Applied Neuropsychology 1998, Vol 5,No 3, 120-131 Copyright 1998 by. Lawrence Exlbaum Associates, Inc. Validation of Memory Error Patterns on the Rey Complex Figure and Recognition Trial John E. Meyers NW lowa Rehabilitation Consultants, Sioux City, lowa, USA Marie Volbrecht Department of Psychology, University of South Dakota, Vermillion, South Dakota, USA ‘The identification and use of Memory Error Patterns (MEPs) for the Rey Complex Figure and Recognition Trial is a new concept. The current series of experiments first validates the presence of MEPs using a cluster analysis, then provides base rate information on a large group of normal control participants. Finally, the MEPs of various clinical groups are examined. The findings of these studies support the presence of MEPs and the clinical rules used to identify these MEPs. Normal control participants are expected to achieve Normal/Other MEPs, whereas mild to moderately impaired participants will generally produce Retrieval or Norma/Other MEPs. In addition, severely impaired participants will produce Storage, En- coding, or Attention MEPs. The usefulness of the MEP in clinical practice is discussed. Key words: neuropsychology, Memory Error Patterns, Rey Complex Figure Test ‘Memory Error Patterns (MEPs) for the Rey Complex Figure (RCFT) and Recognition Trial (RT) were first presented in the test manual (Meyers & Meyers, 1995). This updated manual improved the normative base for the RCFT, including norms for persons ages 6 to 89. ‘Meyers and Meyers (1995) and Meyers and Lange (1994) found that the inclusion of an RT adds a dimen- sion to the RCFT not previously available. The RT consists of 12 parts of the RCFT mixed with 12 distrac- ters, and the individual is instructed toidemtify those that are parts of the original stimulus. Discrimination of normal, brain-injured, and psychiatric participants is good when the RCFT and RT are used together (Meyers & Lange, 1994) MEPs using performance on the RCFT and RT were developed according to the model proposed by Sohlberg and Mateer (1989). This model results in the use of the configurations of Immediate Recall Trial (IT), Delayed Recall Trial (DT), and RT. Originally, five MEP con- figurations based on the relative positions of the IT, DT, and RT scores on the RCFT were identified and ex- plained in the test manual (Meyers & Meyers, 1995) and Special thanks to Glenn Larabee for suggestions on previous versions ofthis work. Requests for reprints should be sent to John E. Meyers, NW Towa Rehabiltaion Consultants, 500 Jackson Street, Suite 340, Sioux. City, IA 51101 USA. E-mail: meyers @willinet ne. 120 verified in further study (Meyers, Bayless, & Meyers, 1996). These configurations were labeled as Attention, Encoding, Storage, Retrieval, and Normal/Other. ‘The general rule for MEPS is that either the IT score or DT score must be below a 7 score of 40 for an MEP to be present. T'scores at or above 40 are not labeled as “errors.” The clinically derived rules for MEPs are presented in Table 1. Meyers et al. (1996) found that the different MEPs were each associated with different functioning levels on the Rancho Scale (rs = .86, p < 001). The use of Rancho levels provides a limited ‘method of identifying degrees of independence, as the Rancho Scale has only general guidelines for subject classification. Fora description of the Rancho Scale, see Lezak (1995). A Retrieval MEP is expected for persons functioning at Rancho Level VIII, Storage MEPs are expected at Rancho Level VI to VII, and Encoding and Attention MEPs are expected at Rancho Levels Ill to IV. Storage, Encoding, and Attention MEPs are ex- pected only for individuals who are extremely impaired cognitively. Tn general, a Normal/Other MEP is a configuration of the IT, DT, and RT T scores that does not match the rules for a Retrieval, Storage, Encoding, or Attention MEP. A Retrieval Type 1 MEP is defined as a V-shaped configuration with Immediate less than Delayed and Recognition less than Delayed. There is one special- case Retrieval MEP that is found in individuals who‘VALIDATION OF MEMORY ERROR PATTERNS ON THE RCFT AND RT ‘Table 1. Comparison of Clinical Rules and Decision Rules Used by Cluster Analysts for MEPS MEP Clinical Role | ‘Cluster Analysis Rule Reteval Type 1 ‘Immediate > Delayed and Delayed < Recognition Same Greater than 3 T score difference highest to lowest Minimum of 3 Tiference between Immediate and between Immediate, Delayed, and Recognition Delayed, and ? Tetween Delayed and Recognition Retrieval Type 2 Immediate and Delayed scores below 24 7 and Same Recognition > 10 T points above Delayed Storage Immediate > Delayed > Recognition Same Drop of more than 3 T from Immediate 10 Minimum of 2 T between Immediate and Delayed Recognition and I Thetween Delayed and Recognition Encoding Immediate and Delayed T scores at or below 24 Combines Attention and Encoding MEPs Increase of 10 T points or less from Delayed to Recognition Attention Immediate, Delayed, and Recognition below 247 Same Same as Encoding ‘Note: MEP = Memory Error Pater. have significant difficulty in recalling the figure under the free-recal setting but who are capable of doing well on the RT. These individuals achieve a backward L- shape. This is still classified as a Retrieval MEP, but for clarity itis labeled as Retrieval Type 2. Theoretically, the Retrieval (Types 1 and 2) MEP is thought to repre- sent impairment in retrieving information from mem- ory. However, when given a cue, the information can be recalled. Therefore, the deficit may be in the retrieval strategy of searching for the information to be recalled. ‘The Retrieval MEP is found in individuals who are generally functioning well with Activities of Daily Liv- ing (ADL) tasks (Meyers et al. 1996). ‘A Storage MEP occurs when there is a slope of declining scores from the IT to the DT and RT T'scores, such that IT is greater than DT, which is greater than RT. There is also one special case of the Storage MEP. If a score falls at or above 25 7 on the IT, but the DT and RT fall at 20 T (bottom of the scale), this is still classified as a Storage MEP. Theoretically, a Storage MEP suggests that information is lost due to poor storage of information. The Storage MEP may repre- sent an initial loss of information after the IT; this is represented by a drop in performance at the DT. How- ever, what separates the Retrieval MEP from the Stor- age MEP is that the individual does relatively more poorly on the RT than on the DT. Itis unknown whether this is due to consolidation difficulties or simple loss of new leaming, but the salient feature is that informa- tion cannot be recalled, even with cues. The Storage MEP is found in very impaired participants (Meyers et al., 1996). ‘An Encoding MEP is very rare and occurs the least often of all the MEPs. The Encoding MEP may be a variant of the Attention MEP. However, for classifica- tion purposes, an Encoding MEP is when the IT and DT T scores fall at or below 24 T and the RT is elevated (although not significantly) equal to or less than 10 7" above the DT. The theoretical explanation of an Encod- ing MEP is that the information was not necessarily perceived accurately (encoded for meaning), but when given cues, some (nonsignificant) improvement in per- formance can be found (jie., the individual at least attended to the stimulus). An Attention MEP occurs ‘when the IT, DY, and RT Tscores fall at or below 24 7. ‘The theoretical basis of the Attention MEP is that the patient is so impaired that he or she cannot even attend to the information; thus, what is not attended to cannot bbe recalled, even with cues. ‘The important factor of the MEP is the profile of the scores on the IT, DT, and RT of the RCFT. Just as a profile on the MMPI-2 is based on the position of the scales in relation to each other (i., a “Conversion V"), the same is true for the MEPs. When matching the MEPS with a particular set of data, it is the shape that is ‘matched using the T scores as references to help dis- criminate one MEP from another (i.e., Encoding vs. Retrieval). Just as an individual’s MMPI-2 Conversion V can be at various levels on the MMPI-2 profile, so can the MEPs be at various levels. Experiment 1 Hypotheses ‘The purpose of this first experiment is to validate the ‘MEPs used in subsequent experiments. It is hypothe- 121(MEYERS & VOLBRECHT sized that the patterns that were identified using clinical judgment will be verified using statistical techniques; in other words, statistical techniques will result in patterns similar or identical to those previously identified using clinical judgment. ‘Methods Participants. ‘There were 518 participants who had previously been administered the RCFT as part of, ‘a neuropsychological examination gathered from a larger data archive. The participants in the data archive represent a general clinical sample. These participants are independent of those who participated in the original development of the clinical rules (Meyers et al, 1996; Meyers & Meyers, 1995). Participants were selected on the criteria that the IT score, DT score, or both, om the RCFT was below 40 T. The mean age was 52.22 years (SD =23.20), with 11.64 years of education (SD =2.99). Of the participants, 244 were female and 274 were male; 54 were left-handed and 464 were right-handed. There were 477 White participants, 27 of mixed or other racial background, 9 African Americans, 2 Hispanics, and 3 Native Americans. Sixty-five participants were injured in motor vehicle accidents, 105 had stroke (CVA), 14 had brain tumor, 13 had anoxic/hypoxic events, 26 had brain injury due to falls or falling objects, 3 had gunshot wounds to the head, 7 were diagnosed with encephalopathy, 9 had multiple sclerosis, 22 had seizure disorders, 6 had hy- rocephalus, 78 were diagnosed with probable dementia ofthe Alzheimer’s type, 69 had various other dementias, 3 had pseudo-dementias, 4 were mentally retarded, 9 were developmentally delayed, 2 had cerebral palsy, 5 had learning disabilities, 6 had attention deficit disorder orattention deficit hyperactivity disorder, 39 hac mental health diagnoses/dual diagnosis, 2 had carbon monox- ide poisoning, 5 had substance abuse diagnoses, 1 had left stenosis less than 80%, and I had a diagnosis of lupus. The remaining 24 participants had other or un- clear diagnoses. ‘The mean Wechsler Adult Intelligence Scale-Re- vised (WAIS-R; Wechsler, 1981) Full-Scale 1Q (FSIQ) was 83.67 (SD = 11.95). For those participants with a loss of consciousness (n = 324), the mean loss was 3.52 days (SD = 12.07). The mean time since injury was 18.19 months (SD = 52.71). Using the Barona, Reynolds, and Chastain (1984) demographic IQ for- ‘mula, the estimated mean FSIQ was 95.27 (SD =6.92) ‘The mean RCFT IT T score was 29.92 (SD = 9.36), the 122 mean DT T score was 27.59 (SD = 7.56), and the mean RT T score was 34.40 (SD = 12.01). Procedures, All participants were administered a battery of neuropsychological tests by trained master’s- level technician or graduate students. All participants were administered the same general battery, although some individuals were unable to complete all tests due to injury (ie., arm in cast, hearing impairment). Materials. ‘The battery consisted of the WAIS-R even subtest short form; Callahan, Schopp, & Johnstone, 1997), Trail Making Test (Army Individual ‘Test Battery, 1944; Reitan & Wolfson, 1985), Judgment of Line Orientation (Benton, Hamsher, Vamey, & Spreen, 1983), Finger Tapping (Reitan & Wolfson, 1985), Finger Localization (Benton et al., 1983), Token Test (S. Spreen & Strauss, 1991), Sentence Repetition (S. Spreen & Strauss, 1991), COWA (FAS; O. Spreen, & Benton, 1969, 1977; see also Lezak, 1995; S. Spreen & Strauss, 1991), Animal Naming (S. Spreen & Strauss, 1991), Boston Naming (Mack, Freed, Williams, & Hen- derson, 1992), Dichotic Listening (Roberts et al., 1994), Auditory Verbal Learning Test (S. Spreen & Strauss, 1991), RFT (Meyers & Meyers, 1995), and the Book- let Category Test (Victoria Revision; S. Spreen & Strauss, 1991). Statistical analyses. Data were the J scores of RCFT DT, IT, and RT, and they were analyzed using K-Means Cluster Analysis. InK-Means Cluster Analysis, the procedure isrun several differenttimes, and adifferent numnber of possible clusters is specified each time. This procedure uses the Euclidean distance as its distance measure. The best solution was chosen by inspecting the significance ofallentering variables. The maximumcom- bined F values will be indicative of the solution that best explains the variance of the sample. In addition, the number of cases that enter each cluster was inspected to achieve a solution without extremely small numbers of cases. (These wouldhave indicated less prevalent, orrare, characteristics in the sample that would not be likely to be useful in classifying new individuals.) The conver- ‘gence criterion was set at 02 and the maximum allowed ‘number of iterations was set at 10. Because the previously clinically defined MEPs ‘numbered 5, a five-cluster solution was tried first (com- bined F value = 1070.97). Then a four-cluster solution was investigated. When it was noticed that the com- bined F value was greater (combined F value 1230.24), a three-cluster solution was investigated. TheVALIDATION OF MEMORY ERROR PATTERNS ON THE RCFT AND RT combined F value for this solution was smaller (com- bined F value = 1216.512), sono further analysis inthis direction was done. At this point, solutions with more ‘than five clusters were investigated. Both the six-cluster (Combined F value = 1027.81) and seven-cluster (com- bined F value = 981.041) solutions proved to have smaller combined F values than the four-cluster solu- tion. In addition, the combined F values declined from six to seven clusters. Therefore, no further exploration in this direction was pursued. It was determined that the four-cluster solution was most explanatory. In none of the solutions investigated was there any clusters of extremely small numbers of people. Therefore, this did not prove to be an issue when selecting the four-cluster solution as the best. To test the solution at which we arrived, the sample ‘was split in half randomly and the analysis was run again using only half the sample. It was assumed that the same results would be found. Then, the solution obtained using the split sample was tested by using the resultant clusters to classify the whole sample. If the solution proved to be sound, the cluster centers would change only slightly or not at all during the classification, The clusters that resulted from this were compared to the clusters formed using the entire sample to check for any discrepancies. It was assumed that none would be noted. ‘The final clusters from the split sample analysis were used for the interpretation, ‘As in factor analysis, inspection of the cluster char- acteristics is necessary to define the meaning of the clusters. The cluster centers for a cluster on each vari- able form a profile typical of the individuals in that cluster. In cluster analysis, the difference in scores between clusters is maximized and the differences in scores within each cluster is minimized. Therefore, the resultant clusters offer distinct and different profiles that ‘occur in the sample. After inspection, and using knowl- edge of the concepts involved in the task, clusters were named in a descriptive manner. Results Data were analyzed using a K-Means Cluster Analy- sis of those participants who had 7 scores less than 40 oneither the ITs or DTs. Analysis included the ITs, DTS, and RTs of the RCFT. The convergence criterion of 02 ‘was met after six iterations. The solution that maxi- mized the variance explained included four clusters. All three variables were significant in the solution: Imme- diate, F(, 514) = 378.74, p = .000; Delayed, F3, 514) =317.10,p =.000; and Recognition, F(3, 514) =534.41, ‘p=.000. The cluster centers forthe solution are depicted in Table 2. ‘The best solution on the split sample (n = 252) also included four clusters. The convergence criterion of 02 ‘was met after seven iterations. Again, all three variables were significant: Immediate, F(3, 248) = 197.59, p = 000; Delayed, F(3, 248) = 137.52, p = .000; and Rec ognition, F(3, 248) = 238.66, p = 000. After restoring the whole sample and running a classification based on these clusters, the cluster centers remained essentially the same. The cluster centers for both of these solutions are also depicted in Table 2, with descriptive names assigned. In addition, Table 3 indicates the number of cases included in each cluster solution. The participant classifications arrived at by the clas- sification procedure of the whole sample were exam- ined via analysis of variance (ANOVA) based on their cluster assignment. The variables included in the analy- sis were age, years of education, loss of consciousness, months since injury, demographic-based estimate of FSIQ (Barona et al., 1984), WAIS-R Verbal IQ (V1Q), WAIS-R Performance IQ (PIQ), and WAIS-R FSIQ. ‘Table 2. Final Cluster and Resultant Descriptive Names for Spl Sample Analysis, Split Sample” ‘Whole Sample” (Classtication™ Cluster Number Imm _Da_—_Ree__—iImm_—iDel_—siRec_—smm =~—Del_—Ree_—_—Descriptive Name 1 mn 2 4 2m mM 4 BM 2 44 Retrieval Typed 2 3 2 mB Benton 3 4 BB 0 3532 Storage 4 4384686855 Retiewal Type L ‘Nove: mm Immediate Recall Trial of Rey Complex Figure Trial (RCT); Del = Delayed Recall Trial of RCFT; Rec = Recognition Trial of RCFT n= 252." 18. 123MEYERS & VOLBRECHT ‘Table 3. Cases Included inthe Resultant Clusters for All Analyses (Classification by Custer Number ‘Whole Sample” Split Sample? Split Sample lution’ _ Descriptive Names t 107 3 107 Revrieval Type 2 179 76 ist Attention 3 119 46 108 Storage 4 113 1 Ma Retrieval Type 1 e518. = 82 ‘Table 4. Descriptive Statistics and Test Scores for the Four Cluster With Independent Samples Tests of Significance Variable Guster 1 Cluster 2 Cluster 3 Cluster 4 Age 45.56 (20.07, 5796(21.39)9 6055 (23.82), 4441 (23.19, Education 11.79( 241) 11.79( 2.24) 11,30 ( 3.08) 11.61( 391) Male 6 6 st 86 Female 46 85 37 56 Right-Handed 9 139 a 129 Left-Handed 8 2 n 3 Months 2432(54.00) 1853 (50.18) 8.40(35.56) 20.65 (63.12) DFSIQ 94.78( 7.81) 9629 ( 5.68) 95.12, 6.84) 94.59 ( 7.47) vig 85.72 (11.00), 81.65 (10.58) 88 58 (10.43).0 92.09 (11 31). FIQ 82.48 (11.19), TLOZ(1260» 84171 (12:72), 91.45 (LAT. FSIQ 82.66 ( 9.81). 77.49 (1092), 8484 (11.74), 90:31 (1099). ‘Nove: Standard deviations are in parentheses. Subscripts with the same letters are nt significantly different at p<. 05; subscripts with different letters are significantly different at p <.O1 (except forthe difference between Clusters | and 2 on Verbal IQ [VIQ}, which is significantly different at p =.04). DFSIQ = Demographic Full-Scale 1Q; PIQ = Performance 1Q; FSIQ = Full-Scale IQ ‘The Scheffé method of post hoc analysis was used for tween clusters in gender or handedness. The remaining those variables that obtained significance in the omni-_variables could not be validly tested because of the large bus ANOVA. The descriptive data on the individual number of cells that included no participants. The ex- cluster groups are presented in Tables 4 and 5. pected count fell below 5 in 60.0% of the cells for race, ‘There were no significant differences between 14.3% of the cells for occupation, and 77.7% of the cells. ‘groups found for years of education, loss of conscious- for diagnosis. ness, months since injury, or demographic-based esti- ‘mate of 1Q (all ps > .05). The clusters were found to differ significantly by age, F(3, 514) = 17.80, p=.000. Discussion The clusters also differed significantly on WAIS-R VIQ, FG, 492) = 23.80, p = .000; WAIS-R PIQ, F(3, Results of Experiment 1 show that the MEPs as 490)=35.27, p=.000; and on WAIS-RFSIQ, F(3,494) indicated in the Cluster Analyses fall into four clusters =34.22, p =.000. The multiple comparisons results can _(see Figure 1). These clusters very closely match the also be found in Table 4. As can be seen in the table, MEPs previously defined by clinical observation. The those patients with the Attention MEP had significantly Attention MEP corresponds to Cluster 2, which shows lowered cognitive performance than those patients who the IT, DT, and RT scores all below 24 T. The Encoding achieved Retrieval MEPs. This difference occurred de- MEP appears to be a variant of the Attention MEP and spite the fact that no differences inestimated premorbid _is subsumed under this category. A Storage MEP corre- 1Q were found. sponds to Cluster 3. This profile shows a downward ‘Nominal variables were compared using the Cros- _dectine in scores as suggested in the clinical observation stabs method of SPSS. Variables included were cluster rules. Both forms of the Retrieval Profile were found in ‘membership, gender, handedness, race, occupation, and _the Cluster Analysis. The V-shaped profile as described diagnosis. There were no significant differences be- earlier represents a Retrieval Type 1 MEP and corre- 124VALIDATION OF MEMORY ERROR PATTERNS ON THE RCFT AND RT sponds to Cluster 4 in Table 2. The second version of a Retrieval MEP is found in Cluster 1 and is labeled Retrieval Type 2. After the participants were classified by the Cluster Analysis, their individual records were examined to ‘Table 8. Diagnostic Groups for Each Cluster determine the minimum rules for membership in each cluster. These minimum rales are presented in Table 1. Itcan be easily seen that the Cluster Analysis rules and the mules previously developed by clinical experience are very similar. The clinical observation nules are not Diagnosis (Cluster 1 Other/ Unknown Motor Vehicle Accident 1 Brain Tumor Anoxia Blow to the Head Gunshot Encephalopathy “Maltple Sclerosis Dementia 1 Hydrocephalus 0 MR/PDYADDILD 8 co 1 ‘Mental Health 10 LcvA 9 RCVA 7 Other CVA 7 Let Epilepsy 4 Right Epilepsy 1 Ober Epilepsy 0 "Nowe: MR/DD/ADDILD = mental reiardation/developmental delay/attention deficit disorder/leaming disability; Ch left cerebrovascular accident; RCVA = right cerebrovascular accident; CVA = cerebrovascular accident i Buvocucn Cluster 4 Re 0 1 1 5 1 9 4 6 rey o 6 onsasnsKnsas ee ‘Sye|pewuy uonuBooay Figure. Example of Memory Error Patterns (MEPs) numeric values from Whole Sample K-Means (Cluster Analyses 7 scores. 125MEYERS & VOLBRECHT significantly different from the decision rules used sta- tistically in the Cluster Analysis. The original clinical rules appear appropriate and statistically valid for iden- tification of the MEPs. The results suggest that the patterns of scores (MEPs) on the ITs, DTs, and RTs of, the RCFT are statistically unique in their relations and that, although there is not a statistical difference in the scores individually (ic., 3 T score points for the Re- trieval Type 1 MEP), there is a difference in the con- figurations that is significantly different from other patterns of scores, Therefore, the rules for the MEPs that ‘were originally presented in the test manual and cross- validated in the Meyers et al. (1996) study have been again validated statistically in the current experiment and do appear to represent a statistically vatid method of identifying MEPs. ‘Based on the results of the K-Means Cluster Analy- sis, the MEPs as hypothesized based on clinical obser- vation did appear in the data analysis results. Therefore, the hypothesis presented in Experiment 1 was upheld. ‘The MEPs do appear in data from impaired participants. All participants in this group had at least one score (T or DT) that fell below 40 T. Therefore, all patterns observed demonstrated difficulties. Not all patients in clinical practice show difficulties on the RCFT and RT, and so subsequent experiments should contain control participants who are not expected to show any deficits. Few control participants would show scores low enough to qualify for an MEP. Comparison of the MEP based on cluster assignment ‘and clinical rules shows a 91% agreement in placement of Attention and Storage versus Retrieval versus Other MEPS. The 9% error rate was due to the difference in the 3 7 score points total variance (highest to lowest) used in the clinical rule versus the 3-point difference between IT and DT and 2-point difference between DT and RT (Cluster Analysis rules) for the Retrieval MEP. ‘The 91% correct classification rate suggests the clinical rules are valid for profile discrimination of MEPs. Experiment 2 Hypotheses It is hypothesized that few control participants will show scores on the RCFT that would be low enough to {qualify for an MEP. If any do fall low enough to qualify for an MEP, they will not display Storage or Attention MEPs as these have been found previously only with very impaired patients. Some normal control partici- pants may produce Retrieval MEPs, 126 ‘Methods Participants. ‘The normative pool of participants gathered for the RCFT was collected from several dis- ‘tinct settings. Prior to testing, all participants were screened for a history of neurological dysfunction, psy- chiatric disorder, leaming disability, or substance abuse. “There were 134 participants drawn from several univer- sity settings in the United States and Canada. These participants received course credit for their participation The second group consisted of 74 friends and family ‘members of patients in a residential brain injury treat- ‘ment facility. A sample of 393 participants was collected using advertising, fliers, and word of mouth from com- ‘munities in the United States and Canada. Ninety-six of these participants were paid a nominal fee for participa- tion in the norming process. Urban and rural residents, were represented approximately equally in the sample. ‘The manual gives a detailed description of the partici- pants in this normative pool (Meyers & Meyers, 1995). All participants gave informed consent to participate in ‘the norming study and all participation was voluntary. Procedures. The scores of the 601 participants on the ITs, DTs, and RTs were converted to T scores based on the age of the participant according to the manual instructions. The T scores for each individual were then entered into a computer program written according to the clinically derived MEP classification rules and were then classified into their respective MEPs. Materials. Each participant was administered the RCFT and RT according to the standardized instruc- tions in the test manual. Statistical analyses. Statistical analysis of the data is contained in the test manual. The MEPs for each participant were classified according to the clinical ob- servation rules into their respective MEPs by acomputer program written according to the clinical observation rules. Results ‘The MEP classification results for the 601 control participants were as follows: 89.4% (537/601) of the participants showed a Normal/Other MEP; 10.3% (62/601) showed a Retrieval pattern; and .3% (2/601) showed a Storage pattern. ‘Anexamination of the protocols for the 2 participants who produced Storage MEPS revealed that they wereVALIDATION OF MEMORY ERROR PATTERNS ON THE RCFT AND RT marked by the author at the time of testing as “poor motivation” based on the participants’ behavior during the testing (3 years prior to the current study). Both of the participants came from university settings in which they were given extra credit for participation in the normative study. Discussion Ttappears that MEPs are consistent in control groups. Normal/Other MEPS can be expected from normal in- dividuals, and Retrieval MEPs are less often found in normal individuals but can still be present. The two individuals who produced Storage MEPs at the time of the data collection for the RCFT norming were included in the normative study, as there was no “objective” reason (at that time) to exclude them from the normative study. It is entirely conceivable that the 2 participants ‘who produced the Storage MEPs may not have been motivated to do well on the RCFT and RT, but were there only to receive their extra credit for participation. Therefore, based on the results of Experiment 2, it ‘appears that normal control participants do not gener- ally produce Storage or Attention MEPs. When an MEP is produced, a Normal or Retrieval MEP is expected unless reduced motivation is present. Experiment 3 Hypotheses In accordance with the results obtained in previous published research with MEPs, itis hypothesized that only very impaired participants will produce Storage or Attention MEPS. In previous studies, the use of Rancho classification was used to identify level of impairment. In the current experiment, length of unconsciousness is used as an indicator of severity of injury. Methods Participants. There were 108 individuals who were referted for neuropsychological assessment for whom data were collected. Some of these participants were also involved in Experiment 1. None of these people were involved in litigation, and all were seen as part of their rehabilitation programming. All partici- pants sustained a closed head injury from either a motor vehicle accident, fall, or blow to the head. There were 28 female participants and 80 male participants in the sample: 96 were right-handed and 12 were left-handed; 105 were White and 3 were of other ethnic backgrounds. Other descriptive variables for the group are included in Table 7, Procedures. All participants were administered the same battery of tests as indicated in Experiment 1, and their MEPs were calculated via the computer pro- ‘gram used in Experiment 2. Materials, Each participant was administered the same basic battery of neuropsychological tests as indi- ‘cated in Experiment 1 Statistical analyses. ‘The MEPs for each partici- pant were identified using the computer program indi- cated in Experiment 2 (according to the clinical rules already presented in Experiment 1). A Spearman rho correlation matrix was calculated for the MEP, loss of consciousness (LOC), VIQ, PIQ, and FSIQ scores. Results ‘There was a significant correlation overall for the total sample using LOC and MEP (rs = -26, p =.006). Examination of the individual MEPs revealed that no individual with less than 4 days of LOC had a Storage or Attention MEP. Not surprisingly, participants with longer LOC had more impaired MEPs and lower WAIS-R scores (VIQ, PIQ, FSIQ) and lower IT, DT, and RT scores. Table 6 shows the correlation matrix for these variables. Separating the group into LOC less than 4 days and equal to or greater than 4 days and using at test of independent samples showed that there were significant differences between the groups as indicated in Table 7. The MEPs were also significantly different between the groups, 7°(6, N = 108) = 28.824, p = .000, with Group 2 participants showing Attention and Stor- ‘Table6. Correlation of Variables From Closed Head Brain Injury Whole Group Variable LOC -MEP_—VIQ_—PIQ__—FSIQ Loc =26" Layee 5608 506 ‘MEP 26" 336s 374 ‘Note: LOC = Loss of consciousness; MEP = Memory Error Pater; ‘VIQ = Verbal 10; PIQ = Performance IQ; FSIQ = Full-Scale IQ. 006. **p = 000. 127MEYERS & VOLBRECHT Table 7. Means, Standard Devianons, and t Tests of Significance Between Groups Separated Based on LOC 3 Days or Less (Group!) oF LOC 4 Days or More (Group 2) Variables Group 1 Group 2 Significance LOC ays) Al 84) 1957 (21.45) 4611 = 6.118 Months. 31370773) 49.10 01.88) 106) =—1 085 FSIQ 98.60 (13.0, 84541214) 1102) = 5.628, Immediate 46.59.1213) 35.62(15 56) 184825) =3.98 Delayed 42.16 (1.47), 3447(15.47) 181.950) = 2.859 Recognition 4679 (10.11) 34.19.0413) 179914) =5.174 Attention 0 4 Storage ° 2 Retrieval B 8 "Norma/Other 48 2B ‘Nore: Standard deviations are in parentheses, LOC = lss of consciousness; FSIQ = Full-Scale 1Q *LOC is less than or equal to 3 days; n= 61. “LOC is greater than or equal to 4 days: age MEPs and the Group 1 participants showing mostly ‘Normal/Other or Retrieval MEPs. Discussion Results of this third experiment indicate that the MEPs do follow the predicted course, in that those participants with longer LOC (ie., more severe brain injury) tend to show more impaired MEPs and lower scores on the RCFT and RT. Therefore, the MEPs do appear to have a relation with the degree of impairment. ‘An Attention or Storage MEP is not expected in partici- pants with mild brain injury but may be present in ‘moderate to severe brain injury. Experiment 4 Hypotheses In accordance with the results obtained in previous published research with MEPs, it is hypothesized that only very impaired participants—meaning those who are under close supervision due to serious impairment of cognition—would produce Storage or Attention MEPs. Methods Participants. ‘There were 156 participants who were referred for neuropsychological assessment and were interviewed along with their family members. ‘Some of these participants were also involved in Experi- 128 available for interview were included in this study. Information was gathered as part of the assessment procedure to identify whether the participants were functioning independently or dependently. Independent participants were defined as needing no assistance in ADL or with budgeting or finances and were considered by family members (who ride with the participant) to have no difficulty with driving or safety judgment. Dependent participants were defined as those recei ing 50% or more assistance with ADL and with budg- eting and finances. These individuals were considered to be unsafe in driving and judgment and were under 24-hr supervision by family or in institutional care. Participants who were receiving some occasional help from family members but were not under 24-hr super- vision were excluded from the study. Procedures, All participants were administered the same battery of tests as indicated in Experiment I. ‘The participant's functional status as independent or dependent was not revealed to the technician who ad- ministered the tests, although some of the participant's status may have been obvious to the technician There were 42 female and 82 male participants in Group 1 (independent n= 124); 111 were right-handed and all but 12 were White. The diagnoses were varied, with 53 having injury from a motor vehicle accident; 26 suffered injury from blows to the head, fall, or gunshot to the head; 13 had CVA; 5 had brain tumors; 3 had anoxic events; 4 had encephalitis; 4 had multiple scle- tosis; 9 had seizures; and the remainder had various other diagnoses. Group 2 (dependent n = 32) consisted of 14 female and 18 male participants, of which 28 were right-handedVALIDATION OF MEMORY ERROR PATTERNS ON THE RCFT AND RT and all but 1 was White. Twelve had injury from a motor vehicle accident, 3 had a blow to the head, 3 had anoxic events, 1 had a brain tumor, 2 had multiple sclerosis, 4 had seizure disorders, 4 had CVA, and the rest had varying diagnoses. Table 8 contains information for comparison of the two groups. Following the administration of the tests, the partici- pants’ scores were calculated by the technician for all tests administered and the data were entered into a database along with the participants’ living status (in- dependent or dependent). Using the same computer program as identified in Experiment 2, the participants’ MEPs were calculated. Materials. All participants were administered the test battery as indicated in Experiment 1, and the MEPS were calculated using the computer program identified in Experiment 2 Statistical analyses. ‘The test scores for the vari- ables are indicated in Table 8, and the ITs, DTs, and RTs ofthe RCFT were subjected to independent sample ttest (one- or two-tailed as appropriate to the data). Results ‘The independent group (Group 1) showed a mean FSIQ of 94.63 (SD = 11.56). The mean T scores on the ITs, DTs, and RTs on the RCFT were 43.20 (SD = 13.85), 41.44 (SD = 13.76), and 46.23 (SD = 10.63), respectively. The mean of the dependent group (Group 2) on the FSIQ was 76.28 (SD = 8.38). Mean T scores Table 8 Descriptive Sta onthe RCFT were 21.88 (SD=5.44),21.88(SD=4.17), and 22.94 (SD = 5.49) for the ITs, DTs, and RTS, respectively. The mean scores of performance on the ITs, DTs, and RTs were significantly different using a two-tailed t test of independent samples, 1(129.84) 13.56, p = .000; 1(150.47) = 13.59, p = 000; (96.99) 17.10, p = .000, respectively. Forty-seven participants in the independent group (Group 1) demonstrated a Retrieval MEP (37/124), and 87 showed a Normal/Other MEP. The dependent group (Group 2) demonstrated predominantly Attention MEPs, with 26 individuals achieving this MEP (Encod- ing = 5), 3 had Storage MEPs, 2 produced Retrieval MEPs, and 1 individual obtained a pattem that did not ‘match any profile and was classified as “Other.” None of the independent functioning group produced an At- tention or Storage MEP. Discussion The results of the study show that individuals who are able to function independently in the community would be expected to produce Retrieval or Normal [MEPs and would not be expected to produce Storage or Attention/Encoding MEPs. It is possible for dependent individuals to produce Retrieval or Normal MEPs. This ‘may suggest that there are other factors, such as physical health, that can affect a person's ability to function independently. However, most dependent persons pro- duce Attention or Storage MEPs. Not surprisingly, individuals who have experienced longer periods of unconsciousness are more likely to be is and Test Scores for Independent (Group I) and Dependent (Group 2) Partieipants With Independent Samples {Test of Significance Group Variable N Mm sD Signiffeance i ‘Age 124 3735 1208 1058)=—199 2 22 3784 13.60 i Education 124 1331 281 1132.56) =-2 64 2 32 1247 1.08, a Loss of consciousness 106 267 779 £23.17) =-2.1 2 B 13.08 2228 a “Months postiayury 14 2626 0459 1038) 2-547 2 32 3432 437 1 Barona (1984) FSIQ m4 97.64 592 192.86) = 187 2 32 9178 317 1 WAIS-R FSIQ 14 94.63, 1156 16498) = 10.14 2 2 76.28 838 ‘Note: PSIQ = Full-Scale 1Q; WAIS-R = Wechsler Adult Intelligence Seale Revised, 29MEYERS & VOLBRECHT dependent and show Attention or Storage MEPs. De- pendent individuals are more likely to have lower over- all neuropsychological test scores. A comparison of the ‘time postinjury for the two groups showed there was no significant difference, (133) =-.54, p = 58. There was some difference in the groups’ level of education; how- ever, this did not seem to negatively impact perform- ance on the RCFT, as previous examination of ‘education as a variable in the norming sample indicates that education is not a significant factor once age is controtied for. General Discussion ‘The results of Experiment 1 indicate that the MEPs do exist in a sample of general neuropsychological patients. The rules for identification of MEPs were validated by a Cluster Analysis, and the decision rules used by the Cluster Analysis are similar to those pre- viously developed clinically. The use of the clinically bbased rules do result in identification of MEPs that are statistically valid, For general clinical practice, the use of the clinically derived rules is recommended. Experi- ‘ment 2 shows the base rates for MEPs in a large sample of normal controls. The results indicate that, unless ‘motivation is a factor, normal controls do not achieve Attention or Storage MEPS. Experiment 3 found that not only are Attention and Storage MEPs not found in persons who have mild brain injury, but that it takes a moderate to severe injury to produce an Attention or Storage MEP. The results of previous studies found that only individuals who are unable to live independently are expected to obtain an Attention or Storage MEP (Meyers et al, 1996). The results of Experiments 3 and 4 support this previous finding, MEPs may be clinically useful in several ways. First, if the referral question for the neuropsychological evaluation asks if a patient can live independently, drive car, and so forth, and the individual produces an Alttention or Storage MEP, this would suggest that the patient (cognitively) would not be able to be inde- pendent. However, if a person produces a Retrieval or Normal/Other MEP, one may express more optimism for the patient's ability to function independently. The findings of these four experiments support the validity of the use of MEPs associated with the RCFT and RT. In addition, the results suggest that in the ease of a mild injury, one might question the motivation of the ial and the validity of test performance if a Patient obtains an Attention or Storage MEP and if a 130 lengthy LOC was not well documented. Production of an Attention or Storage MEP by an individual with a suspected mild brain injury would raise suspicion of motivation for the test performance. Future research on the MEPS could examine the relation of the MEPs in such populations as Korsakoff’s patients, It may be clinically relevant to look at these types of individuals to see if specific MEPs might be identified inthis type of well-defined group. 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