"Kids are notoriously bad self-reporters. They have difficulty identifying their feelings and thoughts, and they find it hard to convey their subjective experiences," said Steven Smith, Ph.D., a pediatric psychologist at Harvard Medical School and lead author. "Parents can be more reliable, but they have their own issues and biases."

By the time a problem warrants clinical attention, frightened children may downplay their feelings and behaviors while frustrated parents may exaggerate it, Smith said. Consequently, additional tests may help clinicians make a diagnosis. The Rorschach test requires subjects to view a series of inkblots and describe the images they see. During test administration, clinicians have an opportunity to observe the attitudes and behaviors of young patients first-hand while engaging and assessing their thought processes in a less self-conscious activity.

"A person's responses to the inkblots can reveal exactly how and when they have trouble staying in reality," said Matthew Baity, graduate student and coauthor.

Interpreting inkblots may seem highly subjective. However, over the last several decades psychologists have devised a standardized system for coding patients' answers according to the images they see, where those images appear in the inkblot, how closely their interpretation resembles the inkblot, and a variety of other factors. Coded results can be grouped and analyzed in numerous combinations. Each combination constitutes an index, which can be used to assess particular cognitive processes or personal attitudes.

The Schizophrenic Index has been used to help identify thought disorders because the inability to think logically or sequentially is strongly associated with schizophrenia. The index often produces false positives when applied to children, especially among those who are bright and creative. Such imaginative children often demonstrate divergent thought processes and unexpected responses, which the index interprets as disordered thinking.

In the current research, the investigators examined 42 children, ranging in age from 8 to 18 years, who had been admitted to a psychiatric hospital for diagnosis and treatment. Parents submitted a behavior rating for each child, and each child completed a self-report and a Rorschach exam on admissions.

Rather than just analyzing Rorschach results according to the Schizophrenic Index method, the researchers also examined the results using a newly developed index called the Perceptual-Thinking Index. They found that the new index showed a slightly higher correlation to self-reports and behavior ratings than did the standard index. Further, the Perceptual-Thinking Index reported fewer false positives, indicating that the new index more accurately measured disordered thinking and psychosis in children.

The study won the Walter Klopfer Prize for distinguished contribution to the literature in personality assessment, awarded by the Society for Personality Assessment.

In addition to reducing misdiagnosis rates, the reliability of the Perceptual-Thinking Index may restore confidence in the utility of the Rorschach test as a whole. Over the past several decades, a growing number of clinicians have dismissed the inkblot exam as too subjective for use as a diagnostic tool. The current study provides empirical evidence that Rorschach results are related to perceptual processes and can be used to help identify thought disorders.

"It's all about collecting as much information as you can," explained Baity. "This study suggests that the Rorschach can be used to back up other evidence of mental illness, which can lead to a more accurate diagnosis. That's especially important for children, where diagnosis tends to be more difficult and uncertain."
Related journal article:
J Pers Assess 2001 Dec; 77(3): 447-463.
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