Use of Projective Techniques with Children: A Review of Contemporary Research Studies

Chris Piotrowski

        A review of the mental health literature clearly indicates that both clinicians and researchers have, for many decades, considered various projective measures as suitable and pragmatic assessment instruments in the mental health evaluation of children. The aim of the current study is to present a brief overview of recent scholarship reflected in this body of literature on projective assessment with child samples, based on a bibliographic analysis. To that end, a comprehensive search of the database PsycINFO identified 250 peer-reviewed articles with a focus on projective tests and children. Of these, the author selected 38 studies or key references cited in these publications. Based on an aggregated analysis of this contemporary bibliographic dataset (2000-2022, inclusive), the author contends that projective techniques have been found to have empirical support for critical clinical issues such as the ability to reveal latent psychodynamics, identify cognitive deficits, and differentiate select diagnostic groups in children and pediatric populations. These attributes of projective measures are a key feature in the assessment of children, where issues such as developmental milestones, social adaptations, emotion regulation, and verbal expression are central clinical challenges. A select historical bibliography of key studies and books is provided.

 

Introduction:

        From an historical perspective, projective techniques were in the limelight in the mid-20th century, evident by exponential levels of both research and clinical attention (Bolander, 1977; Bram & Peebles, 2014; Frauenhoffer et al., 1998; Lemov, 2011; Levy, 1949; Murstein, 1965; Piotrowski, 2022, 2015a; Reiman, 1950). And much of this scholarly attention has had a focus on the use of projective measures in the psychological assessment of children (see Aaron, 1967; Acklin, 1995; Bernadette, 2008; Bowyer et al., 1966; Brody & Carter, 1982; Constantino et al., 1992; Goldfarb, 1949; Haworth, 1962; Krahn, 1985; Mehr, 1952; Parkin, 2001; Rabin, 1986; Reynolds & Kamphaus, 1990; Sivec & Hilsenroth, 1994). This body of literature includes thematic tests (Breen, 1998; Chandler et al., 1989; Lis et al., 2005; Schroth, 1979), sentence completion measures (Dykens et al., 2007; Lanyon, 1971; Westenberg, 2002), and drawing techniques (Bender & Wolfson, 1943; Jolley, 2010; Koppitz, 1966; Manning, 1987; Nava, 1965; Piotrowski, 2016; Richey, 1965; Senol & Ochilbek, 2020; Tukel et al., 2018;Woolford et al., 2015). Interestingly, there are copious studies on the application of projective tests in the psychological evaluation of children in the context of allegations of sexual abuse (Babiker, 1993; Garb et al., 2000; West, 1998).

        A host of survey data of mental health professionals on the topic of psychological testing with children, over the past 4 decades, indicate that projective tests have been and continue to be frequently relied upon in practice settings (Hojnoski et al., 2006; Holaday et al., 2000; Hutton et al., 1992; Kennedy et al., 1994; Oakland et al., 2016; Stinnett et al., 1994). Moreover, copious survey findings from professional training sites with an emphasis on child assessment confirm graduate level instruction on projective tests (Elbert & Holden, 1987; Piotrowski, 2015b; Piotrowski & Belter, 1999; Prout, 1983; Stedman et al., 2018; Tuma & Pratt, 1982; Wilson & Reschly, 1996).

While much of this literature is somewhat dated, it would be worthwhile to review the extent of investigatory focus on projective techniques reflected in recent research on children. To that end, the aim of current study is to provide a brief synopsis of contemporary studies (2000-2022) with a focus on the applications of projective tests with child/pediatric samples.

Bibliometric Review:

        Bibliometric analysis entails the quantitative study of patterns reflected in bibliographic publications. Such methodological designs allow investigators to identify a select body of research literature indexed in scholarly repositories (Krippendorff, 2012). Since the focus of the current study is on projective techniques in reference to children, a Boolean strategy was employed, based on keyword, for year 2000-2022 inclusive, with the search terms ‘projective techniques’, ‘Rorschach’, ‘House-Tree-Person’, ‘Draw-A-Person’, ‘Human-Figure-Drawings’, ‘Kinetic Family Drawing’, ‘Children’s Apperception Test’, ‘Sentence Completion’,‘TEMAS’, ‘Hand Test’, and ‘Somatic Inkblot Series’. The repository of scholarship was the database PsycINFO. Cumulatively, the search output produced 250 previewed articles. So as to provide a contemporary perspective, these results limited the output for research over the last 2 decades (see Table 1). Keep in mind that this body of references does not include books, book chapters, or dissertations specifically on these projective measures. Of this set of articles, the author scanned the bibliographic output and selected key studies that reflected the literature on the use of various projective measures with children. Based on this procedure and review, Table 2 provides a brief synopsis of 38 key studies.

 

Table 1. Number of Articles (2000-2022) with Test/Child or Children as a Keyword in PsycINFO

Measure	Journal Articles
	N
Rorschach	97
Human figure drawings	28
Draw-A-Person	17
Sentence Completion	12
House-Tree-Person	9
Somatic Inkblot Series	8
Children’s Apperception Test	7
Kinetic Family drawings	7
Hand Test	6
TEMAS	6

 

Brief Overview of Key Studies:

        Table 2 presents 38 key studies based on a) the search of PsycINFO, where the Boolean online search had a focus on the use of projective techniques with children or child case studies, and b) a selective review of several references obtained by scanning the bibliography of articles from the search. While most of these studies are empirical in nature, several report on case study findings. Moreover, it must be noted that in addition to clinicians leading these research efforts, a number of studies are led by researchers in the sub-field of school psychology.

        In support of the credibility regarding these investigations concerning children is that most of the studies are published in leading journals in the field of psychology. Moreover, almost all the major projective tests are represented in this review of contemporary research. Moreover, it must be kept in mind that these studies appear as published articles; the online search did not access research on projective measures that may have been presented at professional conferences, non published studies that never see the light of day (see ‘File Drawer’ issue; Wagner, 2021). Hence, the volume of recent scholarship on projective assessment with children can be estimated to be larger than presented in the current review.

Table 2. Recent Studies with a Focus on the Use of Projective Techniques with Children

Study	Projective Measures	Major Finding
Lagunes et al. (2022)	Draw-A-Person	25% of pre-school children showed deficits on the Psychological Function Index; SES was a significant factor.
Simon & Claudon (2021)	Children’s Apperception Test	Authors  introduce  a  novel contemporary scoring system for the CAT.
Yu & Lee (2021)	Rorschach	In a case study of a 6-year-old boy, the Rorschach provided a clinical medium for enhancing therapeutic exploration.
Magnusson et al. (2021)	Drawings-Talk technique	In investigatory police interviews with preschool age children, drawings may impair recall accuracy with suggestive prompts.
Navarro et al. (2020)	Various projective tests	Study concludes that the validity of projective tests has been inconsistent for the evaluation of sexually abused children.
De Michele et al. (2019)	Rorschach	The Rorschach Trauma Content Index was diagnostic in identification of child sexual abuse.
Borsa (2019)	Draw-A-Person	The DAP items such as ‘presence of teeth’, ‘exaggerated shoulders’, and ‘clawed fingers’ were indicators for aggression.
Resende et al. (2019)	Rorschach	The Rorschach Developmental Index (DI) was found to be strongly associated with nonverbal intelligence; the DI is effective in assessing various aspects of children’s psychological development.
Celik et al. (2019)	Draw-A-Person	In a sample of children who migrated from their home country due to war, anxiety scores from the DAP were elevated compared to a control group.
Roysircar et al. (2017)	House-Tree-Person	In a sample of children who experienced post-2010 earthquake, the HTP proved useful in assessing resiliency and vulnerability.
Cronin et al. (2017)	Human Figure Drawing	In this study of cognitive development in pre-teen children, HFDs showed variability in validity estimates.
Backos & Samuelson (2017)	Kinetic Family Drawings (KFD) and DAP: Screening Procedure for Emotional Disturbance (DAP: SPED)	The KFD was more effective than the DAP in identification of children exposed to intimate partner violence.
Meyer (2016)	Rorschach	Rorschach scores were linked with neuropsychological perceptual synthesis skills (perceptual   accuracy   and   perceptual representations), and verbal abilities.
Jothimani & Kumar (2016)	DAP case study	The DAP was useful in expressing educational concerns and behavioral problems.
Khorshidi et al. (2016)	Draw-A-Person	The authors found a significant relationship

		between the drawing characteristics (signs/patterns) and both normal and abnormal psychological issues in young boys.
Saraiva & Ferreira (2016)	Rorschach	Study compared 3 personality styles (antisocial, oppositional-defiant, hyperkinetic) in children; behavioral problems were a function of style.
Brechet (2015)	Draw-A-Person	In this study on representation of romantic love, latency-age children showed graphic indicators of love; Girls expressed more ‘signs’ of love than boys.
Bonoti & Misalidi (2015)	Human Figure Drawings	In this study on emotional expressiveness, children showed graphic contextual HFD cues for basic emotions, as opposed to ‘social’ emotions, such as shame or pride.
Zhao et al. (2015)	House-Tree-Person	Findings showed drawing ‘signs’ such as a lack of windows, round collar, and arms of variable thickness, were related to pupils’ somatization symptoms.
Reese et al. (2014)	Rorschach	Study compared Exner’s CS with the modern R-PAS in children; Few differences were found, other than fewer responses noted on for the R-PAS.
Li et al. (2014)	‘Synthetic’ House-Tree-Person	With children with high-functioning autism, the S-HTP identified deficiencies in social interaction, self-concept, and family relationships.
Brainard et al. (2014)	Rorschach	Study concluded that learning-disabled (versus non-learning disabled) children have deficits in their  ability  to  perceive,  interpret,  and coordinate information from their environment.
Storey et al. (2014)	Rorschach and other projective measures	Projective assessment is key to determination of mental impairment, learning disabilities, diagnostics, and treatment planning of young children from disadvantaged communities.
Sanyal (2013)	Somatic Inkblot Series-II	For emotionally withdrawn children, SIS-II provides a vehicle to penetrate in to the unconscious in a non-threatening manner.
Campos (2012)	Rorschach	In a clinical case study of a young boy (age 7), the Rorschach was therapeutically useful in dealing with his grandfather’s traumatic death.
Azam & Aftab (2012)	Hand Test	The findings showed significant sex differences on aggression, acting-out, and problem-solving styles.
Amil et al. (2010)	Rorschach, Human-Figure- Drawings, Hand Test, Kinetic Family Drawings	In the assessment of child sexual abuse, the findings indicated that projective techniques had limited utility.
Once & Wise (2010)	Story-Telling techniques	In studying the impact of the 1999 Turkish earthquake, young children (age 7) showed

		trauma-related symptoms 2 years post-disaster.
Alreja et al. (2009)	Somatic Inkblot Series-II	In studying 30 mentally retarded children, the SIS-II differentiated number of responses, human/animal movement, rejection of images, and pathological anatomy.
Miller & Nickerson (2007)	Various projective techniques	Although projective tests are used by school psychologists, the authors question the validity of these methods.
Hojnoski et al. (2006)	Various projective measures	School psychologists rely on a host of projective tests, particularly in the assessment of socio-emotional evaluation of children.
Blanchouin et al. (2005)	House-Tree-Person/Draw-A-Person	These projective tests contribute to several psychopathological signs expressed by sexual abused children.
Smith et al. (2005)	Hand Test	The Hand Test differentiated medically ill versus psychologically disturbed children on aggression, withdrawal, and psychopathology.
Tressoldi et al. (2004)	Various projective tests	Based on inadequate norms on Italian populations, the authors contend that projective measures should be limited to idiographic assessment, not for use in legal settings.
Savage (2003)	Somatic Inkblot Series (SIS)	Case study of a young boy (age 14) and his psychological reaction to his parent’s divorce; The SIS proved useful in providing therapeutic avenues to pursue.
Seitz (2001)	Projective tests	Authors discuss several of the drawbacks of projective  tests  in  reference  to  children’s pictorial abilities.
Veltman & Bowne (2000)	Projective drawings	Drawings are useful in evaluation of child abuse/maltreatment.
Jacquemin et al. (2000)	Various projective tests	Projective measures have utility in pediatric settings.

 

Conclusion:

        Despite the fact that both criticisms and limitations regarding projective tests continue to the present day (see Jurovaty and colleagues, 2022), the current review offers supportive evidence on the clinical utility of projective techniques in the assessment of children. Based on scholarly evidence, projective measures can serve as key assessment tools in the evaluation of mental health factors in children, including insights into the nature of personality characteristics, dynamics of inner mental life, etiology of copious psychopathologies, salient factors in behavior disorders, and deficits in social relationships.

        At the same time, this review supplants bibliographic evidence that projective techniques, despite perennial criticisms noted in the literature, continue to attract both clinical and research attention across a myriad of patient populations (e.g., Piotrowski, 2022). In fact, the most recent test use survey of practicing psychologists (n=293) confirms that 55% of these practitioners rely on at least 1 projective test (including the H-T-P, DAP, Kinetic Family Drawing, and the Children’s Apperception Test; see Hanigan, 2021). Hence, the evidence is clear that although projective tests may have lost their historical stature in the field of psychological assessment, these measures are not scientifically moribund (see Piotrowski, 2019, for discussion). However, continued usage with specific projective tests will largely depend on their status in professional training programs worldwide (see Piotrowski, 2015b, for a review), as well as continued presence in the contemporary psychological literature through books in the field of mental health assessment (e.g., Dubey et al., 2019; Weiner & Kleiger, 2021), including texts on psychological testing of children (Smith & Handler, 2015).

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