Art Therapy: Journal of the American Art Therapy Association, 25(1) pp. 15-23 © AATA, Inc. 2008 Assessing Portrait Drawings Created by Children and Adolescents With Autism Spectrum Disorder Nicole Martin, Lawrence, KS Abstract Literature Review The ability to attend to the human face is a striking and Autism as a disorder possibly characteristic deficit for individuals with autism spec- trum disorder (ASD). This study collected and reviewed data on Autism spectrum disorder (ASD), also called “autism,” how people with ASD approach the drawing task and represent is a neurodevelopmental condition characterized by qualita- faces in particular. Drawings that were created by 25 children tive impairment in social interaction and communication as and adolescents with autism spectrum disorder and 15 neuro- well as the presence of restricted, repetitive, and stereotyped typical children were collected for a pilot study of the Portrait patterns of behaviors, interests, and activities (American Drawing Assessment. Participants with ASD were rated as more Psychiatric Association, 2000). ASD is a nonscientific term engaged and conversational during the art therapy assessment describing any individual with a diagnosis on the autism than their neurotypical counterparts, contradicting widespread “spectrum” (Childhood Disintegrative Disorder, Autistic characterization of people with ASD as asocial. Portrait draw- Disorder, Rett’s Disorder, Pervasive Developmental Dis- ing was found to be successful as a structured, concrete means for order, and Asperger’s Syndrome). Communication, imagi- engaging in relationships and holds potential as a therapeutic nation, and social relationships comprise the traditional task for developing face processing and face recognition skills. triad of deficiencies in individuals with ASD. Although not a national estimate, recent statistics from the Centers for Introduction Disease Control and Prevention (CDCR) report that in the 20 U.S. communities surveyed, between 6 and 7 children in “Autistics have problems learning things that cannot be 1,000 have an ASD diagnosis (about 1 in 150 children) thought about in pictures.” (Grandin, 1996, p. 29) (CDCR, 2007). ASD is present in equal numbers across cultures and social classes; however, ASD is three to four For reasons still not fully understood, people with times more likely to manifest itself in males rather than autism have difficulty interacting with the faces of others. females. ASD is by definition an early onset disorder and Yet as an art therapist, I have always enjoyed drawing my signs of its presence must be noted prior to age three clients’ portraits and having them reciprocate with their (American Psychiatric Association, 2000). portraits of me. When viewing my drawings, often a look Brain imaging technology reveals that the range of typ- would come over the faces of my clients with ASD that ical behaviors presented in a child with ASD (such as per- seemed to say: This is me? This intervention was portrait severating, difficulty reading social cues, and sensory drawing with all of the magic and none of the usual inse- over/under stimulation) is due to unique challenges in per- curity encountered by the task, because individuals with ceptual filtering and sensory processing (Belmonte et al., ASD seem generally indifferent to socially based concerns 2004). Either the lack or excess of sensory stimulation can such as drawing skill or enduring the gaze of another per- cause frustration, fear, and confusion in the minds of chil- son. Autism is one of few disorders characterized by this dren with ASD. Self-stimulating behaviors such as rocking, unusual and problematic relationship with the human face, hand-flapping, humming, or spinning objects, as well as yet drawing has been a way in which these children and I unusual motor activity like walking on tiptoe, are usually seem to connect. This study was inspired by such experi- present to some degree in children with ASD. ences, and a desire to document both the process and prod- Scientific research on the etiology of ASD currently ucts of a drawing session with young people with ASD. I clusters around three areas: brain abnormalities, immuno- developed the Portrait Drawing Assessment (PDA) to look logic vulnerability factors, and genetics. Contemporary for trends in the data and to initiate a more comprehensive imaging technology has revealed a variety of abnormalities look at art made by children and adolescents with ASD. including unusual serotonin levels within several brain structures of individuals with ASD (Belmonte et al., 2004; Editor’s note: Nicole Martin, MAAT, LPC, is the owner of Schultz & Klin, 2002). The inability to pinpoint a specific Sky’s the Limit Studio, LLC, specializing in creative arts therapies ASD site in the brain suggests a pervasive alteration of neu- for individuals with autism spectrum disorder and their families. ral processing (Belmonte et al., 2004). Potential environ- The research for this article was conducted while Ms. Martin was a graduate student at the School of the Art Institute of Chicago. mental factors that have been explored are numerous and Correspondence concerning this article may be sent to the author include trauma at birth, food allergies, exposure to elements at http://arttherapyandautism.com such as mercury and cadmium, and an imbalance of diges- 15 16 ASSESSING PORTRAIT DRAWINGS CREATED BY CHILDREN AND ADOLESCENTS WITH ASD tion hormones (Newschaffer, 2006). Since the human ge- Autism and faces nome code was mapped, a handful of chromosomes impli- cated in autism have been found. Research trends indicate Sensory issues related to ASD interfere with one of the that ASD likely will be described in the future as a genetic most fundamental ways in which children learn, that is, by susceptibility aggravated by environmental factors. “reading” adult faces. For children with ASD, attending to the human face is a challenge and forced eye contact is Art therapy and ASD uncomfortable. Visual information about others is usually gathered by stolen, even peripheral, glances. Tyler Fihe, a Art therapy with children with ASD has focused on 14-year-old with ASD, described his experiences with engaging the child in art making in order to address deficits human faces as follows: in communication and imagination (Evans & Dubowski, 2001). As a graphic, nonverbal means of communication, My eyes are unable to move up and down and left to right art can provide relief to the child for whom verbal commu- at will without me moving my head in the direction I’m fac- ing. I can see things really well from the corner of my eyes. nication is frustrating, overwhelming, too direct, or even When I look at someone facing me sometimes I see three nonexistent. Art therapy is occasionally the child’s primary eyes instead of two, and it looks scary so I avoid directly treatment, especially if the child is nonverbal, is primarily looking at people sometimes. This makes it hard for people impaired by emotional factors, or responds poorly to to know whether I’m paying attention to them or not. behavioral interventions (Kornreich & Schimmel, 1991). (Willoughby, 2003, p. 89) Art therapy projects are structured to address goals such as improving fine and gross motor skills, nonverbal commu- Interacting with human faces seems to present a unique nication, socialization, creativity and imagination, expres- challenge to children with ASD, as does being able to dis- sion of feelings, and sensory exploration and regulation. By tinguish between subtle differences in emotion within the helping autistic children progress from schematic (formu- self and with others, particularly socially-based emotions laic) drawing to the realm of representational drawing and such as embarrassment (Capps, Yirmiya, & Sigman, 1992). symbolic thinking, art becomes a tool for them to make When tested to match photographs of both intact faces and sense of their environment. faces with some facial clues missing (e.g., eyebrows, mouth) Making an image provides the child with a sense of according to emotion and identity, the scores of adolescents mastery, autonomy, visual pleasure, and a link to the world with ASD were lower than for non-autistic controls at large. Children with autism often are very visually- (Hobson, Ouston, & Lee, 1988). However, when the same oriented and have a strong need for sensory input. In my faces were presented to the children upside down, the ado- experience, I have found that art therapy can utilize the lescents with ASD showed a remarkable improvement in scores and performed better than their typical peers, whose child’s visual strengths to address treatment goals while scores dropped. It may be that the reason for the autistic providing a socially appropriate outlet for self-stimulatory adolescents’ superior performance on an upside-down face behaviors and sensory needs. For many children with ASD, task is due to what Bruner (1964) identified as an iconic the art-making process attracts them more than a desire to way of thinking in people with ASD. Iconic thinking is complete a finished product (Emery, 2004). By adapting “concrete and dominated by immediate input and surface projects to meet the child’s individual needs, the art thera- appearances” (Mitchell, 1996, p. 202). pist ensures success so that the child can participate as a The study by Hobson et al. (1988) posited that chil- creative and productive person in a normalizing experience dren with ASD see the human face more as an abstract pat-