#47 – Assessment Process for Age 5 – 8 – Part 1

Assessment Process for Age 5 – 8 – Part 1

On Magical Thinking

From the opening paragraph of Wikipedia page on “Magical Thinking: 

Magical thinking is the belief that unrelated events are causally connected despited the absence of any plausible link between them, particularly as a result of supernatural effects. Examples can include the idea that personal thoughts can influence the external world without acting upon them, or that objects must be causally related if they resemble each other or came in contact with each other in the past. Magical thinking is a type of fallacious thinking and is a common source of invalid causal inferences. Unlike the confusion of correlation with causation, magical thinking dos not require the events to be correlated. In psychology, magical thinking is the belief that thoughts by themselves can bring about effects in the world or that thinking about something corresponds with doing it. These beliefs can cause a person to experience an irrational fear of performing certain acts or having certain thoughts because of an assumed correlation between doing so and threatening calamities. (Note: this entire Wikipedia page is a good introductory to the topic of magical thinking as a whole) 

Using Piaget’s stage model of cognitive development, the 2 – 7 year old is commonly in the Pre-operational Stage, characterized by wha Piaget defines as symbolic thought. Magical thinking is a component. With what appears to be considerable overlap, the 7 – 11 year old usually operates in the Concrete Operational Stage, characterized by operational thought. The subsequent stage covering adolescence and adulthood is termed Formal Operations and is characterized by the use of abstract concepts. Some children aged 10 and 11 years olds are capable of thinking in these terms.

Piaget writes about the psychological impacts of loss, trauma, and other upsetting events on this Pre-operational  bracket and how they differ from those reactions of people who are older children, adolescents, and adults. Again from the Wikipedia page, citing Piaget:

Due to examinations of grieving children, children of this age (2 – 7) strongly believe that their thoughts have an impact on the rest of the world. It is posited that their minds will create a reason to feel responsible if they experience something tragic that they do not understand, i.e. a death. During this age, children often feel they are responsible for events occurring or are capable of reversing an event simply by thinking about it and wishing for a change…Magical thinking is found particularly in children’s explanations of experiences about death, whether the death of a family member or pet…These experiences are often new for a young child, who at that point has no experience to provide an understanding of the event’s ramifications. A child may feel responsible for what has happened simply because they were upset with the person who died, or played too roughly with the pet. There may also be the idea that if they wished hard enough, or performs just the right act, the person or pet could choose to come back to life, snd not be dead any longer.

The vulnerabilities a young child may experience include a sense of responsibility when negative events occur to themselves or family members or friends. They may harbor personal remorse for the misfortunes of family members and friends that in reality have little or nothing to do with the child. They can assume that others certainly feel the same way that they do. Magic creates memorably beautiful experiences for the young child, but also produce an equally forceful dark side that can portend emotional struggles in the future, both near and far off in time. A good therapy can help.

The CBT-oriented family therapy approach to child and adolescent mental health assessment processes is usually a delineation of existing client problems, history, other previous and current   therapies, other mental health or relational problems among family members, and other individual or family life factors that may be impacting this new client. To the degree possible, the presenting problems are defined by the end of the assessment process in behavioral terms that can understood by the family participants and be measured in one way or another. Unless compromised by problems with cognitive development, the child provides important, objective assessment information for the therapist.

One could argue, with merit, that a secondary role for the therapist is to help facilitate the 5 – 7 year old child’s movement away from magical thinking and into a more realistic frame of reference. That objective could be sought in individual therapy, but family therapy is a viable alternative.The outcome data of this study suggests that 5 – 7 years olds improving to the same general degree as did the older youth. The family approach where the parent(s) are actively involved in one way or another to meet the client’s therapeutic needs was effective. Some kids were presumably still engaged with magical thinking at the outset of clinical work, and by the end of an effective treatment, they are thinking more objectively about the problems, the others, and most importantly about themselves. Even in modest gain, trust is enhanced. It takes a village, so to speak.

Beginning at age 5 and possibly as late as 8, the child attains the ability to objectively view themselves, describe their own thoughts, feelings, and behaviors, share their experiences and points of view, with degrees of accuracy develop opinions about the motivations of others and why sequences occurred as they may have. They may not be fully disclosing, or are shy, or fearful of new situations, or be initially distrustful, but what they can do in sincerity is participate in a reality-based assessment process by contributing information and experiences, given with a ring of truth to them. 

The 8 – and – older child may also acknowledge some responsibility for their problems, which they may or may not disclose, and can come to understand that others may have a different point of view to be considered. Human problems are almost necessarily overdetermined, a concept within which these concrete operational stage children can cope and avoid wholly blaming themselves. Magical thinking makes clinical approaches used for older children and adolescents assessments less feasible for many of these 5 – 7 year old clients. A different approach is likely needed for those who fall in the latter group.

In deference to the maxim “first do no harm”, the least desired impact of an assessment session  for a youth still engaged with magical thinking, s to reinforce their sense of perpetration or unworthiness. Lacking the objectivity needed to engage in frank and thoughtful discussions about self-and-others, they can answer probing questions about themselves and their families with some level of forthrightness and still end up feeling internally worse because their guilt or flaws have somehow been reinforced. 

About the Assessment

The two basic purposes of the child assessment are to inaugurate a therapeutic relationship with the new client, and to develop a cogent clinical understanding of the client to review and discuss with the parent(s) in the subsequent summary and recommendations session. With the older children and adolescents, coming to at least a rudimentary understanding of the new client during the initial meeting is primarily a result of the verbal information received from the young person over the course of interview. Secondarily, the subjective impressions formed through observing and experiencing the young person relate and act become part of the presentation to the parent in the following summary and recommendations session. 

Think of the assessment as having vertical and horizontal components. The vertical represents that portion of the interview dealing with the problems that the client is experiencing personally, including possible exploration areas of: the symptoms; length of duress; efforts to solve or resolve; adjustments or accommodations that impacts daily life; emotional, social, and scholastic impacts; various coping mechanisms they may be using; etc. The horizontal dimension could include a few elements of client’s environment: including: parents and how they impact both positively and negatively the problems the client is experiencing and the same for siblings and other family members; how the other family members relate to each other, including mother and father; interactions with schoolmates; expectations of teachers; and possibly even extra-curricular experiences. The interviewing is not formulaic. The questions are driven intuitively, based on the sufficient clinical training, supervision, consultation, and experience needed to conduct a therapy process independently.

The clinical intent of the younger child’s assessment session’s outset is to use the same approach as used with the older children and adolescents as far as possible.

For the older child, In Piagetian terms, the ‘concrete operational’ thinking typical for ages 7 – 11, responding to this kind of interview takes the capability of taking at least a basic objective perspective in which they can view themselves in the context of their larger environment. The session, at this point usually 25 – 30 minutes total, then moves from the interviewing into the evaluative phase preceding the conclusion. 

Some of the 6, 7, and 8 year old clients could meaningfully engage with the necessary objectivity to portray their realities accurately. The four 6 and 7 year old youngsters mentioned in the previous post who began talking with that first “So, what can I do for you? question could do so. Most clients this age, though, seemed less able to maintain that objectivity toward themselves as they answered basic questions, i.e. unsure, straying, timorous, hesitant, more inclined toward the uncomfortable ‘I don’t know’ response. 

Their transition from the more formal interview just described to the observational mode about to be outlined was usually comfortable.They generally enjoyed the tasks and play that ensued and began to offer more unsolicited, “chatter” during a game. The suggestion here is that their presumed difficulties with the usual objective interview was less due to discomfort and more toward inability. 

For the client age 7 and under, the relative degree of information coming from verbal information compared to observation and experience are effectively switched. With those under age 8, and the occasional 8 year old as well, the assessment is based much more on how the new client handles given tasks and the skill with which they interact. The particular tasks and activities used were chosen for their ease of implementation, the quality of responses received, and the interest they generated during an experience that could easily be anxiety-provoking. 

To Start

The assessment for the younger ones began with the same greeting, often kneeling in front of them for eye contact as they often remained seated while being introduced by their parent, and offer a short explanation of what was to occur while their parent remained in the waiting room. Once the child was seated on the office couch, that same opener of “what can I do for you” was used, which may sound bit ridiculous for a 5 or 6 year old save for two reasons. 

First, these younger ones did begin talking after that first question more frequently than their older counterparts. Four memorable young clients, two boys and two girls among the eight 5 – 8 years olds during the last three years of the practice did so. Secondly, among the benefits afforded by these first reactions was an opportunity to point out their precocity both to them and to the parent(s). Still, though, many were not sufficiently mature in their thinking capacities to help sustain a fruitful discussion about problems and issues, to wit and copied from the chart notes of the assessment session:

This is the first time I’ve met with Quentin, a 6 1/2 year-old first grader brought in by father and step-mother with concerns about oppositional defiant behaviors. Quentin was talking by the second question. He said he was here for “behavior issues” and “tantrums”. He says he gets mad and when he gets mad he starts throwing things, and then he gets in more trouble. He said that his family refers to him as “The Hulk” and “Godzilla” because he gets so angry. He says that at his mother’s house he has better behavior because they get to go more places. I’m not sure that’s the case. He said he gets angry when he gets in trouble because his brothers are “annoying” him, or when one brother is “bullying him”, and when people call him names. He talked about breaking a closet door. Punishments include going to the corner, going to his room, no video games, not being allowed to go to his brother’s room, toys taken away, and to sleep in the hallway because his bed is broken. He broke the bed by jumping on it after being told not to by his step-mother. He will also get punished for “lying”. He said he missed Christmas one year because he was in trouble and had been “bad at Mom’s”. I asked him how come he gets in trouble at his Mom’s and at his Dad’s but nowhere else? He said “Because my sibs bother me”. Then I pushed him a bit harder and he said he gets into trouble at home because he has “fun everywhere else”.

This very bright handful and youngest of four children in the family had a turmoiled couple of years following a split between his parents when he was a year old. Custody was initially shared with the children, going back and forth between his parents’ homes for a week at a time. His father became the residential parent when he became engaged to the current step mother, the mother then having every other weekend. Quentin’s adjustment was by far the most difficult. In hindsight, he was very likely engaged in magical thinking at the time of the therapy interview, still working out evident feelings of anger, but also presumptively from guilt and fear, neither of which were indiscernible day to day. By the end of a two year, full family therapy involving the six family members and covering multiple issues beyond those of the client, he had roundly improved.

The vignette is presented as an example of a cognitively pre-operational child in an assessment session. The initial part of the interview, which lasted maybe ten minutes, could have continued, but the result would likely be somewhat barren of detailed terms for the following summary and recommendations session with the father and step-mother. Hence the early shift into the next phase of the assessment interview. 

Into The Evaluative Portion

As a result of experimenting with younger clients over time, the evaluative portions of the older children’s session that included the depression and anxiety inventory, the self-confidence self rating, the ego development sentence completion, and the socio-moral response to the Heinz Dilemma were not particularly helpful. The tools could be used in select instances with the pre-operative children, but not very often.

For the 5 – 8 group, the depression-anxiety inventory was already collected from the parents during the intake, and the terminologies and inferences were often difficult to grasp. Again, one purpose of this interview was to begin establishing a clinical relationship, and going through the symptoms with kids this young was as likely to create more anxiety as not. The self-concept rating scale, most younger ones were confused by the ten-point self-rating scale for each of the six categories (behavior, intellectual and school status, physical appearance and attributes, etc.). Interestingly, I did give the self-concept evaluation to 6 1/2 year old Quentin, and while he rudimentarily understood the concept of the 1 – 10 scale, he rated himself a 1 in three categories and a 10 in the other three. That result would not be considered valid. As for the socio-moral evaluation, my tendency was to use the Heinz Dilemma for kids 9 or 10 and above. Those young people could adequately separate themselves from the Dilemma’s circumstance of possible death by cancer, where the younger kids ran the risk of internalizing.

The ego development sentence completion was regularly more frequently used with the youngest group. Answers ranged from the ego-development stages one to three, with one and two typical for kids in K and 1st Grade students, and two – three typical for grades  two – three students. Occasionally a level 4 answer came from an 8 year old, but none in this cohort. Responses with special qualities would generate a bit of unanticipated praise. The parents were also apprised during the next session, this time with an explanation of why and how the answer stood out.

Five other activities were commonly included during the evaluative portion with the pre-operational, which would typically take 30 – 35 minutes. They included: a set of three drawings, one of the family, one of the client themselves, and one of anything they wanted to draw; a brief feeling identification exercise; story telling; and one of two interactive games. Most child therapists have their own preferences, but for those who are beginning or considering this kind of work, these particular activities are presented as an example of an array. 

The family drawings in and of themselves could easily take up much of the remaining time, particularly with more perfectionistic kids. Getting to the interactive games occurred probably  half of the time, but on occasion with particularly anxious, wary youngsters, the interactive playing was inserted at the beginning of the evaluation or after the drawings. 

The most tangible source of information for the parents came from the three drawings the child completed. To them, their child at that moment is alive and talking as they imagine him or her at work. First and foremost, they could see for themselves the results. Virtually all the other information they receive is by word. The drawings provided a focus for observations about the child and family for all two or three of us, a conduit for an exchange of interpretations, insights, revelations, concerns, satisfactions, the uplifting and the sobering, and  emerging, new thoughts about their child and their situation. 

On Children’s Drawings in Therapy

During the same era as when Erikson and Piaget were developing their stage models concerning human growth in differing areas, Victor Lowenfeld published his initial findings in 1947 on the childhood stages of artistic growth. They are as follows:

Stage 1 – Scribbling, Age 1 – 2: Children at this age are engaged in the physical activity of drawing. There is no connection between marks and representation at this stage. However, toward the end of this stage, children begin to give marks names. This stage is mostly the enjoyment of purely making marks.

Stage 2 – Preschematic Stage, Age 3 – 4:   Children are beginning to see the connections between the shapes they draw and the physical world around them. Circles and lines may be described as people and objects that are physically present in the child’s life. It is in this stage that children first make the connection to communicating through their drawings.

Stage 3 – Schematic Stage: Age 5 – 6, where children have clearly assigned shapes to objects they are trying to communicate. There is a defined order in the development of drawing. Drawings at this stage have a clear separation between the sky and the ground. Often the sky is a strip of blue at the top and is a strip of green on the ground, and a strip of brown at the bottom. Objects are often placed on the ground instead of floating in space. Objects of importance are more often drawn larger than those that are of lesser importance.

Stage 4 – Dawning Realism – Age 7 – 9, at this age children are beginning to be more critical of their own work. It has become evident that a structured order to drawing objects is no longer sufficient. While a schema is still used to create drawings, it is more complex than in earlier stages. Overlapping can be seen, and a sense of spatial relationships is more evident.

Stage 5 – The Pseudorealistic Stage, Age 9 – 11:  In previous stages, the process in making the visual art was great importance. In this stage, the product becomes most important to the child. This stage is marked by two psychological differences. In the first, called Visual, the individual’s artwork has the appearance of a looking at stage presentation. The work is inspired by visual stimuli. The second is based on subjective experience. This type of an individual’s Nonvisual artwork is based on subjective interpretations emphasizing emotional relationships to the external world as it relates to them.

Interpreting Meaning

Two parents came in with concerns about their two older boys, at that time aged 9 and 6. With them they brought their 2 week old baby girl, who laid quietly in her Moses basket at the Mom’s feet through out the first session. The family had moved from Europe a year earlier, and was now newly arrived in Seattle. The father was a working artist for a large tech firm and the mother remained the homemaker. The boys were both having social adjustment and academic performance problems at school as well as behavior issues at home. In particular, the mother was feeling overwhelmed. 

The process was 5 years long, entailing about 170 sessions all told. By the end, both boys were excelling in school in their particular areas of expertise, making friends, contributing to their classes, less defiant and disruptive at home, still with challenges, but their problems were now in the area of more ordinary. The baby-turned young girl was brought to most every meeting, She never sat in on sessions, per se. Once mobil and over time, she contentedly and imaginatively availed herself of most everything the waiting room play area had to offer. To her, coming to the office was just part of family life, and to her I must have been a family-like character of sorts. 

Around the age of 2 1/2, the girl began organized imaginary play, in this instance taking the few stuffed animals from the waiting room, bringing them to an office stuffed chair by a window away from the meeting area. The office itself was about 300 sq. ft., so she could play quietly and not be a distraction. But as a background, we could hear her talking to her little gathering, rearranging them on the chair, and continue talking just sweet, cute, sweet. She later began to draw on the dry erase board in the waiting room, and would make a point of showing us her work as the family left. I was impressed. She clearly had the father’s genes. And she was the nicest kid. 

She shifted from mothering her little clan to the building blocks on the waiting room carpet, fashioning a circular perimeter housing two and three block-high structures, presumably houses in her little world. We could hear her talk to imaginary family or neighbors or whoever they might be in her world, and she went through the same routine of showing us her work, this time as her family was leaving, session after session. Best background ever. 

Some time during the last year of the family’s therapy and now about 4 1/2, she came into the office from the waiting room where she had been busily drawing, and for the first time I could recall, she interrupted the session. She came up to my chair and proudly handed me a crayon drawing on a white page she had just finished, and with this lilting accent of her homeland said, ”This is for you!”, accenting the ‘you” with a rising intonation.

I looked at her work and was stunned, then looked at the father. He obviously didn’t know exactly what she’d drawn, or maybe he did but never gave on. He faintly smiled with raised eyebrows and a barely discernible nod, inferring a “See?” She had drawn the basics of a smiling girl with long yellow hair in a short dress, all with a degree of form and accuracy that could have come from an artistic 9 or10 year, but with her own indelible stamp. The legs were charicatured to more than twice the length of upper body, perfectly straight and parallel within shoes identically turned to the left. This was not drawing. This was art. She could tell I was impressed as I thanked her, and went back to the open-doored waiting room.

For the next maybe 10 sessions, over four or five months,  she repeated the routine like theater. “This is for you!” Her picture continued to improve though, the legs even longer, the clothing now colored, the facial expression a bit more detailed, the hair tied with a big red bow toward the end. If you re-read the descriptions of the 3 – 4 year old preschematic and the 5 – 6 year old schematic, she was so far beyond.

In ways, understanding meaning in a child’s art is a melding of several factors, to include: 

their particular developmental stage of art skills relative to their age; their own self-perception; their experiences, particularly as they relate to their being in a therapy office; their family history; the environment in which they are nurtured and live; when in the course of their therapy the art is being done; and, more broadly, what was going on in their world at the time. Events matter.

While all these points are largely abstractions, aided by an expertise, some things reasonably close to truths about the child can be learned and translated into the helping process.

Particular aspects of the child’s work come under scrutiny, for example the use of a color, facial expressions, who is or is not in the family picture, their portrayed sizes relative to each other, completeness of the body, the activity being depicted, and the composition of the surrounding environment. Particular mental health issues are said to be associated with specific aspects of a child’s drawing, ranging from depression, anxiety, and relational disturbances to what are contemporarily considered more brain-related disorders like PTSD and OCD. One unbeknownst and fascinating, to me anyway, correlation of drawing by those involved with the latter class of disorder cropped up in the context of research in preparing for this post, and will appear in Part 2.

In going through some of the on-line literature about assessing children’s drawing for the clinical purposes, a gleaning tendency toward conclusive certainty emerges, which taken literally can be troublesome. Like the global components of art appreciation listed above, clinical correlations with aspects of drawings are broadly based on observation, knowledge, and experience, and narrowly applied to the  case itself. They are opinions, and not the result of empirically-based research, at least insofar as I’ve seen over the years of perusing articles where the meaning of drawings is the topic. This does make a difference in how the information gained from the drawings is conveyed to the parents and subsequently processed by them.

Taking the vignette above and applying some of the assertions about the meaning as seen in a child’s work, the drawn character’s yellow hair, by one account read, represents the girl’s anxiousness, the red bow a representation of anger, and the exaggerated legs a fear of impending disaster and the ability to get away quick. None of those remotely apply to this child that I learned about from the parents and watched as she developed. 

Understanding the child’s drawings or specific aspects of the work like color, composition, likeness, or activity is a matter of the suggestive rather than the assertive.The correlation can be  reasonably linked, but quite possibly overwrought if fused. More importantly, sharing thoughts about possibilities based on experience and knowledge with both the child and the parents leads to interactive discussions and disclosures, which hopefully and eventually lead toward a mutual understanding and purpose. That process that stands in contrast to a professional declarative with diagnostic and treatment implications. To understand the child, particularly one who is troubled in some way or another, ’it takes a village’.

Managing The Drawing

The directive was simply, “I’d like you to make three drawings, one of your family together, one of yourself doing something, and last a picture of whatever you’d like draw. Here are the crayons, and you can use the table here (small rectangular coffee table between client couch and  the ancient stuffed rocker; crayon marks would come off the table with a little work, occasionally needed). 

I was generally quiet as they worked, may make a comment about something interesting or different that had been drawn, more along the lines of relationship building than gaining clinical knowledge. After they completed each picture, I would have them identify the characters and what was happening. Any further questions were casual rather than done with an intent to confer insight. At this point, the clinical relationship was more the forethought. Before they finished the assignment, I looked for something that stood out in an interesting way that could be brought out to bear and praised.

As I understand their role, art therapists will start doing overt clinical work with the individual from the beginning. They know what they’re doing, and usually in great depth. For me, doing overt clinical work during the drawing exercise was out of the question, which for many art therapists would likely be a planned part of their process. In some part, my interest was what kind of impact the experience of this first sit-down had with the client in and of itself, that being the most conservative kind of treatment. Suggesting a different way to feel about a particular situation, get along better with a sib, do something active to deal with anxiety, seek companionship when depressed, go to a safe place when angered, and so on with a thousand possibilities of suggestion could come after the next session with the parents and a treatment agreement reached. 

The child had known me now for all of maybe 10 -12 minutes, and I wanted to know more, facilitate the clinical relationship, and gain the parents’ confidence first. The support of that approach is that no case terminated after the child and adolescent interview, 56/56. What I did do during the drawing was keep notes on elements of the particular drawing that may have clinical significance as per the body of knowledge I had, done to review later, dictate notes, and prepare for the summary and recommendation session with the parents.

Noted Elements Of Client Drawings

Perhaps the major value of child drawings is in the discussions they can generate between the clinician and the parents in the subsequent session and thereafter. Diagnostic or interpretive declarations by the clinician of what one thing or another means in a child’s drawing can scuttle what could be an educative moment for both therapist and parents. The language used in this particular aspect of the overall assessment and treatment plan development is one of couching, i.e.: this often means…; this could possibly say…; what’s your take on this; have you seen this before; and in general working off each others thoughts.

Over time and with sufficient sampling, the following points are likely to arise in the drawing and become a note of mention:

Who is in the family drawing: For the most part, the drawings included the client, parents and other children. In cases of divorced or separated parents, the choice of the child is something of a dilemma, and several variations occur, including: the original family, as if nothing happened or if the parenting arrangement is evenly split; the home of the primary parent without the step parent, if one exists, or with the step-parent with their children, or at the other parent’s home and with their new partner and children to boot, etc. etc. etc.: I hesitated to explore with the child why they chose what they did during this particular question during the introduction session. The tendency was to accept the depiction as face value, and ask the involved parent what significance they may see. 

Who is left out: One can assume some kind of tension with the missing factor that could theoretically be explored with about why age the 8-and-under, brand new client left that person or people out, but again in this first session with the child, now perhaps fifteen to twenty minutes in, the strong inclination was to explore this with the parent(s). Some kind of history exists that is worth understanding, bu the parent is most probably in the better position to initially discuss. The therapist could aways get back to the child at a later time.

Extra, non-family  people in the family picture – This result was not common, and I believe often a manifestation of an already known cognitive issue, i.e. spectrum or other boundary-laden mental health issue, and reasonable to ask the client about the presences as well as addressing the question with the parent(s).

Presence of a yellow sun – Over time, I became more and more impressed with high-90%  frequency that a yellow sun would appear somewhere in the child’s drawing, usually in the drawing of themselves, but sometimes in the family picture. One not appearing at all was worth noting and leading to some kind of plan to explore the significance directly. In terms of the child I viewed the sun as an expression of being nurtured. I usually made note of the sun’s presence in the meeting with parents, providing that little bit of unanticipated reinforcement that doesn’t hurt.

Yellow streaked with orange – As per Lowenfeld, the presence of the sun is a personal extension of the child. Based on the uncommon happenstance, I believe a correlation between an orange streaked sun and a prevailing tension between mother and child existed. The tensions were likely already covered during the intake with the parents, and may or may not be needing mention. Discretion is a fixture on the therapist’s shoulder during these initial sessions.

Red and black  –  Predominant or significant use of red is widely considered to represent anger. Similarly, black is seen as representing depression. These two assertions seem have the most concurrence within the field of understanding children’s drawings, or at least the most commonly cited. When either or both of these appear in drawings, I did point them out during the following parents session. If anger and/or depression was part of the presenting problems, the parents would basically just nod, and we went ahead. If not, though, the question for them was what were their thoughts were about the suggested correlations, or were there other ways to view their child, and follow that track to some kind of working hypothesis between us. In other words, red being anger and black being depression were not presented as statements of fact, but rather an observation worth exploring and see where the discussion leads.

Baselining: A word for using the entire page, top to bottom and side to side. I heard or read  somewhere long ago that baselining was an indicator of a clinically significant anxiety, and found the correlation usually fit. Whether and how to address this with the parents is basically the same as that with dominating use of red and black above.

Relative size of characters: The pre-schematic 5 – 6 year old group are those most likely to have relative distortions of size. They did not occur often at all. When done at that age these were usually overlooked as far as the discussions the parents was concerned, unless one of the parents wanted to talk about their child’s perceptions, or when the distortion was gross. I can’t remember a specific example, that having occurred some time ago. The reaction was  more likely one of mild humor toward age normalcy than a knotted concern. The discussions that did occur must have had to do with fairly relationships, particularly as they impacted the client child.

Noted Elements – Missing Pieces and Constricted Coloring  –  to be continued on next post…

Thanks to Kimberly McMartin, MA, LMHC

Helped organize website, etc.

Clinical Colleague and Friend