Perceptual and Motor Skills, 1992, 75, 1311-1319.

© Perceptual and Motor Skills 1992

THE RUFF 2 AND 7 SELECTIVE ATTENTION TEST:

A NEUROPSYCHOLOGICAL APPLICATION 1

RONALD M. RUFF, HENDRlK NIEMANN, CHARLES C. ALLEN,

CHARLES E. FARROW, THOMAS WYLIE

School of Medicine
University of California, San Diego

Summary.- The neuropsychological application of the Ruff 2 and 7 Selective At-

tention Test as a measure of visual selective attention was investigated. The instru-
ment was constructed as a paper-and-pencil approach to evaluate sustained attention uti-
lizing different disrracror conditions in the study of voluntary or intentional aspects of
attention. Four patient groups with cerebral lesions confined to either the right or left
anterior or left or right posterior region (ns = 8, 8, 8, 6) were studied. Patients with
right-hemispheric lesions showed a greater over-all reduction in processing speed inde-
pendent of the serial or parallel processing mode in comparison to individuals with
left-sided lesions. Furthermore, as predicted, the two groups with anterior brain dam-
age showed a larger discrepancy berween serial and parallel processing modes than pa-
tients with posterior lesions. Specifically, the right frontal cases showed the greatest dif-
ferential of accuracy on the serial and parallel tasks.

The Ruff 2 and 7 Selective Attention Test, or the 2 and 7 Test, was
developed with the aim of clinically assessing an individual's attentional ca-
pacity while (1) self-pacing target selection over a 5-min. period and (2) com-
paring different distractor conditions known to influence selection speed. (3)
The test was designed for easy administration in a paper-and-pencil format to
allow assessment at a patient's bedside without having to rely on the aid of
computers, tachistoscope, etc.
Within clinical settings, the most popular attention test administered is
the Digit Symbol subtest from the WAIS-R, which has a proven sensitivity
of capturing brain dysfunctioning (Wechsler, 1958). However, the duration is
only 90 seconds, which limits the evaluation of prolonged sustained atten-
tion, i.e., 5 min. represents the lower time limit for evaluating monotonous
processing (e.g., Broadbent, 1971; Parasuraman & Davies, 1984). Moreover,
the Digit Symbol subtest evaluates, in addition to attention, the capacity for
incidental learning, since the varying degrees of memorization of the nine
symbols influence the speed of processing (Estes, 1974; Lezak, 1983). Thus,
the Digit Symbol subtest or the subsequently developed Symbol-Digit Test
(Smith, 1968) measure sustained attention in a limited and confounded man-
ner. Having to select the numerical targets 2 and 7 does not represent a
significant memory load, since even severely amnestic patients can retain two

I Address requests for reprints to Ronald M. Ruff, Ph.D., Rehabilitation Center, St. Mary's
Hospital and Medical Center, 450 Stanyan Street, San Francisco, CA 94117-1079.
1312 R. M. RUFF, ET AL.

digits over prolonged periods without delay from interference (e.g., Lezak,
1983; Butters & Cermak, 1980).
On the 2 and 7 Test, the subject is asked to cross out the digits 2 and
7 in two conditions. In one condition, the 2s and 7s are randomly inter-
spersed among other digits, and in the second condition the distractors are
made up of alphabetical letters. These two distractor conditions were select-
ed on the basis of the experimental evidence put forth by numerous cogni-
tive psychologists, claiming that the selection of targets among distractors
from different stimulus categories (e.g., selecting digits from alphabetical let-
ters) allows enhanced identification compared with selecting targets from the
same stimulus category (e.g., selecting the digits 2 and 7 from other digits).
Selecting targets from different stimulus categories has been described as rep-
resenting a more parallel search or even an automatic in/ormation processing,
while selecting targets from the same stimulus category is thought to require
a more serial search or controlled in/ormation processing. The theory of seri-
al and parallel processing initially proposed by Brand (1971) followed by
Treisman (1982) as well as Schneider and Shiffrin's proposed distinction of
controlled and automatic information processing (1977; Shiffrin & Schneider,
1977) are linked to specific experimental paradigms, e.g., tachistoscopic pre-
sentations. Thus, it is a leap for us to propose that these two modes of
information processing also occur on the 2 and 7 Test, which is a paper-
and-pencil cancellation task. However, in a previous study, Ruff, Evans, and
Light (1986) reported data which showed that normal adults were signifi-
cantly slower in the digit-digit than digit-letter condition. Further evidence
supporting the differential processing speeds was documented when monkeys
were able to select out of a 3 x 3 array a single green diamond faster when
the distractors were different colored shapes than when they were different
green shapes (Bolster, Pribram, & Ruff, 1981). Thus, the differential for
selecting targets faster among distractors from different vs same stimulus cat-
egories appears to be a robust finding.
The purpose of this study was to explore the neuropsychological applica-
tion of the 2 and 7 Test by cross-validating the earlier studies of Wilkins,
Shallice, and McCarthy (1987) and Verfaellie, Bowers, and Heilman (1988)
who indicated, when using different experimental tasks, that the right hemi-
sphere was involved in voluntary or intentional aspects of attention. From
this abstraction we hypothesized that patients with right-hemispheric lesions
should show an over-all greater reduction in their processing rate irrespective
of the processing condition than patients with left-hemispheric lesions, both
groups matched against normals.
In a second question, we explored whether the distinction between se-
rial and parallel processing is diagnostically useful and whether deficits in
either one can be related to lesions in different areas of the brain. Shallice
 RUFF 2 AND 7 ATTENTION TEST 1313

(1982) proposed a model of planning with a similar distinction of two types

of information processing and suggested that both types are monitored by
different areas of the brain. According to Shallice, serial or controlled pro-
cessing should be under the control of the frontal lobes whereas parallel
processes are similar to skills or schemas which may be predominantly under
control by posterior portions of the brain. We hypothesized then that pa-
tients with anterior lesions should show a larger discrepancy between the dig-
it-letter and the digit-digit condition than patients with posterior lesions.
METHOD

Subjects
A cohort of 30 patients were selected who satisfied the following crite-
ria: (a) unilateral cerebral lesions were restricted to either the anterior region
(involving portions of the frontal lobe) or to the posterior region (involving
portions of the temporal, parietal, and occipital lobes). Agreement of three
judges who reviewed CT-scans, neurosurgical, or neurological reports was
required for inclusion of subjects in the lesion groups. (b) Also, right-hand-
edness, (c) no motor deficits associated with peripheral damage, and (d) no
history of hospitalization for psychiatric reasons were required. The selection
process resulted in a sample of eight patients each with either right or left
frontal lobe lesions and of six and eight patients with right and left posterior
lesions, respectively. The reader not experienced with selecting patients with
focal cerebral lesions should appreciate that great care was taken to select our
patients out of hundreds of clinical cases examined over the years. No doubt
a greater sample size would be desirable; however, this would require work-
ing with this population for additional years. if the above rigid selection cri-
teria were utilized.
Demographic data together with over-all levels of intellectual function-
ing and finger-tapping speed by the dominant hand are presented in Table 1.
The latter was included to account for the possibility that differences on the
2 and 7 Test might have been due to motor speed.
To provide a standard against which to compare the performance of the
patients, a group of 60 normal subjects was selected from a larger standard-
ization sample; for more information, see Baser and Ruff (1987). The nor-
mals were comparable to the patient group in terms of age (M = 31.2 yr.,
SD = 4.1) and education (M = 12.9 yr., SD = 1.5).
Procedure
The 2 and 7 Test requires the subject to cross out numerical targets as
quickly as possible. The targets are embedded either in alphabetical capital
letters (parallel processing) or in blocks of digits (serial processing).
At first a sample of each block which consisted of three lines was pre-
sented to the patient to ensure that the instructions were understood; see
1314 R. M. RUFF, ET AL.

TABLE 1
DEMOGRAPHIC AND SELECTED PSYCHOMETRIC CHARACTERISTICS OF LESIONED GROUPS

Characteristic Lesioned Groups

Right Anterior Left Anterior Right Posterior Left Posterior
n,8 n, 8 n, 6 n, 8
Gender
Male 7 5 4 5
Female 1 3 2 3
Age, yr.
M 30.8 24.6 27.2 37.0
SD 6.2 5.1 11.2 14.0
Education, yr.
M 13.9 12.8 13.0 15.1
SD 2.4 1.5 2.4 3.3
Full Scale IQ
M 90.4 97.4 102.3 101.3
SD 20.0 13.5 9.9 12.8
Finger Tapping*
M 42.1 4l.0 46.5 47.4
SD 5.3 14.2 9.8 7.8
Note.- The subtests of Wechsler Adult Intelligence Scale-Revised (Wechsler, 1981) were used
to estimate the Full Scale IQ; the Finger-Tapping Test (Reitan & Davison, 1974) was employed
to assess the fine motor speed of the hands. The one-way analyses of variance indicated only a
trend for age (F3 26 = 2.38, p > .09); however, analyses for education, Full Scale IQ, and fin-
ger-tapping were nonsignificant.
*Dominant hand.

Fig. 1. If errors were made during the practice trial, the examiner empha-
sized the need for accuracy. The subject was told to begin the search from
the top left side of the line and to proceed to the second and third lines in a
similar fashion. After completion of the sample, the subject was instructed
that in the main part of the test similar blocks would be presented. The sub-
ject was told that, after a brief period of time the examiner would say
"Next," at which time the subject was to start a new block. Finally, speed of
performance was again emphasized.
The test comprises 20 blocks of three lines with a time limit of 15 sec.

2GOXC7MJ7HZRNGAS2YWQ2LHBZGJNV7ET2PRVMJ
HSTQ2C7KLWC7XMT7KTR2AVPIWOC2GJ7LS2BNVW
7TQXR2PH7FDABM2WHKAST20PHWED2TRNEQX2PK

3 107 894 4 705 3 763 8 5 2 3 6 5 6 9 7 0 8 9 1 5 784 3 6 2 8 6

3 2 8 6 5 4 2 809 129 1 892 8 1 3 764 5 3 7 804 6 7 9 6 2 9 1 2
839 1 8 3 7 8 9 4 6 5 9 1 4 7 0 8 6 7 1 303 9 1 023 3 894 1 265 5

FIG. 1. The 2 and 7 Test (note that sample blocks of targets are embedded in either letters
or digits)
 RUFF 2 AND 7 ATTENTION TEST 1315

per block. The sequence of distractors is as follows (D = digits; L = letters):

D, L, L, D, D, L, D, L, L, D, D, L, D, L, L, D, L, D, L, D. The blocks
are printed on two 8lf2 - x ll-in. pages which are taped together on the back
sides. Each line contains 10 target and 40 distractor stimuli. The distance be-
tween target and dis tractors is equal. The target location is randomized
throughout each line.
To score the test the total number of hits and errors (i.e., omissions and
commissions) were computed separately for each distractor condition. For the
purpose of the present study the following scores were used:

(1) Speed: sum of hits "digit-letter" (DL) and hits "digit-digit" (DD),

(total hits DL and DD) - (total errors DL and DD)

(2) Accuracy: ------------~-- __--~__---------- xlOO
(total hits DL and DD)

From these scores two ratios were computed to investigate differential effects
of the two distractor conditions:

(total hits DL)

(a) Processing 1:
(total hits DD)

(hits DL - errors DL)j(hits DL)

(b) Processing 2:
(hits DD - errors DD)/(hits DD)

Hypotheses and Statistical Analysis

Hypothesis 1.-If the right hemisphere is involved in intentional or vol-
untary aspects of attention, then patients with right-sided lesions should
show a lower mean processing rate on the 2 and 7 Test irrespective of the
distractor condition than individuals with left-sided lesions. No differences
should be observed along the anterior-posterior dimension of brain lesions,
and the interaction between the two factors should be nonsignificant. A
2 x 2 analysis of variance was computed with the Speed score as the depen-
dent variable. In addition, the Accuracy score was subjected to a similar
analysis; it was expected that voluntary aspects of attention would not affect
the accuracy of the performance.
Hypothesis 2.-If the frontal portions of the brain monitor serial pro-
cessing and the posterior areas of the brain are involved in parallel process-
ing, then the performance on the 2 and 7 Test of patients with frontal le-
sions should differ from those with posterior lesions. The former group of pa-
tients should have a larger ratio (Letter condition/Digit condition) than the
latter group. No differences should be observed according to the side of le-
sion, and the interaction between the laterality and the anterior-posterior fac-
tor should be nonsignificant. We tested this hypothesis by computing a 2 x 2
analysis of variance. Both ratio scores were employed as dependent variables,
1316 R. M. RUFF, ET AL.

since it was unclear whether the brain lesions would affect speed or accuracy
of performance under serial and parallel processing conditions.
RESULTS
Hypothesis 1
Patients with right-sided lesions performed on the 2 and 7 Test at a sig-
nificantly lower processing rate (Speed score) than patients with left-sided
lesions (FI •26 = 10.96, P< .005), thereby supporting the first hypothesis; see
Table 2. As predicted, the location of the lesion along the anterior-posterior
dimension was without influence (F I •26 = 1.87) as was the interaction (F ,.26 =
.10).
Surprisingly, not only the processing rate but also the accuracy was af-
fected by the location of the lesion; see Table 2. For the Accuracy score a
trend was obtained for both laterality (F,.26 =2.92, p<.10) and the interac-
tion term (FI 26 = 3.52, P< .08). Patients with right anterior lesions performed
the least accurately, whereas the left anterior group obtained a mean score
similar to that of the normal subjects. Posterior lesioned groups maintained a
middle position and did not differ from each other.

TABLE 2
MEANS AND STANDARD DEVIATIONS OF SPEED AND ACCURACY SCORES
ON THE RUFF 2 AND 7 TEST FOR LESIONED GROUPS AND NORMALS

Groups n Speed Accuracy

M SD M SD
Right Hemisphere
Anterior 8 176.0 47.9 79.5 15.6
Posterior 6 204.7 43.8 90.0 5.0
Left Hemisphere
Anterior 8 236.4 54.4 94.2 3.5
Posterior 8 254.3 33.3 88.6 15.0
Normal 60 284.4 47.2 94.4 4.7

Hypothesis 2
The results of the analysis of variance for the Processing 1 score did not
support the hypothesis that anterior lesions would differentially affect the
speed of serial processing, thereby increasing the ratio between parallel and
serial processing for this patient group (F,.26 = .02). As expected the laterality
factor (F,.26 = .03) and the interaction term (FI .26 = .01) were nonsignificant.
In contrast, a trend was found for the Processing 2 score. Patients with
anterior lesions showed a larger discrepancy in their accuracy under the two
processing conditions than patients with posterior lesions (FI •26 = 2.88, P <
.10). The mean ratio for the latter patient group was comparable to that for
the normal subjects; see Table 3. As expected, the right-left differences (F' 26
< .01) and the interaction (F,.2 6 = .003) were nonsignificant. .
 RUFF 2 AND 7 ATTENTION TEST 1317

TABLE 3
MEANS AND STANDARD DEVIATIONS OF PROCESSING 2 SCORES ON THE
RUFF 2 AND 7 TEST FOR LESIONED GROUPS AND NORMALS

Groups n Processing 2
M SD
Anterior
Right 8 1.09 .13
Left 8 1.08 .08
Posterior
Right 6 1.02 .03
Left 8 1.04 .05
Normal 60 1.04 .04

DISCUSSION
The present study supports the neuropsychological application of the 2
and 7 Test. According to this simple paper-and-pencil measure, our investiga-
tion showed that patients with right-sided lesions performed at a significant-
ly reduced processing rate relative to patients with left-sided lesions. This
finding is consistent with the experimental findings of Wilkins, et al. (1987)
and Verfaellie, et at. (1988) who reported that right-sided brain lesions tend-
ed to affect voluntary or intentional aspects of attention. Moreover, the find-
ings are not confounded by reduced motor speed. On one hand, the lesioned
groups did not differ in their finger-tapping speed (pure motor speed mea-
sure) with the dominant hand, and on the other hand, it is unlikely that a
lesion in the right hemisphere would affect fine motor speed or coordination
of the ipsilateral or dominant hand. Individuals with right-frontal lesions not
only worked more slowly but also less accurately than the other patient
groups. Although all patient groups performed more slowly than the normal
subjects, the left-frontal lesioned patients were as accurate as the normal
subjects.
The two distractor conditions within the test allow a potentially inter-
esting distinction. According to the literature, automatic or parallel informa-
tion processing is faster and relatively effortless, whereas controlled or serial
information processing is slower and more effortful. However, the underlying
brain mechanism in these two attentional processes is poorly understood.
Shallice (1982) has argued that controlled processing is primarily monitored
by the frontal portions of the brain and the posterior regions of the cortex
are involved in the automatic processing of information. In the present
study, we made a first attempt in evaluating the clinical usefulness of this
concept with a paper-and-pencil test. It was predicted that patients with an-
terior lesions would show a deficit in controlled processing, thereby increas-
ing the ratio between the two processing modes. Of two scores only one
(ratio of accuracy) showed a trend in the predicted direction. A number of
factors may be related to this result. The patient sample included different
1318 R. M. RUFF, ET AL.

etiologies, and the sample sizes were quite small. In spite of these limita-
tions, an alternative explanation may be pertinent for both conditions: if
visual-search strategies are inefficient, frontal lesions may interfere with auto-
matic processes by making them become more controlled and thereby reduce
the processing rate by the same amount.
In summary, the Ruff 2 and 7 Selective Attention Test is an easily ad-
ministered instrument which not only assesses deficits in speed and accuracy
of information processing but also is shown to be sensitive to differential
neuropathology. Further neuropsychological application seems appropriate.
Since our first publication (Ruff, et al., 1986), we have normed this test on
360 adults stratified by age, gender, and education, and 100 subjects have
been retested to establish its reliability. Some applications have begun, since
the test has been shown sensitive to early detection of AIDS (Schmitt,
Bigley, McKinnis, Logue, Evans, Drucker, & the AZT Collaborative Work-
ing Group, 1988). The 2 and 7 Test was also used with the Traumatic Brain
Injury Data Bank (Levin, Gary, Eisenberg, Ruff, Barth, Kreutzer, High, Port-
man, Foulkes, Jane, Marmarou, & Marshall, 1990), and particularly the
speed score was one of the key predictors of returning to work or school
(Ruff, Marshall, Crouch, Klauber, Levin, Barth, Kreutzer, Eisenberg, Jane,
Marmarou, & Foulkes, in press).

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Accepted October 22, 1992.