Neuropsychology Copyright 1995 by the American Psychological Association Inc

1995, Vol. 9, No. 3, 364-377 0894-4105/95/S3.00

Developmental Trends in Visuospatial Analysis and Planning:

I. Copying a Complex Figure
Natacha A. Akshoomoff and Joan Stiles
University of California, San Diego

An existing scoring system was used to assess the accuracy of the children's ability to copy the
Rey-Osterrieth Complex Figure. The authors also developed additional measures to more
precisely describe the process used by children in copying this figure. The findings suggest that
children between the ages of 6 and 9 break the figure up into simple components but improve in
their ability to integrate the figure with age. Younger children demonstrated a similar pattern of
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performance when copying the main features of the Rey-Osterrieth Complex Figure in isolation.
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The results of this study suggest that when faced with tasks requiring more advanced types of
spatial analysis, children adopt strategies that proved successful when they were younger. Children
have a variety of spatial analytic strategies available by age 6, but the strategy that they use is a
function of pattern complexity and the capabilities of the child.

The Rey-Osterrieth Complex Figure was designed more
than 50 years ago for assessing visuospatial construction,
planning, and memory in both adults and children (Osterrieth,
1944; Rey, 1941; see Corwin & Bylsma, 1993, for a translation).
There have been several attempts to describe developmental
change in copying the Rey-Osterrieth Complex Figure, but the
complexity of the form has made this a difficult task. Four
published studies have reported that until approximately age 9,
most children use a piecemeal approach (Karapetsas & Kan-
tas, 1991; Kirk, 1985; Osterrieth, 1944; Waber & Holmes,
1985). In this approach, details are juxtaposed, one next to the
other without any apparent overall plan, yet the figure is often
globally recognizable. After age 9, productions have been
described as more configurational; that is, most participants
start their drawing with the base rectangle or a detail that
adjoins the rectangle and complete the large rectangle before
drawing the rest of the figure. Although these are valid and
useful descriptions of performance in the school-age period,
they present an incomplete picture of children's performance
on the figure in terms of both the range of strategies children
adopt in copying this complex visual pattern at each age and
the systematic patterns of developmental change evident
across the age span.
Examination of the existing developmental data from the
figure suggests that by age 6, children attend to and attempt to
reproduce both the elements and the overall configuration of
the pattern (Karapetsas & Kantas, 1991; Kirk, 1985; Oster-
Natacha A. AkshoomofT and Joan Stiles, Department of Psychology,
University of California, San Diego.
This research was supported by a postdoctoral fellowship from the
San Diego McDonnell-Pew Center for Cognitive Neuroscience, Na-
tional Research Service Award 1F32-HD07639, and Grant 1R01-
HD25077 from the National Institute for Child Health and Child
Development. We thank our participants and their parents, and
Gretchen Kambe, Ryan Skrable, and Youngsuk Kim for assistance
with data collection and scoring.
Correspondence concerning this article should be addressed to Joan
Stiles, Department of Psychology, University of California, San Diego,
La Jolla, California 92093-0109.
rieth, 1944; Waber & Holmes, 1985). It is equally clear that
children's reproductions are less complete and less well
organized than those of adults. In assessing children's perfor-
mance on this figure, we suggest taking into consideration the
processes that are used in copying spatial patterns in terms of
what we call spatial analysis. Spatial analysis involves two
processes: (a) the identification of the constituent parts of a
spatial pattern and (b) integrating those parts into a coherent
whole. Central to this definition is the notion of a visual
pattern as a hierarchically organized structure. Within the
structure, the whole can also be described as comprising the
most global level of the pattern and the parts the more local
levels. A simpler hierarchy might have just two levels, such as
local level line segments arranged to form the letter A. The A
combined with other letters would form a more complex
hierarchy (a word), and multiple words would form an even
more complex structure (a sentence). Research within the
developmental literature has focused on the question of
whether children process information in a piecemeal fashion
and attend only to the parts or whether they attend in a holistic
manner without examining the parts (e.g., Carey & Diamond,
1977; Elkind, 1969; Elkind, Koegler, & Go, 1964; Gibson,
1969; Kemler, 1983; Werner, 1948). There is now considerable
evidence that even preschool-age children process information
analytically (e.g., Odom & Cook, 1984; Tada & Stiles, in press;
Tada & Stiles-Davis, 1989; Ward, 1987, 1988). That is, they
identify the constituent parts of a spatial pattern and integrate
those parts to form a coherent whole. Whereas young children
clearly analyze forms, there is systematic change in the
character of that analysis. Young children parse out simpler
and more spatially independent parts than older children, and
they combine those parts using simpler sets of relations than
older children (Tada & Stiles, in press; Tada & Stiles-Davis,
1989; Vurpillot, 1976). Thus there are systematic changes in
both the types of parts that are identified and the integration of
those parts with development.
This pattern of change is illustrated in a copying task in
which young children are asked to copy simple geometric
forms, such as a plus sign, an X, or an asterisk. In this task

364
 VISUOSPATIAL ANALYSIS DEVELOPMENT
children typically parse out small independent units, and they
use simple combinatorial rules to organize them into the larger
patterns. By the time children reach 6 or 7 years of age, they
are generally competent in copying these types of simple
geometric forms and drawing them in a manner similar to
adults. Figure 1 shows an example of this developmental
progression. When asked to copy the divided square, 3-year-
olds produce four independent closed forms; later they begin
with the perimeter square but return to the separate squares to
depict the internal organization; later they add a central
partition but still produce the squares. Finally, at about age 6,
they produce a divided square.
In this sequence, developmental change is marked by the
increasing integration of the spatial array. That increased
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integration is evident in both the nature of the pattern
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elements and in the relations between those elements. In
addition, the structure and in particular the complexity of the
pattern influences the way in which the child processes the
spatial properties of the form. For example, children who use
an adult strategy to copy a plus sign may use a developmentally
earlier strategy when copying an X. That is, they may use two
long lines crossing at the midpoint for the plus sign, but four
short lines radiating from a central point when copying the X.
There is an extensive literature documenting that oblique lines
are more difficult for children to process than lines oriented
along a principal orthogonal (e.g., Herman, 1976; Herman &
Golab, 1975; Rudel, 1982). Thus it appears that thesis a more
difficult pattern for young children to copy than the plus sign
because it requires them to process oblique lines; that in-
creased difficulty affects the way in which the child analyzes the
form.
The method used in the current series of experiments begins
with the assumption that the analysis of any pattern involves
identifying a set of parts and integrating those parts to form an
MODEL Developmental Sequences: Ages 3 - 6 years
/\
\/
' approximate age forms are typically mastered by 50V. of normal children
Figure 1. Schematic examples of young children's copy performance.
365
organized whole. In that sense, it builds on existing findings
from younger children copying simpler patterns in order to
provide a more complete description of the change in school-
age children's performance on the Rey-Osterrieth Complex
Figure copying task. The Rey-Osterrieth Complex Figure is
conceptualized here as a more complex instance of the class of
patterns used in earlier work. Thus, the performance of
school-age children on the Rey-Osterrieth Complex Figure is
assumed to reflect developmental change in children's spatial
ability, which is characterized by change in both the nature of
the identified pattern elements and the relations between
those elements. The complexity of the Rey-Osterrieth Com-
plex Figure is predicted to yield a richer array of analytic
strategies than that observed with simpler patterns, yet the
type and range of strategies observed should mirror those
observed in the earlier developmental period.
One can look at the Rey-Osterrieth Complex Figure as a
hierarchically organized structure comprised of more global
levels (e.g., the main rectangle) and other more local level
elements (e.g., the single line details). It is clearly a multilevel
hierarchy, but there is more than one way to specify the
different levels. It is possible that adults and children differ in
their conceptualization of what elements comprise the more
global and the more local levels of the array. For example, an
adult may recognize the rectangle as a major element in the
figure with other features embedded on the inside and at-
tached to the outside, whereas a child may view the figure as a
collection of small intermediate level structures concatenated
to form the larger whole. This view may help to explain
previous studies that have found age-related differences in
performance on this task (Kirk, 1985; Osterrieth, 1944; Waber
& Holmes, 1985).
In the first experiment, the process used to copy the
Rey-Osterrieth Complex Figure and the accuracy with which it
\/
/\
>—< ss*
 366 NATACHA A. AKSHOOMOFF AND JOAN STILES
was copied was assessed in children age 6-12 and adults. In the
first part of the second experiment, children ages 4-8 were
asked to copy the main features of the Rey-Osterrieth Com-
plex Figure (presented separately) to determine how children
of different ages parse and integrate the parts in these more
simple forms. The second part of the second experiment
consisted of a within-subjects comparison of fragmentation of
the main features of the Rey-Osterrieth Complex Figure and
fragmentation of the main features when they were presented
separately to determine how strategy use changes as a function
of task demand.
Experiment 1
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In this experiment, we used a modified version of the Boston
Qualitative Scoring System for the Rey-Osterrieth Complex
Figure (BQSS; Stern et al., 1994) for scoring children's
reproductions of this figure. This new scoring method was
designed primarily for use in clinical neuropsychological prac-
tice and in neurocognitive research with adults. The scoring
system includes eight separate measures that assess the prod-
ucts of the participant's drawing efforts. The product measures
include feature presence, accuracy, placement, fragmentation,
size, perseveration, and confabulation. The Planning measure
assesses the process by which the participant reproduced the
figure and a description of the qualitative aspects of the
individual's performance.
This is the first study that has attempted to use the BQSS to
score children's data. In applying the scoring system, we found
that the product measures could be directly applied to the
children's data. However, the Planning measure failed to
capture many of the differences observed in the children's
copies, particularly among those produced by younger chil-
dren. Thus a modified planning measure was introduced.
Method
Participants. There were a total of 160 participants, 20 in each of
eight age groups. The age groups were 6-6.6 years (M = 6.3 years),
7-7.8 years (M = 7.4 years), 8-8.8 years (M = 8.3 years), 9-9.9 years
(M = 9.4 years), 10-10.7 years (M = 10.3 years), 11-11.9 years
(M= 11.4 years), 12-12.8 years (M = 12.4 years), and adults 19-28
years (M = 21.9 years). There were equal numbers of male and female
participants in each age group. The children were tested in the
laboratory, local community centers, and a local middle school. All of
these children were in regular school placement and did not have a
history of major medical illness, psychiatric illness, developmental
disorder, or significant visual or auditory impairments. The adults were
college students who participated as part of a class requirement.
Stimuli. The stimulus (see top of Figure 2) measured approxi-
mately 4.25 x 5.5 inches (10.8 x 14.0 cm) and was printed on a
laminated 8'/2 x 11 inches (21.6 x 28.0 cm) white piece of paper. Each
participant was given a white piece of paper of the same dimensions
and colored felt-tipped pens for drawing.
Procedure. Participants were instructed to copy the figure as
exactly as possible and were told that at specific intervals, they would
be given a different colored pen to continue their drawing. Pens were
switched approximately every minute, or when the participant began
to draw a new part of the figure. Switching pens allowed for an easily
visualized record of the order in which the figure was drawn. The
participant was not allowed to rotate the model or the blank sheet of
paper. When participants stated that they had completed their copy,
the stimulus and the participants' sheets were taken away. The
participant was provided with a blank sheet of paper and was
immediately asked to draw the figure again from memory. The
complete results of the immediate memory performance for these
same participants are reported in a separate paper (Akshoomoff &
Stiles, 1995). Each participant was tested individually, and all sessions
were videotaped.
Data reduction. Two trained raters scored 120 of the drawings. A
sample of 27 drawings were scored by both raters, with 93% agreement
across all of the BQSS measures (described below). When scoring the
drawings for the two additional planning measures we devised (de-
scribed below), each rater would first classify the Starting strategy and
then go on to identify the Progression strategy used by the participant.
There was 90% agreement between the two raters across 120 drawings
for these measures. A third trained rater scored 20 of these drawings
and obtained 80% agreement with the previous raters across the BQSS
measures; this rater scored the remaining 40 drawings.
Product measures. The drawings were scored with the BQSS. This
system divides the figure into three sets of features (six Configural
Elements, nine Clusters, and seven Details) that are ordered by level
of importance to the structure of the figure (see Figure 2). The
Configural Elements are most critical to the pattern structure and
include the large rectangle, the vertical and horizontal bisectors, the
main diagonals, and the large triangle to the right of the rectangle. The
Clusters are of secondary importance to the pattern structure and are
made up of one or more shapes and/or line segments that appear to
form a coherent gestalt within the main figure, which are considered
important secondary features. The Details are the remaining single
line features.
These three sets of features were scored according to their Pres-
ence, Accuracy, Placement, and Fragmentation. The Presence scores
indicates that a feature is present in the drawing, regardless of the
quality of the representation. The Accuracy score reflects the quality
of the features in the drawing (i.e., completeness, size, proportion,
correctness of angles, straightness of lines, and accuracy of intersec-
tions with other features). Details are not scored for Accuracy. The
Placement score indicates whether the feature is placed in the proper
region of the figure (Clusters and Details only). The six Configural
Elements and Cluster 1 are rated for Fragmentation, a measure of
seeing the individual features as whole units (i.e., whether the feature
is drawn in a complete pen stroke and completed before another part
of the figure is started). Fragmentation of Rectangle A is weighted on
a scale of 1 to 3 based on the structural importance of the rectangle.
The remaining features are scored once for fragmentation.
The final scores for each participant were determined with the
BQSS conversion tables that place all measures on a l-to-5 scale. For
the Presence, Accuracy, and Placement scores, a score of 5 = 100%,
4 = 67%-89%, 3 = 33%-67%, "2" = 25%-33%, and 1 = 0%. The
Fragmentation scores represent the number of fragmentation errors:
5 = 0, 4 = 1-2, 3 = 3-5, 2 = 6-8, and 1 = 9 or more.
The BQSS provides objective criteria for determining deviations in
the Size of the production (Reduction, Horizontal Expansion, and
Vertical Expansion) and Rotation of the entire figure. Templates
included with the manual give guidelines for assigning scores to the
participant's drawing (from 5 = no deviations in size or no rotation to
1 = extreme deviations in size or extreme rotation).
The BQSS also provides criteria for rating Perseveration and
Confabulation. A Perseveration is any recognizable inappropriate
repetition. This includes repetitions of components within a Cluster or
replication of any part of the figure, such that it appears more than
once throughout the figure. A Confabulation is any novel, unrelated
addition to the figure. Scores for each measure are ranked from 5 (no
perseveration or no confabulation) to 1 (extremeperseveration or extreme
confabulation).
 VISUOSPATIAL ANALYSIS DEVELOPMENT
CONFIGURAL ELEMENTS
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A
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DETAILS
Figure 2. Configural Elements, Clusters, and Details from the Boston Qualitative Scoring System for the
Rey-Osterrieth Complex Figure (Stern et al., 1994).
Process measures. The scoring criteria for Planning in the BQSS
are meant to provide a qualitative summary of the overall planning and
organizational approach used by the participant. Planning is consid-
ered independently from the BQSS product measures with specific
criteria (see Stern et al., 1994). A score of 5 (no planning deficits)
indicates the rectangle was drawn first (or Cluster 6 was drawn first
and is immediately followed by the rectangle) and Configural Ele-
ments B-E were drawn before any clusters or details. A score of 4
(mild planning deficits) indicates that the general sense of the impor-
tance of the rectangle was preserved, and the rectangle was not broken
into separate quadrants. A score of 3 (moderate planning deficits)
indicates that the rectangle and Configural Elements B-E were
treated in a piecemeal fashion, but the structure of the figure was not
destroyed (e.g., left to right, top to bottom, or drawing one quadrant at
a time), or four or more clusters-details were interspersed between
completion of Configural Elements. A score of 2 (significant planning
deficits) indicates significant structural and organizational problems
where the existing or implicit rectangle is still recognizable. A score of
1 (extreme planning deficits) indicates there was no appreciation for
367
CLUSTERS
the overall structure and organization of the original stimulus, and the
order appears to be completely haphazard.
When reviewing preliminary data from over 60 drawings from
children using this scoring system, we noted that the BQSS Planning
score was not sufficiently sensitive to developmental trends; indeed,
this score appeared to be misleading with regard to developmental
trends. The designation of the children's performance as reflecting
different levels of planning deficit is clearly inappropriate. Within the
context of a developmental study, the use of less sophisticated, less
detailed, or less well-integrated approaches to pattern reproduction
are unlikely to index deficit. Rather these differences in processing
strategy will inform the understanding of normal patterns of develop-
mental change. With the BQSS Planning score criteria, over 60% of
these drawings obtained a Planning score of 3, although different
strategies within this rating were apparent. It was clear that a
refinement of the BQSS Planning score data was necessary to capture
differences in the data.
For this reason, a wider range of planning categories was defined
based on descriptive results from previous studies (Kirk, 1985; Oster-
 368 NATACHA A. AKSHOOMOFF AND JOAN STILES

rieth, 1944; Waber & Holmes, 1985). The data were reviewed without
knowledge of the age of the participant. Three different ways were
defined to characterize the method that participants used to start their
drawings and within each of these categories, four subcategories
describing in more detail the ways in which participants completed the
figure were specified.
Starting strategies were classified as Perimeter, Partial Perimeter,
and Nonperimeter. The Perimeter strategy is defined as drawing the
outer contour of the figure first, including some combination of
Clusters 2 and 3 and Configural Element F before drawing any internal
items. The Partial Perimeter strategy consists of drawing a portion of
the outer contour first and then adding the inner and outer details of
the figure before completing the entire outline. The Nonperimeter
strategy is one that does not fall into these other two categories.
The Progression strategies note what the participant does next in
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children's reproductions of the Rey-Osterrieth Complex Fig-
ure. The presence scores are shown in Figure 3. The data were
analyzed with a 2 x 7 x 3 mixed design repeated measures
analysis of variance (ANOVA). Between-subjects variables
included gender (male or female) and age (6, 7, 8,9,10,11, and
12 years) and the within-subjects variable was feature (Config-
ural Elements, Clusters, and Details). The analysis revealed a
significant main effect for age, F(6,126) = 9.63, p < .001, and
feature, F(2, 252) = 44.25, p < .001, as well as an Age x
Feature interaction, F(\2, 252) = 3.72, p < .001. There is
clearly a ceiling effect for the Presence of Clusters across all
age groups and Tukey post hoc multiple comparison tests
revealed no significant differences between the age groups

completing the figure. We identified four distinct categories that best (ps > .05). Tukey post hoc multiple comparison tests revealed
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described the data from children ages 6 through 12. These categories
were (a) the rectangle is complete (even if fragmented) and Configural
Elements B and C were drawn as continuous lines; (b) the figure was
broken into two major units and constructed unit by unit; (c) the figure
was broken into three or more major units and constructed unit by
unit; (d) inconsistent placement of remaining items. These categories
contrast with the five Planning categories of the BQSS, which piace a
greater emphasis on the integrity of the rectangle rather than describ-
ing the method that the participant used in parsing the figure. All
drawings that receive a BQSS Planning score of 1 would also be in the
Inconsistent Placement category, and all that receive a BQSS Planning
score of 5 would be in the complete rectangle category.
Results
The data from the 20 adult participants are included in
Figures 3-8 but are not included in the statistical analysis.
Product measures. Results for the product measures all
show systematic change with age in the accuracy of the
that the 6-year-olds' scores for Presence of Configural Ele-
ments and Details were significantly lower than the children
ages 8 and older (p < .05). Tukey post hoc multiple compari-
son tests revealed that the 7-year-olds' scores for Presence of
Details were significantly lower than the 8-year-olds and
children 10 and older (ps < .05).
The Accuracy scores were analyzed with a 2 x 7 x 2 mixed
design repeated measures ANOVA. Between-subjects vari-
ables included gender and age and the within-subjects variable
was feature (see Figure 3). There was a significant main effect
of age, F(6, 126) = 9.27, p < .001. A linear trend analysis
revealed that accuracy of both feature types (Configural
Elements and Clusters) increased significantly with age
(p < .001).
The Placement scores were analyzed with a 2 x 7 x 2 mixed
design repeated measures ANOVA. Between-subjects vari-
ables included gender and age and the within-subjects variable
was feature (see Figure 3). There was a significant main effect

PRESENCE ACCURACY PLACEMENT

7 8 9 10 11 12 Adult 7 8 9 10 11 12 AduR 7 8 9 10 11 12 Adult

AGE (years) AGE (years) AGE (years)

CONFIGURAL ELEMENTS

CLUSTERS

DETAILS

Figure 3. Presence, Accuracy, and Placement scores for 6- to 12-year-olds and adults in Experiment 1.
BQSS = Boston Qualitative Scoring System for the Rey-Osterrieth Complex Figure.
 VISUOSPATIAL ANALYSIS DEVELOPMENT
FRAGMENTATION
o score of 3. Drawings that were characterized by smaller units
CO
8
00
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9 10 11 12 Adult
AGE (years)
Figure 4. Fragmentation scores for 6- to 12-year-olds and adults in
Experiment 1. BQSS = Boston Qualitative Scoring System for the
Rey-Osterrieth Complex Figure.
of age, F(6, 126) = 12.64, p < .001. A linear trend analysis
revealed that placement of both feature types (Clusters and
Details) increased significantly with age (p < .001).
A 2 x 7 ANOVA revealed no significant age or gender
differences in Fragmentation scores. The mean scores across
all of the children were generally in the moderately frag-
mented range (see Figure 4). Data from the sample of 20
young adults suggests that the adult pattern is not achieved
until after age 12. More than 90% of the children fragmented
the rectangle at least once. Approximately 70% of participants
fragmented the main diagonals (Configural Elements D and
E). Fragmentation of the main horizontal bisector, the main
vertical bisector, and Cluster 1 were also fairly common (52%,
43%, and 36%, respectively).
The Size scores (Reduction, Horizontal Expansion, and
Vertical Expansion) were analyzed separately with 2 x 7
(Gender x Age) ANOVAs. There were no significant main
effects for age or gender and no significant interactions
(ps > .05). The majority of the children drew the figure
approximately the same size as the original.
A 2 x 7 (Gender x Age) ANOVA revealed that there was a
significant main effect of age in the Rotation scores, F(6, 126)
= 4.75, p < .001. Six of the 6-year-old participants obtained a
score of 4 (20-30° rotation), and one 6-year-old participant
drew the figure at a 90° rotation. The remaining 120 partici-
pants received a score of 5, except 2 who received a score of 4.
The Perseveration and Confabulation scores were analyzed
separately with 2 x 7 (Gender x Age) ANOVAs. Although
these two measures were analyzed separately, they are pre-
sented together in Figure 5. There was a significant Age x
Gender interaction, F(6, 126) = 2.18, p < .05 and a significant
main effect of age in the perseveration scores, F(6,126) = 5.50,
p < .001. The scores among the 6-, 7-, and 8-year-old girls
remained in the moderately perseverative range and then
improved after age 8, whereas same-age boys showed linear
improvement in their level of perseveration from ages 6 to 12.
There was also a significant main effect of age in the Confabu-
369
lation scores, F(6,126) = 11.59, p < .001. With increasing age
of participants, we noted fewer perseverations and confabula-
tions in the reproductions.
Process measures. A Pearson chi square test between the
BQSS Planning scores of the seven age groups was significant,
X2 (24, N = 140) = 50.04,p < .001. As shown in Figure 6,52%
of the children between ages 6 and 12 received a Planning
and inconsistent placement of the features within the whole
figure (Planning scores of 1 and 2) were infrequent among
children over age 8 or 9. There was an increase in BQSS
Planning scores after age 9, indicating a greater appreciation
for the main rectangle and preservation of structure. These
drawings were characterized by the use of larger units and a
more configurational approach.
A Pearson chi square test of the Starting strategies used
across the seven age groups was not significant, x2(12,
N = 140) = 16.02, p > .10 (see Figure 7). Children between
the ages 6 of 12 used the three Starting strategies with nearly
equal probability, but by adulthood there was a shift toward
adopting the nonperimeter strategy. The nonperimeter strat-
egy represents those participants that did not use the perim-
eter or partial perimeter strategy and thus includes subjects
who started with the rectangle. However, only 3.5% of the
children started with the entire rectangle (all of whom were
between the ages of 10 and 12); this accounts for only 10% of
the children who used this Starting strategy. In contrast, 50%
of the adult sample drew the entire rectangle first.
There were differences in the Progression strategies among
participants age 6 to 12,x2 (18, N = 140) = 49.11,p < .001. As
shown in Figure 8, children age 8 and older were more
systematic in the method they used to complete the Rey-
Osterrieth Complex Figure than children ages 6 and 7.
Although 80% of the adults drew the figure with a complete
rectangle and nonfragmented horizontal and vertical bisectors,
this was true of only 40% of the 11- and 12-year-old children.
The Inconsistent Placement category included the most
incomplete and disorganized attempts by younger children.
However, two thirds of the children (22 out of 34 total) within
this category began their drawing by producing the full or
partial perimeter of the figure, reflecting an appreciation for
the overall configuration. Their mean Presence scores for
8 9 10 11 12 Adult
AGE (years)
Figure 5. Perseveration and Confabulation scores for 6- to 12-year-
olds and adults in Experiment 1. BQSS = Boston Qualitative Scoring
System for the Rey-Osterrieth Complex Figure.
 370 NATACHA A. AKSHOOMOFF AND JOAN STILES

PLANNING SCORES
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5 = Rectangle & Configural Elements drawn first

4 = Figure drawn in a logical sequence, taking the whole into account
3 = Rectangle & Configural Elements treated in a piecemeal fashion
2 = Significant structural/organizational problems; rectangle recognizable
1 = No appreciation for overall structure/organization; order appears haphazard

Figure 6. Planning scores for 6- to 12-year-olds and adults in Experiment 1. Scores ranged from 5 (the
rectangle and Configural Elements B-E were drawn first) to 1 (poor planning).

Configural Elements (4.4), Clusters (4.8), and Details (3.8)
were all within the high-average range, although below those
of the other children (4.9, 4.9, and 4.6, respectively). The same
was true for these children's mean Accuracy scores for
Configural Elements and Clusters (2.4 and 2.5 vs. 3.4 and 3.3,
respectively) and Placement scores for Clusters and Details
(3.5 and 3.7 vs. 4.3 and 4.4, respectively).
Discussion
The results of this experiment show that the BQSS is
sensitive to age-related changes in performance and provides
useful information for scoring children's reproductions of the
Rey-Osterrieth Complex Figure. We also found that children
as young as 6 are able to give a fair representation of this
complex figure. As in previous studies of children's perfor-
mance on this task (Osterrieth, 1944; Waber & Holmes, 1985),
we found that most of the details are produced and placed
accurately by children when they reach the age of 9.
The primary goal of this study was to assess children's
planning skills when copying a complex figure. The BQSS
Planning score was not entirely satisfactory for this purpose.
The Planning score criteria suggest that there is an ideal
method for drawing the figure (i.e., drawing the rectangle and
main features of the figure first before completing the rest of
the figure) and variations from this are termed deficits. It is
clear that better organization is associated with using the base
rectangle as the salient organization unit in the Rey-
Osterrieth Complex Figure (Waber & Holmes, 1985). Whereas
only 25% of adult participants drew the figure in the ideal
manner, the majority of adults did preserve the importance of
the rectangle in their reproductions. In contrast, a large
number of children between the ages of 8 and 12 treated the
rectangle and main features of the figure in a piecemeal fashion.
Although reproductions that fall within this category differ in terms
of planning and organization, the BQSS places them all together.
Therefore, it was necessary to expand the planning categories, both
in terms of Starting strategy and Progression strategy, to better
evaluate age-related trends in performance.
There were no significant age-related differences in Starting
strategy. As in the original study of children's performance on
this test (Osterrieth, 1944), approximately one third of the
children between the ages of 6 and 10 started with the overall
contour of the figure, an approach that is rarely found among
adults. Less than 10% of the children between the ages of 10
and 12 started with the base rectangle (and none of the
children under age 10), although most of these older children
had a complete rectangle present within their drawings.
The increased frequency of higher Planning scores among
the older children corresponded with the use of larger organi-
zational units when completing the figure, as described by the
Progression strategy categories we developed after observing
the strategies used by children. Both the Progression and
Starting strategy categories we developed explicitly state the
strategy used by the child and thus more easily describe the
 VISUOSPATIAL ANALYSIS DEVELOPMENT 371

case, then it is not surprising that young children have so much

STARTING STRATEGY SCORES
difficulty in copying a complex figure that is comprised of many
types of geometric forms.
On the other hand, it may well be that analysis of a complex
form elicits very different planning strategies than analysis of
simpler elements in isolation. The structure of the overall
pattern hierarchy may influence the child's analysis of the
visual array. Therefore, the characterization of a child's spatial
analytic ability based only on his or her copy of one complex
form may be misleading. Developmental change may not be
well defined in terms of changes in a single strategy type.
Rather, the complexity of the task may interact with the type of
processing approach used. The child may have a variety of
strategies at his or her disposal, but the ability to use a
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particular strategy may be determined by the complexity of the

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visuospatial task presented.

By this account, it is possible that the child may use a very
different strategy to produce a feature when it is presented in
isolation (e.g., the main rectangle) than when it is presented
within the context of the larger form. Such a finding would be
problematic for an account of developmental change in spatial
analysis that posits the use of the same underlying approach at
different points in development. The same child could conceiv-
Perimeter ably be judged as a piecemeal processor if only performance on

Partial Perimeter PROGRESSION STRATEGY SCORES

Non-Perimeter

Figure 7. Starting strategy data for 6- to 12-year-olds and adults in

Experiment 1.

changes in spatial analysis that are observed with development

on this task than the categories used in other scoring methods
(Kirk, 1985; Osterrieth, 1944; Waber & Holmes, 1985).
Figure 9 shows representative drawings, in terms of Starting
and Progression strategy, from a subset of the children in this
experiment. Also shown are the drawings from children who
used the least common strategy for participants their same age.
One can see that when older children adopt an approach that
appears more frequently among younger children (such as the
Inconsistent Placement approach), they are able to more
effectively integrate the figure and also obtain higher scores on
the BQSS product measures, than when this approach is used
by younger children. When younger children adopt strategies
that are more commonly found among older children, they
obtain higher scores on the BQSS product measures than
children their same age who adopt the more common (less Complete Rectangle with Continuous
Horizontal and Vertical Bisectors
efficient) planning strategies.
2 units
Experiment 2
3 or more units
Experiment 1 showed that most children under 9 years of
age are not able to accurately produce and place all of the
Inconsistent Placement
details in the Rey-Osterrieth Complex Figure. These results
may indicate that children this age are not yet capable of
copying the main features of this figure (e.g., the main Figure 8. Progression strategy data for 6- to 12-year-olds and adults in
rectangle or diagonal bisectors) as an adult does. If this is the Experiment 1.
 372 NATACHA A. AKSHOOMOFF AND JOAN STILES

Representative Drawing Outlier Drawing

6 years

A.

Non-Perimeter Partial Perimeter

Inconsistent Placement Complete Rectangle
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8-9 years

C. D.
Non-Perimeter Perimeter
3 or more units Inconsistent Placement

11-12 years

E.

Non-Perimeter Non-Perimeter
Complete Rectangle Inconsistent Placement

Figure 9. Representative drawings from Experiment 1 in terms of Starting strategy and Progression
strategy.

the Rey-Osterrieth Complex Figure is examined, whereas a
different judgment would be made if the ability to copy the
core form in isolation was assessed. To test this possibility, in
Experiments 2A and 2B children's performance on smaller
subunits of the Rey-Osterrieth Complex Figure was examined
and compared with performance on those same units within
the context of the larger form.
Experiment 2A
In the present experiment, children ages 4 through 8 were
asked to copy three figures that represented extractions of the
Rey-Osterrieth Complex Figure. The accuracy of the chil-
dren's drawings and the manner in which they parsed them was
compared across the age groups to determine at what age
children are able to accurately copy these figures.
Method
Participants. There were a total of 100 participants, 20 in each of
five age groups. The age groups were: 4.2—4.9 years (M = 4.6 years),
5.2—5.9 years (M = 5.5 years), 6—6.9 years (M = 6.4 years), 7-7.8 years
(M = 7.3 years), and 8-8.9 years (M = 8.4 years). There were equal
numbers of boys and girls in each age group. Participants were tested
in the laboratory and in local community centers and schools. All of
these children were in regular school placement and did not have a
history of major medical illness, psychiatric illness, developmental
disorder, or significant visual or auditory impairments.
 VISUOSPATIAL ANALYSIS DEVELOPMENT 373

FORM1 FORM 2 FORM 3
Figure 10. Stimuli used in Experiment 2A.
Stimuli and procedure. The stimuli are shown in Figure 10. Each
form was laser printed on a 4.25 x 5.5 inches (10.8 x 14.0 cm) sheet of
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Osterrieth (1944) found that the Rey-Osterrieth Complex
Figure can be divided into 18 features that form a whole by at
least 75% of adult participants (large rectangle, horizontal and
vertical bisectors, two diagonal lines, large triangle on the right
side, etc.). It is not clear if young children divide this figure up
into a similar set of features. In Experiment 1, we found that
children between the ages of 6 and 12 fragmented the main
features of the figure to a similar extent, whereas adults
exhibited less fragmentation. In spite of this, the older children
were better able to integrate the figure and were more
organized in their approach to copying the figure.
In Experiment 2A, children under age 6 clearly parsed out
the parts of three figures that represented extractions of the
Rey-Osterrieth Complex Figure and arranged them in a

white paper and measured 2.5 x 2 inches (6.4 x 5.1 cm) or 2.5 x 3.5 configuration, but in a manner that was different from that of
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(6.4 x 2.9 cm). The examiner placed each test sheet directly in front of older children and adults. That is, 4- and 5-year-old children
the child. The child was told to make one "just like this one" below the appeared to use the same types of strategies that have been
model using a colored felt-tipped pen. Form 1 was given first, followed described for 3- and 4-year-old children when they are asked to
by Form 3 and Form 2. copy simpler forms (Tada & Stiles, in press; Tada & Stiles-
During the same testing session, 38 of the 60 participants between
Davis, 1989). In general, however, children drew the basic
the ages of 6 and 9 were first administered the Rey-Osterrieth
Complex Figure (copy and immediate memory), following the proce- components of the Rey-Osterrieth Complex Figure in a
dure outlined in Experiment 1. This was followed by administration of manner similar to adults by the time they were 6 years of age.
this experiment. The Rey-Osterrieth Complex Figure data from 22 of The current experiment directly compared how children age
these same participants was also used in Experiment 1. 6 and older copied the main features of the Rey-Osterrieth
Data analysis. The drawings were scored for accuracy and fragmen- Complex Figure when they were in the context of the figure
tation. Form 1 and Form 2 were scored as accurate if the criteria and when they were presented in isolation. We predicted that
specified in the BQSS (Stern et al., 1994) for Cluster 1 was met. Form 3 based on the results of Experiment 2A very few children would
was scored as accurate if the Stern et al. criteria for Configural fragment these forms when they were presented in isolation,
Elements A-E were met.
Each form was scored as, fragmented if the child used more parts to
produce the construction than would be expected for an adult. The
criteria used were as follows: Form 1 = six lines (four lines forming a
rectangle with two lines crossing inside); Form 2 = seven lines (four
lines forming a rectangle with three lines crossing inside); Form 3 =
eight lines (four lines forming a rectangle with four lines crossing
inside). Any form drawn with more lines, because of additional
fragmentation of the lines, was scored as incorrect. Accuracy and 100-,
fragmentation were scored separately. Perseverations did not influ-
ence scoring for either of these measures.

Results and Discussion 40-

Figure 11 shows the percentage of participants who accu-

rately copied the forms and the percentage of participants who
fragmented the forms. By age 6, the majority of the partici-
pants in this experiment copied and parsed the forms accord- AGE (YEARS)
ing to criteria. Pearson chi square tests revealed that there
were no significant differences in the number of 6-, 7-, and
8-year-olds who drew the three forms accurately or parsed FRAGMENTATION
them according to criteria (ps > .1).
Among the children under age 6 in this sample, three
dominant strategies for copying these forms were identified (seg-
mented forms radiating around a central point, segmented forms
extending from a principal orthogonal and using unsegmented
lines). Examples of these strategies is shown in Figure 12.

Experiment 2B
Previous studies of the Rey-Osterrieth Complex Figure AGE (YEARS)
have not directly assessed the units parsed out by children of
different ages and the manner in which they are configured. Figure 11. Results from Experiment 2A for 4 to 8-year-olds.
 374 NATACHA A. AKSHOOMOFF AND JOAN STILES
but these same children would fragment these features more
often when presented within the context of the Rey-Osterrieth
Complex Figure.
Method
Participants. There were a total of 70 participants, 10 in each of
seven age groups. The age groups were 6.2-6.8 years (M = 6.6 years),
7-7.9 years (M = 7.4 years), 8-8.8 years (M = 8.3 years), 9-9.8 years
(M = 9.5 years), 10-10.7 years (M = 10.4 years), 11-11.9 years
(M= 11.5 years), and 12-12.8 years (M = 12.5 years). There were
equal numbers of boys and girls in each age group. Participants were
tested in the laboratory, local community centers, and a local middle
school. Of the participants in Experiment 1, 85 were given the copy
task in Experiment 2A; 63 of these participants were randomly
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selected for this experiment; data from the remaining 7 participants
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were collected after Experiment 1 was completed. The data from
the 30 children between the ages of 6 and 9 were included in
Experiment 2A.
Stimuli and procedure. The stimuli and the procedure were the
same as in Experiments 1 and 2A. Each child was asked to copy the
Rey-Osterrieth Complex Figure and then draw it from memory. They
were then given the copy task used in Experiment 2A.
Data analysis. Fragmentation of the Rey-Osterrieth Complex
Figure was scored according to the BQSS (Stern et al., 1994). Data
from the tally sheets were used to determine the number of times each
participant fragmented the main rectangle, the horizontal and vertical
FORM1 FORM 2 FORM 3
C.
Figure 12. Sample drawings from 4-year-olds (A and B) and a
5-year-old (C) in Experiment 2A. Row A drawings are examples of the
dominant strategy used by the youngest children. Row B drawings
represent an intermediate strategy. Row C drawings represent the
nonfragmented strategy typically used by adults.
bisectors, the diagonal bisectors, and Cluster 1. If a feature was scored
as not present with the Stern et al. (1993) criteria, it was not included
in the fragmentation analysis for that feature. Data from the copy task
was also scored for fragmentation according to the criteria used in
Experiment 2A.
Form 3 from the copy task is similar to the main structure of the
Rey-Osterrieth Complex Figure (Configural Elements A, B, C, D, and
E; see Figure 1). Therefore, fragmentation of Form 3 in the copy task
was compared with fragmentation of these same features when
copying the Rey-Osterrieth Complex Figure. Form 2 from the copy
task is the same as Cluster 1 in the Rey-Osterrieth Complex Figure if
the horizontal bisector is also included (see Figure 1). If the horizontal
bisector is not included, then Form 1 is the same as Cluster 1.
Results and Discussion
None of the participants in this experiment fragmented any
part of the rectangle or the horizontal or vertical bisectors
while copying Form 3. In contrast, 93% of these participants
fragmented the main rectangle at least once, 64% fragmented
the horizontal bisector, and 30% fragmented the vertical
bisector while copying the Rey-Osterrieth Complex Figure. As
was found in Experiment 1, there were no age-related differ-
ences in fragmentation frequency.
A McNemar symmetry chi square test of the within-subjects
comparison of fragmenting the diagonal bisectors while copy-
ing the Rey-Osterrieth Complex Figure and fragmenting the
diagonal lines while copying Form 3 was significant, \2(l,
jV = 70) = 48.08,/> < .001; 82% of the participants fragmented
the diagonal bisectors in the Rey-Osterrieth Complex Figure
but only 7% fragmented the diagonal bisectors in Form 3.
A McNemar Symmetry chi square test of the within-subjects
comparison of fragmenting Cluster 1 while copying the Rey-
Osterrieth Complex Figure and fragmenting the diagonal lines
while copying Form 1 was significant, x2 (1, N = 70) = 22.15,
p < .001; 38% of the participants fragmented Cluster 1 in the
Rey-Osterrieth Complex Figure, but only 1 participant (1.5%)
fragmented the diagonal bisectors in Form 1. The within-
subjects comparison of fragmenting Cluster 1 while copying
the Rey-Osterrieth Complex Figure and fragmenting the
diagonal lines while copying Form 2 was also significant, x2 (1,
N = 70) = 17.64,p < .001; 38% of the participants fragmented
Cluster 1 in the Rey-Osterrieth Complex Figure, and 6.15%
fragmented the diagonal lines while copying Form 2.
This experiment confirmed the results from Experiments 1
and 2A with a within-subjects design. By the time children
reach the age of 6, they draw the main features that make up
the Rey-Osterrieth Complex Figure with the smallest number
of line segments possible. When these same features are
presented in conjunction with a number of other line segments
and closed forms, they are drawn in a very different matter by
the same children. This pattern appears to be consistent across
children between the ages of 6 and 12.
General Discussion
The results of the present study present a different view of
developmental change in children's performance on the Rey-
Osterrieth Complex Figure than previous interpretations.
Introducing the more general notion of the spatial analysis of a
 VISUOSPATIAL ANALYSIS DEVELOPMENT
hierarchically organized structure provides insight into what
aspects of performance change with age. In this study, children
as young as 6 years of age included most of the features that
comprise the Rey-Osterrieth Complex Figure in their draw-
ings. The accuracy of the reproductions improved with age,
and change was evident in the process by which children
approach the task of copying the form. Indeed, improvement
in accuracy among older children coincided with the parsing of
larger units in the figure and improvement in the manner in
which they were configured. However, it is also interesting to
note that accurate copies of the figure do not require advanced
strategies (see Figure 9, Example F), and more advanced
strategies do not ensure accurate renderings (see Figure 9,
Example B). Thus product and process are not necessarily
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yoked on this task.
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Children over age 9 more often used larger organizational
units to complete the figure and demonstrated a greater
appreciation for the main rectangle than younger children. A
previously completed study concluded that children under age
10 appeared to be aware of the components of the figure but
did not organize a plan that took into account the spatial
relationships among them (Kirk, 1985). We would argue that
just as in previous studies of younger children copying simpler
patterns (e.g., Odom & Cook, 1984; Tada & Stiles, in press;
Tada & Stiles-Davis, 1989; Ward, 1987,1988), children under
age 10 do analyze the spatial relationships among the compo-
nents of the Rey-Osterrieth Complex Figure. Thus descrip-
tions of children as being configurational or piecemeal proces-
sors fail to capture the changes demonstrated in Experiments 1
and 2. Instead, these results show that increased integration of
the spatial array is found with development, both in terms of
the nature of the pattern elements and in the relations
between those elements.
It is important to note that the complexity of the Rey-
Osterrieth Complex Figure frequently elicits analytic strate-
gies which serve to simplify the task of reproducing the form.
Two examples of the most common processing strategies used
by the younger children in this study illustrate this point. One
common approach used by young children was termed Incon-
sistent Placement, where the order of copying the figure
appears to be somewhat haphazard (see Figure 9, Example A).
Another common strategy was more systematic, where the
child parsed out simple, well-defined units from the array and
combined them using adjacency relations (see Figure 9,
Example C). Both of these strategies serve to simplify the
copying task by allowing the child to focus on small, compar-
atively isolated units of the pattern rather than larger, embed-
ded features of the form such as the core rectangle. The
strategy for relating these more isolated parts is also relatively
simple. Children can focus on the relation between two parts at
a time, with only a very general consideration of the whole.
These simplified strategies generally result in a loss of accu-
racy, but the major features and organization are relatively
preserved.
Experiment 2 demonstrated that the particular strategy used
in copying the Rey-Osterrieth Complex Figure was not the
only one available to the child. When the main features of the
Rey-Osterrieth Complex Figure were presented in isolation,
most children by the age of 6 used adultlike strategies to copy
375
and parse them. Specifically, they drew the outer box and used
the minimum number of lines to divide the internal space.
These same children parsed these same lines significantly
more often when they were presented in the context of the
Rey-Osterrieth Complex Figure. These findings demonstrate
that the children were clearly analyzing the features in both
instances but used different strategies to copy the features,
depending on the context. The children's use of more ad-
vanced strategies make it difficult to formulate a singular
characterization of children's spatial processing at any point in
development. Rather, the strategy used is affected by the
complexity of the task. There are clearly processing limitations
in childhood that result in the kinds of performance observed
here. That is, the size of the array that can be dealt with
effectively is a function of age and complexity. However, these
appear to be limitations that involve both the identification of
the constituent parts of a spatial pattern and the integrative
aspects of spatial analysis. It is analysis undergoing change.
The results of Experiment 2 also make it difficult to argue
that age-related differences in copying the Rey-Osterrieth
Complex Figure may be attributable to differences in grapho-
motor competence. Although graphomotor skills may certainly
continue to improve after the age of 6, this explanation is not
sufficient to account for the results. Results from recent
studies in our laboratory also demonstrate that the differences
observed between younger and older children are more attrib-
utable to children's conceptualization of spatial patterns than
their graphomotor competence. In one study, children be-
tween the ages of 3 and 5 were asked to copy several forms and
were also asked to assemble the forms using precut strips of
paper (Tada & Stiles, in press). Although the assembly task
required less fine motor skill than the copying task, the way
children parsed and configured the forms did not differ.
Preschoolers in another study were asked to copy several
forms, as well as make perceptual judgments (Feeney & Stiles,
in press). In the perception task, the target form (e.g., a plus
sign), and three choices representing the adult, intermediate
child, and younger child interpretations (e.g., two long lines,
one long line and two short lines, and four short lines) were
presented. Children were asked to select which choice best
matched the target. The parts produced in copying the forms
were consistent with those chosen in the perception task. It is
also interesting to note that the types of strategies that young
children use to copy simple forms often involve more steps
than those used by older children and adults (see Figure 1).
Thus the age-related differences in the identification of the
constituent parts and the integration strategies used by chil-
dren when copying the Rey-Osterrieth Complex Figure do not
appear to be attributable to differences in graphomotor
competence, but rather the influence of the complexity of this
figure on conceptualization of the spatial pattern.
It is difficult to determine what neural systems may be
contributing to performance on this task during development,
and if the changes seen in performance with development
reflect changes in the neural systems involved in this type of
complex spatial analysis. Studies of the performance of adult
patients with focal brain injury suggest that both the left
 376 NATACHA A. AKSHOOMOFF AND JOAN STILES
hemisphere and the right hemisphere contribute to perfor-
mance on this task, as well as the prefrontal cortex (Binder,
1982; Kaplan, 1988). In general, adults with damage to the
right hemisphere fail to integrate the figure and adults with
damage to the left hemisphere have difficulty reproducing the
individual components of the figure. These findings are in
agreement with the larger adult literature on the contribution
of both hemispheres to spatial analytic processing (e.g., Robert-
son & Lamb, 1991). Work from our own laboratory has shown
that differential patterns of specific spatial deficits are also
found among children who have suffered early focal right
hemisphere and left hemisphere injury, because of a prenatal
or perinatal stroke (Stiles & Nass, 1991; Stiles & Thai, 1993).
These data suggest that the neural systems for processing
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spatial information are specified early in development and are
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comparable to the systems responsible for spatial analysis in
adulthood. Changes in performance on spatial tasks with
development appear to reflect maturation and increased
organization of both the right and left hemisphere.
The Rey-Osterrieth Complex Figure task is often used in
the clinical neuropsychological evaluation of children. Our
results suggest a number of points to consider when using this
test with children. The BQSS may prove to be an improvement
over the existing Osterrieth (1944) scoring method. Although
Osterrieth's data from 235 Swiss children between the ages of
4 and 15 are also often used as norms, this practice should be
used cautiously. As in most tests used with children, it is
necessary to obtain a large normative sample in order to
account for the large degree of variability seen among normal
children of the same age, the often rapid changes in perfor-
mance that are found with development, and the possible
effects of demographic variables on neuropsychological test
performance. The data from the current study in no way
represents a normative sample suitable for this use but, rather,
represents data from a moderately sized sample of normally
developing children. Considering the difficulty of this task,
data from children under age 10 need to be treated with
caution. One also needs to consider a number of factors that
can influence performance on this task (e.g., graphomotor
skills, visual perceptual abilities, and problem-solving skills) by
testing these skills separately, if possible, as part of the
neuropsychological battery. With these caveats, we believe
that the Rey-Osterrieth Complex Figure is a useful tool for
assessing visuospatial construction, planning, and memory in
the clinical neuropsychological evaluation of children, as well
as in experimental investigations of cognitive and neurocogni-
tive development.
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