Draw-a-Man Test

Purpose

The Draw-A-Man Test (Goodenough, 1926) has been widely used as a measure of intellectual maturation in children, to elicit personality type and unconscious material, and as part of neuropsychologic test batteries. The test has also been used to identify the presence of unilateral spatial neglect (USN) in adult patients post-stroke.

In-Depth Review

Purpose of the measure

The Draw-A-Man Test (Goodenough, 1926) has been widely used as a measure of intellectual maturation in children, to elicit personality type and unconscious material, and as part of neuropsychologic test batteries. The test has also been used to identify the presence of unilateral spatial neglect (USN) in adult patients post-stroke.

Available versions

The Draw-A-Man test was published by Goodenough in 1926.

Features of the measure

Items:
There are no actual items in the Draw-A-Man Test. Patients are given a blank piece of paper (8.5 x11) entitled “Draw an Entire Man” and pencil, and are asked to draw an entire man from memory.

Scoring:
Chen-Sea (2000) developed a new scoring method for the Draw-A-Man Test specifically for examining the presence of USN. Rather than use the original quantitative 10-point scoring method that was not able to distinguish patients with personal neglect from healthy controls, this new method scores drawings that show only homogenous unilateral body parts as having USN and those with homogenous bilateral body parts as normal. This scoring system was found to have a high inter-rater reliabilityA method of measuring reliability . Inter-rater reliability determines the extent to which two or more raters obtain the same result when using the same instrument to measure a concept.
. Agreement between two raters was 95.45% for the participants without brain insult and 100% for the participants with strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain., demonstrating the ability for this scoring method to discriminate patients with personal neglect from those without personal neglect.

Time:
It takes less than 5 minutes to complete the Draw-A-Man Test.

Training:
The examiner must be able to distinguish homogenous unilateral body parts (indicates presence of USN) from homogenous bilateral body parts (indicates normal functioning), as drawn by the patient.

Subscales:
None.

Equipment:
A pencil and a blank piece of paper (8.5 x11) entitled “Draw an Entire Man”.

Alternative Forms of the Draw-A-Man Test

Quantitative 10-point scoring method of the Draw-A-Man Test.

• Using a blank piece of paper and a pencil, the seated patient must draw an entire man. The picture is scored by giving one point for the presence of each of the following body parts: head, trunk, right arm, left arm, right hand, left hand, right leg, left leg, right foot, and left foot. The total score of this version of the test is 10 (see Figure 1). This method has not been found to be able to distinguish patients with personal neglect from healthy controls (Chen-Sea, 1995b).

Figure 1. Perfect score of 10 points.

(Source: Chen-Sea, 2000)

Client suitability

Can be used with:

• Patients with strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain..
• Patients must be able to hold a pencil to complete the test.

Should not be used with:

• Patients who have had a left strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. and patients who are left handed.
• Need to rule out the presence of apraxia, given that this may impact the validityThe degree to which an assessment measures what it is supposed to measure.
  of testing results.

In what languages is the measure available?

Not applicable.

Summary

What does the tool measure?	Unilateral Spatial Neglect (USN) in the personal and extrapersonal space (as well as the presence of anosagnosia). Other constructs: intellectual ability/cognitive function/body image.
What types of clients can the tool be used for?	Adults with strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain..
Is this a screeningTesting for disease in people without symptoms. or assessment tool?	ScreeningTesting for disease in people without symptoms. .
Time to administer	Less than 5 minutes.
Versions	Quantitative 10-point scoring method of the Draw-A-Man Test
Other Languages	Not applicable.
Measurement Properties
ReliabilityReliability can be defined in a variety of ways. It is generally understood to be the extent to which a measure is stable or consistent and produces similar results when administered repeatedly. A more technical definition of reliability is that it is the proportion of “true” variation in scores derived from a particular measure. The total variation in any given score may be thought of as consisting of true variation (the variation of interest) and error variation (which includes random error as well as systematic error). True variation is that variation which actually reflects differences in the construct under study, e.g., the actual severity of neurological impairment. Random error refers to “noise” in the scores due to chance factors, e.g., a loud noise distracts a patient thus affecting his performance, which, in turn, affects the score. Systematic error refers to bias that influences scores in a specific direction in a fairly consistent way, e.g., one neurologist in a group tends to rate all patients as being more disabled than do other neurologists in the group. There are many variations on the measurement of reliability including alternate-forms, internal consistency , inter-rater agreement , intra-rater agreement , and test-retest .	Internal consistencyA method of measuring reliability . Internal consistency reflects the extent to which items of a test measure various aspects of the same characteristic and nothing else. Internal consistency coefficients can take on values from 0 to 1. Higher values represent higher levels of internal consistency.: No studies have examined the internal consistencyA method of measuring reliability . Internal consistency reflects the extent to which items of a test measure various aspects of the same characteristic and nothing else. Internal consistency coefficients can take on values from 0 to 1. Higher values represent higher levels of internal consistency. of the Draw-A-Man Test. Test-retest: Two studies have examined the test-retest reliabilityA way of estimating the reliability of a scale in which individuals are administered the same scale on two different occasions and then the two scores are assessed for consistency. This method of evaluating reliability is appropriate only if the phenomenon that the scale measures is known to be stable over the interval between assessments. If the phenomenon being measured fluctuates substantially over time, then the test-retest paradigm may significantly underestimate reliability. In using test-retest reliability, the investigator needs to take into account the possibility of practice effects, which can artificially inflate the estimate of reliability (National Multiple Sclerosis Society). of the Draw-A-Man Test and both reported adequate test-retest. Inter-rater: One study examined the inter-rater reliabilityA method of measuring reliability . Inter-rater reliability determines the extent to which two or more raters obtain the same result when using the same instrument to measure a concept. of the Draw-A-Man Test and reported excellent inter-rater.
ValidityThe degree to which an assessment measures what it is supposed to measure.	Construct: Convergent: Correlated with activities of daily living (ADL)Basic tasks that involve bodily issues (bathing, dressing, toileting, transferring, continence, eating and walking) that are done on a daily basis. performance measured by the Klein-Bell ADL Scale. Known groups: The Draw-A-Man Test was able to discriminate patients with personal neglect from those without personal neglect.
Does the tool detect change in patients?	Not applicable.
Acceptability	The Draw-A-Man Test should be used as a screeningTesting for disease in people without symptoms. tool rather than for clinical diagnosis of USN. Apraxia must be ruled out as this may affect the validityThe degree to which an assessment measures what it is supposed to measure. of test results. This test cannot be completed by proxy. Patients must be able to hold a pencil. Patients with hemiparesis on their dominant side may have difficulty completing the test.
Feasibility	The Draw-A-Man Test takes only 5 minutes to complete and requires minimal training to score (must be able to distinguish homogenous unilateral body parts from homogenous bilateral body parts). Only simple equipment is required (a pencil and paper).
How to obtain the tool?	All that is required is a blank piece of paper (8.5×11) entitled “Draw an Entire Man”, and a pencil. The patient is asked to draw an entire man from memory.

Psychometric Properties

Overview

The Draw-A-Man Test has rarely been used with patients with strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. in the right hemisphere to determine USN. For the purposes of this review, we conducted a literature search to identify all relevant publications on the psychometric properties of the Draw-A-Man Test as a measure of USN.

Reliability

Internal consistencyA method of measuring reliability . Internal consistency reflects the extent to which items of a test measure various aspects of the same characteristic and nothing else. Internal consistency coefficients can take on values from 0 to 1. Higher values represent higher levels of internal consistency.:
No evidence.

Test-retest:
Chen-Sea (1995, reported in Chen-Sea, 2000) administered the Draw-A-Man Test to 19 patients with strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. in a pilot study, and found that the test showed adequate test-retest reliabilityA way of estimating the reliability of a scale in which individuals are administered the same scale on two different occasions and then the two scores are assessed for consistency. This method of evaluating reliability is appropriate only if the phenomenon that the scale measures is known to be stable over the interval between assessments. If the phenomenon being measured fluctuates substantially over time, then the test-retest paradigm may significantly underestimate reliability. In using test-retest reliability, the investigator needs to take into account the possibility of practice effects, which can artificially inflate the estimate of reliability (National Multiple Sclerosis Society).
(r = 0.50).

Gordon et al. (1984) also reported an adequate test-retest reliabilityA way of estimating the reliability of a scale in which individuals are administered the same scale on two different occasions and then the two scores are assessed for consistency. This method of evaluating reliability is appropriate only if the phenomenon that the scale measures is known to be stable over the interval between assessments. If the phenomenon being measured fluctuates substantially over time, then the test-retest paradigm may significantly underestimate reliability. In using test-retest reliability, the investigator needs to take into account the possibility of practice effects, which can artificially inflate the estimate of reliability (National Multiple Sclerosis Society).
for the Draw-A-Man Test (r= 0.62) in patients with right brain damage.

Inter-rater:
Chen-Sea (1995, reported in Chen-Sea, 2000) administered the Draw-A-Man Test to 19 patients with strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. in a pilot study, and found that the test showed excellent inter-rater reliabilityA method of measuring reliability . Inter-rater reliability determines the extent to which two or more raters obtain the same result when using the same instrument to measure a concept.
(r = 0.96).

Chen-Sea (2000) administered the Draw-A-Man Test to 51 patients with strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. and 110 age-matched controls without brain injury. The test had a high inter-rater reliabilityA method of measuring reliability . Inter-rater reliability determines the extent to which two or more raters obtain the same result when using the same instrument to measure a concept.
, as two blinded raters had 96% agreement for the patients with neglect and 100% for those without neglect.

Validity

Criterion:
No evidence.

Construct:
Convergent:
Chen-Sea (2000) reported significant correlations of the Draw-A-Man Test with activities of daily living (ADL)Basic tasks that involve bodily issues (bathing, dressing, toileting, transferring, continence, eating and walking) that are done on a daily basis. performance measured by the Klein-Bell ADL Scale (Klein & Bell, 1979). Subjects with personal neglect had lower scores in five areas of ADL as compared to those without personal neglect.

Known groups:
Chen-Sea (2000) administered the Draw-A-Man Test to 51 patients with strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. and 110 age-matched controls without brain injury and found that all of the controls were correctly classified as normal, and 13 of the 51 strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. patients were categorized as having USN. The results of this study demonstrate the ability of the Draw-A-Man Test to discriminate patients with personal neglect from those without personal neglect.

Responsiveness

No evidence.

References

• Chen-Sea, M-J. (1995a). Test-retest reliability of Draw-A-Man Test. Unpublished manuscript, National Cheng Kung University, Tainan, Taiwan.
• Chen-Sea, M-J. (1995b). Performance of normal and right CVA patients on Draw-A-Man Test. Unpublished manuscript, National Cheng Kung University, Tainan, Taiwan.
• Chen-Sea, MJ. (2000). Validating the Draw-A-Man Test as a personal neglect test. Am J Occup Therap, 54, 391-397.
• Goodenough, F. L. (1926). The measurement of intelligence by drawing. New York: World Books.
• Gordon, W. A., Ruckdeschel-Hibbard, M., Egelko, S., Diller, L., Simmens, S., Langer, K. (1984). Single Letter Cancellation Test in Evaluation of the Deficits Associated with Right Brain Damage: Normative Data on the Institute of Rehabilitation Medicine Test Battery. New York: New York University Medical Center.
• Klein, R. M., Bell, B. J. (1979). Klein-Bell Activity of Daily Living Scale: Manual. Seattle: Division of Occupational Therapy, University of Washington.

See the measure

How to obtain the Draw-A-Man Test?

All that is required is a blank piece of paper (8.5 x11) entitled “Draw an Entire Man”.