Correlation between Vanderbilt ADHD Diagnostic Scale and the Draw-a-Man Test in School Children
Introduction: The Draw-A-Man Test (DAMT) is a culture free developmental process test to assess children’s nonverbal abilities. It has been widely used to measure their intellectual and psychological development. The possible correlation between the results of DAMT and the attention deficit hyperactivity disorder (ADHD) symptoms was investigated in school-age children.
Methods: Non-probability sampling method was used to select students aged 48-137 months, who are students in private educational institution from Nursery 1-2 and Primary 1-2-3-4 grades. Students were selected from private school in capital city, Abuja, Nigeria. Children were asked to draw a human figure on a piece of paper for DAMT. The Vanderbilt ADHD Diagnostic Rating Scale (VADRS) was used to assess the ADHD symptoms.
Results: There was negative correlation between DAMT and classroom behavioral performance score in VADRS. Additionally, there was positive correlation between DAMT and academic performance score in VADRS. However, there were no correlation between both DAMT-1 and DAMT-2 and other ADHD symptom scores.
Discussion: A previous study showed that decreased DAMT scores were associated with behavioral and cognitive disabilities. The results of present study suggest that DAMT is not convenient to screen the ADHD in school age children. Conclusion: DAMT can be a good indicator for academic and classroom performances related to ADHD but it is not convenient to screen the ADHD symptoms in school age children.
Draw-a-man test, ADHD, Vanderbilt diagnostic rating scale, Children
The importance of child development, psychology and education increases gradually in recent years. Many studies have been conducted to have correct and scientific information related to normal and abnormal developmental processes . Different developmental capabilities such as gross and fine motor skills, personalsocial skills, language and communication and problem-solving (cognition) can be assessed in children . A lot of questionnaires to discover developmental or educational delays in children worldwide have been established and validated accurately and systematically .
The Draw-A-Man Test (DAMT), first conceived by Dr. Florence Goodenough in 1926, is a developmental process test to assess children’s culture free nonverbal abilities . It has been widely used by child psychiatrists to measure intellectual and psychological development in children [5,6]. Also, DAMT has rarely been used with right cerebrovascular accident patients to determine personal neglect . DAMT is a skill test to measure a child's mental age through a figure drawing task. It estimates the progress of learning visual, cognitive, and motor skills by having the candidate draw a human figure, scoring the drawing for presence and quality of figure features, and comparing the score to children's typical rate of acquisition of figure features.
The Vanderbilt ADHD Diagnostic Rating Scale (VADRS) is a psychological assessment tool for teachers/parents of children aged 6 to 12 designed to measure the severity of attention deficit hyperactivity disorder (ADHD) symptoms. In 2002, the AAP and the National Initiative for Children’s Healthcare Quality (NICHQ) jointly published a toolkit to be used in the assessment and treatment of ADHD in primary care settings (available at www.nichq.org) . This rating scale is open to the public .
In a recent study, behavioral and cognitive disabilities were associated with the results of DAMT in school-age children . DAMT may be relevant to detect behavioral abnormalities such as attention deficit and hyperactivity in the classroom in school-age children. This is a hypothetical study. We hypothesized that the results of DAMT may be correlated with the data resulted from VADRS in school-age children.
Teachers of students (n=239) who had classes at the time of the study were approached and requested to participate in the study. Nonprobability sampling method (purposive sampling) was used to select students aged 48-137 months, who are students in private educational institution from Nursery 1-2 and Primary 1-2-3-4 grades. Students were selected from private school in capital city, Abuja, Nigeria. Age of the participants was not different statistically by gender.
In respect to ethical concerns, the purpose of the study was briefly explained to all the parents and teachers of the participants, and researchers promised that test results would be kept confidential and only accessible by school management. Guidance and counselor of the respective educational institutions were also involved in the study as volunteers, in order to see the progress of their students and for transparency purpose. Exclusion criteria were known or diagnosed health problems, such as psychiatric and central or autonomic nervous system diseases and physical or mental disabilities. Also, children with ADHD diagnosed clinically did not include the study.
The experimental protocol was in accordance with international ethical standards. The study was carried out in accordance with the Helsinki Declaration (1975, revised in 1996-2013). The study was descriptive cross-sectional. All parents and teachers of students voluntarily gave a written informed consent to participate in the study. The study was anonymous. A paperand- pencil based method of drawing figure was utilized. The study was conducted between March 2018 and January 2019.
Assessment of DAMT-1 and DAMT-2
Children were asked to draw a human figure on a piece of paper (Figure 1). The rating scale contains 51 items. Each item was identified and scored carefully. Presence and ratio of the item were dominant features during scoring. Some pictures contained uncertain shapes, and those ones were evaluated by other expertise and vote of majority was used to mark that item or not.
Figure 1. Some examples of drawing of participants by their chronological ages.
There are two important questions researchers being asking about conducting the Draw-a-Man test: validity and reliability of the test. As per Anastasi et al. , reliability of the test means “consistency of the scores obtained by the same person, when re-examined by the same test on different occasions”. Dunn et al.  was one of first to question reliability of Draw-a-Man test in his study, where he conducted the test twice and checked correlation between two them, reaching correlation coefficient of 0.93. We, therefore, decided to conduct the test twice, with 1 week gap between them, to get more reliable data and to check if tests will differ in correlation with other features.
Assessment of VADRS
Attention, hyperactivity, oppositional defiant and conduct disorders and anxiety or depression symptoms and academic and classroom behavioral performances were measured using Vanderbilt ADHD Diagnostic Teacher Rating Scale.
Measured values are given as a mean ± standard deviation (SD). Statisticalanalysis was performed using SPSS for Windows version 18. The Student’s t and one way ANOVA tests were used to compare the depression scores in the participants. A p value less than 0.05 was considered statistically significant.
In total sample, there were significant negative Pearson correlations between age and classroom behavioral performance score in Vanderbilt Diagnostic Teacher Rating Scale (r=0.29, p=0.00) and also between age and Grade Point Average (GPA) (r=0.26, p=0.001). Also, there were the similar negative correlations for male (VADRS: r=0.31, p=0.00; GPA: r=0.26, p=0.01) and female (VADRS: r=0.3, p=0.001; GPA: 0.26, p=0.02) participants.
In total sample, there were significant negative Pearson correlations between DAMT-1 and classroom behavioral performance score in Vanderbilt Diagnostic Teacher Rating Scale (r=0.22, p=0.002). Also, there were the similar negative correlations for male (r=0.25, p=0.01) and female (r=0.26, p=0.02) participants.
In total sample, there were significant negative Pearson correlations between DAMT-2 and classroom behavioral performance score in Vanderbilt Diagnostic Teacher Rating Scale (r=0.16, p=0.002). Also, there were the similar negative correlations for male (r=0.19, p=0.02) and female (r=0.26, p=0.02) participants.
In total sample, there were significant positive Pearson correlations between DAMT-1 and academic performance score in Vanderbilt Diagnostic Teacher Rating Scale (r=0.15, p=0.03). Also, there were the similar positive correlation for female (r=0.26, p=0.02) participants, but not for male.
In total sample, there were significant positive Pearson correlations between DAMT-2 and academic performance score in Vanderbilt Diagnostic Teacher Rating Scale (r=0.16, p=0.03). Also, there were the similar positive correlation for female (r=0.29, p=0.006) participants, but not for male.
In total sample, there were significant negative Pearson correlations between GPA and VADRS (Inattention: r=0.35, p=0.00; Hyperactivity/ impulsivity: r=0.28, p=0.001; Oppositional defiant and conduct disorders: r=0.28, p=0.00). Also, there were the similar negative correlations for male (Inattention: r=0.47, p=0.00; Hyperactivity/ impulsivity: r=0.42, p=0.00; Oppositional defiant and conduct disorders: r=0.43, p=0.00; Anxiety or depression symptoms: r=0.26, p=0.02) participants, but not for female.
There were no statistically significant correlation between DAMT (1 and 2) and other ADHD scores (Inattention, Hyperactivity/ impulsivity, Oppositional defiant and conduct disorders, Anxiety or depression symptoms) in Vanderbilt Diagnostic Teacher Rating Scale.
The VADRS includes both parent and teacher versions of standardized measure of ADHD symptoms. It contains lots of the information required to make a DSM-IV–based diagnosis of ADHD and to screen for common co-morbidities [13,14]. The American Academy of Pediatrics guidelines mentioned the importance of screening for co-morbid learning disorders as part of ADHD evaluations, because about 30% of children with ADHD also meet the criteria for the learning disorders .
The VADRS includes achievement items that ask about children’s reading, math, and writing abilities. The utility of a teacher rating scale, the Academic Performance Rating Scale was examined, in identifying children who should be referred by physicians for a psycho-educational evaluation. Bennet et al. reported that it had adequate clinical utility and could be used by physicians to screen for the learning disabilities, that is, teacher’s rating of children’s reading ability and math ability .
In the present study, there were negative correlations between both DAMT-1 and DAMT-2 and classroom behavioral performance score in VADRS in total sample, and both male and female subjects. Additionally, there were positive correlations between both DAMT-1 and DAMT- 2 and academic performance score in VADRS in total sample and in female subjects but not in male subjects. However, there were no correlation between both DAMT-1 and DAMT-2 and other ADHD symptom scores in VADRS (Inattention, Hyperactivity/ impulsivity, Oppositional defiant and conduct disorders, Anxiety or depression symptoms). Actually these results are very interesting. In a recent study, delayed DAMT scores were associated with behavioral and cognitive disabilities, but DAMT performance indicators were insufficient to use DAMT as a screening or diagnostic test . It can be stated that DAMT is not convenient to screen the ADHD in school age children but it can be a good indicator for academic and classroom performances related to ADHD. Also, in the present study, there were negative correlations between GPA and ADHD symptoms including inattention, hyperactivity/ impulsivity, and oppositional defiant and conduct disorders. High levels of ADHD symptoms are related to severe negative outcomes, which underscore the importance of identifying early markers of these behavior problems . There are a lot of studies in which children with ADHD show significant academic difficulties in school settings [18,19]. Also, many studies reported that ADHD symptoms is together with multiple neuropsychological deficits [20,21]. The negative correlations in the present study between GPA and ADHD symptoms and above mentioned studies that support them show the reliability of the results of the present study.
As a consequent, DAMT may be an indicator classroom behavioral performance and academic performances in school age children but not convenient to screen the ADHD symptoms including inattention, hyperactivity/impulsivity, oppositional defiant and conduct disorders, anxiety or depression symptoms.
This study was conducted in collaboration of Nile University of Nigeria and Nigerian Tulip International College (NTIC), both Abuja, Nigeria. We want to appreciate the management of NTIC for their tireless efforts and collaboration during the research.
- Berk LE. Development through the lifespan. 7 edn, Pearson Education India 2017, p 864.
- Harris GA, Cleland J, Collie A, et al. Cognitive assessment of a trekking expedition to 5100 m: A comparison of computerized and written testing methods. Wilderness Environ Med 2009; 20:261-268.
- Vameghi R, Sajedi F, Habibollahi A, et al. Cross-cultural adaptation, validation and standardization of ages and stages questionnaire (asq) in iranian children. Iran J Public Health 2013; 42:522-528.
- Scott LH. Measuring intelligence with the Goodenough-Harris drawing test. Psychol Bull 1981; 89:483-505.
- Franzen MD. Reliability and validity in neuropsychology assessment. New York Plenum 1989.
- Frederiksen N. Toward a broader conception of human intelligence. Am Psychol 1986; 41:445–452.
- Chen-Sea MJ. Validating the draw-a-man test as a personal neglect test. Am J Occup Ther 2000; 54:391-397.
- Becker SP, Langberg JM, Epstein JN. Clinical utility of the Vanderbilt ADHD diagnostic parent rating scale comorbidity screening scales. J Dev Behav Pediatr 2012; 33:221-228.
- Chollat C, Joly A, Houivet E, et al. School-age human figure drawings by very preterm infants: Validity of the draw-a-man test to detect behavioral and cognitive disorders. Archives de Pédiatrie 2019; 26:220-225.
- Wolraich ML, Lambert EW, Worley KA, et al. Psychometric properties of the Vanderbilt ADHD diagnostic parent rating scale in a referred population. J Pediatr Psychol 2003; 28:559-568.
- Wolraich ML, Feurer I, Hannah JN, et al. Obtaining systematic teacher report of disruptive behavior disorders utilizing DSM-IV. J Abnorm Child Psychol 1998; 26:141-152.
- DuPaul, GJ, Stoner G. ADHD in the Schools: Assessment and intervention strategies. 2nd Edn Guilford Press New York 2003.
- Bennet AE, Power TJ, Ricardo EB, et al. Identifying learning problems in children evaluated for ADHD: The academic performance questionnaire. Pediatrics 2009; 124:633-639.
- Sjöwall D, Bohlin G, Rydell AM, et al. Neuropsychological deficits in preschool as predictors of ADHD symptoms and academic achievement in late adolescence. Child Neuropsychol 2017; 23:111-128.
- Jitendra AK, Dupaul GJ, Someki F, et al. Enhancing academic achievement for children with attention-deficit hyperactivity disorder: Evidence from school-based intervention research. Dev Disabil Res Rev 2008; 14:325-330.
- Daley D, Birchwood J. ADHD and academic performance: Why does ADHD impact on academic performance and what can be done to support ADHD children in the classroom? Child Care Health Dev 2010; 36:455-464.
- Castellanos FX, Sonuga-Barke EJ, Milham MP, et al. Characterizing cognition in ADHD: Beyond executive dysfunction. Trends Cong Sci 2006; 10:117-123.
- Nigg JT, Willcutt EG, Doyle AE, et al. Causal heterogeneity in attention-deficit/hyperactivity disorder: Do we need neuropsychologically impaired subtypes? Biol Psychiatry 2005; 57:1224-1230.
2Department of Physiology, Faculty of Basic Medical Sciences, College of Health Sciences, Nile University of Nigeria, Abuja, Nigeria
Citation: Ochilbek Rakhmanov, Senol Dane, Correlation Between Vanderbilt ADHD Diagnostic Scale and the Draw-a-Man Test in School Children, J Res Med Dent Sci, 2019, 7(6): 74-78.
Received Date: Aug 05, 2019 / Accepted Date: Dec 02, 2019 /