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TEST REVIEW The Boston Qualitative Scoring System

for the Rey-Osterrieth Complex Figure
Kyle Brauer Boone
Published online: 09 Aug 2010.

To cite this article: Kyle Brauer Boone (2000) TEST REVIEW The Boston Qualitative Scoring System for the
Rey-Osterrieth Complex Figure, Journal of Clinical and Experimental Neuropsychology, 22:3, 430-432, DOI:
10.1076/1380-3395(200006)22:3;1-V;FT430

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2000, Vol. 22, No. 3, pp. 430-432 © Swets & Zeitlinger

TEST REVIEW

The Boston Qualitative Scoring System for the Rey-

Osterrieth Complex Figure
Kyle Brauer Boone
Harbor-UCLA Medical Center/UCLA School of Medicine, Torrance, California
Downloaded by [Case Western Reserve University] at 12:56 31 October 2014

The Rey-Osterrieth Complex Figure has a long
history within the field of neuropsychology. The
figure was originally published by Rey (1941)
nearly 60 years ago as a measure for assessing
visual spatial copying and memory skills in
brain damaged individuals. Osterrieth (1944)
contributed a standardized scoring procedure
and normative data on French-speaking subjects
(230 children and 60 adults) as well as some
brain-injured samples. The Rey-Osterrieth fig-
ure has become one of the most commonly used
neuropsychological tests in research paradigms
and is referenced in over 200 publications. In
addition, the Rey-Osterrieth figure is the 21st
most frequently employed psychological test in
forensic neuropsychology, and is administered
in 16% of forensic neuropsychological examina-
tions (Lees-Haley, Smith, Williams, & Dunn,
1995).
Despite the Rey-Osterrieth figure’s wide-
spread use, some shortcomings are apparent in-
cluding: 1) a rudimentary scoring system which
results in single quantitative scores which do not
capture all performance parameters; and 2) lim-
ited normative data. Osterrieth’s original scoring
system involves dividing the figure into 18 dis-
crete units, with 2 points possible for each unit
(i.e., 1 point for correct reproduction and 1 point
for correct location), and a score of .5 assigned
to distorted units inaccurately placed. The scor-
ing algorithm does not characterize qualitative
aspects of performance such as planning strat-
egy or perseverations. Some subjectivity is in-
volved in determining how distorted or mis-
placed a detail must be to lose credit, although
most reported interrater reliabilities have been
surprisingly high (i.e., .80 to .99; cf. Mitrushina,
Boone, & D’Elia, 1999). While several norma-
tive samples with a combined n > 500 are avail-
able for older ages (Beery, Allen, & Schmitt,
1991; Boone, Lesser, Hill-Gutierrez, Berman, &
D’Elia, 1993; Chiulli, Haaland, LaRue, & Garry,
1995; Van Gorp, Satz, & Mitrushina, 1990),
much less data are available on younger,
English-speaking normals (combined n = 67;
Delaney, Prevey, Cramer, & Mattson, 1992;
Huhtaniemi, Haier, Fedio, & Buchsbaum, 1983).
From 1973 until the 1990s, 16 different new
scoring systems or modifications of the original
Osterrieth scoring paradigm were developed to
enhance quantitative objectivity of scoring
and/or to attempt to rate qualitative aspects of
performance (cf. .Mitrushina, Boone, and
D’Elia, 1999, for summaries of each). However,
the normative and clinical samples have gener-
ally been small, and up until now, none of these
approaches have attained wide usage.
The most recent addition to the field, the Bos-
ton Qualitative Scoring System (BQSS), was
developed by Stern and colleagues (1999) and is

Address correspondence to: Kyle Boone, Ph.D., ABPP-ABCN, Department of Psychiatry, Box 495, Harbor-
UCLA Medical Center, 1000 W. Carson Street, Building F-9, Torrance, CA 90509-2910. E-mail: boone@
humc.edu
Accepted for publication: November 5, 1999.
 TEST REVIEW
available through Psychological Assessment
Resources. The authors indicate that they were
pursuing dual goals in developing their system:
to provide quantitative summary scores and to
formulate a system of qualitative ratings. BQSS
administration involves three trials: copy, imme-
diate recall, and 20-to 30-minute recall. For each
trial, 17 qualitative scores are generated, most
rated on a 5-point scale. In addition, 6 summary
scores are computed by combining various qual-
itative scores.
Downloaded by [Case Western Reserve University] at 12:56 31 October 2014
The advantages of the BQSS include a well-
described comprehensive scoring system, a large
standardization sample (n = 433) ranging in age
from 18 to 94, and an emerging literature on
BQSS scores in various clinical groups such as
traumatic brain injury, Alzheimer’s disease, Par-
kinson’s disease, ischemic vascular dementia,
HIV+ , alcohol abuse, and attention deficit hy-
peractivity disorder. In addition, of particular
importance, the manual indicates that the BQSS
has higher sensitivity, but in particular, higher
specificity, and in discriminating clinical groups
and controls than the traditional 36-point scoring
system. Specifically, the BQSS averages 77%
for both sensitivity and specificity while the
original system averages 72% sensitivity but
only 60% specificity.
However, there are some disadvantages to the
BQSS. First, the time commitment to learning
and using the scoring system (including metric
ruler, plastic templates, reference guide, and 100
pages of scoring criteria) appears to be consider-
able. The authors admit that scoring of one’s
first protocol will be ‘‘very time consuming’’,
although they emphasize that their raters uni-
formly exhibited a ‘‘steep learning curve’’, with
most rapidly achieving a total scoring time of 10
to 15 minutes for all three trials. In addition, a
Quick Scoring Guide, requiring a total of 5 min-
utes of scoring time, is available for those situa-
tions in which less precise scores are adequate.
A second concern focuses on the lack of an
empirical basis for the clinical interpretations of
the qualitative scores. For example, it is sug-
gested that patients with right hemisphere dam-
age may obtain lower Configural Presence and
Accuracy scores, while patients with left hemi-
sphere damage may obtain relatively lower
431
Cluster and Detail Presence and Accuracy
scores. However, these conclusions were not
based on observations of BQSS scores in pa-
tients with right versus left hemisphere damage,
but rather are derived from sparse literature on
other tests showing that patients with unilateral
right hemisphere damage process details but not
the overall gestalt or configuration of a figure,
while patients with unilateral left hemisphere
damage show the opposite pattern. It is problem-
atic to use an instrument to draw inferences re-
garding the presence of lateralized dysfunction
without empirical evidence that the instrument
can in fact be used in this manner.
In a related vein, while many of the qualita-
tive scores are used to document executive dys-
function, the evidence that particular qualitative
scores actually tap executive abilities is limited.
The presence of significant correlations between
the BQSS Fragmentation, Planning, Perseve-
ration, and Organization scores and various ex-
ecutive tasks such as Wisconsin Card Sorting
Test perseverative responses and categories
completed, Trails B, the Controlled Oral Word
Association Test, and WAIS-R Similarities is
cited as evidence of convergent validity. How-
ever, the correlations are modest at best (r =
–.22 to .49), suggesting minimal amounts of
shared test score variance. In addition, the corre-
lations between the BQSS scores and non-exec-
utive test scores are not reported. Thus, it is pos-
sible that these BQSS scores actually correlate
more highly with non-executive tasks, which
would render them questionable as measures of
executive function.
Finally, while inter-rater reliability is rela-
tively high for most BQSS scores (kappa coeffi-
cient . 80), lower inter-rater reliability was
revealed for several scores including cluster
placement (0.53), detail placement (0.53), rota-
tion (0.66), and neatness (0.69).
In conclusion, the BQSS appears to be a
highly commendable and exhaustive attempt to
objectively capture important information con-
tained in patient reproductions of the Rey-
Osterrieth figure not measured in the traditional
scoring technique. The normative base of the
BQSS is strong but information regarding the
performance of a wider range of clinical groups,
 432 KYLE BRAUER BOONE
in particular, focal and lateralized brain injury,
is needed to corroborate the recommended inter-
pretations of particular scores. Given that the
authors have already demonstrated a commit-
ment to studying clinical groups with the BQSS,
it is anticipated that these data will appear
shortly. In addition, eventual development of a
computer scoring program which would accept
scanned protocols would make the BQSS much
more user friendly and would circumvent the
problem of mediocre interrater reliability of
Downloaded by [Case Western Reserve University] at 12:56 31 October 2014
some of the scores.
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