复旦大学：《艺术治疗》课程教学资源（扩展文献阅读）Qualitative fersus Quantitative Approach to Evaluating

Copyright 1990 by the American Psychological As ol.2.No. 4,365-373 Clinical Psychology A Qualitative Versus Quantitative Approach to Evaluating the draw-A-Person and Kinetic Family drawing A Study of Mood- and Anxiety-Disorder Children Deborah J. Tharinger and Kevin Stark University of Texas at Austin This study compared 2 methods of scoring the Draw-A-Person(DAP)and the Kinetic Family Drawing(KFD): A quantitative scoring method based on traditional individual indicators was contrasted with a qualitative scoring method based on an integrative approach designed to assess overall psychological functioning. The participants were 52 children with a mean age of 1 1 years. Using DSM-III-R. they were assigned to the following groups: mood disorder (n= 12), anxiety disorder (n =11), mood/anxiety (n= 16), control (n= 13). Unlike scores from the quantitative approach, scores obtained from the qualitative approach on the daP differentiated children with mood disorders and mood /anxiety disorders, but not children with only anxiety disorders, from control children. Similarly, and again unlike scores from the quantitative approach scores from the qualitative approach on the K fd differentiated children with mood disorders (but not mood/anx DAP and KFD scoring methods were significantly correlated with self-reported self-concept and aspects of family functioning. It appears that an integrated, holistic approach to scoring projective drawings, reflec tive of overall psychological functioning of the individual and of the family, can be a useful adjunct in assessing children with internalizing disorders The assessment of internalizing disorders in children (ie. into the assessment of mood and anxiety disorders in children, depression and anxiety) presents problems that are not appar- this research is noteworthy for its lack of empirical investiga- ent for disorders with more obvious overt behavioral character- tions into the utility of projective techniques with such popula- istics. The emotional discomfort and subjective feelings of dis- tions(Kendall, Cantwell, Kazdin, 1989) tress that are central aspects of internalizing disorders are more Historically, projective techniques have accompanied most difficult for parents, teachers, and often psychologists to iden- psychological assessments of children and adults. They have fy accurately and reliably. Even when interviewed, children been used to measure unconsciously repressed or consciously may experience considerable difficulty in naming, describing, suppressed material, and more recently they have been used to subjective state. However, systematic input from children gain an understanding of cognitive processing(Meichenbaum themselves is critical in the assessment of internalizing dis- ported to be among the most frequently used tests by psycho orders(Cytryn& McKnew 1980). This input must be obtained gists in clinical practice(Lubin, Larsen in a manner that minimizes demands for verbal expression and Lubin, Wallis, Paine, 1971; Loutitt & Browne, 1947; Sund- is sensitive to the child's level of development(Quay La berg, 1961; Wade Baker, 1977) and in school settings with Greca, 1986). In the past decade, diagnostic interviews, self-rating scales of tional problems(Eklund, Huebner, Groman, Michael, 1980 depression and anxiety, and parent and teacher checklists have Fuller Goh 1983: Goh, Teslow,& Fuller, 1981; Prout, 1983; appeared that have facilitated the assessment of internalizing Vukovich, 1983). Projective drawings typically are used with disorders in children. In addition it has been common clinical children to gain an understanding of inner conflicts, fears, per- practice to supplement such measures with projective tech- niques and thus gain a broader understanding of the young ceptions of others, and interactions with family members, as ster's self-perceptions and way of perceiving his or her world. well as to generate hypotheses that serve as a springboard for However, although there exists a burgeoning body of research further evaluation(Cum 1986 The most common projective drawing technique used with children is the Draw-A-Person(DAP; Harris, 1963), also re- We thank the students who assisted in the collection of this ferred to as the Human Figure Drawing(HFD; Koppitz, 1968) data. Special thanks go to Judith Watkins and Gayle Vincent for their Numerous scoring methods for evaluating emotional function assistance with conceptual formulation and data management ing in children have been proposed for the DAP, of which the Correspondence concerning this article should be addressed to Deborah Tharinger, Education Building 504, University of Texas at Austin, Austin, Texas 787 in 4 e. oppitz System is the best known. The Koppitz System con- ts of 30 individual emotional indicators, derived from the work of Machover(1949)and from Koppitz's clinical exper

Psychological Assessment: A Journal of Consulting and Clinical Psychology 1990, Vol.2, No. 4,365-375 Copyright 1990 by the American Psychological Association, Inc. 1040-3590/90/S00.75 A Qualitative \fersus Quantitative Approach to Evaluating the Draw-A-Person and Kinetic Family Drawing: A Study of Mood- and Anxiety-Disorder Children Deborah I Tharinger and Kevin Stark University of Texas at Austin This study compared 2 methods of scoring the Draw-A-Person (DAP) and the Kinetic Family Drawing (KFD): A quantitative scoring method based on traditional individual indicators was contrasted with a qualitative scoring method based on an integrative approach designed to assess overall psychological functioning. The participants were 52 children with a mean age of 1 V/* years. Using DSM-III-R, they were assigned to the following groups: mood disorder (n = 12), anxiety disorder (n = 11), mood/anxiety (« = 16), control (n = 13). Unlike scores from the quantitative approach, scores obtained from the qualitative approach on the DAP differentiated children with mood disorders and mood/anxiety disorders, but not children with only anxiety disorders, from control children. Similarly, and again unlike scores from the quantitative approach, scores from the qualitative approach on the KFD differentiated children with mood disorders (but not mood/anx￾iety disorders) from control children. In addition, scores from the qualitative DAP and KFD scoring methods were significantly correlated with self-reported self-concept and aspects of family functioning. It appears that an integrated, holistic approach to scoring projective drawings, reflec￾tive of overall psychological functioning of the individual and of the family, can be a useful adjunct in assessing children with internalizing disorders. The assessment of internalizing disorders in children (i.e., depression and anxiety) presents problems that are not appar￾ent for disorders with more obvious overt behavioral character￾istics. The emotional discomfort and subjective feelings of dis￾tress that are central aspects of internalizing disorders are more difficult for parents, teachers, and often psychologists to iden￾tify accurately and reliably. Even when interviewed, children may experience considerable difficulty in naming, describing, or verbally communicating their emotional discomfort and subjective state. However, systematic input from children themselves is critical in the assessment of internalizing dis￾orders (Cytryn & McKnew, 1980). This input must be obtained in a manner that minimizes demands for verbal expression and is sensitive to the child's level of development (Quay & La Greca, 1986). In the past decade, diagnostic interviews, self-rating scales of depression and anxiety, and parent and teacher checklists have appeared that have facilitated the assessment of internalizing disorders in children. In addition, it has been common clinical practice to supplement such measures with projective tech￾niques and thus gain a broader understanding of the young￾ster's self-perceptions and way of perceiving his or her world. However, although there exists a burgeoning body of research We thank the many students who assisted in the collection of this data. Special thanks go to Judith Watkins and Gayle Vincent for their assistance with conceptual formulation and data management. Correspondence concerning this article should be addressed to Deborah Tharinger, Education Building 504, University of Texas at Austin, Austin, Texas 78712. into the assessment of mood and anxiety disorders in children, this research is noteworthy for its lack of empirical investiga￾tions into the utility of projective techniques with such popula￾tions (Kendall, Cantwell, & Kazdin, 1989). Historically, projective techniques have accompanied most psychological assessments of children and adults. They have been used to measure unconsciously repressed or consciously suppressed material, and more recently they have been used to gain an understanding of cognitive processing (Meichenbaum, 1977). For several decades, projective drawings have been re￾ported to be among the most frequently used tests by psycholo￾gists in clinical practice (Lubin, Larsen, & Matarrazzo, 1984; Lubin, Wallis, & Paine, 1971; Loutitt & Browne, 1947; Sund￾berg, 1961; Wade & Baker, 1977) and in school settings with children who have been referred for suspected social and emo￾tional problems (Eklund, Huebner, Groman, & Michael, 1980; Fuller & Goh, 1983; Goh, Teslow, & Fuller, 1981; Prout, 1983; Vukovich, 1983). Projective drawings typically are used with children to gain an understanding of inner conflicts, fears, per￾ceptions of others, and interactions with family members, as well as to generate hypotheses that serve as a springboard for further evaluation (Cummings, 1986). The most common projective drawing technique used with children is the Draw-A-Person (DAP; Harris, 1963), also re￾ferred to as the Human Figure Drawing (HFD; Koppitz, 1968). Numerous scoring methods for evaluating emotional function￾ing in children have been proposed for the DAP, of which the Koppitz System is the best known. The Koppitz System con￾sists of 30 individual emotional indicators, derived from the work of Machover (1949) and from Koppitz's clinical experi- 365

DEBORAH J. THARINGER AND KEVIN STARK ence Koppitz has reported that three or more emotional indi- method, however, has been harshly criticized because their cators on her system appear to diferentiate the DAPs of groups manuals include no information on reliability or validity and of children with and without emotional and behavioral prob- fail to define precisely the scoring variables(Harris, 1978) lems(Koppitz, 1968) Other scoring systems for the KFD, based on the Burns and Researchers have examined the relationship between certain Kaufman features, have been proposed by McPhee and Wegner emotional indicators in DAPs and depression and anxiety in 1976), Meyers(1978), Nostkoff and Lazarus ( 1983),and both adults and children. According to Machover (1949), OBrien and Patton(1974). Although these four systems have deeply regressed or neurotically depressed persons are likely to obtained satisfactory interrater reliabilities, they have not been draw small or diminutive figures. To test this hypothesis, Lew- successful at consistently differentiating the drawings of chil- nsohn(1964)compared the drawings of 50 depressed and non- dren with and without emotional problems(see reviews by depressed adult psychiatric patients and reported a statistically Cummings, 1986; Knoff Prout, 1985). Reynolds(1978)has significant, but actually quite small, difference between the offered a quick reference guide for developing clinical hy pothe heights of the drawings produced by the depressed and normal ses from childrens K FDs. His guide includes 37 signs, secured groups. Roback and Webersinn(1966)and Holmes and wie- from numerous scoring methods, that have been proposed as derhold(1982)failed to find a significant difference in the size being clinical indicators of family dysfunction. Although infor of drawings produced by an adult normal and depressed psychi- mation on reliability and validity of the guides as a scoring atric sample. In a study with depressed children, Gordon, Lef- system are not provided the guide may prove to be a useful kowitz,and Tesiny(1980)investigated three structural charac- tool. Studies specifically investigating the KFDs of depressed teristics of DAPs: size, vertical placement on the page, and line and anxious children, regardless of the scoring system used intensity. They found a significant relationship with size for girls have not been reported and no significant relationships between vertical placement on Overall, research findings indicate that the results of scoring the page or line intensity with depression as rated by the chil- systems based on individual emotional indicators have not dif- en or their teachers. On the basis of their study ferentiated the human-figure drawings of children with specific and from interpretation of previous research, these authors internalizing disorders from those of normal children In prac- questioned the validity of assessing depression in children us- tice, it often is the gestalt of a human figure drawing that is ing structural characteristics of human-figure drawings. clinically evaluated to derive a sense of the overall degree of a Manifestations of anxiety in figure drawings have been the childs disturbance or distortion in relation to the self and the subject of a great deal of speculation and a moderate number of family. It was hy pothesized here that the clinical usefulness of empirical investigations(Sims, Dana, Bolton, 1983). Studies human-figure drawings may lie in their overall presentation of have been of two types: experimental studies of stress induc- the psychological functioning of the individual and of the fam tion(e.g Doubros Mascarenhas, 1967; Sturner, Rothbaum, ily and not in their interpretation by a single or sum of specific Visintainer, Wolfer, 1980)and correlational studies of valid emotional indicators. The aim of the present study was to inves ity (e.g, Craddick, Leipold, Cacauas, 1962; Viney Aitkin, tigate empirically this holistic practice to determine if it would Floyd, 1974). In studies of stress induction, the frequency of prove to differentiate children with distinct internalizing dis- anxiety indices is compared for subjects receiving stressful orders from normal children. This study compared two meth treatments and for control subjects. In correlational studies ods of scoring DAPs and Kfds in a sample of children diag- anxiety score derived from the daP is related to an indepen- nosed according to the revised third edition of the diagnostic dent measure of anxiety. Although different indices of anxiety and Statistical Manualof Mental Disorders(DSM-1II-R, Ameri- n the drawings have been used in the various studies(typical can Psychiatric Association, 1987)as having a mood disorder, indicators of anxiety include shading, erasures, and line rein- anxiety disorder, or both, along with a normal control group forcement), results have generally failed to support an interpre - For each type of drawing, a scoring method based on existing tation that anxiety is manifested in, and can be interpreted individual emotional indicators was contrasted with a newly from, human-figure drawings constructed scoring method based on a qualitative, integrative, Another projective drawing technique that commonly is and holistic approach. In addition, to evaluate the often-made sed with children is the Kinetic Family Drawing(KFD; Burns claim that the DAP is a projective measure of self-concept, the Kaufman, 1970, 1972), which purportedly assesses a childs childrens scores on the two methods of scoring the DAPs were perceptions of the interpersonal relations within his or her fam- examined in relation to an objective measure of self-reported ily. The kFd has achieved moderately widespread use among self-concept. Similarly, to explore the hypothesis that the KFd psychologists who work with children because of the recogni- is a projective measure of perception of one's family, the chil- and treatment of emotional disorders of children(Reynolds, correlated with an objective measure of self-reported family 1978). On the kFD, the child is asked to draw a picture of functioning everyone in his or her family doing something. Burns and Kauf man hy pothesized that the stipulation that everyone in the drawing had to be doing something would permit self and fam- Method ily attitudes to become more apparent. Burns and Kaufman( 1970, 1972)have developed two als for scoring the KFD. Their system is based The participants were 52 children, 4i girls and i l boys in grades 4 tation of actions, styles, and symbols in the drawings. Their through 7, from five suburban schools. They were drawn from a sample

366 DEBORAH J. THARINGER AND KEVIN STARK ence. Koppitz has reported that three or more emotional indi￾cators on her system appear to differentiate the DAPs of groups of children with and without emotional and behavioral prob￾lems (Koppitz, 1968). Researchers have examined the relationship between certain emotional indicators in DAPs and depression and anxiety in both adults and children. According to Machover (1949), deeply regressed or neurotically depressed persons are likely to draw small or diminutive figures. To test this hypothesis, Lew￾insohn (1964) compared the drawings of 50 depressed and non￾depressed adult psychiatric patients and reported a statistically significant, but actually quite small, difference between the heights of the drawings produced by the depressed and normal groups. Roback and Webersinn (1966) and Holmes and Wie￾derhold (1982) failed to find a significant difference in the size of drawings produced by an adult normal and depressed psychi￾atric sample. In a study with depressed children, Gordon, Lef￾kowitz, and Tesiny (1980) investigated three structural charac￾teristics of DAPs: size, vertical placement on the page, and line intensity. They found a significant relationship with size for girls and no significant relationships between vertical placement on the page or line intensity with depression as rated by the chil￾dren, their peers, or their teachers. On the basis of their study and from interpretation of previous research, these authors questioned the validity of assessing depression in children us￾ing structural characteristics of human-figure drawings. Manifestations of anxiety in figure drawings have been the subject of a great deal of speculation and a moderate number of empirical investigations (Sims, Dana, & Bolton, 1983). Studies have been of two types: experimental studies of stress induc￾tion (e.g., Doubros & Mascarenhas, 1967; Sturner, Rothbaum, Visintainer, & Wolfer, 1980) and correlational studies of valid￾ity (e.g., Craddick, Leipold, & Cacauas, 1962; Viney, Aitkin, & Floyd, 1974). In studies of stress induction, the frequency of anxiety indices is compared for subjects receiving stressful treatments and for control subjects. In correlational studies, an anxiety score derived from the DAP is related to an indepen￾dent measure of anxiety. Although different indices of anxiety on the drawings have been used in the various studies (typical indicators of anxiety include shading, erasures, and line rein￾forcement), results have generally failed to support an interpre￾tation that anxiety is manifested in, and can be interpreted from, human-figure drawings. Another projective drawing technique that commonly is used with children is the Kinetic Family Drawing (KFD; Burns & Kaufman, 1970,1972), which purportedly assesses a child's perceptions of the interpersonal relations within his or her fam￾ily. The KFD has achieved moderately widespread use among psychologists who work with children because of the recogni￾tion of the important role of family dynamics in the etiology and treatment of emotional disorders of children (Reynolds, 1978). On the KFD, the child is asked to draw a picture of everyone in his or her family doing something. Burns and Kauf￾man hypothesized that the stipulation that everyone in the drawing had to be doing something would permit self and fam￾ily attitudes to become more apparent. Burns and Kaufman (1970,1972) have developed two man￾uals for scoring the KFD. Their system is based on the interpre￾tation of actions, styles, and symbols in the drawings. Their method, however, has been harshly criticized because their manuals include no information on reliability or validity and fail to define precisely the scoring variables (Harris, 1978). Other scoring systems for the KFD, based on the Burns and Kaufman features, have been proposed by McPhee and Wegner (1976), Meyers (1978), Nostkoff and Lazarus (1983), and O'Brien and Patton (1974). Although these four systems have obtained satisfactory interrater reliabilities, they have not been successful at consistently differentiating the drawings of chil￾dren with and without emotional problems (see reviews by Cummings, 1986; Knoff& Prout, 1985). Reynolds (1978) has offered a quick reference guide for developing clinical hypothe￾ses from children's KFDs. His guide includes 37 signs, secured from numerous scoring methods, that have been proposed as being clinical indicators of family dysfunction. Although infor￾mation on reliability and validity of the guides as a scoring system are not provided, the guide may prove to be a useful tool. Studies specifically investigating the KFDs of depressed and anxious children, regardless of the scoring system used have not been reported. Overall, research findings indicate that the results of scoring systems based on individual emotional indicators have not dif￾ferentiated the human-figure drawings of children with specific internalizing disorders from those of normal children. In prac￾tice, it often is the gestalt of a human-figure drawing that is clinically evaluated to derive a sense of the overall degree of a child's disturbance or distortion in relation to the self and the family. It was hypothesized here that the clinical usefulness of human-figure drawings may lie in their overall presentation of the psychological functioning of the individual and of the fam￾ily and not in their interpretation by a single or sum of specific emotional indicators. The aim of the present study was to inves￾tigate empirically this holistic practice to determine if it would prove to differentiate children with distinct internalizing dis￾orders from normal children. This study compared two meth￾ods of scoring DAPs and KFDs in a sample of children diag￾nosed according to the revised third edition of the Diagnostic and Statistical ManualofMental Disorders(DSM-III-R; Ameri￾can Psychiatric Association, 1987) as having a mood disorder, anxiety disorder, or both, along with a normal control group. For each type of drawing, a scoring method based on existing individual emotional indicators was contrasted with a newly constructed scoring method based on a qualitative, integrative, and holistic approach. In addition, to evaluate the often-made claim that the DAP is a projective measure of self-concept, the Children's scores on the two methods of scoring the DAPs were examined in relation to an objective measure of self-reported self-concept. Similarly, to explore the hypothesis that the KFD is a projective measure of perception of one's family, the chil￾dren's scores on the two methods of scoring the KFDs were correlated with an objective measure of self-reported family functioning. Method Subjects The participants were 52 children, 41 girls and 11 boys in Grades 4 through 7, from five suburban schools. They were drawn from a sample

DRAW-A-PERSON AND KINETIC FAMILY DRAWING 367 Table DSM-III-R Diagnoses by Clinical Group Mood disorders Anxiety disorders Mood and anxiety disorders Dysthymic xiety disorder(1) Anxiety disorder paration anxiety (2 anxiety (2) ysthy mic disorder/overanxious disorder/separation anxiety () separation anxiety(I) Overanxious disorder/dysthymic disorder(I Overanxious disorder/depressive disorder N.O.S. (1) Overanxiousdisorder/separation anxiety/depressive disorder NOS(3) Note, Numbers in parentheses indicate the number of cases of the disorder in the clinical group. DSM- III-R= Diagnostic and Statistical Manualof Mental Disorders(3rded, rev American Psychiatric Assoc tion, 1987); N.O.S. not otherwise specifi of children who participated in a larger school-based study of child- was devised by Reynolds and Richmond 1985)and is a 37-item self-re- hood depression and anxiety. The majority (86%)were white, 6% were port measure designed to assess the level and nature of anxiety in Black, 4% were Hispanic, and 3% were from other racial groups. All of children and adolescents from 6 to 19 years of age. The choices are Yes the children were in regular education. They ranged in age from 9 to and No, with Yes indicating that a statement is descriptive of the childs 1444 years old, with an overall mean age of 1 14 years. through tl feelings or actions. the yes responses are sun procedures described below, children were included as part of the clin- score. High scores indicate a high level of anxiety. The RCMAS is ical sample if they received a DSM-11l-R diagnosis based on the K- reported to have high internal consistency (=77-88)across a variety SADS interview of a mood disorder(n=12; 9 girls and 3 boys), anxiety of ages and populations and adequate test-retest reliability (ru=68) disorder(n=11; 10 girls and 1 boy), or mood and anxiety disorder over a 9-month period( Reynolds richmond 1985). s), and completed all est(S Schedule for Affective Disorders and Schizophrenia for School-Age not included due to their absence on the day the drawings were col- hildren(K-SADS). This interview schedule appropriate for clinical lected). Specific DSM-III-R diagnoses are indicated by group in Ta- or research assessments, was developed by Puig-Antich& Ryan(1986) ble 1. The process of assigning diagnoses and resulting reliability data This is a semistructured interview that measures depression as well asa are presented under Procedures. For the control group, 13 children(9 number of additional DSM-III(American Psychiatric Association, girls and 4 boys)were selected who had completed all measures of 1980)and DSM-III-R diagnostic categories. The K-SADS can be interest, did not receive a DSM-III-R diagnosis or elevated scores on used with children ages 6 to 16 and yields a rating of the presence, he screening measures, and reported little sy mptomatology on the absence, and severity of symptomatology. The mood and anxiety dis- K-SADS. Mean scores by group on all measures used to screen the orders sections of the Present Episode format of the fourth edition of Revised Children's Manifest Anxiety Scale(RCMAS), and the Sched- demonstrated high diagnostic reliability for mood (Ambrosini, Metz, ule for Affective Disorders and Schizophrenia for School-Age Children Prabucki, Lee, 1989: Kendall, Stark, Adam, 1990; Last& Strauss, 1990; Mitchell, McCauley, Burke, Calderon, Schloredt, 1989)and anxiety(Last Strauss, 1990)disorders. In addition, sufficient inter nal consistency(Ambrosini et al 1989)and test-retest reliabil (Apter, Orvaschel, Laseg, Moses, Tyano, 1989) have been reported Childrens Depression Inventory (CDI). This inventory was devel- Ambrosini and colleagues conclude that the achievement of high diag oped by Kovacs(1983)on the basis of the Beck Depression Inventory nostic, scale, and symptom reliability support the K-SADS as a rel monly used self-report measure of depression for children 7-17 years Coopersmith Self-Esteem Inventory(CSEI). This inventory was de- of age. The CDI consists of 27 items designed to assess the presence veloped by Coopersmith and measures an individual's personalevalua and severity of the overt symptoms of depression over the 2 weeks prior tion of self-worth Form B(Coopersmith, 1975)includes 25 short state to the assessment. a three-alternative choice format is used. the ments of both a positive and negative valence that the child rates as like hoices are scored from 0-2, with total scores of 19 or greater consid- me or unlike me. The items are keyed so that a high score reflects red to be indicative of a significant level of depression(Kovacs, 1983). positive self-esteem. The CSEI Form B has demonstrated adequate The CDi is reported to have high internal consistency with normal( test-retest and internal consistency reliability (.-81; Reynolds, an- 94)and emotionally disturbed (= 80)fifth-and sixth-grade students denson, Bartell, 1985). Saylor, Finch, Spirito, Bennett, 1984). In addition, acceptable test- Self-Report Measure of Family Functioning(SRMFF). This inven retest reliability (u=.77)over a 3-week period has been reported tory was developed by Bloom(1985 ) It consists of 75 items that were (Smucker, Craighead, Craighead, Green, 1986) selected from the Family Environment Scale(Moos Moos, 198 1) Revised childrens Manifest Anxiety Scale(RCMAS). This inventory Family-Concept Q-Sort(Van Der Veen, 1965), Family Adaptability

DRAW-A-PERSON AND KINETIC FAMILY DRAWING 367 Table 1 DSM-III-R Diagnoses by Clinical Group Mood disorders (n=12) Anxiety disorders Mood and anxiety disorders (n=16) Major depression (3) Dysthymic disorder (4) Depressive disorder N.O.S. (5) Generalized anxiety disorder (1) Anxiety disorder N.O.S. (10) Major depression/overanxious disorder (3) Dysthymic disorder/generalized anxiety disorder (1) Depressive disorder N.O.S./separation anxiety (2) Depressive disorder N.O.S./anxiety disorder N.O.S. (1) Major depression/overanxious disorder/separation anxiety (2) Dysthymic disorder/overanxious disorder/separation anxiety (1) Dysthymic disorder/generalized anxiety disorder/ separation anxiety (1) Overanxious disorder/dysthymic disorder (1) Overanxious disorder/depressive disorder N.O.S. (1) Overanxiousdisorder/separationanxiety/depressive disorder N.O.S. (3) Note. Numbers in parentheses indicate the number of cases of the disorder in the clinical group. DSM￾III-R = Diagnostic and Statistical Manual of Mental Disorders (3rd ed., rev.; American Psychiatric Associa￾tion, 1987); N.O.S. = not otherwise specified. of children who participated in a larger school-based study of child￾hood depression and anxiety. The majority (86%) were White, 6% were Black, 4% were Hispanic, and 3% were from other racial groups. All of the children were in regular education. They ranged in age from 9'/2 to 14V4 years old, with an overall mean age of 1 PA years. Through the procedures described below, children were included as part of the clin￾ical sample if they received a DSM-III-R diagnosis based on the K￾SADS interview of a mood disorder (n = 12; 9 girls and 3 boys), anxiety disorder (n = 11; 10 girls and 1 boy), or mood and anxiety disorder (n = 16; 13 girls and 3 boys), and completed all measures of interest (5 were not included due to their absence on the day the drawings were col￾lected). Specific DSM-III-R diagnoses are indicated by group in Ta￾ble 1. The process of assigning diagnoses and resulting reliability data are presented under Procedures. For the control group, 13 children (9 girls and 4 boys) were selected who had completed all measures of interest, did not receive a DSM-III-R diagnosis or elevated scores on the screening measures, and reported little symptomatology on the K-SADS. Mean scores by group on all measures used to screen the participants, that is, the Children's Depression Inventory (GDI), the Revised Children's Manifest Anxiety Scale (RCMAS), and the Sched￾ule for Affective Disorders and Schizophrenia for School-Age Children (KSADS), described below) are reported in Table 2. Instrumentation Children's Depression Inventory (CDI). This inventory was devel￾oped by Kovacs (1983) on the basis of the Beck Depression Inventory (Beck, Ward, Mendelson, Mock, & Erbaugh, 1961). It is the most com￾monly used self-report measure of depression for children 7-17 years of age. The CDI consists of 27 items designed to assess the presence and severity of the overt symptoms of depression over the 2 weeks prior to the assessment. A three-alternative choice format is used. The choices are scored from 0-2, with total scores of 19 or greater consid￾ered to be indicative of a significant level of depression (Kovacs, 1983). The CDI is reported to have high internal consistency with normal (ra = .94) and emotionally disturbed (/•„ = .80) fifth- and sixth-grade students (Saylor, Finch, Spirito, & Bennett, 1984). In addition, acceptable test￾retest reliability (ru = .77) over a 3-week period has been reported (Smucker, Craighead, Craighead, & Green, 1986). Revised Children's Manifest Anxiety Scale (RCMAS). This inventory was devised by Reynolds and Richmond (1985) and is a 37-item self-re￾port measure designed to assess the level and nature of anxiety in children and adolescents from 6 to 19 years of age. The choices are Yes and No, with Yes indicating that a statement is descriptive of the child's feelings or actions. The Yes responses are summed for a total anxiety score. High scores indicate a high level of anxiety. The RCMAS is reported to have high internal consistency (ra = J7-.88) across a variety of ages and populations and adequate test-retest reliability (rtl = .68) over a 9-month period (Reynolds & Richmond, 1985). Schedule for Affective Disorders and Schizophrenia for School-Age Children (K-SADS). This interview schedule, appropriate for clinical or research assessments, was developed by Puig-Antich & Ryan (1986). This is a semistructured interview that measures depression as well as a number of additional DSM-III (American Psychiatric Association, 1980) and DSM-III-R diagnostic categories. The K-SADS can be used with children ages 6 to 16 and yields a rating of the presence, absence, and severity of symptomatology. The mood and anxiety dis￾orders sections of the Present Episode format of the fourth edition of the interview were used in the current investigation. The K-SADS has demonstrated high diagnostic reliability for mood (Ambrosini, Metz, Prabucki, & Lee, 1989; Kendall, Stark, & Adam, 1990; Last & Strauss, 1990; Mitchell, McCauley, Burke, Calderon, & Schloredt, 1989) and anxiety (Last & Strauss, 1990) disorders. In addition, sufficient inter￾nal consistency (Ambrosini et al., 1989) and test-retest reliability (Apter, Orvaschel, Laseg, Moses, & Tyano, 1989) have been reported. Ambrosini and colleagues conclude that the achievement of high diag￾nostic, scale, and symptom reliability support the K-SADS as a reli￾able diagnostic tool for use with children. Coopersmith Self-Esteem Inventory (CSEI). This inventory was de￾veloped by Coopersmith and measures an individual's personal evalua￾tion of self-worth. Form B (Coopersmith, 1975) includes 25 short state￾ments of both a positive and negative valence that the child rates as like me or unlike me. The items are keyed so that a high score reflects positive self-esteem. The CSEI Form B has demonstrated adequate test-retest and internal consistency reliability (ra = .81; Reynolds, An￾derson, & Bartell, 1985). Self-Report Measure of Family Functioning (SRMFF). This inven￾tory was developed by Bloom (1985). It consists of 75 items that were selected from the Family Environment Scale (Moos & Moos, 1981), Family-Concept Q-Sort (Van Der Veen, 1965), Family Adaptability

68 DEBORAH J. THARINGER AND KEVIN STARK Mean Scores by Group Membership Mood disorder disorde n=13) Age(years) 1.211.6 64924.135.50283248 RCMAS 66.7564365.0077771006.1240.339,28 1952528.78132.36157221069220397.777.18 KSADS-Anxiety 1624220.52154.7215.07217.7544.43124.3824 2 Koppitz Emotional Indicators 3.00 2.22 2.64 1.86 2.13 1. 45 1.69 1.38 DAP Integrative System scor 4081.082641.573.061.182001.00 KFD Integrative System score 3.061.342461.33 Note. CDI =Children's Depression Inventory; RCMAs=Revised Children's Manifest Anxiety Scale; KSADS= Schedule for Affective Disorders and Schizophrenia for School-Age Children; DAP= Draw-A- Person; KFD= Kinetic Family Drawing. and Cohesion Evaluation Scales(Olson, Bell, Portner, 1978), and the piece of paper I would like you to draw a whole person It can be ar Family Assessment Measure(Skinner, Steinhauer, Santa-Barbara, kind of person you want to draw, just make sure that it is a whole 98)as a result of a series ofinvestigations of the psychometric proper- person and not a stick figure or a cartoon figure ties of these measures. In its original form, the measure consists of Kinetic Family Drawing(KFD). For the KFD, paper was p three dimensions and 15 scales. Each scale consists of five items. the and the instructions consisted of On this piece of paper dra Relationship dimension, which captures the characteristics of the rela- ture of everyone in your family doing something. Draw whole tionships among family members, consists of the following six scales: not cartoon or stick people. Remember, make everyone doing some- Cohesion, Expressiveness, Conflict, thing: some kind of actio zation, and Disengagement. The value dimension, which represents s: Intellectual/c ural Orientation, Active/Recreational Orientation, and Moral/Re- Procedures ligious Emphasis. These scales were not of interest in this study and were not included in the present analyses. the third dimension, the A multiple-gate assessment procedure(Kendall, Hollon, Beck System Maintenance dimension, which reflects the management style Hammen, Ingram, 1987)was followed with parental permission of the parents and the family's perceptions about who controls their ecured at each step of the process consistent with the regulations of lives, consists of the following six scales: Organization, External Locus the Institutional Review boardofthe University Permission for partici of Control, Democratic Family Style, Laissez-Faire Family Style, Au- parents of 720 children, which represented 42% of the student popula thoritarian Family Style, and Enmeshment tion. The cDi and the rCMas were used to assess the children in (SRMFF-C)by simplifying the language in the directions and items, mission letter was sent home to the parents of the children who (a) removing double negatives, and simplifying the descriptive anchors to scored 19 or greater on the CDI(n=40), (b)received aTscore of 60or Never, Sometimes, and Always. Because theoriginalSRMFF was modi- greater on the RCMAS ( =62), or (c) exceeded the cutoff scores on fied and originally standar the 15 scales was examined (Stark, Humphrey, Lewis, Crook, 1990). participation in a second screening were received from 80%(=32)of score corn the children who reported depressive symptoms, 90%(=56)of the Disengagement, Laissez-Faire Family Style, and External Locus of children who reported anxious symptoms, and 95%(n=72)of the Control scales did not meet minimal psycho andards of reli- children who reported both depressive and anxious symptoms ability and were dropped Items 14, 22, 25, and 5I also were droppe Parents of the children who once again scored 19 or greater on the because of unacceptable item-to-total score correlations. Conse. CDI (n=8), 60 or greater on the RCMAS(n-35), or above the cutoff quently, the aforementioned unacceptable scales and items were not scores on both(= 69 )received a third letter requesting permission to included in the present analyses. The internal consistency reliability of interview their child. within 10 days, permission was received from the nine rem scales of interest was Cohesion, ,a=69; Expressive- 93%(n= 104)of the parents, and each child was individually inter ness,'= 78: Conflict, r..66: Organization, .53: Family Sociabi- viewed with the K-SADS. Doctoral psychology students, unaware of Idealization, r=70; Democratic Family Style, r subjects CDl and RCMAS scores, conducted the K-SADS interview 73; Authoritarian Family Style, /= 50; Enmeshment, Ta=51. A more Prior to the actual interviews, they were trained until they reached a thorough discussion of the development and psychometric evaluation criterion of90% agreement on the symptom ratings. Interviews ofallof of the SRMFF-C can be found in Stark et al. ( 1990) the subjects were audiotaped. One-fourth of the tapes were randomly Draw-A-Person(DAP). For the administration of the DAP, the chil- selected and re-rated as a reliability check. The average percentage of dren were provided with two sheets of white typing paper and a pencil agreement for the depression symptoms was 87.5%, and the averag with an eraser, and the following instructions were given. "On your percentage of agreement for the anxiety symptoms was 93.6% as a

368 DEBORAH J. THARINGER AND KEVIN STARK Table 2 Mean Scores by Group Membership Group Mood disorder Oi-12) Anxiety disorder (»=H) Mood/anxiety disorder (n=16) Control (» = 13) Measure M SD M SD M SD M SD Age (years) CDI RCMAS KSADS-Depression KSADS-Anxiety 2 Koppitz Emotional Indicators 2 Reynolds Emotional Indicators DAP Integrative System score KFD Integrative System score 11.5 25.17 66.75 195.25 162.42 3.00 5.00 4.08 4.00 1.2 9.71 6.43 28.78 20.52 2.22 2.05 1.08 1.13 11.6 20.18 65.00 132.36 154.72 2.64 5.91 2.64 2.64 1.5 6.49 7.77 15.72 15.07 1.86 2.30 1.57 1.69 11.9 24.13 71.00 210.69 217.75 2.13 5.94 3.06 3.06 1.5 5.50 6.12 22.03 44.43 1.45 2.67 1.18 1.34 12.0 2.83 40.33 97.77 124.38 1.69 5.15 2.00 2.46 1.3 2.48 9.28 7.18 2.47 1.38 1.82 1.00 1.33 Note. CDI = Children's Depression Inventory; RCMAS = Revised Children's Manifest Anxiety Scale; KSADS = Schedule for Affective Disorders and Schizophrenia for School-Age Children; DAP = Draw-A￾Person; KFD = Kinetic Family Drawing. and Cohesion Evaluation Scales (Olson, Bell, & Portner, 1978), and the Family Assessment Measure (Skinner, Steinhauer, & Santa-Barbara, 1983) as a result of a series of investigations of the psychometric proper￾ties of these measures. In its original form, the measure consists of three dimensions and 15 scales. Each scale consists of five items. The Relationship dimension, which captures the characteristics of the rela￾tionships among family members, consists of the following six scales: Cohesion, Expressiveness, Conflict, Family Sociability, Family Ideal￾ization, and Disengagement. The Value dimension, which represents family values, consists of the following three scales: Intellectual/Cul￾tural Orientation, Active/Recreational Orientation, and Moral/Re￾ligious Emphasis. These scales were not of interest in this study and were not included in the present analyses. The third dimension, the System Maintenance dimension, which reflects the management style of the parents and the family's perceptions about who controls their lives, consists of the following six scales: Organization, External Locus of Control, Democratic Family Style, Laissez-Faire Family Style, Au￾thoritarian Family Style, and Enmeshment. The wording of the original SRMFF was modified for children (SRMFF-C) by simplifying the language in the directions and items, removing double negatives, and simplifying the descriptive anchors to Never, Sometimes, and Always. Because theoriginal SRMFF was modi￾fied and originally standardized on college students, the reliability of the 15 scales was examined (Stark, Humphrey, Lewis, & Crook, 1990). Using internal consistency and item-to-total score correlations, the Disengagement, Laissez-Faire Family Style, and External Locus of Control scales did not meet minimal psychometric standards of reli￾ability and were dropped. Items 14, 22, 25, and 51 also were dropped because of unacceptable item-to-total score correlations. Conse￾quently, the aforementioned unacceptable scales and items were not included in the present analyses. The internal consistency reliability of the nine remaining scales of interest was Cohesion, ra = .69; Expressive￾ness, r, = .78; Conflict, ra = .66; Organization, ra = .53; Family Sociabi￾lity, r, = .54; Family Idealization, ra = .70; Democratic Family Style, ra = .73; Authoritarian Family Style, /•„ = .50; Enmeshment, r, = .51. A more thorough discussion of the development and psychometric evaluation of the SRMFF-C can be found in Stark et al. (1990). Draw-A-Person (DAP). For the administration of the DAP, the chil￾dren were provided with two sheets of white typing paper and a pencil with an eraser, and the following instructions were given. "On your piece of paper I would like you to draw a whole person. It can be any kind of person you want to draw, just make sure that it is a whole person and not a stick figure or a cartoon figure." Kinetic Family Drawing (KFD). For the KFD, paper was provided and the instructions consisted of "On this piece of paper, draw a pic￾ture of everyone in your family doing something. Draw whole people, not cartoon or stick people. Remember, make everyone doing some￾thing; some kind of action." Procedures A multiple-gate assessment procedure (Kendall, Hollon, Beck, Hammen, & Ingram, 1987) was followed with parental permission secured at each step of the process consistent with the regulations of the Institutional Review Board of the University. Permission for partici￾pation in the initial screening portion of the study was secured from parents of 720 children, which represented 42% of the student popula￾tion. The CDI and the RCMAS were used to assess the children in large groups for symptoms of depression and anxiety. A second per￾mission letter was sent home to the parents of the children who (a) scored 19 or greater on the CDI (« = 40), (b) received a rscore of 60 or greater on the RCMAS (n = 62), or (c) exceeded the cutoff scores on both measures (n = 76). Parental permission and child assent for participation in a second screening were received from 80% (n = 32) of the children who reported depressive symptoms, 90% (n = 56) of the children who reported anxious symptoms, and 95% (n = 72) of the children who reported both depressive and anxious symptoms. Parents of the children who once again scored 19 or greater on the CDI (n = 8), 60 or greater on the RCMAS (n = 35), or above the cutoff scores on both (n = 69) received a third letter requesting permission to interview their child. Within 10 days, permission was received from 93% (n = 104) of the parents, and each child was individually inter￾viewed with the K-SADS. Doctoral psychology students, unaware of subjects' CDI and RCMAS scores, conducted the K-SADS interviews. Prior to the actual interviews, they were trained until they reached a criterion of 90% agreement on the symptom ratings. Interviews of all of the subjects were audiotaped. One-fourth of the tapes were randomly selected and re-rated as a reliability check. The average percentage of agreement for the depression symptoms was 87.5%, and the average percentage of agreement for the anxiety symptoms was 93.6%. As a

DRAW-A-PERSON AND KINETIC FAMILY DRAWING sult of these interviews, 14 children received a diagnosis of a mood the three exploratory items, depicted in Table 3, ranged from 77% to isorder, ll, a diagnosis of an anxiety disorder, and 19, a diagnosis of 100%, Disagreements were resolved through discussions by the two both a mood and anxiety disorder. As mentioned earlier, 5 of these scorers. Total scores on the Koppitz DAP System were obtained by subjects were not included in this study because of missing human. summing the number of emotional indicators present, excluding the figure drawing data. three exploratory items. eliability of the diagnoses was evaluated through the fo Each DAP also was scored using a second approach that is a qualita- procedure. a summary form was constructed that listed the DSM-Il tive, integrative scoring system designed to measure Psychological diagnosis of (a) major depression, (b)dysthymic Functioning of the Individual on a scale from I to 5. On this scale, I disorder,(c)depressive disorder not otherwise specified, (d)over- equals the absence of psychopathology (ie, very healthy psychological anxious disorder, (e)generalized anxiety disorder, (f)separation anxi- functioning), and 5 equals the presence of severe psychopathology (i.e ety, and (g)anxiety disorder not otherwise specified. Two raters, ery poor psychological functioning). To develop the system, called doctoral level psychologist and a doctoral student in psychology inde pendently transferred the symptom ratings from the depressive and previous training and experience scoring and evaluating projective anxiety symptoms of the K-SADS interviews of each child to the sum- drawings (who had not participated in the scoring using the Koppitz ary forms. During the process of assigning diagnoses, the raters DAP System), completed a forced sort of the 52 drawings into five piles compared the symptom ratings on the summary forms to the dsM- of equal number on the l to 5 scale(the actual distribution was 10, 10, III-R diagnostic criteria. The following decision rules were used when 11, 11, 10). The sorters were unaware of the group membership of ead determining whether a symptom was present at a severe enough level to child and were only aware of each childs age. Subsequently, the two be considered symptomatic of a disorder. A symptom rating of 4 or sorters were interviewed by Deborah J. Tharinger to determine what greater on the K-SADS was considered clinically significant on the integrative features of the drawings influenced their ratings and differ- symptoms, and a rating of 3 or greater was considered to be inically significant for the anxiety symptoms. On the overlapping Four characteristics of Psychological Functioning of the Individual symptoms, a rating of at least 4 was necessary for the symptom to be were identified as representing the process experienced by the two onsidered clinically significant. On the basis of these rules and the raters and include(a)inhumanness of the drawing (b) lack of agency symptom ratings, DSM-Il-R diagnoses were independently assigned (i. e, inability of the individual in the drawing to effectively interact ith the world ) (c) lack of well l sion diagnoses was 91%, and it was 93% for the anxiety disorders diag- and (d) the presence of a hollow, vacant, or stilted sense in the individ- noses. Where there were disagreements, the raters came to a consensus ual portrayed in the drawing. a clearer sense of these characteristics is and then assigned a diagnosis where appropriate. gained through placing oneself in the position of the individual de Concurrent to completion of the aforementioned K-SADS inter- picted. The pathological end of the scale will now be described. inhu- views, additional parental permission and child assent were secured manness of the drawing refers to a quality whereby one would feel ani- for children who scored in the nondepressed and nonanxious range on malistic, grotesque, or monstrous, or if clearly human, as though one he screening administration of the CDi and rCMAs (n=30). These were missing essential body parts either because they were absent or youngsters completed a second administration of the measures in disconnected Lack of agency refers to a sense that the individual de- small groups. Permission was received for all but one child. All 29 of picted would be unable to effect any change in his or her world; a sense the children again scored in the nondepressed and nonanxious range of powerlessness that was often reflected in the pose of the individual on the second administration of the CDi and the roMAs They then Lack of well being, as mentioned above is reflected in negative facial were individually interviewed with the K-SADS. One of the children expressions of the individual, such as an angry, scared, or sad face. a teen children who were least symptomatic on the K-sads and com- interacting (i. e has sufficient power or force but is somehow frozen pleted all other measures of interest were selected to be the control and unable to move or use the power that may well be available to him or her). These four characteristics constitute a holistic and impression Additional measures were then completed by the clinical and con- istic sense of the drawings. That is, it is not a matter of rating a drawing trol samples in a small group format (4 to 8 children). During the first a 5 on each of the four characteristics that results in a score of 5 on the of these group assessments, the children were asked to produce a daP drawing. Rather, it is an integrative combination of the four character and a K FD. Each drawing took approximately 10 min to complete The istics that results in the overall rating of the drawing. children were seated at desks and tables, separated from each other. In Following the explication of these characteristics and methods, a ubsequent group assessment sessions, numerous self-report measures new rater, also experienced with projective drawings, was trained in were obtained from the children. Of interest to this study were the the resulting method, and she sorted the DAPs according to the set CSei and nine selected scales of the srmFf-c distribution on the five-point scale. In addition, one of the original Scoring of projectives. The daP drawings were scored using two raters again sorted the drawings, taking into account changes and clari- methods, The Koppitz DAP System ( Koppitz, 1968), which consists of fications in the system Reliability was computed between the scores of 30 individual emotional indicators that are scored for presence or ab. these two raters. The Spearman rho, a correlation coefficient for sence, was used (see Table 3 for a list of the indicators). Three explor- ranked data, was computed to be 84. Disagreements were resolved atory items, presence ofa happy face, a sad face, and a worried face also through discussion between the two raters, and an agreed-on score were included. Two psychology graduate students, who were unaware assigned of all other information except the age of the child, used the Koppitz The 52 K FD drawings also were scored using two methods. Becaus DAP System to score the DAPs Scorers were required to reach 90% of the poor performance of scoring systems based on the Burns and agreement on example drawings before scoring the actual drawings, To Kaufman( 1970, 1972)method (reviewed earlier). none of them wer obtain a measure of interrater agreement, 50% of the drawings(26) chosen. Instead, an approach similar to that used in the Koppitz were scored by both scorers. The G Index of Agreement was calculated tem was sought, For thestudy, the Reynold s guide was adapted into the to be 92% for the entire Koppitz DAP System of 30 emotional indica- Reynolds KFD System, consisting of the 37 individual indicators(see tors. The G Index of Agreement for the 30 individual items as well as Table 4 for a list of the indicators). The signs were scored for presence

DRAW-A-PERSON AND KINETIC FAMILY DRAWING 369 result of these interviews, 14 children received a diagnosis of a mood disorder, 11, a diagnosis of an anxiety disorder, and 19, a diagnosis of both a mood and anxiety disorder. As mentioned earlier, 5 of these subjects were not included in this study because of missing human￾figure drawing data. Reliability of the diagnoses was evaluated through the following procedure. A summary form was constructed that listed the DSM-1II￾R symptoms for a diagnosis of (a) major depression, (b) dysthymic disorder, (c) depressive disorder not otherwise specified, (d) over￾anxious disorder, (e) generalized anxiety disorder, (f) separation anxi￾ety, and (g) anxiety disorder not otherwise specified. Two raters, a doctoral level psychologist and a doctoral student in psychology inde￾pendently transferred the symptom ratings from the depressive and anxiety symptoms of the K-SADS interviews of each child to the sum￾mary forms. During the process of assigning diagnoses, the raters compared the symptom ratings on the summary forms to the DSM￾III-R diagnostic criteria. The following decision rules were used when determining whether a symptom was present at a severe enough level to be considered symptomatic of a disorder. A symptom rating of 4 or greater on the K-SADS was considered clinically significant on the depression symptoms, and a rating of 3 or greater was considered to be clinically significant for the anxiety symptoms. On the overlapping symptoms, a rating of at least 4 was necessary for the symptom to be considered clinically significant. On the basis of these rules and the symptom ratings, DSM-IH-R diagnoses were independently assigned to each youngster that met the diagnostic criteria. Interrater agree￾ment was then computed. The percentage of agreement for the depres￾sion diagnoses was 91%, and it was 93% for the anxiety disorders diag￾noses. Where there were disagreements, the raters came to a consensus and then assigned a diagnosis where appropriate. Concurrent to completion of the aforementioned K-SADS inter￾views, additional parental permission and child assent were secured for children who scored in the nondepressed and nonanxious range on the screening administration of the GDI and RCMAS (n = 30). These youngsters completed a second administration of the measures in small groups. Permission was received for all but one child. All 29 of the children again scored in the nondepressed and nonanxious range on the second administration of the GDI and the RCMAS. They then were individually interviewed with the K-SADS. One of the children reported a diagnosable mood disorder during the interview. The thir￾teen children who were least symptomatic on the K-SADS and com￾pleted all other measures of interest were selected to be the control group. Additional measures were then completed by the clinical and con￾trol samples in a small group format (4 to 8 children). During the first of these group assessments, the children were asked to produce a DAP and a KFD. Each drawing took approximately 10 min to complete. The children were seated at desks and tables, separated from each other. In subsequent group assessment sessions, numerous self-report measures were obtained from the children. Of interest to this study were the CSEI and nine selected scales of the SRMFF-C. Scoring of projectives. The DAP drawings were scored using two methods. The Koppitz DAP System (Koppitz, 1968), which consists of 30 individual emotional indicators that are scored for presence or ab￾sence, was used (see Table 3 for a list of the indicators). Three explor￾atory items, presence of ahappyface, a sad face, and a worried face also were included. Two psychology graduate students, who were unaware of all other information except the age of the child, used the Koppitz DAP System to score the DAPs. Scorers were required to reach 90% agreement on example drawings before scoring the actual drawings. To obtain a measure of interrater agreement, 50% of the drawings (26) were scored by both scorers. The G Index of Agreement was calculated to be 92% for the entire Koppitz DAP System of 30 emotional indica￾tors. The G Index of Agreement for the 30 individual items as well as the three exploratory items, depicted in Table 3, ranged from 77% to 100%. Disagreements were resolved through discussions by the two scorers. Total scores on the Koppitz DAP System were obtained by summing the number of emotional indicators present, excluding the three exploratory items. Each DAP also was scored using a second approach that is a qualita￾tive, integrative scoring system designed to measure Psychological Functioning of the Individual on a scale from 1 to 5. On this scale, 1 equals the absence of psychopathology (i.e., very healthy psychological functioning), and 5 equals the presence of severe psychopathology (i.e., very poor psychological functioning). To develop the system, called the DAP Integrative System, two psychology doctoral students with previous training and experience scoring and evaluating projective drawings (who had not participated in the scoring using the Koppitz DAP System), completed a forced sort of the 52 drawings into five piles of equal number on the 1 to 5 scale (the actual distribution was 10,10, 11,11,10). The sorters were unaware of the group membership of each child and were only aware of each child's age. Subsequently, the two sorters were interviewed by Deborah J. Tharinger to determine what integrative features of the drawings influenced their ratings and differ￾entiations. Four characteristics of Psychological Functioning of the Individual were identified as representing the process experienced by the two raters and include (a) inhumanness of the drawing, (b) lack of agency (i.e., inability of the individual in the drawing to effectively interact with the world), (c) lack of well being of the individual in the drawing, typically reflected in facial expressions indicating negative emotions, and (d) the presence of a hollow, vacant, or stilted sense in the individ￾ual portrayed in the drawing. A clearer sense of these characteristics is gained through placing oneself in the position of the individual de￾picted. The pathological end of the scale will now be described. Inhu￾manness of the drawing refers to a quality whereby one would feel ani￾malistic, grotesque, or monstrous, or if clearly human, as though one were missing essential body parts either because they were absent or disconnected. Lack of agency refers to a sense that the individual de￾picted would be unable to effect any change in his or her world; a sense of powerlessness that was often reflected in the pose of the individual. Lack of well being, as mentioned above, is reflected in negative facial expressions of the individual, such as an angry, scared, or sad face. A hollow, vacant, or stilted sense suggests that the individual is capable of interacting (i.e., has sufficient power or force but is somehow frozen and unable to move or use the power that may well be available to him or her). These four characteristics constitute a holistic and impression￾istic sense of the drawings. That is, it is not a matter of rating a drawing a 5 on each of the four characteristics that results in a score of 5 on the drawing. Rather, it is an integrative combination of the four character￾istics that results in the overall rating of the drawing. Following the explication of these characteristics and methods, a new rater, also experienced with projective drawings, was trained in the resulting method, and she sorted the DAPs according to the set distribution on the five-point scale. In addition, one of the original raters again sorted the drawings, taking into account changes and clari￾fications in the system. Reliability was computed between the scores of these two raters. The Spearman rho, a correlation coefficient for ranked data, was computed to be .84. Disagreements were resolved through discussion between the two raters, and an agreed-on score was assigned. The 52 KFD drawings also were scored using two methods. Because of the poor performance of scoring systems based on the Burns and Kaufman (1970, 1972) method (reviewed earlier), none of them were chosen. Instead, an approach similar to that used in the Koppitz Sys￾tem was sought. For the study, the Reynold's guide was adapted into the Reynolds KFD System, consisting of the 37 individual indicators (see Table 4 for a list of the indicators). The signs were scored for presence