ROTATION STYLE ON THE BENDER GESTALT TEST 179

SUMMARY

Style of rotation on the Bender Gestalt Test is introduced as a new approach in studying the phenomena oE rotation. Four styles of rotation are defined: Clock- wise (C), counter-clockwise (CC) , indeterminate (I), and mixed (M). Replication of an earlier study reveals a remarkable consistency in rotation style for the general medical patient. The long-term psychiatric patient is comparable only in employ- ment of the CC style. Age, intelligence, education, and to some extent, diagnosis, are important variables in discriminating between rotaters and non-rotaters; direction of rotation is influenced by these parameters. Style of rotation may be an index of chronicity and/or regression.

REFERENCES 1. BENDER, LA~JRETTA. In Forward to: An Evaluation of the Bender-Gestalt Test. Tolor, A. and

2. CLORE, G. L. Kent EG-Y: Differential scormg and correlation with the WAIS. J. consult.

3. FABIAN, A. A. Vertical rotation in visual-motor performance: Its relationship to reading re-

4. FABIAN, A. A. Clinical and experimental studies of school children who are retarded in reading.

5. FULLER, G. B. and LAIRD, J. T. The Minnesota Percepto-Diagnostic Test. Brandon, Vt.: Journal

6. GRIFFITFI, R. M. and TAYLOR, VIVIAN H. Incidence of Bexe:-g%talt figure rotations. J. ww

7. JERNIGAN, A. J. Analyses of Bender-Gestalt figure rotatioil in a GM$S hospital population. V. A . Newsletter for Research in Psydwlogy, 1964, 6, 14.

8. SILVERSTEIN, A. B. and MOHAN, P. J. Bender-Gestalt figure rotations in the mentally retarded.

Schulberg, H. C. Springfield, Ill.: Char1es.C. Thomas, 1963.

Psychol., 1963, 27, 372.

versals. J. e d ~ . Psychol, 1945,36, 129-154.

Quart. J . Child Behav., 1951, 3, 1537.

of Clinical Psychology, Monograph Supplement No. 16, Jmu

Sult. Psychol., 1960, 24, 189-190.

J . consult. Psychol., 1962, 86,386388.

KOPPITZ’ BENDER SCORING SYSTEM AND BRAIN INJURY IN CHILDREN

JOSEPH FRIEDMAN, ROBERT D. STROCHAK, SIDNEY GITLIN A N D MITCHELL L. GOTTSAGEN

Center for Child Guidance, Philadelphia, Penna.

INTRODUCTION The detection and assessment of minimal brain injury and its ramifications

for personality have been of constant interest to those working in child clinics, One of the major approaches to this problem has been through the application of the Bender Visual Gestalt Test“, 3 * 4 * 5 . * ) . Recently Koppitz(6, ’) has developed a scoring system (hereafter referred to as the DSSB) especially applicable to younger children (ages 5-10). This system is based on the conviction that the development of the visual-motor apparatus is orderly and that increasingly better execution of the Bender figures should occur with age. Conversely, errors in this performance may be viewed as due to developmental lags or as attributable to brain injury. Koppitz ( 6 ) conducted a study attempting to distinguish between brain injured (BI) and non-brain injured (NBI) children through the DSSB and reported promis- ing results. Her research design involved the differentiation between a known group of medically confirmed BI children and a “normal” control sample, a situation which is rarely obtained in clinical settings. Rather, clinicians are typically called upon to examine patients suspected of brain injury for various reasons and by use of their methods and skills to support or contraindicate its presence. By virtue

180 J. FRIEDMAN, R. D. bTROCHAK, S. GITLIN AND M . L. GOTTSAGEN

of the absence of prior knowledge, this differential diagnosis is both more typical of actual practice and more difficult. It is the purpose of this investigation to apply the DSSB in making this distinction.

METHOD Subjects and Criteria. From a variety of sources (including the files of 2 child

clinics and 2 private practitioners) Bender protocols (along with IQ’s and CA’s at time of testing) were obtained for 49 children between the ages of 5 and 10 years. All Ss had been suspected of being brain injured and were selected because of the availability of definitive medical-neurological evidence to serve as the criteria for inclusion in brain injured or non-brain injured groups. This evidence included at least two of the following: neurological examinations, EEG’s, skull films and pneu- moencephalograms.

Our sample included 6 cases in which one or more Bender designs were omitted or incomplete due to the Ss’ inability to cope with the task; these Ss were deleted from the study. Six further cases were unscorable by the DSSB. This latter group was included in some of the calculations because they seemed to represent the grossest type of Bender failures and therefore most likely to occur most frequently among brain injured children.

Scoring Procedures. Initially, two psychologists independently scored all the Benders according to Koppitz’ DSSB. The remaining two authors scored sub- samples of the cases, again independently. No scorers were aware of age, sex, intelligences or neurological findings at this point. The scorers could achieve no greater than 60% agreement on the individual errors. With such limited item reliability, any calculation of the reliability of the total score seemed spurious.

The first two authors scored the records again in each other’s presence. Differences were discussed and when the manual failed clearly to point the way, they adopted an approach stressing minimal re- quirements.

Treatment of the D a t a The DSSB’s were coniputed for each S. Those above the error mean for Koppitz’ age norms were considered suggestive of brain injury, while those at or below the error mean were considered non-brain injured. The same data were then reconsidered, this time requiring a DSSB of one standard deviation more above the appropriate age norm to indicate brain injury. The results of both of these procedures were compared with the actual medical-neuro- logical diagnosis.

Thirdly, those individual errors that Koppitz stressed as most related to brain injury were examined. The hypothesis here was that such errors would cluster in the records of those Ss with demonstrable brain injury. Finally, an effort was made to discern whether there was a tendency for I& level to differ between our brain injured and non-brained injured groups, and whether I& level, rather than organic impairment, was reflected in the DSSB.

RESULTS Of the 37 scorable cases, 26 obtained scores above the appropriate age means,

suggesting the presence of BI. Only 11 of these 26 had positive neurological findings, resulting in a 60% yield of false positives. Of those 11 cases resulting in scores below the appropriate mean, only 4 were neurologically clear.

Upon reevaluation of the same data, this time requiring a score of 1 standard deviation above the appropriate age mean, only 8 of 1.5 positive DSSBs received medical confirmation. With 22 cases falling less than 1 standard deviation above the DSSB, 12 had neurological findings negative for BI. The added accuracy obtained by this step is obviously minimal.

Turning from total scores, we next focused upon those errors Koppitz posits as hcing especially significant (at the .01 level of confidence) for dctcrting €31 a t

A second approach was devised.

KOPPITZ’ BENDEH SCORING SYSTEM AND BRAIN INJURY IN CHILDHEN 181

various ages. Of those 18 cases with positive medical evidence of BI, 10 had none of these errors, 4 cases had 1 such error, and of the 4 remaining cases none exceeded 4 of these errors. If perchance we assume the Bender to be the criterion of BI (rather than the predictor variable), then 13 of the 19 positive cases had none of Koppitz’ sigiiificant errors, and only 1 case had as many as 4.

Finally we attempted to discern whether the DSSB scores indicating BI or non-BI were a function of the IQ’s. Our sample of 31 was negatively skewed with regard to IQ (Mean = 90.60, SD = 19.29), and included 3 cases in the defective group. Of 13 cases wit,h I& of 100 or bet’ter, 8 received medical confirmation of organicity, and of the 29 below this point 12 were likewise organic. Thus organicity, neurologically defined, occurred a t roughly the same rate in the 2 subgroups. When DSSB svores are considered in relation to I&, 20 of 29 slower children do poorly on the Bender while only 7 of 13 brighter children also do poorly. Thus, higher I& docs not entirely preclude a poor DSSB score, lower I& children do have more difficulty in executing the Bender, and slower children may be erroneously considered neurologically handicapped on the basis of DSSB.

As a final procedure we considered the 6 unscorablr records t.0 represent ex- amples of gross inability to cope with the visual-motor task and assumed this would occur nrost frequently among the organic children. Even of these 6, 2 had negat,ivc neurological findings.

DISCUSSION The authors are acutely aware of the shortcoillings of this study. The saniple

of 37 to 43 children, while admittedly small, is not insignificant because they were studied thoroughly from a neurological point of view. The present investigators were once-removed from the actual collection of both psychological and medical- neurological data in most of the cases. Thus, we were not in a position to observe the qualitative nature of the copying process which Koppitz points out is an ini- portarit factor in niaking a diagnosis. However, this is a eoninion pitfall in research based on data collected by others and does not semi sufficient to negate our findings.

Prior research ( 6 ) yielded generally favorable results from the DSSB when applied to normal controls and known brain-injured children. In this investigation, utilizing a sample in which all the caws were suspected of such injury, the sanie system generally fails to correspond with the selected medical criterion. Indeed we find a large number of unconfirmed neurological cases achieving a positive DSSB score ( I5 of 19 cases).

We alluded earlier to difficulty in obtaining inter-scorer reliability. The DSSB Manual ( 7 sonietinies incompletely stipulates the criterion for scoring an error. We found questionable issues related to several of the 2.5 errors listed by Koppitz. For exaniple: On Bender Figure i4E G it is an error if the two wavy lines cross a t the extreme, but exactly what is the extreme? Such questions were a t the root of our original failurc t’o obtain good reliability.

SUUMARY Thr Iioppitz Ilevelopniental Scoring System for the Bender (DSSB) was

applied to a saiiiple of 43 children suspected of brain injury. When compared with iriedjcal-ncuroloRical findings, the DSSR failed to approach significant levels as a predictor of organic dysfunction. Individual errors reported to be niost highly related t,o brai 11 injury were exaiiiined and even among those cases with demonstrable brain injury this association was niininial. Problems of explicitness in the scoring nianual resul t,cd in sonic difficulty i n establishing inter-scorer reliability. The authors stressed the need to distinguish between brain daniage as neurologically proven fact and as a concept covering wide behavioral possibilities. In both situ- ations, similar t,herapeutic, and educational techniques often prove effective. The DSSB was not originally intended for use i n detecting organicit,y, and its appli- c.at,ioii to surh a task should he approached with caution.

182 J. FRIEDMAN, R. D. STROCHAK, S. GITLIN AND M. L. GOTTSAGEN

REFERENCES 1. BENSBERG, G. J. Performance of brain injured and familial mental defectives on the Bender

2. BIRCH, H. T. (Ed.) Brain Damage in Children: the Biological and Social Aspects. Baltimore:

3. CHOROST, S. B., SPIVACK, G. and LEVINE, M. Bender Gestalt rotations and EEG abnormalities

4. GOLDBERG, L. R. The effectiveness of clinician's judgments: the diagnosis of organic brain

5. HANVIK. L. A note on rotations in the Bender Gestalt Test. J. consult. Psuchol.. 1953.9.339.

Gestalt Test. J. consult. Psychol., 1952, 16, 61-64.

William and Wilkins Co., 1964.

in children. J. consult. Psychol., 1959,2S, 559.

damage from the Bender Gestalt Test. J. consult. Psychol., 1959,2S, 25-33.

6.

7.

KOPPITZ, E. M. Diagnosing brain damage in young children with the"Bender Gestalt Test.

KOPPITZ. E. M. The Bender Gestalt Test for Young Children. New York: Grune and Stratton, J . consult Psychol., 1962, ,??6, 541-546.

- 1964.

diagnostiche Moglichkeiten. 2. diagnost. Psychol., 1956, 4, 174. 8. WEWETZER, K-H. Bender Gestalt Test bei Kindern: Auswertungs Methode und differential

WHERE TO BEGIN TESTING ON THE 1960 STANFORD-BINET L-M* DONALD G. WELLS AND DUILIO T. PEDRINI

Glenwood (Zowa) State HospitabSchool Glenwood State HospitaLSchool University of Omaha

PROBLEM One of the problems with an age scale like the 1960 Stanford-Binet L-M is

knowing where to start testing. Rather than give all the subtests, the test authorsC3) state that one should first test downward until all the subtests at an age level are passed (basal) and then upward until all the subtests at an age level are failed (ceil- ing). If the examiner begins too high, the person being tested could become so dis- couraged from failure that his overall score might drop. If the examiner starts too low, he will administer more levels and spend more time than necessary at the risk that the client might become tired and not work as well as he could have.

One way to know where to start would be to administer the Picture Vocabulary (PV) and/or the verbal Vocabulary (VV) subtests first. Since these two subtests occur at multiple levels, their scores would give an approximation of the client's level of performance. Vocabulary also is one of the best predictors of the overall test score, since the vocabulary subtests correlate from .61 to .96 with the overall scale.

The purpose of this study was to determine what basal levels are most commonly found to correspond to a given PV or VV score. In addition, mental age levels and peak levels of performance were also computed for each PV and VV score. Mental age equivalents for the 1937 revision were previously presented by Cureton"). The peak level of performance is the highest level at which the client still passes at least one subtest.

PROCEDURE This study used 2081 Ss, including 388 from the Glenwood State Hospital-

School for the retarded, and 1693 from the Child Study Clinic of the University of Omaha. Females comprised about one-third of the total. The age range was 4 through 21 years and the I& ranged from 10 to 170. All had been administered the 1960 revision of the Stanford-Binet by trained examiners. All I Q s below 30 were computed using the method described in Appendix A of the manual@) and in Ap- pendix C of Pinneau's(2) book.

Sievers who was taught by Dr. L. M. Terman. *The senior author was taught this technique by the co-author who was taught by Dr. C. H.