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The Clinical Neuropsychologist

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Assessment and Development of

Organizational Ability: The Rey
Complex Figure Organizational
Strategy Score (RCF-OSS)*
Peter Anderson , Vicki Anderson & Jenny Garth
Published online: 09 Aug 2010.

To cite this article: Peter Anderson , Vicki Anderson & Jenny Garth (2001) Assessment and
Development of Organizational Ability: The Rey Complex Figure Organizational Strategy Score
(RCF-OSS)*, The Clinical Neuropsychologist, 15:1, 81-94, DOI: 10.1076/clin.15.1.81.1905

To link to this article: http://dx.doi.org/10.1076/clin.15.1.81.1905

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 The Clinical Neuropsychologist 1385-4046/01/1501-081$16.00
2001, Vol. 15, No. 1, pp. 81±94 # Swets & Zeitlinger

Assessment and Development of Organizational Ability:

The Rey Complex Figure Organizational
Strategy Score (RCF-OSS)*
Peter Anderson1,2,3, Vicki Anderson1,2,3, and Jenny Garth2
1
Royal Children's Hospital, Melbourne, 2University of Melbourne, Australia, and 3Murdoch Children's
Research Institute
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ABSTRACT

The Rey Complex Figure Organizational Strategy Score (RCF-OSS) was devised for pediatric populations to
cater for developmental variability. A sample consisting of 376 children aged between 7.0 and 13.11 years
was recruited for the standardization of RCF-OSS. The interrater reliability (.85 to .92) and temporal stability
(.79 to .94) of the RCF-OSS are acceptable. RCF-OSS correlated moderately with RCF accuracy, memory
and organization, however it seems to be measuring an independent aspect of performance, possibly strategy.
Moderate linear relationships were observed with executive function and memory measures. Considerable
age-related variation in strategy formation was observed with signi®cant maturity occurring between the
ages of 7 years and 11 years. Surprisingly, older children used fragmented strategies more than the younger
age groups. In conclusion, the RCF-OSS is a useful adjunct to traditional accuracy scoring procedures, and
the normative data indicates that organizational skills may not consolidate until middle to late adolescence.

The Rey Complex Figure Test (RCF) is a popular
measure of neuropsychological function. It was
originally devised by Rey (1941; 1993 transla-
tion) and later standardized and normed for both
children and adults by Osterrieth in 1944. The test
requires the subject to copy, as accurately as
possible, a complex geometrical ®gure consisting
of a large rectangle, vertical and horizontal cen-
terlines, two diagonals, as well as external attach-
ments and internal sections of the large rectangle
(Figure 1). After an interval, which varies for
different administration protocols, and without
any previous forewarning, the subject is asked
to draw what they recall of the ®gure.
For over 50 years the RCF has been employed
in clinical practice with adults. De®cient perfor-
mance on the test has been reported in a range of
adult populations, including patients with frontal
lesions (Messereli, Seron, & Tissot, 1979), right
and left hemisphere damage (Binder, 1982;
Kaplan, 1983), dementias (Brouwers et al.,
1984) and temporal lobe epilepsy (Piquet et al.,
1994). Qualitative descriptions from these studies
suggest that the organizational strategies and
quality of errors may vary according to pathology.
For example, right brain-damaged adults tend to
produce distorted drawings and often neglect the
left side, whereas patients with left-sided damage
are inclined to divide the con®gural components
into sections and draw the ®gure in a fragmented
fashion (Binder, 1982); schizophrenic patients
usually start with the con®gural components


We would like to thank all the children and families that participated in this research project. We would also like to
acknowledge the efforts of Genevieve Lajoie, who was responsible for recruitment and data collection. The study
was supported by a Developmental Grant from the Royal Children's Hospital, Melbourne.
Address correspondence to: Peter Anderson. Department of Psychology, Royal Children's Hospital, Parkville.
Victoria 3052, Australia. Tel.: 61 3 9345 6590. Fax: 61 3 9345 6002. E-mail: anderson@cryptic.rch.unimelb.edu.au
Accepted for publication: December 2, 2000.
 82 PETER ANDERSON ET AL.
Fig. 1. Rey Complex Figure.
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(i.e., large rectangle) but tend to include bizarre
segments, retrace lines, and misplace elements
(Osterrieth, 1944); adults with frontal lesions tend
to repeat elements that are already present,
modify elements into more familiar items, draw
additional items on components, and omit impor-
tant elements (Messerli, Seron, & Tissot, 1979);
and patients with right temporal lobe epilepsy
often include distortion errors on their recall
drawings (Piquet et al., 1994).
An accurate reproduction of the RCF is gen-
erally considered to require intact `executive
functions', which are de®ned as the skills neces-
sary for developing goals, holding them in active
memory, and monitoring performance (Stuss,
1992). Recent research indicates that executive
skills are functional early in life and exhibit a
prolonged developmental course (Passler, Issacs,
& Hynd, 1985; Welsh, Pennington, & Grossier,
1991; Diamond & Goldman-Rakic, 1989; Levin
et al., 1991). The developmental trajectory of
executive functions are thought to parallel the
extended neurodevelopment of the prefrontal
regions of the brain (Anderson, 1998), beginning
in infancy (Diamond & Goldman-Rakic, 1989)
and continuing through the pre-school years
(Welsh, Pennington, & Groissner, 1991), middle
childhood (Levin et al., 1991) and adolescence
(Anderson et al., in press). At present, our under-
standing of executive function development is
compromised by measurement issues. For ins-
tance, the vast majority of the executive function
tasks were designed for adult populations, may be
of little interest or relevance to children, and
frequently lack suf®cient normative data (Ander-
son, 1998). Also, it is a tenuous practice to apply
adult measures to children as it is yet to be proven
that localized dysfunction in adults can be gen-
eralized to children, and it is clear that brain-
behavior relationships in adults are not analogous
to those observed in children (Fletcher & Taylor,
1984).
The RCF is one neuropsychological tool
designed for adults that has been successfully
employed with school-aged children. The task is
age appropriate for children aged 6 years or older
and normative data indicates that it is sensitive to
developmental changes (Akshoomoff & Stiles,
1995a, 1995b; Waber & Holmes, 1985, 1986).
In addition, performance on the RCF has been
found to discriminate children suffering from
both developmental and acquired CNS disorders,
including ADHD (Cahn et al., 1996), reading
disability (Waber & Bernstein, 1995), generalised
and frontal brain damage (Matthews, Anderson,
& Anderson, in submission), traumatic brain-
injury (Garth, Anderson, & Wrennall, 1995),
cerebral infection (Grimwood et al., 1995), and
cranial irradiation (Brouwers et al., 1984; Waber,
Bernstein, Tarbell, & Sallan, 1992).
While the RCF may be able to detect neuro-
psychological de®cits or delayed development
associated with brain dysfunction in children,
there is no conclusive evidence that performance
on the task is speci®cally related to executive
skills or underlying frontal lobe dysfunction.
Although executive functions such as planning
and organizational skills have been reported to be
important for the ef®cient completion of the RCF
(Bennett-Levy, 1984; Binder, 1982; Hamby,
Wilkins, & Barry, 1993; Kirk, 1985; Waber &
Holmes, 1985), lower order skills are also acti-
vated during the task. Visuo-constructional ability
(Spreen & Strauss, 1991), perceptual organization
(Lezak, 1995), sensorimotor coordination and
graphomotor skills (Kirk, 1985), and visual mem-
ory (Lezak, 1995; Liberman, Stewart, Seines, &
Gordon, 1994; Spreen & Strauss, 1991) are also
thought to contribute to overall task performance.
Thus, performance on the RCF is dependent on
numerous factors, and de®ciency or developmen-
tal delay in any of these areas may lead to a poor
outcome.
 RCF ORGANIZATIONAL STRATEGY SCORE (RCF-OSS)
Numerous scoring procedures have been
developed for the RCF with the aim to assess
performance and differentiate the in¯uence of
speci®c cognitive skills. Most procedures have
focused on accuracy (copy and recall) or level of
organization. Accuracy scores quantitatively
measure the precision of the reproduction, and
the recall score re¯ects visual memory function
(Bennett-Levy, 1984). The accuracy scoring sys-
tem adapted from Osterrieth (1944) is still popu-
lar, however more recently the Boston Qualitative
Scoring System (BQSS; Stern et al., 1994) has
been developed for adult populations, and a
system for children has been devised by Waber
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and Holmes (1985, 1986). Different organiza-
tional strategies are possible when copying the
RCF, and both qualitative and quantitative scoring
systems have been developed to evaluate these
approaches (Akshoomoff & Stiles, 1995a, 1995b;
Bennett-Levy, 1984; Binder, 1982; Hamby, Wilk-
inson, & Barry, 1993; Stern et al., 1994, Shorr,
Delis, & Massman, 1992; Waber & Holmes,
1985, 1986). It is important to note that accurate
drawings do not require ef®cient and conceptual
strategies, and these advanced strategies do not
necessarily result in good reproductions.
In comparison to accuracy procedures, organi-
zational scoring systems are less likely to be
in¯uenced by motor and coordination problems
and more likely to measure perceptual and orga-
nizational abilities. Therefore, the utilization of
both forms of assessment (i.e., accuracy and
organization) should assist in the differentiation
of perceptual and executive skills and increase the
speci®city of the RCF. Children as young as 6
years of age are able to draw most of the features
in the complex ®gure, and by 9 years of age the
majority of the details are included and placed
correctly (Akshoomoff & Stiles, 1995a; Waber &
Holmes, 1985). However, the level of organiza-
tion, planning and the type of strategies utilized
varies across childhood (Akshoomoff & Stiles,
1995a; Waber & Holmes, 1985) and these
changes may provide some insight into the deve-
lopment of perceptual and executive skills. Not
surprisingly, organizational strategies are also
signi®cantly associated with the quality of recall,
such that more ef®cient strategies are related to
better recall than fragmented or haphazard stra-
83
tegies (Akshoomoff & Stiles, 1995b; Bennett-
Levy, 1984). Consequently, it is also important
to take into account organizational strategy when
assessing visual memory with the RCF.
Osterrieth (1944, 1993) was the ®rst to identify
the capacity of the RCF to assess planning and
organizational skills. He described seven proce-
dural types in children and adults, however his
qualitative rating system ignored some variable
and less systematic strategies. Most of the recent
organizational scoring systems (Bennett-Levy,
1984; Binder, 1982; Shorr et al., 1992) are based
on the premise that perceptual organization is
re¯ected by the order in which the subject copies
the segments of the ®gure (Bennett-Levy, 1984).
The Con®gural (Binder, 1982), Strategy (Bennett-
Levy, 1984 ) and Perceptual Cluster (Shorr et al.,
1992) scores are well known qualitative scoring
procedures that share three similarities. First, they
assess the continuation or fragmentation of lines
and elements. Second, they were each designed
for adult populations, and ®nally, an objective of
all systems was to assist in the interpretation of
poor recall scores. These methods are sensitive to
brain pathology in adult populations, although
their applicability to children is unknown.
Uncertainty with respect to age-related levels
of performance on the RCF is a major limitation
for its use in pediatric assessment. It is essential to
determine age expectations if it is to be used to
identify developmental deviations in children
with brain dysfunction. Our current understand-
ing of developmental transitions on the RCF is
in¯uenced by the ®ndings of Waber and Holmes
(1985, 1986), Kirk (1985), and Akshoomoff and
Stiles (1995a). The Waber and Holmes (1985,
1986) scoring system was speci®cally devised to
cater for developmental changes. This system
includes an objective 5-level rating, evaluating
goodness of organization (poor to excellent),
which includes sublevels to produce a 13-point
organization scale. They found a gradual increase
in organizational scores and con®gurational stra-
tegies between the ages of 5 and 14 years. Kirk
(1985) examined the starting and progression
strategies in children and adolescents, and found
that those aged between 6 to 11 years adopted
predominately non-structured strategies whereas
older children tended to utilize more structured
 84 PETER ANDERSON ET AL.
and con®gurational strategies. Akshoomoff and
Stiles (1995a) used the BQSS (Stern et al., 1994)
to examine visuospatial analysis and planning
across childhood. They found that the Planning
score from the BQSS was not developmentally
sensitive, and like Kirk (1985), they devised a
system for pediatric populations that rated the
starting and progression strategies. Akshoomoff
and Stiles (1995a) noted that children over age 9
were more likely to focus on larger units and had a
greater appreciation of the base rectangle than the
younger children. Despite applying ef®cient orga-
nizational strategies on simpli®ed ®gures, chil-
dren aged between 6 and 9 years tended to use
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haphazard strategies or systematically focused on
small well-de®ned units in a piece-meal fashion
when confronted with a more complex geometric
®gure (Akshoomoff & Stiles, 1995a).
As reported, a number of organizational scor-
ing systems have been devised for adult and
pediatric populations. Troyer and Wishart
(1997) recently reviewed 10 qualitative systems
for the RCF and concluded that no current orga-
nizational scoring system has total acceptance.
This ®nding is not surprising given the differing
objectives of the scoring procedures. The limita-
tions identi®ed in scoring procedures include
inadequate psychometric properties, insensitivity
to developmental variations in childhood, insuf®-
cient developmental normative data, inability to
differentiate lower and higher order skills, and
dependency on post-hoc rating of the ®nal-pro-
duct.
In the attempt to address these limitations, we
have developed an alternative qualitative scoring
system, the Rey Complex Figure Organizational
Strategy Score (RCF-OSS). The intention was to
devise a scoring system with: (a) good construct
validity; (b) high sensitivity; (c) high speci®city;
(d) good inter-rater reliability and temporal sta-
bility; (d) reliable normative data; and (e) easy to
learn protocol that is quick to use. These objec-
tives mirror those of Hamby, Wilkins and Barry
(1993), although the RCF-OSS is speci®cally
designed for pediatric populations. It caters for
strategies adopted by young children, and with a
large normative sample, allows for developmental
variability. Building on the systems developed by
Kirk (1985) and Akshoomoff and Stiles (1995a),
the RCF-OSS attempts to utilize a sequential or
process-oriented approach, whereby the sequence
of drawn elements are assessed. Although the
RCF-OSS evaluates both starting and progression
strategies, it differs from the procedure described
by Akshoomoff and Stiles (1995a) in that both
strategy levels are integrated into a single vari-
able. In contrast to the classi®cations described
by Kirk (1985), the RCF-OSS provides detailed
instructions which may result in greater
objectivity.
The RCF-OSS rates drawings on a 7-point
scale that are labeled according to the level of
organizational strategy. Similar to other qualita-
tive scoring systems, the RCF-OSS places signif-
icant importance to the base rectangle and the
vertical and horizontal midlines (often referred to
as the `con®gural components') due to their role
in the alignment of the external attachments and
internal sections. This paper aims to describe the
RCF-OSS in detail; measure the inter-rater relia-
bility and temporal stability of the RCF-OSS;
examine it's construct validity and speci®city;
and ®nally, describe age-related performance on
the RCF.
METHOD
Subjects
The sample consisted of 376 children (180 males,
196 females), aged from 7.0 years to 13.11 years.
Subjects were divided into 7 age groups (7.0±7.11
years, 8.0±8.11 years, 9.0±9.11 years, 10.0±10.11
years, 11.0±11.11 years, 12.0±12.11 years, 13.0±
13.11 years), with approximately equal numbers of
males and females in each age group. Children with
a history of neurological, developmental, or psy-
chiatric disorders and those requiring special educa-
tional assistance were excluded from participation.
All subjects spoke English as their ®rst language.
Socioeconomic status (SES) was determined using
the Daniel's Scale of Occupational Prestige (1983)
on which parental occupation is rated from 1 and 7,
with a score of 1 re¯ecting high SES and a score of 7
indicating low SES. Table 1 outlines the character-
istics of the sample.
Procedure
Participants were recruited from schools within a
metropolitan area. Three primary and secondary
 RCF ORGANIZATIONAL STRATEGY SCORE (RCF-OSS) 85

Table 1. Demographic Characteristics of Sample. colors. Three psychologists also scored the same 50
drawings a week later to measure temporal stability.
Age group SES To investigate the convergent validity of the
(in years) Males Females Total M (SD) RCF-OSS, an additional group of `traditional'
executive function tests was administered. These
7.0±7.11 28 23 51 4.3 (1.8) included the Controlled Oral Word Association Test
8.0±8.11 21 30 51 4.3 (1.1) (Gaddes & Crockett, 1975), Trail Making Test
9.0±9.11 29 30 59 4.4 (1.1) (Reitan, 1958), Rey Auditory-Verbal Learning
10.0±10.11 28 31 59 4.4 (1.3) Test (Rey, 1993), and the Tower of London Test
11.0±11.11 18 33 51 4.7 (1.1) (Anderson, Anderson, & Lajoie, 1996; Shallice,
12.0±12.11 30 24 54 4.3 (1.2)
1982). These tests have been reported to evaluate
13.0±13.11 26 25 51 4.2 (1.2)
different aspects of executive function, including
Total 180 196 376 abstract thought, mental ¯exibility, planning and
organizational ability (Lezak, 1995; Walsh, 1978).
Some memory tests, Block Span (Milner, 1971),
Digit Span (Wechsler, 1991), Spatial Learning Test
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(L'Hermitte & Signoret, 1972) and Story Recall

schools were randomly chosen from the 10th, 30th,
50th, 70th, and 90th socioeconomic percentile levels
according to census information on the school
catchment areas. Letters of participation were sent
to the schools from each percentile level. In each of
these schools, one grade was randomly selected from
each age level (year 2 to year 8). Letters giving
detailed information about the study were then sent
to two males and two females randomly selected
from the identi®ed grade. A maximum of 16 males
and 16 females were chosen from each school
population.
Families agreeing to participate completed a
questionnaire including details of parental occupa-
tion, language spoken at home and child's medical
and developmental history. Children meeting selec-
tion criteria were assessed on an individual basis
within the school environment. A quali®ed psychol-
ogist administered the Rey-Osterrieth Complex
Figure Test (RCF) to all children, along with a
number of other neuropsychological measures des-
cribed below. The copy task was administered and
scored according to the format developed by Taylor
(1959), as described in Lezak (1995). Children were
given a different pencil color every 30 s to record the
order in which the ®gure was drawn. After an
interference period of 3 min children were asked to
draw all they could remember of the ®gure. Recall
was scored using the same procedures as the initial
reproduction. The RCF-OSS and the ®ve levels of
organization described by Waber and Holmes (1986)
were calculated for each copy drawing. Four
registered psychologists were trained to use the
RCF-OSS in a single training session in order to
evaluate inter-rater reliability. The psychologists
then independently scored 50 random copy drawings
following the RCF-OSS instructions, as outlined in
Table 2. The order in which components of the ®gure
were drawn was determined by different pencil
(modi®ed from Luria's Neuropsychological Battery;
Christensen, 1979), were also included in the test
battery in order to examine the discriminate validity
of the RCF-OSS. Tests were administered over two
sessions each lasting between 30 and 45 min. Tests
were administered in a set order, and Table 3 lists the
test battery and their order of administration.
RESULTS
Table 4 provides scores for accuracy, memory,
and Waber's ®ve levels of organization (Waber &
Holmes, 1986) for the sample, divided into age
groups. These ®gures indicate the expected incre-
ments in performance on the RCF for all mea-
sures, representing the expected development of a
range of cognitive skills through middle child-
hood and into adolescence.
Four quali®ed psychologists independently
rated 50 randomly selected copy drawings using
the RCF-OSS. The RCF-OSS generates ordinal
values, and thus inter-rater reliability was calcu-
lated using Spearman's correlation coef®cient.
The level of agreement between the four inde-
pendent raters ranged between .85 and .92. This
level of agreement indicates that the RCF-OSS
has good inter-rater reliability. The temporal sta-
bility coef®cients ranged between .79 and .94,
indicating acceptable intra-rater reliability.
Construct Validity
The construct validity of the RCF-OSS was
investigated by examining both the convergent
and discriminate validity of the measure. Con-
 86 PETER ANDERSON ET AL.

Table 2. The RCF Organizational Strategy Score.

General Information
The vertical and horizontal centerlines are pivotal to organization of the drawing and signi®cant components of
RCF-OSS.
The accuracy of drawing is not being measured, consequently parts of ®gure may be missing or drawn incorrectly.
The orientation of drawing may be incorrect
The examiner should carefully record sequence in which ®gure is completed.
Retrospective scoring can often increase rating dif®culty.

De®nitions
Rectangle: refers to large rectangle and is a con®gural component of ®gure.
Centerlines: refers to vertical and horizontal bisectors of rectangle. Centerlines are also con®gural components of
®gure, and separately drawn portions must connect.
Contour: refers to outline of ®gure. This may (or may not) include total outline, such as cross, diamond, or triangle.
Diagonals: refers to diagonals of rectangle. Diagonals do not have to be completed as single whole lines and
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sections of each diagonal do not have to connect.

Outside attachments: refers to all sections of ®gure external to rectangle, includes left vertical cross; horizontal
cross below rectangle; triangle on top of rectangle; triangle on right side of rectangle; small box below rectangle.
Internal sections: refers to all internal sections of large rectangle which could be divided into half, quarters or
eighths. This includes : four parallel lines and small horizontal line in left upper quadrant; circle with three dots and
small vertical line in right upper quadrant; rectangle with diagonals in left upper and lower quadrants; ®ve parallel
lines along diagonal in right lower quadrant.
Alignment: refers to an ``attempt'' (i.e., perfect execution not necessary) to align or connect outside attachments
and internal sections with centerlines. Alignment of diagonals refers to an ``attempt'' to connect sections of each
diagonal at midpoint junction of vertical and horizontal centerlines.

RCF-OSS Instructions
Level 7 ± excellent organization. Con®gural elements, the rectangle and centerlines, are completed ®rst
Criteria: (a) rectangle is drawn ®rst (may include the left hand cross);
(b) both vertical and horizontal centerlines are drawn directly after the rectangle;
(c) all of the internal sections, outside attachments and the diagonals aligned with centerlines.

Level 6 ± conceptual organization. Vertical and horizontal centerlines are drawn early.
Criteria: (a) either rectangle, contour, an internal section or outside attachments is drawn ®rst;
(b) both centerlines are drawn as whole single lines and completed prior to drawing diagonals and
internals sections;
(c) diagonals are aligned with centerlines (i.e., meet at the midpoint junction);
(d) majority of internal sections and outside attachments are aligned with centerlines.

Level 5 ± part-con®gural organization. Vertical and horizontal centerlines are present.

Criteria: (a) either rectangle, contour, an internal section or outside attachment is drawn ®rst;
(b) both centerlines are present;
(c) at least one internal section or outside attachment is aligned with vertical centerline, and at least one
internal section or outside attachment is aligned with horizontal centerline;
(d) at least one centerline is drawn as a whole single line, whilst remaining centerline can be completed
fragmentally (i.e., in segments), although portions must connect.
(e) a piecemeal approach is not adopted.

Level 4 ± piecemeal / fragmented organization. Piecemeal, fragmented or part-whole approach (subunits/

sections are drawn sequentially piece by piece).
Criteria: (a) either rectangle, contour, an internal section or outside attachment is drawn ®rst;
(b) only one centerline is completed as a whole single line unless the contour or rectangle is completed
®rst, in which case, neither centerline can be completed as a whole;
(c) remaining internal sections and outside attachments are completed one at a time in a piecemeal
manner (subsequent sections of drawing can be aligned with segments of centerlines).
 RCF ORGANIZATIONAL STRATEGY SCORE (RCF-OSS) 87

Table 2. (Continued).

Level 3 ± random organization. Only one complete centerline is used for alignment.
Criteria: (a) either rectangle, contour, an inside section or outside attachment is drawn ®rst;
(b) one complete centerline aligned with at least one internal section/outside attachment is present
(centerline can be completed fragmentally, i.e., in segments, although segments must connect);
(c) remaining centerline, if present, is not utilized for alignment of other components;
(d) if present, segments of an incomplete centerline can be utilized to align sections of drawing;
(e) piecemeal approach is not adopted.

Level 2 ± poor organization. Criteria for levels 3 to 7 have not been satis®ed.
Criteria: (a) any attempt to draw ®gure;
(b) any part of ®gure is drawn ®rst;
(c) if present centerlines are not aligned to any of internal sections or outside attachments;
(d) piecemeal approach is not adopted.
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Level 1 ± unrecognizable or substitution. No attempt is made to draw ®gure. Child may draw a substitution or
an unrecognizable scrawl.

Table 3. Test Measures and Order of Administration.

Test Measure Score employed in statistical analysis

Block Span Maximum block span (Block Span)

Digit Span Maximum digit span, forward (Digit Span)
Trail Making Test Time to completion, Part A (Trails A)
Time to completion, Part B (Trails B)
Number of errors (Trails-errors)
Spatial Learning Test Total no. of cards recalled (SPLT-tot)
Rey Auditory Verbal Learning (RAVLT) Total no. of words recalled Trail 1 (RAVLT-T1)
Total no. of words recalled over 5 trails (RAVLT-tot)
Story Recall Test Total recall score (Story-recall)
Rey-Osterrieth Complex Figure (RCF) Copy score (RCF-copy)
Recall score (RCF-recall)
Levels of organization score (RCF-organ)
Strategy score (RCF-OSS)
Controlled Oral Word Association (COWAT) Total number of words generated (COWAT)
Tower of London Test Number of correct trials (TOL-trials)
Number of extra attempts (TOL-attempts)
Raw score (TOL-raw score)

Table 4. Developmental Trends for Accuracy, Memory, and Levels of Organization (Waber & Holmes, 1986)
Scores on the RCF.

7yr 8yr 9yr 10yr 11yr 12yr 13yr

(n ˆ 51) (n ˆ 51) (n ˆ 58) (n ˆ 59) (n ˆ 51) (n ˆ 54) (n ˆ 51)

Accuracy Score M (SD) 22.0 (6.9) 24.0 (5.9) 27.6 (3.5) 29.1 (3.9) 28.9 (4.9) 31.1 (5.2) 31.4 (2.9)
Memory Score M (SD) 11.1 (5.5) 11.6 (6.0) 13.7 (5.0) 16.3 (5.9) 17.7 (4.9) 17.9 (6.6) 19.7 (6.1)
Organization Score M (SD) 1.6 (0.8) 1.9 (0.9) 2.1 (0.8) 2.4 (1.0) 2.6 (0.9) 3.3 (1.0) 3.5 (0.9)
 88 PETER ANDERSON ET AL.

Table 5. The Correlation of the RCF-OSS with Other Neuropsychological Measures.

Spearman's Spearman's
Test score rho Test score rho

Executive Functions Memory

COWAT .29 Block Span .18
TOL-trials .27 Digit Span .23
TOL-attempts ÿ .12 SPLT-tot .20
TOL-raw score .33 RAVLT-T1 .16
Trails A ÿ .28 Story-recall .26
Trails B ÿ .35
Trails errors ÿ .12
RAVLT-tot .27
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RCF-copy .51
RCF-recall .42
RCF-organ .52

Fig. 2. Relationship of RCF-OSS with other executive function tests.

vergent validity was assessed by examining the
relationship of the RCF-OSS with scores from a
number of other tests that are purported to mea-
sure executive function, while discriminate valid-
ity was assessed by examining the relationship of
the RCF-OSS with other non-executive function
scores.
Convergent Validity. Overall, the RCF-OSS cor-
related moderately (.12 to .35) with traditional
measures of executive function (see Table 5). The
correlations were lower than expected, however
this may be partly due to the selection of exe-
cutive function tests and the ordinal values of the
RCF-OSS. The mean scores for the executive
 RCF ORGANIZATIONAL STRATEGY SCORE (RCF-OSS)
function measures were calculated for each RCF-
OSS level. Figure 2 demonstrates relatively strong
linear relationships between performance on all
the executive function measures (TOL, COWAT,
RAVLT, and Trails B) and organizational strategy
on the RCF. In general, children who utilized
conceptual strategies, that is, more organized
approaches, on the RCF were more likely to per-
form better on other executive function tasks than
children who adopted poor or piece-meal strate-
gies. The results depicted in Figure 2 imply
moderate convergent validity for the RCF-OSS.
Discriminate Validity. The RCF-OSS also did not
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correlate strongly with memory tests (.18 to .26),
but again this maybe related to the ordinal nature
of the RCF-OSS. The mean scores for these var-
iables were calculated for each RCF-OSS level.
Linear relationships between performance on the
memory measures and organizational strategy on
the RCF were also observed (see Figure 3). In
summary, performance on the memory measures
was associated with the organizational strategy
used on the RCF. Children who utilized sophisti-
cated strategies performed better on memory
tasks than children who adopted inef®cient stra-
tegies. These ®ndings suggest relatively poor dis-
criminative validity for the RCF-OSS.
Fig. 3. Relationship of RCF-OSS with memory measures.
89
Speci®city
The RCF-OSS correlated signi®cantly and posi-
tively with RCF copy (.51) and recall (.42) accu-
racy. Not surprisingly, the results suggest that the
organizational strategy adopted during the initial
reproduction was related to the accuracy of both
the copy and recall drawings, such that conceptual
strategies were likely to result in more accurate
drawings. RCF-OSS was also associated with
RCF-organ. (.52), the ®ve levels of organization
described by Waber and Holmes (1986). As exp-
ected, the RCF-OSS is strongly associated with
other RCF outcome scores. However, the strength
of the relationships suggests that RCF-OSS may
also assess an aspect of performance that is not
measured by typical RCF scores, increasing the
speci®city of the RCF.
Developmental Trends. To simplify the investiga-
tion of age-related variation in organizational
strategies, levels 1, 2, and 3 were collapsed and
labeled as `Poor' strategies, levels 4 and 5 were
classi®ed as `Fragmented' and `Part-con®gural'
strategies respectively, while levels 6 and 7 were
collapsed and labeled as `Conceptual' strategies.
The results indicate that younger children adopted
different organizational strategies than older chil-
dren (see Table 6), with considerable age-related
 90 PETER ANDERSON ET AL.
Table 6. Developmental Trends for Organizational Strategy on the RCF.
7yr 8yr
Organizational strategy (n ˆ 51) (n ˆ 51)
Poor (%) 60.8 37.2
Fragmented (%) 19.6 27.5
Part-con®gural (%) 19.6 27.5
Conceptual (%) 0 7.8
variation occurring between the ages of 7 and 10
years. The majority of 7 year olds adopted poor
(60.8%) or fragmented (19.6%) strategies when
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copying the RCF. Eight year olds performed
considerably better with 55% adopting fragmen-
ted or part-con®gural strategies and nearly 8%
utilizing a conceptual approach. By the age of 10
years, approximately 60% of the children used
either part-con®gural or conceptual organiza-
tional strategies and only 15% could be classi®ed
as fragmented and 22% as poor.
Only a small minority of children aged 11
years or above used poor strategies, however
signi®cant age variation remained in the other
levels. Fragmented or piece-meal approaches are
considered less effective and ef®cient, and sur-
prisingly, these strategies were adopted by more
12 and 13 year olds than any other age level.
Approximately 25% of 11 year olds and nearly
30% of 12 year olds used conceptual strategies in
contrast to only 14% of 13 year olds. The ®ndings
suggest that the development and re®nement of
organizational strategies continue into middle to
late adolescence.
DISCUSSION
The RCF is a popular neuropsychological test
because it can be administered easily and quickly,
it is sensitive to brain pathology (Binder, 1982;
Kaplan, 1983; Messereli, Seron, & Tissot, 1979;
Matthews, Anderson, & Anderson, in submis-
sion), and it is appealing to children and adults.
Numerous attempts have been made to assess the
level of organization in RCF drawings, however
as yet, no procedure has been globally accepted
(Troyer & Wishart, 1997). The present study has
9yr 10yr 11yr 12yr 13yr
(n ˆ 58) (n ˆ 59) (n ˆ 51) (n ˆ 54) (n ˆ 51)
24.1 22.0 11.8 13.0 0
22.4 15.3 15.7 29.6 33.3
46.6 45.8 47.1 27.8 52.9
6.9 17.0 25.5 29.6 13.7
examined the reliability, validity and utility of a
newly developed scoring procedure for the RCF.
The RCF-OSS has been designed to assess orga-
nizational strategies, with particular focus on
developmental issues such as age related varia-
tions during childhood.
Psychometric Properties
Three of the independent raters had only limited
training with the RCF-OSS indicating that it is
easy to apply. The RCF-OSS has good inter-rater
reliability (.85 to .92), comparable to the reli-
ability coef®cients of other RCF qualitative scor-
ing procedures that range from .62 to .98 (Troyer
& Wishart, 1997). Temporal stability was also
acceptable (.79 to .94). For this sample, the
sequence in which elements were drawn was
determined by different pencil colors provided
in a set time frame. Higher inter-rater reliabilities
and temporal stability may have been achieved if
more ¯exibility was allowed in the system of
sequential recording.
The RCF-OSS demonstrated moderate linear
relationships with other traditional executive
function measures (i.e., TOL, COWAT, Trails B,
and RAVLT), providing some evidence of con-
vergent validity. Children who adopted concep-
tual strategies on the RCF tended to perform
better on other measures of executive function.
Despite moderate linear relationships, the RCF-
OSS did not correlate highly with the other
executive measures. This can be at least partly
explained by the qualitative and ordinal nature of
the RCF-OSS. Also, a different selection of
executive function measures that focus on strate-
gic behavior may have provided stronger associa-
tions. However, it should be noted that measures
of executive function rarely correlate strongly due
 RCF ORGANIZATIONAL STRATEGY SCORE (RCF-OSS)
to the novelty of the tasks and the multi-dimen-
sional nature of their assessment. It is dif®cult to
truly assess the convergent validity of the RCF-
OSS as there are few measures suitable for
children that qualitatively evaluates strategic
behavior. Although this hinders our capacity to
assess the validity of this scoring system, it also
illustrates the need for such a measure.
The RCF-OSS was also mildly related with
outcome scores from memory measures (Block
Span, Digit Span, RAVLT-T1, Story-recall). The
positive linear relationships that are illustrated in
Figure 3 imply that children who used ef®cient
strategies were more likely to perform better on
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memory tasks than children that utilised inef®-
cient strategies. In general, the RCF-OSS exhib-
ited similar relationships with executive function
and memory measures. From this ®nding we
postulate that strategic behavior plays a signi®-
cant role in the completion of both executive fun-
ction and memory tasks. However, it is important
to note that the RCF-OSS did not correlate
`strongly' with any of the measures administered,
and therefore this scoring procedure appears to be
assessing a separate aspect of cognitive function-
ing. Overall, the construct validity of the RCF-
OSS requires further investigation, but these pre-
liminary ®ndings provide some initial support.
The sensitivity and speci®city of the scoring pro-
cedure is the subject of a separate study.
The RCF-OSS correlated strongly with scores
on the RCF such as copy (.51) and recall (.42)
accuracy. These associations imply that children
who utilize conceptual strategies whilst copying
the ®gure are also likely to draw and recall it more
accurately than children who used random or
fragmented approaches. Conceptual strategies
involve imposing an appropriate framework or
con®guration such as the large rectangle and the
vertical and horizontal midlines. These concep-
tual strategies are considered more effective as
alignment is easier with a basic structural unit and
fewer components need to be drawn. Strategies
that impose a framework also assist when recal-
ling the ®gure because a logical approach was
initially developed and fewer rules and sections
need to be remembered. Although fragmented
approaches can result in accurate drawings, they
are considered less ef®cient as they increase the
91
likelihood of alignment and relationship errors
(Messerli et al., 1979).
The relationship between RCF-OSS and RCF-
organ (Waber & Holmes, 1986) was consistent
with those recorded for other executive function
measures, although this relationship may have
been expected to be greater. RCF-organ is an
objective rating system that relies on a post-hoc
analysis of the ®nal product. However, it focuses
on the alignment of components and is strongly
related to accuracy (.66). RCF-organ would
appear to be particularly useful for assessing the
overall precision of the drawing, with the RCF-
OSS more suitable for evaluating organizational
strategy and process. Not surprisingly, other qua-
litative or organizational scoring systems are
reported to correlate signi®cantly with copy and
recall accuracy (Bennett-Levy, 1984; Hamby
et al., 1993; Shorr et al., 1992; Waber & Holmes,
1986).
The RCF-OSS appears to be related to tradi-
tional RCF scores such as accuracy, recall, and
organization (alignment), however it also seems to
be measuring a further, independent aspect of
performance. We speculate that this scoring sys-
tem assesses strategic behavior and provides
unique insight into the child's strategic and pro-
blem solving abilities.
Developmental Trends
Consistent with the ®ndings from previous devel-
opmental studies (Akshoomoff & Stiles, 1995a;
Kirk, 1985; Waber & Holmes, 1985), signi®cant
developmental changes in organizational strategy
were observed. More than half of the 7-year-old
group copied the ®gure in a random or obscure
manner, while another 20% preferred a fragmen-
ted approach. The proportion of children using
piecemeal strategies had increased to nearly 30%
by age 8. The proportion of young children
adopting piecemeal strategies was lower than
expected given the ®ndings of Osterrieth (1944)
and Waber (1979), however this may re¯ect the
differences in de®nition and categorization. Over-
all, the ®ndings supports the view that children
aged between 6 and 8 years tend to focus on small
units of the design or compensated with hapha-
zard strategies (Akshoomoff & Stiles, 1995a;
Kirk, 1985). Based on these results it is inferred
 92 PETER ANDERSON ET AL.
that children aged 7 years and younger have
dif®culty adopting an integrated perspective and
clear strategy, and is consistent with knowledge
regarding growth spurts in cerebral development,
particularly with regards to the frontal lobes
(Stuss, 1992).
By age 9, only 24 % of the children were
adopting poor strategies with most children opting
for a fragmented or conceptual approach. In fact
nearly half of the 9 year olds utilized a part-
con®gural approach whereby they preferred semi
holistic (i.e., conceptual) strategies. Akshoomoff
and Stiles (1995a) reported a similar trend in
9 year-olds, although Kirk (1985) reported an
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increase in fragmented strategies at this age. This
developmental trend continued through to age 13
by which time none of the children were found to
be using poor strategies. Although most children
aged 8 years and above were capable of imple-
menting a strategy when completing the RCF,
notable age related variations were observed to
continue through to age 13. According to Kirk
(1985), between the ages of 7 and 12 years child-
ren should develop the capacity to perceive the
®gure as a `whole' and begin to adopt conceptual
strategies. Our results partially supported the
observations of Kirk (1985), as there was a dev-
elopmental increment with regards to the propor-
tion of children initiating conceptual strategies.
However, one third of the 13 year olds preferred a
fragmented or piecemeal approach, with more 13
year olds utilizing fragmented strategies than any
other age group. Based on the proportion of
children adopting conceptual or part-con®gural
strategies, the 11-year-old age group exhibited
better organizational ability than the 12 and 13
year olds. Seventy-three percent of 11 year olds
satis®ed this criteria, in contrast to 57.4% (12 year
olds) and 67.6% (13 year olds).
Interpretation of developmental transitions is
problematic with a cross sectional design, how-
ever there appears to be a marked shift towards
fragmented strategies in children aged 12 and 13
years when compared to the children aged 10 and
11 years. Inconsistencies are not uncommon in
developmental studies (e.g., Anderson, Anderson,
& Lajoie, 1996) and may re¯ect `gappiness',
abrupt increases and decreases in ef®ciency (Kirk,
1985), that occur during periods of developmental
transition. Greater self-regulation and monitoring
which inhibits complex and conceptual appro-
aches is a possible explanation for the regression
in organizational strategy observed in the 12 and
13 year olds. Within the classroom setting, chil-
dren around this age are often encouraged to plan
and structure their approach to complex tasks so
that speci®c components of the task are com-
pleted sequentially. Sample selection bias could
be an alternative interpretation, however this is
unlikely given the normal developmental trends
documented for the other measures administered
and for the accuracy and memory scores on the
RCF itself. The average copy and recall accuracy
scores were higher for the 12 and 13 years olds in
comparison to the younger children, suggesting
that fragmented strategies can be just as effective
if they are planned carefully and logically. Accor-
ding to Osterrieth (1944), 83% of adults adopt a
conceptual or part-con®gural approach and only
15% use a piecemeal approach. Differences bet-
ween studies complicate direct comparisons,
although these ®ndings suggest that further devel-
opmental changes in organizational strategy occur
during middle to late adolescence.
These ®ndings impact on our understanding of
executive function development. It is now well
accepted that certain executive skills emerge at a
young age, in particular skills such as anticipa-
tion, planning, impulse control, set maintenance,
and self-monitoring (Welsh et al., 1991). Execu-
tive function development is thought to follow a
multi-stage process (Anderson, 1998), with the
greatest period of functional development occur-
ring between the ages of 6 to 8 years (Passler et al.,
1985). Higher order skills such as complex plan-
ning, conceptual reasoning, and strategy forma-
tion have been reported to approach adult-level
performance at 10 years, or adolescence (Ander-
son, 1998; Welsh et al., 1991). These inferences
have been based on executive function measures
that generally adopt end point scores, but it
remains to be determined whether children who
reach this adult-level of performance use adult
strategies. Our results demonstrate that perfor-
mance is not necessarily based on the most
ef®cient strategies and suggest that the develop-
ment of certain higher order skills such as orga-
nizational ability may plateau later than expected.
 RCF ORGANIZATIONAL STRATEGY SCORE (RCF-OSS)
CONCLUSIONS
The primary advantage the RCF-OSS has over
many other qualitative scoring systems is its
suitability to pediatric populations. The RCF-
OSS is also easy to learn, and for experienced
raters, drawings can be scored within 30 seconds.
Preliminary analyses indicate that the inter-rater
reliability and temporal stability are reasonable.
Further research is required to determine it's
construct validity, sensitivity and speci®city, but
initial investigations are encouraging. RCF-OSS
measures a distinct aspect of performance, pre-
sumed to be organizational strategy, and is a
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useful adjunct to typical RCF scores such as copy
and recall accuracy.
The RCF is a useful neuropsychological tool
that allows for the assessment of organizational
ability across the developmental spectrum. Our
®ndings imply that organizational skills do not
consolidate until at least mid adolescence. As our
data suggests, the capacity to utilize organiza-
tional strategies is likely to begin in early child-
hood and proceed through stages of skill
development, implementation, modi®cation and
re®nement. These ®ndings highlight the need for
pediatric based scoring procedures with appropri-
ate normative data that incorporate approaches
used by children and adolescents.
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