FAYETTEVILLE, Ark. — A team of researchers from the University of Arkansas has determined that a new interpretation of the Rorschach inkblot test may provide a more accurate assessment of thought disorders in children and adolescents. The research has earned them a national award from the Society for Personality Assessment, and their findings may help restore clinical confidence in the 80-year-old inkblot test.

Mental illness and cognitive deviance can be more difficult to diagnose in children than in adults. Clinicians typically rely on self-reports from the young patients and behavior ratings from parents or guardians to help assess psychological problems. But such methods can be subjective and inaccurate.

"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, a recent UA doctoral graduate, now a pediatric psychologist at Massachusetts General Hospital and Harvard Medical School. "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. So psychologists collect additional information by conducting more objective clinical tests.

One such test, the Rorschach, asks subjects to view a series of inkblots and describe the images they see. Administering the Rorschach gives psychologists an opportunity to observe the attitudes and behaviors of their young patients first-hand while engaging and assessing their thought processes in a less self-conscious activity.

"A lot of psychologists like the Rorschach because it gives them a chance to interact with the patient one-on-one, and it can give a more direct glimpse into their perceptions and thought processes," explained Matthew Baity, a UA doctoral student and co-author of the study. "A person’s responses to the inkblots can reveal exactly how and when they have trouble staying in reality."

Interpreting inkblots may seem like a highly subjective procedure, but 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 psychologists use to assess particular cognitive processes or personal attitudes.

For example, psychologists have long applied the Schizophrenic Index (SCZI) to help identify thought disorders. They do so because the inability to think logically or sequentially that characterizes mild thought disorders — as well as the delusions and hallucinations that characterize severe thought disorders — are strongly associated with schizophrenia. But the SCZI 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 SCZI interprets as disordered thinking.

Smith and Baity — along with UA professors Eric Knowles and Mark Hilsenroth (now a professor at Adelphi University) — examined a group of 42 children, ranging in age from 8 to 18, 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 upon being admitted.

But rather than just analyzing the Rorschach results according to the SCZI, the UA researchers also examined the results using a new index, called the Perceptual-Thinking Index (PTI). They found that the PTI showed a slightly higher correlation to the self-reports and the behavior ratings than did the SCZI. Further, the PTI reported fewer false positives than the SCZI, indicating that this new index more accurately measured disordered thinking and psychosis in children.

The study won Smith and his co-authors the Walter Klopfer Prize for distinguished contribution to the literature in personality assessment, awarded by the Society for Personality Assessment. It is the first study to apply the PTI to adolescents, and it gives clinical psychologists a new and more reliable tool for identifying thought disorders in younger patients.

Such a tool can be extremely valuable considering the fact that wrongly diagnosing children with a thought disorder can result in long-lasting ill effects.

"Labeling is one problem associated with misdiagnosis. Saying a child has a mental illness can cause peers and parents and teachers to start treating the child differently, and that can lead to serious social issues," Smith said. "The other danger is taking treatment down a path where it doesn’t need to go — whether that treatment takes the form of therapy or medication."

But in addition to reducing the rate of misdiagnosis, the reliability of the PTI may help restore confidence in the accuracy and utility of the Rorschach test as a whole. Over the past several decades, a growing number of psychologists have dismissed the inkblot exam as too subjective for use as a diagnostic tool. The University of Arkansas study provides empirical evidence that Rorschach results are related to psychological processes and that they can be used to help identify psychological conditions.

"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."

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