Content uploaded by Magda Di Renzo
Author content
All content in this area was uploaded by Magda Di Renzo on May 16, 2017
Content may be subject to copyright.
Volume 7 • Issue 2 • 1000291
J Psychol Psychother, an open access journal
ISSN: 2161-0487
Research Article Open Access
Di Renzo et al., J Psychol Psychother 2017, 7:2
DOI: 10.4172/2161-0487.1000291
Research Article OMICS International
Journal of Psychology & Psychotherapy
J
o
u
r
n
a
l
o
f
P
s
y
c
h
o
l
o
g
y
&
P
s
y
c
h
o
t
h
e
r
a
p
y
ISSN: 2161-0487
Correlations between the Drawing Process in Autistic Children and
Developmental Indexes
Magda Di Renzo*, Chiara Marini, Federico Bianchi di Castelbianco, Lidia Racinaro and Monica Rea
Institute of Ortofonologia (IdO), Via Tagliamento 25, 00198 - Rome, Italy
Abstract
Objective: In developmental age the drawing process represents one of the best tools to assess the level of
maturity reached by the child in his various areas of functioning. This study considers a sample of 84 children aged
between 2.5 and 15 years, all diagnosed with autism, evaluated by an expert team of professionals, in order to
highlight the drawing stage reached and the correlation with the severity of autistic symptoms assessed by the ADOS
and cognitively evaluated with the Leiter-R nonverbal scale.
Methods: The drawing level was observed in spontaneous production by establishing a scale ranging from the
presence of the disordered scribbling to the presence of the body schema, taking into account the stereotypes that
can lead to some echo-graphic representations that are similar to the echo-lalic productions of the verbal language.
Results: The results showed a signicant correlation between the drawing production and the Social-Affection
component of the ADOS, so demonstrating that the delay in the drawing is heavily inuenced by an emotional as
well as intellectual inhibition.
Conclusion: Through some examples of drawings it is also emphasized the relationship between drawing and
chronological age and the difference that emerges between drawings made in the evaluation context and those that
come to life during the therapeutic process.
Keywords: Autism spectrum disorder; Drawing; Graphic activitie;
Emotional components; Developmental prole; ADOS 2; Leiter-R
Introduction
In developmental age, drawing is one of the best tools to objectify
the level of maturity reached by the child in psychomotor, cognitive
and emotional areas and, at the same time, it represents a valuable
communication instrument in both educational and therapeutic elds.
In fact, of any graphic image or sign we can analyze many elements
that lead to subjectivity and then to the inner world of the subject who
realized it, as can be seen also from the drawing tests elaborated in the
psychodiagnostic context. Drawing is, in fact, for the child, a unique
experience of representation of the self and the world, so constituting
one of the main channels of expression of his mental and physical
condition. rough the use of his gestures the child impresses on the
sheet a trace that gradually becomes the tool to explore the environment
and to leave a shareable mark of himself. According to most of the
authors, the maturation of drawing expressiveness is proportional to
the maturation of cognitive and emotional functions [1-4].
Research shows that children with autism spectrum disorder have
a lower somatosensory perception than normotypical age-matched
children [5-8]. Other studies also emphasized that the hand function is
less developed compared with children of typical development [9]. Huri
stressed that the preference of autistic children for hard objects respect
to so ones allows considering a minor tactile awareness compared
to normotypical children [5]. is view is in line with what has been
shown by Frances Tustin [10] as a result of a separation that did not
occur from the care-giver. In addition, the diculty of initiating and
planning activity is oen impaired in children with autism, and it is
related to the presence of restricted and repetitive behaviors [11] and
this could inhibit the motor planning necessary for the realization of
the drawing.
In an interesting research where autistic children with and without
an upper extremity trauma history were compared there was evidence
that children with the presence of motors trauma had lower scores at the
*Corresponding author: Magda Di Renzo, Institute of Ortofonologia (IdO), Via
Salaria 30, 00198, Rome, Italy, Tel: 0039-068542038; Fax: 0039-068413258;
E-mail: m.direnzo@ortofonologia.it
Received November 29, 2016; Accepted March 02, 2017; Published March 09, 2017
Citation: Di Renzo M, Marini C, Bianchi di Castelbianco F, Racinaro L, Rea M (2017)
Correlations between the Drawing Process in Autistic Children and Developmental
Indexes. J Psychol Psychother 7: 291. doi: 10.4172/2161-0487.1000291
Copyright: © 2017 Di Renzo M, et al. This is an open-access article distributed
under the terms of the Creative Commons Attribution License, which permits
unrestricted use, distribution, and reproduction in any medium, provided the
original author and source are credited.
Sensory Integration and Praxis Test and in somatosensory perception
[5]. is study demonstrates the relationship between somatosensory
perception and hand function in autistic children with upper extremity
trauma. Although the presence of unusual sensory behaviors is still not
part of the diagnostic criteria, the DSM 5 emphasizes their importance
in the structuring of autism. e somatosensory perception plays a key
role in the early years of life. In autistic children a lower somatosensory
perception is associated with decits in communication, in motor skills
and social abilities [8].
e drawing activity, object of analysis in this research, is a key
element of both the evaluation phase and of the therapeutic work
that children with autism spectrum disorder receive at the Institute of
Ortofonologia, in Rome. e therapeutic project in which the child,
his family and the school are involved provides outpatient activities
(for a total of 10 h per week), home-care intervention (4 h per week),
informative sessions and individual or group counseling for parents,
in addition to educational support at school as well as medical,
neuropsychological, physiatrist, psychological and speech therapist
evaluations. e purpose of this treatment model is to emphasize
the emotional and relational dimension to expand the repertoire
of communicative behavior, thus allowing the expression of latent
intellectual and social abilities.
Citation: Di Renzo M, Marini C, Bianchi di Castelbianco F, Racinaro L, Rea M (2017) Correlations between the Drawing Process in Autistic
Children and Developmental Indexes. J Psychol Psychother 7: 291. doi: 10.4172/2161-0487.1000291
Page 2 of 9
Volume 7 • Issue 2 • 1000291
J Psychol Psychother, an open access journal
ISSN: 2161-0487
A study conducted on a sample of autistic children included in the
therapeutic project, well highlighted that the drawing developmental
stages of these children are slowed if compared with those of typically
developed children of the same age but however could express the
characteristics of personality of each one [12]. Correlating drawing
development to the level of autistic symptomatology of each child we
found that the decrease of the ADOS score corresponded to an increase
in drawing that in its manifestation took a greater communicative
value, so becoming a valuable tool for assessing the relational openness.
In fact, when a child begins to use his own drawings to
spontaneously represent objects of the surrounding world, this opens
an important channel of communication which allows him to express
needs and desires. Unlike words, which evoke in the child invisible
sound tracks, drawings leave tangible traces that allow the child a more
concrete comparison with the world. Considering the diculties that
the child with autism spectrum disorder encounters in integrating the
various senses and in conceptualizing them, it is better understood as
how important is draw, if intended as act of knowledge.
e diculties in sensory integration are responsible for most of
the problems of autistic children. Ayres stressed the importance of an
adequate sensory organization in order to use the objects and interact
with the world [13]. In a psychodynamic framework, the lack of sensory
integration is a result of the defensive mechanism of dismantling which
protects the child from a relationship with the objects that is perceived
as too threatening. e trace that the child produces can be a rst step
towards the integration process because it is acted by the child himself
who can go up to where his potentialities allow.
A not appropriate drawing of the children is not the consequence
of an altered aesthetic or physical development (such as visual or ne
motor problems), but of a strong inhibition of the socio-relational
components. is observation is supported by the fact that also those
children with autism spectrum disorder with have an appropriate
intellectual level show delays in drawings [14]. Children with autistic
disorder showed, in fact, many diculties to express and give shape
to their emotional state because of an aective attunement decit that
interfered on both verbal and non-verbal behaviors such as drawing
[15,16]. e drawing productions of these children were aected by the
marked decrease in social integration and communication. As already
pointed out, in fact, the drawing development, both in production
and in spontaneous copying of graphic stimuli, resulted correlated
with the severity of autistic symptoms and delayed in comparison to
chronological age.
According to Machover [17] we know that the gure drawn
represents the author himself and provides information about the
perception that he has of his body and desires. On the basis of the
presence of certain details and the manner in which the various parts of
the body are elaborated or omitted it is possible to infer the emotional
condition of the subject, that otherwise would not be communicable in
a symbolic way.
e representation of the body is always, in fact, in the early stages
of development, a transposition of the knowledge achieved and at the
same time a stimulus for new bodily sensations. So that the concept
of image of the human gure and the feelings with it associated could
become meaningful for the child there must be body awareness and self-
perception. is perception typically starts around the second half of
the rst year of life when the child begins to separate the outside world
from the inside, to make himself aware of each part of his body, of his
position in the environment, of his ability to control movements and to
respond to sensations coming from the outside world [18,19]. Because
of the diculty that the autistic child has to attune with the outside
world, all these experiences are greatly compromised and require a
careful observation by therapists to promote those stimulations which
are necessary to better attune.
In the therapeutic project of the Institute of Ortofonologia, which
provides constant monitoring through clinical evaluations, it was
noted that the rst signicant drawings oen come to life within the
therapeutic setting, there where the communication with the other
acquires its importance. In fact, the child, in the therapeutic context,
within a signicant relationship, becomes able to lower his defense
mechanisms and to express, so more, his emotional experiences
through nonverbal instruments, unlike what happens in assessment
context. Only within a meaningful context the drawing could become,
for the autistic child, a means to tell to another his own needs, desires
and emotions even if in the absence of verbal language.
Objectives of the research here presented are: to evaluate the
drawing development of children with autism spectrum disorder, both
in relation to the severity of the symptoms and of the cognitive level; to
investigate the dierences in drawings in connection with the age and
the time spent in the therapy path.
Method
Participants
e research sample consisted of 84 children with a diagnosis of
autism spectrum disorders (ASD), who had an age comprised between
the 2.58 and 15.00 years (M=7.63 years; SD=3.2) at the time of the
assessment. Of these, 15 were female and 69 were male (Table 1). Most
children were Italian (93%); there also were an African minority (2%),
Asian (2%) and Eastern Europe (3%).
Procedures
Children who participated in this study came in consultation at the
Institute of Ortofonologia in Rome (IdO), between 2006 and 2015, with
a diagnosis of autism spectrum disorders and a request for treatment.
e diagnosis of these children was conrmed according to the
diagnostic criteria of DSM-IV and DSM-5 and to the score obtained
at the Autism Diagnostic Observation Schedule, First and Second
Edition (ADOS-2) [20,21] that indicates their severity. e assessments
Mean SD Minimum Maximum
Chronological Age, years 7.63 3.4 2.58 15.00
ADOS 16.08 6.2 1 26
SA 11.79 4.8 1 20
RRB 4.18 2.2 0 8
IQ 68.77 21.4 36 103
Drawing Level 2.94 1.6 0 5
Legend: SA: Social Affect ADOS-subscale; RRB: R Restricted and Repetitive Behavior; IQ: Intelligence Quotient Score
Table 1: Description of the sample of 84 children with ASD (mean, ds, max-min range): age, ADOS-2 scores, IQ scores, drawing Level.
Citation: Di Renzo M, Marini C, Bianchi di Castelbianco F, Racinaro L, Rea M (2017) Correlations between the Drawing Process in Autistic
Children and Developmental Indexes. J Psychol Psychother 7: 291. doi: 10.4172/2161-0487.1000291
Page 3 of 9
Volume 7 • Issue 2 • 1000291
J Psychol Psychother, an open access journal
ISSN: 2161-0487
considered in this study refer to the period between 2014 and 2015, so
include both children newly arrived at the Institute both children who
were already taken into care. Aer four years of therapy, some of these
children were not more in the ADOS autism spectrum category.
e diagnosis of children involved in autism research was prepared
by a group of experts with at least 10 years of experience (psychologists/
psychotherapists, child neuropsychiatrists, neurologists and other
specialized gures). e sample of this research did not include
children with certied neurological damage, sensory disabilities
or under 2 years old. is study was carried out in accordance with
the recommendations of the national guidelines and the APA ethic.
All subjects gave their informed consent for inclusion before they
participated in the study. e study was conducted in accordance with
the Declaration of Helsinki.
Measures
Autism diagnostic observation schedule, second edition: e
Autism Diagnostic Observation Schedule-Second Edition [20,21]
is a semi-structured standardized assessment concerning the areas
of communication, social interaction, play, and repetitive and
restricted behaviors. It is considered a gold standard so being the most
commonly standardized measure used in research protocols. It has
strong psychometric properties, including good reliability and validity.
e ADOS-2 includes ve modules, but during the assessment process,
just one module is administered and it is selected on the basis of the
expressive language level and chronological age of the child:
Toddler Module: For children between 12 and 30 months of age
who do not constantly use sentences in their speech. is module
allows you to precisely identify children at risk of autism spectrum
disorders (ASD);
Module 1: For children aged from 31 months who do not
continuously use sentences in their speech;
Module 2: For children of all ages who use sentences in the speech,
without being verbally uent;
Module 3: For verbally uent children and adolescents;
Module 4: For verbally uent older adolescents and adults.
In Modules 1 to 4, the algorithm scores are compared to get one
of three classications: Autism, Autism Spectrum, and Not Spectrum.
e cut-o for the ADOS-2 classications ADOS-2 varies according
to the module used and to the child’s language level. e ADOS-2,
in addition to providing an overall score, also measures the domain
of Social Aection (SA) and the domain of Repetitive and Restricted
Behaviors (RRB). e SA includes the evaluation of aspects related
to communication and reciprocal social interaction. e RRB
includes unusual sensory interests, mannerisms, repetitive interests
and behaviors and stereotyped-idiosyncratic use of words and/or
vocalizations.
Leiter international performance scale-revised: e Leiter
International Performance Scale-Revised [22] is designed for the
evaluation of intellectual functions of children and adolescents aged
between 2 and 20 years. e Leiter-R is formulated to meet the clinical
need of evaluating the non-verbal intelligence through a comprehensive
analysis of the strengths and weaknesses of the child, with a view to a
diagnosis that includes both neuropsychological and cognitive aspects.
Non-verbal cognitive abilities do not require the ability to perceive,
manipulate and reason with words and numbers, so that the scale
can be administered completely without the use of verbal language,
including instructions, because it does not require verbal responses
from the subject. e validity coecients of the IQ score was calculated
for each age group (alpha 0.92 to 0.93). e Leiter-R has good evidence
of its validity, with data from a wide analysis from the criterion related
studies, the accuracy of classication of intellectual disability and
various studies related to the construct [22]. e IQ score has a mean
of 100 and a standard deviation of 15. e intellectual disability is
indicated by a composite score that is two standard deviations or more
below the average, so that a score of 70 constitutes the borderline value.
e drawing evaluation: e drawing process was evaluated in
semi-structured observation in which an examiner unknown to the
child asked him to spontaneously draw, providing markers and A4
sheet of paper. e examiner was not the therapist who has followed the
child in the course of therapy and this in order to make the evaluation
as objective as possible, so avoiding excessive distortions dictated by
familiarity built within the therapeutic relationship.
e drawings obtained were evaluated by referring both to the
process of drawing (through semi-structured observations) both to
the nal product, considering the close relationship of space and time
implied by the drawings of that child at that time of his evolution.
Specically, with regard to the process of drawing, the following
parameters were observed:
- e attitude of the child during the administration and the activity.
It was observed how that activity was accepted (if the child
starts drawing waiting for the administration, or anticipating
it; if the child initially refuses the activity going away and/or if
he interrupts the activity several times).
- Eye contact during the action (if present, discontinuous or
absent).
- e use of color (if the child tends to use only one or several).
- e prehension of the instrument (functional, high into a st or
between the ngers).
- e presence of interaction with the examiner during the activity,
by observing if the drawing is used in a relational manner or
not.
- e duration of the drawing and the attentive level.
- e use of the space in the sheet.
- e form and the order of the elements that constitute the
drawing.
- e line, shape, proportion and erasures (if the child asks for
other sheets or gets them individually).
- e child’s posture while drawing.
Considering the above mentioned parameters detected during the
activity, the drawing was then placed in a specic phase of the drawing
development, following the stadial theories [19]. ese theories
provide a key to understanding the dierent developmental steps of
drawings, distinguishable according to age, always keeping in mind the
individuality of the child and the context. In this way the drawings of
the sample were evaluated, codied and placed within the following
5-point scale [14,19].
Citation: Di Renzo M, Marini C, Bianchi di Castelbianco F, Racinaro L, Rea M (2017) Correlations between the Drawing Process in Autistic
Children and Developmental Indexes. J Psychol Psychother 7: 291. doi: 10.4172/2161-0487.1000291
Page 4 of 9
Volume 7 • Issue 2 • 1000291
J Psychol Psychother, an open access journal
ISSN: 2161-0487
Level 0. Refusal to draw or absence of productions.
Level 1. Disordered, random scribbling (age range 2 to 3.6 years):
uncontrolled graphic marks, in which all the surface of the sheet is
used, with little or no visual control over motor activity.
Level 2. Controlled scribbling (age range 2 to 3.6 years): Graphic
marks are smaller and controlled and there is a growing ability to
visually control the motor activity.
Level 3. Named scribbling, with meaning attribution (age range 2
to 3.6 years old): the child connects his graphic marks to objects of the
outside world so originating the representative world.
Level 4. Preschematic (Age range 3.7-5, 6 years): deliberate attempts
to represent reality even if the dierent elements are not well organized
on the sheet.
Level 5. Schematic (age range 7-8 years): the drawing has
appropriate form to represent an object of reality; the space-time
parameters are achieved and the drawing is well recognizable.
Following the evaluation of the drawing level, the child was asked
to draw a human gure giving access to a pencil and a sheet, in order
to verify the presence of the body image in children with ASD. Given
the variety and severity of autistic symptoms of the sample, it was
impossible to use the Human Figure Test through the typical modes of
the standardized Machover test [8], because it was not possible to use
the same administrations to all subjects (because of the verbal language
decits and the discontinuous attentive diculty), so preventing the
reliable and valid use of the relative scale.
Data analysis: We used the Statistical Package for Social Sciences
(SPSS) version 21 for data analysis. Signicance level was set at alpha
0.05 (two-tailed). Analysis of Variance (ANOVA) was used to evaluate
dierences between groups. Eect sizes were reported as partial eta
squared (η2
p), A η2
p of 0.02 was considered a small eect size, 0.13 a
medium eect size and 0.23 a large eect size. Correlation analysis was
performed to analyze the relationship between dependent variables.
Chi-squared analyses were conducted to examine group dierences in
demographic variables between the categorical variables. Finally, the
linear regression analysis was conducted to identify predictors of the
level of drawing.
Results
e 84 children in the sample were divided according to the ADOS-
2 scores in: children with severe autism (AUT; 78.6%), children with
autism spectrum disorder (SpD; 8.3%); children out of the cut-o for
the spectrum (No-spectrum; 13.1%). e children were in therapy, on
average, from 3 years and 3 months (SD=2.4).
e drawing development in children with ASD
As shown in Table 2, in the AUT Group about the 6% of children
refuses to draw or is not able to, about the 44% of children were in the
scribbling phase, about the 47% of the children achieved preschematic
and schematic drawings.
In addition, all the AUT children with preschematic and schematic
drawings also reached the ability to produce the body schema.
In the SpD group, about the 14% of children refuses to draw or is
not able to, approximately the 70% of children were in the scribbling
phase, about the 14% of children produced preschematic drawings; no
child realized schematic drawings. Only 1 child was able to draw the
body schema.
In the No-spectrum group, nobody refuses to draw or is not able to
and nobody realizes disordered scribbling, approximately the 45.5% of
children produced controlled scribbling or with meaning attribution,
about the 55% realized preschematic and schematic drawings. More
than the 50% of children was able to draw the body schema.
Investigate chronological age dierences and therapy
duration
Dividing the children into age groups, that is: 2-5 years (N=32), 6-9
years (N=31) and 10-15 years (N=21) a signicant dierence emerged
(F2,83=18.47; p<0.001; η2
q=0.33), so that the drawing level in ASD
children increased with the age, and the body schema started to appear
in about the half of them between 6 and 9 years of age, while it is almost
always present aer 10 years of age.
e children, also, were divided according to the time already
spent in therapy at the time of the drawing assessment. Children who
had about 3-4 years of therapy behind them showed a signicantly
higher level of drawing (F3,83=5.80, P<0.001; η2
q=0.17) than those who
attended therapy from 1-2 years. ese dierences are accentuated
with the increasing of the children’s chronological age (Table 3).
As for the representation of the body schema, there was a signicant
dierence compared to the chronological age of children: of the 38
children with the body schema, 3 were preschoolers, 17 were 6-9 years
old and 18 were 10-15 years old (Chi square=31.6, p<0.001).
Correlation between drawing level, cognitive skills, autistic
symptoms
e analysis of the correlations showed that the drawing level
improves with the increase of the age of children and the improve
of the ADOS scores, and in particular with the improve of the Social
Aections (SA). However there is no correlation between drawing and
restricted, repetitive behaviors (RRB).
Finally, the drawing scores have a higher correlation with IQ scores
than with ADOS scores (Table 4).
To show that ADOS scores relate directly to drawing level, a
regression model was conduct, with drawing level as the dependent
variable and IQ entered as the rst predictor and ADOS scores as
Drawing level AUT (N=66) % SpD (N=7) % No-spectrum (N=11) %
Refuses or is not able to 4 6.1 0 0.0 0 0.0
Disordered, Random Scribbling 14 21.2 1 14,3 0 0.0
Controlled Scribbling 15 22.7 2 28.6 2 18.2
Named Scribbling, with meaning attribution 2 3.0 3 42.9 3 27.3
Preschematic 19 28.8 0 0.0 1 9.1
Schematic 12 18.2 1 14.3 5 45.5
Body Schema 31 47.0 1 14.3 6 54.5
Table 2: Division according to the drawing level of AUT (N=66), SpD (N=11) and No-spectrum (N=7) children.
Citation: Di Renzo M, Marini C, Bianchi di Castelbianco F, Racinaro L, Rea M (2017) Correlations between the Drawing Process in Autistic
Children and Developmental Indexes. J Psychol Psychother 7: 291. doi: 10.4172/2161-0487.1000291
Page 5 of 9
Volume 7 • Issue 2 • 1000291
J Psychol Psychother, an open access journal
ISSN: 2161-0487
the second (Figure 1). When ADOS scores was adding as a predictor,
results in a signicant change in the variance explained by the model,
so we can assume that ADOS scores inuence drawing over and above
IQ (Table 5).
By way of explanation in Figure 2 we can examine a spontaneous
drawing that is in delay if compared to typical development: the child
is 8 years old and has an autistic disorder with severe symptoms
(ADOS=19) and an IQ that cannot be assessed, neither with the Leiter-R
scale, because of the his relational closure and his labile attentive times.
His spontaneous production can be placed in the disordered scribbling
stage that normally is acquired at about two years of age.
In Figure 3, there is an example of a stereotypical image: here we
nd small squares, colored with a precise succession of colors (red,
green and yellow) which cover all the space of the sheet. In this drawing,
no living objects appear and the movement is absent. e author is a 10
years old child who has an autistic disorder assessed using the ADOS
with a score of 19 and an intellectual disability assessed through the
Leiter-R with an IQ score of 50.
During the execution of the drawing, which took place in an
observational context, the child showed a strong relational closure
also through an echolalic verbal language, a rigid body posture and a
discontinue eye contact that made it impossible any intervention to
change the interaction and its realization, since stereotypies prevent
the exibility necessary to modify the process in reference to external
stimuli.
Observing and evaluating the drawings of autistic children we
notice that many of them do not use the drawing in a communicative
and relational way, but in a stereotyped way to evade the context. In
fact, as well as many children use bizarre verbal language so oen
repeating words, sounds or phrases they heard say (echo-lalia), in the
same way they produce stereotyped drawings, copying or repeating
forms many times (echo-graphic).
From 2 to 5 years From 6 to 9 years From 10 to 15 years
Drawing Score 1.9 (0.2) 3.2 (0.2) 4.1 (0.3)
Refuses or is not able to, % 12,5 19,4
Disordered Scribbling, % 25,0 19,4 4,8
Controlled Scribbling, % 34,4 6,5 9,5
Named Scribbling, with meaning attribution, % 18,8 29,0
Preschematic, % 6,3 25,8 42,9
Schematic, % 3,1 19,4 42,9
Body Schema, % 9.4 54.8 85.7
Legend: SA: Social Affect ADOS-subscale; RRB: R Restricted and Repetitive Behavior; IQ: Intelligence Quotient Score
Table 3: Drawing development in children divided by age.
SA RRB IQ Drawing level
ADOS2 0.95** 0.74** -0.52** -0.46**
SA 0.55** -0.48** -0.51**
RRB -0.46** -0.15
IQ 0.39**
Legend: SA: Social Affect ADOS-subscale; RRB: R Restricted and Repetitive Behavior; IQ: Intelligence Quotient Score
Table 4: Correlation between drawing scores, ADOS-2 scores and IQ scores.
Figure 1: Drawing trend in ASD children according to chronological age and the therapy duration.
Predictors R R squared B SE P 90%–95% CI Exp(B) Collinearity statistics
Lower / Upper Tolerance VIF
IQ scores .397 .147 .029 .007 .001 .014 / .044 1.00 1.00
ADOS scores .464 .215 -.117 -.464 .001 -.166 / -.068 1.00 1.00
Table 5: Regression Model.
Citation: Di Renzo M, Marini C, Bianchi di Castelbianco F, Racinaro L, Rea M (2017) Correlations between the Drawing Process in Autistic
Children and Developmental Indexes. J Psychol Psychother 7: 291. doi: 10.4172/2161-0487.1000291
Page 6 of 9
Volume 7 • Issue 2 • 1000291
J Psychol Psychother, an open access journal
ISSN: 2161-0487
Stereotyped drawings are distinguished from those spontaneous for
their static character, rigid and close to the surrounding environment.
e drawing, in these cases, does not lead the child to an adaptation
nor to an interaction neither to the nal “product” nor to the drawing
process. In stereotyped drawings, in fact, the dialogical component fails
and this means of communication is used as a tool of estrangement
from the surrounding environment.
In the Figures 4-6 it can be seen as the rst attempts to represent
the human gure are connected to the emotional-relational state rather
than to the chronological age and cognitive level. However, it is again
emphasized that there are completely dierent ways of development
and that it cannot assess the aective and cognitive level of a child on
the basis of a single drawing.
In the Figure 4, without taking account of the orientation in the
vertical direction, it is represented a circle that would be the head with
all the elements of the face, eyes, nose, mouth, ears and hair. e author
is a child of six years and four months with autistic symptomatology in
the absence of intellectual disability, which obtained an ADOS score of
13 and an IQ score of 71 in the Leiter-R, which is a borderline value.
In the Figure 5, a nine years old child, who has severe autistic
symptoms as measured by the ADOS with a score of 14 and a cognitive
development that cannot be assessed through the Leiter-R, produces
only some elements of the face without the contour of the head and the
body. It stands out in particular the choice of excluding the contour of
the face, since it is unusual, and of including, instead, the pupils.
Both designs are incomplete and strongly inadequate if compared
Figure 2: 6 years old girl; ADOS score: 21 (severe symptoms); IQ: 52 (moderate retardation).
Figure 3: 10 years old boy; ADOS score: 19 (severe symptoms); IQ: 50 (moderate retardation).
Citation: Di Renzo M, Marini C, Bianchi di Castelbianco F, Racinaro L, Rea M (2017) Correlations between the Drawing Process in Autistic
Children and Developmental Indexes. J Psychol Psychother 7: 291. doi: 10.4172/2161-0487.1000291
Page 7 of 9
Volume 7 • Issue 2 • 1000291
J Psychol Psychother, an open access journal
ISSN: 2161-0487
Observing the Figures 4 and 6 we can see that these two children,
albeit presenting the same IQ, show a dierent capacity of representing
the body schema and the gure 6, which belongs to a younger child,
is better than the other. Considering many variables, this dierence
seems attributable to the lower level of autistic symptoms and not to
the age.
If we consider two drawings of the same child we can do further
reections. In the Figures 7 and 8, in fact, we observe the body schema
produced in two dierent contexts in a time frame of about a month. It
is a 7 years old child with an ADOS score of 12 and an IQ score of 116.
e Figure 7 was carried out in an assessment context while the Figure
8 was made in a therapeutic setting. ey both are not complete of all
the elements of the body schema and appear immature and altered with
respect to the age and especially if compared to the child’s IQ but both
express the emotional state of the child although if in dierent ways for
the quality and quantity. In particular in the Figure 7 emerges a strong
inhibition, an emotional block related to the performance requested
by the operator. is interpretation is conrmed by the observation of
the child’s behavior during the execution of the drawing because even
through his body posture he shows a strong inhibition and high anxiety
levels. Instead the second drawing (Figure 8) reveals a greater peace in
the drawing process by which the child is able to express with a soer
style his self-perception.
In comparing drawings of the same child in dierent contexts,
we found that they oen dier signicantly. In particular we found
that in the therapeutic setting: there are fewer occasions of refusal in
performing drawings; the emotional connotation of the graphic image
Figure 4: 6 years old boy; ADOS score: 13 (severe symptoms); IQ: 71.
Figure 5: 9 years old boy; ADOS score: 14 (severe symptoms); IQ: not evaluable.
to the age criterion, but at the same time they both express, in their
diversity, the specicity of each individual author. e rst drawing
of the human gure, even if in late, also indicates the way in which
the child perceives and shows the beginning of a more structured
intellectual process.
In the Figure 6, however, we can examine the drawing of the so
called “big head”: the autistic child who drew it at the age of 4 years and
11 months by submitting had an autistic disorder with mild symptoms
(ADOS score of 8) and no intellectual disability (IQ score of 71). His
drawing production was impaired because these kinds of representations
usually appear around the age of three. It should be noted that this drawing
was realized as a result of a treatment path, thanks to which the changed
his ADOS diagnosis. At his rst ADOS administration, in fact, the child
obtained a score of 20 which placed him in a severe symptoms category
(it was at the intake that is two years before this drawing). It appears
that the child, thanks to the good course of treatment and then to the
reduction of symptoms, could acquire a greater perception of the self and
the surrounding world that allowed him also to draw the human gure.
is drawing production can be read as a positive indicator, predictive of
his emotional state. As evidence of this, the same child in later years of
his course of treatment achieved further signicant improvements in all
the developmental areas.
Figure 6: Four 11 years old boy; ADOS score: 8 (mild symptoms); IQ: 71.
Figure 7: Body schema made by a 7 years old boy; ADOS score: 12
(sever symptoms); IQ: 116.
Citation: Di Renzo M, Marini C, Bianchi di Castelbianco F, Racinaro L, Rea M (2017) Correlations between the Drawing Process in Autistic
Children and Developmental Indexes. J Psychol Psychother 7: 291. doi: 10.4172/2161-0487.1000291
Page 8 of 9
Volume 7 • Issue 2 • 1000291
J Psychol Psychother, an open access journal
ISSN: 2161-0487
is stronger than that produced in observational settings; the child
uses this production to express his emotional experiences in order to
communicate them to the therapist (who can then reuse drawings to
work on the main elements emerged).
Conclusion
e results demonstrate the close relationship of drawing with the
level of autistic symptomatology. All children who are part of an autism
spectrum disorder have a signicant delay in the drawing process, and
this delay is not related to the IQ, but rather to the Social Aection
area investigated by the ADOS-2. Within the Social Aect area may be
included all the tactile and proprioceptive feelings that allow the child
a relational opening. A signicant fact that emerges from the research
is that the drawing development improves with age and duration of
therapy. e increased presence of the body schema in children aged
from 6 to 9 years is in fact due to therapy duration of at least 2 or 3
years.
Children who at the time of the assessment obtained a score of No-
Spectrum (determined by four years of prior therapy) show graphic
capabilities far superior to that of other groups, thanks to a greater
social openness that allows the child to use drawings communicatively.
e fact that children come out of the ADOS diagnoses of autism have
signicantly improved their autistic production shows how the initial
diculties were pervasive and not specic. In children from 10 to 15
years old, instead, the appearance of the humane gure is linked not
only to a greater maturity, but also the various stimuli received in
family, educational and therapeutic contexts. It is important to stress
that when there is the representation of the human gure, this appears
immature and impaired with respect to age. However, we could also
show that the presence of the human gure constitutes a sign of a
positive development of autistic symptoms. In fact, the appearance of
the body schema is an important relational opening index for an autistic
child, since it demonstrates his initial ability to recognize himself with
his own body and then to dierentiate himself from the other.
e highlighted data allow us to state that none of the children
included in the Turtle Project has a special ability to draw. is
is in contrast to a part of the scientic literature that emphasized
extraordinary drawings abilities of a specic sample with autism
spectrum disorder in absence of intellectual disability [23,24]. In
particular, it was found that the characteristic of the artistic work of
these individuals was their visual realism, specically the linearity,
which captures the contours, and the prospect of an object or scene.
However, some other studies [25,26] already refuted the notion of a
connection between drawings skills and autism, in particular showing
that autistic children do not get better performance than those of
children with typical development with corresponding mental age, and
that visual realism is not a feature of all autistic children’s drawings.
ese studies also found that the artistically gied autistic individuals
may have much in common with not autistic people artistically gied
[23].
In this research we observed that children of our sample have a
diculty in their drawing ability that increases with the severity of
symptoms and, in addition, that none of them possesses unique skills.
In conclusion we can say that the delay in drawing development
supports the concept of a pervasive disorder noting that the lack of
communication aects not only the verbal level, but all the expressive
channels and imaginative processes, as it is clear also from the poorness
or lack of symbolic play.
It seems important to emphasize the fact that a therapeutic
approach, which could properly take account of the emotional
component of development, promotes the natural unfolding of some
of the child’s abilities including those inherent the drawing process.
e spontaneous appearance of the drawing, in our experience, it is
always a result of a greater relational opening of the child and then an
expansion of the cognitive strategies necessary to adapt to the outside
world. Recent researches [27-29] documented how generally the
cognitive level and also intellectual inhibition are closely related to the
ADOS score and if this decreases, thanks to the course of treatment,
as a result the intellectual inhibition will reduce and the IQ score of
the subject will increase. Similarly the autistic symptoms may block the
drawing development, in the sense that serious symptoms correspond
to a low IQ score and to a drawing level which strongly deviates from
the norm.
In patients belonging to the Turtle Project we found that some
children, at a distance of approximately one year from the rst
observation, signicantly improved their drawings and this nding also
was conrmed at the ADOS retest and at the Leiter-R with a positive
change of diagnosis and with an IQ improvement.
Many of the children, in the course of treatment, signicantly
changed the type of response given to the various tests and in some
cases, following the ADOS score, went from an autistic disorder to
an autism spectrum or to an absence of the disorder, accompanying
these results also to a positive intellectual change. In particular, for a
subsample of 78 children in the Turtle Project who were administered
the ADOS procedure in dierent time periods, there was a signicant
improvement: 31 children (40%) achieved a less severe ADOS
diagnosis, among which the 24% got an ADOS score lower than 7, so
placing out of the autistic spectrum.
Finally, in this paper we also highlighted the usefulness and desirability
of using the drawing tool both in an observational context and in therapy,
especially considering the lack of attention until now attributed to this
aspect. Children’s scribbling and drawings, even those of autistic children,
are valuable materials for reading the path of growth, through the evolution
of signs, forms and composition: real and proper elements of a grammar
and syntax of the grapho-pictorial language.
Figure 8: Body schema made by the same child of the Figure 7, in a
therapeutic setting.
Citation: Di Renzo M, Marini C, Bianchi di Castelbianco F, Racinaro L, Rea M (2017) Correlations between the Drawing Process in Autistic
Children and Developmental Indexes. J Psychol Psychother 7: 291. doi: 10.4172/2161-0487.1000291
Page 9 of 9
Volume 7 • Issue 2 • 1000291
J Psychol Psychother, an open access journal
ISSN: 2161-0487
Acknowledgement
This article is based on the activities of the Institute of Ortofonologia (IdO) of
Rome. We are grateful to the psychologist, child psychiatrist, speech therapist,
parents and children whose participation made this work possible.
References
1. Olivero Ferraris A (2012) Il signicato del disegno infantile. Bollati Boringheri,
Torino.
2. Pizzo Russo L (2015) Il disegno infantile. Storia, teoria, pratiche. Aesthetica,
Palermo.
3. Cannoni E (2005) Lo sviluppo del disegno [The drawing development]. Carocci,
Roma.
4. Crocetti G (2008) I disegni dei bambini. Metafore e simboli del benessere
bambino [The drawings of children. Metaphors and symbols of child welfare].
Armando Editore, Roma.
5. Huri M, Mehr BK, altuntaş O, Kayiha H (2014) Yaygın gelişimsel bozukluğu
olan ve normal gelişim gösteren çocukların taktil tercihlerinin karşılaştırılması.
Ergoterapi ve Rehabilitasyon Dergisi 2: 21-28.
6. Huri M, Şahin S, Kayıhan H (2016) Investigation of hand function among
children diagnosed with autism spectrum disorder with upper extremity trauma
history. Ulus Travma Acil Cerrahi Derg 22: 559-565.
7. Roley SS, Mailloux Z, Parham LD, Schaaf RC, Lane CJ, et al. (2015) Sensory
integration and praxis patterns in children with autism. Am J Occup Ther 69: 1-8.
8. Azouz HG, Khalil M, El Ghani HMA, Hamed HM (2014) Somatosensory evoked
potentials in children with autism. Alexandria Journal of Medicine 50: 99-105.
9. Provost B, Heimerl S, Lopez BR (2008) Levels of gross and ne motor
development in young children with autism spectrum disorder. Physical and
occupational Therapy In Pediatrics 27: 21-36.
10. Tustin F (2013) Autistic states in children. Routledge, London, UK.
11. Di Renzo M, di Castelbianco FB, Vanadia E, Petrillo M, Racinaro L, et al. (2016)
Assessment of executive functions in preschool-aged children with autism
spectrum disorders: Usefulness and limitation of BRIEF-P in clinical practice. J
Child Adolesc Behav, pp: 1-7.
12. Di Renzo M, Marini C, Bianchi di Castelbianco F (2013) Il processo graco
del bambino autistico [The drawing process of the autistic child]; Magi, Roma.
13. Ayres AJ (2004) Sensory integration and praxis tests manual: Updated edition.
Western Psychological Services, Los Angeles, CA.
14. Luquet G (2001) Children’s drawings. Free Association Books, London.
15. Grandin T (2001) Autism and visual thought. Erikson, Trento.
16. Jolley RP, O’Kelly R, Barlow CM, Jarrold C (2013) Expressive drawing ability in
children with autism. Br J Dev Psychol 31: 143-149.
17. Machover K (1949) Personality projection: In the drawing of a human gure.
Charles Thomas Publisher, Springeld.
18. Longobardi C, Pasta T, Quaglia R (2012) Manuale del disegno infantile.
Vecchie e nuove prospettive in ambito educativo e psicologico [The manual of
the infantile drawing. Old and new perspectives in education and psychology];
UTET University, Verona.
19. Pizzo Russo L (2015) Il disegno infantile. Storia, teoria, pratiche [The infantile
drawing. History, theory, practices]; esthetica, Palermo.
20. Lord C, Rutter M, Di Lavore PC, Risi S (2005) Autism diagnostic observation
schedule. Organizzazioni Speciali, Florence, Italy.
21. Lord C, Rutter M, Di Lavore PC, Risi S, Luyster RJ, et al. (2013) Autism
diagnostic observation schedule. Hogrefe, Florence, Italy.
22. Roid GH, Miller LJ (2002) Leiter–R: Leiter International Performance Scale–
Revised. Organizzazioni Speciali, Florence, Italy.
23. Simmons DR, Robertson AE, McKay LS, Toal E, McAleer P, et al. (2009) Vision
in autism spectrum disorders. Vision Res 49: 2705-2739.
24. O’Connor N, Hermelin B (1990) The recognition failure and graphic success of
idiot-savant artists. J Child Psychol Psychiatry 31: 203-215.
25. Smith Ad, Kenny L, Rudnicka A, Briscoe J, Pellicano E (2016) Drawing rmer
conclusions: Autistic children show no evidence of a local processing bias in a
controlled copying task. J Autism Dev Disord 46: 3481-3492.
26. Allen ML, Craig E (2016) Brief report: Imaginative drawing in children with
autism spectrum disorder and learning disabilities. J Autism Dev Disord 46:
704-712.
27. Di Renzo M, Bianchi di Castelbianco F, Petrillo M, Racinaro L, Rea M (2015)
Assessment of a long-term developmental relationship-based approach in
children with autism spectrum disorder. Psychol Rep 117: 26-49.
28. Di Renzo M, Bianchi di Castelbianco F, Vanadia E, Petrillo M, Racinaro L, et
al. (2016) From the emotional integration to the cognitive construction: The
developmental approach of turtle project in children with autism spectrum
disorder. Autism Open Access 6: 1-9.
29. Di Renzo M, Petrillo M, Bianchi di Castelbianco F (2011) Le potenzialità
intellettive nel bambino autistico. Nuove prospettive attraverso l’interpretazione
del Test Leiter-R. [The intellectual potential of the autistic child: new perspectives
through the interpretation of the Leiter-R scale]; Magi, Rome.
Citation: Di Renzo M, Marini C, Bianchi di Castelbianco F, Racinaro L, Rea
M (2017) Correlations between the Drawing Process in Autistic Children and
Developmental Indexes. J Psychol Psychother 7: 291. doi: 10.4172/2161-
0487.1000291
OMICS International: Publication Benefits & Features
Unique features:
• Increased global visibility of articles through worldwide distribution and indexing
• Showcasing recent research output in a timely and updated manner
• Special issues on the current trends of scientic research
Special features:
• 700+ Open Access Journals
• 50,000+ editorial team
• Rapid review process
• Quality and quick editorial, review and publication processing
• Indexing at major indexing services
• Sharing Option: Social Networking Enabled
• Authors, Reviewers and Editors rewarded with online Scientic Credits
• Better discount for your subsequent articles
Submit your manuscript at: http://www.omicsonline.org/submission/
