Personality attributes of children with behavior problems. An exploratory analysis with the Exner Comprehensive System of the Rorschach Inkblot Test and implications for the socio-historical clinical practice approach

Saraiva, A.B. Quintino Aires Institute, Lisbon, Portugal CIEC — Research Center on Child Studies, Lisbon, Portugal

Ferreira, J. Quintino Aires Institute, Lisbon, Portugal

Introduction

Disruptive behavior disorders are among the easiest of mental health childhood disorders to identify because they are expressed through objective behaviors such as tantrums, aggression, excessive argumentativeness, stealing, and other forms of defiance or intolerance to authority. Disorders like oppositional defiant disorder (ODD) and conduct disorder (CD) first attract notice when they interfere with academic performance, or family and peer relationships. Behaviors typical of dis­ruptive disorders can have some resemblance to attention-deficit/hyperactivity disorder (ADHD) — particularly when impulsivity and hyperactivity are also in­volved — but ADHD, ODD, and CD are considered separate conditions that can occur independently (APA, 2013; OMS, 1996).

Both the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5), and the International Statistical Classification of Diseases and Related Health Problems, 10th Edition (ICD-10) have established diagnostic criteria for ADHD, ODD, and CD. A comparison of the two diagnostic approaches finds slight discrepancies between the two. Table 1 presents the structure of classification and respective codes regarding these behavioral disorders.

North American studies have estimated the prevalence of early childhood be­havioral disorders, but numbers can vary significantly from study to study, depend­ing on the purpose, methodology for population selection, and criteria used to diagnose the disorders and identify functional impairment. The results of these studies indicate that about one out of every three to four youths is estimated to meet the lifetime criteria for a DSM mental disorder (Costello et al, 2004). After anxiety disorders, considered the most frequent condition in children, ADHD is the most common neurobehavioral childhood disorder as it affects large numbers of children throughout the world (Solovieva & Quintanar, 2015). As previously noted, there is also no agreement on the prevalence of ADHD. Nevertheless, a Spanish study reveals a range of incidence from 1.5% to 18% in different popula­tions (Cardo, 2010); another study estimates that approximately 5.29 % meet the criteria for ADHD (Polanczyk et al., 2007). According to the DSM-5, the annual prevalence of CD is 2% to 10%, with a median of 4% (APA, 2013). ODD has an estimated lifetime prevalence of 10.2% (Dickstein, 2010).

Considering the previously cited psychopathological diagnostic classifications for which there are generally agreed-upon definitions, it is important to discuss and develop the concepts that the study addresses. DSM-5 has recently reclassi­fied ADHD from “Disorders Usually First Diagnosed in Infancy, Childhood or Adolescence” to “Neurodevelopmental Disorders.” ADHD is a behavioral condi­tion that makes focusing on everyday requests and routines especially challenging. Children with ADHD typically have trouble organizing tasks and activities, fail to pay attention to details, are unable to remain seated in appropriate situations, and find it difficult to stay focused, make plans, and consider the consequences of their actions. Excessive talking, fidgeting, noisiness, difficulty playing quietly, and problems adapting to changing situations represent another set of symptoms. It is common to subdivide the disorder into two groups — inattention and hyperac­tivity/impulsivity — both having to be consistent to a degree that is maladaptive and inconsistent with the child’s developmental level (APA, 2013). Children with ADHD can also be defiant, socially challenging or aggressive, and there is known co-morbidity and premorbidity between ADHD and ODD (Pardini & Fite, 2010). ADHD has been reconsidered in the latest edition of the DSM, so that it now fea­tures three different types: the predominantly inattentive type; the predominantly hyperactive-impulsive type; and finally, the combined type, when both core symp­toms coincide (APA, 2013).

Table 1. Comparison between the taxonomy of the DSM-5 and ICD-10

DSM-5	ICD-10
Attention-Deficit/Hyperactivity Disorder (314.01) Category: Neurodevelopmental Disorders Code 314.00 Predominantly inattentive presentation Code 314.01 Predominantly hyperactive/impulsive  presentation	Attention-deficit hyperactivity disorders (F90) Code F90.0 Attention-deficit hyperactivity disorder, predominantly inattentive type Code F90.1 Attention-deficit hyperactivity disorder, predominantly hyperactive type Code F90.2 Attention-deficit hyperactivity disorder, combined type Code F90.8 Attention-deficit hyperactivity disorder, other type Code F90.9 Attention-deficit hyperactivity disorder, unspecified type
Conduct disorder (312.81) Code 312.81 Conduct disorder, childhood-onset type Code 312.82 Conduct disorder, adolescent-onset type Code 312.89 Conduct disorder, unspecified onset	Conduct disorder (F91) Code F91.0 Conduct disorder confined to family context Code F91.1 Conduct disorder, childhood-onset type Code F91.2 Conduct disorder, adolescent-onset type CodeF91.3 Oppositional Defiant disorder Code F91.8 Other Conduct disorders Code F91.9 Conduct disorder, unspecified
Oppositional Defiant disorder (313.81)

The concepts of CD and ODD draw from psychopathology and characterize two kinds of antisocial behavior that are clinically significant (Kazdin & Whitley, 2006). The inclusion of a chapter on disruptive, impulse-control, and conduct dis­orders is new to the DSM-5; it includes Oppositional Defiant Disorder (ODD), Conduct Disorder (CD), and Intermittent Explosive Disorder. According to DSM-5 criteria, CD is characterized by behavior that violates either the rights of others, or age-appropriate societal norms or rules. The essential feature is a repetitive and persistent pattern, and the symptoms must cause significant impairment in social, academic, or occupational functioning. The disorder is typically diagnosed prior to adulthood. CD may also be described as juvenile delinquency in criminal tax­onomy, where both psychological and legal definitions are combined. It is also well established that CD can be a premorbid condition for Antisocial Personality Dis­order (APD), as in adult criminality, especially when lack of empathy and deficient affect are fundamental traits.

The symptoms of ODD are now grouped into three types: angry/irritable mood, argumentative/defiant behavior, and vindictiveness (APA, 2013). Broader labels such as disruptive, challenging, or troublesome may encompass both CD and ODD, reflecting the impact that the behavior has on disturbing the social environ­ment. Whatever the case may be, a child behavior disorder consists of a marked pattern of social impairment and maladjustment that results in repetitive acting-out behavior, not just in an isolated incident.

The present study decided on an alternative terminology — behavior prob­lem — as it offered a wider definition and subsumed a variety of behaviors. To put the subtypes of pattern behaviors into focus, a broader taxonomy was adopted, namely the hyperkinetic, oppositional defiant, and antisocial behavior profiles.

Regardless of the difficulties hyperkinetic children may display, specifically in close relationships like those with family members or schoolmates and teachers, few attempts have been made to understand the relationship between specific fea­tures of hyperkinetic behavior and socio-emotional functioning, using standard­ized tests like the Rorschach Inkblot Test (Cotugno, 1995). When associated with the Exner Comprehensive System, the Rorschach provides useful data on a wide range of personality attributes, and important insight into personality structure and the complex relationship between behavioral patterns and the effect of these on socioemotional functioning. It is clear that the Rorschach test should not be the only instrument used, but an important part of an overall psychological evaluation. In fact, the Rorschach test is a vital complement to more standardized and even survey instruments, and neuropsychological investigation should play a leading role in any rigorous clinical evaluation (e.g., Akhutina & Pylaeva, 2011; Kholod­naya & Emelin, 2015; Solovieva & Quintanar, 2015; and others).

The aim of this study was to examine the data set underlying personality at­tributes as demonstrated on Exner’s Rorschach Comprehensive System in children labeled with hyperkinetic, oppositional defiant and antisocial profiles. For accom­plishing this main objective, similarities and differences in personality attributes of the three groups were analyzed. Results are presented and discussed in light of the cultural-historical perspective (Luria, 1973; Vygotsky, 1993) and the specific clinical interpretation of the Quintino Aires Institute (Quintino-Aires, 1999; 2009; 2014).

Perspective of the Vygotsky-Luria school

When looking into the philosophical science that dominates human science’s con­ceptualization and methodology, particularly about psychology, one realizes that classical Western thinking, following Cartesianism, provides theories and para­digms that emphasize fragmentation and compartmentalization of knowledge about mind and body. This conception defines the direction and still underlies ob­servations and practices of dealing with child behavioral problems. Contemporary psychology, based on philosophical science, has provided the foundation for the classification of scientific approaches, leading to an actual state of scientific knowl­edge characterized by the concept of postnonclassical science (e.g., Pervichko & Zinchenko, 2014; Quintino-Aires, 2014; Zinckenko & Pervichko, 2012; 2013).

Hyperactivity, as in ADHD, is a relatively recent historical category in child studies. In contemporary clinical psychology supported by the Vygotsky-Luria school, syndrome analysis is one of the most essential methodological principles used for dealing with complex self-developing open systems and studying psychic phenomena like personality attributes (Luria, 1973; Vygotsky, 1993; Zinchenko & Pervichko, 2012). The conceptualization of a particular type of syndrome is essen­tial to structural analysis of complex phenomena, to clarify the distinction between the manifestation of psychological factors and the mechanisms responsible for their emergence and functioning. As Zeigarnik’s works show, this enlightenment benefits the psychological interpretation of clinical phenomenology (Nikolaeva, 2011).

Method

Sample

Our sample comprised 39 Portuguese children, 24 males and 15 females, of ages between 6 and 14. These children were selected from a group of clinical patients at a Portuguese Health Institute which has applied the Historical-Cultural approach for many years. Children with behavior problems were classified into three groups: “hyperkinetic,” 20 children (51.3 %); “oppositional defiant,” 11 children (28.2 %); and “antisocial,” 7 children (20.5 %).

The assignment of children to each group was done according to three criteria: a) the description by the family members who accompanied the children to the first consultation, usually the parents; b) interaction with the child in the first consulta­tion; and c) the assessment made by senior psychologists using neuropsychologi­cal investigation with a Lurian battery (BIN, Neuropsychological Research Battery; Juvêncio, 2015; Rua, 2015) and a personality assessment with Rorschach Inkblot Test. This psychodiagnostic methodology is traditional for historical and cultural psychology, and it is an alternative to the psychometrical and cognitive approach.

Table 2. Descriptive data for age in the three groups

	Range	χ	SD
Hyperkinetic (H)	6-12	8.94	1.92
Oppositional Defiant (OD)	6-12	9.91	1.81
Antisocial (AS)	6-14	9.88	2.80

The Rorschach Test was administered and scored by examiners formally trained in the use of Exner’s Comprehensive System (1991, 1993, 2000). Clinical case notes provided a picture of the client’s reports on the child’s behavior at home and school, the client’s reasons for entering therapy, the child’s current symptomatology, and his/her clinical diagnosis. The data collected was analyzed by four judges with train­ing and practice in clinical psychology, who discussed the meaning of the children’s behavior reported by parents, and the results of their assessment.

Three clinical groups were organized according to the criteria proposed by the classification systems of psychological disorders (ICD-10 and DSM-V). Hyperki­netic (H) signified “hyperactivity, agitation, restlessness, low concentration, lack of attention.” Oppositional Defiant (OD) signified “oppositional, defiant, rudeness, disobedience, resistance.” And antisocial (AS) signified “lying, running away from school/home, abuse, aggressiveness, unruliness.” In Tables 2 and 3 we report the age and gender distributions for the children from the three groups.

Table 3. Frequency of gender in the three groups

	H	OD	AS
Male	13	4	7
Female	7	7	1

Because of the exploratory nature of this study and considering the size of the sample, test differences in age and gender were not analyzed. Nevertheless, age av­erages were considered similar, and some differences in gender distribution of the three clinical groups were registered, particularly in the antisocial sample, which consisted of only one female.

Instruments

The goal of identifying personality attributes of several groups with behavior prob­lems was pursued using the Exner Comprehensive System of the Rorschach Inkblot Test (1991, 1993, 2000). The Rorschach Inkblot Test is a projective technique com­posed by 10 psychodiagnostic plates with abstract stimuli made of inkblots. Upon observing each plate, individuals have to express what the ink spots resemble. The Exner Comprehensive System allows a broad picture of the psychological dynamics of the individual. This system evaluates the personality structure to three groups of key variables: Group I — the Perceptual-Thinking Index (PTI), the Depression/ Apathy Index (DEPI), and the Coping Deficit Index (CDI); Group II — control and tolerance of stress; and Group III — dominant styles (or trends) of personal­ity, namely, affective features, self-perception, and interpersonal perception. The three groups of different indices are used for the calculation of three groups de­fined by qualities of mental functioning: The «cognitive triad» refers to information processing, ideation, and cognitive mediation.

All results obtained in this study are presented and discussed in light of the clini­cal interpretation provided by Quintino-Aires (1999; 2009; 2012; 2014). This author provided maladaptation and clinical-reference values, and a clinical-oriented inter­pretation for the variables, chapters, and constellations of the Exner Comprehensive System, in order to obtain an individualized understanding of the patients.

Procedure

In order to provide a uniform coding procedure among the psychologists, data was collected through standard evaluation procedures by clinical psychologists of a health institution certified in Rorschach administration and Exner Comprehensive System procedures. Data was analyzed with SPSS.20. Coding of the Rorschach pro­tocols had an agreement coefficient of 0.95 among four independent judges with training in clinical psychology.

Results

In general, the Rorschach constellations did not indicate psychopathology for ei­ther group, but the Depression/Apathy Index (DEPI) was considered clinically sig­nificant in all three profiles. Table 4 illustrates the first findings on major constel­lations. In line with Exner’s (1993) recommendations, singular variables were not reviewed, but were considered in groups of variables or clusters, relating each other to specific characteristics of personality. We further analyzed similarities and dif­ferences in the results between the groups.

Table 4. Means of major constellations

	H	OD	AS
PTI	2.85	2.00	2.13
DEPI	3.85	3.55	3.63
CDI	3.05	3.55	3.38
SCON	5.20	4.91	5.38

Table 5. Frequency of major constellations with abnormal values (%)

	H	OD	AS
PTI	30.0	18.2	25.0
DEPI=3	35.0	36.4	37.5
DEPI>3	60.0	54.6	50.0
CDI	15.0	27.3	0.0
SCON	5.0	0.0	12.5

Neither the Hypervigilance Index (HVI) nor the Obsessive Style Index (OBS) were present, and, hence, were not considered in the previous tables. The most significant indicator was that all three groups had a DEPI mean greater than 3; this is explained by the fact that 50% or more of each group had a DEPI higher then 3 (4 or higher).

The comparison of profiles shows common aspects in four dimensions: cogni­tive/perceptual skills, self-regulation, relational skills, and self-esteem. As to the first dimension, cognitive/perceptual skills, in all three groups a marked deficit in the reception, interpretation, and meaning of stimuli arising from experiencing the environment was found (W). This deficit directly influences the style of approach­ing the world, expectations, and resources (W:M) and, in a broader sense, process­ing. Cognitive mediation was also impaired, namely self-awareness and awareness of others (X+, F+); there was a difficulty in starting relationships with others (X-), and a tendency for defensiveness (Xu). When ideation was considered, a lack of cognitive flexibility (a:p) was found. Table 6 presents values of indicators for these dimensions.

Table 6. Frequency of Rorschach indicators with abnormal values (%)

		H	OD	AS
Processing	Tendency W	90.0	36.4	75.0
	Tendency Dd	0.0	27.3	25.0
	Both tendency W and Dd	0.0	27.3	0.0
	W<M+50	40.0	54.5	37.5
	W>M+100	45.0	36.4	62.5
	DQv	50.0	72.7	37.5
Mediation	P	75.0	72.0	50.0
	X+	100.0	100.0	100.0
	F+	95.0	100.0	100.0
	X-	90.0	81.8	87.5
	S-	50.0	27.3	25.0
	Xu	100.0	90.9	87.5
Ideation	a<p+2	45.0	27.3	37.5
	a>p+2	45.0	63.6	50.0
	M-	30.0	33.4	12.5
Affect	F : C	70.0	72.7	62.5
	PureC	30.0	18.2	37.5
	Comb:R	75.0	90.9	87.5
Self-perception	3r+(2)/R	75.0	90.9	75.0
	Fr+rF	5.0	9.1	12.5
	FD	90.0	72.7	87.5
	MOR	35.0	45.5	12.5
Interpersonal	COP	85.0	90.9	87.5
	AG	85.0	90.9	100.0
	H:(H)+Hd+(Hd)	95.0	100.0	87.5
	(H)+(Hd):(A)+(Ad)	20.0	36.4	75.0
	(Bt+2Cl+Ge+Ls+2Na)/R	40.0	72.7	50.0
Control	EA	35.0	54.5	25.0
	es	75.0	72.7	100.0
	Adj es	75.0	63.6	100.0
	FM < 3	65.0	45.5	62.5
	FM > 4	20.0	18.2	12.5
	C’	70.0	27.3	75.0

The second dimension evinced a deficit in self-control, poor elaboration (FM), precipitate judgement of others (H:(H)+Hd+(Hd)), and lack of self-analysis (FD). The third dimension concerned relational skills, where low levels of empathy (Comb:R) were observed, an impairment in cognitive mediation, difficulties in bonding (COP), low assertiveness (AG), and a failure to have an accurate representation of others due to hasty judgment (H:(H)+Hd+(Hd)). The fourth dimension that all three groups had in common was related to self-esteem (3r+(2)/R). All participants showed low self-esteem and social identity, and this was associated with a lack of resources and expectations (W:M), sadness, and general lack of energy (DEPI).

But different aspects were also found when comparing all three profiles in relation to the functional characteristics of each behavior pattern. Within the Hyperkinetic (H) group, the children had difficulty regulating action (F:C), were more impulsive, and their emotions overrode conscious reflexive action (PureC).

Children with an Oppositional Defiant profile (OD) had a higher lack of trust in themselves and others (3r+(2)/R); in this case, low expectations (W:M) and re­sources (EA), higher pessimism (MOR), loneliness ((Bt+2Cl+Ge+Ls+2Na)/R), and intrinsic stress were the important distinguishing variables (Adj es). Another core aspect of this profile is that relationships with others and the environment are more difficult (COP, AG; (H:(H)+Hd+(Hd)), and more tense. There is a restriction in these children’s ability to focus, as they have low involvement, less conventionality (P), less flexibility (a:p), and low awareness of themselves and others (S-). Distur­bance of thought also plays a key role (M-), with higher susceptibility to the envi­ronment due to a lack of self-organization (DQv).

Children in the Antisocial (AS) group had a greater deficit of resources for positive relationships, and a lack of resources to deal with stress (EA), like coping skills; in this sense they registered intrinsic stress (Adj es). This group also revealed a deficit in organizing internal information, difficulty in verbally expressing emo­tions and feelings (C’), cognitive rigidity (a:p), a tendency to use a great deal of fantasy in representation of others ((H)+(Hd):(A)+(Ad)), and to a global approach to the world (W). Another set of characteristics of this group related to the bias in self-representation, because greater egotism was present, less disposition for self-analysis (FD), and lower expectations about their own resources (EA).

Discussion

The findings in this study allow a glimpse into hypothetical scenarios of the dy­namic structure of personality profiles, namely the relation to one’s self, others, and the world within a specific, unique, and singular Eigenwelt. The predominance of problems of self-control, precipitate judgment, and overlapping conscious emo­tions characteristic of the Hyperkinetic profile involved more motor and affective features needing rehabilitation of the ability to control and plan action with im­portant psychomotor characteristics. Neuropsychological rehabilitation, or even working with play therapy with a focus on shared attention, will introduce the regulation of alternating communication through joint action (Leal, 2010).

The Oppositional Defiant profile showed less self-confidence, less trust in oth­ers, higher pessimism and loneliness, low resources and expectations, and rather tense relationships. This showed a need for self-awareness through knowing the other. Rehabilitation should be centered in more dialogue, and the experienced “other” should function as a vehicle for consensual meaning, by putting together, naming, and referencing the process.

The Antisocial profile registered a lack of resources to deal with stress, difficulty in expressing emotions and feelings, and egotism. The interpretation of this profile provides us with a need for feeling the other, knowing that the other exists, and finding the limits in one’s self. Confrontation, a work routine, and clear boundary setting are needed in therapy.

In clinical practice, hyperactivity can often be a behavior pattern intersect­ing all three profiles. Aggression is also a behavior that can often be manifest in all of the profiles. Differential diagnosis is essential when dealing with these syndromes, and specific considerations regarding treatment need to be made if serious work is to be pursued (Solovieva & Quintanar, 2015). Finally, an im­portant aspect of the Oppositional Defiant and Antisocial profiles concerns the underlying intentionality behind the behavior. Both can be seen as defiant pat­terns of behavior, but while Oppositional Defiant types manifest reactive and non-intentional aggression, Antisocial types present instrumental and inten­tional aggression.

Conclusion and future directions

With these findings, one can further develop Leal’s (1988) proposed psychopatho­logical system based on the Genetic Affectology theory that presents seven stages of socio-emotional development. To some extent this rationale also has points of similarity with Elkonin’s leading activity concept (Quintino-Aires, 2014).

Quintino-Aires (2014) argues:

“Steps of Genetic Affectology”, by Maria Rita Mendes Leal, serve as the “grammar,” morphology and syntax of personality that allow us to listen/read with sense the pho­nemes produced by the patient, which are then the symptoms expressed in actions and speech. (p. 42)

This exploratory study with groups of children with behavior problems is an example of how syndrome analysis can be used. But further research with larger samples and quasi-experimental designs could help diagnosis and provide guide­lines for making clinical psychological prognoses and suggesting therapeutic plans for each particular client. Further research could also have a focus on testing pa­rental and school environment variables in longitudinal studies and revisit the way ADHD is approached, considering the historical and cultural influence on mean­ings when diagnosing and treating difficult children.

Acknowledgements

The authors would like to acknowledge the staff of the Quintino-Aires Institute, particularly the support and help of two clinical psychologists, Susana Pereira and Patrícia Medeiros, in choosing the study group.

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