Archives of Clinical Neuropsychology 22 (2007) 773–785

Ruff 2 and 7 Selective Attention Test: Normative data,

discriminant validity and test–retest
reliability in Greek adults
Lambros Messinis a,∗ , Mary H. Kosmidis b , Ioanna Tsakona a , Vassilis Georgiou c ,
Eleni Aretouli b , Panagiotis Papathanasopoulos a
a Department of Neurology, Neuropsychology Unit, University of Patras Medical School, Rion, Patras, Greece
b Department of Psychology, Aristotle University of Thessaloniki, Greece
c Departments of Mathematics and Statistics, University of Patras, Greece

Accepted 6 June 2007

Abstract
Rapidly expanding interest in neuropsychological assessment in Greece has made the development of appropriate culture-specific
normative data for core neuropsychological measures essential. In the present study, we sought to establish normative, test–retest
reliability and discriminant validity data for the Ruff 2 and 7 Selective Attention Test in the Greek adult population. We administered
the test using standard procedures to 218 healthy Greek adults (95 men), aged 17–80 years and two adult patient groups (26 detoxified
opiate addicts and 23 HIV seropositive individuals). Using linear regression analyses, we examined the contribution of age, education
and gender on Ruff 2 and 7 performance. We further examined test–retest reliability by administering the test on two occasions to
40 healthy adults, with an intersession interval of 12–14 weeks. The regression analyses revealed that age and education, but not
gender, contributed significantly to participants performance, with older age and lower education contributing to poorer performance
on Speed scores, but only education contributing moderately to Automatic Detection Accuracy scores. Test–retest reliability was
very high (.94–.98) for Speed scores, and adequate to high (.73–.89) for Accuracy scores. Younger adults also demonstrated larger
practice effects compared to older participants. The test appears to discriminate adequately between the performance of detoxified
opiate addicts and HIV seropositive patients and matched healthy controls, as both patient groups performed more poorly than their
respective control group. We present normative data for Speed and Accuracy scores stratified by age and education for the Greek
adult population.
© 2007 National Academy of Neuropsychology. Published by Elsevier Ltd. All rights reserved.

Keywords: Ruff 2 and 7; Selective attention; Sustained attention; Greek normative data; Discriminant validity; Test–retest reliability

1. Introduction

Normative data are often used in clinical neuropsychological assessments as a means to determine the presence
or absence of deficits, as well as the need for further diagnostic or assessment procedures. In Greece, interest in
neuropsychological assessment is expanding rapidly, as the number of psychologists consulting clinically or involved
in research in this area is increasing significantly. There has also been a large increase in the number of research

∗ Corresponding author. Tel.: +30 2610 999 348/243; fax: +30 2610 455 209.
E-mail address: lambros@hellasnet.gr (L. Messinis).

0887-6177/$ – see front matter © 2007 National Academy of Neuropsychology. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.acn.2007.06.005
774 L. Messinis et al. / Archives of Clinical Neuropsychology 22 (2007) 773–785

protocols utilizing neuropsychological test variables as outcome measures by other scientific disciplines, most notably,
university-affiliated neurology and psychiatric clinics in collaboration with neuropsychologists.
The increased demand for neuropsychological assessment in Greece and the lack of appropriate normative data
have led neuropsychologists working in Greece to either develop appropriate new tests (Folia & Kosmidis, 2003;
Kosmidis, Vlahou, Panagiotaki, & Kiosseoglou, 2004) or collect normative data for commonly used neuropsycho-
logical tests developed in other countries (Aretouli & Kosmidis, 2006, 2007a, 2007b; Argirokastritou, Samanda, &
Messinis, 2005; Giannakou & Kosmidis, 2006; Kosmidis et al., 2004; Messinis, Lada et al., 2006; Messinis, Tsakona,
& Papathanasopoulos, 2006; Vlahou & Kosmidis, 2002). Despite these important contributions in providing perfor-
mance data for several core neuropsychological measures in the Greek population, appropriate norms for many other
neuropsychological tests essential to the practicing clinician or researcher are lacking; therefore, the need to create
culture-specific norms is evident. In this respect, we chose to provide performance data for a commonly used and
relatively simple paper-and-pencil neuropsychological test of selective and sustained visual attention, the Ruff 2 and
7 Selective Attention Test (Ruff & Allen, 1996; Ruff, Evans, & Light, 1986).
Deficits in attention are among the most common sequelae of brain damage following disease or injury and can
have multiple negative influences on the lives of patients, possibly contributing to disability in activities of daily living
(Cicerone & Azulay, 2002; Cohen, Malloy, & Jenkins, 1998; Kerns & Mateer, 1998; Weiss, 1996). Consequently,
and despite current conceptual inconsistencies and lack of scientific agreement regarding the specific nature of atten-
tion in the literature, assessment of attentional functions constitutes an integral aspect of clinical neuropsychological
assessments (Cohen et al., 1998).
The 2 and 7 Selective Attention Test was developed to assess sustained and selective aspects of visual attention
(Cicerone & Azulay, 2002; Ruff & Allen, 1996). The test is based on the premise that selective attention (i.e., the ability to
select relevant stimuli while ignoring irrelevant information) can be assessed by comparing automatic detection versus
controlled processing with minimal demands on other cognitive processes such as internal processing of information
or immediate memory (Cicerone & Azulay, 2002). It is based on the theories of Logan et al. (Logan, 1988; Logan
& Klapp, 1991; Logan & Stadler, 1991), which posit two processes through which attention is allocated: automatic
information processing and effortful or controlled information processing (Strauss, Sherman, & Spreen, 2006).
Two types of trials are presented in the test: Automatic Detection trials, in which the target numbers are presented
among distractor letters, and Controlled Search trials, in which the target numbers are presented among other distractor
numbers. Selecting targets from different stimulus categories represents parallel search or even automatic information
processing. This categorical difference between letters and numbers is overlearned, and hence subject to automatic
processing even in semiliterate individuals (Ruff & Allen, 1996). In contrast, selecting targets from the same stimulus
category requires serial search or controlled information processing, i.e., working memory and effortful processing of
stimulus characteristics are required to effectively select targets from distractors (Ruff & Allen, 1996; Ruff, Neiman,
Allen, Farrow, & Wylie, 1992; Strauss et al., 2006).
The actual 2 and 7 test is a paper-and-pencil number-cancellation task that consists of a set of 20 trials (10 Automatic
Detection trials and 10 Controlled Search trials), presented semirandomly in the test booklet, with three lines per trial,
administered consecutively in 15-s intervals. All instructions are provided verbally, and examinees are required to read
through each line and cross out specific targets (always the numbers 2 and 7), working from left to right, while ignoring
other letters or numbers (Ruff & Allen, 1996; Strauss et al., 2006). The total administration time – after a brief practice
set to assure that examinees understand the instructions – is 5 min (Ruff & Allen, 1996).
Several scores can be derived from the 2 and 7 test as described in detail in the test manual (Ruff & Allen, 1996).
Scores are generally based on errors of omission (correct hits) and commission (incorrect responses). Selective attention
is measured by the Automatic Detection and Controlled Search scores and sustained attention is measured primarily by
the Total Speed (number of correctly identified targets during the allotted 5-min duration), and Total Accuracy (number
of targets identified during the 5-min duration divided by the number of possible targets) scores. In the test manual
several discrepancy analysis procedures are further provided in order to evaluate performance on various aspects of
selective attention (Ruff & Allen, 1996).
As regards the contribution of demographic variables on Ruff 2 and 7 performance, age has been found to correlate
moderately with Automatic Detection Speed and Controlled Search Speed (r = −.41 and −.38, respectively; Ruff &
Allen, 1996; Strauss et al., 2006). No significant effects of age have been reported in the literature on any of the accuracy
variables (Strauss et al., 2006). Gender does not appear to influence performance on any of the test variables, as there
are no reports of significant contributions of gender in the literature (Ruff & Allen, 1996; Strauss et al., 2006).
 L. Messinis et al. / Archives of Clinical Neuropsychology 22 (2007) 773–785 775

The literature regarding the specific contribution of formal education on Ruff 2 and 7 performance notes relatively
small effects for Automatic Detection Speed and Controlled Search Speed (r = .19–.24; Ruff & Allen, 1996; Strauss et
al., 2006). Nevertheless, the contribution of education is sufficient to warrant education-based norms on these variables.
Education does not appear to influence performance on any of the Accuracy scores, although higher levels of formal
education may contribute to higher test–retest gains on Speed scores (Lemay, Bedard, Rouleau, & Tremblay, 2004;
Strauss et al., 2006).
As regards the specific contribution of intelligence levels to Ruff 2 and 7 performance, negligible correlations with
FSIQ have been reported (Ruff & Allen, 1996; Strauss et al., 2006). In contrast, modest correlations have been noted
with PIQ when demographically corrected scores were utilized (r = .22–.25; Strauss et al., 2006).
Test–retest reliability has been reported as adequate to high for the 2 and 7, with higher test–retest coefficients
reported for Speed than for Accuracy scores (Lemay et al., 2004; Ruff & Allen, 1996).
The diagnostic utility of the test has been examined in patients with postconcussion syndrome (PCS) (Cicerone and
Azulay, 2002). The authors reported strong positive predictive power for the Speed scores, indicating the diagnostic
accuracy of impaired Speed scores for PCS patients. The 2 and 7 test has also been studied in other clinical populations,
and appears sensitive to injury severity in both adults (Allen & Ruff, 1990; Bate, Mathias, & Crawford, 2001) and
children with TBI (Nolin & Mathieu, 2001). Schizophrenic patients, on the other hand, demonstrate seriously com-
promised Speed scores independent of schizophrenia subtype (i.e., paranoid versus nonparanoid), but Accuracy scores
appear less impaired (Weiss, 1996). Severe forms of depression appear to influence Total Speed scores selectively, but
Total Accuracy scores to a lesser extent (Ruff & Allen, 1996; Strauss et al., 2006). The test’s discriminant validity is
reportedly adequate in discriminating between AIDS and AIDS-related complex patients (Schmitt et al., 1988).
Few studies have explored the test’s usefulness in localizing dysfunction. Despite suggestions that the Ruff 2 and 7
may differentiate between left-and-right hemisphere dysfunction, the evidence in this regard is limited (Ruff & Allen,
1996; Ruff et al., 1992; Strauss et al., 2006; Weiss, 1996). Instead, patients with frontal lesions may be distinguished
from those with posterior lesions, given the former group’s lower Accuracy score in the Controlled versus Automatic
Detection Condition (Ruff & Allen, 1996; Strauss et al., 2006).
Given the specific contributions of age and education on several Ruff 2 and 7 variables reported in the literature, and
the absence of normative data for this test specific to the Greek population, we sought to investigate the demographic
characteristics that influence performance on this test, and also to create norms based on these variables for the Greek
adult population. We further examined the test’s validity in discriminating adults with selective attention deficits, by
assessing a sample of detoxified opiate addicts and a group of HIV seropositive patients as compared to age, gender
and education-matched healthy control groups. Finally, we investigated test–retest reliability and practice effects in a
group of healthy Greek adults with a testing interval of 12–14 weeks and present data stratified by age for Automatic
Detection Speed, Controlled Search Speed, Automatic Detection Accuracy and Controlled Search Accuracy scores.

2. Method

2.1. Participants

Two hundred and eighteen healthy Greek adults (95 men or 43.6%), recruited primarily from two large urban
centers in Southwestern and Northern Greece (sample of convenience), participated in the present study voluntarily,
and after providing written informed consent for their participation. Potential healthy participants were approached
by the experimenters with the goal of including a broad range of adult ages and education levels. Healthy participants
were 17–80 years old (M = 45.07, S.D. = 17.45) and had 2–21 years of formal education (M = 13.01, S.D. = 4.20).
Exclusion criteria were a history of psychiatric, neurological or cardiovascular disorders or of substance abuse or
dependence (including alcohol and benzodiazepine abuse), a history of head injury or any other medical condition
(including significant visual impairments not corrected sufficiently by visual aids) that might affect neuropsychological
performance, and non-native speakers of the Greek language. We further excluded from the study of older adults (over
60 years), who on initial testing obtained scores of less than 27 on the Greek-validated version of the Mini–Mental State
Examination (MMSE; Fountoulakis, Tsolaki, Chantzi, & Kazis, 2000), a brief screening measure for global cognitive
deficits.
We also examined 26 detoxified heroine addicts, recruited from the detoxification and psychosocial substance
rehabilitation program offered at the “Merimna Life Care Unit” in Athens, Greece (age: M = 30.35, S.D. = 7.04; level
776 L. Messinis et al. / Archives of Clinical Neuropsychology 22 (2007) 773–785

of education: M = 10.96, S.D. = 2.40). As a group, these patients had a mean duration of heroine abuse of 12.76 years
(S.D. = 7.80) and a mean age of onset of 21.32 years (S.D. = 7.82). They were heroine (opiate) free an average of
36.69 days (S.D. = 31.08; range 7–125 days). All participants in this group were diagnosed as persons with Opiod
Dependence (DSM-IV-TR criteria; American Psychiatric Association, 2000), and were participating in an opiate
detoxification rehabilitation program after having initially undergone an ultra rapid opiate detoxification procedure.
Patients in this outpatient program receive naltrexone hydrochloride maintenance therapy at a dose of 50 mg/day (an
opiate antagonist which is not addictive, and treats addiction at the receptor level instead of only withdrawing or
substituting opiate agonists) and psychosocial support for a period of 12 months. We excluded participants from this
group who met a current DSM-IV-TR diagnosis of dependence on any other drug or on alcohol, or suffered from
any other medical condition that might affect neuropsychological performance, and non-native speakers of the Greek
language. Participants in this group provided routine urine samples as part of their program requirements and before
the neuropsychological testing session. A urinary toxicology screen further confirmed that no other illicit substances
had been used by these participants following the detoxification procedure.
We also examined a group of 23 HIV seropositive patients (13 asymptomatic and 10 symptomatic), who were
recruited from the outpatient Infectious Diseases Unit, of AHEPA Hospital of the Aristotle University of Thessaloniki
(age: M = 38.39, S.D. = 8.08; level of education: M = 13.91, S.D. = 2.75). As a group, these patients had a mean CD4+ T
lymphocyte count of 554.70/mm3 , (S.D. = 218.25) and 73.9% of the sample was on typical antiretroviral medication.
Participants in this group were classified either as asymptomatic or symptomatic HIV seropositive patients using the
Centers for Disease Control and Prevention HIV staging and classification system (Centers for Disease Control and
Prevention [CDC], 1992). We excluded participants from this group who met a current DSM-IV-TR diagnosis of
dependence on any drug or alcohol, those who were co-infected with Hepatitis C, and non-native speakers of the Greek
language.

2.2. Procedure

Healthy participants were initially screened through a standardized interview at the beginning of the testing
session by the project staff clinical neuropsychologist and physician (in the Southwestern Greece sample) or the
psychologist–experimenter (in the Northern Greece sample), in order to exclude those with health problems or other
exclusion criteria as described above. Participants over the age of 60 were also administered the Greek version of
the MMSE (Fountoulakis et al., 2000). Detoxified opiate addicts were tested as part of a larger study examining the
neuropsychological effects of naltrexone hydrochloride maintenance therapy in heroine addicts (Messinis, Tsakona et
al., 2006). HIV seropositive patients were assessed at the outpatient Infectious Diseases Unit of AHEPA Hospital of
Aristotle University of Thessaloniki, as part of a larger neuropsychological study examining cognition in the HIV/AIDS
population in Greece (Messinis, Tsakona, Kollaras, Malefaki, & Papathanasopoulos, in press). The psychologists who
served as experimenters had been trained intensively in the administration procedures of various neuropsychological
measures, including the Ruff 2 and 7 Selective Attention Test, by doctoral level clinical neuropsychologists.
The administration procedure used was that described in the test manual by Ruff and Allen (1996, pp. 5–6). The
test requires participants to cross out target digits (2 and 7) working across the lines from left to right (i.e., one line at
a time), by finding them among capital letters of the alphabet (automatic detection) or in blocks of digits (controlled
search) in consecutive 15-s increments. Initially, a sample of each block consisting of three lines on the back of the
test booklet was presented to the participant in order to ensure that the instructions were understood. If errors were
made during these practice trials, e.g., errors of omission or commission, skipping a line or section or beginning a
line from the right side of the page, the examiner pointed them out and emphasized the need for accuracy and speed.
The participant was instructed 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 trials, the participant was told that in the main part of
the test similar blocks would be presented, requiring the participant to do what he or she had just practiced in the two
trials. The participant was further told that after a brief time period the examiner would say “Next,” at which time the
participant was to start a new block. Speed and accuracy of performance was again emphasized. The test commenced
immediately following these instructions. Twenty blocks (10 for automatic detection and 10 for controlled search) of
three lines with a time limit of 15 s per block were given. When extreme deviations occurred, the participants were
corrected, without stopping the timing.
 L. Messinis et al. / Archives of Clinical Neuropsychology 22 (2007) 773–785 777

2.3. Statistical analysis

We initially observed our data visually to determine whether the distributions met normality requirements. All data
points that were considered outliers or extreme outliers were excluded from analyses (scores were considered outliers
if they exceeded two standard deviations from the mean and extreme outliers if they exceeded three standard deviations
from the mean). The normality assumption of our data was further investigated using the Kolmogorov–Smirnov
test for normality. Most of our variables were normally distributed; so parametric tests were mainly employed. In
order to investigate the equality of means we used independent sample t-tests for normally distributed variables, and
the Mann–Whitney U-test for variables not normally distributed. In cases where statistically significant differences
were found between the variances of groups, the t-test of unequal variances was used and the degree of freedom
was estimated using the Welch–Satterthwaite approximation. Levene’s test was employed in order to investigate the
equality of variances. Stepwise multiple linear regression analyses were used to examine the potential contribution of
demographic variables (age, sex and years of formal education) to performance on the Ruff 2 and 7 scores. We also
estimated test–retest reliability by calculating Pearson product–moment correlations between Search and Accuracy
scores across two test sessions separated by a 12–14-week time interval in a group of healthy participants grouped by
age. Paired samples t-tests were used to compare means between the two sessions for Speed and Accuracy scores as
these variables were normally distributed. The level of statistical significance was set at p = .05, and all analyses were
conducted using the SPSS 14.0 software.

3. Results

3.1. Influence of demographic characteristics on Ruff 2 and 7 performance

In order to examine the potential contribution of demographic characteristics to performance on the Ruff 2 and 7,
we conducted linear regression analyses (Table 1). Results showed that age and education contributed significantly
to performance on Automatic Detection Speed [F(3, 214) = 86.512, p = <.001], and Controlled Search Speed [F(3,
214) = 67.523, p = <.001]. On these trials, older participants with a lower education level, performed worse than younger
participants with a higher educational level. Only education accounted for a significant proportion of the variance on
the Automatic Detection Accuracy score [F(3, 214) = 12.330, p = <.001], and the Controlled Search Accuracy score
showed a non-significant trend [F(3, 214) = 1.665, p = .052]. Participants with higher educational levels performed
better than participants with lower levels of formal education.
Given the significant contribution of age and education to the Automatic and Controlled Speed scores, the influence
of education on the Accuracy scores as revealed by the regression analyses, and in order to obtain normative data for
the Greek adult population, we grouped our sample into demographic categories. Graphs illustrating changes over the
age range yielded three age groups: 17–39, 40–59 and 60–80 years old. We also grouped our sample based on the
level of education so as to reflect school requirements in Greece (compulsory education is 9 years): 1–9, 10–12 (high
school) and 13 years and above (higher education including technological and other university level education). Table 2
presents means, standard deviations and percentile performance stratified by age and education level.

3.2. Discriminant validity

In order to determine the validity of the Ruff 2 and 7 in discriminating patient groups from healthy participants,
we compared 26 detoxified heroine addicts to 21 healthy controls, matched on sex ratio [x2 (1) = 2.385, p = .122],
level of education [Z = −1.779, p = .075] and age [t(45) = −.641, p = .525]. Independent sample Mann–Whitney U-
tests revealed that the detoxified heroine addicts performed more poorly than the healthy controls on the Automatic
Detection Speed score [Z = −1.980, p = .048] and the Automatic Detection Accuracy score [Z = −2.108, p = .035], but
the groups did not differ on the Controlled Detection Speed and Controlled Detection Accuracy scores. Fig. 1 presents
mean performance of the detoxified heroine addicts and the healthy group on the speed and accuracy dimensions of
the Ruff 2 and 7.
Similarly, we compared 23 HIV seropositive patients to a group of 27 healthy individuals, matched on sex ratio
[x2 (1) = 3.716, p = .054], level of education [Z = −.423, p = .672] and age [t(48) = −.62, p = .951]. Independent sample
t-tests revealed that the HIV seropositive group performed more poorly than the healthy controls on the Automatic
778 L. Messinis et al. / Archives of Clinical Neuropsychology 22 (2007) 773–785

Table 1
Linear regression analyses: Contributions of age, education and gender on Ruff 2 and 7 scores
Score Variable B Std. error B t p R2

ADS (Constant) 157.298 13.598 11.568 <.001 .548

Age −1.196 .129 −9.249 <.001
Education 3.282 .536 6.123 <.001
Gender 5.046 3.867 1.305 .193
ADE (Constant) 15.281 5.685 2.688 .008 .029
Age .008 .054 .149 .882
Education −.428 .224 −1.909 .058
Gender −1.538 1.617 −.951 .343
ADA (Constant) 90.191 2.848 31.664 <.001 .147
Age −.047 .027 −1.733 .085
Education .444 .112 3.952 <.001
Gender .774 .810 .955 .341
CSS (Constant) 130.113 11.185 11.632 <.001 .486
Age −.811 .106 −7.627 <.001
Gender −.248 3.181 −.078 .938
CSE (Constant) 20.249 6.374 3.177 .002 .001
Age −.085 .061 −1.401 .163
Education −.147 .251 −.586 .559
Gender −1.472 1.813 −.812 .418
CSA (Constant) 87.195 3.317 26.288 <.001 .023
Age .005 .032 .174 .862
Gender .456 .943 .483 .629

Note: ADS, Automatic Detection Speed; ADE, Automatic Detection Error; ADA, Automatic Detection Accuracy; CSS, Controlled Search Speed;
CSE, Controlled Search Errors; CSA, Controlled Search Accuracy.

Detection Speed score [t(48) = −2.033, p = .048], Automatic Detection Accuracy score [t(48) = 2.039, p = .047] and
Controlled Search Accuracy score [t(48) = 2.261, p = .029] of the Ruff 2 and 7, with no group difference on Controlled
Detection Speed. Fig. 2 presents mean performance of the HIV seropositive patients and healthy group on the speed
and accuracy dimensions of the Ruff 2 and 7.

3.3. Test–retest reliability and practice effects

A group of 40 Greek healthy adults (17 men or 42.5%), ranging in age from 20 to 71 years with a minimum 12 years
of formal education completed (level of education: M = 15.05, S.D. = 2.85; range 12–21 years), were administered the
Ruff 2 and 7 on two occasions, with a testing interval of 12–14 weeks in order to establish test–retest reliability and to
determine potential practice effects. Test–retest means and reliability coefficients are presented separately for Automatic
Detection and Controlled Search Speed, Automatic Detection and Controlled Search Accuracy scores, grouped by three
age bands (20–39, 40–59, 60–71 years old) (Table 3). Independent sample t-tests revealed that Speed scores were subject
to a practice effect. Participants in all three age bands performed better on the second administration than the first on both
Automatic Detection Speed [20–39 years old: t(15) = −5.702, p = <.001; 40–59 years old: t(10) = −8.566, p = <.001;
60–71 years old: t(12) = −6.895, p = <.001] and Controlled Search Speed scores [20–39 years old: t(15) = −9.725,
p = <.001; 40–59 years old: t(10) = −4.739, p = <.001; 60–71 years old: t(12) = −3.339, p = .006]. For the Accuracy
scores, significant practice effects were detected only for the 20–39 age group on the Automatic Detection Accuracy
[t(15) = −3.194, p = .006] and Controlled Search Accuracy scores [t(15) = −2.800, p = .029] of the Ruff 2 and 7.

4. Discussion

Despite the widespread use of neuropsychological measures in clinical and research settings in Greece in recent years,
normative data for commonly used neuropsychological tests remain largely unavailable. In an attempt to contribute
 L. Messinis et al. / Archives of Clinical Neuropsychology 22 (2007) 773–785 779

Table 2
Normative data stratified by age and level of education
Age

17–39 years 40–59 years 60+ years

Education (years) Education (years) Education (years)

1–9 10–12 13+ 1–9 10–12 13+ 1–9 10–12 13+

– n = 17 n = 70 n = 16 n = 19 n = 33 n = 31 n = 16 n = 16

Automatic Detection Speed

Percentile 5th – 120.0 127.0 82.0 78.0 111.0 60.0 103.0 94.0
25th – 155.0 166.0 100.0 141.0 142.0 84.0 115.0 115.5
50th – 175.0 186.0 144.5 156.0 163.0 96.0 127.0 147.5
75th – 194.0 208.0 167.0 172.0 177.0 115.0 131.0 154.0
95th – 220.0 229.0 184.0 187.0 207.0 147.0 192.0 194.0
M – 170.9 185.1 135.7 154.2 158.8 98.3 127.7 141.6
S.D. – 30.5 31.7 34.3 27.5 28.3 26.6 20.7 31.3
Automatic Detection Accuracy
Percentile 5th – 82.1 90.3 47.1 78.5 90.2 80.6 88.4 89.2
25th – 96.4 97.3 93.5 88.6 93.4 83.0 96.2 94.9
50th – 97.6 98.5 97.3 94.8 96.7 92.3 97.3 96.3
75th – 98.9 99.3 99.1 97.1 98.2 96.7 98.1 96.9
95th – 100.0 100.0 100.0 99.4 99.3 99.2 100.0 100.0
M – 96.7 97.3 93.1 92.9 95.0 90.1 96.7 95.8
S.D. – 4.2 3.4 12.8 5.4 6.5 7.5 2.6 2.3
Controlled Search Speed
Percentile 5th – 97.0 107.0 70.0 68.0 97.0 51.0 86.0 88.0
25th – 116.0 134.0 98.5 116.0 121.0 72.0 102.0 97.5
50th – 140.0 148.5 117.0 129.0 136.0 82.0 110.5 119.5
75th – 157.0 166.0 125.5 140.0 154.0 111.0 120.0 150.0
95th – 193.0 187.0 142.0 147.0 167.0 116.0 151.0 155.0
M – 139.9 150.4 112.2 124.8 135.3 86.5 111.1 121.2
S.D. – 29.5 26.2 19.8 20.3 22.2 22.4 15.7 25.8
Controlled Search Accuracy
Percentile 5th – 73.2 84.6 57.1 66.5 79.9 81.2 89.8 82.8
25th – 90.9 90.7 89.3 83.5 87.5 85.5 91.3 88.5
50th – 93.5 93.8 91.2 91.0 93.7 90.7 95.6 93.1
75th – 95.1 97.3 97.2 95.2 96.0 93.0 97.8 94.4
95th – 97.5 99.2 100.0 99.3 98.8 97.5 99.2 96.4
M – 91.6 92.9 90.0 88.1 91.2 89.6 94.9
S.D. – 5.9 6.0 10.2 9.4 8.2 4.9 3.3 4.4

towards filling this gap, we developed culture-specific normative data for the Greek adult population of a useful and
relatively simple paper-and-pencil neuropsychological test of selective and sustained visual attention, the Ruff 2 and
7 Selective Attention Test (Ruff & Allen, 1996; Ruff et al., 1986), stratified by those demographic characteristics that
contributed significantly to performance on this test. We further provided data on the test’s validity in discriminating
adult patients with selective attention deficits, by comparing the Speed and Accuracy scores of detoxified opiate
addicts on naltrexone maintenance therapy, and HIV seropositive patients to separate age, gender and education-
matched healthy control groups. Finally, we provided data for test–retest reliability and practice effects in a group of
40 healthy Greek adults grouped by age with a testing interval of between 12 and 14 weeks, on Speed and Accuracy
scores. To our knowledge there have been no attempts to date to develop normative data for the Ruff 2 and 7 in the
adult population in Greece.
Consistent with reports in the literature (Ruff & Allen, 1996; Ruff et al., 1986), our data showed that age accounted
for a substantial proportion of the variance in Automatic Detection and Controlled Search Speed performance favoring
younger healthy participants, i.e., a steady decline in performance was observed in Speed scores with increasing age
780 L. Messinis et al. / Archives of Clinical Neuropsychology 22 (2007) 773–785

Fig. 1. Mean performance of the detoxified heroine addicts and the healthy group in the speed and accuracy variables of the Ruff 2 and 7.

in a linear fashion, starting in young adulthood. No significant contributions of age were noted for any of the Accuracy
scores, a finding that is also consistent with reports in the literature (Ruff & Allen, 1996; Ruff et al., 1986). Gender did
not contribute significantly to any of the 2 and 7 scores, a finding that is consistent with the literature on the influence
of this demographic variable on performance scores (Ruff & Allen, 1996).
Reports regarding the effects of formal education on Ruff 2 and 7 performance have indicated that these are relatively
small for Automatic Detection and Controlled Search Speed (Ruff & Allen, 1996). In contrast, we found that level

Fig. 2. Mean performance of the HIV seropositive patients and healthy group in the speed and accuracy variables of the Ruff 2 and 7.
 L. Messinis et al. / Archives of Clinical Neuropsychology 22 (2007) 773–785
Table 3
Test–retest means (S.D.), and reliability coefficients for Ruff 2 and 7 scores stratified by age
Automatic Detection Speed Controlled Search Speed Automatic Detection Accuracy Controlled Search Accuracy

Age group (years) Session 1 Session 2 rtt Session 1 Session 2 rtt Session 1 Session 2 rtt Session 1 Session 2 rtt

20–39 (n = 16) 180.3 (28.56) 191.0 (27.82) .96 142.7 (26.96) 152.8 (27.19) .98 94.6 (5.04) 95.7 (3.89) .89 89.7 (9.19) 91.4 (7.43) .87
40–59 (n = 11) 150.5 (35.72) 158.3 (36.81) .98 125.6 (23.67) 132.6 (25.67) .97 96.0 (2.50) 96.2 (2.27) .73 91.9 (4.24) 93.1 (3.20) .80
60–71 (n = 13) 134.3 (30.08) 138.7 (30.47) .97 112.5 (21.72) 116.1 (22.22) .94 96.4 (1.62) 96.5 (1.40) .78 92.6 (5.01) 93.8 (3.73) .76

Note: rtt , reliability coefficient.

781
782 L. Messinis et al. / Archives of Clinical Neuropsychology 22 (2007) 773–785

of education contributed significantly to Automatic Detection and Controlled Search Speed Scores and to a lesser
extent to Automatic Detection Accuracy scores. Participants with higher levels of education, but in similar age groups,
outperformed participants with lower levels of education. Unlike previous reports (Ruff & Allen, 1996), our data
demonstrated that education appears to influence Automatic Detection Accuracy moderately in addition to Speed
scores. Our findings, unlike other studies (Ruff & Allen, 1996; Ruff et al., 1986) supporting the notion of relatively
inconsistent and insignificant contributions of education to Ruff 2 and 7 performance, demonstrated that education is
a substantial demographic contributor when making normative comparisons for this test.
As regards the influence of intelligence levels on Ruff 2 and 7 performance, negligible to modest correlations with
FSIQ and PIQ have been reported (Ruff & Allen, 1996; Strauss et al., 2006). In the present study, we did not examine
the contribution of intelligence level to Ruff 2 and 7 performance in Greek adults for two reasons: First, there are no
available standardized tests of intelligence in Greece for adults at present.1 Second, we did not include intelligence
level in our evaluations and analyses of our data for practical reasons related to the availability of IQ scores in Greek
participants. If our data were found to be influenced by intelligence level, and thus stratified by this variable, this would
require that participants tested with the Ruff 2 and 7 would also have to complete an intelligence test to establish
Full Scale IQ, before the norms could be used adequately. In clinical outpatient settings, where most Greek adults
with neuropsychological impairments are assessed, intelligence testing, which is highly time consuming and difficult
to complete for certain patient groups, e.g., the elderly, the demented, people with sensory impairments etc., would
prohibit the use of norms stratified by intelligence.
Collectively, our data indicate that older participants with limited formal education, independent of gender, perform
worse than younger participants, with a higher level of formal education on Automatic Detection and Controlled Search
Speed. In addition, participants with high levels of education demonstrate better Automatic Detection Accuracy scores
compared to those with low levels of education. Therefore, a steady and clear decline in Speed scores is evident
with increased age and decreased education. At all ages and levels of education, more targets were identified in the
Automatic Detection than in the Controlled Search condition.
Having established the contribution of demographic characteristics to 2 and 7 performance, we then explored
test–retest reliability and practice effects of the test. In the literature, test–retest reliability has been noted as adequate
to high for the 2 and 7, with higher test–retest coefficients reported for Speed than for Accuracy scores (Ruff & Allen,
1996; Lemay et al., 2004). Our data demonstrated excellent test–retest reliability with high correlation coefficients
(.94–.98) for Speed scores and adequate to high coefficients (.73–.89) for Accuracy scores. This finding is consistent
with reliability data reported in the test manual (Ruff & Allen, 1996), and more recently by Lemay et al. (2004) as
regards Speed scores. Our reliability coefficients regarding Accuracy scores, however, were higher than those reported
either by Ruff and Allen (1996) or Lemay et al. (2004) (Table 3). Although our test–retest interval of 12–14 weeks
is relatively shorter than the standardization sample interval of 6 months (Ruff & Allen, 1996), our opinion is that
this is an adequate interval to obtain clinically useful test–retest data. An advantage of our data regarding test–retest
reliability is the stratification of participants into three age groups starting from young adulthood to older participants
over the age of 60, thereby providing important reliability data across the adult lifespan.
Our data regarding potential practice effects on the 2 and 7 test showed that participants’ performance generally
improved between the two test sessions. Younger adults demonstrated larger practice effects compared to older partic-
ipants. More specifically, younger adults in the 20–39-year old age group had a practice effect of about 11 raw-score
points on Speed scores, compared to older adults over the age of 60, who showed a practice effect of about 4 raw-score
points on Speed scores. Therefore, it appears that age significantly impacts the size of the practice effect on 2 and 7
Speed scores. Our findings are consistent with the preliminary data presented by Ruff et al. (1986), who demonstrated
an increase of approximately 10 raw-score points between sessions for younger adults, and further replicate the more
recently presented data of Lemay et al. (2004), who noted that Ruff 2 and 7 Speed scores were especially sensitive
to practice effects. We were unable to replicate the findings of Lemay et al. (2004), however, regarding decreased
test–retest gains between the second and third test sessions, as we only assessed our participants twice. Regarding
practice effects on the Accuracy scores, our data suggest low to moderate effects, a finding also supported by Ruff and

1 Research is currently being conducted at the Neuropsychological Laboratory of the Department of Neurology, University of Patras Medical

School, in order to obtain normative data for the Wechsler Abbreviated Scale of Intelligence (Wechsler, 1999), a particularly useful and relatively
brief measure of intelligence for clinical and research purposes (Messinis & Tsakona, 2006).
 L. Messinis et al. / Archives of Clinical Neuropsychology 22 (2007) 773–785 783

Allen (1996) in the test manual, and more recently by Lemay et al. (2004). Additionally, the present findings suggest
that younger adults demonstrate significant test–retest effects on Accuracy scores. This finding, however, will require
replication in a larger young adult sample with lower levels of education, as our recruited group had a relatively high
level of education (M = 15.05), as noted previously.
With respect to the test’s validity in discriminating specific patient groups with selective attention deficits from
healthy individuals, our data demonstrated significant differences in performance between a group of HIV seropositive
patients and healthy controls on Ruff 2 and 7 variables. More specifically, the HIV seropositive group achieved poorer
scores than the healthy individuals on the Automatic Detection Speed, Automatic Detection Accuracy and Controlled
Search Accuracy dimensions, but did not differ on Controlled Detection Speed. Findings of significantly lower Speed
scores in AIDS compared to AIDS-related complex patients who were receiving Zidovudine (AZT) treatment for
HIV infection have been reported in the HIV/AIDS literature (Schmitt et al., 1988). In the present study, Automatic
Detection Speed and Accuracy scores adequately discriminated between HIV seropositive patients in less advanced
stages of the disease process, as expressed by the relatively high CD4+ T lymphocyte counts of our HIV seropositive
group (CDC, 1992), and healthy, demographically matched individuals. Our findings suggest that certain Ruff 2 and 7
scores are sensitive to neurological impairment caused by less advanced HIV infection, possibly related to frontostriatal
neuropathology.
The second group of patients assessed in order to establish the discriminant validity of the test was a group of
detoxified heroine addicts who had remained abstinent for an average of 36 days, after having undergone an ultra
rapid opiate detoxification procedure and was receiving naltrexone hydrochloride maintenance therapy. This group
performed significantly worse than a demographically matched group of healthy individuals on Automatic Detection
Speed and Automatic Detection Accuracy scores. This result suggests that the 2 and 7 Automatic Speed and Accuracy
scores adequately discriminate performance of detoxified opiate addicts from matched healthy individuals. The above
findings should, however, be interpreted with caution, as the abstinence period of the former heroine addicts was
relatively short. It is possible that the performance of former heroine addicts might improve with larger abstinence
periods. A possible confound of these data may be the potential influence of naltrexone hydrochloride maintenance
therapy on test performance, although there are no reports in the literature that naltrexone may negatively impact
neurocognitive functioning. Other possible explanations for the finding of lower performance in the detoxified opiate
addicts include the direct toxic effects of a history of concomitant substance abuse, including adulterants, and/or the
interactions of multiple drug abuse (Darke, Sims, McDonald, & Wickes, 2000).
In evaluating the generalizability of the present results, several limiting factors need to be considered. First, the age
and education stratified subgroups utilized in the study were not balanced in size. This is usually the case, however, in
normative studies involving participants from a broad age range who were recruited from the community in a sample of
convenience. Indeed, if one could achieve random sampling from the community, one would expect certain population
trends to be reflected in the sample, i.e., a decrease in level of education as a function of increasing age. This is especially
true for the Greek population, as many elderly people educated 40–50 years ago have low levels of education, because
they either did not attend school, left school early or did not attend a university or other higher educational institution,
mainly for socioeconomic reasons (i.e., war, poverty). As a result, the sample sizes for certain subgroups are small (e.g.,
for elderly highly educated individuals and younger adults with limited education). Indeed, the absence of normative
data for young adult participants in the 17–39 age group, with 1–9 years of education is evident in our data. This caveat
could not be avoided as we were unable to recruit participants with very low levels of education in either urban center
in which we collected data, due mainly to formal schooling requirements in Greece, making a minimum of 9 years of
education compulsory. One possible solution to small subgroup sizes is the use of broader age categories to increase
the number of participants per subgroup. This strategy, however, may in turn cause problems related to the boundary
values of the subgroups. Second, the relatively broad age range of our stratified subgroups may be a limiting factor,
and this is especially true for the elderly participants. Elderly individuals typically show a more distinguishable pattern
of performance decline with advancing age, and it would have been preferable to have used narrower groupings, e.g.,
60–65, 66–69, 70–74, 75–80 years old, etc. Third, a lack of familiarity with neuropsychological assessment procedures,
which differ from traditional medical procedures to which elderly individuals in Greece have become accustomed,
may have also influenced our findings. Examiners were, however, well trained in the administration of the Ruff 2 and
7, and had previous experience with elderly research participants. Significant efforts were made in order to ensure
that these participants understood all administration procedures, therefore minimizing this possible limitation. A final
limitation concerns the risk of sampling bias associated with motivation to participate in this study. It would appear
784 L. Messinis et al. / Archives of Clinical Neuropsychology 22 (2007) 773–785

that healthy individuals willing to participate in the study are more motivated and possibly more curious about what
a neuropsychological examination involves. It is also worth noting, however, that Greek participants were not paid
for their participation in this study, therefore motivational issues related to the participants’ maximum output are
speculative.
Despite the potential limitations to the generalizability of the present normative data, the present study provides much
needed performance data on a brief, psychometrically sound and clinically useful measure of selective and sustained
attention on healthy adults and clinical groups specific to the Greek culture. The present findings serve as a reference
point for the neuropsychological assessment of selective and sustained attention in the Greek population across the
adult age range, with the exception of the older old. Further, it provides appropriate normative data, rather than having
to inappropriately rely on U.S.-based norms or normative data used for English-speaking or other populations.
Future research is desperately needed in order to provide normative data for the child and older old population
in Greece, as normative data are generally lacking, not only in Greece, but internationally. Additional investigations
to establish the relationship of the Ruff 2 and 7 Selective Attention Test to other measures of attention, e.g., Digit
Symbol Modalities Test and other verbal and non-verbal core neuropsychological measures is also important. Finally,
the diagnostic utility of the test warrants further exploration in clinical populations in Greece.

Acknowledgements

We would like to thank Dr. Dimitri Theodoroulea and the “Merimna Life Care Unit” in Athens, Greece for access
to their patients, Theodore Paxino; Katerina Perrotti, Maria Diakou, Eleni Koutsonakou and Areti Metsovitou for their
assistance with the data collection.

References

Allen, C. C., & Ruff, R. M. (1990). Self-Rating versus neuropsychological performance of moderate versus severe head-injured patients. Brain
Injury, 4, 7–17.
American Psychiatric Association. (2000). DSM-IV-TR: Diagnostic and statistical manual of mental disorders (4th ed., Text Revision). Washington,
DC: American Psychiatric Press.
Aretouli, E., & Kosmidis, M. H. (2006, July). Cultural differences on Wisconsin Card Sorting Test performance: What do neuropsychological tests
really measure? 26th International Congress on Applied Psychology, Athens.
Aretouli, E., & Kosmidis, M. H. (2007, May). Are cancellation tests culture-free? Paper accepted to the 9th European Conference on Psychological
Assessment & 2nd International Conference of the Psychological Society of Northern Greece.
Aretouli, E., & Kosmidis, M. H. (2007, May). Rey–Osterrieth Complex Figure Test: Greek norms and cultural and demographic influences. Paper
accepted to the 9th European Conference on Psychological Assessment & 2nd International Conference of the Psychological Society of Northern
Greece.
Argirokastritou, E., Samanda, T., & Messinis, L. (2005, December). Preliminary normative data for the Symbol Digit Modalities Test (SDMT) in
Greece. 10th Panhellenic Conference of Psychological Research, Ioannina, Greece.
Bate, A. J., Mathias, J. L., & Crawford, J. R. (2001). Performance on the Test of Everyday Attention and standard tests of attention following severe
traumatic brain injury. The Clinical Neuropsychologist, 15(3), 405–422.
Centers for Disease Control and Prevention. (1992). Revised classification system for HIV infection and expanded surveillance case definition for
AIDS among adolescents and adults. Morbidity and Mortality Weekly Report, 41, 1–18.
Cicerone, K. D., & Azulay, J. (2002). Diagnostic utility of attention measures in postconcussion syndrome. The Clinical Neuropsychologist, 16(3),
280–289.
Cohen, R. A., Malloy, P. F., & Jenkins, M. A. (1998). Disorders of attention. In P. J. Snyder & P. D. Nussbaum (Eds.), Clinical neuropsychology: A
pocket handbook for assessment (pp. 541–572). Washington, DC: American Psychological Association.
Darke, S., Sims, J., McDonald, S., & Wickes, W. (2000). Cognitive impairment among methadone maintenance patients. Addiction, 95, 68–95.
Folia, V., & Kosmidis, M. H. (2003). Assessment of memory skills in illiterates: Strategy differences or test artifacts? The Clinical Neuropsychologist,
17, 143–152.
Fountoulakis, K. N., Tsolaki, M., Chantzi, H., & Kazis, A. (2000). Mini Mental State Examination (MMSE): A validation study in Greece. American
Journal of Alzheimer’s Disease and Other Dementias, 15, 342–345.
Giannakou, M., & Kosmidis, M. H. (2006). Cultural appropriateness of the Hooper Visual Organization Test? Greek normative data. Journal of
Clinical and Experimental Neuropsychology, 28, 1023–1029.
Kerns, K. A., & Mateer, C. A. (1998). Walking and chewing gum: The impact of attentional capacity on everyday activities. In R. J. Sbordone & C.
Long (Eds.), Ecological validity of neuropsychological testing (pp. 148–169). Boca Raton, FL: St. Lucie.
Kosmidis, M. H., Vlahou, C. H., Panagiotaki, P., & Kiosseoglou, G. (2004). The verbal fluency task in the Greek population: Normative data and
clustering and switching strategies. Journal of the International Neuropsychological Society, 10, 164–172.
 L. Messinis et al. / Archives of Clinical Neuropsychology 22 (2007) 773–785 785

Lemay, S., Bedard, M. A., Rouleau, I., & Tremblay, P. L. G. (2004). Practice effect and test–retest reliability of attentional and executive tests in
middle-aged to elderly subjects. The Clinical Neuropsychologist, 18(2), 284–302.
Logan, G. D. (1988). Toward an instance theory of automatization. Psychological Review, 95, 492–527.
Logan, G. D., & Klapp, S. T. (1991). Automatizing alphabet arithmetic: Is extended practice necessary to produce automaticity? Journal of
Experimental Psychology: Learning, Memory, and Cognition, 17, 179–195.
Logan, G. D., & Stadler, M. A. (1991). Mechanism of performance improvement and consistent mapping memory search: Automaticity or strategy
search? Journal of Experimental Psychology: Learning, Memory, and Cognition, 17, 478–496.
Messinis, L., Lada, E., Famellou, P., Chrisoulaki, K., Konstantinos, K., & Papathanasopoulos, P. (2006, March). Normative data for the WCST-64
card edition in Greece. 20th Panhellenic Congress of Neurology, Larissa, Greece.
Messinis, L., & Tsakona, I. (2006). Wechsler Abbreviated Scale of Intelligence (WASI) (Greek translation and preliminary performance data).
Unpublished data, Neuropsychological Laboratory, Department of Neurology, University of Patras Medical School, Greece.
Messinis, L., Tsakona, I., Biris, A., Theodorouleas, D., Mentis, M., & Papathanasopoulos, P. (2006, November). Neuropsychological functions of
detoxified opiate addicts treated with an opiate antagonist. 1st Pan-Hellenic Congress of Scientists in Care of Patients with Chronic Diseases,
Larissa, Greece.
Messinis, L., Tsakona, I., Kollaras, P., Malefaki, S., & Papathanasopoulos, P. Neuropsychological deficits of HIV seropositive patients in different
stages of the disease process (in Greek). Manuscript in press.
Messinis, L., Tsakona, I., & Papathanasopoulos, P. (2006, July). Rey Auditory Verbal Learning Test (RAVLT): Normative data for the Greek adult
population. International Neuropsychological Society, Zurich, Switzerland.
Nolin, P., & Mathieu, F. (2001). L “importance de la sensibilite des measures neuropsychologiques dans l” identification des deficits chez des enfants
ayant subi un traumatisme craniocerebral leger. Revue de Neuropsychologie, 11(1), 23–38.
Ruff, R. M., & Allen, C. C. (1996). Ruff 2 and 7 Selective Attention Test professional manual. Odessa, FL: Psychological Assessment Resources,
Inc.
Ruff, R. M., Evans, R. W., & Light, R. H. (1986). Automatic detection versus controlled search: A paper and pencil approach. Perceptual and Motor
Skills, 62, 407–416.
Ruff, R. M., Neiman, H., Allen, C. C., Farrow, C. E., & Wylie, T. (1992). The Ruff 2 and 7 Selective Attention Test: A neuropsychological application.
Perceptual and Motor Skills, 75, 1311–1319.
Schmitt, F. A., Bigley, J. W., Mckinnis, R., Logue, P. E., Evans, R. W., Drucker, J. L., & the AZT Collaborative Working Group. (1988). Neuropsy-
chological outcome of Zidovudine (AZT) treatment of patients with AIDS and AIDS-related complex. New England Journal of Medicine, 319,
1573–1578.
Strauss, E., Sherman, Elisabeth M. S., & Spreen, O. (2006). A Compendium of Neuropsychological Tests: Administration, norms, and commentary
(3rd ed.). New York: Oxford University Press.
Vlahou, C. H., & Kosmidis, M. H. (2002). The Greek Trail Making Test: Preliminary normative data for clinical and research use. Psychology: The
Journal of the Hellenic Psychological Society, 9, 336–352 [in Greek].
Wechsler, D. (1999). Wechsler Abbreviated Scale of Intelligence (WASI): Manual, Harcourt assessment. New York: The Psychological Corporation.
Weiss, K. M. (1996). A simple clinical assessment of attention in schizophrenia. Psychiatry Research, 60, 147–154.