Patient Presentation
A 3-year-old male came to clinic for his health supervision visit. He was happy to see his doctor and gave him a picture as well. “See that is you and that is me,” he says proudly pointing out two circles among what appeared to be individual lines and scribbles.

The pertinent physical exam showed a smiling preschooler with normal vital signs and growth parameters around the 50%. His examination was normal. The diagnosis of a healthy male was made. The doctor asked him to tell him more about the picture. “That’s blue and that is green,” he said pointing out correctly some different colored lines. “Thank you for such a lovely drawing with all its pretty colors. I’m glad you made this for me,” the doctor said as the patient and mother smiled.

Discussion
Observing children in the office setting can provide a wealth of information about the skills, development, health and family. While the office setting may have some limitations, much can be gleaned. For example, the picture above or drawings and writing on a whiteboard in the room can offer lots of possibilities for interacting with the child and also for commenting to the parents about the child’s developmental abilities.

Arnold Gesell, MD, PhD. was a developmental pediatrician who studied and codified how children develop and mature over time. As part of his work, he noticed when certain figures are able to be drawn by children and that this had a consistent developmental progression. These figures are often referred to as Gesell figures. Understanding how children develop and those “milestones” form the basis of screenings, evaluations and interventions to help children and families.

Learning Point
Young children are interested in drawing and writing early on, and each figure they learn to draw builds upon their previous skills. Children need opportunities to practice the figures before one can be perfected. For example, children will learn to scribble around 18 months of age. They then will make continuous circle-like drawings before being able to stop the circle once the continuous line is enclosed. Similarly, children will learn to draw a line when about two years old but orienting more than one line, and especially crossing lines, is more difficult so a child is older when they learn to do this.

Spatial orientation also develops over time and is needed for more complex figures such as crosses, squares, triangles and diamonds. The ability to stop when the figure is enclosed (e.g. circle, square, triangle, diamond) also requires practice and maturity.

Using the outlines of the actual numbers can provide one memory aid for remembering how children learn to draw figures. The number represents the age in years when a child usually can draw the figure. Note that there are 2 different styles for the number four. The first shows a cross which is drawn by younger 4 year olds, while the second one shows a square which is drawn by older 4 years olds. Lines are 2 year old activities with the horizontal being drawn first at a younger age and the vertical being drawn as an older 2 year old.

Figure 137 – Ages of children in years with associated figures they are able to draw.

Questions for Further Discussion
1. At what ages does three-dimensional awareness and drawing occur?
2. What is the Goodenough-Harris test?
3. What are indications for referral to an occupational therapist? A review can be found here

Related Cases

Disease: Gesell Figures | Child Development | Infant and Toddler Development

Symptom/Presentation: Health Maintenance and Disease Prevention

Specialty:
Developmental Disabilities | General Pediatrics | Occupational Therapy

Age: Preschooler

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for these topics: Child Development and Toddler Development.

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Arnold Gesell. In: Wikipedia. ; 2023. Accessed November 21, 2023. https://en.wikipedia.org/w/index.php?title=Arnold_Gesell&oldid=1180399578

Gesell Theory. Gesell Program in Early Childhood. Accessed November 21, 2023. https://www.gesell-yale.org/pages/gesell-theory

Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa