Dincolo de linii și culori: analiza gestului grafic în diagnosticul și terapia psihiatrică pediatrică

Introduction and conceptual framework

Within the framework of pediatric psychiatry and psychotherapy, we employ a complex, integrated bio-psycho-socio-cultural perspective in our efforts to foster harmonious development and optimal adaptation of children within their natural life environments. Consequently, a thorough understanding of child development and a diverse repertoire of diagnostic and interventional tools are required. This approach extends beyond psychofarmacology, which, although occasionally necessary, frequently does not represent a first-line or isolated diagnostic and therapeutic measure.

Graphic expression activities utilized in child psychiatry constitute valuable assets in this endeavor. They are highly accessible, age-appropriate from early childhood, and sustain the prolonged and repeated engagement of the therapist, thereby providing the necessary timeframe to establish a positive transference relationship with the child⁽¹⁾.

Correspondingly, a central question emerges: what are the objectives of plastic art activities for children presenting with psychiatric disorders? In other words, when should these methods be deployed, what goals do they serve, and how do they function as active diagnostic instruments?

To ensure comprehensive theoretical and practical deployment, the visual artistic process requires a multidimensional functional analysis. From a clinical perspective, it cannot be reduced to a mere recreational activity; rather, it can be conceptualized through three fundamental dimensions:

• as a mechanism for psychic sublimation and projection;
• as a symptomatic manifestation within the graphic gesture of disorders involving severe psychic disintegration (such as psychoses);
• as a means of expressing the individual’s relationship with the world from a developmental perspective.

In this latter instance, which is highly prevalent in pediatric psychiatry, the analysis of children’s graphic productions enables the exploration of neuropsychic development, particularly with regard to conceptual-symbolic maturation⁽²⁾.

Implicitly, it becomes beneficial to monitor multiple facets as they manifest during the creative process and within the final productions. Critical areas of focus include: the investigation of formal deficiencies, behavioral patterns during the task, interpersonal dynamics, clinical indicators of severe pathology and the projective-symbolic analysis of the artwork.

Formal deficiencies and anomalies as a mirror of psychic development

Graphic expression serves as a direct indicator of psychic development and reflects how the modeling and integration of elaborate psychic processes occur through symbolization⁽³⁾. The qualitative evaluation of drawing allows for the identification of specific cognitive-perceptive schemata through which the child analyzes, synthesizes, compares and concretizes the surrounding reality.

In the clinical domain, a deficit in symbolic maturation often translates into the subject’s confinement within a predominantly concrete perceptual relationship with the world, alongside impairments in thought and language.

This is manifested through dyspraxia, graphic productions that defy systematization, or those characterized by primitive, impoverished, monotonous and stereotyped schematization. Conversely, where the cognitive level is higher and a compensatory development of the logical-instrumental dimension occurs, the deficit expresses itself through rigid, intellectualized, or deviant artistic delivery.

Observation of child behavior and correlated indicators

A rigorous clinical analysis does not restrict itself to the final outcome (the drawing as a finished product) but focuses dynamically on the active process and the direct observation of the child’s behavior during creation, alongside correlated anamnestic data. This dynamic dimension reflects underlying affective states – such as anger, fear, elation, self-esteem levels, a heightened need for control, risk-taking capacity, or submissiveness and an excessive need for interpersonal validation⁽⁴⁾.

Technical indicators systematically monitored throughout the process include:

• drawing initiative versus the requirement for step-by-step guidance;
• instrument grip and the pressure exerted on both the tool and the paper – ranging from weak pressure and hesitant gestures resulting in barely visible drawings, to energetic, impulsive, or aggressive motions expressed through excessive pencil pressure that may perforate or tear the paper;
• fractured lines and sharp angles;
• the positioning of figures and their spatial relationship within the boundaries of the page;
• adherence to contours versus the need for boundary infraction;
• the isolation of figures through encircling, framing, or placement within protected spaces.

The intersubjective relationship and transference

The artistic process can be understood as a mediator in the child’s relationship with others and, by extension, within the transference dynamic with the therapist⁽⁵⁾. Multiple modes of intersubjective manifestation can be observed through the artwork, ranging from severe isolation – as seen in autism or secondary withdrawal (driven by severe anxiety or psychotic mechanisms) – to dysfunctional, excessive, or qualitatively inappropriate attention-seeking strategies. Interpersonal deficits may be revealed through idealized human figures or, conversely, through ambiguous, grotesque representations, as well as provocative or violent formulas and expressions.

Clinical indicators of severe pathology

Within the context of differential diagnosis and risk monitoring (autism spectrum, psychoses, suicidal risk), certain graphic elements constitute major red flags⁽⁶⁾. These include:

• Marked impoverishment of the graphic gesture, accompanied by confusion between the visible and invisible elements within a frame, or between the perceived object and its background, reflecting significant perspective anomalies that signal severe distortions in the laws of reality perception.
• Difficulty in initiating the graphic gesture, establishing a termination point, or accepting the current production as complete and final (e.g., through endless erasing, restarting and unlimited perfectionism), revealing fundamental deficits in perceptual-cognitive integration.
• A compulsion toward excessive schematization and organization as a mechanism to compensate for the instability of primary spatial-temporal intuition.
• Figure fragmentation or distortion as an expression of the dissolution of psychic-physical unity.
• Graphic “neologisms”, serial, stereotyped and rigid repetitions of elements within the framework of formal thought disorders characteristic of psychotic conditions or autism.
• Unusual, bizarre figures serving as expressions of hallucinatory-delusional symptomatology.
• The introduction of symbols associated with death and violence, correlated with auto- and hetero-aggressive tendencies.

Projective value and exploration of the inner universe

In psychiatric and psychodynamic psychology, graphic productions are also interpreted for their value as products of the unconscious, following a pathway distinct from the rational-logical course of consciousness. Consequently, they reflect processes such as displacement and condensation, aligning more closely with metaphoric-poetic dreamstate expressions than with linear, causal (metonymic) relationships. Visual representation thus possesses a fundamental projective value, offering partial access to the child’s unconscious preoccupations, anxieties, traumatic life events, internal conflicts, as well as identification and identity-forming processes^(7,8).

The clinical case studies detailed hereafter aim to highlight a selection of the elements described above, keeping in view that the theoretically circumscribed dimensions can only be partially isolated from one another; they are naturally intricate, overlapping, dynamic and mutually influential.

We have refrained from using a standardized interpretation matrix, opting instead to integrate multiple aspects easily observable by the practicing clinician of any child psychiatric or psychological theoretical orientation, thereby avoiding an excessively dogmatic guidance of the clinical path. For each individual child, it is imperative to account for age-specific characteristics, the developmental and cultural environment, and the multitude of discrete, subtle factors capable of influencing any act, including the graphic one. A moderate interpretative stance that eschews absolute diagnostic certainties is strongly recommended.

The 10-year-old boy presents with irritability, stubbornness and dominant behavior within groups, alongside temper tantrums characterized by clastic outbursts and hetero-aggressiveness. Reading and writing skills are virtually absent, and his counting ability is limited to 5. A preference for intense, saturated colors is observed, alongside an impaired mastery of the object schema, resulting in an approximate shape that is predominantly anthropomorphic or phallic. Additionally, he exhibits a distinct interest in objects with offensive or defensive functions, specifically a gun and a hook (Figure 1).

The 8-year-old boy is occasionally aggressive, exhibits learning difficulties in reading and writing, omits letters, uses words inappropriately, and he associates ideas through superficial and metonymic links while employing a peculiar tone of voice. He presents with intermittent stuttering, a tendency to generate imaginary scenarios and impaired temporal orientation for events. He struggles to make and maintain friendships.

The drawing was developed progressively, with the child adding characters and actions throughout the process (Figure 2). He first drew serial floral elements, followed by a tree, a human figure holding a stick (“that I haven’t drawn yet”) and an animal – a wolf (later adding, “falling on its belly”). He then added the sky and the sun, and the final figure was a suspended character (in black) whom he named “Jesus”, adding that he heals the blind. When questioned about his motivation for placing this figure at the top, he stated: “It’s Jesus because he comes from above” (vine de sus), meaning he is up there (îi sus). We note the unusual representation, characterized by a need to demarcate the sky, and a narratively developed composition featuring the human and animal figures separated by a tree. Furthermore, the figure of the Savior who heals is depicted differently from a standard human figure: it is larger, colorless, possesses multiple limbs and features a rather zoomorphic head surrounded by something between a halo and big ears. Finally, we observe the concrete reasoning the child relies upon in his attempt to integrate the name with the function of the figure.

The parents of the 6-year-old boy are divorced; the mother reports role rejection/maladaptive maternal bonding, stating: “feelings are not for me”. The grandfather is a priest, while the grandmother is a social worker. The patient presents with spatial-temporal disorientation (e.g., today/tomorrow, front/back) and dysgrammatism characterized by the inappropriate use of verb tenses. Phenotypically, he exhibits a phobia of toy eyes (scopophobia-like features), psychomotor agitation, aggression, inattention, impulsivity and delayed academic achievement. When demonstrating physical aggression toward others and questioned about his behavior, he responds: “I don’t know, the one with horns” (suggestive of externalization of agency or primitive projection). He reports nightmares featuring dinosaurs. The somatic complaints include frequent psychogenic abdominal pain and stress-induced exacerbation of atopic dermatitis. History is negative for a transitional object.

The drawing, depicting two characters from the “Sonic” video game franchise, exhibits an atypical, bottom-up construction sequence, beginning with the characters’ feet and progressing toward the head. Prior to this, the patient divided the page using an unconventional method: drawing two parallel horizontal lines, resembling an equal sign (=). This ambiguity and paradoxical quality persist in the composition, where a heart symbol – traditionally representing affection – is interposed between the two isolated characters, both of whom are depicted with markedly angry facial expressions (Figure 3).

For the 12-year-old boy, paternal history is significant for suicide (Figure 4). The patient exhibits severe, escalating aggressive episodes, including making homicidal threats with a knife toward family members. He engages in repetitive self-harm, resulting in multiple facial lesions. Perceptual disturbances are present, characterized by illusions of moving objects, auditory hallucinations (hearing his name being called), hypervigilance/suspiciousness and ideas of reference. The affective profile reveals deep-seated resentment alternating with intense guilt. He presents with high cognitive functioning, demonstrating advanced and extensive reading skills, alongside intermittent manipulative behaviors.

The parents of the 6-year-old boy are divorced; the mother exhibits perfectionistic traits in her parenting role. History is significant for severe, persistent crying episodes during infancy. He attended a Montessori kindergarten, being currently enrolled in a mainstream school. Clinical presentation includes inattention, out-of-seat behavior during classes and a tendency to dominate peers, frequently reminding them of rules and engaging in tattling behaviors. He reports boredom during lessons and exhibits socialization difficulties. Although he enjoys mathematics, he demonstrates a distinct propensity for inventing idiosyncratic, unconventional, idiosyncratic problem-solving methods. His speech features dysgrammatismus, alongside the use of atypical vocabulary. His cognitive profile is characterized by logical yet rigid thinking, with IQ of 143.

The drawing produced by a child with a superior IQ paradoxically displays modest graphic and fine motor execution. The body schema is poorly integrated/deficient, and the graphic process follows an atypical developmental sequence: executing from the bottom-up, progressing from fragmented details to the overall whole and utilizing a layered drawing technique from depth to surface. Furthermore, the graphic expression exhibits a marked tendency toward serialization, mannerisms and stereotypy (Figure 5).

The clinical presentation of the 7-year-old boy is characterized by severe aggression, impulsivity, attention-seeking behaviors and intense sibling/interpersonal jealousy. He presents with an average intelligence quotient (IQ) accompanied by profound learning difficulties. The patient demonstrates a strong affective attachment to his foster mother; however, she is no longer capable of providing care, placing him at imminent risk of secondary abandonment. The free drawing is visually sparse, yet it depicts a highly unconventional theme rarely selected by children. The thematic focus on “God” (“Doamne-Doamne”) introduces an unexpected level of complexity and abstract dimensionality in a patient with a history of precocious sexualization, severe relational trauma and the acute distress of impending disruption of his primary caregiving placement (Figure 6).

The clinical profile of the 15-year-old girl is characterized by a depressed mood, social withdrawal, markedly reduced intrafamilial communication, weeping episodes, poor peer integration at school and pronounced fatigability. Historically, she exhibited high submissiveness toward her primary teachers. Her background is significant for migratory stress (frequent relocations between Spain and Romania) and the recent bereavement of a young aunt with whom she shared a close bond.

The patient reports long-standing, childhood-onset perceptual disturbances; she notes that she has “always” experienced visual hallucinations of faces that “do not speak, but it is as if they are telling me something”, as well as other partial or fully formed apparitions. Somatosensory/tactile hallucinations are present, described as an electric-shock sensation in her hands. Auditory phenomena include tinnitus-like symptoms and auditory hallucinations of her name being called, accompanied by a distinct sense of a presence. Her sexual orientation is currently unestablished.

The drawing is schematic and rapidly executed, depicting a poorly defined visual figure entitled “What I see”. This kind of perceptive anomalies and graphic presentation is highly characteristic of drawings produced by adolescents presenting with a latent risk of psychosis or an active onset of a psychotic illness (Figure 7).

The clinical profile of the 9-year-old girl is characterized by social withdrawal, shyness, markedly restricted verbal and nonverbal expression (suggestive of selective mutism), attention deficit and significant academic difficulties. She belongs to a large family – the mother is substantially younger than the father – and is illiterate.

The serial and stereotypical drawing utilizes a bright color palette, selected by a patient who exhibits severe verbal under-expression. Centered in the composition is a windowless house featuring a marginally positioned, elevated/suspended door. Within the interior of the structure, the patient has depicted herself as a blue, anatomically incomplete figure (Figure 8).

The clinical presentation of the 6-year-old boy includes psychomotor agitation, inattention and defiant, abusive verbal behavior directed toward his teacher. He demonstrates a marked appetite for horror films, engaging in repetitive viewing restricted solely to violent scenes. He exhibits social disinhibition, characterized by repeated, non-consensual kissing of female peers. Motor tics, mannerisms and behavioral idiosyncrasies are present, including forced abdominal respiratory movements and the wetting of his eyelids with saliva. He shows a strong preoccupation with feminine clothing and accessories, which he frequently wears, and used a female pseudonym to refer to himself during kindergarten.

The thematic family drawing is characterized by a binary color selection: pink for himself and his mother, and blue for his father and brother (Figure 9). The bodies are rapidly executed with abrupt, imprecise graphic strokes and are depicted without limbs. Notably, he attributes the same long hairstyle to both himself and his mother, despite currently having short hair. During the task, he laughingly remarked that he “accidentally” drew a dress on his father. Throughout the clinical interaction, the patient remained voluble, euphoric, and exhibited a pronounced desire for physical contact.

The 9-year-old girl was diagnosed with an emotional disorder, presenting with overweight. The patient is institutionalized. She exhibits excessive affection-seeking and clinging behavior toward staff members, specifically referring to the clinical psychologist as her mother. Her cognitive-verbal profile includes confabulations and the elaboration of complex imaginary scenarios (e.g., claiming that her biological mother lost a pregnancy and subsequently asserting that she herself gave birth to her own sister). She frequently appends fabricated details to real events and displays behavioral expansiveness. Conversely, she manifests intermittent avoidance of physical contact, refusing embraces and demonstrating oppositional, negativistic and unreactive behaviors. The drawing is stylized and idealized, portraying herself in a manneristic, cheerful and performative pose (Figure 10).

The 13-year-old boy was diagnosed with autism spectrum disorder (ASD), presenting severely restricted verbal abilities. His expressive language is limited to a few isolated words uttered repetitively, occasional two- or three-word combinations and echolalia. The clinical presentation is further characterized by psychomotor agitation, repetitive and stereotypical movements and severely impaired global functioning. The graphic execution is profoundly deficient/impoverished relative to chronological age, remaining at the developmental stage of producing repetitive circular figures that cover the surface of the page (Figure 11). The patient has not yet acquired object schema representation.

The 6-year-old girl comes from a separated family; the father is accused of child sexual abuse against the patient. She describes the paternal abusive acts while exhibiting ambivalent affect (“mixed impressions of good and bad”). She subsequently developed childhood masturbation. Her relational pattern with her mother is characterized by affection interspersed with intermittent blocking of contact. She displays marked ambivalence toward her younger sister, alternating between hostility/jealousy and overprotective behaviors. Speech and language disturbances include intermittent stuttering, speech articulation defects, word inversions, regressive language and neologisms.

The patient draws prolifically, utilizing high-intensity colors and violent contrasts. Although she appears smiling, the underlying anxiety is clinically evident; she exhibits approval-seeking behaviors and a highly childish demeanor. She generates rich verbal narratives during the graphic process, fluidly shifting the names and intentions of her characters. Among these, she depicts an angry male figure who is upset because “he did something bad” and wears a mask to conceal his identity, but he is subsequently captured by Baba Yaga and “thrown into green mucus water”. She then abruptly alters the narrative timeline, drawing this character’s child, who later transforms into the mother, depicted as happy (Figure 12a). She subsequently draws the character “Huggy Wuggy”, stating with an expression of satisfaction: “he has teeth, but I like it” before shifting her intent again to draw an eyeless old woman alongside a bear cub and its mother expressing mutual affection (Figure 12b). The final figure depicts a balloon with a clown-like face, featuring highly chromatic, yellow eyes with hyper-elongated eyelashes containing internal embedded figures and a large mouth. The overall graphic presentation conveys a sense of psychological excess and mild perceptual idiosyncrasy (Figure 12c).

The 12-year-old boy presents with a neurodivergent cognitive structure. The clinical profile is characterized by restlessness, suspiciousness, a restricted peer network and latent inhibited aggressive tendencies. During direct clinical interaction, the patient appears frowning and tense, exhibiting speech blocks, tangentiality/narrative digressions and avoidant eye contact. He expresses an aversion to cats and dogs, stating that “they have claws that can rip everything apart”. His drawings are highly schematic and executed in a cross-sectional perspective, resembling a floor plan in which spaces are demarcated by generally rectangular shapes. Throughout the assessment, he maintains this style of representation, characterized by precise labeling, executed rapidly in pencil without hesitation (Figures 13a and 13b).

The 16-year-old girl was diagnosed with severe intellectual disability and minor residual neurological sequelae. She can name only a few colors, and she counts up to 10 with concrete/visual support. Behaviorally, she is affectionate but highly sensitive to criticism, exhibiting social withdrawal in unfamiliar environments. Her medical history is significant for recurrent headaches. The drawing is characteristically sparse for an adolescent, utilizing a cheerful color palette. The house is centered within the composition, featuring windows positioned atypically high in the upper corners, contiguous with the outer perimeter of the structure. A lamp is unnaturally visible through the window, the hole graphic presentation reflecting profound deficits in the cognitive-perceptual processing of reality (Figure 14).

The 5-year-old girl is currently in foster care, undergoing the adoption process. She and her brother were institutionalized into foster care following the death of their maternal grandmother, who had raised them after maternal abandonment; the father is unknown. Upon initial placement, the children were severely neglected, with poor hygiene and ectoparasitosis. The patient exhibited geophagy. Her language development was age-appropriate. Currently, she presents with hyperactivity and a cheerful mood, demonstrating strong attachment to her foster family alongside affectionate behavior toward the prospective adoptive family; she exhibits dominant behavior toward her younger brother. During direct clinical interaction, she displays adhesive behaviors, emotional overarousal and affectionate psychomotor agitation.

The patient depicts two houses, a tree and a self-portrait on the same page. The tree features a crown and a root system, each comprised of two symmetrical, somewhat isolated elements, with a prominent hollow in the trunk. Around the second house, effectively isolating it, she drew a black, ovoid halo; this boundary was subsequently interrupted by several colored spots, suggesting a fluid shift in graphic intent toward zoomorphic figures discovered during the drawing process (Figure 15).

Conclusions

Visual arts activities in children and adolescents can be effectively utilized as a complementary diagnostic tool, yielding relevant and often surprisingly accurate graphic confirmations. In other cases, drawings illuminate children’s underlying preoccupations far more readily than verbal expression – concerns that might otherwise have remained subtle or undisclosed, despite their clinical significance, transcending the boundaries of concrete, everyday experience.

Furthermore, the therapeutic benefits must not be overlooked; the healing potential of art therapy has long been empirically established, driven by complex and often subtle mechanisms⁽⁹⁾. Several of these mechanisms can be summarized, as follows.

Instrumental role: stimulates cognitive development and the perceptual integration of reality, supports fine motor coordination, and enhances the child’s capacity for abstraction.

Transference relationship: the informal clinical framework allows the therapist to validate the child, as well as to receive, reflect and confirm the unconscious message projected into the artwork.

Sublimation/redirection of drives: provides a secure, structured pathway to channel primitive and destructive drives into artistically invested, meaningful objects.

Revelatory aspect: by actively encouraging creative exploration and avoiding the imposition of rigid graphic schemata, this therapy liberates self-expression and unlocks latent psychic resources for psychological healing.

Conflict of interests: none declared

Financial support: none declared

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