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To cite this article: Philip S. Fastenau (1996) Development and Preliminary Standardization of the
Extended Complex Figure Test (ECFT), Journal of Clinical and Experimental Neuropsychology, 18:1,
63-76, DOI: 10.1080/01688639608408263
To link to this article: http://dx.doi.org/10.1080/01688639608408263
1380-3395/96/1801-63$12.00
0 Swets & Zeitlinger
ABSTRACT
Recognition and matching trials were designed for the Rey-Osterrieth Complex Figure Test (ROCFT).
Following pilot testing and expert review, they were standardized using 90 community-dwelling adults
(58% female, ages 30 to 88). Recognition has 30 multiple-choice items for different figural elements;
scores distributed normally with strong item-total correlations and with normally distributed item difficulties. Cronbach alphas were .84, .61, and .81 for the Total, Global, and Detail Scales. Recognition correlated
.81 with ROCFT recall and .65 with Visual Reproductions. Matching has 10 multiple-choice items; scores
were negatively skewed with a substantial ceiling effect. Alpha for Matching was .58, limited in part by
few items. Matching correlated .h8 with Judgment of Line Orientation and .74 to .90 with copy trials. Both
Recognition and Matching discriminated 34 patients with intractable epilepsy from 34 matched controls.
Overall, Recognition appeared to be reliable and showed evidence of validity. By comparison, Matching
reliability and validity were less impressive and warrant further examination.
* This study was partially funded by the APA Science Directorate. The author acknowledges A1 Manning and
Broughton Hospital, Morganton, 3, for supporting the pilot; Jane Holmes Bernstein for her expert input; Norm
Abeles, Lauren Harris, Neal Schmitt, and Bert Karon for suggestions on the standardization study; John Fisk,
Jeanne Bennett, and Henry Ford Hospital for supporting the clinical validation study; Natalie Denburg, Linda
Sloan, Eric Fertuck, Jennifer Winer, Sandy Scott, Katy Parcells, Lidia Domitrovic, and Mike Finton for assisting
with data collection and processing; Roger Halley for mobilizing material resources; and Dana Atkinson Fastenau
for her loving support. Address correspondence to the author at University of Michigan Medical Center, Neuropsychology Program, 480 Med Inn Building, Box 0840, 1500 East Medical Center Drive, Ann Arbor, Michigan,
48 109-0840, USA.
Accepted for publication: June 15, 1995.
64
PHILIP S. FASTENAU
ognition trials may suffice as screening instruments, they may be too few for reliable and sensitive diagnostics.
The Rey-Osterrieth Complex Figure Test
(ROCFT; Osterrieth, 1944; Rey, 1941; Rey &
Osterrieth, 1993), like VR, measures free recall
only. As an advantage over VR, the ROCFT
uses an intricate stimulus that is asymmetrical in
its design. The complexity of this stimulus
seems to better tax the upper range of visualspatial processing as compared to the VR stimuli. Furthermore, it appears to be more resistant
to verbal mediation (Casey, Winner, Hurwitz, &
DaSilva, 1991). As a product of this complexity,
patterns of fragmentation, neglect, rotation, and
distortion on the ROCFT correspond to some
degree with the location and type of neurological insult (e.g., Binder, 1982; Brouwers, Cox,
Martin, Chase, & Fedio, 1984; Kaplan, 1988;
Lezak, 1983; Milberg, Hebben, & Kaplan,
1986).
The ROCFT administration that is most popular (Knight, Kaplan, & Ireland, 1994; Lezak,
1983) includes a copy and immediate recall trial,
followed 20 to 60 min later by a delayed recall
trial. However, there is neither recognition nor
matching. In the three studies presented here,
recognition and matching trials were developed
to supplement the ROCFT. These trials were
designed to follow the copy, immediate free recall, and delayed free recall trials. This elaborated administration will be called the Extended Complex Figure Test (ECFT). This article describes the design of the ECFT, pilot results and expert review, preliminary standardization with a relatively healthy population, and
preliminary validation with a clinical sample.
PILOT STUDY
DESIGN OF THE NEW MEASURES
Initially, 20 recognition items were designed for
the ROCFT using theory, findings in the literature, and patient records. Figure l exemplifies
the format. Each item consisted of a vertical array of five choices: one element from the original ROCFT stimulus and four distractors, or
Fig. 1.
65
66
PHILIP S. FASTENAU
METHOD
DISCUSSION
Subjects
RESULTS
Cronbachs alpha for the recognition task was
0.68 (p < .001). Three items detracted from the
overall reliability; deletion of those three items
would raise alpha slightly (0.70). Recognition
total scores (number correct) correlated moderately with raw scores on Picture Completion ( r =
.62, p < .001) and Block Design ( r = .60, p <
.001). For Recognition, most corrected item-total correlations ranged from .26 to .60 (p < .05);
four were not significant ( r < .200, p > .05).
Recognition scores distributed fairly normally
between 12 and 20 with the exception of two
outliers in the lower tail (scores of 5 and 8) and
a slight ceiling effect. The mean was 15.7 (SD=
3.0) with the outliers and 16.2 (SD = 2.2) without the outliers.
PRELIMINARY STANDARDIZATION
FINAL REVISIONS IN ITEM DESIGN
Recognition
Some revisions were made based on the pilot
results and based on other research. One item
was dropped because the item-total correlation
was negative, indicating that those subjects with
good overall performances tended to fail that
item. Right-specific items were added based on
the results obtained by Ogden (1987). She found
that, when speech impairments could be controlled in studies of neglect, neglect in the right
visual field was as frequent as neglect in the left
visual field, although right neglect tended to be
less severe and less enduring. Because the recognition trial can circumvent language deficits,
it seemed especially important to add right-specific items to the Detail Scale. These revisions
expanded the set to 27 items.
Expert appraisal was solicited for initial evaluation of the instruments content validity and
for suggestions to improve on its design. Holmes-Bernstein has examined the design qualities
of the ROCFT and has used it extensively with
children (see Waber, Bernstein, & Merola, 1989;
Waber & Holmes, 1985, 1986). She reviewed
the recognition items and suggested additional
modifications, including the addition of some
Matching
Matching items were created from I0 of the 30
recognition items by placing each vertical array
next to a reproduction of the standard (Figure 2 ) .
The matching set included one base rectangle,
one main substructure, four left-detail, and four
right-detail items, All 10 items constituted the
Total Scale; the left-detail items and the rightdetail items comprised the Left- and Right-Detail Subscales, respectively. The total administration of the ROCFT and the two supplementary trials will hereafter be referred to as the
Extended Complex Figure Test (ECFT;
Fastenau & Denburg, 1994).
HYPOTHESES
Recognition
ECFT Recognition Total scores were expected
to distribute normally in this normal sample,
with no ceiling or floor effects. Every item was
expected to correlate positively with the Total
score, indicating that each item discriminates
between good and poor performance overall. In
addition, there was an attempt to achieve a wide
range of item difficulties (easy items to foster a
67
m
m
m
Fig. 2.
Matching
ECFT Matching was designed to be a much easier task. Total scores were expected to skew
negatively with a prominent ceiling effect. It
was predicted that difficulty indices would be
very low and that item-total correlations would
be limited by a restriction of range on the Total
68
PHILIP S. FASTENAU
ory measures.
METHOD
Subjects
The normative sample was comprised of 90 healthy
community-dwelling adults who reported no recent or
active central nervous system conditions and who
lived independently in the community. Volunteers
with uncorrected visual or hearing impairment or with
impaired use of the preferred hand were excluded.
Subjects were solicited from four religious organizations in a midwestern city of 150,000 residents. The
organizations received a monetary contribution for
each of the participants from their group, together
with a bonus for recruiting equal numbers of men and
women from each of ten 5-year age bands (30-34,3539, .._70-74, 75-and-over). This incentive created an
age- and sex-stratified sample; furthermore, because
each organization was equally represented among men
and women and across age groups, potential socioeconomic differences between organizations were unlikely to confound age and sex analyses.
The total normative sample consisted of 38 men
and 52 women. Age ranged 30 to 80 years with one
88-year-old ( M = 55.9, M n = 54.5, Sf)= 14.1). The
younger group (ages 30 to 54, n = 47) was 55% female, and the older group (ages 55 and beyond, n =
43) was 61% female. These sex ratios closely approximate the 1990 U.S. census (51% and 57%, respectively; U. S. Department of Commerce, 1990). Education ranged 8 to 25 years (M and M n = 15.2, SD =
3.0). In this sample, 97% had at least a high school
education, which is higher than the 75% observed nationally among people over age 25 (U. S. Department
of Commerce, 1990). Among the older adults, 88%
had 12 or more years of schooling, compared to 56%
nationwide (U. S. Department of Commerce, 1990).
Therefore, this sample was more educated than the
average U.S. citizen. Age-corrected WAIS-R Vocabulary scale scores ranged 5 to 19 ( M and M n = 12.5, SD
= 2.3).
A structured interview assessed the past history of
potentially confounding health conditions. It addressed the following conditions (percent of the sample
with a positive history): closed-head injury with loss
of consciousness (16%). unexplained loss of con-
sciousness @%), cerebrovascular disease (4%),hydrocephalus (O%), seizures (1 %), intracranial surgery
(1 %), hypertension (3 I%, all well-controlled), coronary artery disease (18%), diabetes (lo%, all wellcontrolled), pulmonary disease (lo%), renal disease
(16%), and hepatic disease (2%).
Levels of depression were assessed using the Beck
Depression Inventory (BDI; Beck, 1978); the mean
and median scores were well within normal limits (5.3
and 4, respectively). Eight percent of the sample
scored in the mildly depressed range, and 2% scored
in the moderate to severe range; these percentages
correspond with national incidence rates, indicative
that the sample is representative on this dimension.
Levels of reactive and chronic anxiety were assessed
using the State-Trait Anxiety Inventory (Spielberger,
Gorsuch, Lushene, Vagg, & Jacobs, 39833; summary
indices for State scores ( M = 30.8, Mn = 29, SD = 8.8)
and for Trait scores ( M = 32.8, M n = 31.5, SD = 8.9)
were virtually identical to those for the standardization sample.
Instruments
Table 1 provides the descriptive data for all of the
measures analyzed in this study. The battery included
the Wechsler Adult Intelligence Scale-Revised Vocabulary subtest (Wechsler, 1981) and Judgment of
Line Orientation Test (JOLO; Benton, Hamsher, Varney, & Spreen, 1983). Wechsler Memory Scale-Revised (WMS-R; Wechsler, 1987) Visual Reproductions (VR) Immediate and Delayed Recall were also
included, followed by a copy trial for those same stimuli (Fastenau & Sloan, 1993).
The ECET trials were administered in the following order: Copy, Immediate Recall (no latency after
the copy trial), Delayed Recall (20-min latency), Recognition, and Matching. Scoring criteria for ECFT
drawings were modeled after the WMS-R VR scoring
(Wechsler, 1987). Interrater reliability (two raters) on
23 sets of drawings that spanned a wide range of ability was good for the copy drawings (Pearson product
moment r = .90) and very good for immediate and
delayed recall drawings (Y = .97 for both).
Procedure
All subjects were tested individually. Most subjects
completed the exam in one session; several older subjects required two sessions for optimal testing. The
testing for all subjects consisted of two segments of
cognitive testing (each lasting 50 to 75 min), separated by a break during which they completed the
emotional inventories. The ECFT was administered in
one segment, and the WMS-R was administered in the
other segment. The order of the segments (ECFT first
or WMS-R first) was counterbalanced; subjects were
assigned to the two segment conditions blindly, stratified within each age-sex cell.
69
Table 1. Demographic and Test Data, by Group, and T Tests Comparing Patients to Controls.
~
Measure
~~
Standardization
Sample
Epilepsy
Patients
Matched
Controls
( n = 90)
( n = 34)
( n = 34)
SD
SD
~
SD
M
~
~~
1
~~
Demographics
Age (Years)
Education (Years)
% Female
% Left-Handed
55.9
15.2
57.8
7.8
40.4
13.9
70.6
8.9
14.1
3.0
9.9
2.3
43.9
14.8
64.7
15.6
9.3
2.1
48.0
28.1
17.4
9.5
5.4
10.3
5.7
0.9
-1.49
-1.61
.I4
.11
-0.84
.61
.40
-1.83
-1.77
-1.75
-1.62
.04
.04
.04
.05
.51
Test Scores
ECFT Copy
ECFT Delayed Recall
ECFT Recognition
ECFT Matching
VR Copy
VR Delayed
JOLO
47.4
26.9
16.0
9.4
38.0
27.5
25.5
6.1
9.7
5.7
1.0
3.5
9.0
3.9
44.7
23.3
15.0
9.0
8.9
12.3
5.8
1.3
Note. T tests were two-tailed for demographics and one-tailed for test scores. ECFT = Extended Complex Figure
Test; VR = WMS-R Visual Reproductions; JOLO =Judgment of Line Orientation.
RESULTS
The analyses in this study were conducted using
SPSS (SPSS, Inc., 1990).Because of the relatively
large number of significance tests performed on
this data set, precautions were taken to control for
alpha inflation. Hypotheses were clearly articulated at the outset of the study. Also, a conservative alpha was adopted: Results significant at .05
were regarded as trends; results with p < .01 only
were considered to be reliable.
ECFT Recognition
Total scores distributed normally. Descriptives
are presented in Table 2; where age or sex effects neared significance (p < .05), the results
were stratified accordingly.
Point-biserial correlations between each item
and the Total score were corrected by partialling
out the variance in the Total score that was due
to the item itself. All coefficients were positive:
26 were significant at p < .01 (rs = .24 - .60);
two approached significance ( r = .22 and .18; p
< .05); and two others were not statistically sig-
nificant ( r = .12 and .09; p > .05). Item-difficulty indices (percent of the sample that responded incorrectly) ranged from 3% to 85% and
distributed roughly normally. The mean item
difficulty for the 30 items was 46.5%.
Correlations among scales and subscales are
presented in Table 3. The Global Scale and Detail Scale correlated moderately but not perfectly (.75, corrected for unreliability). The
Left- and Right-Detail Subscales correlated perfectly with one another (.99, corrected). Cronbachs alpha reliabilities are presented on the
diagonal. Within the scales and subscales, no
item detracted from any of the reliabilities except for one item on the Left Detail Subscale,
and that alpha was reduced by less than .02.
Odd-even and split-half reliability coefficients
were similar to alpha (.81 and .78, respectively)
after the Spearman-Brown correction for lengthrelated attenuation.
ECFT Recognition scores were correlated
with other measures of visual memory and with
measures of visual perception (Table 4). After
correcting for attenuation due to imperfect reli-
70
PHILIP S. FASTENAU
Group
SD
Total Scalea
Total
Younger
Men
Women
Older
Men
Women
16.0
5.7
20.0
16.1
4.5
5.7
14.4
13.7
5 .o
5.6
Detail Scalea
Total
Younger
Men
Women
Older
Men
Women
11.3
4.6
14.9
11.6
3.5
4.4
9.6
3.6
4.5
9.0
Total
Younger
Older
2.4
2.3
2.3
6.1
7.0
5.2
~
3.6
2.0
5.1
3.7
1.7
1.8
3.2
2.4
1.6
1.8
Global Scaleb
Total
4.7
1.8
Note. Sample sizes were: Total, 88; Younger, 47; Older, 41; Men, 37; Women, 5 1; Younger Men, 21 ; Younger
Women, 26; Older Men, 16; Older Women, 25.
a Age and sex effects (p < .05).
No age, sex effects (p > .05).
Age effect only (p < .05).
ability, ECFT Recognition Total scores correlated positively and highly with ECFT Delayed
Recall and with VR Delayed Recall (.81 and .65,
respectively). Correlations with immediate trials
of ECFT and VR were virtually redundant of
those with delayed trials and, therefore, were not
71
DEVELOPMENT OF THE E C R
DET
L-DET
R-DET
TOT
.77
1.24
.61
.75
.65
.53
.39
.49
.73
.81
.86
.9 1
1.24
.97
.59
.99
.62
.66
1.02
1.18
1.15
1.18
.8 1
.88
.84
Matching Trial
~~
L-DET
R-DET
TOT
.40
3.07
.08
.92
.99
4.27
.55
.82
.58
Note. Diagonal values (italicized) are Cronbachs alpha reliabilities. Values above the diagonals are corrected for
attenuation due to unreliability in the scales; values below the diagonal are not corrected. All correlations are
significant (p < ,0005, one-tailed). GLO = Global Scale, DET = Detail Scale, L-DET = Left-Detail Subscale, RDET = Right-Detail Subscale, TOT = Total Scale.
of ECFT Recognition with JOLO was not significantly weaker than its correlation with VR Delayed Recall ( t = 1.238, p > .05, one-tailed).
ECFT Matching
Total scores were negatively skewed. They correlated negatively with age ( r = --.25, p = .Ol),
but not with sex or the interaction term 0,> .05).
Scores for the total sample ranged from 6 to 10
( M = 9.4, Mn = 10.0, SD = 1.0). Scores for the
younger group ranged from 7 to 1 0 ( M = 9.6, M n
= 10.0, SD = 0.8), whereas scores for the older
group ranged from 6 to 10 ( M = 9.3, Mn = 10.0,
SD = 1.2).
Corrected item-total correlations were positive and significant, ranging from .24 (p < .01)
to .41 (p < .001). Three items were answered
correctly by everyone in the sample, resulting in
zero variance. Difficulty indices were very low
(ranging from 0% to 18%).
Cronbachs alphas are presented in Table 3.
The Total Scale had a modest inter-item reliability ( . 5 8 ) , suppressed in part by three items with
zero variance. None of the other items detracted
from the Total Scale alpha coefficient. Subscale
reliabilities were limited by too few items and
72
PHILIP S. FASTENAU
~
Memory
Perception/Construction
.84
.71
.57
.81
.91
.65
.67
.6 1
.92
.26**
.40
.64
.56
.64
.58
.44
.62
.54
.46
.55
.66
29***
.55
.56
.48
.47
.50
.49
.58
.58
.68
.80
.60
.49
.90
.74
.60
.73
Memory
1 . ECFT Recognition
2. ECFT Delayed
3. VR Delayed Recall
Perception/Construction
4. ECFT Matching
.18*
5. JOLO
6. ECFT Copy
7. VR Copy
.46
.38
.39
.46
.65
.52
.71
.89
.63
.84
Note. Diagonal values (italicized) are Cronbachs alpha reliabilities. Values above the diagonals are corrected for
attenuation due to unreliability in the measures; values below the diagonal are not corrected. ECFT = Extended
Complex Figure Test; VR = WMS-R Visual Reproductions; JOLO = Judgment of Line Orientation.
* p < .OS ** p < .01 *** p < ,005 All other correlations,p < .0005, one-tailed.
DISCUSSION
ECFT Recognition
Predictions regarding the distribution of Total
scores and regarding item characteristics were
completely supported. Total scores distributed
normally; they correlated significantly with age,
so descriptives were tabulated for younger and
older subjects. Corrected item-total correlations
showed that all but two items effectively discriminated between higher and lower performance on the Total score. Item-difficulty indices
reflected that the test samples a broad range of
ability levels so that there were items within virtually everyones capability and items to challenge people with even very good memory abilities. Yet, the set of items converges on an item
difficulty of 50%, where discrimination is maximized.
Reliability hypotheses were also well supported. The ECFT Recognition Total Scale had
very homogeneous content. Subscale alphas
ranged from moderate to high, in rough relation
to the number of items on each scale. Each of
the items contributed substantially to the integrity of its host scale. Correlations among scales
and subscales supported the uniqueness of the
Global and Detail Scales, but the Left Detail and
Right Detail Subscales did not measure any
unique variance in this healthy sample. These
ECFT Matching
As predicted, Total scores were negatively
skewed. They declined with age, so descriptives
were provided for younger and older subjects.
Although the relationship with age was statistically significant, the actual raw score differences were minimal (approximately one-quarter
point). The Total sample descriptives should
serve the clinician well for preliminary norms.
Predictions regarding item characteristics
were supported. Seven coefficients were positive and moderate, indicating that the items effectively discriminated between higher and
73
METHOD
Subjects
RESULTS
The analyses in this study were conducted using
SPSS 6.1 (SPSS, Inc.; 1994). Predictions were
directional so one-tailed tests were used. Results
at p < .05 were considered reliable.
ECFT Recognition
In this mixed sample, corrected item-total correlations were positive: 26 were significant at p <
.05 (rs = .24 - .61); four were not statistically
significant (i-s = .06 - .18; p > .05). Item-total
correlations were similar when each group was
analyzed separately. Item-difficulty indices
(percent of the sample that responded incorrectly) ranged from 9% to 8 I % and distributed roughly normally. These ranged 15% to
82% for patients and 3% to 82% for controls.
The mean item difficulty for the 30 items was
46.0% for the mixed sample, proving slightly
more difficult for patients (51.1% for patients,
41.9% forcontrols). Cronbachs alpha reliability
was .83-.84 when the groups were analyzed separately and .84 when they were analyzed
together. None of the items detracted from alpha
74
PHILIP S . FASTENAU
ECFT Matching
In the mixed sample, corrected item-total correlations were positive: Six were significant at p <
.05 ( T S = .25 - .49); two were not statistically
significant ( T S = .04 - .13;p > .05); two had zero
variance (answered correctly by all). Analyzed
by subgroup, similar results were obtained from
the patient group; for the controls, five items
were statistically significant while the other five
had zero variance. Item-difficulty indices ranged
from 0% to 22%, and their distribution was negatively skewed. The mean item difficulty for the
10 items was 9.4% (9.9% for patients, 5.4% for
controls). Cronbachs alpha reliability was .58
for the patient group and for the combined
group; the control group yielded an alpha of .47,
suppressed in part due to half of the items being
answered correctly by all controls. None of the
items detracted significantly from alpha for either group.
Similar to the recognition trial, comparisons
of the matching trial distributions of the two
groups showed considerable overlap in scores.
The patients scored significantly lower than
matched controls, but the difference in scores is
smaller than that which could be detected clinically (one-half point). The median and mode for
both groups was 10, a perfect performance. The
other descriptives and t-test values (one-tailed)
are presented in Table 1.
DISCUSSION
For the patient sample, item characteristics and
alpha reliability coefficients were virtually identical to those obtained from the matched control
GENERAL DISCUSSION
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