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Can Projective Drawings Detect if a Child


Experienced Sexual or Physical Abuse?: A
Systematic Review of the Controlled Research
ARTICLE in TRAUMA VIOLENCE & ABUSE MARCH 2012
Impact Factor: 3.27 DOI: 10.1177/1524838012440339 Source: PubMed

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Can Projective Drawings Detect if a Child


Experienced Sexual or Physical Abuse?:
A Systematic Review of the
Controlled Research

TRAUMA, VIOLENCE, & ABUSE


13(2) 97-111
The Author(s) 2012
Reprints and permission:
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DOI: 10.1177/1524838012440339
http://tva.sagepub.com

Brian Allen1 and Chriscelyn Tussey2

Abstract
Clinical observations have suggested that children who experience physical or sexual abuse may provide indicators in their
drawings that can distinguish them from nonabused children. Some have even suggested that a childs drawings and the interpretive
testimony of a trained mental health clinician should be admissible in court as evidence of a childs abuse status. Many of these
comments, however, may reflect a limited consideration of the available research. The current article provides a comprehensive
literature review of the controlled research to determine whether any graphic indicators (e.g., genitalia, omission of body parts) or
predefined scoring system can reliability and validly discriminate abused from nonabused children. Results indicate that, although
individual studies have found support for various indicators or scoring systems, these results are rarely replicated, many times
studies finding significant results suffer from serious methodological flaws and alternative explanations for findings (e.g., mental
illness) are often present. No graphic indicator or scoring system possessed sufficient empirical evidence to support its use for
identifying sexual or physical abuse. A discussion of the legal ramifications of these results is provided.
Keywords
physical abuse, child abuse, sexual abuse, forensic interviewing, projective drawings

Child maltreatment is a historically underappreciated social


problem often compounded by the difficulty of accurately
determining the validity of allegations of abuse. Current estimates are that as many as 8% of boys and 25% of girls in the
United States experience sexual abuse before the age of 18
(Pereda, Guilera, Forns, & Gomez-Benito, 2009); however,
findings indicate that less than half of all victims may report the
abuse (Finkelhor, Hotaling, Lewis, & Smith, 1990). Once children do report an experience of abuse, the allegations may
appear unbelievable and may be retracted in the face of mounting consequences to family members and loved ones. Additionally, allegations of abuse frequently lack corroborating
physical evidence. As a result of these factors, prosecution of
maltreatment is often difficult, and it is not uncommon for
mental health professionals to be consulted during the investigation of abuse allegations.
Recognizing that many children may refuse to answer
questions about their abuse, may deny abuse occurred, or have
difficulty verbalizing their experiences, some researchers
began looking to less direct forms of acquiring information.
In the early 1980s, clinicians published numerous reports
detailing the unique features of drawings completed by sexually abused children, such as explicit genitalia and the omission
of hands (Burgess, McCausland, & Wolbert, 1981; Goodwin,
1982; Kelley, 1984). These observations spurred research

efforts to examine the validity of using drawings to determine


sexual abuse and led to many preliminary conclusions that
trained clinicians could detect sexual abuse by interpreting a
childs drawings (Malchiodi, 1990; Miller, Veltkamp, & Janson,
1987). Some went so far as to assert that a childs drawings and
comments, along with the interpretive testimony of a trained
mental health professional, should be admissible in court as evidence of possible sexual abuse (Cohen-Liebman, 1995).
Conte, Sorenson, Fogarty, and Rosa (1991) surveyed 212
mental health clinicians considered to have expertise in the
evaluation of child sexual abuse. Results indicated that 87%
of respondents endorsed the use of free drawings during evaluations, although the manner in which those drawing were
used was not specified. Oberlander (1995) surveyed 31 clinicians in the Boston-area who performed child sexual abuse evaluations to ascertain the types of assessment instruments used

Department of Psychology, Sam Houston State University, Huntsville, TX,


USA
2
Bellevue Hospital Center, New York University, New York, NY, USA
Corresponding Author:
Brian Allen, Department of Psychology, Sam Houston State University, Box
2447, Huntsville, TX 77341, USA
Email: ballen@shsu.edu

98
and justifications for their use. Twenty-eight participants
(90%) believed that childrens drawings were useful, some citing research suggesting the presence of sexually explicit material distinguishes sexually abused from nonabused children,
and that emotional upset at the drawing of the abuse suggests
molestation occurred.
Near the turn of the 21st century, the appropriate use of projective techniques in the assessment of child abuse was controversial. A significant advancement in this debate, however, was
the application of more sophisticated statistical techniques. A
meta-analysis by West (1998) examined 12 studies using projective techniques, including drawings, to discriminate whether
a child had experienced sexual abuse. She calculated an average effect size of d .81, commonly considered large (Cohen,
1988) and concluded that projective techniques are an effective
tool in identifying sexually abused children. However, Garb,
Wood, and Nezworski (2000a) point out that West systematically excluded all nonsignificant findings from her metaanalysis and calculated an effect size for only those findings
that resulted in significant statistical results. Garb, Wood, and
Nezworski (2000b) reanalyzed the data used by West, including all nonsignificant results from the identified studies, and
obtained a more modest estimated average effect size ranging
from .35 to .46.
The nature of the data used by West (1998) and Garb et al.
(2000b) prevents making definitive conclusions about the ability of projective drawings to detect child sexual abuse for three
primary reasons. First, many of the studies compared children
experiencing sexual abuse and displaying psychiatric symptoms to normative data or a control group of children not drawn
from a clinical sample. This leaves open the possibility that any
significant results may have detected emotional distress of
unknown origin as opposed to the experience of sexual abuse.
Second, the meta-analyses did not examine the type of test used
or the scoring system employed, but rather grouped findings
from all identified studies together. It is possible that one particular scoring system or graphic indicator did perform adequately across studies. Third, these meta-analyses were not
comprehensive. Many examinations of the utility of projective
drawings were inexplicably omitted from the West metaanalysis, and correspondingly from the Garb et al. analysis.
These limitations call for a comprehensive evaluation of the
research to determine the suitability of projective drawings in
the evaluation of child sexual abuse.
Numerous authors have evaluated the extant research pertaining to the use of drawings in determining the validity of
sexual abuse allegations. The results of these reviews vary
widely, from conclusions that drawings are useful in distinguishing victims from nonvictims (Burgess & Hartman,
1993; Cohen-Liebman, 1995; Miller et al., 1987), to those suggesting inconclusive findings (Hagood, 1994; Trowbridge,
1995; Veltman & Browne, 2002), and others eschewing the use
of these techniques for the identification of abuse (Murrie,
Martindale, & Epstein, 2009). However, each of these reviews
is limited in some way. Some draw primarily on case reports as
evidence (Burgess & Hartman, 1993; Miller et al., 1987), while

TRAUMA, VIOLENCE, & ABUSE 13(2)


others give weight to uncontrolled studies, many with poor
interrater reliability (Cohen-Liebman, 1995; Hagood, 1994;
Trowbridge, 1995; Veltman & Browne, 2002); some base conclusions on a noncomprehensive review of the available
research (Murrie et al., 2009). Absent from the current literature is a comprehensive review of the research, one that focuses
on studies comparing sexually abused children with an appropriate control group, evaluated by defined a priori criteria.
Not to be overshadowed by the relatively immense attention
paid to the issue of sexual abuse, are the attempts made by clinicians and researchers to identify unique features of the drawings of physically abused children. Similar to sexual abuse,
identification of indicators of physical abuse in drawings may
be used in the assessment and determination of physical abuse,
and in subsequent legal proceedings. Numerous studies have
investigated this issue and are in need of consolidation. This
article provides a comprehensive review of the empirical literature to determine whether the analysis of childrens drawings
using identified indicators or defined scoring systems in order
to detect sexual or physical abuse is supported by the scientific
evidence.

Procedure
Inclusion Criteria
The goal of this review was to identify and examine all studies
meeting each of the following criteria:
1.
2.
3.
4.

Published in a peer-reviewed journal prior to 2011.


Utilized a defined nonabused control group (either normative or clinical).
Clearly specified evaluation criteria prior to the analysis of
data.
The experimental group consisted of children and/or adolescents experiencing either sexual abuse or physical
abuse, but not a combination of different forms of maltreatment (few studies were identified that included groups
with multiple forms of abuse and that met other inclusion
criteria; to assist with interpretation these comparisons are
not reviewed).

These criteria effectively eliminate data resulting from studies


not submitted to or accepted by peer evaluation (e.g., unpublished dissertations and manuscripts), single case reports,
research lacking an appropriate comparison group, examinations based on scales and scoring algorithms constructed after
the initial collection and analysis of data, and post hoc clinician
interpretation. In addition, studies that used a sample of multiply traumatized children were excluded because of the potential for cross-contamination, additive, or interaction effects
that may obscure results.

Literature Search
An exhaustive literature search was performed to identify studies meeting inclusion criteria. The PsycINFO, MEDLINE, and

Allen and Tussey


PILOTS databases were utilized to identify potential studies,
and the following keywords were used: projective, sexual
abuse, physical abuse, drawing, human figure drawing, Kinetic
Family Drawing (KFD), House-Tree-Person, Draw-A-Person
(DAP). In addition, the reference lists of all identified studies
and literature reviews were examined to locate additional
research that may meet inclusion criteria. The search resulted
in 13 reports pertaining to sexually abused children, and 10
studies examining physically abused children.

Literature Review
Even though some protocols and techniques were evaluated
with sexually abused and physically abused populations,
results from these two populations may be expected to differ
because of the phenomenological differences in the experiences. As such, studies pertaining to these populations are
examined separately. Two primary methods of interpreting
childrens drawings are evident in the research: One focused
on identifying specific features of the childs drawing, or
graphic indicators, and the other attempting to define a scoring system or algorithm that can distinguish between abused
and nonabused children. A primary goal of this review is to
identify any scoring systems and/or graphic indicators of
childrens drawings that are consistently indicative of
abuse. Therefore, studies are grouped together based on the
type of assessment protocol utilized (e.g., human figure
drawings, kinetic drawings), and the scoring procedure evaluated. Finally, studies are evaluated in light of their methodological rigor, including interrater reliability, blinding of
the raters to participant condition, the degree of match
between the abused and control groups on extraneous factors (e.g., mental health status), and statistical procedures
employed.

Studies of the Drawings of Sexually Abused


Children
Graphic Indicators
Numerous hypothesized graphic indicators of sexual abuse
are provided in the literature, including: disorganized body
parts, hearts, genitalia, and overemphasized or omitted body
parts, among others (Malchiodi, 1998; Riordan & Verdel,
1991). Commentators have suggested that a given indicator
conveys a specific meaning, such as the omission of persons
suggesting a sense of being abandoned or disorganized body
parts indicating psychopathology resulting from prolonged
abuse (Cohen-Liebman, 1995; Miller et al., 1987). Therefore, one would expect to note the presence of any one of
these indicators in the drawings of sexually abused children
more frequently than in the drawings of nonabused children.
Two primary forms of drawings have traditionally been used
for interpretation purposes: human figure drawings, and
kinetic drawings (see Table 1).

99

Human Figure Drawings


Goodenough (1926) is typically credited with being the first to
develop a drawing technique for psychological purposes. Her
initial attempts to identify concomitants of intelligence
required the child to draw-a-man. Later researchers began
asserting that personality and emotional factors were also evident in the human figure drawings of children (Hammer, 1958;
Koppitz, 1966), leading to many revisions of the initial Goodenough technique. The most popular of these protocols include
the Draw-A-Person (DAP; Koppitz, 1968) and House-TreePerson (Buck, 1948) tests. Although each of these approaches
is different from the others in some way, they all share a common procedure of having the child draw a human figure. Therefore, these techniques are reviewed here collectively.
Genitalia. The most often cited indicator of childhood sexual
abuse is the explicit drawing of genitalia. In 1968, Koppitz collected drawings from over 1,800 children between the ages of 5
and 12 and noted that less than 1% explicitly drew genitalia on
human figures. Building on these findings, DiLeo (1973) conducted his own review of childrens drawings and also concluded that depictions of genitalia are extremely rare;
however, DiLeo went on to conclude that when genitalia was
present, it was most likely the result of surgery focused on the
pelvic region or sexual abuse. Indeed, a number of the earliest
reports, based on case observations and uncontrolled studies,
appeared to confirm DiLeos assertion (e.g., Burgess et al.,
1981; Kelley, 1984).
The first controlled research specifically examining the
presence of genitalia in the drawings of sexually abused children was published by Hibbard, Roghmann, and Hoekelman
in 1987. These authors obtained human figure drawings from
52 children suspected of experiencing child sexual abuse
(CSA), and 52 control children drawn from pediatric medical
clinics. They evaluated the childrens drawings for the presence of five body parts: eyes, vagina, penis, navel, and anus.
Despite using a one-tailed Fishers exact test and having sufficient interrater reliability, no significant difference between the
sexually abused and nonabused groups was found at the p < .05
level. Finding that only 6 of the 104 children drew genitalia (5
CSA, 1 control), the authors concluded that the study lacked sufficient power to demonstrate statistically significant results;
however, the authors did calculate that sexually abused children
in their study were 5.4 times more likely to draw genitalia than
the children in the control group. Despite the lack of statistically
significant results and the low rate of children drawing genitalia,
the authors concluded that the presence of genitalia on a drawing
should alert one to the possibility of sexual abuse.
Hibbard and Hartmann conducted two follow-up examinations to the initial Hibbard et al. (1987) study. In the first examination (Hibbard & Hartmann, 1990b), the authors followed a
similar methodology to the initial study but increased the sample sizes to 94 children suspected of experiencing CSA and 100
control group children. In this study, analyses again did not
demonstrate any significant differences for breasts, navels, or

100
Total Score
Total score
None
None
Lower LILIF score
Penis or vagina
EI category: anxiety

D-A-M: 4 indicators
HFD: Koppitz

EI total score; EI total red flag itemsa

Scale: Preoccupation with sexually relevant


concepts

H-T-P: 12 indicators
KFD: 12 indicators
Free Draw: 12 indicators
H-T-P: 12 indicators
KFD: LILIF

HFD: Koppitz

H-T-P/DAP: Van Hutton

Scale: Preoccupation with sexually relevant


concepts

Significant Findings

None
None
Total Score
Total Score
None

Three scales: Aggression and hostility;


withdrawal and guarded accessibility;
alertness for danger, suspiciousness, and lack
of trust
Three scales: Aggression and hostility;
withdrawal and guarded accessibility;
alertness for danger, suspiciousness, and lack
of trust
None

Non-significant findings

Breasts, navels, rectums


All EI indicators, including: genitalia, arm length,
clouds, omission of body parts, and size of
body parts; EI categories: anger, impulsivity,
insecurity, shyness; Total score
52 alleged CSA survivors; 52 normal controls DAP: Five indicators
None
Penis, vagina, eyes, anus, navel
12 CSA runaway survivors; 24 runaway controls DAP: 20 indicators
Less ambiguous gender, faint/sketchy line quality 18 indicators, including: figure completion,
genitalia, breasts, omission of body parts,
covering genital area, legs pressed together
23 CSA survivors; 17 normal controls
H-T-P/DAP: Van Hutton
Four scales: Preoccupation with sexually rele- None
vant concepts; aggression and hostility;
withdrawal and guarded accessibility; alertness for danger, suspiciousness, and lack of
trust
47 CSA survivors; 82 normal controls
H-T-P: Van Hutton
None
Five scales: Preoccupation with sexually
relevant concepts; aggression and hostility;
withdrawal and guarded accessibility;
alertness for danger, suspiciousness, and lack
of trust; total score
12 CSA psychiatric survivors; 12 normal
KFD: Four indicators, Two scales Indicators: Graphic-representative immaturity, None
controls
omission of subjects, body distortion,
emotional proximity; Scales: depression,
anxiety
72 indicators, including: oversexualized figures,
30 CSA psychiatric survivors; 30 psychiatric
DAP: 74 indicators 6 scales
Indicators: Hands omitted, sufficient body
overt genitalia, hand covering genital region,
controls
integration; Scale: Wedges/phallic/circle
vacant eyes; 5 scales, including: sexuality,
sexual features, breasts, shapes
anxiety, poor self-esteem
18 CSA psychiatric survivors; 17 psychiatric
HFD: 2 indicators
None
Over elaboration of male sexual features,
controlsindicators
overelaboration of female sexual features

40 CSA survivors; 40 psychiatric controls


30 CSA psychiatric survivors; 30 normal
controls
94 alleged CSA survivors;100 normal controls
65 alleged CSA survivors; 64 normal controls

89 CSA survivors
77 psychiatric controls

26 CSA survivors; 37 psychiatric controls; 39


normal controls

20 CSA survivors; 39 psychiatric controls

H-T-P/DAP: Van Hutton

Technique: Scores

Note. D-A-M Draw-a-Man; DAP Draw-a-Person; HFD Human Figure Drawing; H-T-P House-Tree-Person; KFD Kinetic Family Drawing; LILIF Like to Live in Family rating procedure.
a
The three groups differed significantly on these variables, but no indication was provided regarding the differences between the three groups and the accurate classification of cases based on these variables was 43.14% and
49.02%, respectively.
b
This study included the subjective opinion of raters on 15 separate dimensions; however, only the two indicators identified here were of sufficient detail to accurately describe what was being rated.
Note. All significant findings indicate that the CSA groups scored significantly more maladaptive than the control group.

Yates, Beutler, and Crago (1985)b

Sidun and Rosenthal (1987)

Piperno, Di Biasi, and Levi (2007)

Palmer et al. (2000)

Louw and Ramkisson (2002)

Hibbard, Roghmann, and Hoekelman (1987)


Howe, Burgess, and McCormack (1987)

Study 2
Hackbarth, Murphy, and
McQuary (1991)
Hibbard and Hartman (1990a)
Hibbard and Hartman (1990b)

Cohen and Phelps (1985)


Study 1

Chantler, Pelco, and Mertin (1993)

20 CSA survivors;

Blanchouin, Olivier, Lighezzolo, and Tychey


(2005)
39 normal controls

Sample

Study

Table 1. Studies Examining the Projective Drawings of Sexually Abused Children

Allen and Tussey


anuses; however, the researchers combined penis and vagina
into one category and, using a one-tailed Fishers exact test,
found that children in the CSA group were more likely to draw
a penis or vagina (7 of the 94) than the control group (1 of the
100). In the second follow-up study (Hibbard & Hartmann,
1990a), the researchers collected human figure drawings from
65 children suspected of experiencing CSA and 64 children
from general medical clinics. They evaluated these drawings
based on the 30 indicators originally proposed by Koppitz
(1968) to identify emotional problems. One of these indicators
is the presence of genitalia in drawings. As in the original
study, the two groups did not differ significantly on the depiction of genitalia, although the authors again noted that a greater
proportion of the CSA group drew genitalia (3 of the 65) than
did the control group (0 of the 64).
Other studies have examined the issue of genitalia in childrens drawings. Howe, Burgess, and McCormack (1987) compared 12 adolescent runaways who reported sexual abuse
histories with 24 runaways reporting no history of abuse. There
were no significant differences between the two groups on the
number of depictions of genitals or breasts in their drawings.
Sidun and Rosenthal (1987), in a study comparing 30 sexually
abused clients receiving mental health services with 30 control
clients also receiving therapy, found no significant differences
between the drawings of the two groups in regard to genitalia,
breasts, or overt sexual features. Similarly, Yates, Beutler, and
Crago (1985) examined the drawings of 18 sexually abused
therapy clients and 17 nonabused therapy clients. Again, analyses did not detect any differences in the presentation of female
and male sexual features.
The studies by Sidun and Rosenthal (1987) and Yates et al.
(1985) are particularly interesting for two reasons. First, control groups included children receiving mental health services.
The inability of these studies to find significant differences,
whereas other studies using nonpsychiatric control groups did,
suggests that emotional problems may be an important factor in
explaining the presence of genitalia in childrens drawings.
Second, it should be noted that neither of these two studies nor
the Howe et al. (1987) study, identified an increased likelihood
of sexually abused children to draw genitalia compared to the
control group. These findings directly contradict those of Hibbard and her colleagues. Perhaps, the safest conclusion one can
draw is that the presence of genitalia in a drawing may be indicative of either emotional problems, sexual abuse, or both;
however, with the available research suggesting extremely
small differences in the drawing of genitalia between target and
control groups, the risk of making a false-positive decision or
incorrectly inferring a history of sexual abuse, is significant.
Sexually related features. Although explicit genitalia is the
most often discussed potential indicator of sexual abuse in childrens drawings, other indicators believed related to genitalia
or sexual disturbance also have been proposed and studied.
Such indicators include attempts to conceal sexual regions,
including drawing the legs pressed together or placing hands
over the genital region and features conveying a sense of

101
exposure, for instance, drawing transparent clothes. In a more
psychoanalytic sense, some have suggested that drawing elongated objects, wedges, or circles are representative of a phallus,
which can cause harm (Malchiodi, 1990) and are suggestive of
sexual abuse. Only three identified studies examined these
indicators.
Sidun and Rosenthal (1987) examined a total of 74 indicators in their study of 30 psychiatric clients with CSA histories
and 30 psychiatric control clients. Among these indicators were
hands covering the pelvic region, trouser fly, circles, wedges,
and phallic-like objects. The only indicator significantly different between the two groups was the presence of a trouser fly;
however, the results ran opposite to the hypothesis with the
control group drawing more pictures with a trouser fly than the
CSA group. When combining circles (e.g., buttons on clothes,
balls, suns), wedges, and phallic-like objects (e.g., canes, cigarettes) into one composite score, analyses were able to distinguish between the two groups, with the CSA group drawing
significantly more of these objects than the control group. The
authors note that these results must be interpreted with caution
because the large number of analyses (80) could produce significant results at the p .05 level by chance at least 4 times.
Howe et al. (1987), in their study with runaway youth, studied a total of 20 indicators in the drawings of sexually abused
and nonabused children, including covering of the genital area,
transparent clothing, dark lines on the clothing around the genital area, and legs being pressed together or crossed. None of
these features distinguished the CSA group from the nonabused
group. Similarly, a study by Hibbard and Hartman (1990a) did
not find significant differences between the control group and
the CSA group on the number of drawings displaying transparencies or legs pressed together. These results do not support the
contention that sexually abused children draw more sexually
related graphic indicators than nonabused children. The only
significant finding in this realm (Sidun & Rosenthal, 1987)
required a composite scale of indicators to detect a significant
difference, and the number of analyses in the study significantly increased the possibility that this difference was
obtained in error.
Body parts/organization. Cohen-Liebman (1995) notes that
sexually abused children may draw elongated arms or legs as
a sign of victimization, omission of body parts as a sign of helplessness or abandonment, and disorganized body parts may
suggest a loss of control or severe psychopathology. Others
suggest that compartmentalization of the figure or individual
parts may suggest one is seeking protection (Miller et al.,
1987). As with sexually related features, only three studies
have examined these indicators.
The study by Hibbard and Hartman (1990a) included 16 of
these indicators, including the omission of numerous body
parts (e.g., eyes, arms, legs, feet, mouth, neck, hands), poor
integration of parts, big hands, short arms, long arms, and
asymmetrical limbs. None of these indicators discriminated
between the CSA and nonabused groups. Similarly, Howe
et al. (1987) found no evidence to suggest that sexually abused

102
children are more likely to draw incomplete figures, omit body
parts, or emphasize the face or hair. Sidun and Rosenthals
(1987) analyses were unable to find significant differences for
any overemphasized body parts, asymmetrical or abnormal
limb length, or the omission of fingers or eyes; however, they
did report two significant findings. First, the CSA group was
more likely than the control group to omit hands from their
drawings. Second, the control group displayed poorer body
integration than the CSA group, counter to the expectation that
CSA survivors would display poorer body integration. As
before, given the large number of analyses, it is quite possible
that these significant results were found in error. In summary,
the preponderance of available controlled research does not
demonstrate that the human figure drawings of sexually abused
children are any more likely than control groups of normal or
emotionally disturbed children to omit, display abnormal size,
or poorly integrate body parts.
Other indicators. Numerous other graphic indicators of sexual
abuse have been proposed and studied. In reviewing the controlled research, no studied indicators were replicated as more
often present in the drawings of sexually abused children.
Howe et al. (1987) found that sexually abused children may
be more likely to draw figures with less ambiguous gender and
to display a faint line quality; however, Sidun and Rosenthal
(1987) were unable to replicate the finding in regard to line
quality and did not find a significant difference in the drawing
of sexually undifferentiated figures. Additional findings suggest that the following graphic indicators do not differentiate
sexually abused and nonabused children: shading, monsters,
clouds, presence of teeth, slanting figure, small figure, big figure, and the use of color (Hibbard & Hartman, 1990a; Howe,
Burgess, & McCormack, 1987; Sidun & Rosenthal, 1987).
Composites. In addition to individual graphic indicators,
some researchers have constructed composite scores of indicators in an attempt to define a scale that may discriminate sexually abused from nonabused children. For instance, Cohen and
Phelps (1985) constructed a scale that included 12 individual
graphic items they hypothesized would manifest more frequently in the drawings of sexually abused children. Utilizing
the House-Tree-Person technique, they compared the total
number of these indicators present in the drawings of 89 CSA
survivors and 77 children receiving mental health services.
They found that the CSA group included significantly more
of these indicators than the control group; however, the actual
magnitude of the difference was small (less than .5 of an indicator) and only one rater scored each drawing. The authors conducted a second study, utilizing the drawings of 40 individuals
from each of the two groups. Initial results from this analysis
demonstrated that the interrater reliability between two scorers
was moderate (.51), prompting the researchers to use four raters
for each drawing and only count an indicator as present if at
least three raters agreed. Using this method, the composite
score of indicators did not discriminate between the sexually
abused and control groups. The moderate interrater reliability

TRAUMA, VIOLENCE, & ABUSE 13(2)


of the second study caused the authors to question the validity
of the results from the first study.
Sidun and Rosenthal (1987), in addition to evaluating
74 graphic indicators, also constructed six composite scales.
These scales included grouping indicators according to the belief
that they denoted anxiety, sexuality, and poor self-esteem. The
authors did not find support that any of these composites distinguished the sexually abused group from the nonabused,
therapy-receiving control group. The only composite that did
significantly distinguish between the groups was the summation of circles, wedges, and phallic-like objects discussed previously. Although research is limited, no present data support
the conclusion that a composite score of graphic indicators distinguishes sexually abused children from nonabused children.
The only significant findings in this regard were not replicated
and presumably suffered from poor interrater reliability (Cohen &
Phelps, 1985) or may have been obtained by chance (Sidun &
Rosenthal, 1987).

Kinetic Drawings
Kinetic drawings, as the name implies, are designed to include
motion or an activity within the picture. The most popular of
these drawings is the Kinetic Family Drawing (KFD; Burns
& Kaufman, 1970), which asks children to draw their family,
including themselves, engaged in an activity. It is believed that
this type of drawing displays the interpersonal communication,
emotional support, and activities characteristic of the family
from the childs perspective (Peterson & Hardin, 1997). Only
three controlled studies were identified that examined the presence of specific indicators or a composite score of indicators in
the KFDs of sexually abused children.
Piperno, Di Biasi, and Levi (2007) examined the KFDs of 12
sexually abused children receiving mental health services and
12 control group children selected from local schools. The
drawings were scored for graphically expressive maturity,
omitted subjects, body distortions, identification roles, and
emotional proximity. Scoring involved a decision of present
or absent and, although the criteria were described in a general
sense, no procedures were defined in the article to aid the
reader in determining whether any one indicator was present.
One assessor administered and evaluated the drawings, and the
decisions of the rater were examined and approved by a clinical
team. A series of chi-squared analyses revealed significant differences between the groups on each of the identified indicators. In addition, the researchers constructed two scales,
depressive feelings and feelings of relationship anxiety and/
or anguish, which required the presence of at three of the five
indicators scored separate from the indicators listed above.
Again, the scoring of these scales was on a present or absent
basis. As before, significant differences were obtained for both
scales between the sexually abused and control groups. The
results of this study are limited due to the fact that raters do not
appear to have been blinded as to the childs abuse status and
the agreement among independent raters was not examined.
The authors note that the findings of this study do not support

Allen and Tussey


the use of their technique to identify abused children but suggest utility in understanding emotional distress.
Cohen and Phelps (1985), in the first study of their article,
obtained KFDs from 89 CSA survivors and 77 children receiving therapy. Using a composite score of indicators, they
detected a significant difference between the CSA and control
group; however, the difference was small with the CSA group
depicting .22 of an indicator more than the control group on
average. During their follow-up study, Cohen and Phelps found
that the interrater reliability of their composite for the KFDs
was low (.37) and they choose not to proceed with examining
group differences. As before, the poor interrater reliability
prompted the authors to question the results from the first
study.
Hackbarth, Murphy, and McQuary (1991) collected KFDs
of 20 sexually abused children receiving counseling and 30
control children recruited from a local school. They analyzed
the drawings using the Like to Live in Family scale developed
by Burns (1982), which requires raters to evaluate the drawing
for signs of positive family relationships. Interrater reliability
was good (.73) and the ratings from five different counselors
were averaged to obtain the score. The results of a t test
revealed that the CSA group scored significantly lower than the
control group, indicating more family problems or less support.
Although the authors suggest that the scale can be useful in
determining sexual abuse, the differential mental health status
of the groups, the fact that all of the sexually abused children
were abused by a family member, and the lack of replication,
places significant limitations on their conclusion. To date, the
quality and results of these studies and the lack of consistent
findings does not support the use of KFDs for determining a
history of sexual abuse.

Scoring Systems
Although individual graphic indicators appear the most popular
method of interpreting childrens drawings, others have
attempted to develop and validate a defined scoring system
in an effort to detect sexual abuse. Most often, these scoring
systems utilize a number of individual indicators and provide
summary scores. For the purposes of this review, a scoring system is defined as a published guide that directs investigators on
the features of indicators necessary for their scoring and the
proper method of computing a summary score. Two scoring
systems were identified in the literature that had been utilized
in controlled trials.

Koppitz Emotional Indicators


Koppitz (1966) hypothesized, based on her clinical experience
and associated research, that 30 features of childrens human
figure drawings could effectively discriminate emotionally disturbed children from well-adjusted children. She categorized
these 30 indicators into three groups: those reflecting poor
quality of the drawing (e.g., poor integration of parts, asymmetry of limbs), those not typically included in childrens

103
drawings (e.g., genitals, hands cut off), and omissions of typical features (e.g., no eyes, no arms). In her comparison of 76
public school children and 76 children receiving mental health
services, 8 of these features were significantly different at the
p < .05 level (poor integration, shading limbs, slanting figure,
tiny figure, big figure, short arms, hands cutoff, no neck).
Her most noteworthy conclusion was the finding that the
emotionally disturbed children drew significantly fewer
total indicators than their counterparts (p < .001). Although
this initial study had several limitations (e.g., one evaluator,
evaluation was not blind, the school children were selected
because of their superior academic and emotional functioning), Koppitz (1968) concluded her system was successful
and published a volume devoted to describing the appropriate manner of using her approach for screening childrens
human figure drawings.
Although she did not hypothesize that her scoring criteria
could discriminate sexual abuse, two studies have evaluated
the use of these indicators for that purpose. Hibbard and
Hartman (1990a) examined the drawings of 65 alleged victims of sexual abuse and 64 children drawn from general
medical clinics. In addition to not finding any significant
individual indicators (as noted above), no significant difference was found for the total number of indicators drawn.
Additionally, they examined differences in the scores of the
emotions/behaviors categories proposed by Koppitz (1984)
for classifying the indicators according to their presumed
underlying emotional symptom (impulsivity, insecurity/inadequacy, anxiety, shyness/timidity, anger/aggressive). The only
significant finding was that the sexually abused group scored
higher on the anxiety category. Given that the authors performed over 35 separate statistical analyses in this study, it
raises the possibility that this lone significant result was
found in error.
Chantler, Pelco, and Mertin (1993) collected human figure
drawings from 26 sexually abused children, 37 children receiving therapy, and 39 children attending a public school. They
examined whether the total score of Koppitz indicators could
effectively discriminate between the three groups. Although
they found that the sexually abused group drew the most indicators (p < .001), a discriminant function analysis found that
these indicators classified children in their correct group only
43% of the time. They also examined the utility of total red flag
items, those indicators that Koppitz (1968) identified as being
especially indicative of emotional problems. As before, they
found that the sexually abused group drew significantly more
of these items (p < .01), but correct classification rate was only
49%. These findings contradict the results of Hibbard and Hartman (1990a), suggesting that a definitive conclusion is not
available. However, Chantler and colleagues demonstrated
that, even with a statistically significant difference, the use of
the total score or total red flag items by clinicians may lead
to more incorrect classifications of cases than correct ones.
These results do not support using the Koppitz total score, emotions/behaviors categories, or red flag item total score, to assess
for a history of sexual abuse.

104

Van Hutton Scoring System


Van Hutton (1994) published a manual describing a scoring
system to detect sexual abuse in children based on drawings
from the House-Tree-Person and DAP procedures. The system
provides scores for four scales: Preoccupation with sexually
relevant concepts (SRC); aggression and hostility (AH); withdrawal and guarded accessibility (WGA); and alertness for
danger, suspiciousness, and lack of trust (ADST). The scale
themes were based on common problems reported with sexually abused children, and the items were based on her review
of the literature for indicators that may be indicative of each
of the four themes. She collected H-T-P and DAP drawings
from 20 sexually abused children and compared them with the
drawings of 145 children collected from public schools and
summer day camps to develop cutoff scores for her system.
Louw and Ramkisson (2002) examined the validity of the
Van Hutton system with a sample of 23 sexually abused and
17 nonsexually abused Indian girls living in South Africa. The
primary author collected H-T-P and DAP drawings from both
groups and analyzed them according to the Van Hutton criteria.
Total scores were calculated for each scale and significant differences emerged on all four scales at the p < .01 level using the
MannWhitney U test. No analyses were completed for
the total score. This study had several limitations, including the
primary author collecting and scoring all drawings, thereby
insuring the data were not scored blind to participant condition
and the scores were not validated by an independent reviewer.
Another study collected drawings from 39 public school students and 39 children diagnosed with a mental health condition
(Blanchouin, Olivier, Lighezzolo, & Tychey, 2005). The drawings were scored according to the Van Hutton system and cutoffs were used to create two groups. These data were compared
with the results reported for the 20 sexually abused children
originally described by Van Hutton. The results of a series of
chi-squared tests found that the SRC scale significantly discriminated between the sexually abused group, and both the clinical and the nonclinical control groups at the p < .01 level.
However, no significant differences were found for the AH,
WGA, and ADST scales. The authors did not specify if one
or multiple raters were used.
Perhaps, the most methodologically rigorous study of the
Van Hutton system was completed by Palmer and colleagues
(2000). They collected archival H-T-P drawings from 47 sexually abused children and 82 nonabused children from the community. The drawings were then evaluated by two raters blind
to the childs abuse status. The interrater reliabilities for the
four subscales varied from .397 (ADST) to .604 (SRC), while
reliabilities for individual items fluctuated from .01 (Picasso
eye) to 1.00 (Palm tree, hair on body, scars, animals drawn
larger/better, steps leading to blank wall). The low to moderate
interrater reliabilities of the subscales are notable because the
authors state that all evaluators participated in numerous training sessions to reach agreement on how to score ambiguous
items. Results of discriminant function analyses found that
none of the four scales, or the total score for all scales,

TRAUMA, VIOLENCE, & ABUSE 13(2)


significantly distinguished the two groups. In summary, across
three studies, the only subscale from the Van Hutton system
that obtained significant results more than once was the SRC
subscale. The most methodologically sound study of the group,
however, did not find significant results for the SRC subscale
and suggested that interrater reliability for all of the subscales
may be poor. These findings suggest that the current evidence
does not support the use of the Van Hutton system to detect
sexual abuse.

Analyses of the Drawings of Physically


Abused Children
Although much of the earliest research examining child maltreatment and projective drawings focused on sexual abuse,
significant research also examines hypothesized indicators of
physical abuse in childrens drawings. With few exceptions,
the same graphic indicators hypothesized to identify sexual
abuse are investigated as possible indications of physical abuse.
Although some scoring systems have been developed, few controlled studies are available as applied to physical abuse. All
suitable research examining individual graphic indicators and
scoring systems are reviewed here according to the projective
technique employed (See Table 2).

Human Figure Drawings


Omissions. One of the most often researched graphic features of the human figure drawings of physically abused children is the omission of body parts, typically arms, hands,
legs, and feet. Culbertson and Revel (1987) collected drawings
from 20 emotionally disturbed children, 20 learning disabled
children, and 20 physically abused children diagnosed with
an emotional disturbance and/or a learning disability. Two
trained raters scored each of the drawings using the Koppitz
emotional indicators and a list of indicators compiled by the
authors from unknown sources. Interrater reliability for both
protocols was good (.89 for the Koppitz indicators and .85 for
the authors list). The researchers found significant differences
for the omission of arms and feet; however, they did not obtain
significant results for the omission of eyes, nose, mouth, legs,
hands, body, and neck. The authors did not complete pairwise comparisons, so it is not possible to determine from the
publication which groups differed significantly, although the
authors note that the physically abused group scored the highest
on each significant finding. The mixing of abuse and emotional/learning disability variables in the target group inherently confounded the study.
However, Prino and Peyrot (1994) collected human figure
drawings from 21 physically abused children and 21 nonabused
children. They examined these pictures for the omission of
hands, feet, and noses and did not find any significant differences between the abused and nonabused groups. Perhaps, the
most interesting results were obtained by Blain, Bergner,
Lewis, and Goldstein (1981), who collected drawings from
32 physically abused children receiving mental health

105

30 CPA survivors; 30 normal controls

39 CPA runaway survivors; 24 runaway


controls
10 CPA survivors; 10 normal controls

12 CPA psychiatric survivors; 12 normal


controls

21 CPA survivors; 21 normal controls

6 CPA survivors; 12 normal controls

Four CPA and one CSA survivors; 23 normal


controls

6 CPA survivors 12 normal controls

Hjorth and Harway (1981)

Howe, Burgess, and


McCormack (1987)
Manning (1987)

Piperno, Di Biasi, and Levi


(2007)

Prino and Peyrot (1994)

Veltman and Browne (2000)

Veltman and Browne (2001)

Veltman and Browne (2003)

None
None
Three indicators, including: incomplete figures, disproportionate size of family
members, disproportionate size of self in
relation to family

KFD: Burns
KFD: 33 indicators

Omitting feet, omitting nose


None

FKD: Manning

KGD: Nine indicatorsb


FKD: Manning

HFD: Nine indicatorsb

KFD: 4 indicators, 2 scales

FKD: Three indicators

DAP: Four indicators

Indicators: Inclement weather, larger size of


weather, movement of weather; Scale:
Total score
Indicators: Graphic-representative immaturity, omission of subjects, body distortion,
emotional proximity; Scales: depression,
anxiety
None

8 indicators, including:complexity of head,


pressured lines, no clothing, vacant eyes,
absence of figure in center of page,
omitted feet, omitted arms, head over
of total figure
6 indicators, including: Fewer erasures,
absence of clothing, absence of detail,
absence of fingers, asymmetry, horizontal
arm position
Less ambiguous gender

DAP: 17 indicators

DAP: 8 indicators

3 indicators, including transparencies absent,


arms omitted, feet omitted

DAP: Koppitz

Five indicators, including: Smoke present from


Chimney (House), absence of windows on
ground floor (House), difference in size of
arms or legs (Person), omission of feet
(Person), disproportion in size of the head
(Person)
Smoke present from chimney (House)

Significant Findings*

Number of red flag indicators; Total score


30 indicators, including,omission of person,
long arms of legs, anxiety actions, isolation
actions, distorted figures, erasures, floating figures, transparencies

Teeth, omitting hands, omitting feet, omitting


nose
Teeth, omitting mouth
Indicators: Inclement weather, size of
weather, movement of weather;
Scale: Total score
Total score

None

None

Figure completion, line quality, color

2 indicators, including: Size of drawing, environmental objects

14 indicators, including: clouds, fruit on trees,


absence of feet, size of limbs, absence of
windows, person composed of geometric
figures, vacant eyes
27 indicators, including: teeth, clouds/rain/
snow, eyes omitted, poor integration of
parts, asymmetry of limbs, nose omitted
9 indicators, including: body distortions, teeth,
large figure, hands cut off, petal fingers,
talon fingers

10 indicators, including: clouds, fruit


on trees, vacant eyes, multiple persons
drawn, ladder leaning on tree, house is
transparent, person composed of geometric figures

Nonsignificant findings

Note. DAP Draw-A-Person; ED emotionally disturbed; FKD Favorite Kind of Day; HFD Human Figure Drawing; H-T-P House-Tree-Person; KFD Kinetic Family Drawing; KGD Kinetic Group Drawing; LD
learning disabled.
a
The authors reported only that there were significant differences among the three groups, but did not complete pair-wise comparisons to delineate which groups were significantly different; however, in each of the
significant findings they note the physically abused group scored the highest.
b
Not all studied indicators were reported by the authors.
Note. All significant findings indicate that the CPA groups scored significantly more maladaptive than the control group, at the p < .05 level.

20 CPA LD or ED survivors; 20 ED controls;


20 LD controls

H-T-P: 15 indicators

32 CPA psychiatric survivors; 32 psychiatric


controls

Culbertson and Revel (1987)a

H-T-P: 15 indicators

32 CPA psychiatric survivors; 45 normal


controls

Blain, Bergner, Lewis, and


Goldstein (1981)

Technique: Scores

Sample

Study

Table 2. Studies Examining the Projective Drawings of Physically Abused Children

106
treatment, 32 nonabused children receiving mental health treatment, and 45 children selected from a local school. When comparing the abused group with the school group, analyses
showed that abused children were significantly more likely to
omit feet from their drawings; however, this difference was not
observed when the abused group was compared to the nonabused clinical group. These results suggest that the omission
of feet may be attributable to the status of receiving mental
health services as opposed to the experience of physical abuse.
Taken together, there is no replicated evidence to suggest that
omitting a bodily feature from a drawing distinguishes physically abused children from their nonabused peers.

Body parts/organization. As with the drawings of sexually


abused children, researchers have examined the possibility that
physically abused children are more likely to draw elongated
arms and legs, include body parts not typically observed in the
drawings of nonabused children, and poorly organize or distort
body parts. Hjorth and Harway (1981) obtained human figure
drawings from 30 physically abused children and compared
them to the drawings of 30 nonabused children from the community. They noted that the drawings of the abused group
demonstrated significantly more asymmetry and horizontal
arm positioning than the control group. Blain et al. (1981) also
found significant differences in the size of arms and legs, as
well as differences for disproportionate size of head, when the
drawings of abused children were compared to nonpsychiatric
controls but did not find these differences when the drawings of
abused children were compared to the drawings of children
receiving mental health treatment. Similarly, Culbertson and
Revel (1987) were unable to find significant differences for
limb asymmetry, poorly integrated parts, or body distortions
when examining the drawings of abused children and nonabused children diagnosed with an emotional disturbance or
learning disability. This last study did find a significant difference when examining a disproportionate size of head. In summary, it does not appear that poor body integration or
asymmetry of limbs is indicative of physical abuse as significant findings were not present when the control group displayed a psychiatric condition; results pertaining to a
disproportionate size of head have not been replicated and conflicting findings are present.
Two body parts, in particular, have received attention in the
drawings of physically abused children: vacant eyes (drawing
eyes without pupils) and teeth. Culbertson and Revel (1987)
found significant differences for vacant eyes among their three
groups of subjects; however, Blain et al. (1981) did not find significant differences between the abused group and either of
their psychiatric and nonpsychiatric control groups. In the two
published studies available, no evidence was found to suggest
that physically abused children are more likely to draw teeth in
their pictures (Culbertson & Revel, 1987; Prino & Peyrot,
1994). At the current time, sufficient evidence does not exist
to support using either vacant eyes or teeth as indications of
possible physical abuse.

TRAUMA, VIOLENCE, & ABUSE 13(2)


Other indicators. Numerous other graphic indicators have
been investigated. Significant, but unreplicated and limited
findings, were found for: drawing smoke from the chimney
of a house (Blain, Bergner, Lewis, & Goldstein, 1981), lack
of transparencies, complexity of head, figure not drawn in the
center of the page (Culbertson & Revel, 1987), fewer erasures,
no clothing, absence of detail (Hjorth & Harway, 1981), and
less ambiguous gender (Howe et al., 1987). There is conflicting evidence regarding pressured or dark lines as distinctive
of the drawings of physically abused children (Culbertson
& Revel, 1987; Howe et al., 1987). No evidence was found
to suggest that any of the following are present more often
in the drawings of physically abused children: clouds, fruit
on trees, person composed of geometric shapes, unusually
large figures, environmental objects, and the use of color
(Blain et al., 1981; Culbertson & Revel, 1987; Hjorth &
Harway, 1981; Howe et al., 1987).

Favorite Kind of Day (FKD)


One projective technique, developed by Manning (1987),
instructs children to draw their FKD. These drawings are then
scored for the presence of inclement weather (e.g., rain, snow),
a disproportionate size or excessive amount of the weather features, and if the weather appears to be falling on other aspects
of the picture. Manning trained three volunteers in the use of
her rating procedure, which included rating the presence of
each of the three features on a scale from 1 (definitely not present) to 5 (definitely present). Each of the raters then scored
drawings from a group of 10 physically abused children and
10 children attending a local school. Interrater reliability for the
total score was calculated as .74 and scores from all three raters
were summed for statistical analysis. Significant results (p <
.001) were obtained for each of the three features as well as the
total score. Rather large differences were reported for each feature and the total score (abused group 13.7, control group
4.2).
Veltman and Browne (2000) conducted two replication
trials of the FKD technique. In the first study, the researchers
used a sample of six physically abused children and two
matched control groups each consisting of six children from
local schools. The scoring procedure was the same as in the
Manning (1987) study and three raters were trained and utilized. As with the Manning study, total score interrater reliability was acceptable (.77); however, unlike the Manning study,
no significant differences were found for any of the three
weather features or the total score. In their second study, Veltman and Browne (2001) asked raters to evaluate the pictures of
a class of 28 children, 4 of whom had suffered physical abuse
and 1 sexual abuse. Using the FKD technique, the raters were
only able to correctly detect one of the five maltreated children,
and neither rater identified even the potential of maltreatment
from the drawings of the other four abused children. However,
at least two nonabused children were identified by one or both
raters as most likely abused, and five of the nonabused children
were classified as undetermined. Statistical analyses were

Allen and Tussey


unable to detect any significant differences between the drawings of abused and nonabused children. The researchers did
report acceptable total score interrater reliability (.83). Interestingly, the significant results obtained by Manning (1987) failed
to be replicated in two subsequent trials. As such, it does not
appear that the FKD technique has sufficient basis to warrant
its use in detecting the physical abuse of children.

Kinetic Drawings
Controlled research has studied a number of different
approaches to interpreting the kinetic drawings of physically
abused children. Veltman and Browne (2003) examined the
kinetic family drawings of 6 physically abused children and
12 children drawn from local schools for the presence of 33
indicators originally cataloged by Peterson and Hardin
(1997). Of these, they found significant differences for only
three: incomplete figures, disproportionate size of family members, and disproportionate size of self in relation to family.
Prino and Peyrot (1994) found that physically abused children
were more likely to omit feet and noses from a kinetic group
drawing, but found no differences for the omission of mouth
or presence of teeth. Piperno et al. (2007) observed significant
differences between 12 physically abused children receiving
therapy and 12 normal controls for each of their four indicators
(graphic-representative immaturity, omission of subjects, body
distortion, emotional proximity) and two scales (depression,
anxiety); however, as noted above, the scoring criteria used
by Piperno et al. was vague and it is unclear what constituted
the presence or absence of an indicator.
None of the identified significant findings have been replicated and conflicting evidence exists in the case of some of
these findings. For instance, the study by Veltman and Browne
(2003) did not find significant differences for the omission of
persons, distorted limbs, and a scale of feeling/mood, which
appears to contradict the Piperno et al. findings pertaining to
omission of subjects, body distortion, and scales of emotional
functioning. It is also unclear if significant findings are indicative of physical abuse or the result of emotional disturbances
that may be observed in nonabused children. In addition, a
study by Veltman and Browne (2001) found that raters were
unable to distinguish maltreated children from nonmaltreated
children by identifying the number of indicators present in their
drawings and had an exceptionally high false identification
rate. At the present time, the available controlled research does
not support the interpretation of kinetic drawings as a tool in
identifying physical abuse.

Conclusions
The use of childrens drawings in determining sexual or physical abuse was initially supported by case reports and uncontrolled research, leading many to assert that clinical
interpretation was a valid approach to identifying signs of
abuse. Controlled research, which more systematically examines the differences between abused and nonabused children,

107
was slower to develop. Over the past 30 years, controlled
research examined various scoring systems and individual graphic indicators. The quality of these studies varied widely and,
accordingly, interpretations of the findings are often difficult.
Previous reviews and commentaries commonly singled out significant findings as evidence of the validity of this approach
and neglected contradictory findings, methodological weaknesses, and poor reliability.
Although many studies found myriad significant findings
(e.g., omitted hands, poor body integration), other trials failed
to observe similar results. In addition, as the methodological
rigor of the study increased, the likelihood of finding significant results decreased. The failure of consistent replication,
especially under more rigorous conditions, suggests the likelihood of erroneous findings. Therefore, one cannot assert from a
scientific perspective that any identified indicator or scoring
system is valid for the purpose of identifying child sexual or
physical abuse.
The most often identified and studied indicator of sexual
abuse in children is the explicit drawing of genitalia. The result
of this review suggests contradictory findings. A series of studies by Hibbard and colleagues (1987, 1990a, 1990b) found a
significant difference only once and identified a nonsignificant
trend in the other two studies, with sexually abused children
drawing a penis or vagina more often than their nonabused
peers. Studies by other researchers were unable to find significant results or identify trends, including two studies that utilized a clinical control group (as opposed to the Hibbard and
colleagues studies that utilized a nonclinical control group).
Although many clinicians believe the drawing of explicit genitalia is suggestive of a history of sexual abuse (Oberlander,
1995), the current review finds that the sensitivity of this technique to the experience of sexual abuse is poor as very few
sexually abused children actually draw explicit genitalia. Even
findings that did suggest possible merit, observed relatively
small differences between the abused and nonabused groups.
Therefore, even if drawings of genitalia are more common
among sexually abused children, the rarity of such drawings
and the significant likelihood of incorrectly classifying a child
as sexually abused, discourage the use of this indictor in
assessment.
As well as problems with the validity of interpreting drawings to detect abuse, many of the identified indicators and scoring systems displayed poor interrater reliability. Sufficient
interrater reliability is generally considered .80 or greater (Heiman, 1999; Landis & Koch, 1977). Many of the studies identified failed to report interrater reliability; however, those that
did displayed a wide variation. Although some individual indicators displayed acceptable interrater reliability, none of the
scoring systems examined consistently reported reliabilities
above .80. This suggests that, even when using a defined scoring system or graphic indicator, results may depend a great deal
on the judgment of the clinician interpreting the drawings.
Proponents of the interpretive value of drawings maintain
that other factors also must be considered when evaluating for
a history of abuse, such as interviews and collaborative reports

108
(Cohen-Liebman, 1999; Peterson & Hardin, 1997). In other
words, projective drawings may be only another piece of information to consider. However, the consideration of invalid and
unreliable forms of data may reduce the accuracy of ones judgment; more information is not always better if the information
is poorly suited for answering the question at hand (Erickson,
Lilienfeld, & Vitacco, 2007). The poor reliability and validity
demonstrated by projective drawings suggests that giving
weight to these techniques may reduce the accuracy of ones
judgment. For instance, Chantler et al. (1993), in the only identified study of its kind, compared the predictive accuracy of the
Louisville Behavior Checklist (LBC; an objective standardized
questionnaire) to the number of Koppitzs red flag indicators
present in childrens drawings. Using the LBC, 75% of children
were correctly classified as sexually abused, nonabused and
emotionally disturbed, or nonabused and nondisturbed. The
total number of Koppitz red flag indicators correctly classified
49% of children. When used in combination, the number of red
flag indicators and the LBC correctly classified 77% of the
children; a minimal improvement over the LBC alone.
Although confidence intervals were not provided, the small
magnitude of difference between the combination of scores and
only the LBC suggests little, if any, benefit to the addition of
the Koppitz flag indicators. However, given that clinicians
rarely use statistical or algorithmic procedures when arriving
at conclusions, it may be expected that weight given to results
of the Koppitz indicators during the assessment procedure may
actually reduce the accuracy of ones assessment than if the
LBC was used solely.
The poor results found for the interpretation of childrens
projective drawings should not detract from other uses of drawings. For instance, some research suggests that children may
provide more details of an event if asked to draw the event
or are shown a human figure drawing after providing a verbal
description of their experience (Aldridge, Lamb, Sternberg,
Orbach, Esplin, & Bowler, 2004; Katz & Hershkowitz,
2010). Although still in need of further research, these
approaches utilize drawings as aids in prompting child recall.
The current literature review demonstrates that attempts to
identify projective indicators of sexual and physical abuse in
drawings completed by children are not supported by the existing evidence.

Legal Implications
Practitioners are urged to carefully consider the results from the
current review. While the implementation of psychological
tests, and use of projective drawings, continues in forensic
assessment, the court system has been involved in the ongoing
development of criteria for admissibility of expert testimony.
In order to be accepted as an expert, the professional should
have scientific, technical, and/or specialized knowledge that
will assist the fact finder with the legal question.
The original legal standard developed to guide expert testimony was Frye v. United States (1923), which states that an
expert opinion should be based on procedures that have

TRAUMA, VIOLENCE, & ABUSE 13(2)


general acceptance in that discipline. Under the Frye test,
expert opinion based on scientific technique was inadmissible
unless the technique was generally accepted as reliable in the
relevant scientific community. The Federal Rules of Evidence
(FRE) were introduced in 1975, and a revision of FRE (1992),
Rule 702 (FRE 702), relaxed Frye parameters by allowing federal, and some state courts, to permit admissibility of information that is helpful or provides assistance to the trier of
fact, so long as it is accepted within a specialized professional community (OConner & Krauss, 2001).
Eventually, the Daubert rule was formed from three United
States Supreme Court cases including Daubert v. Merrell Dow
Pharmaceuticals (1993), General Electric v. Joiner, (1997),
and Kumho Tire v. Carmichael, (1999). This trilogy of cases
resulted in a two-pronged test to determine expert testimony
admissibility. Essentially, testimony had to be both scientifically valid and reliable. Under Daubert, the four criteria used
to distinguish pseudoscience from science in the courtroom
are (1) the theory or technique is falsifiable (it can be and has
been tested), (2) the theory or technique has been subjected to
peer review and published in professional journals, (3) the theory or technique has a known or potential rate of error and
there are standards controlling the techniques operation,
and (4) the theory or technique enjoys general acceptance
within a relevant scientific community. These criteria are
not exhaustive, and the court did not rule that testimony had
to include all four elements. Currently, the Daubert standard
is the rule of evidence in United States federal legal proceedings and in many states; however, there are some jurisdictions
which continue to adhere to the Frye standard, Rule 702 of the
FRE, or a variation of these standards.
The current study highlights difficulties with the theoretical
underpinnings of projective drawings in the use of child abuse
evaluations, the potential confounds and limitations of these
measures, and the professional criticism and questionable relevance of the drawings. In essence, Daubert requires that admissible expert testifiers speak to products of scientific
methodology. Psychometric assessment requires fidelity to
reliability, validity, and normative comparisons in order to be
considered scientific, and as this review illustrated, projective drawings for the use of child abuse assessment have not
consistently been found to meet these requirements. Indeed,
regardless of the admissibility standard utilized, these measures
are unlikely to be admitted without issue, if at all. Given the
aforementioned deficits, it is logical, and perhaps necessary,
that challenges would emerge when testifying about projective
drawings as used in these forms of evaluations.
The current findings are not new; rather, they represent a
more comprehensive and methodologically rigorous review
pertaining to this topic than those previously completed. For
example, in a previously related, but broader, example of the
potential pitfalls associated with projective measures in forensic evaluations, Lally (2001) examined the utility of human figure drawings in court. Lally concluded that the two most
commonly used methods for scoring human figure drawings,
global impressions, and specific signs, did not satisfy the

Allen and Tussey


Daubert (1993) criteria. Lally also noted that overall rating
scales, such as the Koppitz and Van Hutton scoring systems,
seem to partially meet a number of the Daubert (1993) criteria
and may be admissible; however, their validity is questionable,
their conclusions are limited, and they seem to offer little additional information over other psychological measures. Indeed,
the data presented in the current review support Lallys original
conclusions.
In accordance with recommendations made by Lilienfeld,
Wood, and Garb (2000), the present authors suggest that clinicians avoid administration of human figure drawings throughout the course of child sexual abuse evaluations. McKinzey and
Ziegler (1999) argue that despite the Daubert (1993) criteria,
projective techniques will likely continue to be admitted to
court. However, similar to cautions of Lilienfeld et al., the current authors warn that a Daubert motion to determine admissibility may alert the trier of fact to the difficulties associated
with projective measures, and due to the many challenges associated with these measures as presented here and in previous
research, even if admitted into court proceedings the mental
health professional who defends the measures may be vulnerable to professional criticism.
A careful examination of the current scientific data, legal
standards guiding expert testimony, and contemporary professional guidelines elucidates the difficulties that a mental health
professional may face when testifying about projective drawings in child abuse cases. Consequently, the use of these measures in such evaluations warrants significant caution. The onus
lies on the expert to demonstrate to the scientific community
that such measures possess sufficient psychometric properties
to assess experiences such as sexual and/or physical abuse.
Given the clinical opinions that can arise in part from test interpretations, and the potentially life-changing decisions that can
result from legal proceedings, it is necessary that this burden is
high. The current review suggests that the aforementioned projective measures are unlikely to satisfy this standard.
Acknowledgments
The authors wish to thank Ms. Alexandra Tellez and Ms. Claire Sauvagnat for their assistance in translating articles.

Declaration of Conflicting Interests


The authors declared no potential conflicts of interest with respect to
the research, authorship, and/or publication of this article.

Funding
The authors received no financial support for the research, authorship,
and/or publication of this article.

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Bios
Brian Allen, PsyD, is an assistant professor in the department of psychology at Sam Houston State University. His research interests are in the
areas of personality development following childhood trauma, the applications of attachment theory to clinical practice with maltreated children,
and the development, implementation, and dissemination of evidencebased practices for children. His research has been published in outlets
such as Child Maltreatment, Journal of Traumatic Stress, Trauma, Violence, & Abuse, and Journal of Interpersonal Violence, among others. He
provides training to doctoral students in the use of Trauma-Focused CognitiveBehavioral Therapy and ParentChild Interaction Therapy, and
maintains a small practice utilizing these interventions.
Chriscelyn Tussey, PsyD, is the director of psychological assessment in
the department of psychiatry at the New York University/Bellevue Hospital Center. Her research and clinical interests are in the areas of civil and
criminal forensic assessment and neuropsychological assessment, symptom validity testing in psychiatric populations, and public policy
informed by the interface of psychology and law. She currently provides
supervision to graduate students and doctoral interns in the administration and interpretation of psychological instruments and assessment
procedures.