The Rey-Osterrieth Complex Figure Test (RCFT)

Introduction
The Rey Complex Figure Test (RCFT) stands as a pivotal tool within the realm of
neuropsychological assessment, offering clinicians a window into the intricate workings of
cognitive functioning. Developed by Swiss psychologist André Rey in the early 20th century,
this test presents participants with a deceptively simple yet intricately detailed line drawing,
challenging them to reproduce it from memory after a delay. Through its multi-faceted approach,
the RCFT evaluates an array of cognitive domains, including visuospatial abilities, memory
encoding and retrieval, and executive functions. Its standardized administration and scoring
procedures, coupled with its sensitivity to subtle cognitive impairments, have positioned the
RCFT as a cornerstone of psychological evaluations across diverse clinical populations.

Figure:

History of the RCFT

The Rey Complex Figure Test (RCFT) was developed by Swiss psychologist André Rey in the
early 20th century. Rey initially designed the test as part of his research on the effects of brain
injury and neurodegenerative diseases on cognitive functioning. He sought to create a visual-
spatial task that could assess various aspects of cognitive processing beyond what traditional
paper-and-pencil tests could measure. The Complex Figure Test was first designed in 1941 and
then standardized in 1944, which provided preliminary standardized data for 230 children and 60
adults to form the widely used Rey–Osterrieth Complex Figure (ROCF) test.
The original version of the test consisted of a single complex line drawing, which participants
were asked to copy. Rey administered the test to individuals with brain injuries, neurological
disorders, and psychiatric conditions, observing their performance and identifying patterns of
cognitive impairment.
Over time, the RCFT underwent refinements and modifications to enhance its reliability and
validity as a psychological assessment tool. Researchers and clinicians around the world began to
recognize its utility in assessing visuospatial abilities, memory, and executive functions across
diverse populations and clinical settings.
The RCFT has since become a standard component of neuropsychological assessments, with
numerous studies validating its effectiveness in diagnosing conditions such as traumatic brain
injury, Alzheimer's disease, and attention-deficit/hyperactivity disorder (ADHD). Its widespread
use underscores its significance as a versatile and valuable instrument in the field of clinical
psychology.

Equivalent and simplified versions of Rey–Osterrieth Complex Figure (ROCF). In 1941, Rey
developed the classic ROCF (A). To avoid the learning effect by using the same figure twice,
some studies have developed multiple equivalent versions of the ROCF, such as the Taylor
figure (B), the modified Taylor figure (C), the Mark figure (D), and various versions of the
Medical College of Georgia Complex Figures (E–H). Subsequently, multiple simplified versions
of ROCF (I, K, L) were developed. The Benson figure (I) is less affected by executive
function. (K) has been proven to be suitable for the elderly. Kim developed (L) for digital
assessment tools. Similarly, the simplified Taylor figure (J) has also been confirmed to suit the
low-educated elderly.

Components of the RCFT:

The Rey Complex Figure Test (RCFT) comprises three main components: the copying phase,
immediate recall phase, and delayed recall phase. Each phase serves a distinct purpose in
assessing various aspects of cognitive functioning. Let's explore each component in detail:

1. Copying Phase:
Description: During the copying phase, participants are presented with the Rey Complex Figure
stimulus card and instructed to reproduce the figure as accurately as possible onto a blank sheet
of paper.
Assessment: This phase primarily evaluates participants' visuospatial abilities, visual perception,
and motor skills. It assesses their ability to perceive the complex visual stimuli, analyze its
spatial relationships, and accurately reproduce it using fine motor coordination.
Importance: The copying phase provides valuable insights into participants' immediate
visuospatial processing abilities. It serves as a baseline assessment of their perceptual and motor
skills, allowing clinicians to observe how they approach and execute a complex visual task in
real-time.
2. Immediate Recall Phase:
Description: Following the copying phase, participants are asked to reproduce the Rey Complex
Figure from memory onto a new sheet of paper immediately after completing the copying task.
Assessment: The immediate recall phase assesses participants' short-term memory, working
memory, and cognitive organization. It evaluates their ability to retain and recall visuospatial
information over a brief delay, without access to the original stimulus.
Importance: This phase provides insights into participants' memory encoding, retention, and
retrieval processes. It allows clinicians to assess the fidelity of their memory representation of
the figure and their ability to organize and reproduce spatial information from memory
accurately.
3. Delayed Recall Phase:
Description: After a delay period (typically ranging from 10 to 30 minutes), participants are
asked to reproduce the Rey Complex Figure from memory once again onto a new sheet of paper.
Assessment: The delayed recall phase evaluates participants' long-term memory retention and
retrieval processes. It assesses their ability to retain and recall visuospatial information over an
extended period, providing insights into the durability of their memory traces.
Importance: This phase offers valuable information about the persistence of participants'
memory representations over time. It allows clinicians to assess the stability of their memory
recall and identify any decay or degradation in memory performance following a delay, which
can be indicative of underlying cognitive impairments or neurological conditions.

Purpose of the RCFT

1. Assessing Visuospatial Abilities:
The RCFT is particularly adept at evaluating an individual's visuospatial abilities, which
encompass the perception and interpretation of visual information in space. This includes skills
such as visual discrimination, spatial orientation, and the ability to accurately reproduce complex
visual stimuli. By examining how participants approach the task of copying and recalling the
complex figure, clinicians can gain insights into the integrity of their visuospatial processing
abilities.

2. Evaluating Memory Functioning:

Memory assessment is a central component of the RCFT. Through the immediate and delayed
recall phases, clinicians can evaluate different aspects of memory functioning, including short-
term memory, long-term memory, and memory retrieval processes. Participants' performance on
these recall tasks provides valuable information about their memory capacity, retention abilities,
and the effectiveness of encoding strategies employed during the initial exposure to the figure.

3. Assessing Executive Functions:

Executive functions refer to a set of higher-order cognitive processes responsible for goal-
directed behavior, cognitive flexibility, problem-solving, and self-regulation. The RCFT engages
executive functions by requiring participants to plan and execute a task, monitor their progress,
and adapt their approach as needed. Observing how individuals organize and strategize during
the copying and recall phases can yield insights into their executive functioning abilities,
including planning skills, cognitive flexibility, and inhibitory control.
During the copying phase of the RCFT, individuals with intact executive functions will typically
demonstrate effective planning and organization in their approach. They might start by outlining
the basic shape of the figure, strategically dividing it into manageable sections, and then
gradually filling in details. They may also exhibit flexibility in their strategy, adjusting their
approach as they encounter challenges or errors. For instance, if they notice a discrepancy in
their drawing, they may employ problem-solving skills to correct it and maintain overall
coherence.
Conversely, individuals with executive dysfunction may struggle with planning and organization
during the copying phase. They might exhibit difficulties in initiating the task, becoming
overwhelmed by the complexity of the figure, or displaying impulsive behavior such as
haphazardly filling in details without a clear strategy. Their drawings may lack cohesion, with
disproportionate or disorganized elements reflecting deficits in executive functioning.

4. Evaluating Planning Skills:

Planning skills are closely intertwined with executive functions and involve the ability to devise
and implement organized strategies to achieve a specific goal. In the context of the RCFT,
participants must effectively plan their approach to copying and reproducing the complex figure,
considering factors such as spatial relationships, symmetry, and detail orientation. Their
performance provides clinicians with information about their planning abilities, problem-solving
strategies, and capacity for strategic thinking.
During the recall phase of the RCFT, individuals with strong planning skills will demonstrate an
organized and systematic approach to reproducing the figure from memory. They may begin by
mentally visualizing the overall structure of the figure, breaking it down into component parts,
and then systematically reconstructing each element in a logical sequence. Their drawings may
exhibit a high level of detail, symmetry, and accuracy, reflecting careful planning and attention
to spatial relationships.
In contrast, individuals with poor planning skills may struggle to effectively reconstruct the
figure from memory. They may exhibit difficulties in recalling the spatial layout of the figure,
omitting key elements or inaccurately reproducing their relative positions. Their drawings may
appear disjointed or fragmented, lacking the cohesive structure and detail characteristic of well-
planned representations. These difficulties may stem from deficits in executive functions such as
planning, organization, and cognitive flexibility, impacting their ability to strategize and execute
the task effectively.

5. Diagnostic Utility:
Beyond its role in assessing specific cognitive functions, the RCFT holds significant diagnostic
utility across a spectrum of neurological and psychiatric conditions. It is commonly employed in
the diagnosis and differential diagnosis of conditions such as traumatic brain injury, dementia
(including Alzheimer's disease), stroke, multiple sclerosis, and developmental disorders such as
autism spectrum disorder (ASD) and attention-deficit/hyperactivity disorder (ADHD). By
identifying patterns of cognitive strengths and weaknesses, the RCFT aids clinicians in
formulating accurate diagnoses, prognosticating outcomes, and developing targeted intervention
plans tailored to individuals' cognitive profiles.
Alzheimer's Disease (AD):
Alzheimer's disease is characterized by progressive cognitive decline, particularly in memory,
executive functions, and visuospatial abilities. The RCFT is instrumental in detecting early signs
of cognitive impairment associated with AD and monitoring disease progression over time.
Individuals with AD typically demonstrate deficits in memory and visuospatial processing,
reflected in their performance on the RCFT. During the copying phase, they may struggle to
accurately reproduce the complex figure, omitting details or misplacing elements due to impaired
visual perception and spatial orientation. In the recall phases, they may exhibit significant
difficulties in remembering and accurately reproducing the figure from memory, indicative of
deficits in encoding, retention, and retrieval processes. By analyzing patterns of performance on
the RCFT, clinicians can differentiate between normal age-related cognitive changes and
pathological decline associated with AD, facilitating timely diagnosis and intervention.

Attention-Deficit/Hyperactivity Disorder (ADHD):

ADHD is characterized by symptoms of inattention, impulsivity, and hyperactivity, which can
impact cognitive functioning across multiple domains. The RCFT provides valuable insights into
the cognitive profile of individuals with ADHD, particularly in assessing executive functions,
attentional control, and planning abilities. During the copying phase, individuals with ADHD
may demonstrate impulsive or disorganized drawing strategies, rushing through the task without
adequate planning or attention to detail. Their drawings may lack coherence and exhibit errors
indicative of difficulties in sustaining attention and inhibiting impulsive responses. In the recall
phases, they may struggle to reproduce the figure accurately from memory, showing deficits in
working memory capacity and organization. By examining their performance on the RCFT in
conjunction with other assessment measures, clinicians can elucidate the cognitive impairments
underlying ADHD symptoms and tailor interventions to address specific areas of difficulty.

Autism Spectrum Disorder (ASD):

Autism spectrum disorder is characterized by persistent deficits in social communication and
interaction, as well as restricted interests and repetitive behaviors. The RCFT offers valuable
insights into the visuospatial and executive functioning abilities of individuals with ASD,
complementing assessments of social and communication skills. While some individuals with
ASD may perform within the average range on the RCFT, others may exhibit specific difficulties
related to visuospatial processing and planning. During the copying phase, they may demonstrate
idiosyncratic drawing styles or exhibit rigid adherence to detail, reflecting a preference for
sameness and difficulties with cognitive flexibility. In the recall phases, they may struggle to
reproduce the figure accurately from memory, showing deficits in mental rotation and spatial
reasoning. By considering their performance on the RCFT alongside other clinical observations
and assessment measures, clinicians can develop tailored interventions to support their cognitive
and adaptive functioning within the context of ASD.

Scoring Methodology:
The scoring of the RCFT, based on the scoring criteria developed by Rey (1941; Corwin &
Bylsma, 1993) and presented in Lezak (1995). Rey’s scoring system divides the complex figure
into 18 units; each unit is scored separately for both accuracy and placement. The Rey Complex
Figure, with the 18 scoring units numbered, is illustrated in Figure 1. Specific criteria were
developed for scoring the accuracy and placement of units of drawings.
The scoring methodology for the Rey Complex Figure Test (RCFT) involves evaluating
participants' performance across multiple dimensions, including accuracy, organization, and
detail. Deviations from the original figure are carefully assessed to glean insights into
participants' cognitive functioning. Let's delve into each aspect in detail with suitable examples:

Accuracy:
Description: Accuracy refers to the extent to which participants' reproductions of the Rey
Complex Figure correspond to the original stimulus in terms of overall shape, proportions, and
spatial relationships.
Example: If the original figure contains a specific geometric shape or pattern, such as a circle or
a series of intersecting lines, accurate reproduction would entail participants correctly replicating
these elements in their drawings. Deviations from the original figure, such as misshapen or
omitted components, would indicate reduced accuracy in reproduction.
Organization:
Description: Organization assesses the structural coherence and spatial arrangement of
participants' drawings, including the logical sequencing and grouping of elements within the
figure.
Example: A well-organized reproduction of the Rey Complex Figure would exhibit clear
delineation of component parts, with elements grouped and positioned in a logical manner. For
instance, participants may systematically reproduce the figure by first outlining the perimeter,
then filling in internal details, and finally adding finer features. Disorganized drawings, on the
other hand, may lack cohesive structure, with elements scattered or haphazardly arranged.

Detail:
Description: Detail refers to the level of granularity and completeness in participants'
reproductions of the Rey Complex Figure, encompassing the inclusion of specific features,
intricacies, and embellishments present in the original stimulus.
Example: A highly detailed reproduction of the figure would capture fine-grained elements such
as intersecting lines, internal patterns, and small geometric shapes with precision and accuracy.
Participants may demonstrate attention to detail by faithfully replicating intricate components
and subtle nuances present in the original stimulus. Conversely, drawings lacking detail may
appear sparse or incomplete, with significant omissions or simplifications of complex features.
Scoring:
A score of 0, 0.5, 1, or 2 is assigned to each unit of the figure based on accuracy and placement
criteria. Unit scores are then summed to obtain the raw score for that drawing. The same scoring
criteria apply to all three drawing trials. Thus, raw scores ranging from 0.0 to 36.0 may be
obtained for the Copy, Immediate Recall, and Delayed Recall trials. For each unit of the figure, a
score of 2 is assigned if the unit was drawn accurately and placed correctly. A score of 1 is
assigned if the unit was drawn accurately, but was placed incorrectly. A score of 1 is assigned if
the unit was drawn inaccurately, but was placed correctly. A score of 1 is also assigned if the unit
was duplicated (i.e., drawn twice) in the drawing, but at least one of the duplicates was drawn
accurately and placed correctly. A score of 0.5 is assigned if the unit was drawn inaccurately and
was placed incorrectly, but is still recognizable. A score of 0.5 is assigned if the unit was
duplicated in the drawing, and both units were drawn inaccurately and were placed incorrectly,
but both were still recognizable. A score of 0 is assigned if the unit was omitted altogether or
was drawn inaccurately and placed incorrectly, and was not recognizable.
For each scoring unit, both a general scoring principle and specific scoring criteria are presented.
The specific scoring criteria specify accuracy and placement ratings in terms of precise distance
measurements
Scoring the recognition trial :
A true positive response on the Recognition trial occurs when a respondent indicates that he or
she recognizes an element that is part of the Rey Complex Figure (i.e., circles a target item).
Recognition trial Items 2, 5, 7, 8, 9, 12, 13, 15, 19, 20, 22, and 24 are target items. Sum the
number of these items that were circled, and enter this value as the raw score for Recognition
True Positives. A false positive response on the Recognition trial occurs when a respondent
indicates that he or she recognizes an element that is not part of the figure (i.e., circles a
distractor item). Recognition trial Items 1, 3, 4, 6, 10, 11, 14, 16, 17, 18, 21, and 23 are distractor
items. Sum the number of these items that were circled, and enter this value as the raw score for
Recognition False Positives.
A true negative response on the Recognition trial occurs when a respondent indicates that he or
she does not recognize an item that is not part of the figure (i.e., does not circle a distractor item).
The Recognition True Negatives raw score is the inverse of the Recognition False Positives raw
score. Therefore, subtract the Recognition False Positives raw score from 12, and record this
value as the raw score for Recognition True Negatives. A false negative response on the
Recognition trial occurs when a respondent indicates that he or she does not recognize an item
that is part of the figure. The Recognition False N negatives raw score is the inverse of the
Recognition True Positives raw score. Therefore, subtract the Recognition True Positives raw
score from 12, and record this value as the raw score for Recognition False Negatives.
The Recognition Total Correct raw score is the sum of the Recognition True Positives and
Recognition True Negatives raw scores. Sum these two scores and record this value as the
Recognition Total Correct raw score. After the raw scores for the RCFT have been calculated
and entered their respective spaces on page 1 of the test booklet, corresponding normative scores
may be recorded.

Interpretation of Deviations:
When interpreting deviations from the original figure in participants' drawings, clinicians
consider the nature and pattern of errors across dimensions such as accuracy, organization, and
detail. Significant discrepancies may suggest underlying cognitive impairments or difficulties in
specific cognitive domains:
Inaccuracies: Substantial errors or distortions in reproducing key elements of the figure may
indicate deficits in visuospatial perception or motor coordination.
Disorganization: Chaotic or disjointed drawings lacking coherent structure may suggest
difficulties in planning, executive functioning, or cognitive organization.
Lack of Detail: Sparse or rudimentary drawings with minimal detail may reflect deficits in
attention, visual processing, or memory encoding.

Reliability:
Test-Retest Reliability: Studies have reported test-retest reliability coefficients for the RCFT
ranging from around 0.60 to 0.90, indicating moderate to high levels of consistency over time.
Inter-Rater Reliability: Inter-rater reliability coefficients for the RCFT have been reported in the
range of 0.70 to 0.90, suggesting generally good agreement among raters in scoring the test.
Validity:
Content Validity: Content validity for the RCFT is supported by the fact that the test assesses key
cognitive functions related to visuospatial constructional ability, memory, and organizational
skills, which are relevant to its intended purpose.
Construct Validity: Construct validity has been demonstrated through correlations between
RCFT scores and performance on other neuropsychological measures assessing similar
constructs. For example, studies have shown significant correlations between RCFT scores and
measures of visuospatial ability, memory function, and executive functioning.