Analysis of the Reality Comprehension Clock Test (RCCT) for Individuals Diagnosed with Down Syndrome

Validity and Reliability: Analysis of the Reality Comprehension Clock Test (RCCT) for Individuals Diagnosed with Down Syndrome

H, Roy Olsson Jr

OBJECTIVES: The purpose of this study was to determine the validity and reliability of the RCCT with individuals diagnose with Down Syndrome (DS). METHODS: Thirty-nine individuals diagnosed with DS completed the Wechsler Adult Intelligence Scale (WAIS) and two Reality Comprehension Clock Tests (RCCT) five to seven days apart. RESULTS: Criterion-related validity was strong between the WAIS and RCCT with a coefficient of .80. Additionally, the RCCT was able to discriminate between the American Association for Mental Disorders classifications (p

KEY WORDS: Alzheimer’s Disease; Assessment; Clock Tests; Dementia; Down Syndrome; Mental Retardation; Reality Orientation.

Down Syndrome (DS) (trisomy 21) is one of the most serious birth defects affecting 1 case per 1,000 births (Centers for Disease Control [CDC] 1991). DS is the most common cause of mental retardation in North America. Individuals with DS have a life expectancy that has increased from 8 years in 1929 to 45 years in 1989. A study of individuals with DS living in British Columbia reported that over 50% live into their 50’s, 40% to age 60 and 13% to age 68 (Baird & Sadovnick, 1989). Individuals with DS are more likely to show declines in functioning after reaching age 50 than are adults with mental retardation (MR) from other etiologies (Zigman, Schupf, Zigman & Silverman, 1993).


One of the most serious problems with increased lifespan in individuals with DS has been the appearance of Dementia of the Alzheimer Type (DAT). DAT is a growing health problem and is the leading cause of death among elderly people (Crocker, 1988). DAT is a chronic degenerative disorder that causes premature senile dementia. The development of dementia in mid-life is an increased source of mortality and morbidity for individuals with DS. Improved medical care and the creation of community programs have resulted in a shift in medical care to the community physicians. The influx of DS adults places primary care physicians and health care providers in a situation of “need to know”.

Health care providers “need to know” that the clinical features of dementia in people with DS are similar to dementia in the general population. These changes include; loss of memory, cognitive decline, changes in adaptive behavior, neurological changes and language difficulties (Holland, Hon, Huppert, Stevens & Watson, 1998). Declines in functioning of individuals with DS has been attributed to the presence of Alzheimer disease (AD) neuropathology which has been found on autopsy in virtually all cases over 40 years of age (Mann, 1993). While significant AD like changes are observed as early as 30 years of age, prevalence rates of clinical dementia characteristics of AD begin to escalate in the fourth and fifth decade of life. Even without dementia, adults with DS are known to have declining cognitive function (Das, Divis, Alexander, Parrila & Naglieri, 1995). Thus, it is suggested that early signs of dementia may be detected by approved exams that discriminate between individuals with DS and non-DS beginning at age 40 (Das & Mishra, 1995). When assessing DS and AD, several molecular and clinical similarities have been detected. The most noteworthy is the hyperproduction of B-amyloid in the brains of individuals affected with AD as well as aging DS individuals followed by dementia. Also, individuals with AD exhibit dermatoglyphic patterns similar to those in DS (Petronis, 1999). Other molecular researchers have found that DS adults with apolipoprotein E3/4 and 4/4 genotypes are four times more likely to develop AD symptoms compared to those with the 3/3 genotype (Schupf et al., 1998). Although this is known, it does not answer when or why dementia manifests, or if its progression can be slowed with any interventions.

One difficulty in detecting dementia in individuals with DS is the lack of standardized measures to detect dementia. A second difficulty in detecting AD in individuals with DS is due to pre-morbid intelligence performance on standard cognitive instruments. Thus, signs of early DAT may go unrecognized in adults with MR. The clinical symptoms and signs of early disease are frequently missed because of limited communication skills and memory loss. Therefore, it has been suggested that testing include individuals who are of a sufficiently high level of functioning and apply more sensitive diagnostic measures that will provide for a closer association between neuropathology and early signs of AD. To detect dementia, tests should include the use of tasks that involve articulation, planning and attention rather than coding of simultaneous and successive (visuospatial, auditory) information (Das & Mishra, 1995).


To determine if early signs of aging and/or dementia could be detected the Reality Comprehension Clock Test (RCCT) can be used to assess subtle changes in memory and overall cognitive functioning. RCCT was designed to assess reality orientation and comprehension by asking individuals to draw a clock while looking at a sample picture of a clock (Figurel). The RCCT consists of four functional categories that measure Number Awareness, Visual Spatial Functioning, Visual Task Performance and Orientation/Memory. The individual verbally receives instructions to complete the drawing that will, in the end reproduce the clock photo that they reviewed. Points are awarded for the duplication. Administration of the test is 10 – 30 minutes. Thus, the RCCT was used in this study.


The purpose of this study was to determine the validity and reliability of the RCCT with individuals diagnosed with DS. The research questions addressed by this study included: (1) Is there a relationship between the RCCT and the Wechsler Adult Intelligence Scale for individuals diagnosed as DS?; (2) Can the RCCT administered to individuals diagnosed with DS discriminate between the American Association for Mental Disorders (AAMD) classifications?; (3) Is there a relationship between the first and second administration of the RCCT to individuals diagnosed with DS?; and (4) Is there a relationship between the RCCT novice Certified Mental Retardation Specialist (CMRS) and one senior author of the RCCT (expert) when scoring the RCCT?



The subjects were a convenient sample of 39 adults diagnosed with DS employed by six sheltered workshops in Northwest Ohio. Of the 39, nine (23.1%) were classified as mildly retarded, twenty (51.3%) as moderately retarded and ten (25.6%) as severely/profoundly retarded. Twenty-six (67%) were males and thirteen (33%) were females. The age range was 27-51 with a mean of 40.4 and a standard deviation of 5.9. Twenty-two (56.4%) lived with their family, eight (20.5%) lived in a small group home setting of between four to eight residents, eight (20.5%) lived independently or semi-independently, and one (2.6%) lived in a group home larger than 8 residents.

Testing Instruments

Assessment tools used were the RCCT and the Wechsler Adult Intelligence Scale (WAIS). The WAIS (1955) is used to measure the intelligence quotient (IQ) of adults. The full-scale score from the WAIS was used as the score to compare with the RCCT. The RCCT is designed to obtain cognitive comprehension by drawing a picture of a clock. Subjects look at a picture of a clock and attempt to duplicate the picture. A total of 67 points can be awarded for (1) visual task performance (20 pts max), (2) visual spatial placement (23 pts max), (3) number awareness (15 pts max), and (4) orientation/memory (9 pts max).


Each of the subjects was given the RCCT twice between a five and seven day interval by a CMRS. The first RCCT score was compared to the resident’s annual full-scale WAIS IQ score using a Pearson’s r to determine criteria-related validity. In addition, an ANOVA and Tukey N.D. were used to determine if there was a difference in RCCT scores based on mental retardation classification (Mild, Moderate, Severe/Profound). The first score from the RCCT was also compared to the second RCCT using a Pearson’s r to determine test-retest reliability. Finally, the first score from the RCCT (scored by CMRS) was compared to a RCCT Senior Author’s score of the same clock test.


Demographic information (sex, living arrangement and AAMD classification were analyzed using a Chi-Square. The analysis indicated the subjects were male (Chi-Square = 4.3 p

A Pearson’s r of .80 (p

Table 1 delineates RCCT scores compared to AAMD classification for Mental Retardation. A probability of less than .001 indicates that the RCCT can discriminate between individuals classified as Mild, Moderate and Severe/Profound. Results parallel previous findings of the RCCT’s ability to discriminate between scales for the Reisburg, academic grade levels pre-school thru second (Brock, et al., 1999) and AAMD classification (Olsson, Ellis & Kucharewski, 2002).

A Pearson’s r of .98 indicated a strong relationship (p

Results of this study confirm the validity and reliability of the RCCT as a brief measure of cognitive functioning with individuals diagnosed with DS. Previous studies (Brock et al, 1999; Olsson, Greniger & Kucharewski, 2000; Olsson, Kucharewski & Eichner, 2001; & Olsson, Ellis & Kucharewski, 2002) have confirmed the validity and reliability of the RCCT with individuals diagnosed with Alzheimer’s disease and MR. Given the favorable findings that the present study yielded, it is possible that the RCCT could also prove to be a useful and appropriate tool with mentally retarded adults, particularly those with DS. Previous findings (Brock et al, 1999; Olsson, Greniger & Kucharewski, 2000; & Olsson, Kucharewski & Eichner, 2001) suggested strong interrater reliability of the RCCT with various professionals (nurses, recreational therapists, kinesiotherapists, mental retardation professions, and social workers) and students. The previous interrater reliability studies reviewed professionals and students who received training as well as those who administered and scored the RCCT by only reading the manual. Stumbo (2002) cautioned that there are differences between agreement and accuracy when calculating interrater reliability. Agreement (high reliability coefficients) of two or more raters administering and scoring an assessment does not indicate the rater scored the assessment correctly. To obtain accuracy, this study compared novice rates (n = 5) with a senior author of the RCCT. The high interrater coefficient between the novice raters and expert rater along with the interrater results from previous RCCT studies suggests professionals administering the RCCT can consistently and accurately arrive at the correct score.


AD is a debilitating disease that poses many physical, social, psychological and management problems for the individual, their health care providers and family members. Long term preservation of function is a major concern of everyone involved. The early diagnosis and implementation of appropriate interventions may delay the entry into a long term care facility.

Physicians, nurses and allied health care professionals are challenged by caring for those diagnosed with AD as well as those with DS and AD combined. In order to provide appropriate care for patients with co-morbidity, health professionals must have a basic knowledge about gerontology as well as an understanding of the co-existing diseases. For instance, most nursing education programs and allied health care programs stress acute care rather than chronic or community care. Few students learn about caring for patients with dementia, chronic mental illness or the geriatric population. In the early stages of the disease, many patients are cared for at home or live in a group home thus, health care professionals often do not see these patients until 2 to 10 years after diagnosis. Although they are cared for at home, at some point, most will require help from a professional caregiver. In order to meet the needs of the community, health care education programs, such as nursing, need to have faculty serve as mentors to their students by role modeling quality practice when caring for adults with DS and AD as well as geriatric patients. Students should have the opportunity to care for patients with co-morbidity when such clinical experiences are available to help them prepare for the NCLEX exam.


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Roy H. Olsson Jr, PhD, CTRS, Professor, and Department Chair; Sociology; Suzanne Wambold, PhD, RN, Associate Professor and Department Chair, Nursing; both are in The College of Health and Human Services, University of Toledo, Toledo, Ohio.

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