Can Projective Drawings Detect if a Child Experienced Sexual or Physical Abuse?

: A Systematic Review of the Controlled Research

Brian Allen1 and Chriscelyn Tussey2

TRAUMA, VIOLENCE, & ABUSE 13(2) 97-111 The Author(s) 2012 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/1524838012440339 http://tva.sagepub.com

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.

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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

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).

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Sample 20 CSA survivors; 39 normal controls 20 CSA survivors; 39 psychiatric controls H-T-P/DAP: Van Hutton Scale: Preoccupation with sexually relevant concepts H-T-P/DAP: Van Hutton Scale: Preoccupation with sexually relevant concepts Technique: Scores Significant Findings Non-significant findings 26 CSA survivors; 37 psychiatric controls; 39 normal controls 89 CSA survivors 77 psychiatric controls 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 H-T-P: 12 indicators KFD: 12 indicators Free Draw: 12 indicators H-T-P: 12 indicators KFD: LILIF D-A-M: 4 indicators HFD: Koppitz Penis or vagina EI category: anxiety Total Score Total score None None Lower LILIF score HFD: Koppitz EI total score; EI total red flag itemsa None None Total Score Total Score None

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

Study

Blanchouin, Olivier, Lighezzolo, and Tychey (2005)

Chantler, Pelco, and Mertin (1993)

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

Cohen and Phelps (1985) Study 1

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

Hibbard, Roghmann, and Hoekelman (1987) Howe, Burgess, and McCormack (1987)

Louw and Ramkisson (2002)

Palmer et al. (2000)

Piperno, Di Biasi, and Levi (2007)

Sidun and Rosenthal (1987)

Yates, Beutler, and Crago (1985)b

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

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.

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.

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.

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

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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.

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,

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

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

Technique: Scores H-T-P: 15 indicators Significant Findings* Nonsignificant findings 10 indicators, including: clouds, fruit on trees, vacant eyes, multiple persons drawn, ladder leaning on tree, house is transparent, person composed of geometric figures

Study

Sample

Blain, Bergner, Lewis, and Goldstein (1981)

32 CPA psychiatric survivors; 45 normal controls

32 CPA psychiatric survivors; 32 psychiatric controls

H-T-P: 15 indicators

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)

Culbertson and Revel (1987)a DAP: Koppitz 3 indicators, including transparencies absent, arms omitted, feet omitted

20 CPA LD or ED survivors; 20 ED controls; 20 LD controls DAP: 17 indicators

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

Hjorth and Harway (1981)

30 CPA survivors; 30 normal controls

DAP: 8 indicators

2 indicators, including: Size of drawing, environmental objects

Howe, Burgess, and McCormack (1987) Manning (1987) FKD: Three indicators

39 CPA runaway survivors; 24 runaway controls 10 CPA survivors; 10 normal controls

DAP: Four indicators

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

Figure completion, line quality, color None

Piperno, Di Biasi, and Levi (2007)

12 CPA psychiatric survivors; 12 normal controls

KFD: 4 indicators, 2 scales

Prino and Peyrot (1994)

21 CPA survivors; 21 normal controls

HFD: Nine indicatorsb

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

None

Veltman and Browne (2000)

6 CPA survivors; 12 normal controls

KGD: Nine indicatorsb FKD: Manning

Omitting feet, omitting nose None

Veltman and Browne (2001)

Four CPA and one CSA survivors; 23 normal controls

FKD: Manning

None

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

Veltman and Browne (2003)

6 CPA survivors 12 normal controls

KFD: Burns KFD: 33 indicators

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

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

105

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.

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.

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).

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.

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.

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

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,

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.

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

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

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.

109
indicators to establish child abuse. Journal of Clinical Psychology, 37, 667673. *Blanchouin, C., Olivier, M.-C., Lighezzolo, J., & de Tychey, C. (2005). Dysharmonie de volution, abus sexuel et dessin: approche comparative chez lenfant par la grille diagnostique de Van Hutton. dico Psychologiques, 163, 465475. Annales Me Buck, J. N. (1948). The H-T-P technique: A qualitative and quantitative scoring manual. Journal of Clinical Psychology, 4, 317396. Burgess, A. W., & Hartman, C. R. (1993). Childrens drawings. Child Abuse & Neglect, 17, 161168. Burgess, A. W., McCausland, M. P., & Wolbert, W. A. (1981). Childrens drawings as indicators of sexual trauma. Perspectives in Psychiatric Care, 19, 5057. Burns, R. C. (1982). Self-growth in families. New York, NY: Brunner/ Mazel. Burns, R. C., & Kaufman, S. M. (1970). Kinetic Family Drawing (K-F-D): An introduction to understanding children through kinetic drawings. New York, NY: Brunner/Mazel. *Chantler, L., Pelco, L., & Mertin, P. (1993). The psychological evaluation of child sexual abuse using the Louisville Behavior Checklist and human figure drawing. Child Abuse & Neglect, 17, 271279. *Cohen, F. W., & Phelps, R. E. (1985). Incest markers in childrens artwork. Arts in Psychotherapy, 12, 265283. Cohen, J. (1988). Statistical power analysis for the behavioral sciences (2nd ed.). Hillsdale, NJ: Lawrence Erlbaum. Cohen-Liebman, M. S. (1995). Drawings as judiciary aids in child sexual abuse litigation: A composite list of indicators. Arts in Psychotherapy, 22, 475483. Cohen-Liebman, M. S. (1999). Draw and tell: Drawings within the context of child sexual abuse investigations. Arts in Psychotherapy, 26, 185194. Committee on Ethical Guidelines for Forensic Psychologists. (1991). Specialty guidelines for forensic psychologists. Law and Human Behavior, 15, 655665. Committee on the Revision of the Specialty Guidelines for Forensic Psychology. (2011, March 18). Specialty guidelines for forensic psychologists, [6th draft]. Retrieved from http://www.ap-ls.org/ aboutpsychlaw/3182011sgfpdraft.pdf Conte, J. R., Sorenson, E., Fogarty, L., & Rosa, J. D. (1991). Evaluating childrens reports of sexual abuse: Results from a survey of professionals. American Journal of Orthopsychiatry, 61, 428437. *Culbertson, F. M., & Revel, A. C. (1987). Graphic characteristics on the Draw-A-Person test for identification of physical abuse. Art Therapy, 4, 7883. Daubert v. Merrell Dow Pharmaceuticals, Inc., 509 U.S. 579, 113 S. Ct. 2786 (1993). DiLeo, J. H. (1973). Childrens drawings as diagnostic aids. New York, NY: Brunner/Mazel. Erickson, S. K., Lilienfeld, S. O., & Vitacco, M. J. (2007). A critical examination of the suitability and limitations of psychological tests in family court. Family Court Review, 45, 157174. Federal rules of evidence. (1992). Boston: Little, Brown. Federal rules of evidence, 28, U.S.C. (West, 1975). Federal rules of evidence, 702 (2011).

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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Trowbridge, M. M. (1995). Graphic indicators of sexual abuse in childrens drawings: A review of the literature. Arts in Psychotherapy, 22, 485493. Van Hutton, V. (1994). House-Tree-Person and Draw-A-Person as measures of abuse in children: A quantitative scoring system. Odessa, FL: Psychological Assessment Resources. *Veltman, M. W. M., & Browne, K. D. (2000). An evaluation of favorite kind of day drawings from physically maltreated and nonmaltreated children. Child Abuse & Neglect, 24, 12491255. *Veltman, M. W. M., & Browne, K. D. (2001). Identifying childhood abuse through favorite kind of day and kinetic family drawings. Arts in Psychotherapy, 28, 251259. Veltman, M. W. M., & Browne, K. D. (2002). The assessment of drawings from children who have been maltreated: A systematic review. Child Abuse Review, 11, 1937. *Veltman, M. W. M., & Browne, K. D. (2003). Trained raters evaluation of Kinetic Family Drawings of physically abused children. Arts in Psychotherapy, 30, 312. West, M. M. (1998). Meta-analysis of studies assessing the efficacy of projective techniques in discriminating child sexual abuse. Child Abuse & Neglect, 11, 11511166. *Yates, A., Beutler, L. E., & Crago, M. (1985). Drawings by child victims of incest. Child Abuse & Neglect, 9, 183189.

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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.