J. Child Psychol. Psychiat. Vol. 36, No. 8, pp.

1459-1473, 1995
Elsevier Science Ltd. Printed in Great Britain

0021-9630(95)00069-4)

Performance of Children with ADHD on the

Rey-Osterrieth Complex Figure: A Pilot
Neuropsychological Study

Larry J. Seidman, Kenneth B. Benedict, Joseph Biederman,

Jane H. Bernstein, Kari Seiverd, Sharon Milberger,
Dennis Norman, Eric Mick and Stephen V. Faraone
Abstract—This study evaluates the performance of boys with Attention Deficit
Hyperactivity Disorder (ADHD) on the Rey-Osterrieth Complex Figure (ROCF)
taking into consideration familiality and comorbid psychiatric and learning disorders
(LD). Sixty-five children with ADHD performed at developmentally lower levels of
Copy Organization and Recall Style than did 45 controls. ADHD children with LD
scored significantly lower on Copy Organization than did ADHD children without
LD, whereas psychiatric comorbidity and familiality had no effect. These results
suggest that a developmental analysis ofthe ROCF identifies organizational difficulties
associated with ADHD and that these impairments cannot simply be attributed to
comorbidities associated with ADHD.

Keywords: Rey-Osterrieth Complex Figure, ADHD, learning disability, comorbidity,

organizational ability
•
Abbreviations: ADD: Attention Deficit Disorder, ADHD: Attention Deficit Hyperactivity
Disorder, LD: Learning Disorders, PET: Positron Emission Tomography, ROCF: Rey-
Osterrieth Complex Figure, K-SADS-E: Schedule for Affective Disorders and
Schizophrenia for School-Age Children-Epidemiologic version, WISC-R: Wechsler
Intelligence Scale for Children-Revised, WISC-III: Wechsler Intelligence Scale for
Children—Third Edition, WRAT-R: Wide Range Achievement Test—Revised

Introduction
It is well known that Attention Deficit Hyperactivity Disorder (ADHD) has
neuropsychological consequences that affect academic functioning and adaptation
to the demands of the social environment (Barkley, 1990). For example, it

Accepted manuscript received 2 May 1995

Requests for reprints to: Joseph Biederman, Pediatric Psychopharmacology Unit (ACC 725),
Massachusetts General Hospital, Fruit Street, Boston, MA 02114.

1459
1460 L. J. Seidman et al.

appears that children with ADHD tend to perform poorly on neuropsychological

tasks that are sensitive to frontal lobe dysfunction in adults (Gorenstein, Mammato
& Sandy, 1989; Grodzinsky &: Diamond, 1992; Seidman etal., in press; Shue 8c
Douglas, 1992). Moreover, a Positron Emission Tomography (PET) study of adults
with ADHD has demonstrated reduced global and regional glucose metabolism
in the premotor and superior prefrontal cortex, areas of the brain associated
with attention and executive functions (Zametkin etal., 1990). However, in their
recent review of the neuropsychological literature on frontal lobe dysfunction
in ADHD, Barkley and his colleagues noted the inconsistent results and
methodological hurdles faced by research in this area (Barkley, Grodzinsky &:
DuPaul, 1992).
Although discrepancies across studies could be due to methodological differences
there may be other reasons to account for the inconsistency offindlings.In recent
years, increasing attention has been given to the heterogeneity of symptoms in
ADHD, especially the high levels of comorbidity which have been found in clinical
and epidemiological samples of children with ADHD (Biederman, Newcorn 8c
Sprich, 1991). These studies showed that the comorbidity ofADHD goes beyond
that of antisocial disorders to include anxiety and depression as well. Considering
that anxiety, depression and conduct disorders may also be associated with specific
cognitive deficits, it is critical to evaluate their role in the neuropsychology of
ADHD. Indeed, little is known about how these factors affect the severity and
pattern of cognitive problems in children with ADHD.
Family studies consistently have found relatives of ADHD probands to be at
increased risk for ADHD (Biederman ^^ a/., 1992; Biederman, Faraone, Keenan,
Knee 8c Tsuang, 1990; Cantwell, 1972; Faraone &: Biederman, 1994; Loney,
Whaley-Klahn, Rosier 8c Conboy, 1982; Morrison & Stewart, 1971; Schachar 8c
Wachsmuth, 1990; Stewart, deBlois 8c Cummings, 1980; Welner, Welner, Stewart,
Palkes 8c Wish, 1977), suggesting that familial ADHD may represent another
subtype of ADHD worthy of investigation with respect to neuropsychological
performance (Seidman et al., 1995). Similarly, recent work has also identified
learning disabilities as another nonpsychiatric comorbidity of ADHD (Faraone
etal., 1993a; Semrud-Clikeman^/a/., 1992). Since learning disabilities are widely
considered to be neuropsychological disorders, it is crucial to distinguish
neuropsychological function in subjects with ADHD with learning disability (LD)
from ADHD without LD.
Our prior work found more school failure, learning disability and intellectual
impairment among children with ADHD compared with normal control children
(Faraone et al., 1993b). We also previously found that those with ADHD were
significantly more impaired on various neuropsychological measures compared
with controls irrespective of psychiatric comorbidity status (Seidman et al., in
press). Moreover, those with a family history of ADHD were most impaired and
ADHD probands with LD showed a pattern suggestive of reduced motor
dominance and extremely slow reading speed. However, our previous results
provided limited information regarding the underlying mechanism that might
account for the observed neuropsychological deficits. Thus in this report, we
follow-up our prior work by evaluating the heuristic value of a more intensive
 Rey-Osterrieth Complex Figure in ADHD 1461

Study of neuropsychological processes using the Rey-Osterrieth Complex Figure

(ROCF) (Osterrieth, 1944; Rey, 1941), a task that involves copying a complex
visual figure, first from a model and then from memory.
The ROCF is of particular interest because it taps a relatively broad set of
functions of theoretical relevance to ADHD (e.g. attention, organization, motor
planning, and learning and retention of complex information) in the context
of other functions (i.e. visual-perceptual and constructional abilities) that are
thought to be less central to the disorder. It also imposes minimal time and
procedural demands, thus increasing its potential value in the clinical assessment
of ADHD. However, scoring ofthe ROCF has been complicated by the absence
of a standard, universally accepted system, a difficulty which has also limited
research activity with this instrument. Fortunately, the scoring problem has been
attenuated by the availability and growing acceptance ofthe developmental scoring
system developed by Waber and Holmes (1985; 1986). In addition to tallying
the number of parts successfully reproduced (accuracy), the Waber-Holmes system
assesses the degree to which these parts are organized in relation to one another
(organization), and determines the style in which the figure is reproduced (part-
oriented or configurational).
Review ofthe literature reveails six studies which have addressed the performance
of children with ADHD on the ROCF. Douglas and Benezra (1990) report that
the quality of ROCF copy productions of children with ADHD were significantly
poorer than those of reading disabled and control children, although they do
not specify the dependent variable or the scoring system from which it was derived.
In contrast, other studies have found no differences between subjects with
ADHD and control subjects on ROCF copy productions, at least when they are
assessed with measures that are presumably similar to the accuracy variable from
the Waber-Holmes system (McGee, Williams, Moffitt &: Anderson, 1989; Moffitt
& Silva, 1988). Nor has accuracy of ROCF recall been found to distinguish ADHD
and control groups (McGee et al., 1989; Moffitt 8c Silva, 1988); however, McGee
and colleagues (1989) report that accuracy of recall productions was significantly
worse for a group of children with both ADHD and reading disabilities.
Although groups of ADHD and control children have generally not been
distinguished by ROCF copy accuracy, they have been impaired on copy
organization as assessed by the Waber-Holmes system. For example, Grodzinsky
and Diamond (1992) found that the ROCF copy productions of children with
ADHD were significantly less organized than those of control subjects. Barr,
Douglas and Sananes (1990) detected similar differences between ADHD and
control children on copy organization but not copy style. Furthermore, they
report significant improvement in copy organization after treatment with Ritalin
(Methylphenidate) in another sample of boys with ADHD. In contrast to these
findings, Barkley et al. (1992) failed to find differences in the organization of
ROCF copy productions of ADHD, ADD, LD, and control children. However,
their sample was small and a trend towards better organization for control children
is evident in their data. Organization and style of recall productions, and the
relation between copy and recall variables have not been addressed together in
any of the studies identified in the literature.
1462 L. J. Seidman et al.

While the above research findings are mixed, it is important to consider the
divergent methodologies employed in these studies. For example, only two of
the studies (McGee et al., 1989; Moffitt 8c Silva, 1988) used both copy and recall
conditions, and only one ofthe studies (Barr et al., 1990) comes close to using
the full complement of available scoring options. Three ofthe studies (Douglas
& Benezra, 1990; McGee et al, 1989; Moffitt 8c Silva, 1988) fail to specify which
dependent measure and scoring system were utilized. Thus, variables of primary
theoretical interest in the study of the ROCF, such as organization, encoding
style, and retention, have been frequently overlooked. The importance of
analyzing ROCF data from a process-oriented standpoint has been emphasized
in the adult neuropsychological literature, where copy strategies have been shown
to predict the quality of recall productions (Bennett-Levy, 1984; Shorr, Delis 8c
Massman, 1992). Absence of group difference tends to be found in studies with
small sample sizes, raising concerns regarding statistical power (Barkley et al.,
1992; Moffitt & Silva, 1988). Only two ofthe studies examined the issue of psychiatric
comorbidity, one in terms of additional psychiatric conditions (Moffitt 8c Silva,
1988), the second from the standpoint of other cognitive (i.e. learning disabled)
disorders (McGee, Williams &: Silva, 1987), and, furthermore, none has addressed
both psychiatric and cognitive comorbidity simultaneously. Because commonly
observed comorbid conditions such as language-based learning disabilities are
also presumed to have a distinct neurocognitive basis, research must demonstrate
that the cognitive effects associated with ADHD are not simply an artifact ofthe
other neurological condition. This need is underscored by recent research
indicating that learning disabled children receive lower organization scores on
the ROCF (Klicpera, 1983; Waber 8c Bernstein, 1994).
The present study was designed to address some ofthe limitations associated
with previous research on ROCF production in children with ADHD. First, the
sample of ADHD children is relatively large (A^=65). Second, family history,
comorbid psychiatric conditions and comorbid learning disabilities were taken
into consideration. Third, the Waber-Holmes developmental scoring system was
used so that accuracy, organization, and style variables could be analyzed for
both copy and recall conditions. Fourth, age and Full Scale IQ were controlled
for; age is bound to have a large impact on cognitive test performance and IQ
discrepancies are often found between ADHD and control children (Barkley,
1990; Faraone et al., 1993b). Finally, a larger range of ages was studied so we
could assess developmental trends within and between groups. The importance
of examining developmental trends in ROCF performance, one ofthe guiding
principles ofthe Waber and Holmes system, has been highlighted in recent research
where differences between groups vary as a function of age in studies of ADHD
(Grodzinsky 8c Diamond, 1992), LD (Waber 8c Bernstein, 1994), and normal
children (Waber, Bernstein 8c Merola, 1989).
Twoapriori hypotheses were tested in this pilot phase of ROCF data collection.
First, it was predicted that children with ADHD would perform less well than
control children on ROCF variables pertaining to organization and planning of
production, presumably because ADHD is a neurocognitive disorder that disrupts
these functions. Second, we expected that the observed differences between ADHD
 Rey-Osterrieth Complex Figure in ADHD 1463

and control groups on organization and planning of production would not be

solely a function of other factors that may affect performance on a complex
constructional and learning task, namely comorbid psychiatric disorders,
comorbid LD, age, or general level of intelligence.

Method
Detailed study methodology is reported elsewhere (Biederman et al., 1992). Briefly, subjects
were 65 individuals with ADHD and 45 normal controls from a larger study examining the intellectual
and academic performance of ADHD children and their siblings. The original study included
140 referred probands with ADHD and 120 normal controls and their 822 first-degree biological
relatives (Faraone et al, 1993b). This subsample was a consecutive series of probands and normal
comparisons seen in the fourth year of a longitudinal study of ADHD. The subjects were ascertained
from two sources; one pediatric, one psychiatric. All probands were Caucasian, non Hispanic
males originally sampled between the ages of 6 and 17. Children who presented with major
sensorimotor handicaps (e.g. paralysis, deafness, blindness), psychosis, autism, or an estimated
IQ less than 80 were excluded. To minimize the potential confounds of severe poverty, subjects
from the lowest HoUingshead-Redlich socioeconomic class (Hollingshead, 1975) were also excluded.
Each ofthe ADHD probands met diagnostic criteria for current ADHD at the time ofthe clinical
referral (i.e. each had at least eight ADHD symptoms active at that time); at the time of recruitment
each had active symptoms of the disorder.
Psychiatric assessments of probands relied on the Kiddie SADS-E (epidemiologic version) (Orvaschel
& Puig-Antich, 1987). Diagnoses were based on independent interviews with the mothers and
direct interviews of probands, except for children younger than 12 years of age, who were not
directly interviewed. The assessment personnel were unaware of proband diagnosis and
ascertainment site (Faraone ^^a/., 1993b). We used the same methods for interviewing and making
diagnoses as in previous studies, which achieved high reliability (Biederman et al., 1990). The
definition of a group of subjects with ADHD-I-psychiatric comorbidity was operationally defined
by presence of either anxiety, depressive or conduct disorders. Subjects with at least one first-
degree relative diagnosed with ADHD were considered to have familial ADHD.
The interviewers assessed academic achievement with the Arithmetic Subtest ofthe Wide Range
Achievement Test—Revised (WRAT-R; Jastak &: Jastak, 1985) and the Gilmore Oral Reading test
(Gilmore & Gilmore, 1968). They assessed intellectual functioning with the Vocabulary, Block
Design, Arithmetic, Digit Span, and Coding subtests of the Wechsler Intelligence Scales for
Children-Revised (WISC-R) (Wechsler, 1974). Using the methods of Sattler (1988), Full Scale IQ
was estimated from the Vocabulary and Block Design subtests.
Reynolds (1984) provides a thorough review of measurement issues involved in the definition
of learning disabilities. A procedure recommended by him and others (Frick et al, 1991) was
selected for use in this study. First, Full Scale IQ and achievement scores are converted to the
Z-scores ZIQ and ZA. Expected achievement score, ZEA, is then estimated by the regression equation:
ZEA=''IQA X ZiQ

where riQA is the correlation between the IQ and achievement tests. Values from the control
sample were utilized; these were .53 and -.07 for arithmetic and reading, respectively. Then, h the
discrepancy score is ZEA-ZA and its standard deviation is (1 -^^IQA) ^'^- We defined as learning disabled
any subject who had a value greater than 1.65 on the standardized discrepancy score:

The ROCF was administered individually to subjects by the interviewers described above according
to the methods described by Waber and Holmes (1985; 1986). The figure was reproduced such
that the base rectangle measured 8.0 cm X 5.5 cm. The figure was photocopied and centered onto
a white piece of paper measuring 8.5" X 11". Subjects were first asked to copy the figure onto
another 8.5" X 11" piece of white paper placed horizontally. They were encouraged to copy the
figure as neatly and accurately as possible. The subjects were given a sequence of colored pencils
1464 L. J. Seidman et al.

with which to draw the figure so that their approach to construction could be more easily discerned
for scoring purposes. Pencils were changed every 45 seconds for children under 9 years of age,
every 30 seconds for children older than 9, and every 20 seconds for subjects older than 16.
Interviewers also kept a record of the order in which lines were drawn, again as an aid to later
scoring efforts. A separate scoring sheet was designed for this purpose and was kept out of sight
during the administration.
After copying the ROCF the interviewers administered the WISC-R Vocabulary and Digit Span
tests. Following a 20-25 min delay the subjects were instructed to draw the ROCF again on a
similar piece of paper, without use ofthe original or previously constructed figure. Subjects were
given only one colored pencil to complete this task. As in the copy condition, the examiner kept
a record ofthe order in which lines were drawn.
Scoring ofthe ROCF was done by two Ph.D level clinical psychologists who were unaware of
all characteristics ofthe subjects including diagnosis. They used the Waber-Holmes scoring system
(Waber 8c Holmes, 1985; 1986). They were trained and supervised in this method by one of this
system's originators Qane Holmes Bernstein, Ph.D), scoring all copy and recall productions in
terms of Accuracy, Organization, and Style of production. Accuracy scores range anywhere from
1 to 65; organization scores (copy, recall) range from 1 to 13. Style categories are coded 1 (part-
oriented) to 4 (configurational) in the copy condition, and from part 1 (part-oriented) to 3
(configurational) in the recall condition. Interrater reliability was determined by having JHB
score 20 proband and control protocols on the same variables. A high level of agreement was
achieved for all six variables ranging from 94 to 100% agreement.
Accuracy and Organization data were analyzed using multiple linear regression techniques.
Style was converted into a dichotomous variable for ease of interpretation; Copy Style categories
of less than four were coded as nonconfigurational while Copy Style categories of four were considered
to be configurational. Recall Style ratings of less than three were grouped together as
nonconfigurational while Recall Style ratings of 3 were coded as configurational. Data were analyzed
using multiple logistic regression. Each regression model was assessed with a variety of diagnostic
techniques to determine whether its assumptions were met. All variables met the necessary
assumptions with the exception of Copy Accuracy which was subjected to a rank normal scores
transformation. Models included age, estimated IQ, family history of ADHD (having at least one
first-degree relative diagnosed with ADHD), presence of learning disability, and presence of psychiatric
comorbidity. This latter grouping was a comparison of those ADHD subjects with (A'^=36) and
without (A''=29) anxiety, depressive or conduct disorders. Because the sample size was relatively
small, we chose not to stratify the sample by specific comorbidities. Demographic variables were
analyzed by Student's f-test.

Results
Demographic variables
ADHD probands did not differ significantly from control subjects in terms of
mean age (14.2 vs. 14.0), grade (8.2 vs. 8.6), or socioeconomic status. The groups
did differ significantly with regard to estimated Full Scale IQ (/7<.OOO5); the
ADHD probands had a mean Full Scale IQ of 110.6 and the control subjects
had a mean Full Scale IQ of 119.4. The ADHD probands had a lower verbal IQ
as estimated by the vocabulary subtest (107.0 ± 14.8 vs. 115.5 ± 11.8,/? = .002)
and a lower performance IQ as estimated by the block design subtest (112.4 ±
16.3 vs. 122.0 ± 13.7,/7=.OO2). Eighteen subjects with ADHD also had a learning
disability (14 had arithmetic disability and nine had reading disability). Three
controls had a learning disability (two with arithmetic and one with reading)
disability. The rates of learning disability were significantly different between
 Rey-Osterrieth Complex Figure in ADHD 1465

ADHD and controls (28% vs. 7%,p=.OO6). Demographic data for the subjects
is presented in Table 1.

Table 1. Demographic characteristics in a sample of ADHD probands and controls

Demographics All ADHD ADHD + Family ADHD + Comorbidity ADHD + LD Controls
History
{N=65) {N=2l) (N=36) (7V= 18) (iV=45)
Mean SD Mean SD Mean SD Mean SD Mean SD
Age 14.2 3.3 15.0 3.0 14.9 5.5t* 14.1 2.2 14.0 3.4
Grade level 8.2 3.0 8.8 3.2 8.9 3.21:* 7.7 2.0 8.6 3.4
SES 1.7 0.8 2.0 0.8t* 1.8 0.9 1.8 0.9 1.5 0.6
IQ estimate 110.6 14.0t** 108.7 14.4t** 110.3 15.lt** 106.5 14.4t** 119.4 9.4
t ADHD vs. Controls by Mest; *p<.05; **p<.Ol.
t ADHD with vs. ADHD without Learning Disabilities, Family History, or Comorbidity.
Underlined values are significant.

ROCF variables
ADHD vs. normal controls. The children with ADHD obtained significantly lower
Copy Organization scores than the control children (see Table 2). ADHD status
remained highly significant {p < .004) in predicting Copy Organization scores even
when controlling for the significant effects of age {p < .0001), estimated IQ {p < .04),
and Copy Accuracy (p < .0002). There was no difference between groups on Copy
Accuracy once the significant effects of age {p < .001) and IQ {p < .03) were taken
into account. There was no difference between groups on Copy Style when
controlling for age and IQ, neither of which contributed significantly to prediction
(see Table 2). OFthe three recall variables, ADHD and control subjects differed
significantly only in terms o£ Recall Style. ADHD status significantly predicted
{p < .01) Recall Style scores even when controlling for the nonsignificant effect
of IQ and the significant effect of age (p < .02). Thus 72% ofthe control children
recalled the figure in a configurational manner while only 50% ofthe children
with ADHD did so.

ADHD and learning disabilities. ADHD children with comorbid learning disability
(LD) obtained significantly lower (p < .03) Copy Organization scores than ADHD
children without identified LD and both performed significantly more poorly
than controls. Age and IQ did not contribute significantly to prediction of Copy
Organization scores when in the same model as LD status. LD status did not aid
in the prediction of Copy Style, Recall Organization or Recall Style scores.

ADHD, psychiatric comorbidity and family history. Psychiatric comorbidity did not
contribute significantly to the prediction of either Organization or Style scores in
either Copy or Recall conditions, although there was a trend {p < .06) for lower
Recall Organization scores in ADHD probands with psychiatric comorbidity versus
1466 L. J. Seidman et al.

those without psychiatric comorbidity. Family history ofADHD was not significantly
related to any ROCF variable.
Age played an important role in the prediction of scores. Age contributed
significantly to the prediction of all variables (it was positively correlated with
performance) except Copy Style, even when controlling for ADHD status and IQ.
However, in no case was there a significant interaction between age and ADHD
status.

Table 2. Rey-Osterrieth complex figure test performance in ADHD probands and controls

Organization All ADHD ADHD + Family ADHD + Comorbidity ADHD + LD Controls

History
(TV = 65) (Ar=i8)
Mean SD Mean SD Mean SD Mean SD Mean SD
Copy
Organization 8.7t** 4.1 9.6 4.4 9.1t** 4.0 7.2t**** 4.7 11,.1 3,.1
Accuracy 62.5t* 7.3 62.2 9.1 62.5 7.2 60.8t*t* 10.3 64,,0 3 .3
Recall
Organization 7.3 4.4 7.4 3.9 6.8 4.4 6.3 4.2 8.:3 4 .4
Accuracy 48.7 12.2 47.6 12.0 49.5 11.2 47.5 13.8 53,.2 8,.0
Style % % % % %
Copy
Configurational 40.6 47.6 36.1 38.9t* 42.2
Outer Part, Inner 9.4 0.0 13.9 11.1 6.7
Configurational
Outer 29.7 23.8 36.1 16.7 28.9
Configurational
Inner Part
Part 20.3 28.6 13.9 33.3 22.2
Recall
Configurational 50.0t* 47.1 45.51" 52.9 71.4
Intermediate 24.1 23.5 21.2 11.8 19.0
Part 25.9 29.4 33.3 35.3 9.5
t ADHD vs Controls by Mest; */)<.O5 ; **jf)<.OI.
t ADHD with vs ADHD without Learning Disabilities, Family History, or Comorbidity.
Underlined values are significant.

Effects of medication. Forty six (71%) ofthe 65 ADHD subjects were receiving
medications (some more than one) whereas none (0%) of the controls were
medicated. Thirty one (48%) were taking stimulants (methylphenidate, A/^=26;
dextroamphetamine, N=2>', pemoline, N=2), 22 (34%) were taking tricyclic
antidepressants (desipramine, N=17; nortryptiline, N=S; imipramine, N=2)
 Rey-Osterrieth Complex Figure in ADHD 1467

and 15 (23%) were taking other psychotropic medications.

Table 3 shows ROCF results comparing the 46 children with ADHD on one
or more medication with the 19 on no medication. Analyses indicated that ADHD
subjects with and without any medication were significantly impaired on Copy
Organization compared to controls. Those who were taking medication were also
significantly impaired on Recall Accuracy and Recall Style. Inspection ofthe means
of all ROCF variables suggests a similar pattern of performance in unmedicated
and medicated ADHD subjects.

Table 3. Association between medication use and Rey-Osterrieth scores

Organization ADHD + Medication ADHD-- Medication Normal Controls

{N = 46) {N=19) (iV = 45)
Mean SD Mean SD Mean SD
Copy
Organization 8.9t 4J 8.2t 4.1 11.1 3.1
Accuracy 62.6 M 62.2 9.3 64.0 3.3
Recall
Organization 7.5 4^ 6.8 4.1 8.3 4.4
Accuracy 48.2t 13.0 49.9 10.1 53.8 8.0
Style % % %
Copy
Configurational 42 40 44
Recall
Configurational 48t 56 72
t /><.O5 when compared with normal controls.
Underlined values are significant.

Discussion

The results supported both of our hypotheses. Children with ADHD

demonstrated less organized performance on the ROCF when compared to control
children, and the differences in functioning observed between the groups were
not explained by comorbid psychiatric conditions, LD, age or estimated IQ.
These results add to our previous work which found more school failure, LD,
intellectual impairment and neuropsychological dysfunction among children
with ADHD compared with normal control children (Faraone et al., 1993b; Seidman
et al., in press). Those results corroborated other studies by finding impairments
in both achievement and ability measures (Barkley, 1990; Frick et al., 1991; McGee
et al., 1989). Moreover, our ROCF data emphasizing the copy organizational
deficits in ADHD supports previous research using the Waber-Holmes scoring
1468 L. J. Seidman et al.

system with ADHD children (Barr et al., 1990; Grodzinsky & Diamond, 1992).
When copying the ROCF, the ADHD children were less accurate in their
renderings, leaving out a significantly larger number of specific features than
did the control children. However, the difference between the groups on the
accuracy measure was no longer significant after controlling for the effects of
age and IQ. Furthermore, the large majority of children with ADHD included
nearly every scorable component of the ROCF, and in most instances when
omissions occurred, only a small fraction of total scorable units were excluded.
Style of copy reproduction also did not distinguish the two groups. Less than
half of the children in each group used a configurational style (i.e. reproducing
larger perceptual units such as an entire diagonal line) when copying the figure,
while the majority in each group reproduced the figure by drawing smaller
units, one step at a time.
ADHD children were significantly impaired on the organization of copy,
which assesses the extent to which various elements of the reproductions were
organized in relation to one another. Their lower level of functioning on this
m'^asure was not a function of differences in age, IQ, or the number of ROCF
elements included in the reproduction.
When asked to reproduce the ROCF from memory, children with ADHD and
control subjects did not differ significantly in the number of elements remembered
or in the extent to which the elements were organized in relation to one another.
However, a significantly larger percentage of control subjects recalled the figure
using a configurational style. Thus, in the recall condition the ADHD children's
organization of the figure improved in relation to the control children but a
significantly smaller proportion of them made the shift to a configurational style
of reproduction.
These results have a number of potential implications regarding the
neuropsychological functioning of children with ADHD. First, the relative
weakness in organization observed in the copy condition—together with
comparable performance in terms of accuracy and style of production—confirms
previous research findings (Barr ^^a/., 1990; Grodzinsky 8c Diamond, 1992) and
generally supports the notion that children with ADHD suffer from cognitive
difficulties that are both specific and identifiable. Second, the lack of difference
in accuracy scores in both conditions, and the comparable organization scores
in the recall condition, suggest that other cognitive functions such as visual-
motor integration and visual memory are relatively intact in this ADHD sample.
Third, the relative improvement observed for children with ADHD in organization
following a 20 min interval suggests that their initially low organization scores
may have been in part a function of impulsivity and lack of planning.
A related and fourth implication stems from the significant difference in the
percentage of children using a configurational style at recall. This finding
suggests that the difference between groups may extend beyond one of impulse
control and planning. A configurational approach to recall implies that a subject
has perceived and then imposed a specific organization on output. This style is
associated with older children (and hence more mature cognitive functioning)
both in this sample and the one on which the scoring system was developed
 Rey-Osterrieth Complex Figure in ADHD 1469

(Waber & Holmes, 1985; 1986). Although this variable is labeled "style" in the
Waber and Holmes system, it may also tap higher order organization skills,
particularly in the recall condition prior to which there has been a period of
time to consolidate information in memory. If this interpretation is correct,
significantly fewer children with ADHD imposed a higher level of organization
on recall production, even when accounting for the significant effects of age
and IQ.
Consideration of comorbidity status revealed that the ADHD children with
LD achieved significantly lower organization scores in the copy condition than
the ADHD children without LD. In contrast, no differences were found between
the groups with and without LD on any ofthe other ROCF variables. The relatively
lower organization scores associated with LD is consistent with prior research
using the ROCF (Klicpera, 1983; Waber 8c Bernstein, 1994), and underscores
the necessity to account for this source of variance in future research. The children
with ADHD who did not have LD performed significantly worse as a group than
the control children, indicating that LD does not completely account for the
difference in organization scores found between ADHD subjects and control
subjects. However, learning disabilities did appear to have an additional
compromising effect on the organization score ofthe ROCF.
In order to determine the neurocognitive basis for the effect of LD on ADHD
it will be necessary to have more refined definitions of LD based on more
comprehensive LD assessment. In a larger sample, it would also be useful to
determine if the ROCF correlates of LD were dependent on the method of defining
LD. We were limited by the heterogeneous composition of the LD group
employed in this study as well as by the broader lack of consensus regarding the
most reliable and valid definition of learning disability. Future research might
contrast ADHD children with language-based LD with ADHD children with
nonverbal LD to determine if they perform differently on the ROCF (Semrud-
Clikeman 8c Hynd, 1990; Weintraub 8c Mesulam, 1983). Making these distinctions
will aid in further clarifying the cognitive effects associated with LD and ADHD.
Although preliminary, the data indicate that ADHD children with comorbid
psychiatric conditions did not differ significantly from ADHD children without
comorbidity on any of the ROCF variables. This outcome suggests that the
impairment indexed by the ROCF may be a correlate of ADHD and not of its
commonly associated comorbid conditions. However, a trend towards lower
organization scores on recall was found for the ADHD children with psychiatric
comorbidity, thus suggesting that a significant difference might emerge in studies
with greater statistical power. Moreover, our sample size was too small to consider
the specific effects of anxiety, depression or conduct disorders.
Another limitation of our design is that approximately 71% of the ADHD
children were medicated at the time of assessment compared to none of the
controls. The effects of medication in this sample are unclear because probands
were not only receiving stimulants to treat ADHD symptoms (which tend to
improve some aspects of attentional functioning, (Barkley, 1990) but they were
also receiving other medications whose neuropsychological effects may be less
positive. However, analyses indicated that subjects with ADHD with and without
1470 L. J. Seidman et al.

any medication were significantly impaired on Copy Organization compared to

controls. Moreover, inspection of the means of all ROCF variables suggests a
similar pattern of performance in unmedicated and medicated ADHD subjects.
Clearly, more work in larger samples ofboth medicated and nonmedicated subjects
is needed to clarify further the effect of medications on ROCF performance in
ADHD.
A limitation of our study is that its sampling rules selected a relatively high-
functioning sample. This is clearly seen in the relatively high mean IQ scores
of our ADHD and control subjects. These high scores are, however, consistent
with our exclusion criteria. We excluded subjects with a Full Scale IQ less than
80 and subjects from the lowest socioeconomic stratum. Also, children with ADHD
were excluded from our normal control sample. Given that both social class
(Matarazzo, 1972) and ADHD are predictive of intellectual functioning, our control
group should have higher than average WISC-R scores. We also note that
WISC-R IQ scores are approximately five points higher than those obtained
contemporaneously from its revision, the WISC-III (Flynn, 1987; Wechsler, 1991).
The results from this pilot study suggest that the ROCF, when used in
conjunction with the Waber-Holmes developmental scoring system, is a promising
indicator ofthe planning and organizational difficulties associated with ADHD.
That the differences between various ADHD and control groups are limited to
certain variables underscores the utility of a more complex scoring method such
as the developmental system. The differentiated pattern of results also represents
a first step in specifying more clearly the cognitive difficulties associated with
ADHD which may lead to more specific psychoeducational interventions.
Planning and organizational skills, represented by the organization and style
variables, clearly warrant further examination, as do issues of learning and memory
that become evident with inclusion of recall productions. Furthermore, the present
research findings need to be replicated in girls and further attention will need
to be given to the developmental trends associated with the cognitive effects
associated with ADHD and its comorbid conditions. Future research needs to
link ROCF measures of organizational capacity with direct measures of cerebral
functioning before concluding that these cognitive deficits in ADHD are due to
hypothesized abnormalities in frontal networks (Cummings, 1993).

Acknowledgements—This work was supported, in part, by USPHS (NIMH) grant ROlMH-41314-

01A2 (J.B.). We thank Drs. Benjamin, Kolodny, and Krauss from the Pediatric Department of
the Harvard Community Health Plan, Dr. James Perrin from the Pediatric Service of the
Massachusetts General Hospital and Ms. Deborah O'Donnell for their contribution to this work.

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