.3 7.2 RCFT variable 21.3 Note. n= 100 100.. Sign ificant factor loadings are printed in bold. 72 ^ Ta Tabl blee 14 17 presents the classification rates for this discrimi Descriptive Information for the Clinical Samples nant function. An overall correct classification rate of Brai Brainn-in inju jurred patients "W 61.1% was obtained. Given that the probability of Group membership in each group was 33.3%, RCFT mea sures of visuospatial recall are also considered effec Ps Psyc ychi hiat atri ricc Norm Normal al patients subjects tive at discriminating among the three groups. criminant function was calculated to evaluate the Age (years) M SD 38.1 3 3 .2 34.7 inc r e me ntal v alidity a sso c i a t e d w i t h t h e R C F T 11.5 11.0 9.3 Recognition trial measures. Age-corrected T scores for Immediate Recall, Delayed Recall, Recognition Education (years) (years) M SD R Rec ec a ll a n d re co gn itio it io n va ria ri a bl es . A final dis 12.8 12.4 13.4 2 .6 2.5 1 .8 Total Correct, Recognition False Positives, and Recognition False Negatives were used to predict group membership. Table 18 presents this data. An Gender (%) M a le 5 0 .0 5 0.0 5 3 .3 F e m a le 5 0 .0 50.0 4 6.7 Note, n —30 for all groups. overall correct classification rate for this variable set of 77.8% was obtained. Compared to using only the RCFT recall variables, the addition o f the recognition variables increases the overall correct classification rate from 61.1% to 77.8%, an increase of 16.7%. revealed that the brain-injured group performed sig nificantly poorer than the psychiatric and normal groups, and the psychiatric group performed signifi These results indicate that the addition of the RCFT Recognition trial variables produces higher classifica tion rates than those obtained by including just the Recall measures. These results provide additional cantly poorer than the normal group on both the w Immediate Recall and Delayed Recall trials. That is, all three groups were significantly different fr from om each other on the Recall variables. For the remaining RCFT variables, post hoc mean testing revealed that the brain-injured group performed significantly below the psychiatric and normal groups, but the psychiatri psychiatricc and normal groups did not differ significantly from each other. support for the incremental clinical validity and util ity associated with the RCFT Recognition trial. It should be noted that, for all three discriminant func tion analyses, brain-injured patients and normal sub ject je ct s we were re pr pred ed ict ed mo re accu ac curat rat ely tha n wer weree ps y chiatric patients. Profile Analysis of Memory Patterns The RCFT performance of the brain-damaged Disc rim rim inant Function Function A na lysis patie pa tie nt sam ple (n = 98, due to exclusion of two sub Copy variables. The clinical utility of the RCFT je ct s wi th m is issi si ng da ta) ta ) wa s st stud ud ied ie d fr from om the pe r was also examined by linear discriminant function spective of identifying distinct profile types that analysis. Group membership was predicted by a lin reflect qualitative differences in memory perfor w ear discriminant function using Copy and Time to mance. The patients were also rated as to their status w Copy as the predictor variables. Age-corrected T scores, rather than raw scores, were used to control on the Rancho Los Amigos Scale at the time of test ing by a psychometrician, who assigned ratings based for the effects of age. Table 16 presents the classifica upon direct observation of the patient’s behavior and tion rates for this discriminant function. An overall interviews with the patient’s occupational therapist, speech therapist, therapist, and family members. % c correct classification rate of 57.8% was found. Given c that the probability of membership in each group was 33.3%. RCFT copy measures are considered effective c at discriminating among the three groups. This interpretive approach is similar to the code type approach used to interpret multiscale personality inventories (Greene, 1991) and is based on the theo Re ca ll var iab iables. les. A second discriminant function retical discussion of memory performance by was computed using Immediate Recall and Delayed Sohlberg and Mateer (1989). Raw RCFT scores for Recall T scores to predict group membership. Table the brain-injured patients were converted to T scores W 73 W V Table 15 ANOVA Results for the Clinical Samples Group Brain-injured patients Psychiatric patients Normal subjects M 24.7a 32.4b 3 4. 6 b SD 9. 9.4 4 4.9 4. 9 2 .2 M 3 8 5 .6 a 2 6 9 .8 b 2 0 3 .6b SD 1 6 0.8 1 1 8 .9 79 .1 M 9.4a 18.1b 2 5 .0C SD 6 .5 8 .9 5.2 M 7.6a 16.0b 2 4 .5C SD 6 .1 9.2 9. 2 6 .0 M 16.0a 2 0 .3b 21.4b SD 2.1 1.4 1 .6 RCFT variable F Copy 20 9*** Time to Copy r 16.5*** Immediate Recall Delayed Recall 3 6 .8 * * * 4 0 .5 ** * Recognition Total Correct Recognition True Positives 81.4*** M 6 .7 a 9 .6 b 9 .7 b SD 2.7 1.6 1.4 M 2.7a 1.3b 0.4b SD 3. 3.2 2 1 .2 0 .6 9 .3 a 3. 3.2 2 1 0 .7 b 1 .2 1 1 .6 b 0 .6 M 5.3a 2.4b 2.3b SD 2.7 1 .6 1.4 2 2 .8 *** Recognition False Positives 9 9*** Recognition True Negatives 9 9*** M SD Recognition False Negatives 2 2 . 8 *** Note, n = 30 for all groups. M eans with different subscripts are significantly different on post hoc testing a t p < .05. * p < .05. ** p < .01. *** p < .001. using the age-corrected normative tables presented in In order to further validate the criteria for rating A p p e n d i x C . Th e sc o re s fo r Im m e d i a t e R e c a l l , memory profile patterns, these patterns were predicted Delayed Recall, and Recognition Total Correct were using linear discriminant function analysis from pro file d. Th Thee senio se nio r auth author, or, wh o was blind bli nd to iden id en ti fying and diagnostic information, rated each profile Immediate Recall, Delayed Recall, and Recognition Total Correct T scores in the brain-damaged sample. a c c o rd i n g t o t h e h i e ra rc h i c a l c ri t e ri a t h a t w a s Memory profile patterns were coded for data analysis pres pr esen en ted in ch ap ter 5 (In ter terpr preta etatio tio n). Tab Table le 19 p re  in the following manner: attention pattern = 1; encod sents the means and standard deviations for the RCFT ing pattern = 2; storage pattern = 3; retrieval pattern = memory variables for each memory profile type. 4; and normal and other patterns = 5. Predicted profile Figure 20, presented in chapter 5, illustrates the mean patter pat ter ns we were re comp co mp ar ared ed to the pat ter terns ns det determ erm ine d by age-corrected T scores scores for each mem ory profde type type.. clinical rating. A linear discriminant function was 74 Table 16 Discriminant Function Analysis Using RCFT Copy Variables Actual status Predicted group membership Brain-injured Psychiatric patients patients Normal subjects Total 8 1 30 2 6 .7 3 .3 Brain-injured Cy n 21 % 70.0 Psychiatric 7 12 3 6.7 2 3.3 40.0 3 3 24 10.0 1 0.0 n 11 % 30 Normal n % 30 80.0 Table 17 Discriminant Function Analysis Using RCFT Recall Variables Predicted group membership Actual status Brain-injured patients Psychiatric patients Normal subjects Total Brain-injured <s^ n 24 5 1 % 80.0 1 6 .7 3 .3 n 12 7 % 40.0 23.3 36.7 n 2 4 24 % 6 .7 1 3 .3 80.0 30 Psychiatric 30 11 Normal c 30 v^. Table 18 Discriminant Function Analysis Using RCFT Recall and Recognition Variables v^ Predicted group membership Actual status Nw- Psychiatric patients Normal subjects Total 28 2 0 30 93.3 6. 7 Brain-injured patients Brain-injured n % <L/ 0.0 Psychiatric n 3 % 1 0 .0 6 6 .7 20 7 30 2 3 .3 Normal Sw n 1 7 'w % 3.3 2 3 .3 30 22 7 3 .3 75 Table 19 Means and Standard Deviations for RCFT Memory Variables by Memory Pattern RCFT variable Memory profile pattern Immediate Recall Delayed Recall Recognition Total Correct 20.5 1.8 20.8 2.9 20.8 2.7 21.7 3.3 21.4 2.8 30.6 5.1 36.4 4.7 34.6 4.9 26.9 5.1 28.6 10.0 26.8 9.0 46.5 8.6 Attention M SD Encoding M SD Table 21 Group Centroids for Memory Profile Patterns Predicted by Immediate Recall, Delayed Recall, and Recognition Total Correct T Scores Centroids Memory profile patterns First function Second function Attention Encoding Storage Retrieval Normal or other - 2. 526 04 -1.4216 1 -0 . 7 7 0 1 7 0.73301 2.44738 0.64778 , - 0 .4 9 1 7 3 1.79101 -1.75592 1.86168 Storage M SD Retrieval M SD files were classified as attention patterns, 9.3% as Normal/or other M In the brain-damaged sample, 22.6% of the pro encoding patterns, 10.3% as storage patterns, 37.8% as retrieval patterns, and 20% as normal or undiffer entiated patterns. Profile categories were then com 51.2 51.2 46.8 pa re red d to the Ranc Ra ncho ho Los Lo s Am igo s lev el, and are pr e SD 6.4 7.7 7.1 sented in Table 22. A chi-square analysis revealed a significant relationship between memory profile pat- Note. All data are T scores. terns and Rancho Los Amigos level, yj' (16) = 126.5, p < .0001. Attention patterns were equally prevalent obtained that correctly classified 82.65% of profiles. for patients at Rancho Los Amigos Levels IV, V, and Table 20 presents the unstandardized discriminant VI. A similar pattern was noted for the encoding pat coefficients for the first and second functions. Table t e rn . S t o ra g e p a t t e rn s w e re m o st p re v a l e n t fo r 21 presents the group centroids for the memory pro Rancho Los Amigos Level VII. The data very clearly file patterns. show that retrieval and normal patterns are found pred pr ed om inan in antly tly in pa patie tients nts fu nc nctio tio nin g at Ra nch o Los Table 20 Discriminant Analysis Prediction of o f Memory Profile Patterns by Immediate Recall, Delayed Recall, and Recognition Total Correct T Scores Immediate Recall Delayed Recall Recognition Total Correct (Constant) from the injury were more often rated as having stor age and retrieval patterns, patterns, w hereas patients who were tested closer to the time o f the injury were more often rated as having attention and encoding patterns. In general, patients at Rancho Los Amigos Levels VII and VIII had higher RCFT scores than patients at Unstandardized discriminant coefficient RCFT variable Amigos level VIII. Patients who were further out Levels V and VI. Patients who were rated as having an attention, encoding, or storage pattern generally First Second function 0.0506896 0.0221114 function -0.0539798 0.1997714 0.1056699 - 6 .22 2 8 5 04 - 0 .1 2 30 8 2 0 0.1546876 required supervision for daily living, because they were unable to function independently. Those with retrieval patterns required less supervision and were more successful at independent functioning (Meyers & Lange, 1994). In a previous study (Knight & M eyers, 1995), a com bination of Rancho Los Amigos Scale rating and memory profile rating 76 Table 22 RCFT Memory Profile Patterns and Rancho Los Amigos Rating in the Brain-Damaged Sample IV Rancho Los Amigos level V VI V II V ili Total 6 27.3 7 31.8 8 36.4 1 4.5 0 0.0 22 1 11.1 3 33.3 3 33.3 2 22.2 0 0.0 9 0 0.0 1 10.0 1 10.0 7 70.0 1 10.0 10 0 0.0 0 0.0 0 0.0 1 2.7 36 97.3 37 0 0.0 0 0.0 0 0.0 1 5.0 19 95.0 20 Memory profile pattern k/ Attention n Row % Encoding V w n Row % , Storage n Row % Retrieval n Row % Normal/or other n Row % Note, n = 98. x 2 ( 16) = 126.5, p < .0001. correctly classified 90% of patients with mild brain patie pa tie nt who pr prod oduc uces es an att attent ent ion pa patte ttern rn to be abl ablee to injury and experimental dissimulators into their find his or her way to an office alone or to live inde respective diagnostic groups. pen den tly. It is the au thor th ors’ s’ cli clinic nic al op opini inion on that tha t cla s The memory profile patterns appear to have some sification sificat ion o f brain-damaged patients by a combination p re s cr ip ti v e va lu e fo r re h ab il it a ti o n p ro gr am m in g of memory profile pattern and Rancho Los Amigos Scale rating provides a useful and more reliable with brain-injured patients. An attention pattern would suggest the need to focus cognitive rehabilita means of identifying functional abilities than the tion efforts on improving attention skills, such as with Rancho Los Amigos ratings alone. This is because Attention Process Training (Sohlberg & Mateer, Rancho Los Amigos Scale ratings do not have specific 1989). An encoding pattern wou ld suggest the need to psyc ps ychom hom etr etric ic cr crite iteria ria and, inst ead ead,, rely only on be behav hav  emphasize the meaning of various stimuli; emphasiz ioral observation. Thus, the use of profile analysis of ing speech therapy in these cases is often helpful. A memory patterns appears to be a valid and useful storage pattern suggests that a depth-of-processing approach to the interpretation of RCFT performance. model which increases the amount of effort focused Base Rate Information on remembering a task may improve memory. c Finally, a retrieval pattern suggests that a patient may The frequency of occurrence of different scores be ne fit fro m a me mo ry bo ok or oth er me mo ry co m  for each scoring unit was examined in the sample of pens pe nsato ato ry strate str ategie gie s suc such h as me mo ry on loci (M (MOL OL)) bra b ra in -d am ag ed p at ie nt s (n = 100), as well as in a or '"pegging” (Wilson, 198 1987). 7). In the original work of Meyers and Lange (1994) matched sample of normal subjects drawn from the RCFT normative sample (n = 100). Tables 23 through and in this present study, it was found that brain 26 present this base rate information. For the drawing damaged patients who had attention, encoding, or trials, the tables present the percentage of each sam storage patterns were generally unable to function ple pl e th at ob tai ne d raw sc score ore s of 2, 1, 0.5 , and 0 fo r independently. Lower profile elevations reflected each scoring unit. For the Recognition trial, Table 26 lower functional ability. One would not expect a prese pr ese nts the pe rce nta ge o f eac h sam ple tha t obtain ob tain ed 77 Table 23 Base Rates of Scores for RCFT Elements for the Copy Trial in Normal Subjects and Brain-Damaged Patients Normal subjects Scoring element Brain-damaged patients 0 0.5 1 2 0 0.5 1 2 1. V er ert ic ic aall C ro ro s s 0 1 16 83 15 14 21 50 2 . L a rrg g e R e ct ct an an g le le 0 0 2 98 9 16 24 53 3. Diagonal Cross 0 0 5 95 16 10 30 44 0 0 1 99 14 6 22 58 0 0 2 98 14 5 25 56 0 0 16 84 13 11 26 50 1 0 0 99 9 2 12 57 0 0 5 95 13 8 24 55 22 58 4. Horizontal Midline 5. Vertical Midline 6 . Small Rectangle Within Large Rectangle (2) 7. Small Horizontal Line Above Small Rectangle ( 6 ) t 8 . Four Parallel Lines 9. Small Triangle Above Large Rectangle (2) 0 0 5 95 12 8 10. Small Vertical Vertical Line Within Large R ectangle (2) 0 0 0 100 19 4 11 66 91 97 6 6 14 5 28 17 60 64 11. Circle With Three Dots 1 2 . Five Parallel Lines 0 0 0 0 9 3 13. Sides of Large Triangle 0 0 6 94 11 5 30 54 14. D ia ia m on on d 1 0 3 96 10 7 14 69 Vertical cal Line Within L arge Triangle (13) 15. Verti 0 0 1 99 21 2 13 64 16. Horizontal Line Within Large Triangle (13) 0 0 1 99 16 3 15 66 17. 0 0 6 94 11 7 27 55 H o rrii zo zo n ta ta l C ro ro ssss 18. Square Attached to Large Rectangle (2) 0 0 8 92 7 5 26 62 Note, Not e, n = 100 for both samples. Data represent the percentage o f raw scores for each scoring unit that was obtained by each sample. Table 24 Base Rates of Scores for RCFT Elements for the Immediate Recall Trial in Normal Subjects and Brain-Damaged Patients Scoring element Normal subjects 2 0 0.5 1 Brain-damaged patient patientss 2 0.5 1 0 1. Vertica l Cro ss 1 10 53 36 30 31 29 10 2. Large Rectangle 0 0 6 94 18 10 26 46 3. Diagon al Cross 0 0 16 84 46 13 16 25 4. Horizontal Midline 0 0 4 96 34 8 14 44 5. Vertical Mid line 0 0 4 96 45 6 13 36 6 . S m aall l R ec ec t a n g gll e W iitt h i n L a r g e R ec ec t a n g gll e ( 2) 13 10 25 52 63 20 8 9 7. Small Horizontal Line Abo ve Small Rectang le ( 6 ) 38 0 8 54 87 1 2 10 8. Fou r Parallel Lines 2 3 24 71 44 27 16 13 9. S m a l l T r i a n g l e A b o v e L a r g e R e c t a n g l e (2 ) 28 2 10 60 72 7 11 10 10 10.. Small Vertical Vertical Line Within Large Rectangle (2) 74 0 9 17 88 5 3 4 11 11.. Circle With Thre e Dots 3 2 21 74 37 8 30 25 12. Five Parallel Line s 13 13.. Sides of Large Triangle Triangle 12 2 2 1 14 16 72 91 51 41 15 7 14 13 39 14. Diamond 6 0 8 86 39 11 15 35 15 15.. Vertical Vertical Line Within Large Triangle (13) 55 0 6 39 83 2 8 7 16 16.. Horizontal Line Within Large Triangle (13) 28 1 1 70 66 2 4 28 17 17.. Horizontal Cross 2 17 56 25 51 24 23 2 18 18.. Square Attached to Lar Large ge Rectangle (2) 11 2 55 32 57 14 24 5 20 Note, No te, n - 100 for both samples. D ata repres represent ent the percentage of raw scores for each scoring unit that was obtained by each sample. 78 Table 25 Base Rates of Scores for RCFT Elements for the Delayed Recall Trial in Normal Subjects and Brain-Damaged Patients Brain-damaged patients Normal subjects V_/ Scoring element 0 0.5 1 2 0 0.5 1 2 1. V e rrtt ic ic aall C ro ro s s 1 10 58 31 30 34 31 5 2 . L ar ar g gee R e ct ct an an g llee 0 0 5 95 23 12 22 43 3. Diagonal Cross 1 0 17 82 50 13 16 21 4. H o rrii zo zo n ttaa l M i d li li ne ne 0 0 4 96 39 7 14 40 Vertical al M idline 5. Vertic 1 0 6 93 39 11 20 30 6 . Small Rectangle Within Large Rectangle (2) 10 6 31 53 65 19 ' 7 9 7. Small Horizontal Line Above Small Rectangle ( 6 ) 33 0 8 58 91 1 1 8 8 . Four Parallel Lines 2 2 30 66 47 28 15 10 19 0 15 66 73 9 9 9 9. Small Triangle Above Large Rectangle (2) 10. Small Vertical Vertical Line W ithin Large Rectan gle (2) 74 0 11 15 94 2 1 3 11. Circle With Three Dots Fiv vee P a ra ra ll ll el el L iin nes 1 2 2 28 17 69 72 37 57 14 15 28 14 21 9 13. S i des des of L ar ar ge T r ia ia ngl nglee 3 0 10 87 46 7 13 34 14. D iiaa m on on d 5 0 7 88 44 8 14 34 Vertical al Line Within L arge Triangle (13) 15. Vertic 52 0 5 43 86 2 6 6 it h i n La La r g e T r i a n g l e ( 1 3 ) 16. H o r i z o n t a l L i n e W it 27 1 2 70 62 3 13 22 17. Horizontal Cross 3 16 60 21 48 26 24 2 12. 14 18. Square Attached to Large Rectangle (2) 11 4 53 62 32 14 2 22 Note, No te, n = 100 for both sam ples. Data represent the percentage of raw scores for each scoring unit that was obtained by each sample. correct and incorrect raw scores for each recognition Delayed Recall trial, but subsequently fails to recog item. The results of the study showed that certain nize the unit during the Recognition trial. units of the complex figure are generally drawn cor A study was undertaken by Knight and Meyers rectly by both brain-damaged patients and normal subjects. (1995) to determine whether these qualitative features of RCFT performance had predictive validity in d e t e c t i n g e x p e ri m e n t a l si m u l a t i o n . K n i g h t a n d Spec pec ial Validity Topic opics s Meyers randomly assigned 70 normal volunteers to Dissim ulati Dissim ulation on a nd M ali aling ng ering Table 26 shows that several items from the one of seven dissim ulation conditions. The conditions Recognition trial (Items 1, 4, 6, 10, 11, 18, 21) are subjects, dissimulation scenario, and goals of dissim rarely answered incorrectly in both normal and brain ulation. No significant differences were found in damaged samples. An incorrect answer on these items RCFT scores among the seven dissimulation groups, is referred to as an Atypical Recognition Error so the groups w ere collapsed for sub sequent analyses. (Knight & Meyers, 1995). In both normal and brain Groups of 100 brain-damaged patients and 100 nor damaged samples, the accurat accuratee drawing o f an individ mal controls were matched to the dissimulators. ual scoring unit (though not necessarily correctly Additional data concerning these samples can be place pl ace d) at the De lay ed Rec all tria l is high hi ghly ly predi pr edicti ctive ve of a correct answer to the corresponding Recognition found in Knight and Meyers. Table 27 presents the frequency of occurrence of trial item. Stated differently, a respondent is highly Atypical Recognition Errors in the normal, brain likely to recognize a scoring unit if he or she correctly damaged, and dissimulating groups in this study. Chi- recalls and draws it at the Delayed Recall trial. A square analysis revealed a highly significant relation Recognition Failure Error refers to a situati situation on where a ship, x 2 (10) = 76.9, p < .0001, between group mem respondent correctly recalls a scoring unit at the be rsh ip and nu m be r of At yp ica l Re cogn co gn ition iti on Err Errors ors.. varied with respect to the information provided to 79 Table 26 Base Rates of Scores for RCFT Elements for Atypical Recognition Errors in the Recognition Trial in Normal Subjects and Brain-Damaged Patients Normal and Subjects, Brain-Damaged Dissimulating SubjectsPatients, Table 27 Group Normal subjects Brain-damaged patients Item Incorrect Correct Incorrect Correct 1 0 100 9 91 2 6 94 35 65 3 10 90 33 67 4 0 100 0 100 5 2 98 11 89 1 error 6 0 100 0 100 7 15 85 25 75 8 16 84 31 69 9 5 95 19 81 10 0 100 0 100 11 0 100 6 94 12 25 75 28 72 13 3 97 25 75 14 3 97 22 78 Number of errors Normal subjects Brain damaged patients Dissimulating subjects 0 errors n 100 79 38 Col umn % 100.0 79.0 54.0 n 0 3 16 Col umn % 0 .0 3 .0 2 2 .9 0 4 7 0 .0 4. 0 10.0 n 0 7 2 Col umn % 0 .0 7. 0 2.9 2. 9 2 errors n Col umn % 3 errors 4 errors 15 7 93 42 58 16 2 98 14 86 n 0 4 4 17 8 92 31 69 Col umn % 0 .0 4. 0 5.8 18 0 100 0 100 5 or more errors 19 24 76 47 53 n 0 3 3 20 17 83 39 61 Column % 0 .0 3.0 4.4 4. 4 21 0 100 8 92 22 9 91 33 67 100.0 100.0 70.0 14 56 86 23 24 7 22 93 78 44 Total Note. %2 (10) = 76.9, p < .0001. Note, n = 100 for both samples. Data represent the percent age of raw scores for each item that was obtained by each sample. No ne o f the no norm rm al subje su bjects cts made ma de eve n one At Atyp ypica ica l encoding pattern, 35.7% produced a storage pattern, Recognition Error. Conversely, 21% of the brain- 8.6% produced a retrieval pattern, and 4.3% produced injured patients patients and 46% of the dissimulating subjects a normal/other pattern. Given the validity results pre made one or more of these errors. However, these sented previously, brain-injured individuals who errors were only made by brain-damaged patients obtain an attention, encoding, or storage pattern functioning below Rancho Los Amigos Level VIII. might be expected to be unable to function indepen Stated differently, a person with a mild brain injury who is functioning independently would not be dently. Therefore, respondents with suspected brain injury who are able to function independently would expected to produce this type of error. Knight and be ex expe pecte cte d to pro du duce ce eit he herr a ret riev al or a no norm rm al/ Meyers (1995) reported good discrimination between other pattern. An independently functioning individ experimental dissimulators and mildly brain-injured ual who produces an attention, encoding, or storage pat ien ts. Th ey foun fo und d th that at 37. 37.1% 1% o f the dissim dis sim ula tors tor s patte pa tte rn sho uld be evalu ev alu ate d fu furth rth er fo forr qu ques estio tio na nable ble pr od uc ed an at atte te nt io n pa tt tter ern, n, 14.3 14.3% % p ro du ce d an motivation (Knight & Meyers, 1995). 80 Table 28 presents the frequency of occurrence of Depression Recognition Failure Errors in the normal, brain Ne uro ps psych ych olog ol ogist ist s are often oft en ask ed to det determ erm ine damaged, and dissimulating groups. Chi-square the effect of depression on memory performance. analysis revealed a si significant gnificant relationshi relationship, p, % (8) = 61.7, p < .0001, between group membership and Impaired memory m ay be the result of primary neuro number of Recognition Failure Errors. None of the two factors (Caine, 1986). A study was conducted to normal subjects or brain-damaged patients made a determine the relationship between RCFT perfor Recognition Failure Error. Conversely, 28.6% of the dissimulating subjects made one or more Recognition mance and performance on a psychometric measure of depressive symptoms, the BDI. Twenty-f Twenty-five ive volun Failure Errors. At this point, it is cautiously recom teers with no history of neurological disorder who mended that any combination of 2 of these types of scored 15 or greater on the BDI were matched for errors (i.e., two Atypical Recognition Errors; two age, level of education, and gender'to 25 subjects Recognition Failure Errors; or one Atypical Recog drawn from the RCFT normative sample. Subjects nition Error an d one Recognition Failure Error) sug were classified as to whether their obtained BDI score gests the need to further evaluate a respondent for was 13 or less, or 14 or greater. Data were analyzed by a series ser ies of ind epe nd ent en t sam ples t tests. Significant possi po ssi ble qu ques estio tiona nable ble mo motiv tivatio atio n. logical disease, depression, or a combination of these differences between the groups were found for Recognition Total Correct (i = 2.96, p < .01) and Table 28 Recognition Failure Errors in Normal Subjects, Brain-Damaged Patients, Recognition False Negatives (t = 2.06, p < .05). The differences between the two groups on Delayed Recall approached significance (t = 1.87, p < .068). No sig nif ica icant nt gr grou oup p differ dif ferenc enc es wer weree not ed fo r any and Dissimulating Subjects other RCFT variable. Moderate correlations were found between the BDI raw score and Recognition Group Number of errors Brain Normal damaged subjects patients Total Correct (r = -.387) and Recognition False Dissimulating subjects Ne ga gativ tiv es (r = -. 2 56 ). Th e gro up o f patie pa tie nts cla ss i fied as depressed scored on the average 4 .77 lower on Immediate Recall, 6.5 7 lower on Delayed Recall Recall,, and 0 errors 8.87 lower on Recognition Total Correct. n Col umn % 100 100.0 100 1 00 .0 0 0.0 0 0.0 0 0.0 0 0.0 50 71.4 1 error n Col umn % A v a ri e t y o f v a l i d i t y d a t a w a s p re se n t e d . 16 22.9 2 errors n Col umn % Col umn % Col umn % Total derived from the WAIS-R and neuropsychological tests established the convergent and discriminant validity of the RCFT as a measure of visuospatial con 4.3 structional ability (Copy score) and visuospatial mem ory (RCFT Recall and Recognition scores). Factor 0 0.0 0 0.0 0 0.0 4 errors n In t e rc o rre l a t i o n s b e t w e e n R C F T a n d m e a su re s 3 3 errors n Summary of Validity Studies analyses established the factor structure of the RCFT in samples of normal subjects and brain-damaged pat p at ie n ts . B as ased ed on the th e fa ct o r an al ys es , the th e RC FT 0 0.0 0 0.0 1 appears to capture five domains of cognitive function 1.4 ing: visuospatial recall memory, visuospatial recogni tion memory, response bias, processing speed, and 1 0 0 .0 1 0 0 .0 70.0 Note, x 2 ( 8 ) = 61.7, p < .0001. visuospatial constructional ability. Performance on the RCFT differs significantly among brain-damaged 81 patien pat ien ts, ps psych ych iatric iat ric pat ients, ien ts, and he healt althy hy norm no rmal al subsu b- variables was introduced. Subsequent analyses estab- je jects cts . Ove ral rall, l, RC FT measu me asu res are sen sitive sit ive to m em - lished the clinical utility of the profile approach to be rs h ip in th es e gr ou ps ps.. 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P, & Holmes, J. M. (1986). Assessing N. G., Mor Morey, ey, C. E., Dau gh ghtrey trey , E. W., & Ka Kapla plan, n, E. children’s memory productions of the Rey-Osterrieth (1994). The Boston qualitative scoring system for the Complex Figure. Jo u rn a l o f C lin li n ic al a n d E x p e ri Rey-Osterrieth Complex Figure: Description and mental Neuropsychology, 8, 563- 580. interrater reliability. The Clinical Neuropsychologist, 8, 309-322. Psychological cal appraisal o f Taylor, E. M. (1959). Psychologi children with' with' cerebral deficits. Cambridge, MA: Harvard University. Taylor, L. B. (1979). Psychological assessment of neurosurgical patients. In T. Rasmussen & R. Marino (Eds.), Functional neurosurgery (pp. 165-180). New York: Raven. U.S. Department of Commerce, Bureau of the Census. Statistical Abstract of the United States: 1994 (114th ed.). Washington, DC: U.S. Government Printing Office. Waber, D. P, & Holmes, J. M. (1985). Assessing children’s copy production of the Rey-Osterrieth Complex Figure. JJo o u rn a l o f C lini li ni ca l a n d E x p e ri W e c h sl e r, D . (1 9 8 1 ). T h e W e c h s le le r A d u l t In Intel tel lig ence en ce Sca le —Re Revise vise d. New York: The Psycho logical Corporation. Wechsler, D. (1987). Wechsler Memory Scale — Revis Re vis ed. ed . N ew Yor York: k: The Ps ychological Corporation. Wilson, B. (1987). R e h a b il it a ti o n o f m em or y. Ne w York: Gilfor Gil ford. d. Zachary, R. A., & Gorsuch, R. L. (1985). Continuous norming: Implications for the WAIS-R. Jo Jour ur na l o f Clinic Cli nic al Ps Psych ych olo gy, gy , 41, 86-94. mental Neuropsychology, 7, 264-280. 86 Appendix A Sc oring Exa xample mples s Scoring Sheet Scoring Criteria for RCFT Drawings Scoring Element 1. Ver ti ti ccaa l Cros Crosss 2. La rg rg e R eecc ta ta n ng g le le Score Accuracy Placement 2 Accurately drawn Correctly placed 1 Accurately drawn Incorrectly placed 1 Inaccurately drawn Correctly placed 0.5 Inaccurately drawn, but recognizable Incorrectly placed 0 Inaccurately drawn and unrecognizable, or omitted Incorrectly placed Copy 2 ( 0 0.5 0 0 1 0 .5 0 Immediate Recall Delayed Recall 2 0 0.5 0 200.5 0 0 1 0.5 0 2 0 0 .5 0 6. Sm maa ll ll R eecc ta ta n ng g le le 7. Small Horizontal Line above Small Rectangle ( 6 ) 2 ( 0 0.5 0 ( 0 1 0 .5 0 ( 0 1 0.5 0 2 ( 0 0.5 0 ( 0 1 0.5 0 8. Four Parallel Lines 0 1 0 .5 0 9. Small Small Tria Triangle ngle above Large Large Rectangl Rectanglee (2) (2) ( 0 1 0.5 10. Small Vertical Line within Large Rectangle (2) 0 1 11. Circle with Three Dots 12. F ive ive P ar ar al al le le l Li Li n nee s 13. 13. Sides of Large Triangle attached to Large Rectangle (2) 2 ( 0 0.5 0 ( 0 1 0 .5 0 0 1 0.5 () 14. D i am o on nd 0 1 15. 15. Vertical Line within Sides of Large Triangle (13) 0 16. Horizontal Line within Sides of Large Triangle (13) 17. 17. 18. 18. 3. D ia iag on on al al C rro o ss ss 4. Horizonta Horizontall Midl Midline ine of Large Rectangle Rectangle (2) Vertical Midlinc of Large Rectangle (2) 5. 0.5 2 1 0 1 2 1 0.50 2 1 0.5 0 0.5 0 0 1 0.50 2 1 0 .5 .5 0 2 0 0 .5 2 0 0 0 2 1 0 .5 .5 0 2 0 0.5 0 2 0 2 0 0.5 0 2 0 0.5 0 0 2 0 .5 0 2 1 0 .5 0 0 1 0.5 0 200.5 0 0 1 0 .5 0 2 0 0 .5 0 0 1 0.5 0 200.5 0 0 .5 0 0 1 0.50 2 1 0 .5 .5 0 1 1 1 0 0 0 0..5 0 0 .5 0 0 1 0.5 0 2 0 1 0 .5 0 0 1 0.5 0 0 1 Horizontal Cross 0 1 0. 5 0 2 0 0.5 0 2 0 0.5 0 Square attached to Large Rectangle (2) 0 0.5 0 2 0 0.5 0 2 JJL LL _ _0 0 1 1 1 £ 0 .5 0 1 0 0 5 52 2 .0 2 0 .0 14.5 Raw score Raw score Raw score Recognition True Positives = Sum of items 2, 5 , 7 , 8, 9 , 12, 13, 15, 19, 20, 22, and 24 that were circled. Recognition False Positives = Sum of items 1, 3, 4, 6, 10, 11, 14, 16, 17, 18, 21, and 23 that were circled. Recognition True Negatives = 12 minus Recognition False Positives. _A _ A Recognition False Negatives = 12 minus Recognition True Positives. 25 Recognition Total Correct = Recognition True Positives plus Recognition True Negatives. Figure A 1. Scoring Example 1: Scoring Sheet. 88 1 0.50 2 Recognition Trial Worksheet A 0 .5 0 Fi g u r e A2 . Scoring Example 1: Copy trial. Explanation of o f Scores Scores Unit Score Explanation 1. 1 The top part of the cross is mo re than ' / 4 inch ab ove the top o f the Small Triangle (9) (9).. 3. 1 The diagonals intersect more than ' / 4 inch from the true center o f the Large Large R ectangle (2) (2).. 6 . 1 T h e u n i t i s d r a w n as a s q u a r e . 11 11.. 1 The unit is draw n with three sma ll circles, rathe r than three dots, insid e the larger circle. Note.. All other units are drawn accurately and placed properly and receive a score of 2. Note 89 Figure A3. S coring Ex am ple 1 : Im m ediate R ecall tr trial. ial. Explanation of Scores Unit Scor Scoree Explanation 1. 1 The bottom of the cross is more than */ 2 inch above the Horizontal Midline (4). 3. 0 The unit is missing. 5. 0 The unit is missing. 6 . 1 The u nit is placed correctl correctly, y, but the w idth o f the rectangle is greater than the height. 7. 0 The u nit iiss missing. 8 . 1 The un it is drawn accurately, but placed incorr incorrectly. ectly. 9. 1 The vertical side of the Small Triangle is more than l/4 inch aw ay from the V erti ertical cal Midline (5). 10. 0 The unit is missing. 15. 0 17. 1 The unit is missing. The Horizontal Cross is missing the short vertical line that connects it to the Large Rectangle (2). 18. 1 The unit has one too many diagonal lines. No te . All other units are drawn accurately and placed properly and receive a score of 2. 90 Explanation of Scores Unit Score Explanation 1. 2. 3. 5. 6. 1 1 0 0 0.5 7. 8. 0 0.5 9. 10. 1 0 The bottom of the cross is more than */2 inch above the Horizontal Midline (4). The Large Rectangle does not have four comers that meet at right angles. The unit is missing. The unit is missing. The Small Rectangle is drawn inaccurately and positioned more than */4 inch above the Horizontal Midline, but it is still recognizable. The unit is missing. Only three of the Four Parallel Lines are drawn, and the unit is drawn in the wrong quadrant of the Large Rectangle (2). The Small Triangle is drawn as a continuation of the Sides of the Large Triangle (13). The unit is missing. 11. 12. 13. 15. 17. 18. 1 1 1 0 1 0.5 The unit is drawn accurately, but placed incorrectly. The unit is drawn accurately, but placed in the wrong quadrant of the Large Rectangle (2). The top of the Sides of the Large Triangle is not connected to the corner of the Large Rectangle (2). The unit is missing. The cross is attached to the bottom of the Square (18). The diagonal is drawn in the wrong orientation and is placed incorrectly, but it is still recognizable. N ot e. All other units are drawn accurately and placed properly and receive a score of 2. 91 F i g u re A 5 . Scoring Ex amp le 1: Recog nition trial. 92 Scoring Sheet Scoring Criteria for RCFT Drawings Score Accuracy Placement 2 1 1 0.5 Accurately drawn Accurately drawn Inaccurately drawn Inaccurately drawn, but recognizable Inaccurately drawn and unrecognizable, or omitted Correctly placed Incorrectly placed Correctly placed Incorrectly placed 0 Scoring Element 1. Vertical Cro ss 2. Large Rectangle Incorrectly placed Copy Immediate Recall Delayed Recall 0.55 0 © I 0. (2) 1 0.5 0 2 © 0.5 0 2 © 0.5 0 2 © 0.5 0 2 © 0.5 0 3. Diagonal Cross 4. Horizontal Midline of Lar Large ge Rectangl Rectanglee (2 (2)) 5. Verti Vertical cal Midline of Large Rectangle (2) 6 . Small Recta ngle 7. Small Horizontal Li Line ne above Small Rectangle (6 ) 8 . Four Parallel Lines 2 j ) 0 .5 .5 0 (2) 1 0.5 0 9. 10. 10. 11. 11. 12. 13. 14. 15. 15. Small Triangle above Large Rectangle (2 (2)) Small Vert Vertical ical Line within Large Rectangle (2) Circle wit with h Three Dots Five Parallel Lines Sides of Large Triangle attached to Large Rectangle (2) Diamond Verti Vertical cal Line within Sides of Large Triangle (13) 16. 16. 17. 17. Horizontal Line within Sides of Large Triang le (13) Horizontal Cross 18. 18. Square attached to Large Rectangle (2) 2 I 0.5 © 2 © 0.5 0 2 © 0.5 0 I 0.5 © 2 © 0.5 0 2 © 0.5 0 © I 0. 0.55 0 2 (2) 1 0.5 0 © 1 0.5 0 © 1 0.5 0 © I 0. 0.5 5 0 2 1 0.5© 2 ( | 0 .5 0 2 © 1 0.5 0 © 1 0.5 0 2 © 0.5 0 © 1 0 .5 0 © I 0. 0.55 0 © 1 0 .5 0 © 1 0.5 0 0 .5 0 © I 0.5 2 © 0.5 0 © l 0.5 0 2 I 0.5© 2 \ f© 2 I 0.5© 2 © 0.5 0.5 0 © I 0.5 0 2© 0.5 0 © 1 0 .5 0 2 I 0.5© © I 0.5 0 2 1 0 .5 © 2 1 0 .5 © 2 1 0 .5 © 2 © 0.5 0 2 1 0 .5 © 52.0 14.5 10.5 Raw score Raw score Raw score 1 0 2 I 0.5 © 2 ] Q o 0 2 I © 0 0 0 .5 © 2 I 0.5 © © l 0. 0.5 0 2 1 0 .5 © 2 1 2 1 0 .5 © Recognition Trial Worksheet 12 Recognition True Positives = Sum of items 2, 5, 7, 8, 9, 12, 13, 15, 19, 20, 22, and 24 that were circled. Recognition False Positives = Sum of items 1, 3, 4, 6, 10, 11, 14, 16, 17, 18, 21, and 23 that were circled. 11 Recognition True Negatives = 12 minus Recognition False Positives. O Recognition False Negatives = 12 minus Recognition True Positives. 25 Recognition Total Correct = Recognition True Positives plus Recognition True Negatives. F i gure A 6. Scoring Example 2: Scoring Sheet. 93 Figure A7. S c or i ng E xa m pl e 2: Copy t ri ri a l. l. Explanation of Scores Unit Score Exp Explan ana ation 3. 1 1 1 1 The Diagonal Lines intersect more than * /4 inch from the true midpoint of the Large Rectangle (2). 8 . 11. 17. One too many lines are drawn. The lower dot was drawn as a line rather than a dot. The small vertical line that connects the cross to the Large Rectangle (2) is more than l/4 inch from the Vertical Midline (5). Note. All other units are drawn accurately and placed properly and receive a score of 2. 94 Figure A8. Scoring Example 2: Immediate Recall trial. Explanation of Scores w Unit Score Explanation 1. 1 The bottom of the cross is more than lA inch below the Horizontal Midline (4). 2. 1 The u nit is a square rather than a rect rectangle. angle. 3. 0 The un it is missing. 4. The Horizontal Midline is more than * /4 inch below the true center of the Large Rectang le (2). 5. 1 1 The Vertical Vertical Midline is mo re than */ 4 inch from the true center of the Large Rectang le (2). (2). 7. 0 The un it is missing. 8. 0 .5 There are too m any lines and the unit is misplaced, bu t it iiss stil stilll recognizable. 9. 0 The un it is missing. 10. 0 11. 1 The un it iiss missing. The u nit is drawn accuratel accurately, y, but p laced incorrectly. incorrectly. 13. 1 The apex of the Sides o f the Large Triangle Triangle is more than '/ 4 inch from proper placement. 15. 0 The un it iiss missing. 17. 0 The un it is missing. 18. 0 The unit is missing. N ot e. All other units are drawn accurately and placed properly and receive a score of 2. 95 Figure A9. S c or i ng E xa m pl e 2: D e l a ye d R e c a l l tr tr i aall . Explanation of Scores Unit Score Explanation 1. 1 The bottom of the cross is more than lA inch below the Horizontal Midline (4). 2 . 1 The heigh t of the rectangle is greater than its width. 3. 0 The unit is missing. 4. 1 The H orizonta orizontall Midline is more than '/ 4 inch from the true midpoint of the Large Rectangle (2). 5. 1 The Vertical Midline is more than * /4 inch from the true midpoint of the Large Rectangle (2). 7. 0 The unit is missing. 8. 0 .5 T he he F o ou u r P aarr a l l e l L in in es es ar a r e rro o ta ta te te d m o re re tth h an an 3 0 d eg eg re re eess a n nd d aarr e p pll a ccee d in in co co rr rr e cctt l y , b ut ut th e u un n it it is is st st i l l recognizable. 9. 0 .5 Th hee S Sm m al al l T rrii a n gl gl e iiss dr dr a w n aass pa pa r t of o f th e S Sii d es es o f t h e L aarr g e T rrii a n gl gl e ((1 1 3 ) an an d i s m o orr e tth h an an * /4 inch away from the Vertica Verticall Midline (5). (5). Lx 10. 0 The unit is missing. O 11. 1 The unit is drawn accurately, but placed incorrectly. V_x 12. 0 13. 0 .5 .5 The unit is missing. O n e s id id e o f t he he tr tr ia ia n ng g llee d do o eess n no o t o ri ri gi gi na na te te aatt a c o rrn n e r o f t he he L Laa rg rg e R e ct ct aan n g le le (2 (2 ), ), t he he rree is is a c llo o su su re re eerr r o r, r, and the apex of the triangle is misplaced by m ore than */4 inch. 14. 0 The unit is missing. 15. 0 The unit is missing. 17. 0 The unit is missing. 18. 0 The u nit iiss missing. N ot e. All other units are drawn accurately and placed properly and receive a score of 2. 96 Lx F i g u r e A I O . Scoring Example 2: Recognition trial. 97 Scoring Sheet Scoring Criteria for RCFT Drawings A c c u ra c y Placement 2 Accurately drawn Correctly placed 1 Accurately drawn Incorrectly placed 1 Inaccurately drawn Correctly placed 0.5 Inaccurately drawn, but recognizable Incorrectly placed 0 Inaccurately dr drawn and unrecognizable, or omitted Incorrectly pl placed f S co r e Scoring Element Copy Immediate Recall D elayed Recall 1. Vertica l Cro ss 2. Large Rectangle 3. Diagonal Cross 4. Horizontal Midline of Large Rectang le (2) 5. Vertical Vertical Midline of Large Rectangle (2) (2) 6 . Small Rectang le 7. Small Horizontal Line above Small Rectangle (6 ) 8. Four Parallel Lines 9. Small Triangle above above Large Rectangle (2) (2) 10. 10. Small Ver Vertical tical Line within Large Rectangle ((2) 2) 11. 11. Circ le with Thre e Dots 12. 13. Five Parallel Lines Sides of Large Triangle attached to Large Rectangle (2) (2) 14. Diamond 15. Vertical Line within Sid es of Large Triangl e ( 13) 13) 16. Horizontal Line within Sides of Large Triangle ( 13) 17. 17. Horizontal Cross 18. 18. Square attached to Large Rectangle (2) 1 0 .5 .5 0 0 © © © © © © © © © I 0.5 0 .5 0 1 0 .5 0 I 0. 0.5 5 0 1 0 .5 0 1 0. 5 0 1 0 .5 0 1 0 .5 0 1 0 .5 0 1 0. 5 0 2 1 0 0 2 © 0.5 0 © 1 0 .5 .5 0 © 1 0.5 0 © 1 0 .5 .5 0 2 1 0 0 0 2 © 0.5 0 2 © 0.5 0 © \ 0.5 0 © 1 0.5 0 2 2 1 0 0 98 0 © 1 0.5 0 2 1 0 .5 © © I 0. 0.5 5 0 2 1 0 .5 © © \ 0.5 0 0.5© 2 1 0 2 1 0.5 © 2 1 0 .5 © © 1 0 .5 .5 0 © \ 0.5 0 © \ 0.5 0 © \ 0.5 0 © 1 0. 5 0 © 1 0 .5 0 © \ 0.5 0 © \ 0.5 0 © 1 0. 5 0 © 1 0 .5 0 © I 0.5 0 2 I 0.5© 2 1 0.5© 2 I 0.5 0. 5 © 2 1 0.5© 3 6 .0 13.5 13.5 Raw score Raw score Raw score 2 I Q 2 1 0 0 © 1 2 0 0 .5 0 1 0 .5 © 2 1 0 .5 .5 ^ ) 2 1 0 ..5 5© 2 1 0.5© Recognition Trial Worksheet M Recognition True Positives = Sum of items 2, 5, 7, 8 , 9, 12, 13, 15, 19, 20, 22, and 24 that were circled. _ 0 J 2 Recognition False Positives = Sum of items 1, 3, 4, 6 , 10, 11, 14, 16, 17, 18, 21, and 23 that were circled. Recognition Recogniti on True Negatives = 12 minus Recognition False Posit Positives. ives. _2 Recognition Recogniti on False Negatives = 1 2 minus Recognition True True Positives. Positives. 22 Recognition Total Correct = Recognition True Positives plus Recognition True Negatives. F i gu gu r e A l l . Scoring Example 3: Scoring Sheet. 1 Fi Figu gure re A ll . Scoring Example 3: Copy trial. Explanation of Score Scoress Note. All units are drawn accurately ac curately and placed properly and receive a score of of 2 2.. 99 F i g u re re A 1 3 . Scoring Example 3: Immediate Recall trial. Explanation of Scores Unit Sccore S Expla xplana natio tion n 1. 2. 6. 8. 10. 13. 15. 16. 17. 18. 0.5 1 0.5 0 0 0.5 0 0 0 0 The unit is drawn inaccurately and placed incorrectly, but it is still recognizable. The unit is drawn inaccurately, because it has a square shape. The unit is drawn inaccurately and placed incorrectly, but it is still recognizable. The unit is missing. The unit is missing. The unit is drawn inaccurately and placed incorrectly, but it is still recognizable. The unit is missing. The unit unit is is missing. missing. The The unit is missing. Note. All other units are drawn accurately and placed properly and receive a score of 2. 100 100 >_ \ _z Figure A14. Scoring Example 3: Delayed Recall trial. Explanation of Scores Scores w w VJ U w Unit Score Explanation 1. 2. 3. 6. 7. 8. 9. 10 10.. 12. 13. 13. 15. 16 16.. 17. 17. 18. 18. 0.5 The unit is drawn inaccurately and placed incorrectly, but it is still recognizable. The unit is drawn inaccurately, because it has a square shape. One section of the Diagonal Cross is missing. The unit is drawn inaccurately and placed incorrectly, but it is still recognizable. The unit is missing. The unit is missing. The unit is missing. The unit is missing. The unit is drawn accurately and placed properly, even though no diagonal line is present. The unit is drawn inaccurately and placed incorrectly, but it is still recognizable. The unit is missing. The unit is missing. The unit is missing. The unit is missing. 1 1 0.5 0 0 0 0 2 0.5 0 0 0 0 Note. All other units are drawn accurately and placed properly and receive a score of 2. w w 10 101 1 trial. F i gu gu r e A l 5 . Scoring Example 3: Recog nition trial. 1 02 Appendix B Nor No rmat mative Data for U.S. Ce C ens nsus us Age-Matched Sample Normative Data for U.S. Census Age-Matched Sample Raw scores %ile T 35.5-36.0 46 49 19.5 19.5 ,34.5 35.0 42 48 19.0 34.0 34.5 38 47 18.0-18.5 18.5-19.0 18.0 34 46 17.5 17.5 34.0 31 17.0 16.5-17.0 33.5 27 24 45 44 16.0-16.5 16.0 43 15.5 15.5 33.0 21 42 14.5-15.0 14.5-15.0 32.5 18 41 14.0 14.0 32.0 32.0 16 40 13.5 7 71 1 70 31.5 31.0 31.5 14 12 39 38 12.5-13.0 12.0 12.5 12.0 69 30.5 3 31 1.0 10 37 11.5 11.0-11.5 %ile T >99 >8 >80 0 35.0 35.0-3 -36. 6.0 0 >99 80 >99 79 >99 78 >99 77 >99 76 99 75 33.0 99 74 32.5 99 73 99 72 98 98 97 33.5 Recognition Total Correct Delayed Recall Immediate Recall Immediate Recall Delayed Recall Raw scores 24 13 1 3.0-13.5 Recognition Total Correct 20 19 30.5 8 36 10.5-11.0 10.5 30.0 30.0 7 35 10.0 10.0 66 29.5 29.5 5 34 9.5 9.0-9.5 93 65 29.0 29.0 4 33 8.5-9.0 8.5 92 6 64 4 28.5 28.5 4 32 8.0 8.0 90 63 28.0 28.0 3 31 7.5 7.5 88 62 27.5 27.5 2 30 7 7..0 6.5-7.0 86 6 61 1 27.0 27.0 2 29 6.0-6.5 6.0 84 60 26.5 26.5 1 28 5.5 5.5 82 59 25.5-26.0 25.5-26.0 1 27 5.0 5.0 25.0 25.0 1 26 4.5 4.5 1 <1 25 24 4.0 3.5 4.0 3.0-3.5 23 22 3.0 2.5 2. 2.5 5 2.0 96 68 96 67 95 79 9 58 23 18 17 76 73 57 56 24.5 24.0 24.5 24.0 69 55 23.5 23.5 66 54 5 4 22.5-23.0 22.5-23.0 <1 <1 62 53 22.0 22.0 <1 21 2.0 1.5 58 52 21.5 21.5 <1 20 1.5 1. 1.0 0 54 51 21.0 20.5-21.0 <1 <20 0 0..0-1.0 0.0-0.5 0-15 50 50 20.0-20.5 20.0 22 21 16 Raw scores Recognition variables Time Copyto True Positives False Positives True Negatives NeFalse gatives %ile 8-12 0-2 10-12 0 -4 >16 5 11-16 %ile Copy >16 32.5-36.0 0-317 11-16 31.0-32.0 318-339 6-10 28.0-30.5 340-416 2-5 24 2 4.5-27.5 417-599 6 <1 0.0-24.0 600 0-5 7 3 4-12 6-10 9 0-8 6 2-5 7--12 7 <1 104 104 Appendix C Demog mogr raphi phic c all lly yC Co orrec ted Norma Normattiv ive e Data w 105 v> Table Cl Age: 18 Years 0 Months 0 Days Through 19 Years 11 Months 31 Days Raw scores %ile T >99 >99 >99 >99 >99 >99 99 99 99 >80 80 79 78 77 76 75 74 73 99 98 98 72 71 70 Immediate Recall Delayed Recall 36.0 35.5 35.0 36.0 35.5 34.5 34.0 33.5 35.0 34.5 34.0 Raw scores Recognition Total Total Correct %ile T 46 42 38 34 31 27 24 21 18 49 48 47 46 45 44 43 42 41 16 14 12 40 39 38 Immediate Recall Delayed Recall 24.5 25.0 24.5 24.0 23.5 24.0 23.5 23.0 22.5 22.0 21.5 21.0 20.5 Recognition Total Correct 21 23.0 22.5 22.0 21.5 21.0 20.5 ; kJ 20 97 96 96 95 93 92 90 88 86 84 82 79 76 73 69 66 62 58 54 50 69 68 67 66 65 64 63 62 61 60 59 58 57 56 55 54 53 52 51 50 33.0 32.5 32.0 31.5 31.0 30.5 30.0 29.5 29.0 28.5 28.0 27.5 27.0 26.5 26.0 25.5 25.0 33.5 33.0 32.5 10 8 7 5 4 4 3 2 2 1 1 1 1 <1 <1 <1 <1 <1 <1 24 32.0 31.5 31.0 30.5 30.0 29.5 29.0 28.5 28.0 27.5 27.0 26.5 23 26.0 25.5 22 37 36 35 34 33 32 31 30 29 28 27 26 25 24 23 22 21 20 <20 20.0 19.5 19.0 ^_J 20.0 19.5 19.0 18.5 18.0 18.5 18.0 17.5 19 17.0 16.5 17.5 17.0 16.5 _ 16.0 15.5 16.0 1 5.5 Ly 15.0 15.0 14.5 18 14.0 0.0-13.5 0-17 , 14.5 0.0-14.0 Raw scores Recognition variables %ile Copy Time to Copy >16 11-16 6-10 2-5 <1 33.5-36.0 33.0 32.5 31.5-32.0 0..0-31.0 0 0-274 275-292 293-310 311-345 346-600 c True Positives False Positives True Negatives False Negatives 9-12 0-1 11-12 0-3 4 8 7 0 -6 2 3-12 10 0-9 5 6-12 Vy %ile >16 11-16 6-10 2-5 <1 106 106 Table C2 Age: 20 Years 0 Months 0 Days Through 24 Years 11 Months 31 Days Raw scor scores es Raw scores %ile T >99 >99 >99 >99 >99 >99 99 99 99 99 98 >80 80 79 78 77 76 75 74 73 72 71 Immediate Recall Delayed Recall X r 36.0 35.5 35.0 34.5 34.0 33.5 36.0 35.5 35.0 34.5 Recognition Total Corre ct Immediate Recall Delayed Recall %ile T 46 42 38 34 31 27 24 21 18 49 48 47 46 45 44 43 42 41 24.5 24.0 23.5 23.0 22.5 22.0 2 22 2.0 — ---21.5 21.0 21.5 21.0 16 14 40 39 20.5 20.0 20.5 Recognition Total Correct 24.5 24.0 23.5 21 23.0 22.5 20 v v-'; 98 97 96 96 95 93 92 90 88 86 84 82 70 69 68 67 66 65 64 63 62 61 6 60 0 59 79 76 73 69 66 62 58 54 50 58 57 56 55 54 53 52 5 51 1 50 34.0 33.5 33.0 32.5 32.0 31.5 31.0 33.0 32.5 32.0 31.5 31.0 30.5 30.0 29.5 29.0 28.5 24 30.5 30.0 29.5 29.0 23 28.5 28.0 27.5 27.0 28.0 27.5 27.0 26.5 26.0 25.5 25.0 26.5 26.0 25.5 25.0 22 12 10 8 7 5 4 4 3 2 2 1 1 38 37 36 35 34 33 32 31 30 29 28 27 2 20 0.0 19.5 19.0 18.5 18.0 18.0 17.5 17.0 1 1 <1 <1 <1 <1 <1 <1 26 25 24 23 22 21 20 <20 15.5 15.0 14.5 14 14.5 — 14.0 13.5 13.5 — 0.0-13.0 —? 19.5 19.0 18.5 —> 16.5 16.0 15.5 17.5 17.0 19 16.5 16.0 15.0 18 14.0 0.0-13.0 0-17 Raw scores Recognition variables % ile C opy Time Copyto True Positives False Positives True Neg ative ativess False Neg Negativ ativ es %il %ilee >16 11-16 6-10 2-5 <1 33.5-36.0 3 33 3.0 32.5 32.0 0.0-31.5 0-271 272-290 291-309 310-346 347-600 9-12 8 0-1 11-12 0-3 4 7 0 -6 2 3-12 10 0-9 5 6--12 6 >16 11-16 6-10 2-5 <1 '—107 107 Table C4 Age: 30 Years 0 Months 0 Days Through 34 Years 11 Months 31 Days Raw scores scores Raw scores c 'w 'w.. %ile T >99 >99 >99 >99 >99 >99 99 99 99 99 98 >80 80 79 78 77 76 75 74 73 72 71 Immediate Ree ca R ca ll ll D elay ed R ec ec aalll 36.0 35.5 35.0 34.5 34.0 33.5 33.0 36.0 35.5 35.0 34.5 34.0 33.5 33.0 R e c o g n i ti o n Tot Tota l C o rre rrecc t %ile T 46 42 38 34 31 27 24 21 18 16 14 49 48 47 46 45 44 43 42 41 40 39 I m m e d ia te Recall Delayed Recall 23.0 22.5 22.0 21.5 21.0 20.5 20.0 19.5 19.0 23.0 22.5 22.0 21.5 21.0 20.5 18.5 20.0 19.5 19.0 18.5 Recognition Total Corr ect 21 20 w c w c w w W w w C C 98 97 96 96 95 93 92 90 88 86 84 82 70 69 68 67 66 65 64 63 62 61 6 60 0 59 59 32.5 32.0 31.5 31.0 79 76 73 69 66 62 58 54 50 58 57 56 55 54 53 52 51 50 27.0 26.5 26.0 25.5 25.0 24.5 30.5 30.0 29.5 29.0 28.5 28.0 27.5 24.0 23.5 32.5 24 32.0 31.5 31.0 30.5 30.0 29.5 29.0 28.5 28.0 27.5 23 27.0 26.5 26.0 25.5 25.0 24.5 24.0 23.5 22 12 10 8 7 5 4 4 3 2 2 1 1 38 37 36 35 34 33 32 31 30 29 28 27 1 1 <1 <1 <1 <1 <1 <1 26 25 24 23 22 21 20 <2 <20 0 18.0 17.5 17.0 16.5 16.0 15.5 15.0 14.5 14.0 13.5 18.0 17.5 19 17.0 16.5 16.0 15.5 15.0 18 14.5 14.0 13.5 13.0 12.5 12.0 13.0 12.5 12.0 17 11.5 11.0 0. 0.0 0-1 -10 0.5 11.5 11.0 0.0-10.5 0-16 % ile w R a w s c o r es es C w Recognition variables c w w %ile Co C opy T im e to C opy T ru e P o s i tiv e s F a lse Posi Positi tive vess True Ne Nega gati tive vess False N e g a tiv e s >16 11-16 6-10 2-5 <1 34.0-36.0 33.5 33.0 32 3 2.0-32.5 0.0-31.5 0-271 272-293 294-315 316-359 360-600 8-12 0-1 11-12 0-4 7 6 0-5 2 10 3-12 0-9 5 6 7--12 7 >16 11-16 6-10 2-5 2-5 <1 c W 10 109 9 Table C5 Age: 35 Years 0 Months 0 Days Through 39 Years 11 Months 31 Days Raw scores Raw scores Immediate Recall %ile T >99 >80 >99 80 36.0 >99 79 35.5 >99 78 35.0 >99 77 >99 76 34.5 99 75 34.0 99 74 33.5 99 73 33.0 99 72 98 71 32.5 Delayed Recall Recognition Total Correct %ile T Immediate Recall Delayed Recall Recognition Total Correct 46 49 22.0 22.0 21 42 48 21.5 21.5 36.0 38 47 21.0 21.0 35.5 34 46 20.5 20.5 35.0 31 45 20.0 34.5 27 44 19.5 20.0 24 43 19.0 19.5 34.0 21 42 18.5 19.0 33.5 18 41 33.0 16 40 18.0 18.0 32.5 14 39 17.5 17.5 f 18.5 20 98 70 32.0 32.0 12 38 17.0 97 69 31.5 31.5 10 37 16.5 96 68 68 31.0 31.0 8 36 16.0 16.5 96 67 30.5 30.5 7 35 15.5 16.0 95 66 30.0 30.0 5 34 15.0 15.5 93 65 29.5 29.5 4 33 92 64 29.0 29.0 4 32 14.5 90 63 28.5 28.5 3 31 14.0 88 62 2 30 13.5 14.0 86 61 28.0 2 29 13.0 13.5 84 60 27.5 27.5 1 28 82 5 59 9 27.0 27.0 1 27 12.5 79 58 26.5 26.5 1 26 12.0 76 57 26.0 26.0 1 25 11.5 73 56 25.5 25.5 <1 24 69 55 25.0 25.0 <1 23 11.0 66 54 24.5 24.5 <1 22 10.5 62 53 24.0 24.0 <1 21 58 52 23.5 23.5 <1 20 10.0 10.0 54 51 23.0 23.0 <1 <20 0.0-9.5 0.0-9.5 0-16 50 50 50 22.5 22.5 24 28.0 23 22 17.0 19 15.0 14.5 18 13.0 12.5 12.0 17 11.5 11.0 10.5 Raw scores Recognition variables Time to Copy True Positives False Positives True Negatives False Negatives %ile 8-12 0-1 11-12 0 -4 >16 7 2 10 %ile Copy >16 33.5-36.0 11-16 33.0 276-298 .6-10 32.5 299-322 2-5 31.5-32.0 323-369 6 <1 0.0-31.0 370-600 0-5 0-275 3-12 0-9 11-16 5 6-10 6 2-5 7-12 <1 110 110 Table C6 Age: 40 Years 0 Months 0 Days Through 44 Years 11 Months 31 Days Raw scores Raw scores Recognition Iotal Correct Delayed Recall %ile T Immediate Recall 36.0 46 49 21.0 21.0 35.5 42 48 20.5 20.5 35.0 35.0 38 47 20.0 20.0 78 34.5 34.5 34 46 19.5 19.5 >99 77 34.0 34.0 31 45 19.0 19.0 >99 76 33.5 27 44 18.5 99 75 33.5 24 43 18.0 18.5 99 74 33.0 33.0 21 42 17.5 18.0 99 73 32.5 32 32.5 18 41 17.0 17.5 99 72 32.0 32.0 16 40 16.5 17.0 %ile T Immediate Recall >99 >8 > 80 35.5 35.5-3 -36. 6.0 0 >99 80 >99 79 >99 Delayed Recall Recognition Total Correct 20 14 39 12 38 1 16 6.0 16.0 30.5 10 37 15.5 15.5 30.0 30.0 8 36 15.0 29.5 29.5 7 35 14.5 15.0 29.0 5 34 14.0 14.5 29.0 28.5 4 33 13.5 14.0 64 28.5 28.0 4 32 90 63 28.0 27.5 3 31 13.0 88 62 27.5 27.0 2 30 12.5 86 61 27.0 2 29 12.0 12.5 84 60 26.5 26.5 1 28 11.5 12.0 82 59 26.0 26.0 1 27 79 58 25.5 25.5 1 26 11.0 76 57 25.0 25.0 1 25 10.5 73 56 24.5 24.5 <1 24 10 10.0 69 55 24.0 24.0 <1 23 66 54 23.5 23.5 <1 22 9.5 62 53 23.0 23.0 <1 21 9.0 58 52 22.5 22.5 <1 20 54 51 22.0 22.0 <1 <20 50 50 21.5 21.5 98 71 31.5 31.5 98 70 31.0 31.0 97 69 30.5 96 68 96 67 95 66 93 65 92 24 23 22 19 16.5 18 13.5 13.0 17 11.5 11.0 10.5 10.0 9.5 9.0 0.0-8.5 0.0-8.5 0-16 21 Raw scores scores Recognition variables Time to Copy True Positives False Positives True Negatives False Negatives %ile 8-12 0--2 0 10-12 0- 4 >16 5 11-16 %ile Copy >16 33.5-36.0 11-16 33.0 284-308 6-10 32.5 309-333 2-5 31.0-32.0 334-384 6 3 9 6 22-5 5 <1 0.0-30.5 385-600 0-5 4-12 0-8 7-12 <1 0-283 7 6-10 \ Table C7 Age: 45 Years 0 Months 0 Days Through 49 Years 11 Months 31 Days Raw scores Raw scores %ile T Immediate Recall >99 >80 35.0-36.0 >99 80 >99 Delayed Recall Recognition Total Correct %ile T Immediate Recall Delayed Recall 35.0-36.0 46 34.5 42 49 48 20.0 19.5 20.0 34.5 79 34.0 34.0 >99 78 33.5 47 46 19.0 18.5 >99 >99 77 76 33.0 33.5 33.0 38 34 31 45 18.0 18.0 44 32.5 99 75 74 17.5 17.0 17.5 99 27 24 31.5 31.0 42 41 17.0 73 72 21 18 16.5 99 99 32.0 31.5 16.0 16.5 31.0 16 40 15.5 16.0 98 71 30.5 14 39 15.0 15.5 32.5 32.0 30.5 24 43 Recognition Total Correct 19.5 19.0 18.5 20 f V 19 98 70 30.0 30.0 12 38 97 29.5 29.5 29.0 10 37 14.5 14.5 W 96 69 68 8 36 14.0 14.0 O 96 67 29.0 28.5 7 13.5 95 66 28.5 28.0 93 65 28.0 27.5 5 4 35 34 92 90 64 27.5 27.0 27.0 26.5 26.0 25.5 88 63 62 86 84 61 26.5 26.0 60 25.5 82 59 25.0 25.0 79 76 58 57 24.5 24.0 24.5 24.0 73 56 23.5 23.5 69 66 55 54 23.0 22.5 23.0 22.5 62 53 22.0 58 54 52 21.5 22.0 21.5 51 50 21.0 20.5 21.0 20.5 50 23 13.5 33 13.0 12.5 4 32 12.0 12.5 3 2 31 30 11.5 12.0 11.5 2 1 29 28 11.0 10.5 11.0 1 27 10.0 10.5 1 1 9.5 <1 <1 26 25 24 9.0 9.5 23 8.5 9.0 <1 22 <1 <1 21 20 7.5 8.0 <1 <20 0.0-7.0 0.0-7.5 22 21 15.0 18 o 13.0 17 10.0 __s 8. 8.5 5 8.0 16 0-15 VJ Raw scores •w Recognition variables vw / Time to Copy True Positives False Positives True Negatives False Negatives %ile w 8-12 0--2 0 10-12 0- 4 >16 - 5 11-16 6-10 %ile Copy >16 33.0-36.0 11-16 3 32 2.5 0-293 294-320 6-10 32.0 ,321-347 2-5 31.0-31.5 348-400 <1 0.0-30.5 40 4 01-600 7 6 0-5 3 4-12 9 0-8 6 7-12 2-5 <1 1 1 2 :v O Table C8 Age: 50 Years 0 Months 0 Days Through 54 Years 11 Months 31 Days Raw scores Raw scores o O - ^ j o %ile T Immediate Recall >99 >80 33. 33.5-3 5-36.0 6.0 >99 80 33.0 >99 79 >99 78 32.5 >99 77 32.0 >99 76 99 Delayed Recall Recognition Total Correct Delayed Recall 19.0 %ile T Immediate Recall 33.5 33.5-3 -36 6.0 46 49 18.5 33.0 42 48 32.5 38 47 18.0 18.0 34 46 17.5 17.5 32.0 31 45 17.0 17.0 31.5 31.5 27 44 16.5 16.5 16. 5 75 31.0 31.0 24 43 16.0 16.0 99 74 30.5 30.5 21 42 15.5 15.5 99 73 30.0 18 41 15.0 15.0__ 99 98 72 71 16 14 40 39 1 14 4.5 14.0 14.5 30.0 29.5 29.5 29.0 24 Recognition Total Correct 18.5 20 •' 19 w 98 70 29.0 28.5 12 38 13.5 14.0 97 6 69 9 28.5 28.0 10 37 13.0 13.5 96 68 28.0 27.5 8 36 12.5 13.0 96 67 27.5 7 35 12.0 12.5 95 6 66 6 27.0 27.0 5 34 11.5 12.0 93 65 26.5 26.5 4 33 92 64 26.0 26.0 4 32 11.0 90 63 25.5 25.5 3 31 10.5 11.0 88 62 25.0 25.0 2 30 10.0 10.5 86 61 24.5 24.5 2 29 9.5 10.0 84 6 60 0 24.0 24.0 1 28 82 59 23.5 23.5 1 27 9.0 79 76 58 57 23.0 22.5 23.0 22.5 1 1 26 25 8.5 8.0 73 56 22.0 22.0 <1 24 69 55 21.5 21.5 <1 23 7.5 66 54 21.0 21.0 <1 22 7.0 62 5 53 3 20.5 20.5 <1 21 58 5 52 2 20.0 20.0 <1 20 6.5 w 54 51 19.5 19.5 <1 <20 0.0-6.0 c> 50 50 19.0 j w w v_7 23 22 21 18 11.5 17 9.5 9.0 8.5 8.0 16 7.5 7.0 0.0-6.5 0-15 Raw scores Recognition variables O Time Copyto ees PoTsrituiv PoFsaitlisvees ru NeT ga tieves False Negatives %ile 8-12 0-2 10 1 0-12 0 -4 >16 5 11-16 %ile Copy >16 32.5-36.0 11-16 3 2.0 . 307-335 6-10 31.5 336-363 2-5 30.0-31.0 364-419 6 3 9 6 2-5 <1 0.0-29.5 420-600 0-5 4-12 0-8 7-12 <1 0-306 7 6-10 11 113 3 Table C9 Age: 55 Years 0 Months 0 Days Through 59 Years 11 Months 31 Days Raw scores %ile T Immediate Recall >99 >80 32.0-36.0 >99 80 ' 31.5 >99 79 >99 78 31.0 >99 77 30.5 >99 76 30.0 99 75 99 74 99 73 99 98 72 71 Delayed Recall Raw scores Recognition Total Total Correct %ile T Immediate Recall 32.0-36.0 46 49 17.5 17.5 31.5 42 48 17.0 17.0 31.0 38 47 16.5 16.5 30.5 34 46 16.0 16.0 31 45 15.5 15.5 30.0 27 44 15.0 15.0 29.5 29.5 24 43 14.5 14.5 29.0 29.0 21 42 14.0 14.0 18 41 13.5 16 14 40 39 13.0 12.5 28.5 28.5 28.0 28.0 27.5 24 Delayed Recall 13.5 13.0 Recognition Total Correct 20 > ' 19 98 70 70 27.5 27.0 12 38 12.0 12.5 97 69 27.0 26.5 10 37 11.5 12.0 96 68 26.5 26.0 8 36 11.0 11.5 96 67 67 26.0 25.5 7 35 95 66 25.5 5 34 10.5 93 65 25.0 25.0 4 33 10.0 10.5 92 64 24.5 24.5 4 32 9.5 10.0 90 6 63 3 24.0 24.0 3 31 9.0 9.5 88 62 23.5 23.5 2 30 8.5 9.0 86 6 61 1 23.0 23.0 2 29 84 60 22.5 1 28 8.0 8.5 82 59 22.5 22.0 1 27 7.5 8.0 79 58 58 22.0 21.5 1 26 7.0 7.5 76 57 21.5 21.0 1 25 73 56 21.0 20.5 <1 24 6.5 7.0 69 55 20.5 20.0 <1 23 6.0 6.5 66 54 54 20.0 19.5 <1 22 5.5 6.0 62 53 19.5 19.0 <1 21 58 52 19.0 <1 20 5.0 5.5 54 51 18.5 18.5 <1 <20 0.0-4.5 0.0-5.0 0-15 50 5 50 0 18.0 18.0 23 22 21 18 11.0 17 16 Raw scores Recognition variables Time to Copy True Positives False Positives True Negatives False Negatives %ile 8-12 0--2 0 10-12 0-4 >16 5 11-16 %ile Copy >16 32.0-36.0 11-16 3 31 1.5 328-357 6-10 30.5-31.0 358-387 2-5 29.0-30.0 388-448 6 3 9 6 2-5 <1 0.0-28.5 449-600 0-5 4-12 0-8 7-12 <1 0-327 7 6-10 11 114 4 Table CIO Age: 60 Years 0 Months 0 Days Through 64 Years 11 Months 31 Days <_x w Vw Raw scores Raw scores %ile T Immediate Recall >99 >80 30.5 30.5-3 -36. 6.0 0 >99 80 ' 30.0 >99 79 >99 78 29.5 >99 77 29.0 >99 76 28.5 99 75 28.0 99 74 99 73 27.5 99 98 72 71 27.0 26.5 %ile T Immediate Recall 30.5 30.5-3 -36. 6.0 0 46 49 16.0 16.0 30.0 42 48 15.5 15.5 29.5 38 47 15.0 15.0 29.0 34 46 14.5 31 45 14.0 14.5 28.5 27 44 13.5 14.0 28.0 24 43 13.0 13.5 21 42 12 12.5 13.0 27.0 18 41 26.5 26.0 16 14 40 39 Delayed Recall 27.5 Recognition Total Correct 24 Delayed Recall 12.5 12.0 11.5 12.0 11.5 Recognition Total Correct 20 f 19 w Vw- V 'w' Vw- 98 70 26.0 25.5 12 38 11.0 97 69 69 25.5 25.0 10 37 10.5 11.0 96 68 25.0 8 36 10.0 10.5 96 67 24.5 7 35 9.5 10.0 95 66 5 34 9. 9 .0 9.5 93 65 24.0 23.5 4 33 8.5 92 64 64 23.5 23.0 4 32 90 63 23.0 22.5 3 31 8.0 8. 8.5 5 88 62 22.5 22.0 2 30 7.5 8.0 86 61 22.0 21.5 2 29 7.0 7.5 84 60 21.5 21.0 1 28 .82 59 21.0 20.5 1 27 6. 6.5 7.0 79 58 20.5 20.0 1 26 6.0 6. 6.5 5 76 57 20.0 19.5 1 25 5.5 6.0 73 56 19.5 <1 24 69 55 19.0 19.0 <1 23 5.0 5.5 66 54 18.5 18.5 <1 22 4.5 5.0 62 53 18.0 18.0 <1 21 58 52 17.5 17.5 <1 20 4.0 4.5 54 51 17.0 17.0 <1 <20 0.0-3.5. 0.0-4.0 0-15 50 50 16.5 16.5 24.5 23 24.0 22 21 18 9.0 17 16 \\ Vw Raw scores Recognition variables 'w 'k . <w Time to Copy %ile Copy >16 31.5-36.0 0-346 11-16 30.5-31.0 347-378 6-10 30.0 379-409 2-5 28.5-29.5 4 10- 472 <1 0.0-28.0 4 73- 600 True Positives False Positives True Negatives False Negatives %ile 7-12 0-2 10-12 0 -4 >16 5 11-16 6-10 6 0-5 3 9 6 22-5 5 4-12 0-8 7--12 7 <1 115 A -r ^ Tablee C ll Tabl Age: 65 Years 0 Months 0 Days Through 69 Years 11 Months 31 Days Raw scores %ile T Immediate Recall Delayed Recall >99 >80 28.5-36.0 28.0-36.0 >99 80 ' 28.0 >99 79 27.5 >99 78 >99 77 >99 Raw scores Recognition Total Correct %ile T Immediate Recall 46 49 14.0 42 48 27.5 38 47 13.5 13.5 27.0 34 46 13.0 13.0 27.0 26.5 31 45 12.5 12.5 76 26.5 26.0 27 44 12.0 12.0 99 75 26.0 25.5 24 43 11.5 11.5 99 74 25.5 21 42 11.0 99 73 25.0 18 41 10.5 11.0 99 98 72 71 24.5 24.0 16 14 40 39 10.0 9.5 10.5 10.0 25.0 24.5 24 Delayed Recall Recognition Total Correct 20 14.0 > 19 98 70 24.0 23.5 12 38 97 69 23.5 23.0 10 37 96 68 23.0 22.5 8 96 67 22.5 95 66 22.0 93 65 92 64 90 9.0 9.5 36 8.5 9.0 7 35 8.0 8.5 8.5 22.0 5 34 7.5 8.0 21.5 4 33 7.0 7.5 21.5 21.0 4 32 6.5 63 21.0 20.5 3 31 88 62 20.5 20.0 2 30 6.0 6.5 86 61 20.0 19.5 2 29 5.5 6.0 84 60 19.5 19.0 1 28 5.0 82 59 19.0 18.5 27 79 58 18.5 1 1 26 4.5 5.0 76 57 18.0 18.0 1 25- 4.0 4.5 73 56 17.5 17.5 <1 24 3.5 69 55 17.0 17.0 <1 23 66 54 16.5 16.5 <1 22 3.0 62 53 16.0 16.0 <1 21 2.5 58 52 15.5 15.5 <1 20 54 51 15.0 15.0 <1 <20 50 50 14.5 14.5 23 22 21 18 17 7.0 5.5 16 4.0 3.5 3.0 0.0-2.0 0.0-2.5 0-15 Raw scores Recognition variables Time to Copy True Positives False Positives True Negatives False Negatives %ile 8-12 0-2 10 1 0-12 0- 4 >16 5 11-16 %ile Copy >16 30.5-36.0 0-376 11-16 29 29.5 .5-- 3 30 0.0 377-409 6-10 28.5-29.0 410-443 22-5 5 26.5-28.0 444-509 6 <1 0.0-26.0 510-600 0-5 7 3 9 4-12 0-8 6-10 6 2-5 2-5 7--12 7 <1 11 116 6 L, Tab able le 0 2 L. Age: 70 Years 0 Months 0 Days Through 74 Years 11 Months 31 Days Raw scores Raw scores Delayed Recall %ile T Immediate Recall >9 >99 9 >8 > 80 26.5 26.5--36.0 36.0 >99 >99 >99 80 26.5-36.0 26.0 79 78 77 26.0 25.5 25.5 25.0 99 99 76 75 74 24.5 24.0 24.5 24.0 23.5 99 99 73 72 23.5 23.0 >99 >99 25.0 Recognition Total Correct 24 Immediate Recall Delayed Recall Recognition Total Correct 13.0 12.5 12.0 13.0 12.5 20 %ile T 46 42 38 34 49 48 47 46 31 45 11.5 11.0 27 44 10.5 11.0 24 43 42 10.0 9.5 10,5 21 18 16 41 40 12.0 11.5 10.0 9. 9.5 5 9.0 19 A. s V/, v^ V. 98 98 97 96 96 95 93 92 90 71 70 69 68 67 66 65 64 63 62 61 23.0 22.5 22.0 21.5 21.0 20.5 20.0 19.5 88 86 84 60 19.0 18.5 18.0 82 59 17.5 c 69 66 62 58 57 56 55 54 17.0 16.5 %, 79 76 73 53 52 14.5 51 50 14.0 'w 58 54 50 16.0 15.5 15.0 13.5 8. 8.5 5 9.0 12 39 38 8.0 8. 8.5 5 10 37 20.0 19.5 5 4 4 36 35 34 8.0 7.5 20.5 8 7 7.5 7.0 6.5 33 32 3 2 2 31 30 29 1 1 28 1 1 <1 <1 26 25 24 23 <1 <1 <1 22 21 22.5 14 22.0 21.5 21.0 23 19.0 18.5 22 18.0 17.5 17.0 16.5 16.0 15.5 21 15.0 14.5 <1 14.0 13.5 27 20 <20 18 7.0 6.0 5.5 5.0 6.5 6.0 17 5. 5.5 5 4.5 4.0 3.5 3.0 5.0 4.5 4.0 3.5 16 2.5 3.0 2.0 2.5 1.5 2.0 0.0-1.0 0.0-1.5 0-15 %ile Raw scores Recognition variables Sw <w Time to Copy c %ile Copy 29.5-36.0 0-399 <, >16 11-16 400-433 6-10 28.5 28.5-2 -29 9.0 27.5-28.0 2-5 <1 25.5-27.0 0.0-25.0 £ w True Positives False Positives True Negatives False Negatives 8-12 0--2 0 10-12 0-4 5 7 3 434-468 469-538 539-600 9 6 0-5 >16 11-16 6-10 22-5 5 4-12 0-8 6 7--12 7 <1 s_ 'w. 'w. 117 Table C13 Age: 75 Years 0 Months 0 Days Through 79 Years 11 Months 31 Days Raw scores %ile T Immediate Recall >99 >80 24.5-36.0 >99 80 >99 79 24.0 >99 78 23.5 >99 77 >99 76 99 Delayed Recall Raw scores Recognition Total Total Correct Immediate Recall Delayed Recall %ile T 24.5-36.0 46 49 24.0 42 48 11.0 11.0 38 47 10.5 10.5 34 46 10.0 10.0 23.0 31 45 9.5 23.0 22.5 27 44 9.0 9.5 75 22.5 22.0 24 43 8.5 9.0 99 74 22.0 21.5 21 42 8.0 8. 8.5 5 99 73 21.5 18 41 99 72 16 40 7.5 8.0 23.5 21.0 24 Recognition Total Correct 11.5 ? 19 98 71 21.0 20.5 14 39 7.0 7.5 98 70 20.5 20.0 12 38 6.5 7.0 97 69 20.0 19.5 10 37 6.0 6.5 96 68 19.5 8 36 96 67 19.0 7 35 5.5 6.0 95 66 19.0 18.5 5 34 5.0 5.5 93 65 18.5 18.0 4 33 4. 4.5 92 64 18.0 17.5 4 32 4.0 90 63 17.5 17.0 3 31 88 62 17.0 2 30 3.5 86 61 16.5 16.5 2 29 3.0 84 60 16.0 16.0 1 28 2.5 82 59 15.5 1 27 79 76 58 57 15.5 15.0 15.0 14.5 1 1 26 25 73 56 14.5 <1 24 69 55 14.0 14.0 <1 23 66 54 13.5 13.5 <1 22 62 53 13.0 13.0 <1 21 0.5 58 52 12.5 12.5 <1 20 0.0 54 51 12.0 12.0 <1 <20 50 50 11.5 23 22 21 18 17 5.0 4.5 4.0 3.5 3.0 2.0 1.5 16 2.5 2.0 1.0 1.5 1.0 1.0 0.0-0.5 0-15 20 Raw scores scores Recognition variables Time to Copy True Positives False Positives True Negatives False Negatives %ile 8-12 0-2 10-12 0- 4 >16 7 3 9 5 11-16 %ile Copy >16 28.5-36.0 0 -4 2 7 11-16 27.5-28.0 428-463 6-10 26.5-27.0 464-499 2-5 24.0-26.0 500-572 6 4 8 6 2-5 <1 0.0-23.5 573-600 0-5 5-12 0-7 7--12 7 <1 6-10 11 118 8 O Table C14 U Age: 80 Years 0 Months 0 Days Through 89 Years 11 Months 31 Days Raw scores O Raw scores Immediate Recall Delayed Recall Recognition Total Correct 20.5-36.0 20.0 19.5 24 %ile T >99 >99 >99 >99 >99 >99 99 99 >80 80 79 78 77 76 75 74 20.5-36.0 99 73 18.0 20.0 19.5 19.0 18.5 Immediate Recall Delayed Recall 8.5 8.0 7.5 7.0 6.5 8.5 8.0 %ile T 18.0 46 42 38 34 31 27 24 21 49 48 47 46 45 44 43 42 6.0 5.5 6.0 17.5 18 41 5.0 5.5 19.0 18.5 7.5 7.0 6.5 Recognition Total Correct 19

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