A comparison of the diagnostic power of FEATS and Bender-Gestalt test in identifying the problems of students with and without specific learning disorders

https://doi.org/10.1016/j.aip.2021.101760Get rights and content

Highlights

  • There is considerable overlap between four components of FEATS and Bender-Gestalt test.

  • These instruments can assist the diagnosis and differentiation of students with and without SLDs.

  • The application of graphic tests is valuable as a diagnostic tool in clinical decision-making.

Abstract

Purpose: This study compared the predictive power of specific categories of the Formal Elements Art Therapy Scale (FEATS) and Bender-Gestalt test in identifying the problems of students with SLDs. Method: Forty elementary-school students with SLDs were selected from the SLD center of Babol, Iran, and 40 non-SLDs students were chosen from public schools, matched in terms of age, sex, and grade with the group with SLDs. The Wechsler Intelligence Scale for Children (WISC-IV), the Draw a Person Picking an Apple from a Tree (PPAT) test, four scales of FEATS for drawing scores, and the Bender-Gestalt test were administered. The data were analyzed by independent samples t-test, Pearson's correlation test, and MANOVA. Results: The groups significantly differed on the PPAT test, and the students with SLDs had a lower mean score than the non-SLD students on three components of integration, realism, and perseveration, but not on rotation. On the Bender-Gestalt test, the two groups significantly differed on all four components of distortion, disintegration, perseveration, and rotation. The construct validity was confirmed between SLDs and the components of "integration and disintegration" and "realism and distortion" in the two groups. Moreover, the Bender-Gestalt test had a greater effect than the four components of the FEATS, but the difference was small. Discussion: The use of PPAT with FEATS and Bender-Gestalt test can help diagnose children with SLDs.

Introduction

The process of assessment and diagnosis is central to the understanding and treatment of disorders in children and adolescents. Diagnosis in psychology is made using different methods, including tests. The comparison of the performance of different groups using tests and the analysis of the results greatly contribute to understanding, diagnosing, and differentiating various groups.

Specific learning disorders (SLDs) are a group of neurobiological disorders and the main cause of the poor academic achievement of students in elementary schools (Alfons & Flanagan, 2018). The American Psychiatric Association (2013) has proposed three indicators (deficits in reading, writing, and mathematics) for SLDs. Students with SLDs encounter serious problems in academic activities and cognitive functioning despite having an average or even high intelligent quotient (IQ). The prevalence of SLDs has been reported to vary from 5% to 28 % in different countries as assessed by different diagnostic instruments (Hallahan & Kauffman, 2003). Researchers and psychologists pay great attention to SLD screening and diagnosis for the provision of timely intervention and prevention of disorders caused by developmental and academic disabilities (Abolghasemi & Javanshiri, 2012). Poor visual-perceptual skills are among the major problems associated with SLDs and, as such, are of utmost importance in their diagnosis (Nazari, Sayyahi, & Afrooz, 2013).

Art therapy measurements have been officially expanded in the past 40 years. Psychologists and psychiatrists employ graphic measures to assess the cognitive characteristics of their clients. The dimensions of artistic graphic features can identify the symptoms of disorders (Groth-Marnat, 2009). As a very common graphic instrument widely used by psychotherapists, drawings can exhibit clients' strengths and weaknesses and serve as a tool to indirectly express people’s true feelings and tendencies. Adams (2002); Cox (2005); Kimberly (2008), and Margaret (2009) emphasize the importance of drawing and painting in the expression of psychological, emotional, and cognitive features. Adams (2002); Cox (2005); Fleming (2008); Brooks (2009); Brown and Sax (2013); Puglionesi (2016); Rusu (2017), and Yu and Nagai (2020) emphasize the importance of drawing and painting in the expression of psychological, emotional, and cognitive features.

Although art therapists believe that cognitive changes are mirrored in artistic works, or hold that the features of artistic works correlate with some disorders, Gantt and Tabone (1998) believe that these claims need confirmation with experimental and quantitative research. The presentation and introduction of the Formal Elements Art Therapy Scale (FEATS) by Gantt and Tabone was an experimental effort in the domain of graphic arts for scoring the Draw a Person Picking an Apple from Tree (PPAT) test. The aim was to offer a reliable and objective instrument free from cultural, belief, or verbal load, to identify the symptoms of disorders in patients.

Manley (2002) evaluated the usefulness of the scale using the PPAT test in children with and without attention-deficit/hyperactivity disorder (ADHD). The difference between the two groups was significant in three out of the 14 elements of the FEATS (color prominence, detail of objects and environment, and line quality). Wallace et al. (2004) also examined the FEATS to diagnose depression and post-traumatic stress disorder (PTSD) in kidney transplant recipients. The sample included 64 people in the age group of 6–21 years. The results showed that seven out of the 14 elements of this scale demonstrated the disorder in these patients that could not be identified through self-report.

Ghaffari (2011) compared the drawings made by elementary-school students with and without SLDs based on the FEATS scoring of the PPAT test. The goal was to check the validity of the PPAT test in the diagnosis of SLD. Results indicated that, from the 14 components of the FEATS, a significant difference was observed between the two groups in terms of five components of color fit, integration, realism, line quality, and person. Khamesan and Rajabpour Azizi (2013) validated the FEATS for the diagnosis of adolescents' internalizing disorders. The findings revealed that, except for the element of logic, there was a significant difference between the two groups with and without internalizing disorders in other elements of the scale.

Shalev, Papadaki, Kourkoutas, and Or (2019) examined and compared the associations between the perceptions of parental acceptance/rejection in 644 Greek 10−12-year-old children and their PPAT drawings. The drawing scripts were associated with the children’s perceptions of parental behavior, and these associations were found mainly among boys, especially those with highly aggressive parents. These results demonstrate how empirical inquiry into the content of PPAT contributes to the identification of implicit relational representations.

The study by Rajabpour Azizi (2019) on the drawings made by elementary-school students with and without SLDs based on FEATS scoring of the PPAT test showed that, except for the elements of logic and rotation, the students without SLDs had a superior performance to those with SLDs on the other elements. Özer (2010) also compared the performance of clinical and non-clinical groups of students on the PPAT test and the Bender-Gestalt test. These two groups did not differ in emotional indices. The classification of students in the clinical group was accurate in ∼50 % of the cases based on the existence of emotional indices.

Roth, Broder, Levy, Ishai, & Or, 2020 focused on the associations between form and content layers in the PPAT drawings of 126 preschool children aged 5–6.5 years. They also explored the narrative focus of the drawings using an integrated measure of observation that included these two layers. The results showed strong-to-moderate associations between form and content layers; for example, the more a drawing was colorful, the more it was detailed, and the drawn tree was stronger, fruitful, and more accessible for picking. As for the drawing’s narrative focus, most of the drawings depicted narratives that focused on the requested theme. Moreover, most of the drawings in which the picking scene was absent or additional alternative narratives were present were made by boys.

The Bender-Gestalt Visual Motor Test, which overlaps with the components in FEATS, has received considerable attention from psychotherapists and researchers. This test is used for the identification and assessment of students with SLDs and has been employed to evaluate the visual-motor functioning of people with various organic or functional injuries (Mosotho, Timile, & Joubert, 2017). It has also been used in the diagnosis of brain injury (Özer, 2010; Shaughnessy, 2018), dysgraphia (Silverman, 2014), reading and pencil control (Reynolds & Fletcher-Janzen, 2009), and intellectual disabilities; the evaluation of visual-spatial perception and visual processing and coordination; and the prediction of academic achievement (Shahim & Haroonorashidi, 2007). Problems in drawing the patterns provided by this test may be the result of a disorder or under-development in visual perception, motor coordination, or the integrated functioning of the two (Piotrowski, 2016).

Nazari et al. (2013) compared the visual-motor perception of children with SLDs and non-SLD children using the Bender-Gestalt test and concluded that the rate of distortion, disintegration, perseveration, and rotation is significantly higher in children with SLDs. Furthermore, Mehrinejad, Sobhi Gharamaleki, and Rajabi Moghadam (2012) examined the predictive power of the Bender-Gestalt test for reading and spelling difficulties in pre-school children. The findings demonstrated that the error of disintegration in this test is a valid index for predicting pre-school children’s risk of reading and spelling difficulties in first grade. Moreover, based on the results reported by Seddighi Arfai, Tammanaifar, and Dashtbanzadeh (2012), children with SLDs made more errors on the Bender-Gestalt test and had a poorer performance in terms of rotation and disintegration compared to non-SLD children.

Sadeghi, Hashemi Azar, and Kazemi (2012) compared the neuropsychological functioning of students with SLDs and externalizing and internalizing disorders on Wechsler’s intelligence test and the Bender-Gestalt test. Based on the results, there was no difference between the two groups in terms of the frequency of errors and the quality of the drawings. An examination of brain damage errors in students revealed that the group with externalizing disorders had the highest rate of errors in disintegration, using circles for dots, rotation, incompatibility of size, and a wrong number of angles, while the errors made by the internalizing group indicated damage to the frontal or temporal, occipital, and temporal-parietal lobe. Similarly, Moghaddam (2015) investigated the mental rotation and processing speed in students with and without SLDs. The results demonstrated that the mental rotation ability was significantly higher in students with SLD, whereas the processing speed was significantly lower in them compared to non-SLD students.

Cultural, social, and belief differences are minimized in FEATS and Bender-Gestalt test due to their important features, i.e. being perceptual-motor, non-verbal, and standard, and requiring non-verbal responses (Brannigan & Decker, 2006). The application of such diagnostic tools seems to be essential due to the necessity of the early diagnosis of SLDs in the critical developmental period of childhood for preventing the consequences of an untimely diagnosis via treatment and rehabilitation. There are considerable overlaps and similarities between four components of these two tests. Consequently, the examination and comparison of the results of these components may assist the assessment of the power of each in the identification of children with and without SLDs.

Section snippets

Research questions

  • 1

    Is there a difference in the performance of children with and without SLDs on the components of realism, integration, perseveration, and rotation on the FEATS?

  • 2

    Is there a difference in the performance of children with and without SLDs on the components of distortion, disintegration, perseveration, and rotation on the Bender-Gestalt test?

  • 3

    Is there a relationship between the Bender-Gestalt test and the PPAT scored using FEATS in the diagnosis of SLD?

Material and methods

Based on the topic, objectives, and research questions, this study was a descriptive-comparative research. The scores of two groups of children (boys and girls) with and without SLDs on PPAT scored using FEATS as well as the Bender-Gestalt test were compared. The statistical population comprised all elementary-school students diagnosed with SLDs and visiting the SLD clinic in Babol, Iran, in the academic year of 2018−2019. The sample consisted of 80 students (the age range of 7–11 and the mean

Results

This section presents the results for each research question.

Research Question 1: Is there a difference in the performance of children with and without SLDs on the components of realism, integration, perseveration, and rotation on the FEATS?

To answer this research question, an independent samples t-test was run to compare the mean scores of the groups with and without SLD. Table 1 presents the descriptive statistics (mean and SD) and the t-score for comparing the means of the two groups

A

Discussion

This study aimed to compare the performance of students with and without SLDs based on four components of FEATS and the Bender-Gestalt test. Numerous studies had previously focused on the diagnosis and treatment of SLDs, concluding that SLDs are usually accompanied by problems in drawing and writing. A relatively recent approach in SLDs is using graphic tests. However, the major problem associated with the use of such tests for SLDs is the lack of an objective instrument in the research

Conclusion

Based on the results of this and similar studies, one can claim that the use of the two mentioned instruments can assist the diagnosis and differentiation of students with and without SLDs. The use of graphic tests for elementary-school students with SLDs seems to be justifiable considering the tests' non-verbal and culture-independence nature, as well as these students’ considerable problems in drawing and writing. Based on the results of this study, the PPAT test scored using FEATS is a

Data availability

Not applicable.

Funding

Not applicable.

Ethical approval

Not applicable.

Consent to participate

All the participants consented to participation.

Consent for publication

All the authors have consented to the publication of this manuscript.

Availability of data and material

Not available.

Code availability

Not applicable.

Declaration of Competing Interest

The authors declare that there is no conflict of interest. This study received no funding.

References (48)

  • A. Azizi et al.

    Comparison of the effect of rehabilitation, neuro-feedback, and cognitive-behavioral play therapy on visual-motor perception of primary-school students with SLDs [Persian]

    Journal of Neuropsychology

    (2017)
  • D.J. Betts

    A systematic analysis of art therapy assessment and rating instrument literature

    (2005)
  • G.G. Brannigan et al.

    The Bender-Gestalt II

    American Journal of Orthopsychiatry

    (2006)
  • M. Brooks

    Drawing, visualisation and young children’s exploration of “big ideas”

    International Journal of Science Education

    (2009)
  • A. Bucciarelli

    Normative study of the PPAT assessment of sample of college student

    (2007)
  • S. Cox

    Intention and meaning in young children’s drawing

    International Journal of Art & Design Education

    (2005)
  • S. Dashtbanzadeh

    Comparison of the performance of children with and without SLDs on Gestalt-Bender Visual-Motor test [Persian]

    (2011)
  • K.K. Fleming

    What are they telling us? The importance of children’s drawings

    (2008)
  • L. Gantt et al.

    The formal elements art therapy scale: The rating manual

    (1998)
  • F. Ghaffari

    Comparing the drawings made by primary school children with and without SLDs on PPAT scored by FEATS [Persian]

    (2011)
  • G. Groth-Marnat

    Handbook of psychological assessment

    (2009)
  • D. Gussak

    The effectiveness of art therapy in redacting depression in prison populations

    International Journal of Offender Therapy and Comparative Chronology

    (2007)
  • D. Hallahan et al.

    Exceptional learners: Introduction to special education with casebook

    (2003)
  • S. Kersten

    “We are just as confused and lost as she is”: The primacy of the graphic novel form in exploring conversations around deafness

    Children’s Literature in Education

    (2018)
  • View full text