The use of family drawings by children in pediatric practice.

Dr. Martin T. Stein Developmental surveillance, the process of monitoring behavior and development in the context of the child, family, and social environment over time, is a major focus of preventive pediatrics.1 The primary care pediatric setting is well suited for this task because it assumes responsibility for continuity of health care throughout childhood and adolescence. The challenge to achieve the goals of effective developmental surveillance can be seen in the wide variety of developmental and behavioral screening tests created for primary care settings.2 There is not, however, a single test used by most pediatricians, and the test reported as used most widely (the Denver Developmental Screening Test—II) is used primarily when pediatricians suspect a developmental delay.3 The family drawing is an alternative method to survey development at a given moment in time as well as longitudinally in a primary care setting. A single drawing is a snapshot of a child’s point of view of her role in the family, her relationship to other family members, and her self-esteem. Sequential drawings monitor both ordinary and extraordinary events and stresses in a child’s life. In addition to providing a clue to individual behaviors and family relationships, these drawings reflect the maturation of visual, motor, and spatial skills. In this context, it can be used as part of a school readiness examination or during an assessment of neurological or learning problems. At the least, an individual figure can be used in a Draw-a-Person test and scored to generate a developmental age that correlates with visual-perceptual and visual-fine motor functions.4 In the Kinetic Family Drawing (KFD) test, the child is asked to “draw a picture with everyone in your family, all doing something.”5 A clipboard in each examination room, along with a black felt pen, can be available to encourage the routine use of these drawings. In my office practice, children and youths are asked to complete a KFD at each health supervision visit. Other practitioners find it useful when they suspect a specific problem. Although the KFD is a projective test, in which a child reveals her inner feelings about herself and her family, and although it is used by psychologists with a standard set of evaluation criteria, its use in pediatrics can be more subjective. I found it remarkably helpful on many occasions as a way to open a dialogue with parents and children concerning important behavioral and family issues. Typically, the KFD reveals a behavioral issue that has not been brought to the clinician’s attention previously. It is not uncommon for a parent or adolescent to make a significant comment or interpretation about a drawing without any direction from the clinician. When used on a regular basis as a component of developmental surveillance, the KFD illustrates many inner strengths in children and in family relationships. Visual motor maturation, facial affect, the proximity of the child to parents and siblings, and the activities depicted in the drawing might give a clinician an opportunity to comment positively about these strengths. Cultural differences might also be highlighted in the drawings. Caution, however, must be taken in interpreting the drawings. A family drawing is similar to a urinalysis or electrocardiogram; it is only one piece of data at one point in time, and it must not be overinterpreted. I selected several examples of KFDs from pediatric practice. They illustrate the applicability of the KFD in both primary care pediatrics and a consultation practice in behavior and development. The use of drawings can also be a stimulating source of insight about child behavior and development for medical students and residents. The KFDs stimulate discussion among clinicians about child development because they remind us of the extraordinary breadth and individuality of maturation through childhood and adolescence.