VISUAL RETENTION TEST
NO. _ _ __
Arthur l. Benton
-I
RECORD FORM NAME ___________________________________________________________ PLACE OF TESTING ________________________________
FIRST TESTING
ADMINISTRATION
FORM Design
EXAMINER ___________________________________
SECOND TESTING
DATE
Score (0 or 1)
FORM Number of Errors
Errors'
AGE _ _ _ ___ SEX _ _ __
Design
DATE ADMINISTRATION
Score (0 or 1)
Number of Errors
Errors·
I
I
II
II
III
III
IV
IV
V
V
VI
VI
o o
VII
VII
()
N M
o o
"-
I--
VIII
VIII
IX
IX
X
X
Number Correct Score
Number Correct Score
Error Score
'Use symbols; see Chapter 2 of manual.
w
o u o:J
«
Error Score
'Use symbols; see Chapter 2 of manual.
ERROR CATEGORIES:
ERROR CATEGORIES:
Omissions
Omissions
Distortions
Distortions
Perseverations
Perseverations
Rotations
Rotations
to to
Misplacements
Misplacements
'"<:tto
Size Errors
Size Errors
M
Left Errors
Left Errors
Right Errors
Right Errors
o
"
Q)
to 00
to
"to
to
to
REMARKS ____________________________________________________________________________________
INTERPRETATION ____________________________________________________________________________
Printed in the U.S.A.
Copyright 1955, © 1974 by The Psychological Corporation Copyright renewed 1983 by Arthur L. Benton All rights reserved.
75-133AS
9·027426
REVISED VISUAL RETENTION TEST Clinical and Experimental Applications
Arthur L. Benton Professor of Neurology and PsychologY1 University of Iowa
FOURTH EDITION
@ THE PSYCHOLOGICAL CORPORATION HARCOURT BRACE JOVANOVICH, INC.
08-027435
I
Copyright 1955, 1963, © 1974 by The Psychological Corporation
All rights reserved, including translation. No part of this manual, or of the test, recording forms, and norms associated with it may be reproduced in any form of printing or by any other means, electronic or mechanical, including, but not limited to, photocopying, audiovisual recording and transmission, and portrayal or duplication in any information storage and retrieval system, without permission in writing from the publisher. See Catalog for further information.
Printed in U.S.A.
8-027435
PREFACE The fourth edition of the manual for the Revised Visual Retention Test takes account of developments since 1963, the most important of which is perhaps the establishment of normative standards for Administration C (copying of the designs) for children. Chapter 5 reviews recent literature bearing on various clinical and experimental applications of the test not covered in other sections of the manual. ARTHUR
April 1974
111
L.
BENTON
TABLE OF CONTENTS Page
Preface List of Tables ....................................... List of Figures ...................................... Chapter 1. Administration ............................. Introduction ...................................... Administration of the Test . . . . . . . . . . . . . . . . . . . . . . .. . . . Administration A ................................ Administration B ................................ Administration C ................................. Administration D ................................
vii 1 1 1 1 2 2 2
Chapter 2. Scoring ...... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . The Two Scoring Systems ........................... Number ·of Correct Reproductions. . . . . . . . . . . . . . . . . . . Error Score . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Scoring Principles and Samples .......................
4 4 4 4 10
Chapter 3. Norms ................................... , Administration A .................................. , Adult Norms. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. Children's Norms ................................ Administration B . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. Administration C . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. Adult Norms ................................... , Children's Norms ................................ Administration D ..................................
42 42 43 44 45 46 46 47 50
Chapter 4. Diagnostic Interpretation ..................... Performance of Patients with Cerebral Lesions .......... , Qualitative Analysis of Performance ................... , Omission of a Peripheral Figure . . . . . . . . . . . . . . . . . . . .. Rotations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. Size Errors ..................................... Localization of Lesion .............................. Performance of Brain-Damaged Patients on Administration C ................................ Performance of Children ............................ Performance of Mental Defectives .. . . . . . . . . . . . . . . . . . .. Performance of Schizophrenic Patients ................. , Performance of Depressed Patients .................... Performance of Simulators .......................... , Performance in Old Age ............................ Performance under Administration D (Delayed Memory)
51 52 55 56 57 58 58
I
...........................
v
I
...........
,
..............
.
111
Vll
61 64 67 69 71 71 72 72
Page
Chapter 5. Review of Recent Literature .................. Normative Studies ................................ " Reliability and Comparability of Forms . . . . . . . . . . . . . . . .. Correlations with Other Tests. . . . . . . . . . . . . . . . . . . . . . . .. Validity and Clinical Application . . . . . . . . . . . . . . . . . . . . .. Experimental-Clinical Application ..................... Concluding Comments ..............................
74 74 77 78 79 82 85
References .........................................
88
VI
LIST OF TABLES Th~
1 2 3 4 5 6 7 8 9 10 11 12 13 14
~p
Norms for Administration A: Adults - Number Correct Scores. . . . . . . . . . . . . . . . .. Norms for Administration A: Adults - Error Scores . . . . . . . . . . . . . . . . . . . . . . . . . .. Norms for Administration A: Children - Number Correct Scores ................ Norms for Administration A: Children - Error Scores ................... . . . . .. Norms for Administration C: Adults - Error Scores .......................... Norms for Administration C: Children - Number Correct Scores. . . . . . . . . . . . . . . .. Norms for Administration C: Children - Error Scores ......................... Administration C: Superior Children - Number Correct Scores .... . . . .. Administration C: Superior Children - Error Scores . . . . . . . . . . . . . . . . .. Distributions of Deviation Scores, Derived from Number Correct Scores, for Patients with Brain Disease and for Control Patients ........................ " Distributions of Error Scores for Brain-Damaged Patients and for Control Patients ........................ " Distributions of Deviation Scores, Derived from Number Correct Scores, for Brain-Damaged Children and for Emotionally Disturbed Children ............ Mean Number Correct Scores for 504 Normal Subjects, by Age and Intelligence Level. . . . . . . . . . . . . . . . . . . .. Mean Error Scores for 545 Kindergarten Children. . . . . ..
44 44 45 45 47 48 48 49 49 53 62 66 75 76
LIST OF FIGURES Figure
1 2
Page
Types of errors made by R. C. in copying designs (Administration C) of Form C ................. " Examples of reproductions of Form C designs made by schizophrenic patients ........................
VlI
63 70
Chapter 1 ADMINISTRATION Introduction
The Revised Visual Retention Test is a clinical and research instrument designed to assess visual perception, visual memory, and visuoconstructive abilities. There are three alternate forms of the test (Forms C, D, and E). Each form consists of ten designs, with each design containing one or more figures. The time required for the administration of one form is about five minutes. The various modes of administration of the test are as follows: Administration A. - Each design is exposed for 10 seconds, followed by immediate reproduction from memory by the subject. Administration B. - Each design is exposed for 5 seconds, followed by immediate reproduction from memory by the subject. Administration C. - Each design is copied by the subject, with the design remaining in the subject's view. Administration D. - Each design is exposed for 10 seconds, followed by reproduction from memory by the subject after a delay of 15 seconds. Any of the three forms may be used in any mode of administration. Administration of the Test Administration A
The subject is given blank sheets of paper of the same size as the cards on which the designs are printed (5 ~ x 8 ~ inches), and a pencil with an eraser. He is told that he will be shown a card on which there are one or more figures, that he will study the card for 10 seconds, and that when the card is removed, he will draw what he has seen. Either a stopwatch or a watch with a second hand may be used for timing. The design book should be positioned at an angle 1
of about 60 degrees from the surface of the table to permit optimal viewing by the subject. (It should not be placed fiat on the table.) Occasionally, a subject will start to draw the first design before the 10 seconds have elapsed. He should be stopped and told to study the card for the full time of exposure. The examiner may make a comment such as, "I know this design is an easy one, but the others are harder, and I want you to get into the habit of looking at the card for the full 10 seconds." Each card is presented without comment, except that before introducing Design III (the first to include two major figures and a peripheral minor figure), the examiner should say, "Do not forget to draw everything you see." If the subject omits the peripheral minor figure in his reproduction of Design III, the examiner should make the same statement before introducing Design IV. The subject is permitted to make erasures or corrections. No spontaneous praise is offered, but reassurance may be given if the subject asks about the quality of his performance. Administration B
The procedure is essentially the same as for Administration A, except that the subject is told that he will have 5 seconds to study the card. Administration C
The subject is given blank sheets of paper of the same size as the cards on which the designs are printed (5 ~ x 8 112 inches), and a pencil with an eraser. He is told that he will be shown a card on which there are one or more-- figures, and that he is to copy the design, making a drawing which is as much like the original as possible. The card is left in the subject's view while he performs the task. If the subject asks specific questions (e.g., whether size is impor-
tant, whether lines must be perfectly straight), only the same general instruction about making the drawing as much like the original as possible is repeated and no more specific instructions are given. The general instruction should be repeated if it seems that the subject is not exerting optimal effort. If he takes an excessively long time in making a drawing, he should be encouraged to work a little faster. Erasures or corrections are permitted. No spontaneous praise is offered, but reassurance may be given if the subject asks about the quality of his performance. Administration D
The subject is told that he will be shown a card on which there are one or more figures, that he will study the card for 10 seconds, 2
that the card will then be removed, and that after an interval of 15 seconds he will draw what he has seen. Unlike the other modes of administration, the subject is not given blank sheets of paper and a pencil. Instead, the examiner gives him a single sheet of paper (SY2 x 8 1h inches) and a pencil with an eraser as the IS-second postexposure interval ends. Erasures or corrections are permitted. After the subject has finished drawing the design, both his drawing and the pencil are taken from him. Each card is presented without comment, except that before introducing Design III (the first to include two major figures and a peripheral minor figure), the examiner should say, "Do not forget t6 draw everything you see." If the subject omits the peripheral minor figure in his reproduction of Design III, the examiner should make the same statement before introducing Design IV~ No spontaneous praise is offered, but reassurance may be given if the subject asks about the quality of his performance. Sometimes a subject attempts to fill the IS-second waiting interval by starting a conversation with the examiner. When this happens, the examiner should tactfully terminate this by encouraging the subject to concentrate and to keep the design in mind. Soine subjects attempt to retain the memory of a design by sketching it with their fingers on the table top. This is permissible as long as no visual record is made by the finger-sketching.
3
Chapter 2
SCORING The Two Scoring Sy~tems
Scoring of the Visual Retention Test is objective and is accomplished on the basis of explicit principles. Interscorer agreement has been found to be extremely high (r = .95) with respect to total scores, and satisfactory (r = .75-.98) with respect to major categories of errors (Wahler, 1956). Two scoring systems are available for the evaluation of subjects' performances. One, Number of Correct Reproductions, provides a measure of general efficiency of performance; the other, Error Score, takes account of the specific types of errors made by the subject. Number of Correct Reproductions
Each design is judged on an all-or-none basis and given a score of 1 or O. Therefore, the range of possible scores for any single form of the test is from 0 to 10. The principles underlying the scoring of each design of Forms C, D, and E, together with samples of correct and incorrect reproductions, are presented on pages 12-41. The scoring standards are rather lenient because one is interested in the subject's capacity to retain a visual impression and not in his drawing ability. Thus, the size of the reproduction as a whole, as compared with the original design, is not considered in the scoring. However, within a specific design, the relative size of the figures (as compared with each other) is taken into account. Error Score
In any less-than-perfect performance on a design, one or more specific types of errors are necessarily made by the subject. The Error Score system of evaluation classifies errors by type, and provides for a total Error Score. This system, in addition to providing a measure of general efficiency of performance, facilitates analysis of the qualitative characteristics of a subject's performance. 4
The specific types of errors which may be made have been grouped into six major categories: omissions, distortions, perseverations, rotations, misplacements, and size errors. The complete scoring system is as follows: OMISSIONS (AND ADDITIONS) SYMBOL
DEFINITION
M
Omission of the single major figure of Design I or II; scored when the figure is completely omitted or when the subject draws only one or two lines which are not a recognizable attempt to reproduce it. Omission of a right major figure (i.e., in the subject's right visual field); scored when the figure is completely omitted, space being provided for it in the reproduction, or when the subject draws only one or two lines which are not a recognizable attempt to reproduce it. Omission of a right major figure; scored when the figure is completely omitted, no space being provided for it in the reproduction. Omission of a left major figure; scored In the same manner as MR. Omission of a left major figure; scored m the same manner as MR! Omission of a right peripheral figure. Omission of a left peripheral figure. Drawing of an additional figure not present in the original design and not scorable as a distortion (multiple reproduction) or a perseveration.
MR
MR!
ML ML! PR
PL Add
SYMBOL
DEFINITION
SM
Inaccurate reproduction of the single major figure of Design I or II by simple substitution (e.g., square for oblique parallelogram; pentagon for hexagon). Inaccurate reproduction of a right major figure by simple substitution (e.g., circle for square; pentagon for triangle).
SMR
5
SYMBOL
DEFINITION
SML
Inaccurate reproduction of a left major figure by simple substitution; scored in the same manner as SMR. Inaccurate reproduction of a right peripheral figure by simple substitution. Inaccurate reproduction of a left peripheral figure by simple substitution. Inaccurate reproduction of the single major figure of Design I or II in some manner other than simple substitution or rotation (e.g., omission, addition, or misplacement of an" internal detail of the figure, fragmentation of the figure, multiple reproduction of the figure). Inaccurate reproduction of a right major figure in some manner other than simple substitution or rotation; scored in the same manner as 1M. Inaccurate reproduction of a left major figure in some manner other than simple substitution or rotation; scored in the same manner as 1M. Inaccurate reproduction limited to the central overlapping area of the major figures in Design III of Fonn C or D. Inaccurate reproduction of a right peripheral figure in some manner other than simple substitution or rotation (e.g., fragmentation or multiple reproduction of the figure). Inaccurate reproduction of a left peripheral figure in some manner other than simple substitution or rotation.
SPR SPL 1M
IMR
IML
IMC
IPR
IPL
PERSEVERATIONS
A perseveration is a simple substitutive or additive response consisting of the reproduction of a figure present in the immediately preceding design. If the perseverated figure is drawn on consecutive succeeding reproductions, it is scored as a perseveration each time it is drawn. (For example, if a subject draws a circle for the left major figure of Design V of Fonn .C, this is scored as a perseveration since the circle appears as the left major figure of Design IV. If the subject also draws circles for the right major figures of Designs VI and VII, they are
6
also scored as perseverations since they appear to relate back to the presentation of Design IV.) Perseveration is also scored when a peripheral or major figure is drawn so that it is identical with a major figure in the same design. When perseveration is scored, no other type of substitutive or' additive'errot""''is' 'y/ score(rfor~~ifie~'saffie'~ngute:' Noris'a -rotatiohal' eirof'sco'redIf ,/I~ Hie-perseverate
PerM PerMR PerML PerPR PerPL
DEFINITION
Perseveration in Design I. Perseveration figure. Perseveration Perseveration figure. Perseveration figure.
on Design II of the figure presented in the drawing of a right major in the drawing of a left major figure. in the drawing of a right peripheral in the drawing of a left peripheral
ROTATIONS
. . ..s.
s....'~ .)"'/~
0'\, ~~a /~;-l,""'.
SYMBOL
DEFINITION
180M
A plane rotation of approximately 180 degrees of the single major figure of Design I or II. A plane rotation of approximately 90 degrees of the single major figure of Design I or II. A plane rotation of 25 to 65 degrees of the single major figure of Design I or II (but see StM, below). A plane rotation of approximately 45 degrees of the single major figure of Design II, when a figure resting on an angle is drawn as resting on a side. l80-degree plane rotation of a right major figure. 180-degree plane rotation of a left major figure. 90-degree plane rotation of a right major, figure. 90-degree plane rotation of a left major figure. 45-degree plane rotation of a right major figure (but see StMR, below). 45-degree plane rotation of a left major figure (but see StML, below).
90M 45M
StM
180MR -----' l80ML 90MR 90ML 45MR 45ML
7
SYMBOL
DEFINITION
StMR
45 -degree plane rotation of a right major figure, when a figure resting on an angle is drawn as resting on a side. 45-degree plane rotation of a left major figure, when a figure resting on an angle is drawn as resting on a side. ISO-degree plane rotation of a right peripheral figure. 180-degree plane rotation of a left peripheral figure. 90-degree plane rotation of a right peripheral figure. 90-degree plane rotation of a left peripheral figure. 45-degree plane rotation of a right peripheral figure. 45-degree plane rotation of a left peripheral figure. 180-degree rotation in space (mirror-imaging) of an entire design. ISO-degree rotation in space (mirror-imaging) of a right major figure. ISO-degree rotation in space (mirror-imaging) of a left major figure. Rotation of a right major figure scorable as either a 180-degree plane rotation or a 180-degree rotation in space (mirror-imaging). Rotation of a left major figure scorable as either a 180-degree plane rotation or a ISO-degree rotation in space (mirror-imaging). Rotation of a right major figure scorable as either a 90-degree plane rotation or a 180-degree rotation in space (mirror-imaging). Rotation of a left major figure scorable as either a 90-degree plane rotation or al80-degree rotation in space (mirror-imaging). Rotation of the horizontal axis through major figures; scored when one major figure does not extend across the midline of the other.
StML
ISOPR ISOPL 90PR 90PL 45PR 45PL Mir MirMR MirML ISOMR(Mir)
ISOML(Mir)
90MR(Mir)
90ML(Mir)
VerM
8
MISPLACEMENTS
Misplacements are various types of distortions of the spatial relationship between the figures of a design. Only one misplace~~ ment error is scored for any single design. SYMBOL
DEFINITION
Rev
Left-right reversal of the relative positions of the two major figures. Reproduction of overlapping major figures as nonoverlapping. Reproduction of noncontiguou$ figures as contiguous or overlapping. Reproduction of overlapping major figures as overlapping at the wrong juncture. Misplacement of a right peripheral figure so that it is to the left of, between, within, above, or below the major figures. Misplacement of a left peripheral figure so that it is to the right of, between, within, above, or below the major figures. Displacement of a right peripheral figure upward. Displacement of a left peripheral figure upward. Displacement of a right peripheral figure downward. Displacement of a left peripheral figure downward.
NOv Ov WOv MisPR
MisPL
UPR UPL DPR DPL
SIZE ERRORS SYMBOL
DEFINITION
SzMR
Distortion in the relative size of the right major figure; scored when the height of the right major figure is less than % the height of the left major figure, both figures being measured at the point of maximal height. Distortion in the relative size of the left major figure; scored in the same manner as SzMR. Distortion in the relative size of the right peripheral figure; scored when the height of the peripheral figure is greater than % the height of the
SzML SzPR
9
SYMBOL
SzPL
DEFINITION
larger of the two major figures, all figures being measured at the point of maximal height. Distortion in the relative size of the left peripheral figure; scored in the same manner as SzPR.
Thus, the six major scoring categories contain a total of 64 specific errors. It will be noted that the division of errors as they apply to right, left, and central figures more than doubles the number of specific errors. Actually, there are 27 fundamental error-types. The principles of scoring and the sample reproductions on pages 12-41 may be used as a guide when scoring by the Error Score system. For each sample of an incorrect reproduction, the specific errors are indicated directly under the faulty drawing. An incorrect reproduction may include as many as 4 or 5 specific errors. Theoreti~ cally, the possible range of total Error Scores for a single form of the test is very wide. In practice, however, one finds the upper limit to be about 24 errors. At first glance, it may seem that the Error Score system is in~ ordinately detailed and time-consuming, but this has not proved to be the case. Examiners with relatively little scoring experience can accurately score a record containing a fair number of errors in about five minutes. Scoring, recording, and interpretation are facilitated by the use of the Visual Retention Test Record Form. On this sheet, the subject's performance is summarized not only in terms of the total number of errors and the number of errors in each of the six major categories, but also in terms of the total number of "right" (e.g., MR, DPR) and "Jeft" (e.g., PL, SPL) errors which have been made. Scoring Principles and Samples .
The underlying scoring principles for each design, followed by samples of correct and incorrect reproductions (with the specific errors listed under each faulty design), are presented on pages 12-41. Since the scoring is based on explicitly stated criteria, there is usually no question as to whether a reproduction is correct or not. Occasional difficulties that arise in evaluating such aspects as size distortion, or the location of a peripheral figure, can often be resolved by making accurate measurements. In using the Error Score system, one sometimes encounters an 10
incorrect response which can be scored in more than one way. The following examples illustrate this situation: a. When an incorrect placement of an internal detail can be scored either as a rotation or as a distortion, in the interest of consistency, the convention of scoring these errors as rotations has been adopted. Of course, the response must clearly satisfy the criterion of a rotational error that further rotation of the figure would result in a correct reproduction. b. When a response can be scored either as a plane rotation or as a rotation in space (mirror-imaging), the scoring system provides specific symbols for this type of reproduction (e.g., 180MR[Mir], 90ML[MirJ). The specificity of this designation will permit the examiner who is particularly Interested in mirrorimage reproduction to take account of these responses. Other aspects of the Error Score system which warrant emphasis are the following: c. Only one misplacement error is scored for any single figure (e.g., if a lower right peripheral figure is reproduced in the upper left corner, it is scored as MisPR, without account being taken of its upward displacement). d. When the reproduction of a figure is scored as a perseveration, a misplacement or size error can also be scored, if warranted, but a substitutive, additive, or rotational error should not be scored for the figure. e. Difficulty in deciding whether a peripheral figure is too high or too low in relation to the major figures may be encountered when the major figures themselves are drawn in different sizes, on different levels, or on an axis which is not parallel to the edges of the paper. Judgment of the pexiP-h_eraL.fig!l--DL-~!t9"yld be based __Qn..lines~para1lel to the edges .Qf th£ ]!aper (i.e., any rotation in the orientation of the major figures is ignored). In establishing the limits for the major figures, that figure which makes scoring more liberal is taken as the criterion. Thus, if a subject draws the two major figures in different sizes, or on different levels, the peripheral figure might be displaced with respect to one but not the other. In such a case, a displacement error would not be scored.
11
FORM C DESIGN I
Any parallelogram which is not a square, or which the subject indicates is not a square, is considered correct. The figure should rest on a side and not on a corner. The oblique lines should be inclined in the same direction as in the model.
CORRECT
INCORRECT
Subject called this "a square" (SM).
o Figure should rest on side (45M).
o Figure should rest on side (45M).
Subject indicated this was not a square.
12
FORM C
o
DESIGN II
The figure must be a hexagon with one side serving as the base. The sides need not be equal.
CORRECT
INCORRECT
Figure should rest on side (90M).
Figure not a hexagon (SM).
Figure not a hexagon (SM).
13
FORM C
D
DESIGN III
The circles must overlap. The small square must rest on a side, and be drawn so that at least a part of it lies in the area defined by the upper and lower limits of the major figures.
CORRECT
INCORRECT
CD
o
Il
Circles do not overlap (NOv).
Q)
a
Peripheral figure omitted (PR).
a
a
CD
Peripheral figure misplaced (MisPR).
14
FORM C
o
DESIGN IV
The' triangle must rest on a side and must not be a right triangle. The small square must rest on a side, and be drawn so that at least a part of it lies in the area defined by the upper and lower limits of the major figures.
CORRECT
CI
INCORRECT
C1
O~
OLJ
Right major figure is right triangle (SMR).
Cl
Q6
()6
Peripheral figure omitted (PL).
tI
O~ Right major figure too small (SzMR).
15
FORM C DESIGN V
o
The triangle must rest on a side and must not be a right triangle. The small circle must be drawn so that at least a part of it lies in the area defined by the midline and upper limit of the major figures.
CORRECT
INCORRECT
Right major figure incorrect (SMR).
Peripheral figure too low and too large (DPL; SzPL).
o
o
Left major figure inverted (180ML).
16
o
FORM C DESIGN VI
There must be a space between the major figures. The lines within each figure need not extend to the center of the figure. The small circle must be drawn so that at least a part of it lies in the area defined by the midline and upper limit of the major figures.
CORRECT
INCORRECT
[55]
0
QbJ
o
Left major figure rotated (90ML).
[3bJ
C9bJ
0
o
Peripheral figure too low (DPR).
,
~o -
o
0
.J
Left major figure distorted (internal detail drawn incorrectly); right major figure rotated (lML; 180MR).
17
FORM C
v<1>
DESIGN VII
The hypotenuse of the large right triangle must be drawn in the same general direction as in the model. The large square must rest on a corner. The small triangle must rest on a side, and be drawn so that at least a part of it lies in the area defined by the midline and lower limit of the major figures. CORRECT
INCORRECT
o Perseverative reproduction of peripheral figure from Design VI (PerPR).
A Right major figure should rest on angle (StMR).
o
Left major figure rotated: peripheral figure incorrect and too high (45ML; SPR; UPR).
18
FORM C
GO
DESIGN VIII
The curved line in the left square must end at, or very near to, the upper corners of the square. The small triangle must rest on a side, and be drawn so that at least a part of it lies in the area defined by the midline and upper limit of the major figures.
CORRECT
INCORRECT
BO Peripheral figure too low (DPR).
B Right major figure omitted; peripheral figure inverted (MR; 180PR).
so
EJD
o
Peripheral figure incorrect (SPR).
19
D
FORM C DESIGN IX
DJLJ
The curved line in the large square must end at, or very near to, the left corners of the square. The left side of the right major figure must be inclined in the same direction as in the model, and the right side must approximate the vertical position. The small square must rest on a side, and be drawn so that at least a part of it lies in the area defined by the midline and upper limit of the major figures. CORRECT
INCORRECT
[JD Perseverative reproduction of right major figure (same figure was drawn in subject's reproduction of Design VIII and relates back to left major figure of Design VII) (PerMR).
o
o [ff 0 Left major figure rotated; perseverative reproduction of right major figure from Design VIII (180ML [Mir]; PerMR).
o
a
(J]LJ
illL7
Left major figure distorted (internal detail drawn incorrectly); right major figure incorrect (I M L; SMR).
20
FORM C DESIGN X
o The large square must rest on a corner, and the line drawn through it must follow the direction in the model. The diagonal line in the right major figure must originate at the left corner of the figure and follow the direction in the model. The small circle must be drawn so that at least a part of it lies in the area defined by the midline and lower limit of the major figures. CORRECT
v
INCORRECT
0
Left major figure rotated [Mir] ),
~u
(90ML-
n
'0
Perseverative reproduction' of right major figure and peripheral figure from Design IX (PerMR; PerPR).
\$>0
0 Both major figures distorted (internal details drawn incorrectly) (IML; IMR).
21
FORM D DESIGN I
Any rectangle, the entire upper side of which serves as the base of a triangle, is considered correct. Neither side of the triangle may form a right angle where it meets the upper side of the rectangle.
CORRECT
INCORRECT
Lower part of figure not a rectangle (SM).
Entire upper side of rectangle does not serve as base of triangle (SM).
Internal detail drawn incorredly (1M).
22
FORM D
o
DESIGN II
The figure must be a hexagon which rests on a corner. The sides need not be equal.
CORRECT
INCORRECT
Figure not a hexagon (SM).
Figure not a hexagon (SM).
Figure rotated (StM).
23
FORM D
o
DESIGN III
The two squares must rest on corners, and overlap at the same junction as in the model. The small circle must be drawn so that at least a part of it lies in the area defined by the upper and lower limits of the major figures.
CORRECT
INCORRECT
o
o
Rotation of horizontal axis through major figures (VerM).
o
o
Right major figure incorrect (SMR).
o
Peripheral figure misplaced (MisPL).
24
FORMD DESIGN IV
D The triangle must rest on a corner. The small square must rest on a side, and be drawn so that at least a part of it lies in the area defined by the midline and lower limit of the major figures.
CORRECT
CDv
INCORRECT
D Right major figure inverted (180MR).
(]Jv
o
JJ
Perseverative reproduction of periph· eral figure from Design III (PerPR).
CD
D
\7
D
Left major figure rotated; peripheral figure too high (90ML; UPR).
25
FORM D
vB
DESIGN V
The small triangle must rest on a side, and be drawn so that at least a part of it lies in the area defined by the midline and lower limit of the major figures.
CORRECT
A
INCORRECT
VB
UB
Peripheral figure inverted (180PL),
6-
08 Reversal of relative positions of two major figures (Rev),
~
UB Incorrect reproduction of internal de· tail of right major figure (lMR) ,
26
FORM D DESIGN VI
Me
o
The diagonal lines in the large square must originate near the center of the base and end at, or very near to, the upper corners. The small circle must be drawn so that at least a part of it lies in the area defined by the upper and lower limits of the major figures.
INCORRECT
CORRECT
Me
Me
o
Incorrect reproduction of internal detail of left major figure; perseverative reproduction of peripheral figure from Design V (lML; PerPR).
c.
o Incorrect reproduction of internal detail of left major figure; perseverative reproduction of peripheral figure from right major figure (lML; PerPR).
!J Left major figure rotated (90ML).
27
FORM D DESIGN VII
o The diagonal line in the square must not extend more than two-thirds of the distance to the opposite corner. The small square must rest on a side, and be drawn so that at least a part of it lies in the area defined by the midline and lower limit of the major figures.
CORRECT
au
INCORRECT
lJ
o Perseverative reproduction of peripheral figure from Design VI (PerPR).
[JV
0
D Right major figure incorrect; peripheral figure too low (SMR; DPR).
~~
o rI Rotation of horizontal axis. through major figures; peripheral figure too high (VerM; UPR).
28
FORM D DESIGN VIII
D
The diagonal line in the left square must be curved, and that in the right square must be straight. Both lines must follow the direction indicated in the model and end at, or very near to, the corners of the squares. The small square must rest on a side, and be drawn so that at least a part of it lies in the area defined by the upper and lower limits of the major figures. CORRECT
GtsJ
INCORRECT
~
\)
8
0
Incorrect reproduction of internal details of both major figures (IML; IMR).
CS1~
Cl
.c
{SJ 0
Peripheral figure incorrect and too low (SPR; DPR).
[jE;J
~ \2j
0
IJ
Right major figure rotated (90MR[MirJ).
29
FORM D DESIGN IX
o
IUIJ
The small circle must be drawn so that at least a part of it lies in the area defined by the midline and lower limit of the major figures.
INCORRECT
CORRECT
0
ru] Right major figure rotated (180MR[MirJ).
0
rv] Fragmentation - of left major figure (IML).
1)
o Ln]
ruB
Mirror-image rotation of left major figure (MirML).
30
FORMD
80
DESIGN X
o
A horizontal line must be drawn through the semicircle. The square must rest on a corner. The small circle must be drawn so that at least a part of it lies in the area defined by the upper and lower limits of the major figures.
INCORRECT
CORRECT
8<)
eo
o
Fragmentation of left major figure (IML).
0<)
o
Omission of internal detail in left major figure (IML).
o Omission of internal detail in left major figure; addition of internal detail in right major figure; omission of peripheral figure (lML; IMR; PR).
31
FORM E DESIGN I
The figure must be a truncated triangle as in the model. The angles formed by the top side and the lateral sides must be greater than right angles.
CORRECT
I
INCORRECT
...
0 (SM)
....
Q
/
(45M)
t:
~-
B
l
(1M)
32
FORM E
o
DESIGN II
The figure must be a pentagon which rests on a corner. The sides need not be equal. The angles formed by the top side and the lateral sides must be greater than right angles.
CORRECT
INCORRECT
(180M)
(SM)
(SM)
33
FORME
DD
DESIGN III
There must be a space between the two squares. The small triangle must rest on a side, and be drawn so that at least a part of it lies in the area defined by the midline and upper limit of the major figures.
INCORRECT
CORRECT
v
0
a
(180 PL; UPL)
()[J]
600
-
(SPL; Ov)
A
0 0 (MisPL)
34
FORM E DESIGN IV
o
vD
The triangle must rest on a corner. The small circle must be drawn so that at least a part of it lies in the area defined by the midline and lower limit of the rna jor figures.
CORRECT
0
INCO~RECT
0
\70
\70 (UPL)
(:)
90
0
60 (180ML)
()
'70
tlO
(PerPL; MisPL)
35
.0
FORME DESIGN V
The lines in each circle must form a recognizable angle, be correctly placed, and enclose one-sixth to one-third of the area of the circle. The small triangle must rest on a side, and be drawn so that at least a part of it lies in the area defined by the midline and lower limit of the major figures.
CORRECT
INCORRECT
(DPL)
o
(PerPL; IML; IMR)
(UPL; Ov)
36
FORME
D
DESIGN VI
The small triangle within the square must rest on a side. The large triangle must rest on a side. The small square must rest on a side, and be drawn so that at least a part of it lies in the area defined by the midline and upper limit of the major figures.
CORRECT
INCORRECT
0
08 (SPL; SML)
0
6 8 (IMR)
0
~ (IMR)
37
B
FORM E DESIGN VII
The diagonal lines in the large square must originate near the center of the left side and must end at, or very near to, the right corners.
CORRECT
INCORRECT L
}S:J
r2~
rt:i'
(180MUMir] )
(a ' " ) gJ
r2
rD""l (IML; Add)
~
g(
...
o~
~
(IMR)
38
0
FORME
o
DESIGN VIII
The square must rest on a corner. The small triangle must rest on a side, and be drawn so that at least a part of it lies in the area defined by the midline and lower limit of the major figures.
CORRECT
cO
INCORRECT
c
A
<><> (PerPR)
-
0
C
0
~
I! (StMR)
(
<)
~
L:;,.
... <>
(180MUMirJ)
39
FORM E
D
DESIGN IX
The reproduction of the right major figure must include the same essential details as in the model. The small square must rest on a side, and be drawn so that at least a part of it lies in the area defined by the midline and upper limit of the major figures.
CORRECT
INCORRECT
v
c
alA) (PerPL; UPL; SMR)
D
Otvv (SMR)
Reproduction of peripheral figure not quite large enough to warrant scoring as size error.
(PerPL; PerML; SzML)
40
FORM E DESIGN X
D The triangle must rest on a corner, and inc1ude a vertical line drawn through the middle. The lines in the circle must form a recognizable angle, be correctly placed, and enclose one-sixth to one-third of the area of the circle. The small square must rest on a side, and be drawn so that at least a part of it lies in the area defined by the midline and lower limit of the major figures. INCORRECT
CORRECT
0
\V8 (UPL)
IJ
'VV f) ,
(lML)
[J
V(]) (lML; IMR)
41
Chapter 3
NORMS The normative data for the Visual Retention Test apply to all three forms (C, D, and E) of the test. For purposes of clinical or educational interpretation, the three forms may be considered to have equivalent levels of difficulty, even though systematic study has indicated that, under Administration A (reproduction from memory after exposure for 10 seconds), Form C is slightly easier than Forms D and E (see pages 77-78 for further discussion of comparability of forms). The performance of normal subjects on Administration A of the Visual Retention Test correlates highly with intelligence level, the obtained coefficients between scores on the test and scores on standard intelligence scales being approximately. 70. There is also a significant relationship between Visual Retention Test perfonnance and chronological age. Performance level on Administration A shows a progressive rise from the age of 8 years until a plateau is reached at the 14- to IS-year level. This plateau is maintained from the late adolescent years through the thirties. A decline in efficiency of performance occurs in the forties and this decline is progressive, continuing through the successive decades of life. Normative observations indicate a drop of about 1 point in the mean Number of Correct Reproductions for persons aged 45-54 years, and a drop of about 2 points for persons aged 55-64 years, as compared with younger age groups (Benton & Fogel, 1961). The standardization data show no important differences attributable to the factor of sex. These findings of significant relationships between Visual Retention Test performance and general intelligence level, and between test performance and chronological age, make it evident that correct clinical interpretation can be made only within this framework of the age and premorbid intellectual endowment of a patient. The normative data provide the basis for such an interpretation. Administration A
The normative data for Administration A are based on the performance of over 600 subjects, with the following restrictions im42
posed on their selection: (a) no evidence or history of psychosis; (b) with the exception of mentally defective subjects, no evidence of cerebral injury or disease; and (c) no serious physical depletion as a consequence of somatic disease. A majority of the adult subjects were patients in various inpatient and outpatient services of hospitals in Iowa City and Des Moines. A majority of the children were tested at schools in Iowa City, Ottumwa, and West Branch, Iowa. Most of the mentally defective subjects were patients at the Woodward (Iowa) State Hospital and School. Adult Norms
Table 1 presents adult norms for the Number of Correct Reproductions (hereafter called the "Number Correct Score") for Administration A (1 O-second exposure with immediate reproduction). The typical performance levels of subjects of different age groups and inteIIigence are given. Interpretation of a subject's performance should be made on the basis of an expected score appropriate for his age and his assumed original or premorbid intellectual endowment, this judgment having been derived from a consideration of his educational and occupational background, his socioeconomic status, and possibly his performance on other tests. The table is read as follows: For a 50-year:"0Id subject whose premorbid IQ is estimated as superior (i.e., 110 or more), the expected Number Correct Score is 8. His obtained score may be compared with this score. An obtained score which is 2 points below the expected score may be considered to raise the question of acquired impairment of cognitive function. An obtained score which is 3 points below the expected score suggests such impairment. An obtained score which is 4 or more points below the expected score is a strong indication of such impairment. Table 2 presents adult norms for the Error Score for Administration A. As with the Number Correct Score, interpretation of a subject's performance is made on the basis of an expected score appropriate for his age and his assumed original or premorbid intellectual endowment. An obtained score which is 3 points above the expected score may be considered to raise the question of acquired impairment of cognitive function. An obtained score which is 4 points above the expected score suggests such impairment. An obtained score which is 5 or more points above the expected score is a strong indication of such impairment. .
43
Table 1 Norms for Administration A: Adults Expected Number Correct Scores, by Estimated Pre morbid IQ and Age Expected N umber Correct Score, by Age Estimated Pre morbid IQ
15·44
45·54
55·64
110 and above (Superior) 95~109 (Average) 80-94 (Low Average) 70-79 (Borderline) 60-69 (Defective) 59 and below (Very Defective)
9 8
8
7
7
7
6 5 4 3
6 5 4 3 2
6 5 4
Table 2 Norms for Administration A: Adults Expected Error Scores, by Estimated Premorbid IQ an_d Age Expected Error Score, by Age Estimated Premorbid IQ
15·39
40·54
110 and above (Superior) 105-109 (High Average) 95-104 (Average) . 90-94 (Low Average) 80-89 (Dull Average) 70-79 (Borderline.) 60-69 (Defective) 59 and below (Very Defective)
1 2 3 4 5 6 7 8
2 3 4 5 6 7
8 9
55-59
60·64
3
4
4
5 6 7 8 9 10 11
5 6 7 8 9 10
Children's Norms
Table 3 presents norms for children with resp~ct to the Number Correct Score for Administration A. The expected performance levels of children of different ages and intelligence are given. Interpretation is based on a comparison of observed and expected performance. An obtained score which is 2 points below the expected score may be considered to raise the question of a specific disability in visual memory or visuomotor function. An obtained score which is 3 or more points below the expected score may be considered to suggest such a disability. Table 4 presents norms for children with respect to the Error Score for Administration A. An obtained score which is 3 points above the expected score may be considered to raise the question
44
Table 3 Norms for Administration A: Children Expected Number Correct Scores, by Estimated IQ and Age
Estimated IQ
105 and above (High Average and Superior) 95-104 (Average) 80-94 (Low Average) 70-79 (Borderline) 69 and below (Defective)
Expected Number Correct Score, by Age 9 8 10 11 12 13·14
4 3 2 1 0
5 4 3 2 1
6 5 4 3 2
7 6 5 4 " 3
8 7 6 5 4
8 7 7 6 5
Table 4 Norms for Administration A: Children Expected Error Scores, by Estimated IQ and Age
Estimated IQ
105 and above (High Average and Superior) 95-104 (Average) 80-94 (Low Average) 70-79 (Borderline) 69 and below (Defective)
8
Expected Error Score, by Age 12 13-14 9 10 11
7-8 6 5 4 8-9 6 5 10-11 9-10 7-8 7-8 6 12-13 11-12 9 13 10-11 9 7-8 14 14 12 10 9 15
3 4 5 6-7 8
of a specific disability. An obtained score which is 4 or more points above the expected score may be considered to suggest such a disability. Where the table gives two scores for a particular age and estimated 1Q, compare the child's obtained score with the higher value. . The diagnostic significance of children's performance is discussed in Chapter 4 (see especially pages 64-67). Administration B
Data for Administration B (5-second exposure with immediate reproduction) were derived from the performance of 103 medical patients between 16 and 60 years of age and with no history or evidence of brain disease. Their reproductions were evaluated on the basis of the usual criteria, and Number Correct Scores were obtained. Each Number Correct Score was then compared with the score that 45
would be expected for Administration A (1 O-second exposure with immediate reproduction) in the light of the subject's age and estimated IQ, and a deviation score was computed for each subject. The mean deviation score was found to be -1.1. Both the median and modal deviation scores were -1. Thus, under the condition of reduced exposure time, it appeared that performance level, as defined by the number of designs correctly reproduced, was approximately 1 point below performance level for the 10-second exposure. A further comparison was made of the performance of the 76 patients who were under 50 years of age and the 27 patients who were between 50 and 60 years of age. The mean deviation score was -1.2 for the younger subgroup and -.8 for the older subgroup. Median and modal deviation scores were -1 for both subgroups. Von Kerekjarto (1961) made a direct comparison of the performance of 20 normal subjects on Administrations A and B, and found mean Number Correct Scores of 8.5 for Administration A and 7.6 for Administration B. It is evident that the obtained difference of .9 is in essential agreement with the study of 103 subjects described above. On the basis of these findings, it seems justified to conclude that a subtraction of 1 point from each expected Number Correct Score in Table 1 (norms for adults on Administration A) will provide satisfactory norms for Administration B. Administration C Adult Norms
Data for Administration C (copying the designs, with the designs remaining in the subject's view) were derived from the performance of 200 medical patients with no history or evidence of cerebral disease. These patients constituted the control group in studies of brain-damaged patients (Benton, 1962, 1972) described on pages 61-64. Their reproductions were evaluated on the basis of the usual criteria. The distribution of Error Scores in this control group is shown in Table lIon page 62. It will be noted that almost half of the group achieved perfect scores, and that 88 percent made 2 errors or less. Four patients (2 percent) made 5 errors. One of these was a 59-year-old woman with a sixth-grade education and a WAIS Verbal IQ of 77; her poor copying performance probably reflected long-standing mental subnormality. However, the other 3 patients were of average or high-average intelligence and had completed 9 to 12 years of schooling. Table 5 presents normative standards for adult performance on Administration C, based on this group of 200 pa46
Table 5 Norms for Administration C: Adults Interpretation of Error Scores Error Score on Standard lO·Design Version
Error Score on Abbreviated a·Design Version
0-2 3
0-1 2 3
4 5 6 or more
4 5 or more
Interpretation
Average Low Average Borderline Defective Grossly Defective
tients (see the column headed "Error Score on Standard 10-Design Version") . Table 5 also presents norms for an abbreviated eight-design version of Administration C, based on the performance of 100 control patients. , The possibility that the administration could be shortened without loss of diagnostic value was first explored using a sample of 50 patients (44 brain-damaged and 6 control) who had made 4 or more errors on the full ten-design test (Benton, 1972). Error Scores on five abbreviated versions (ranging from the first five designs to the first nine designs) were computed for each patient. Part-whole correlation coefficients between scores on each version and scores on the full test were then determined. It was found that the correlation between scores on the first eight designs and scores on the full test was .97, and that utilization of an eight-design test resulted in no diagnostic misclassifications. Scores on even shorter versions also correlated highly with scores on the full test, but did result in some misclassifications. Thus, it did not seem possible to reduce the length of the test to any substantial degree without some sacrifice in accuracy of interpretation. It appears that the eight-design version can be safely used, b,ut it saves no more than one minute of administration time. However, in some situations even this minimal reduction in time is welcome. Particularly where the subject is clearly performing quite well or quite badly, the examiner can feel free to terminate the test after presentation of the eighth design. (The abbreviated version of the test may be used only with Administration C.) Children's Norms
Children's norms for Administration C were derived from the performance of 236 children aged 6 years 6 months to 13 years 5 months, and enrolled in various public schools in Iowa and Wisconsin (Benton,
47
Spreen, Fangman, & Carr, 1967). The children were randomly selected with the single restriction that their WISe lOs be between 85 and 115. Thus, both retarded and superior children were excluded in establishing the normative standards. The mean lQ of the group was 102.5. Analysis of the performance of boys and girls at each age level disclosed no significant differences attributable to sex, and no consistency in the direction of the differences. Therefore, the data for the two sexes were combined in developing the norms. Table 6 presents the mean Number Correct Score at each age and Table 7 presents the corresponding values for the Error Score. Each table also gives a "Critical Score" for each age - the performance level which is poorer than that of 90 to 100 percent of the children at that age. A more Table 6 Norms for Administration C: Children (IQ Number Correct Scores Age a
N
Mean
36 32 25 22 47 54 20
6.19 7.16 7.28 8.13 8.44 8.64 8.80
SO
= 85-115)
Critical Score
Percent Exceeding Critical Score
2.28 2 92 2.06 3 91 1.86 4 96 1.32 5 100 1.33 5 100 1.23 6 93 1.56 6 90 aAge to nearest birthday (e.g., 7 = 6 yrs. 6 mos. through 7 yrs. 5 mos.).
7 8 9 10 11 12 13
Table 7 Norms for Administration C: Children (IQ Error Scores
= 85-115)
Age a
N
Mean
SO
Critical Score
Percent Below Critical Score
7 8 9 10 11 12 13
36 32 25 22 47 54 20
4.91 3.41 3.08 2.13 1.72 1.42 1.25
3.93 2.77 2.15 1.65 1.56 1.34 1.66
10 7 6 5 5 4 4
89 91 92 91 96 89 90
aAge to nearest birthday (e.g., 7 = 6 yrs. 6 mos. through 7yrs. 5 mos.).
48
precise classification of performance is not presented because of the relatively small number of children at some age levels. It will be noted that there is a rapid rise in performance between the ages of 7 and 10, and a much slower rise between the ages of 10 and 13. The performance of 13-year-old children is very close to the adult level.
Additional data for Administration C were derived from the performance of 79 children aged 6 years 6 months to 13 years 5 months, whose WISe lOs ranged from 116 to 147, with the mean IQ being 125. Their performance is summarized in Tables 8 and 9. Although the study is based on a small number of cases, means and standard deviations are shown by age to get an indication of general trends. In Table 8 Administration C: Superior Children (IQ Number Correct Scores
=116-147)
Age a
N
Mean
SO
7 8 9 10 11 12 13
7 10 15 10 17 18 2
8.00 7.80 8.93 8.20 8.70 9.16 9.00
1.55 .91 2.15 1.70 .95
aAge to nearest birthday (e.g., 7 through 7 yrs. 5 mos.).
Administration C:
6 yrs. 6 mos.
Table 9 Superior Children (IQ Error Scores
= 116-147)
Age a
N
Mean
SO
7 8 9 10 11 12 13
7 10 15 10 17 18 2
2.28 2.40 1.13 2.20 1.35 .83 1.00
1.87 .94 3.36 1.74 .95
aAge to nearest birthday (e.g., 7 through 7 yrs. 5 mos.).
6 yrs. 6 mos.
49
comparing these children with children of average intelligence (Tables 6 and 7), the differences appear to be greater for ages 7 through 9 than for the older groups. Administration D
Standardization data gathered on this procedure are not yet sufficient to provide adequate norms for clinical use. Empirical observations bearing on the diagnostic application of Administration D are discussed in Chapter 4 (pages 72-73).
50
Chapter 4
DIAGNOSTIC INTERPRETATION Cerebral injury or disease is the most frequent determinant of defective performance in visual-memory and visuocbnstructive tasks. It is the sensitivity of tests such as the Visual Retention Test to the effects of cerebral disease that is their outstanding clinical feature, and accounts for their frequent inclusion in psychodiagnostic batteries. Before the inference of cerebral disease is made, however, a number of other possible determinants of defective performance should be considered, such as: a. Lack of adequate effort on the part of hostile, apathetic, asocial, or paranoid patients. b. Inability of severely depressed patients to complete reproductions, particularly of the more complex designs. c. Inability of patients depleted by serious physical disease to complete reproductions, particularly of the more complex designs. d. Autistic preoccupation on the part of schizophrenic patients, leading to irrelevant reproductions. e. Defective graphomotor skill and poor task adjustment because of lack of education or relevant social experience. f. Defective performance on the part of persons simulating mental incompetence. It is particularly important that determinants a, b, and c, above, all having to do with the variables of effort and energy level, receive deliberate consideration. Determinant d, expressed by irrelevant, elaborate, and bizarre reproductions, can hardly escape attention. Determinant e may be encountered in individuals with a background of severe cultural deprivation or in those from non-Western cultures. The characteristics of the performance of persons simulating mental incompetence (determinant f) are discussed in a later section of this chapter. It should also be kept in mind that not every brain lesion will be reflected in poor performance on a perceptual-mnemonic task. Factors
51
such as the size, nature, and locus of the lesion, chronicity, and restitution of function after cerebral insult, playa role in determining performance level. In fact, one finds that a substantial proportion of patients with demonstrable cerebral disease perform adequately. The exact proportion depends, of course, on the characteristics of the sample of patients under study. If the sample consists of patients with "organic brain syndrome" and dementia in a state hospital, one is likely to find 100 percent defective performance. On the other hand, if the sample is restricted to nonpsychotic patients with adequate premorbid intelligence who are being seen in the neurological department of a general hospital, the proportion showing normal performance will be in the range of 40 to 60 percent. Performance of Patients with Cerebral Lesions
The single most significant index of the presence of cerebral disease provided by the Visual Retention Test is the general level of performance, as measured by either the Number Correct Score or the Error Score, both of which are indexes of the accuracy of perception and reproduction. The discriminative efficiency of the test may be illustrated by citing the results of a study of 100 patients with cerebral disease who had been examined at the University Hospital and the Veterans Administration Hospital in Iowa City. These cases were selected at random from the file records of brain-diseased patients who met the following conditions: (a) no evidence or history of psychosis, and (b) an estimated premorbid 10 of at least 80, as judged from educational and vocational history and from performance on the total battery of tests administered. The findings, utilizing deviation scores derived from Number Correct Scores, are presented in Table 10. A total of 57 percent of the patients with brain disease gave defective performances (i.e., deviations of 3 or more points below expected score). Table 10 also shows the distribution of deviation scores for a group of 100 control patients whose records were drawn from the files in a manner similar to that used for the brain-diseased group. (Thus, the control group also showed no evidence or history of psychosis, and had lOs of at least 80. They carried a wide variety of diagnoses, the two most frequent being spinal disc disease and psychoneurosis.) Only 4 percent of the control patients performed at a level which was 3 or more points below expected score. Further comparison shows that 36 percent of the brain-diseased patients gave grossly defective performances (4 or more points below expected level) while none of the control patients produced so deviant a record. Conversely, only 6 percent of the brain-diseased patients scored 1 or 2 points above their expected performance level, while 21 percent of the control patients were in this category.
52
Table 10 Distributions of Deviation Scores, Derived from Number Correct Scores, for Patients with Brain Disease and for Control Patients (Administration A)
Deviation Scorea
2 points above expected score 1 point above expected score Equal to expected score 1 point below expected score 2 points below expected score 3 points below expected score 4 points below expected score 5 or more points below expected score
Bra in·Diseased Patients (N=lOO)
Control Patients (N=100)
2 4 9 16 12 21 . 12 24
4 17 34 29 12 4
o o
aDeviation score equals the difference between the obtained Number Correct Score and the expected Number Correct Score.
The same proportion of both groups (12 percent) earned scores which were 2 points below expected level (thereby raising the question of acquired impairment of cognitive function). Altogether, the scores of 69 percent of the brain-diseased patients were 2 or more points below expected level, while the scores of 16 percent of the control patients were in this category. When Error Scores were used to measure general level of performance in the two groups of patients, virtually the same degree of discriminative efficiency was achieved. This was not unexpected, since the two scoring systems yield scores which have been shown to be very highly correlated. This finding that the more elaborately derived Error Score was not superior to the more simply derived Number Correct Score, with respect to differentiating brain-diseased patients as a group from control patients as a group, confirmed the results of Wahler (1956) who similarly found that scores derived from the two scoring systems did not differ significantly from each other with respect to overall discriminative efficiency. Thus, it appears that any special merit of the Error Score lies in the opportunity it affords for detailed qualitative analysis of a subject's performance. Other studies have confirmed the finding of a relatively high frequency of defective performance in brain-diseased patients, and have provided information about the performance characteristics of specific diagnostic groups. In a study of 12 patients with chronic carbon monoxide poisoning, Ferracuti (1955) found that 11 gave grossly 53
defective Visual Retention Test performances. Wahler (1956) found a mean of 8.4 errors per patient in a group of brain-diseased patients, as compared to 4.7 errors per patient in a group of control patients, with the difference between the means significant at the .001 level of confidence. Von Kerekjarto (1961) analyzed the performance of two groups of patients with multiple sclerosis, one in the acute phase of the disease and the other in remission. The two groups were compared with each other as well as with a control group of normal subjects and a heterogeneous group of brain-damaged patients. The mean performance levels of the three clinical groups were defective, and differed significantly from the mean of the control group "(p < .001). The mean performance levels of the three clinical groups, as defined by either Number Correct Scores or Error Scores, did not differ from each other. However, utilizing a time measure (time taken to reproduce the designs), Von Kerekjarto found that both groups of patients with multiple sclerosis were significantly slower than the heterogeneous braindamaged group. All three clinical groups were significantly slower than the control group, and the multiple sclerosis patients in the acute phase were significantly slower than those in remission. In a second study, Von Kerekjarto (1962) compared the performance of brain-damaged and control patients on the Visual Retention Test, the Bender-Gestalt Test (Pascal-Suttell scoring), the Memoryfor-Designs Test (Graham-Kendall), and the WAIS Block Design test. The two groups of patients were matched for mean age (34 years) and intelligence level (IQ = 99). The Visual Retention Test was found to be the best discriminator among the four tests, with 50 percent of the brain-damaged group performing at a subnormal level as against 6 percent of the control group. L' Abate, Boelling, Hutton, and Mathew (1962) and L' Abate, Vogler, Friedman, and Chused (1963) found that Visual Retention Test performance significantly discriminated between brain-damaged and control patients of comparable age, education, occupational status, and verbal intelligence level. In a further study, L'Abate and Mathews (1963) confirmed the findings of earlier work that length of hospitalization was negatively correlated with performance level, for both braindiseased and schizophrenic patients. More recent studies (Cronholm & Schalling, 1963; Zwaan, De Vries, & Van Dijk-Bleker, 1967; Sterne, 1969; Breidt, 1969, 1970; and Crochelet, 1970) dealing with the degree to which the Visual Retention Test identifies patients with cerebral disease are reviewed in Chapter 5. 54
Qualitative Analysis of Performance
Clinical observers have repeatedly expressed a conviction that the performance of brain-diseased patients in copying designs or in reproducing them from memory will tend to be characterized not only by a general inadequacy but also by distinctive qualitative features, and that these qualitative features possess differential diagnostic significance. It has been held, for example, that rotational errors, perseverations, distortions in the relative size of figures and in their spatial relationships, fragmentation of figures, and reduplicated reproductions all point to disturbance of visual perception which is ascribable to cerebral pathology. Certain motor-executive aspects of performance, such as tremulousness, sketchiness, difficulty in drawing acute angles, and inability to reproduce overlapping figures, have also been considered as distinctive "organic" characteristics. Despite the fact that these generalizations have been made by clinicians of wide experience, their accuracy is a matter of some doubt. Derived from clinical experience (i.e., from uncontrolled observations of brain-diseased patients through the years), the generalizations typically receive empirical support from individual case reports appearing in the literature. It is hardly necessary to point out that while such evidence is always interesting, it is not adequate. Instead, these generalizations should be considered as hypotheses to be investigated, rather than as established facts. Controlled and systematic analyses of the qualitative aspects of performance in well-defined groups of patients are required in order to demonstrate whether certain performance features are in fact peculiarly characteristic of brain-diseased patients. The Error Score system of evaluating performance on the Visual Retention Test was designed to provide a stable framework for such qualitative analyses. In providing the opportunity for recording specific types of errors as well as "right" and "left" errors, this system covers virtually every performance feature that has been mentioned in the literature, and should prove useful in determining which, if any, performance features are distinctively characteristic of the brain-diseased patient. It should also facilitate the study of the test perrormance associated with different types of lesions and with other diagnostic categories, and aid in developmental investigations. Utilizing the Visual Retention Test and a scoring method very similar to the Error Score system presented in this manual, Wahler (1956) investigated the qualitative characteristics of the performance of brain-diseased and control patients, matched for age and educational level. To eliminate the influence of serious general mental impairment or mental deficiency, a Verbal IQ of at least 80 (estimated 55
from the Wechsler-Bellevue Information and Vocabulary tests) was made a criterion for the inclusion of subjects in both groups. As has been noted, the results of Wahler's study showed a highly significant difference (p < .001) in the number of errors made by the two groups. However, with respect to qualitative differences in performance, an overall trend analysis showed that the profiles of the two groups, as plotted for nine different types of errors, were not significantly different. Despite this, certain observed differences were sufficiently striking to suggest further exploration. While the total error ratio for the two groups was 1.8 (Le., the brain-diseased patients made 1. 8 times as many errors in general as the control patients), and while the ratios for most error categories were close to this overall ratio, three categories showed decidedly higher ratios. The braindiseased patients made 3.0 times as many errors of Omission of Peripheral Figure, 3.5 times as many Rotations, and 5.6 times as many Size errors, as the control patients. In the absence of a significant overall difference in types of errors for the two groups, these differences in specific error categories can only be considered as encouraging further exploration .. In this regard, it is possible that one of the procedural modifications of the Visual Retention Test (e.g., delayed-memory administration) may be particularly valuable in eliciting differential responses with respect to certain error categories. Since peripheral figure omissions, rotations, and size errors are among the errors most frequently mentioned in the literature as being characteristic of the visuoperceptive behavior of patients with cerebral disease, a brief discussion of each follows below. Omission of a Peripheral Figure
It is often felt that this simple error may have significant implications for diagnosis, particularly if it is not accompanied by a verbalization by the patient that the figure has been forgotten, thus implying a lack of awareness that such a figure was included in the exposed design. It would seem that the peripheral figure either was not perceived at all when the complex design was presented or, if it was perceived, the perceptual reaction was so weak that not even a momentary trace of it persisted. This failure to reproduce some kind of peripheral figure, correct or incorrect, appears all the more striking when it is considered in the light of successive exposures of several designs, all of which include two major figures and a smaller peripheral figure. Moreover, before the first design of this type (Design III in each form of the test) is presented, the patient is explicitly told to draw everything he sees. If the peripheral figure is omitted in his reproduction, the same instruction is repeated before the next design is presented.
56
Thus, the omission of the peripheral figure occurs despite repeated stimulation and verbal instructions intended to broaden the field of visual attention. This failure to reproduce the peripheral figure has been related to a general constriction in the dynamic visual field which is found in many brain-diseased patients, particularly those with parieto-occipital lesions. Occasionally, the deficit is found in pure form; that is, the patient's reproductions of the major figures of all the designs are correct while, at the same time, not a single peripheral figure is drawn. If, after the test, the patient's attention is called to the fact that most of the designs included a peripheral figure, he will often state that he does not remember seeing the figures. If, then, another form of the test is given to him, there will usually be fewer omissions of the peripheral figure (although such omissions may still occur despite the directly induced set to attend to them), but his reproduction of these figures is usually uncertain and often incorrect, either in form or in placement. It is interesting to note that the patient is usually able to copy the designs quite accurately, with the deficit appearing only when he is required to reproduce them from memory. A related type of error which may be encountered in the unilateral omission, distortion, or misplacement of peripheral figures. Here, the patient tends to make either no response or an incorrect response to peripheral figures located on one side of the major figures, while correctly reproducing peripheral figures situated on the other side. The significance of this type of error is discussed in the next section dealing with the problem of lesionallocalization. Rotations
Rotational errors constitute a favorite "organic sign" for clinical writers. They appear relatively frequently in the productions of braindiseased patients, and readily attract the attention of the examiner. However, they occur in the productions of many control subjects as well. "Stabilization" rotation (the drawing of a figure resting on an angle so that it rests on aside) occurs more frequenly than any other type of rotation and is commonly encountered in both control and brain-diseased SUbjects. Wahler's data indicated that the ratio between stabilization and other types of rotation may differ for these two groups of patients. His control subjects made five times as many stabilization errors, as compared with other types of rotational errors, while the brain-diseased subjects made only twice as many stabilization rotations, as compared with other types. This observation suggests the desirability of distinguishing between the different types of rotational errors in analyses of performance 57
characteristics. Certain types (e.g., mirror-imaging, 90-degree rotation) may prove to be more discriminative than others. Size Errors
With respect to relative size, the typical three-figure design of the Visual Retention Test provides an obvious contrast between the central major figures and the minor peripheral figure, the area of the latter usually being only one-sixteenth as large as the former. In the drawings of normal adults, wide variations in the proportional size of major and peripheral figures are observed; but the peripheral figure is almost always drawn as appreciably smaller than the major figures, with the major figures usually about the same size as the model. From a subjective point of view, it is difficult to see how a subject could do otherwise if he has retained a sufficient impression of the design to make a reproduction of it. Thus, it is a striking experience to observe a brain-diseased patient reproducing the shapes with reasonable accuracy while at the same time neglecting the relative size of the figures. He may draw the peripheral figure as large as the major figures, or he may draw one major figure to be half the size of the other. Localization of Lesion
Whether the site of a cerebral lesion is a significant determinant of performance is still a question to be decided by critical investigation. Characteristically, patients with lesions in the parieto-occipital areas appear to give defective performances most frequently on tasks of the Visual Retention Test type. Conversely, frontal lesions result in such impairment less frequently. The evidence for these generalizations is both indirect and incomplete. In the case of bilateral frontal lobe defect reported by Ackerly and Benton (1947), the patient's performance on the test was at an average level, corresponding favorably to his general intelligence level (Stanford-Binet IQ = 92). Beechley and Rust (1949), utilizing the Visual Retention Test in studying schizophrenic patients who had undergone frontal topectomy, found no significant postoperative decline in performance level, a finding confirmed by Scherer, Winne, Clancy, and Baker (1953). However, it must be noted that these patients were chronic schizophrenics whose preoperative performance was somewhat subnormal. In clinical work, the impression is soon gained that the type of patient most likely to give defective performance, and the type in whom the most grossly defective performance is observed, is the one who proves to have a parieto-occipital lesion. This impression is in accord with an extensive neuropsychological literature which ascribes visuopsychic disorder in general to disturbances in parieto-occipital 58
function. However, a more rigorous study of the relationship of both general performance level and particular performance characteristics to localization of cerebral dysfunction is strongly indicated. The Visual Retention Test performance of those cases of Heilbrun (1956) whose lesions had been localized in the anterior-posterior dimension as well as with respect to hemisphere afforded an opportunity for a preliminary study of this question. Comparing frontal cases with nonfrontal cases (ignoring the size or side of lesion), the difference one might expect was found (i.e., the mean performance level of the nonfrontal cases was lower than that of the frontal cases). Another localization problem of considerable theoretical and practical importance has to do with the relationship of performance to lateral localization of cerebral lesion (i.e., whether the lesion is in the right or left hemisphere). Numerous clinical studies suggest that disease of the right hemisphere leads to particularly defective performance on tasks involving visuoperceptive and visuoconstructive activity. In Heilbrun's study, it was found that performance level on Administration A of the Visual Retention Test was lower for the group of patients with lesions of the right hemisphere than for those with lesions of the left hemisphere. The mean score for patients with right hemisphere lesions was 3.7, while for nondysphasic patients with lesions of the left hemisphere, it was 5.4. This difference, however, was not statistically significant. An important deficit which is related to the lateral localization of cerebral lesion is the phenomenon of nonresponsiveness to stimuli in the left or right halves of visual space in the presence of simultaneous stimulation in the contralateral half. Following incidental observations by earlier researchers, this deficit was investigated by Poppelreuter (1917), who called it a "hemianopic weakness of attention," and shortly thereafter by Holmes (1918), who published confirming observations in a study of disturbances of visual orientation in braininjured patients. Subsequently, the phenomenon was the subject of intensive investigation by a number of researchers, particularly Bender (1952) and his associates. With respect to possible inferences concerning cerebral status, it seems clear that the affected half-field points to dysfunction in the contralateral cerebral hemisphere. With regard to the Visual Retention Test, the unilateral omission, distortion, or misplacement of the peripheral figure, which has been mentioned previously, may be conceived of as expressing this phenomenon of hemianopic weakness of attention or visual extinction. To see if the available data would support this supposition, a rough comparison (ignoring size and anterior-posterior localization of lesion) of the frequency of left and right peripheral figure errors was made, 59
using Heilbrun's patients with unilateral lesions. It was found that in the right-hemisphere cases, the ratio of right peripheral figure errors to left peripheral figure errors was 1.15, while in the left-hemisphere cases the ratio was 1.67, the direction of the difference being in favor of the hypothesis.! However, as in the previous comparison, the difference did not attain statistical significance. Thus, again, a suggestive finding requiring more rigorous investigation was secured. Alajouanine, Castaigne, and Ribaucourt-Ducarne (1960) compared the Visual Retention Test performance of patients with lesions of the occipital lobes to that of patients with lesions restricted to the left or right parietal area. The patients with occipital lesions gave grossly defective performance on both the memory and copying forms of the test. Application of an experimental multiple-choice form of the test also elicited defective performance, even when the test was presented as a form discrimination task with the memory factor eliminated. Patients with left parietal lesions performed defectively on the memory form as well as on the task of copying the designs. However, their performance on the mUltiple-choice form was characteristically better than their drawing performance. Omission of the right peripheral figure was a common feature of the performance of patients with right visual field defects. Patients with lesions of the right parietal area performed on a subnormal level but were nevertheless better than the other groups of patients. A characteristic feature of their performance was defective memory for the spatial relationship of the figures of a design.
.lD-
Frigyesi, Cox, and Solomon (1963) undertook to determine whether the side of lesion in patients with focal cerebral disease would be reflected in certain aspects of Visual Retention Test performance. On the hypothesis that patients with unilateral lesions would have a perceptual defect in the contralateral visual field, it was predicted that these patients would make more errors in reproducing the figures in the contralateral than in the ipsilateral field. It was further predicted that they would have a tendency to draw the reproductions on the side of the sheet of paper corresponding to the unaffected visual field (i.e., an ipsilateral shift of the entire reproduction). Both predictions were confirmed in a study in which 103 patients with unilateral cerebral disease were given Administration A of the Visual Retention Test. Significantly more errors were made in reproducing figures corresponding to the contralateral visual field. Of the 103 patients, 75 showed a lateral shift in their reproductions, and in 73 (97 percent) of these 75 patients, the shift was in the direction ipsilateral to the 1 In general, an excess of right peripheral figure errors over left peripheral figure errors is to be expected, since Form C of the test includes five right peripheral figures as compared with three left peripheral figures.
60
side of the lesion. There was no relationship between overall performance level and size of lesion, but the poorest performance was made by patients with parieto-occipital disease. The authors concluded that the occurrence of contralateral errors and the phenomenon of ipsilateral shift were caused by a primary perceptual defect, and that these performance features were valuable for indicating the side of lesion. Pettifor (1967) compared the distribution of types of errors on Administration A in groups of patients with right and left hemisphere lesions. The patients had been matched for age and sex. The results confirmed the previously cited findings of Frigyesi et aI. (1963). Each group of patients showed a preponderance of errors in the contralateral visual field, the intergroup difference in pattern of lateral errors (left field vs. right field) being highly significant. The patients with right hemisphere disease made more misplacement errors than did those with disease of the left hemisphere. In contrast, the latter group made relatively more distortion errors, and Pettifor suggested that the excessive occurrence of this type of error in patients with left hemisphere lesions may be due to faulty verbal control of sequential movement. Performance of Brain-Damaged Patients on Administration C
The clinical application of the Visual Retention Test as a visuoconstructive task was investigated by giving Administration C to 100 patients with cerebral disease and comparing their performance to that of 200 control patients (Benton, 1962, 1972). The two groups were matched with respect to age and educational background. The distributions of Error Scores for the two groups of patients are shown in Table 11. Ninety-eight percent of the control group had Error Scores of 4 or less. If an Error Score of 4 is adopted as a cutoff point, 20 braindamaged patients performed at a defective level, the majority of these performances being grossly defective in that they were below the entire distribution of scores of the control patients. Certain qualitative differences in performance were also observed. Misplacements, in the form of an upward or downward displacement of a peripheral figure, accounted for 84 percent of the errors of the control group. These patients made relatively few distortions or size errors, and no omissions or rotations. In contrast, misplacements accounted for only 44 percent of the errors of the brain-damaged group, while these patients made a relatively large number of distortions, and some omissions and rotations. It is noteworthy that this trend toward a larger number of distortions, omissions, and rotations was seen in some braindamaged patients whose total Error Scores were within normal limits, as well as in those who performed at a defective level. 61
Table 11 Distributions of Error Scores for Brain-Damaged Patients and for Control Patients (Administration C)
Error Score
Brain-Damaged Patients (N=100)
Control Patientsa (N=200)
o
26
1 2 3 4
24 15 10 5 7 5
96 56
5 6 7-8
9+
2
6
25 12 7 4
o
o o
aTable 5, page 47, is based on the data derived from this group.
The relationship between performance level and the presence of mental impairment was investigated, the latter variable being defined by the difference between obtained and expected WAIS Verbal IQs in view of the patient's educational background (cf. Fogel, 1964). It was evident by inspection that failure on the task was positively related to the presence of mental impairment. Nevertheless, many patients with rather severe mental impairment performed adequately and, conversely, defective visuoconstructive performance was observed in some patients whose verbal intelligence was within normal limits. A brief case report will illustrate this last point and show the nature of the errors made: R. C., a 44-year-old right-handed man with an eighth-grade education and a veteran of World War II, was seen two months after partial removal of a glioma that had invaded the frontal, temporal, and parietal regions of the right hemisphere. His WAIS Verbal IQ was 109, with his subtest scaled scores ranging from 10 to 17. In reproducing the ten designs of Form C of the Visual Retention Test, he made 12 errors (5 distortions, 3 omissions, 3 size errors, and 1 misplacement). Some of his reproductions are shown in Figure 1.
When patients with lesions confined to the left or the right hemisphere were studied, the incidence of defective performance was found to be somewhat higher for patients with right hemisphere lesions (23 percent vs. 14 percent). Perhaps more significant was the finding that, while no patient with a left hemisphere lesion made more than
62
Figure 1. Types of errors made by R. C. in copying designs (Administration C) of Form C. DESIGN II
DESIGN I
o
DESIGN IV
0
OD
0
..
o Distortion.
0
°6W lnf
0
L\
Size error in reproduction of left peripheral figure.
Distortion.
DESIGN V
lJ.
0 DESIGN VII
[7<1> V<[>
DESIGN VIII
A
GO d
D
fj.
Ll
Omission of left peripheral Omission of right peripheral Distortion of left major figure, size error in reprofigure, size error in repro- figure. duction of right major figure. duction of left major figure, distortion of right major figure.
6 errors, 4 patients with right hemisphere lesions made 7 to 24 errors in their JDerformance. Since the control and brain-damaged patients also had been given Administration B of the Visual Retention Test, it was possible to make a direct comparison of performance levels under the two conditions of administration. The phi coefficient between the scores of the control patients on Administrations Band C was .41, while the same statistic for the brain-damaged patients was .52. Thus, there was a substantial relationship between performance levels on the copying and memory tasks. Nevertheless, that the visuoconstructive and mem63
ory factors each play a distinctive role is indicated by a comparison of the frequency of defective performance under the two conditions of administration. As mentioned previously, 20 brain-damaged patients performed defectively on the copying task in the sense that their performance was surpassed by 98 percent of the control group. On the memory task, 25 patients had scores that were 4 or more points below expected scores, a performance level that was surpassed by 99 percent of the control group. Thirteen patients performed defectively on both tasks. Twelve patients who performed adequately on the copying task were defective on the memory task. Conversely, 7 patients who performed adequately on the memory task were defective on the copying task. Thus, there was far from perfect communality in the incidence of defective performance on the two tasks. The possible clinical implications of this finding are illustrated by the fact that, while 25 percent of the brain-damaged patients were identified as defective on the basis of the selected criterion score on the memory form, and 20 percent on the copying form, 32 percent would be identified as defective if performance on either form were taken as the criterion. Performance of Children
The Visual Retention Test has proved to be of value for examining children suspected of having cerebral injury or disease. This finding is in accord with the general clinical experience that these children often show a selective impairment in intellectual function; while verbal abilities are relatively well developed, visuoperceptive and visuomotor performances are significantly impaired (Taylor, 1959). The academic aptitude and the adjustment capacity of such children are frequently overrated because of the relatively good development of language skills, as reflected in fair overall performance on an intelligence scale of the Binet type. Consequently, when such children fail to progress satisfactorily in school, there is a tendency to invoke factors of a psychodynamic nature such as hostility or emotional blocking, or a more superficial variable such as poor study habits, as causative agents. Conversely, the intellectual potentialities of a child who may be suffering from a specific language disability are oftJn underrated on an intelligence scale of the Binet type. Here the use of psychometric instruments such as the Visual Retention Test may provide a broader and more accurate picture of the child's capacities. The standardization data indicate that in the case of normal children of average intelligence, about 4 percent have defective scores, as defined by the normative standards. About 15 percent have scores which are classified as either borderline or defective. In the case of children with cerebral injury who show average or near-average in-
64
telligence (lOs of 85 or" higher), about 25 percent show defective performance, as defined by the normative standards. About 55 percent have scores which are classified as borderline or defective. In general, not quite as sharp a discrimination is achieved in the application of the Visual Retention Test to children as in its application to adults. Nevertheless, a significant discrimination of considerable clinical value is attained. As a group, children of superior intelligence achieve scores which are somewhat above average for their chronological age, but below the level that one might expect from their general intelligence test performance. This finding, which is not unexpected since the children are classified in -the first instance on the basis of extreme performance on the intelligence test itself, was taken into account in developing the normative tables for children. Thus, in Tables 3 and 4, high average and superior children were grouped together. A problem frequently encountered in the clinic is the question of whether a child who shows behavioral or emotional disturbances is brain-damaged. From this standpoint, the question of the influence of emotional disturbance on Visual Retention Test performance is of decisive importance, since the test is designed to aid in the inference of brain damage. Rowley and Baer (1961) investigated this question by comparing the performance of brain-damaged and emotionally disturbed children, matched for mean age and 10 (WISe or WAIS). Their findings (based on deviation scores derived from Number Correct Scores) are summarized in Table 12. Seven of the 25 braindamaged children gave defective performances (deviation score of -3 or more), while only 1 emotionally disturbed child was in this category. On the other hand, 8 of the 25 emotionally dislurbed children made rather poor performances (deviation score of -2) that were not clearly defective. Thus, the observed incidence of defective performance in the emotionally disturbed children was not higher than that found in normal children, but a number of the emotionally disturbed children did perform slightly below expectations for their chronological and mental ages. Rowley and Baer concluded that, " ... the Visual Retention Test has considerable usefulness as an aid in discriminating between brain damage and psychogenic emotional disturbance in children. The occurrence of a defective performance (i.e., deviation score of -3 or more) is an indicator of brain damage and is not likely to be caused by attention or concentration difficulties associated with emotional disturbance. This is not to say that such difficulties may not play a role in determining level of performance. However, when they operate, their typical effect appears to be to depress total score by only one or two points, so that level of performance is still within normal limits." 65
Table 12 Distributions of Deviation Scores, Derived from Number Correct Scores, for Brain-Damaged Children and for Emotionally Disturbed Children a (Administration A)
Deviation Score b
3 points above expected score 2 points above expected score 1 point above expected score Equal to expected score 1 point below expected score 2 points below expected score 3 points below expected score 4 points below expected score 5 points below expected score
Brain-Da maged Children (N=25)
Emotionally Disturbed Children (N=25)
1
o
o 3 4 4 6 4 2 1
3 3 5
5 8
1
o
o
aAdaptedfrom Rowley and Baer (1961). bDeviation score equals the difference between the obtained Number Correct Score and the expected Number Correct Score.
The question of level of Visual Retention Test performance in children with reading disability has not been fully explored. Some observations on older children have been made, but the performance of younger children has not been investigated. In a group of 20 children (from 9 to 11 years of age and of average intelligence), the median Visual Retention Test score was found to be well within normal limits. Only 2 of the children showed defective performance. Similarly, Symmes and Rapoport (1972) found that Visual Retention Test (as well as Bender-Gestalt) performance was unremarkable in a group of carefully screened dyslexic children, and they suggest that, " ... the association of immaturity in visual-motor function that is frequently related to reading difficulty appears only in populations heavily biased in the direction of attendant neurological signs." These findings support the view that reading disability in older children is typically a specific deficit, and is not likely to be reflected in broad visuoperceptive disturbance of the type found in many children with cerebral injury or disease. It is true, of course, that children with cerebral damage often experience special difficulty in learning to read and, if their general inteI1ectual level is sufficiently high, it is justifiable to consider them as baving a reading disability, among other deficits. In these cases, Visual Retention Test performance may be of value in defining the scope of the visuoperceptive impairment. Whether
66
this lack of relationship between reading ability and Visual Retention Test performance, which is found for older children, also holds for younger children with reading problems (including children who may be showing only a transient retardation in the development of reading skills) is an open question. It is quite possible that there is a positive relationship between the two variables at younger age levels, but this remains to be determined. The Visual Retention Test is a task that involves the interaction of visuoperceptive, visuomotor, and visual memory factors. Consequently, failure under Administration A or B sometimes raises the question as to whether visuoperceptive or visuoconstructive disability is the basis of the failure. As has been seen, some brain-damaged adults perform defectively on both the copying and the memory tasks. In the case of some young children and some mental defectives, there is no doubt that it is a visuoconstructive disability, rather than immediate memory impairment, which accounts for observed failure on the memory task (cf. Silverstein, 1962). Nevertheless, it would be wrong to consider Administration A or B of the Visual Retention Test as being simply a visuoconstructive task, since in many cases the factor of memory is of decisive importance. A clinical example which has been reported in detail elsewhere (Benton, 1955) may be cited to illustrate this point. A 9-year-old boy, in the early stages of a cerebral degenerative disease, completely failed the designs of Form D of the test as an immediate memory task (Administration A). His inability to reproduce any of the designs correctly, together with the fact that performance was very poor from a motor-executive standpoint, led the examiner to consider the possibility of either a visuoconstructive deficit or a severe disturbance in visual acuity, although neither possibility seemed likely from the evidence of the child's performance on other tests, including reading. Accordingly, the child was asked to copy the designs (Administration C) of Form C. His drawings, while quite tremulous, wer~ reasonably accurate, thereby excluding visuoconstructive deficit as the causative factor for the complete failure on the memory test. Thus, test performance in this patient disclosed a defect in immediate visual memory which could not have been revealed by the copying task alone. Performance of Mental Defectives
Both adults and children who are mentally defective tend to show inferior performance on the Visual Retention Test, their scores being in consonance with their general intellectual level or mental age rather than with their chronological age. However, wide variation in performance level as compared with mental age level may be observed. 67
Thus, among high-grade defectives and individuals of borderline intelligence (i.e., IQs of 65 to 79), one may encounter normal performance (e.g., Number Correct Scores of 7 to 8 for adults) and grossly defective performance (e.g., Number Correct Scores of 1 to 2 for adults). In general, defectives of the brain-damaged type earn somewhat lower scores than those of the cultural-familial type. Alley (1969) employed Administration C (copying the designs) to determine whether brain-damaged and cultural-familial mental defectives of equal age and intelligence level would differ in this visuoconstructive performance. He found that brain-damaged defectives were significantly poorer on the task than cultural-familial defectives. His results were confirmed in an independent study by Ellis (1971). Two studies have compared qualitative aspects of performance in mental defectives with those in normal children and in patients with cerebral disease. Benton and McGavren (1962), using Administration . A with Form C, matched 36 normal children and 36 mental defectives for Error Score and compared the frequency of each type of error in the two groups. The most striking difference was observed in size errors; the defectives made 18 times as many as the normal children. Seven defective subjects who had made size errors were then given Administration C to determine whether the occurrence of this type of error was due to visuomotor deficit or faulty memory. Four of the 7 subjects made 1 or more size errors in copying the designs. An equal number of defective subjects with comparable Error Scores but without size errors in their memory performance were also given Administration C. There were no size errors in their reproductions. The neuropsychological basis for the occurrence of this apparently distinctive feature in the performance of some mental defectives is not at all clear. However, the phenomenon does provide a further piece of evidence pointing to the similarities that exist between these defectives and patients with acquired cerebral disease. A later study by Benton and Spreen (1964) -compared qualitative features in the performance of mental defectives and patients with: acquired cerebral disease. Thirty-three mental defectives and 33 brain- . damaged patients were matched in pairs for age and for Error Score . on Administration A of the Visual Retention Test. The analysis showed· that the mental defectives made more distortions and fewer perseverations and misplacements than the brain-damaged patients. The incidence of rotations and size errors did not differ in the two groups. In general, the findings were in accord with clinical impression, and suggest that visuoconstructive disability plays a more important role as a determinant of performance level in the defectives than in the: patients with cerebral disease. With respect to the last point, Silverstein. 68
(1962) has presented evidence showing that for mental defectives, there is a relatively high correlation between scores on the Visual Retention Test when it is given as a memory task and scores obtained when it is given as a copying task. Performance of Schizophrenic Patients
As a group, schizophrenic patients show extreme variability on the Visual Retention Test. Some perform within normal limits; the performance of others is similar to that of patients with cerebral lesions; still others make frankly autistic reproductions. A performance which is within norma] limits does not argue against a diagnosis of schizophrenia, but it does imply that at least the basic perceptual and retentive processes are intact. The occurrence of a defective performance of the type usually seen in patients with cerebral disease raises the question of an organic factor in the determination of the deviant behavior. An "autistic" performance is one in which a patient's reproduction has no clear relevance to the original design, or one in which the patient draws objects, symbols, or unduly elaborate designs. Such reproductions are generally made only by schizophrenics or by confabulatory organic patients. Several examples of reproductions (some of them autistic) made by schizophrenic patients are shown in Figure 2. Nickols (1963) posed the question of whether the Visual Retention Test would disclose cognitive deficit in schizophrenic patients which was not reflected in their performance on the W AIS. He did this by comparing WAIS lOs with the "IQ" implied by Visual Retention Test performance, and utilizing a "difference score" as a measure of the capacity of the Visual Retention Test to detect impairment independently of the W AIS. A group of 17 schizophrenic patients was compared with a control group of 17 (composed of neurotic patients or normal subjects), the two groups having been matched for age and education. The mean "difference score" in the control . group was 0, while the mean "difference score" in the schizophrenic group was 25 (mean W AIS 10 of 88 vs. mean Visual Retention Test "IQ" of 63). The author concluded that the Visual Retention Test did in fact disclose cognitive impairment in schizophrenic patients which was not manifest in their W A IS performance. Nickols also tested the hypothesis that Visual Retention Test performance would be more defective in schizophrenics with known brain damage than in those for whom there was no history or evidence of brain disease. The findings were in the predicted direction, but nonsignificant: 14 patients whose records indicated some form of chronic brain syndrome showed a mean "difference score" of 23, while 30 69
Figure 2. Examples of reproductions of Form C designs made by schizophrenic patients. DESIGN II
DESIGN IV
DESIGN III
0
CD
0=
CD:
0
v- ~=
OD
0
0-.1.
06
ParanOId schIzophrenic, male, age 48.
[g5J (5)GJ
DESIGN IX
DESIGN IX
DESIGN VI
0
0
III
DJLJ L1J
©
o
[TILJ
o Hebephrenic, male, age 39.
Catatonic, male, age 45.
patients with no indication of brain damage showed a mean "difference score" of 18. He also compared 19 schizophrenic patients with abnonnal EEG records to 12 schizophrenic patients with nonnal tracings, and found that the abnormal EEG group showed a mean . "difference score" of 25, while the normal EEG group showed a mean . "difference score" of 12. However, this relatively large intergroup· difference in "difference scores" was nonsignificant because the sam- : pIes were small and because there was a high degree of variability • in the "difference scores" for both groups. Nickols' overall conclusion· was that the Visual Retention Test disclosed cognitive deficit in schizophrenics over and above that shown by their W AIS performance, but did not identify a specific organic factor. Watson (1968) compared the Visual Retention Test, the BenderGestalt Test, and the Memory-far-Designs Test (Graham-Kendall): with respect to their capacity to discriminate between a group of.
70
patients diagnosed as having chronic brain syndrome and a group diagnosed as schizophrenic. The Visual Retention Test was the only one of the three which discriminated significantly between the two groups, the mean Error Score being 11.6 for the organics and 8.5 for the schizophrenics. With regard to specific types of errors, the groups differed most markedly in the mean number of distortions (5.0 vs. 3.0) and perseverations (1.3 vs. 0.7). The author concluded that, while the Bender-Gestalt and the Memory-for-Designs Test were not found useful in discriminating between organics and schizophrenics, the results for the Visual Retention Test were "mildly encouraging. " Performance of Depressed Patients>
The performance of depressed patients varies with the severity of the depression. If they can be stimulated to exert adequate effort and attention, their performance is likely to be reasonably good. If, however, their motivational level is quite low and their mental energy insufficient, they tend to do poorly, particularly on the more complex designs. Since depression in mood sometimes complicates the clinical picture in cerebral disease, particularly in the middle and older age groups, its presence may pose an interpretative problem. In the absence of an objective measure of severity of depression, it is not possible to state the relationship between mood disturbance and performance level on the Visual Retention Test with the degree of precision necessary to guide interpretation of performance. All that can be said at this time is that if the patient appears to be only moderately depressed, and if his attention-energy level seems to be adequate under the influence of strong encouragement, he oUght to perform adequately. If he does not, cerebral disease may be suspected. Performance of Simulators
The simulation or exaggeration of behavioral deficit referable to presumptive brain injury is a persistent problem in clinical practice, particularly when the determination of compensation for injuries suffered or of a pension are involved in the case. One question that arises in this connection is how successful a malingerer is in simulating the performance of a brain-damaged patient. Benton and Spreen (1961a, 1961b), using Administration A of the Visual Retention Test, explored one aspect of this question by comparing the performance characteristics of deliberate or "experimental" malingerers with those of brain-damaged patients. Both quantitative and qualitative differences were found. Quantitatively, the performance level of the simulators was significantly lower than that of the brain71
damaged patients. Qualitatively, the pattern of performance (as defined by the relative frequency of different types of errors) of the simulators differed significantly from that of the brain-damaged patients. The simulators made more distortion errors and fewer omission, perseveration, and size errors than the brain-damaged patients.
In another study (Spreen & Benton, 1963), simulation of the performance of mental defectives was investigated. Although simulation of mental deficiency is probably encountered less frequently in clinical practice than simulation of acquired brain injury, it still poses a problem, particularly when questions of legal or criminal responsibility are raised. It was found that the simulators tended to give poorer performances, with significantly fewer correct reproductions and more errors than the mental defectives whose performance they were attempting to produce. Moreover, their reproductions included unusual and bizarre features that are rarely seen in the drawings of mental defectives. Performance in Old Age
Von Kerekjarto (1963) gave Administration A of the Visual Retention Test to 50 normal subjects between the ages of 65 and 75 years. The mean Number Correct Score was 3 points below the expected score for a comparable group of subjects under the age of 45, and the mean Error Score was 7 points above the expected score for the younger group. Retesting with a parallel form three weeks later indicated high stability in performance. The results suggest that, while performance level declines linearly as a function of age when defined in tenns of the Number Correct Score, it declines more precipitously when defined in terms of the Error Score. Apparently there is a higher incidence of absolute or near-absolute failure in reproducing specific designs in the performance of older subjects· than in that of younger subjects. The same tendency may be noted with brain-damaged patients when they are compared with mental defectives (Benton & Spreen, 1964). When tpese two groups were equated for Error Score, the brain-damaged subjects showed a some-: what higher mean Number Correct Score. Performance under Administration D (Delayed Memory)
Administration D of the Visual Retention Test was devised in the expectation that a certain proportion of brain-diseased patients who did not show any noteworthy deficit in immediate memory might show impaired capacity to retain a visual percept over a brief perio& of time (i.e., in short-term memory). The type of clinical observation which led to this expectation is illustrated by the following case report:
72
D. M., a 40-year-old man employed as a minor business executive, had suffered an acute subarachnoid hemorrhage fifteen months before admission to the hospital. He made an apparently good recovery and returned to work. However, he had noticed in the past few months that his memory for recent events seemed to be rather faulty. In addition, his wife had noticed that he was somewhat less efficient than formerly, and rather irritable with their children. For these reasons, he decided on his own initiative to come to the hospital for a diagnostic evaluation. His performance on the Wechsler-Bellevue Scale was superior, his Full Scale IQ being 122. His Verbal Scale IQ was 120 and his Performance Scale IQ was 123. Weighted scores on the subtests ranged from IOta 18. On the Digit Span test, he repeated 7 digits and reversed 5. In short, his performance on this test battery gave no indication of impairment in intellectual function.~ He was given Administration A of the Visual Retention Test, Form E, on which he had a Number Correct Score of 6, failing in his reproductions of the more complicated designs. When this score was compared to an expected score of 9 (in view of his superior intelligence), it was evident that his performance was suggestive of a deficit in visual retention. After an appropriate rest period, he was reexamined with Form D, utilizing a 10-second delayed memory procedure. His performance was markedly defective. He succeeded on the first two designs, which contain only single figures, but failed to reproduce any of the remaining designs correctly. Thus, the delayed memory procedure brought into sharp focus a marked deficit in short-term memory which, to be sure, had already been suggested by his performance on the immediate memory test.
Clinical experience continues to disclose an occasional patient with brain disease who performs relatively well on the immediate memory task (Administration A or B) but who fails badly under the delayed memory procedure (Administration D). However, a study by Breidt (1970), comparing the performance of brain-diseased and control patients on Administrations A and D, failed to show a systematic trend for patients with cerebral disease to give remarkably inferior performance under the delayed memory condition. Breidt found a mean decrease of only 0.4 points in the Number Correct Score under Administration D as compared with Administration A, for the group of control patients, thus confirming the author's original impression that the decline in the performance level of normal subjects is minimal under a condition of delayed reproduction. However, Breidt's findings for a group of 109 brain-damaged patients were essentially the same, with the mean Number Correct Score under Administration D only 0.7 points below the mean score under Administration A. He also investigated the effects of a 30-second delay in a group of 30 brain-damaged patients, and found a slightly larger difference (approximately 1 point) between their performance under this condition and under Administration A.
73
Chapter 5 REVIEW OF RECENT IJTERATURE This chapter reviews recent literature bearing on various aspects of the Visual Retention Test not cover~d in the preceding chapters. The review is organized along topical lines (e.g., normative studies, reliability and comparability of forms, experimental-clinical applications) for the convenience of the reader. Normative Studies
Poitrenaud and Clement (1965) carried out an extensive study of the performance on Administration A of 504 normal subjects (290 men, 214 women) ranging in age from under 45 to over 84 years. The study had two purposes: first, to determine how closely the performance of the subjects would correspond to the published norms and, second, to establish normative standards for the performance of older subjects. The subjects were screened medically and psychologically, and only those in good physical and mental health were included in the study. The authors pointed out that the sample was not truly representative of the French population in that circumstances did not permit the testing of individuals who were of less than average intelligence. Intelligence level was assessed by the Vocabulary Test of Binois . and Pichot and the sample was subdivided into three categories: IQ = 105-114, IQ = 115-124, and IQ = l25-134. Similarly, six' age groups were established to plot performance level as a function: of age. No consistent sex differences in performance appeared. The: basic findings in relation to age and intelligence level are shown in .• Table 13. Inspection of the table shows that the mean performance: levels of the younger subjects were somewhat below the published: norms for individuals of superior intelligence. The data for the older subjects are valuable in their indication of the decline in performance which may be expected with increasing age. Matos Sanchez (1967) conducted a developmental study of 188 Peruvian school children ranging in age from 8 to 14 years. Within: the group, 111 children were classified as having average intelligence'~
74
Table 13 Mean Number Correct Scores for 504 Normal Subjects, by Age and Intelligence Level a (Administration A) Mean Number Correct Score, by Intelligence Level
Age
IQ=105-114
IQ=115-124
IQ=125-134
Under 45
7.1 (N= 19) 6.6 (N=10) 6.1 (N=37) 5.2 (N=67)
8.0 (N=26) 7.4 (N=35) 6.9 (N=65) 6.2 (N=58) 5.6 (N=34) 4.7 (N=l1)
8.7 (N=9) 7.8 (N=17) 7.7 (N=26) 6.8 (N=35) 6.2 (N=19)
45-54 55-64 65-74 75-84
4.4
Over 84
(N=28) 4.0 (N=5)
4.0 (N=3)
aAdapted from Poitrenaud and Clement (1965).
(IQ =: 85-114),48 as superior (IQ = 115 or above), and 29 as subnormal (lQ = 84 or below). Both Administration A and Administration C were given to the children. As expected, there was a progressive rise in performance level with increasing age in the case of both administrations. There were no significant sex differences. The children of superior intelligence made consistently higher scores than those of average intelligence. The mean scores of the children of average intelligence were slightly but consistently below those found in normative studies of North American children. For example, the mean Number Correct Scores for 10-year-old Peruvian , children were 4.7 on Administration A and 6.9 on Administration C, as compared to means of 5.4 and 8.1 for comparable samples of North American children.
Brasfield (1971) gave Adminis tration C to 194 kindergarten children on two occasions four months apart. The mean age of the children was 5 years 7 months at the first testing, and 5 years 11 months at the second testing. While the normative study of Benton et al. (1967) extended down only to 7 years, Brasfield's results provided information on the typical performance of younger children. The mean Number Correct Scores were 3.5 at 5 years 7 months, and 4.5 at 5 years 11 months. These fit in well with the established 75
norms for older children (mean Number Correct Scores of 6.2 at 7 years, and 7.2 at 8 years; see Table 6). Brasfield concluded that Administration C was not too difficult for 5- to 6-year-old children. In a separate study, Beames and Russell (1970) collected data on the Administration C performance of two groups of children, one within the age range of 5 years 6 months to 5 years 11 months (N = 287), and the other within the age range of 6 years 0 months to 6 years 6 months (N = 258). The findings are presented for boys and girls separately in Table 14. Comparison of these children with older children (see Table 7) suggests that copying performance is in a rapid stage of development between the ages of 5 and 7 years. The results, taken together with those 9f Brasfield (based in part on the same samples of subjects), provide normative standards for younger children. The findings of many clinical studies using the Visual Retention Test have normative implications insofar as, for comparative purposes, they employ control groups of patients without cerebral disease. The general trend of the findings of these studies is that medical patients without cerebral disease tend to obtain Number Correct Scores which are somewhat below the published norms for adults. For example, Breidt (1969) found that the mean score of a group of patients with nonneurological diseases on Administration A was 0.62 points below the expected score. Similarly, Zwaan et al. (1967) reported that neurotic patients generally performed at a lower level than that indicated by the published norms. Alley (1968), in a study of 165 mentally retarded children on Administration C, developed specific normative standards, by age, for this group. Table 14 Mean Error Scores for 545 Kindergarten Children a (Administration C)
Girls
Boys Age Range
5 yrs. 6 mos.5 yrs. 11 mos. 6 yrs. 0 mos.6yrs.6mos.
Percent Exceeding Critical Scare Girls Boys
Mean
SO
Mean
SO
Critical Scareb
10.9
6.6
9.8
6.1
20
90
93
9.1
6.0
8.1
6.2
18
90
91
aAdapted from Beames and Russell (1970). bThe performance level which is poorer than that of 90 to 100 percent of the children at that age.
76
Dee and Fontenot (1969) investigated the degree to which lefthanded drawing by right-handed subjects influences performance on Administration C. The question is of some methodological significance in the study of brain-damaged patients, since those with right hemiplegia must either be instructed to draw with the left hand or be excluded from study. If the latter course is taken, this tends to create a bias in comparisons of patients with left and right hemisphere lesions. However, if a right-handed subject draws with his left hand, the examiner is faced with the problem of how to evaluate the results, since a poor performance may have been due to the use of the nonpreferred hand. Dee and Fontenot gave equivalent forms of the Visual Retention Test to 60 right-handed control patients (i.e., without history or evidence of cerebral disease), and instructed them to draw one form with the right hand and the other with the left hand. The results showed no impressive difference in performance between the two hands, the mean Error Score for left-hand reproductions being only 0.4 points higher than the mean Error Score for righthand reproductions. An analysis of the types of errors made indicated a tendency for more distortions when copying with the left hand. Undoubtedly the fact that the established scoring criteria emphasize global accuracy and correct spatial relationships, rather than fine motor skill, accounts for the very small difference. The major implication of the study is that left-handed drawings by right-handed subjects can be used to assess reproductions of designs from models, thereby eliminating a possible source of bias (i.e., the exclusion of patients with severe right-sided motor defect) in comparative studies of patients with unilateral lesions. Reliability and Comparability of Forms
As mentioned in earlier editions of the manual, retest reliability for Administration A (1 O-second exposure with immediate reproduction), as estimated by the correlation coefficient between equivalent forms, has been found to be approximately .85. There is continued evidence that the reliability of each form of the test is satisfactory. Zwaan et al. (1967) reported correlation coefficients ranging from .79 to .84 between the three forms (C vs. D; C vs. E; D vs. E) for Administration A. As mentioned above, Brasfield (1971) gave Administration C to 194 kindergarten children on two occasions four months apart. The correlation coefficient between scores on the two testings was .75. For Administration A, there is evidence that Form D is slightly more difficult than Form C, with Form E occupying an intermediate position. Breidt (1970), comparing Forms C and D (Administration 77
A) in a group of 35 patients, obtained mean Number Correct Scores of 6.4 for Form C and 5.7 for Form D, a difference of 0.7 points. In a similar study with another group of patients, he obtained mean scores of 7.0 for Form C and 6.4 for Form E, a difference of 0.6 points. Zwaan et a1. (1967) also reported that Form C was easier than Form D under Administration A. Curiously, this difference does not appear to hold under Administration C. Benton et a1. (1967) found that, for children, Form D was slightly easier than Form C on the copying task. However, Brown and Rice (1967) and Rice (1968) found no differences in difficulty level among the three forms when they were given, under Administration C, to groups of mentally retarded children. The correlation between immediate reproduction (Administration A) and delayed reproduction (Administration D) has also been investigated. Breidt (1970) obtained a correlation of .83 between Administration A (Form E) and Administration D (Form C) for a group of 22 brain-damaged patients. However, in an analogous study of a second group of 20 brain-damaged patients, he used Form C for Administration A and Form E for Administration D, and obtained a correlation coefficient of only .40. In a third study, using Form C for Administration A and Form E for a condition of 30second delay, Breidt found a correlation of .51. In summary, there was a positive relationship between performance on equivalent forms under immediate and delayed administrations. However, two of the three studies by Breidt yielded correlation coefficients substantially lower than those obtained between two forms under the same administration. Correlations with Other Tests
Many studies have assessed the relationship of the Visual Retention Test to other tests, and positive correlations have consistently been found. However, the degree of association varies widely, ranging from low nonsignificant correlations to coefficients of substantial size, depending upon the nature of the other tests and the character of the groups under investigation. Some representative studies are cited below. In a study of the concept of constructional apraxia, Benton (1967) assessed the relationship of the Visual Retention Test (Administration C) to three-dimensional block construction, l stick construction, 2 and the WAfS Block Design subtest, using a group of 100 braindamaged patients. Phi coefficients were computed for each pair of lDescribed by Benton (l968b). 2Described by Bechtoldt, Benton, and Fogel (1962).
78
test scores. Comparison of the relative size of the phi coefficients showed that the three coefficients between design copying and the three assembling tasks were consistently lower than the coefficients among the three assembling tasks themselves. The implication drawn from these results was that, in clinical investigation, it is probably useful to think in terms of at least two types of cons tructional praxis, an assembling type and a graphomotor type. Breidt (1970) correlated the Visual Retention Test with a number of WAfS subtests (Digit Span, Block Design, Digit Symbol, and Object Assembly), in a group of patients with suspected or confirmed brain damage. The product-moment correlation coefficients ranged from .46 to .62, Digit Span showing the lowest correlation with the Visual Retention Test. Heilbrun (1960) also found only a modest degree of relationship between the Visual Retention Test and Digit Span (r = .42 for control patients; r = .26 for brain-damaged patients) . Zwaan et al. (1967), studying a group of neuropsychiatric patients, found the following correlations between the Visual Retention .61 with Full Scale IO; r .61 with Test and WAfS scores: r Verbal IO; r = .52 with Performance lQ. The median correlation with the WAIS sub tests was .60. The finding that the Visual Retention Test correlated with the WAfS subtests as highly as the eleven subtests tend to correlate with each other led the authors to question whether the Visual Retention Test had any distinctive value in clinical diagnosis.
=
=
Validity and Clinical Application Velborsky (1964) made a comparative study of the performance of normal subjects and of organic, depressed, and schizophrenic patients on Administration A of the Visual Retention - Test. The clinical groups performed at a lower level than the normal subjects, but only the difference between the normal subjects and the de. pressed patients was significant. Performance in all groups 'was correlated with intelligence level. The author concluded that the Visual Retention Test was of little value for the differential diagnosis of organic disease, depression, and schizophrenia. Cronholm and SchalIing (1963) studied a group of 30 patients with chronic focal brain injury and a group of 60 control subjects, with the aim of determining whether a battery of mental tests, including the Visual Retention Test, the Wechsler-Bellevue Scale, and a number of memory tests, would disclose intellectual deficit in the brain-damaged patients. The Visual Retention Test discriminated between the groups at the .01 level. When the groups were equated 79
for Wechsler-Bellevue IQ, the Visual Retention Test still discriminated significantly (p < .05) between them. Analysis of the types of errors made indicated that omissions and perseverations showed the largest intergroup differences. The Visual Retention Test ranked sixth in discriminating power among the eighteen tests given. The authors concluded that the Visual Retention Test was "valid as regards brain injury." Nehlil, Agathon, Greif, Delagrange, and Rondepierre (1965) studied 34 hospitalized neuropsychiatric patients whose behavior had raised the question of intellectual deterioration. Specifically, they compared the patients' performance on the Visual Retention Test and the Wechsler-Bellevue with the electroencephalographic findings. The EEG records of 18 patients were classified as normal, and those of 16 patients as abnormal (paroxysmal activity, diffuse delta or theta rhythms). The Wechsler-Bellevue classified 12 patients as pathologically impaired. There was, however, no association between Wechsler-Bellevue performance and EEG abnormality. The Visual Retention Test classified 20 of the 34 patients as impaired, and there was a significant association between Visual Retention Test performance and EEG abnormality. Eighty-three percent of the patients with EEG abnormality showed defective performance on the Visual Retention Test; in contrast, only 31 percent of the patients with normal EEG records showed defective performance on the Visual Retention Test. The authors interpreted the findings as indicating a relationship between visuoperceptual functions and the physiological processes reflected in the EEG. Zwaan et al. (1967) found that neurotic patients generally performed at a lower level than that indicated by the published norms for the Visual Retention Test. They concluded that the test's clinical application in the Netherlands was of doubtful value. Benton (1967) investigated the relationship between performance on four tests of "constructional praxis" to side of lesion in righthanded patients with unilateral cerebral disease. The tests were the ~ Visual Retention Test (Administration C), Three-Dimensional Block. Construction, Stick Construction, and W AIS Block Design. When defective performance was defined as a score exceeded by 95 percent of a group of 100 control patients without history or evidence of . cerebral disease, it was found that the relative frequency of impairment on the Visual Retention Test and Three-Dimensional Block Construction was approximately twice as high for patients with lesions of the right hemisphere as for those with left hemisphere disease. In : contrast, the frequency of defective performance on Stick Construction and W AIS Block Design was approximately the same for the two hemispheric groups. 80
Sterne (1969) compared the power of the Visual Retention Test, the Porte us Maze Test, and W AIS Digit Span to discriminate between a group of 49 patien ts with cerebral disease and a group of 51 patients without evidence of cerebral disease. The organic group (mean age == 55 years) was older than the control group (mean age == 41 years), and lower with respect to WAIS IQ (94 vs. 101). Both the Visual Retention Test and the Porteus Maze Test significantly discriminated between the groups (p < .01). Neither the total W AIS Digit Span score, nor separate scores for Digits Forward and Digits Backward, were significantly discriminative. When both age and IQ were equalized through analyses of covariance, the Porteus Maze Test no longer discriminated significantly between the groups while the Visual Retention Test retained its discriminative power (p < .01). For the total sample, the correlation coefficient between the scores on the Visual Retention Test and the Porteus Maze Test was .57. Breidt (1969, 1970) compared groups of brain-damaged and control patients on Administration A and found a highly significant (p < .001) difference. The mean Error Score of the brain-damaged patients was 8.2 as compared with 3.8 for the control group. In a second study, he compared the performance of brain-damaged and control patients on Administration D (delayed reproduction). The mean Number Correct Scores were 5.2 for the brain-damaged group and 7.4 for the control group, the difference being highly significant (p < .001). Since Breidt's primary interest was in investigating perseverative tendencies in patients with cerebral disease, he also studied the frequency of perseverative errors in Visual Retention Test performance. Comparing brain-damaged and control patients (N == 42 for each group), he found that the brain-damaged group had a mean of 1.6 perseverative errors as compared to 0.6 for the control group, the difference between these means being significant at the .01 level. Since the relative frequency of other types of errors was not analyzed, it was not possible to determine whether perseverative errors were particularly characteristic of performances of braindamaged patients. An analysis of the qualitative features in the Visual Retention Test performance of brain-diseased and control patients was reported by Poitrenaud and Barrere (1972). The subjects were outpatients under medical care at a geriatric center. The 60 patients in each group were matched in pairs for sex, age, and educational level. In each group, the mean age was 73 years and most of the patients (87 percent) were 65 or older. The majority of the brain-diseased patients carried a diagnosis of cerebrovascular disease, while the control patients were being treated for somatic disease or neurotic or depressive
81
disorders. Mean Error Scores on Administration A were 11.3 for the brain-diseased group and 6.3 for the control group, the difference being significant at the .001 level. The obtained Error Score ratio of 1.8 was exactly the same as that reported earlier by Wahler (1956). Utilizing a modification of the standard scoring system, Poitrenaud and Barrere determined the number of subjects in each group who made each of thirty-six different types of errors. Then they identified seven types of errors that were made by less than 4 percent of the control patients but by a significantly higher proportion of patients with cerebral disease. Among these errors were omission of a major figure without space be~ng provided for it in the reproduction (MR! and ML! in the standard scoring system), reproduction of overlapping figures as nonoverlapping and vice versa (NOv and Ov), and distortion of the relative size of a peripheral figure (SzPR and SzPL). Poitrenaud and Barrere concluded that the results of their study supported the hypothesis that the Visual Retention Test performance of patients with brain disease is qualitatively, as well as quantitatively, different from that of control patients. Experimental·Clinical Application This section discusses a number of studies in which the Visual Retention Test (as well as other tests) was used as an investigative instrument to explore various clinical questions. Thus, the emphasis in these investigations was on substantive issues rather than on the validity of the test.
B urian, Benton, and Lipsius (1962) assessed visual cognitive functions in patients with strabismic amblyopia, using multiple-choice forms of the Visual Retention Test, a fragmented figures test, an embedded figures test, and a tactile-visual matching task (cf. Spreen & Gaddes, 1969). The basic question was whether evidence could be adduced for the presence, in strabismic amblyopia, of a disturbance in higher visual functions which results in an inability to integrate visual information into a meaningful 'percept, a concept first advanced by Vom Hofe (1930). It was felt that if these patients did suffer from an "agnosic" impairment, they should perform defectively with the amblyopic eye on tasks requiring visual-analytic capacity. Each patient was tested with the amblyopic and normal eye separately, and the findings were compared. The results showed no significant differences in performance level. However, in the case of each test, the total time taken for task performance was somewhat greater for the amblyopic eye than for the normal eye. The authors concluded that the functional impairment found in strabismic amblyopia could not be classified as a visual agnosic defect such as that seen in patients with cerebral disease.
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Strunk and Faust (1967) sought to evaluate the role of early brain damage in the pathogenesis of behavioral disturbances in children. Disturbed children were compared to a control group of normal children. The major results of the study were: There was no difference between the disturbed and control groups with respect to a history of early brain damage; neurological signs of abnormality were more frequent in the disturbed group; EEG abnormality was more frequent in the disturbed group; radiographic study indicated a higher frequency of early brain damage in the disturbed group; Visual Retention Test performance showed a significant positive association (p < .05) with these indications of brain damage. Fischer, Schmidt, and Wanke (1968a, 1968b), and Fischer, Schmidt, Wanke, and Petersen (1968a, 1968b), have reported a series of studies on the neurological, intellectual, and psychiatric status of patients after operation for brain tumors. A battery of ten to seventeen tests, including multiple-choice forms of the Visual Retention Test, was used to assess cognitive and psychomotor abilities in the patients and in a control group of psychiatric patients, the groups being matched for age and sex. A group of patients who had been treated for intrinsic tumors (and in whom no sign of recurrence of the tumor was demonstrable at the time of study) showed widespread intellectual defects; only four tests failed to show significant differences between the patients and the controls. Visual Retention Test scores were significantly lower (p < .01) for the patients than for the controls, who performed at a normal level. Psychological test performance showed a closer relationship to the behavioral efficiency of the patients than did the observed neurological deficits. Essentially the same findings were obtained for patients who were studied after removal of meningeomas, although the quantitative differences between the groups were smaller. Eight of the seventeen tests failed to show a significant intergroup difference. The Visual Retention Test significantly discriminated between the groups (p < .01), and showed a significant relationship to size of tumor (p < .05), but not to locus. Further studies were concerned with the aftereffects of infra tentorial and hypophyseal tumors. Cognitive tests, including the Visual Retention Test, generally did not disclose significant impairment in these patients who, however, did show psychomotor deficits. Benton (1968a), in a study of the differential behavioral effects of unilateral frontal lobe disease, found that patients with right frontal lesions performed at a significantly lower level (p < .05) on Administration C than did those with left frontal lesions. When defective performance was defined as a score exceeded by 95 percent of the control patients, it was found that 38 percent of the patients with 83
right hemisphere disease and 10 percent of those with left hemisphere disease were impaired. Lefebvre, Crocq, and Bernard (1969) studied the influence of the vasoactive drug, Hydrosarpan, on the mental processes of 20 patients with cerebrovascular insufficiency associated with arteriosclerosis. A battery of eight tests, including the Visual Retention Test, was employed. An impressive general positive effect was observed. However, different functions showed different degrees of improvement; for example, only 6 of the 20 patients showed improvement in arithmetic reasoning, while 13 showed improvement on a cancellation task (testifying to their increased alertness). Ten patients improved their scores on the Visual Retention Test and on digit span. Crochelet (1970) made a comparative study of 140 patients exhibiting the postconcussional syndrome in various degrees of severity. His test battery included the Visual Retention Test, the Complex Figure Test (Rey) , and the Wechsler-Bellevue Scale. The findings for all the tests were essentially the same. The posttraumatic patients performed at a significantly lower level than a heterogeneous group of 82 patients with functional psychiatric disorders (neurosis, reactive depression, psychopathic disorder). When the posttraumatic patients were classified on clinical grounds with respect to severity of disability, those classified as moderately or severely disabled had decidedly lower scores than the controls. On the other hand, those classified as not, or only slightly, disabled achieved scores which were comparable to those earned by the control patients. The mean Number Correct Score for the control (functional psychiatric) patients on the Visual Retention Test was 6.9, while the mean scores for the severely, moderately, and slightly disabled patients in the posttraumatic group were 4.0, 5.7, and 7.4, respectively. The author concluded that the Visual Retention Test aided in the detection of disabilities in perception and retention in postconcussional patients. At the same time, he pointed out that emotional disorder and psychotic preoccupation disorder can also affect performance on the test adversely, as indicated by the finding that the patients with functional psychiatric disorders performed somewhat below the normal level. Rosales Pizarro (1971) utilized the Visual Retention Test in a study of visual memory in epileptic children. These children showed a poorer performance on the test than did a control group of nonepileptic children with behavior disorders. Moreover, there was an inverse relationship of level of Visual Retention Test performance to both the age of onset of the seizures and their frequency. Since the epileptic patients were lower in general intelligence (as measured
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by the WISe or W AIS), it was not possible to determine whether the observed impairment in visual memory was a specific characteristic of the epileptic patients, or simply a partial expression of a depressed intelligence level. Concluding Comments
That the reliability of the Visual Retention Test, as estimated by the correlation coefficients among equivalent forms, is satisfactory has been repeatedly demonstrated. On the other hand there is evidence that, with Administration A, Form C is slightly easier than Forms D and E. Item analysis has indicated that this is, in large part, due to the circumstance that Design VIII of Form C is relatively easy. The slight difference in level of difficulty is probably not of great significance in the clinical assessment of an individual patient. However, as Breidt (1970) has suggested, it can be important in systematic studies of performance under different modes of administration. It is interesting that this difference in difficulty level holds only for the memory tasks (Administrations A and D) and not for the copying task (Administration C). With respect to the latter administration, there is no consistent evidence for differences in difficulty level among the three forms. The validity of the Visual Retention Test (i.e., the fact that hemispheric cerebral damage is reflected in defective performance on the test) has been confirmed in numerous studies. The studies of Fischer et al. (1968) are particularly interesting in this respect, in their indications that patients with lesions involving the cerebral hemispheres showed defective performance on the Visual Retention Test, while those with lesions at lower levels of the central nervous system (cerebellar and hypophyseal tumor, acoustic neurinoma) performed at a normal level. However, there have been a few studies in which the results were unimpressive, or in which a question was raised about the value of the test because of its correlation with performance on other tests. Like most tests, the Visual Retention Test does indeed correlate with other measures. This is simply a reflection of the pervasive general factor which underlies all human cognitive activity, and of the fact that the processes of the human brain are interactive and integrative in nature. However, the observation that two tests show a substantial positive correlation does not, of course, indicate that they measure the same thing, since even a relatively high correlation (e.g., .70) accounts for less than half of the variance of the abilities measured by the two tests. The crucial question is whether a test adds information to that already provided by other measures. A number of studies (e.g., Nickols, 1963; Cronholm & Schalling, 1963; Sterne, 85
1969) indicate that, at least in certain situations, the Visual Retention Test meets this criterion of clinical utility. When brain-damaged patients are compared to patients with functional psychiatric disorders, Visual Retention Test performance by the latter group is often found to be somewhat below that indicated by the published norms (Crochelet, 1970). This is not surprising, since many factors (other than cerebral disease) which may adversely affect performance are likely to be present in control groups consisting of depressed patients, schizophrenics, and cases of compensation neurosis. There is the further consideration that normative standards may be expected to vary somewhat from one country to another. The comprehensive normative study of Poitrenaud and Clement (1965) showed an average level of performance in subjects of presumably superior intelligence. However, one must raise the question of whether a vocabulary test, such as that of Binois and Pichot, tends to overestimate the intelligence of adult subjects. The fact that not a single subject in their large sample (N = 504) had a vocabulary IQ of less than 105 supports this possibility. The indications are that performance levels on Administrations A and D of the Visual Retention Test are not closely related to locus of lesion in patients with cerebral disease. There appears to be a trend for the poorest performance to be made by patients with lesions in the right parieto-occipital region, but the evidence is inconsistent. There is evidence that certain qualitative features of performance may be associated with side of lesion (Frigyesi et aL, 1963; Pettifor, 1967). On the other hand, copying performance shows a clearer relationship to side of lesion, with patients with right hemisphere disease showing more frequent and more severe defect than those with left hemisphere disease (Benton, 1967, 1968b). Thus, it would seem that the perceptual and perceptuomotor components of Visual Retention Test performance are associated with the functioning of the right hemisphere, while the memory component is not. The memory component is most clearly assessed by the delayed memory condition and it is striking that patients, as a group, show only a modest decline in performance level, as compared to the immediate memory condition. Yet the two administrations can hardly be considered equivalent, as evidenced by the fact that the correlation between them is generally lower than the correlation between the different forms under Administration A. Patients show considerable individual variability in their relative performance under Administrations A and D. Some show no, or mild, defect on Administration A, but marked impairment on Administration D. But most show
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little or no decline under the delayed memory condition. The sources of this individual variability would be worth investigating. Certain types of short-term memory are probably mediated in large part by coding and rehearsal of perceived information. Patients with central linguistic defects might be expected to be impaired in the capacity to engage in such rehearsal. Consequently, one might predict that patients with sensory aphasia would show a steeper decline in performance than other types of brain-damaged patients, under the delayed administration condition. As suggested by Breidt (1970), level of motivation is also a possible factor in determining the relationship between performance under the two administrations. Experimental investigation of these possibilities is indicated.
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REFERENCES Ackerly, S. S. and Benton, A. L. (1947) Report of a case of bilateral' frontal ' lobe defect. Proc., Assoc. Res. Nerv. Ment. Dis., 27:479-504. Alajouanine, T., Castaigne, P. and Ribaucourt-Ducarne, B. (1960) Valeur c1inique de certains tests perceptives et perceptivo-moteurs. In: Les Grandes Activites du Lobe Occipital (Edited by T. Alajouanine). Paris: Masson. Alley, G. R. (1968) Visual Retention Test, Administration C: norms for retarded children. Percept. Mot. Skills, 27:438. Alley, G. R. (1969) Comparative constructional praxis performances of organically and cultural-familial mental" retardates. Amer. J. Ment. Defic., 74:279-282. Beames, T. B. and Russell, R. L. (1970) Normative data by age and sex for five pre-school tests. Report, Neuropsychology Laboratory, University of Victoria. Bechtoldt, H. P., Benton, A. L. and Fogel, M. L. (1962) An application of factor analysis in neuropsychology. Psycho!. Rec., 12: 147-156. Beechley, R. M. and Rust, R. (1949) In: Selective Partial Ablation of the Frontal Cortex (Edited by F. A. Mettler). New York: Hoeber. Bender, M. B. (1952) Disorders in Perception. Springfield, Ill.: C. C. Thomas. Benton, A. L. (1955) Cerebral disease in a child. In: Clinical Studies in Personality (Edited by A. Burton & R. E. Harris). New York: Harper. Benton, A. L. (1962) The Visual Retention Test as a constructional praxis task. Coni. Neurol., 22: 141-155. Benton, A. L. (1967) Constructional apraxia and the minor hemisphere. Coni. Neurol., 29:1-16. Benton, A. L. (1968a) Differential behavioral effects in frontal lobe disease. Neuropsychologia, 6:53-60. Benton, A. L. (1968b) Test de Praxie Constructive Tri-Dimensionnelle. Paris: Editions du Centre de Psychologie Appliquee. Benton, A. L. (1972) Abbreviated versions of the Visual Retention Test. J. Psychol., 80: 189-192. Benton, A. L. and Fogel, M. L. (1961) Test de retention visuelle: normes revues et completees. Rev. Psychol. Appl., 11: 75-77. Benton, A. L. and McGavren, M. (1962) Qualitative aspects of visual memory test performance in mental defectives. Amer. J. Ment. Defic., 66:878-883. Benton, A. L. and Spreen, O. (1961a) Visual memory test: the simulation of mental incompetence. Arch. Gen. Psychiat., 4:79-83.
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Benton, A. L. and Spreen, O. (1961 b) Zur Simulation intellektueller Leistungsdefekte im Benton-Test. Psychol. Beitriige, 7:147-150. Benton, A. L. and Spreen, O. (1964) Visual memory test performance in mentally deficient and brain-damaged patients. Amer. 1. Ment. Defi,c., 68: 630-633. Benton, A. L., Spreen, 0., Fangman, M. and Carr, D. (1967) Visual Retention Test, Administration C: norms for children. J. Spec. Ed., 1: 151-156. Brasfield, D. M. (1971) An investigation of the use of the Benton Visual Retention Test with pre-school children. M.A. Thesis; University of Victoria. Breidt, R. (1969) Perseveration und Himverletzung: Experimental psychologische Untersuchungen zur Wiederholungstendenz bei Hirnverletzten. Dissertation, Tiibingen. Breidt, R. (1970) Moglichkeiten des Benton-Tests in der Untersuchung psychoorganischer Storungen nach Hirnverletzungen. Arch. Psychol., 122:314-326. Brown, L. F. and Rice, J. A. (1967) Form equivalence of the Benton Visual Retention Test in low IQ children. Percept. Mot. Skills, 24:737-738. Burian, H. M., Benton, A. L. and Lipsius, R. c. (1962) Visual cognitive functions in patients with strabismic amblyopia. Arch. Ophthal., 68:785-791. Crochelet, Y. (1970) Considerations sur l'apport de l'examen medicopsychologique dans l'expertise du syndrome postcommotionnel subjectif des traumatises craniens. Acta Psychiat. Be/g., 70:233-279. Cronholm, B. and Schalling, D. (1963) Intellectual deterioration after focal brain injury. Arch. Surg., 86:670-687. Dee, H. L. and Fontenot, D. J. (1969) Use of the non-preferred hand on graphomotor performance: a methodological study. Con!. Neurol., 31: 273-280. Ellis, E. E. (1971) A comparative study of drawing performance in braindamaged and cultural-familial retardates. M.A. Thesis, University of Iowa. Ferracuti, F. (1955) Sui compiti e sugH attributi dello psicologo in un centro di tossicologia dellavoro. Tesi, Universita degli Studi, Roma. Fischer, P.-A., Schmidt, G. and Wanke, K. (1968a) Neurologische, psychiatrische und testpsychologische Befunde nach der Behandlung von hirneigenen Tumoren. Neurochirurgia, 11 :98-112. Fischer, P.-A., Schmidt, G. and Wanke, K. (1968b) Psychische Spatfolgen nach operativer Behandlung von Hypophysentumoren. Arch. Psychiat. Z. ges. Neurol., 210:387-406.
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Fischer, P.-A., Schmidt, G., Wanke, K. and Petersen, U. (1968a) Neuropsychiatrische und testpsychologische Befunde nach Operation infratentorieller Tumoren des Erwachsenenalters. Psychiat. din., 1: 270-298. Fischer, P.-A., Schmidt, G., Wanke, K. and Petersen, U. (1968b) Neuropsychiatrische und testpsychologische Untersuchungen nach Meningeomoperationen. Fortschr. Neurol. Psychiat., 36: 1-49. Fogel, M. L. (1964) The intelligence quotient as an index of brain-damage. Amer. J. Orthopsychiat., 34:555-562. Frigyesi, T., Cox, J. and Solomon, S. (1963) The value of the Benton Visual 'Retention Test in lateralizing cerebral lesions. Proc., 2nd Int. Congo Ment. Retard. Vienna (1961), Part II, 108-115. Heilbrun, A. B. (1956) Psychological test performance as a function of lateral localization of cerebral lesion. J. compo physiol. Psychol., 49:10-14. Heilbrun, A. B. (1960) Specificity of immediate memory function associated with cerebral cortex damage. J. ment. Sci., 106:241-245. Holmes, G. (1918) Disturbances of visual orientation. Brit. J. Ophthal., 2:449-468; 506-516. L'Abate, L., Boelling, G. M., Hutton, R. D. and Mathew, D. L. (1962) The diagnostic usefulness of four potential tests of brain damage. !. consult. Psychol., 26:479. L'Abate, L. and Mathews, B. (1963) Benton Revised Visual Retention, Length of Hospitalization and Psychiatric Diagnosis. Paper read at the 1963 meeting of the Midwestern Psychological Association. L'Abate, L., Vogler, R. E., Friedman, W. H. and Chused, T. M. (1963) The diagnostic usefulness of two tests of brain damage. J. CUn. Psychol., 19:87-91. Lefebvre, P., Crocq, L. and Bernard, J. G. (1969) Traitement des manifestations psychiques de l'insuffisance circulatoire cerebrale chronique. Sem. Hopitaux Paris, 45:312-317. Matos Sanchez, D. A. (1967) Estudio del Test de Retenci6n Visual de Benton en un grupo de ninos de inteligencia promedio y superior. Tesis, Pontifica U niversidad Cat6lica del Peru, Lima. NeWil, I., Agathon, M., Greif, I. L., Delagrange, G. and Rondepierre, I. P. (1965) Contribution a 1'6tude comparative de tests psychometriques de deterioration et de traces EEG. Rev. neurol., 112:293-296. Nickols, I. (1963) Mental deficit, schizophrenia and the Benton-Test. J. Nerv. Ment. Dis., 136:279-282. Pettifor, R. E. (1967) The effects of unilateral brain damage on performance on the Benton Visual Retention Test. Alberta Psychol., 8:5-11. Poitrenaud, I. and Barrere, H. (1972) Etude sur la signification diag- , nostique de certaines erreurs de reproduction au V. R. T. de Benton. ' Rev. Psychol. Appl., 22:43-56. :
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Poitrenaud, J. and Clement, F. (1965) La deterioration physiologique dans Ie Test de Retention Visuelle de Benton: resultats obtenus par 500 sujets normaux. Psychologie Franr;aise, 10: 359-368. Poppelreuter, W. (1917) Die psychischen Schiidigungen durch Kopfschuss im Kriege 1914 bis 1916: die Storungen der niederen und hoheren Sehleistungen durch Verletzungen des Okzipitalhirns. Leipzig: Voss. Rice, J. A. (1968) Form equivalence of the revised Visual Retention Test in mental retardates: an extension. !. Psychol., 68: 159-163. Rosales Pizarro, A. (1971) Les processus de retention visuelle chez les enfants et adolescents epileptiques. These, Bordeaux. Rowley, V. N. and Baer, P. E. (1961) Visual Retention Test performance in emotionally disturbed and brain-damaged children. Amer. 1. Orthopsychiat., 31 :579-583. Scherer, I. W., Winne, J. F., Clancy, D. D. and Baker, R. W. (1953) Psychological changes during the first year following pre-frontal lobotomy. Psychol. Monogr., 67, No.7. Silverstein, A. B. (1962) Perceptual, motor and memory functions in the Visual Retention Test. Amer. 1. Ment. Defic., 66:613-617. Spreen, O. and Benton, A. L. (1963) Simulation of mental deficiency on a visual memory test. Amer. !. Ment. Defic., 67:909-913. Spreen, O. and Gaddes, W. H. (1969) Developmental norms for 15 neuropsychological tests age 6 to 15: Cortex, 5:171-191. Sterne, D. M. (1969) The Benton, Porteus and W AIS Digit Span Tests with normal and brain-injured subjects. 1. Clin. Psychol., 25: 173-175. Strunk, P. and Faust, V. B. (1967) Die hirnorganischer Befunde bei VerhaltensstOrungen im Kindesalter. Arch. Psychiat. Z. ges. Neurol., 210: 152~160. Symmes, J. S. and Rapoport, J. L. (1972) Unexpected reading failure. Amer. !. Orthopsychiat., 42:82-91.' Taylor, E. M. (1959) Psychological Appraisal of Children with Cerebral Defects. Cambridge: Harvard University Press. Velborsky, J. (1964) Der Benton-Test in der klinischen Praxis. Diagnostica, 10:91-102. Vom Hofe, K. (1930) Untersuchungen tiber das Sehen in Fallen von Schielamblyopie. Klin. Monatsbl. f. Augenh., 85:79-80. Von Kerekjarto, M. (1961) Wahrnehmungstests zur Diagnose und Differentialdiagnose der multiplen Sklerose. Eine Untersuchung mit dem Benton Visuellen Merkfahigkeitstest, dem Goldstein-Scheerer Mosaiktest und dem Halstead taktilen Leistungstest. Z. expo Angew. Psychol., 8:369-380.
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Von Kerekjarto, M. (1962) Untersuchungen tiber die Diskriminierungskraft dreier Tests zur Erfassung zerebraler Schiiden. Ein Vergleich der diagnostischen Valenz des Bender-Gestalttests, des Benton Visuellen Merkfiihigkeitstests und des Graham-Kendall Memory-for-Designs Test. Ber. 23. Kongr. Deutsch. Gesellsch. Psychol., Gottingen, Hogrefe. Von Kerekjarto, M. (1963) Zur Altersstabilitiit des Benton-Tests (unpublished manuscript). Wahler. H. I. (1956) A comparison of reproduction errors made by brain-damaged and control patients on a memory-for-designs test. J. Abn. Soc. Psychol., 52:251-255. Watson, C. G. (1968) The separation of NP hospital organics from schizophrenics with three visual motor screening tests. J. Clin. Psychol., 24:412-414. Zwaan, E. J' De Vries, E. and Van Dijk-Bleker, H. (1967) De BentonTest: aspecten bedoeld en onbedoeld. Nederl. Tijdschr. Psychol. Grens., 22:427-438. t
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