F1000Research F1000Research 2046-1402 F1000 Research Limited London, UK 10.12688/f1000research.168814.1 Systematic Review Articles Evaluation of the Bender Visual-Motor Gestalt Test in young subjects: a systematic review

[version 1; peer review: awaiting peer review]

 Lafhal Hicham Conceptualization Data Curation Formal Analysis Investigation Methodology Project Administration Resources Software Supervision Validation Visualization Writing – Original Draft Preparation Writing – Review & Editing https://orcid.org/0009-0006-4245-7043 a 1 2 3 Ahami Ahmed Omar Touhami Conceptualization Data Curation Formal Analysis Investigation Methodology Project Administration Supervision Validation Visualization Writing – Original Draft Preparation Writing – Review & Editing b 1 Goutou Siham Conceptualization Investigation Methodology Resources Software Supervision Visualization Writing – Original Draft Preparation Writing – Review & Editing c 4 Rochdi Atmane Conceptualization Data Curation Formal Analysis Investigation Methodology Project Administration Resources Supervision Validation Visualization Writing – Original Draft Preparation Writing – Review & Editing d 2 Biology, Ibn Tofail University Kenitra Faculty of Sciences, Kenitra, Gharb-Chrarda-Beni Hssen, Morocco Laboratory of Natural Resources and Sustainable Development, Ibn Tofail University Kenitra Faculty of Sciences, Kenitra, Gharb-Chrarda-Beni Hssen, Morocco Rehabilitation, Instituts Supérieurs des Professions Infirmières et Techniques de Sante, Rabat, Rabat-Sale-Zemmour-Zaer, Morocco Continuing Education, children's hospital, Centre Hospitalo-Universitaire Ibn Sina, Rabat, Rabat-Sale-Zemmour-Zaer, Morocco hicham.lafhal@uit.ac.ma ahami_40@yahoo.fr Siham_goutou@hotmail.com atmane.rochdi@uit.ac.ma

No competing interests were disclosed.

 2 9 2025 2025 14 848 22 8 2025 Copyright: © 2025 Lafhal H et al. 2025 This is an open access article distributed under the terms of the Creative Commons Attribution Licence, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Introduction

The Bender Visual-Motor Gestalt Test (BGT) is a widely used tool for assessing visual-motor skills in children. However, its use remains controversial due to persistent questions about its validity and specificity, particularly in screening for neurodevelopmental disorders. This systematic review aims to analyze studies published between 2014 and 2024 that have used the BGT in young subjects, in order to assess its clinical and psychometric relevance in this population.

 Methods

A systematic search was conducted according to PRISMA 2020 guidelines in the PubMed, Embase and Scielo databases, targeting publications between 2014 and 2024. Seventeen studies meeting the inclusion criteria were selected. Their methodological quality was assessed using the Jadad, Newcastle-Ottawa and AMSTAR 2 scales.

 Results

The BGT is used in a variety of contexts (neurodevelopmental disorders, learning disabilities, environmental exposure, etc.). It is useful for initial screening, although its diagnostic sensitivity varies between populations. Some studies integrate the BGT into combined batteries or exploit innovative technological approaches. Results suggest a correlation between age, pubertal development and visuo-motor performance, but gender-related differences remain poorly documented.

 Discussion

The BGT remains a relevant tool for assessing visuomotor function in children, especially when used in a multidimensional framework. Its lack of diagnostic specificity and the heterogeneity of the studies nevertheless highlight the need for further research, particularly longitudinal and normative.

 Bender-Gestalt test Visuomotor assessment Child Neuropsychology Developmental disorders The author(s) declared that no grants were involved in supporting this work. Introduction

Visual-motor, or perceptual-motor, development is an essential component of early neuropsychological function. It refers to the coordinated integration between perceived visual information and executed motor responses, notably in graphic reproduction or hand-eye coordination tasks. These skills are at the heart of fundamental learning, such as reading, writing and mathematical reasoning. 1 Their assessment is therefore of particular importance in screening for neurodevelopmental disorders and difficulties at school.

The Bender Visual-Motor Gestalt Test (BGT), designed by Lauretta Bender in 1938, is one of the most widely used tools for this purpose, and is frequently used by school and clinical psychologists. 2 This test asks children to reproduce a series of standardized geometric figures, enabling observation of perceptual-motor abilities, spatial organization, motor planning and sustained attention. Even in the early decades of its use, authors such as Kitay (1972) emphasized its unique clinical benefits in identifying neurological deficits or atypical cognitive styles. 3 However, Keogh (1969) showed that, while the BGT could globally distinguish atypical from normal children, overlaps between groups limited its individual predictive validity. 4

The BGT was originally conceived as a measure of perceptual-motor maturity, which was assumed to be reached around the age of 11. Since then, numerous studies have confirmed that test performance evolves with age and is generally less influenced by cultural factors than other cognitive tests. 5, 6 This explains its widespread use in children, but also its occasional use in adolescents and adults, particularly in cases of neurological, psychiatric or learning disorders. 7, 8

The use of BGT in contemporary clinical contexts has also been enriched by new perspectives. It is now combined with other psychometric tools or mobilized in innovative technological approaches, including artificial intelligence for automated analysis of graphic productions. Yet, despite this expansion, uncertainties persist as to its sensitivity and specificity for different child profiles, and its discriminative value remains open to debate.

In this context, the present systematic review aims to synthesize the scientific knowledge produced between 2014 and 2024 concerning the use of BGT in young subjects aged 3 to 15. The objectives are to identify the contexts in which the test has been used in clinical, educational or experimental settings, to assess the methodological quality and specific contributions of the studies reviewed, and to identify the current limitations of the tool and prospects for future research in neuropsychological assessment.

 Materials and methods Study design

This study is based on a systematic review conducted according to the PRISMA 2020 (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) recommendations, 9 with the aim of identifying and analyzing studies using the Bender Visual-Motor Gestalt Test (BGT) to assess visual-motor skills in children aged 3 to 15.

 Search strategy

A systematic search was conducted in three electronic databases: PubMed (Medline), Embase and Scielo. The search period covered publications between January 2014 and April 2024. Keywords were selected from the MeSH thesaurus and included: “Bender Visual-Motor Gestalt Test”, “Bender Test”, “Bender Gestalt Visuomotor Test”, and “Visual-Motor Performance Test”. These descriptors were combined with the Boolean operators AND, OR, and NOT to optimize the relevance of the results.

 Inclusion and exclusion criteria

Studies were included if they met the following criteria:

Published between 2014 and 2024, with no language restrictions;

Target population: children aged 3 to 15;

Use of the BGT as a primary or complementary tool for assessing motor skills;

Quantitative, qualitative, observational, experimental studies or systematic reviews.

Excluded:

Publications without full text available;

Studies in which the role of the BGT in the assessment was not clearly defined;

Conference abstracts without an associated full-text article.

Study selection

After eliminating duplicates, titles and abstracts were reviewed independently by two reviewers. Potentially eligible articles were then read in full text to confirm their inclusion. Discrepancies were resolved by consensus.

 Assessment of methodological quality

The quality of the selected studies was assessed using validated tools adapted to the type of study:

Jadad scale for randomized clinical trials. 10

Newcastle-Ottawa scale for observational studies. 11

AMSTAR 2 for systematic reviews and meta-analyses. 12

Data extraction and analysis

A standardized extraction table was used to collect the following information: author’s name, year of publication, study type, objectives, study population, psychometric tools used, main results and conclusions. A second table was drawn up to summarize the methodological characteristics of the studies and assess their relevance, the rigor of the methodology, and the robustness of the conclusions.

 Results

Our study highlighted a scarcity of publications, between 2014 and 2024, on the role of the Bender Visual-Motor Gestalt Test in assessing visuomotor and psychometric skills in young people aged 3 to 15, in a variety of contexts.

In fact, only 40 articles were retrieved by the electronic search. After reviewing the various abstracts and reading the full texts, 17 articles were deemed eligible, meeting our inclusion criteria ( Figure 1).

Flow chart of study selection process and results. Evaluation of studies included in the review. Compilation personnelle des auteurs (Lafhal et al., 2024).
Author/Year Type of study Relevance to this study Clearly stated objectives Appropriate study method Sample Consideration of confounding factors and biases Validation of questions Understandable tables/figures Conclusions supported by results
Orak, Sibğatullah Ali (2024) 13 Prospective observational comparative study Yes Yes Yes Yes No Yes Yes Yes
AKIL, Mustafa (2024) 14 Comparative experimental study Yes Yes Yes Yes No Yes Yes Yes
Ahmadsaraei (2024) 15 Comparative experimental study Yes Yes Yes Yes Yes Yes Yes Yes
Shivangi Sharma, 2022 16 Observational study Yes Yes Yes Yes Yes Yes No Yes
Sarah mufti 2021 17 Comparative cross-sectional study Yes Yes Yes Yes Yes Yes Yes Yes
Tafti, Mahnaz Akhavan, 2021 18 Cross-sectional comparative study Yes Yes Yes Yes Yes Yes Yes Yes
Barbora Blazkova, 2020 19 Cross-sectional study Yes Yes Yes Yes Yes Yes Yes Yes
KILIÇ, Ayben 2020 20 Comparative pilot study Yes Yes Yes Yes Yes Yes Yes Yes
Saniee, S, 2019 21 Quasi- experimental study Yes Yes Yes Yes No Yes Yes Yes
Kyung Hyun Kim, 2019 22 Retrospective observational study Yes Yes Yes Yes Yes Yes Yes Yes
Strait, Julia, 2019 23 Psychometric study Yes Yes Yes Yes Yes Yes Yes Yes
Patrícia Cunha, 2019 24 Analytical observational study Yes Yes Yes Yes Yes Yes Yes Yes
Lívia de Freitas Keppeke, 2018 25 Correlational study Yes Yes Yes Yes No Yes Yes Yes
Mukherjee, Soumava, 2018 26 Observational, correlational, exploratory study Yes Yes Yes Yes Yes Yes Yes Yes
Bildiren, Ahmet, 2017 27 Psychometric study Yes Yes Yes Yes No Yes Yes Yes
Lamônica, Dionísi, 2016 28 Case study Yes Yes Yes Yes Yes Yes Yes Yes
Vasanthi Done 2016 29 Comparative observational cohort Yes Yes Yes Yes Yes Yes Yes Yes
Comparison of characteristics and results of the studies included in the review. Compilation personnelle des auteurs (Lafhal et al., 2024).

Table 2: presents the main characteristics of the included studies, detailing the types of research, assessment tools mobilized, objectives pursued, and populations studied. It reflects the diversity of contexts in which the Bender test is used, from neurodevelopmental disorders to targeted cognitive assessments. This summary highlights the wealth of clinical and experimental applications of the BGT.

Author/Year Type of study Assessment scale Scale Score Study objective Study population Parameters analyzed Means of assessment
ORAK, Sibğatullah Ali 2024 13 Prospective comparative observational study

WISC-R

SCWT

BGT

EEG

Significantly lower verbal and total IQ in SeLECTS group vs. ADHD group

SCWT: completion time significantly longer in SeLECTS + ADHD group vs. SeLECTS alone or ADHD alone

No significant difference in Bender test between groups

Verbal IQ below norm in both SeLECTS and SeLECTS + ADHD groups

Examine the prevalence of ADHD in children with SeLECTS and vice versa, as well as correlations between electroclinical, neurocognitive and comorbidity parameters, via psychometric and electrophysiological tests

Children aged 7 to 13

Groups: SeLECTS, SeLECTS + ADHD, and ADHD (exact numbers not specified, but n=11 for SeLECTS + ADHD)

Verbal IQ, performance IQ, total IQ

Sustained attention (SCWT)

Visual-motor distortions (Bender test)

Epileptiform activity (EEG)

ADHD/epilepsy comorbidity rate

Standardized psychometric tests: WISC-R, SCWT, Bender Gestalt (SeLECTS only)

EEG for identification of epileptiform activity

Intergroup statistical comparisons (p < 0.05 for significance thresholds)

AKIL, Mustafa 2024 14 Comparative experimental study

Bender- Gestalt test

Attention test

Improved scores in visuo-motor integration and selective attention in both groups, but with a higher gain in the cooperative learning group To evaluate the effect of a physical education program incorporating fundamental motor skills using a cooperative learning method on children's cognitive health (visuo-motor integration and attention) 60 boys aged 10 to 11 divided into two groups:

classic method group (mean age: 10.95 ± 0.58 years)

Cooperative learning group (mean age: 10.91 ± 0.42 years)

Visual-motor integration

Selective attention Intra- and inter-group comparison

8-week physical education program (40 min/3 days/week)

Tests administered before and after:Bender-Gestalt, d2 test - Intra- and inter- group statistical analysis

Ahmad saraei. 2024 15 Comparative experimental study Bender Gestalt test Accuracy rate obtained by the models:

MYOLO v5: highest accuracy

MResNet 50: slightly lower accuracy

Compare the performance of two deep learning models (MYOLO v5 vs. MResNet 50) in automatically detecting patterns in children's psychological drawings from the Bender-Gestalt test 386 Bender-Gestalt drawings of children aged 4 to 11; available metadata: age, gender, family composition, psychological evaluation, etc.

Pattern classification accuracy

Comparative performance of the two deep learning architectures

Analysis on pre-processed and semi-automatically annotated images

Deep learning algorithms : MYOLO v5 and MResNet 50

OBGET dataset for children (C-OBGET )

Preprocessing, semi-automatic labeling and deployment of models for comparison

Shivangi Sharma 2022 16 Observational study

Pulse oximeter

Bender Visual Motor Gestalt Test

Electric pulp tester

Physiological, psychomotor and analgesic changes Evaluate changes in physiological, psychomotor and analgesic parameters during nitrous oxide (N 2O) titration in children aged 3-12 years 100 children aged 3 to 12 Oxygen saturation, heart rate, pain and psychomotor performance Oximeter, Bender Visual-Motor Gestalt Test, electric pulpometer test
Sarah mufti 2021 17 Comparative cross-sectional study

Bender Gestalt Test II

 Subtest scores (copy, recall, perceptual, motor) with significant difference in recall test To study neuropsychological functioning in children with and without specific learning disabilities 116 children aged 8 Memory function, with comparison of recall scores between the two groups Bender Gestalt Test II (copy, recall, perceptual and motor test subscales), SPSS 21 analysis
TAFTI, Mahnaz Akhavan. 2021 18 Cross-sectional comparative study

FEATS

BGT

WISC-IV

PPAT

4 FEATS subscales: integration, realism, perseverance, rotation

-Bender-Gestalt: distortion, disintegration, perseverance, rotation

To compare the diagnostic power of the FEATS test and the Bender-Gestalt test in identifying specific learning disabilities (SLD) in students 80 primary school pupils aged 7 to 11 (40 with SLI, 40 without SLI), matched for age, gender and grade. Sample recruited in Iran (Babol SAD center and public schools)

FEATS and Bender-Gestalt subscale scores

Intergroup differences (TAS vs. non-TAS)

Construct validity between components

PPAT test

FEATS scales (4 subscales)

Bender-Gestalt test

WISC-IV

Statistical analysis: t-test, Pearson correlation, MANOVA

Barbora Blazkova 2020 19 Cross-sectional study

BGT

RCPM

Links between prenatal oxidation and cognitive performance Investigating the impact of PM2.5 particle-related oxidative damage during the prenatal period on children's cognitive development at five years of age 5-year-old children, n = 169, born in 2013 and 2014, living in Karvina (polluted area) and Ceske Budejovice (control area) Prenatal PM2.5 levels, oxidation biomarkers in urine and plasma (8-oxodG, 15- F2t-IsoP), cognitive tests Measurement of PM2.5 levels during the 3rd trimester of pregnancy, cognitive tests (BGT and RCPM)
KILIÇ, Ayben 2020 20 Comparative pilot study

WISC-R

BGTender

Significantly weaker performance subtests: → image completion (p = 0.024), → image arrangement (p = 0.001), → object assembly (p = 0.000)

Significantly weaker verbal subtests:→ similarity (p = 0.021), → judgment (p = 0.048)

Assessing the neuropsychological development of children with primary monosymptomatic nocturnal enuresis using standardized cognitive tests

30 children with primary monosymptomatic nocturnal enuresis

30 matched control children (mean age ≈ 8 years; equal distribution F/H

Verbal and non-verbal reasoning

Perception visuo-motor and integration

Short-term memory, abstract thinking, problem solving

Psychometric assessment with WISC-R (6 verbal subtests and 6 of performance) - Bender Gestalt test
Saniee, S 2019 21 Quasi- experimental study

WCST

BGT

Behavioural Flexibility Rating Scale

Significant improvement:

Cognitive flexibility: Bender (ηp 2 = 0.84), WCST (ηp 2 = 0.87)

Behavioural flexibility (ηp 2 = 0.79)

Repetitive behaviors (ηp 2 = 0.45)

Develop and evaluate a training program (SSIT) aimed at improving cognitive and behavioral flexibility (set- shifting) in children with high-functioning autism 13 children aged 5 to 7 with high- functioning autism spectrum disorder (HFA)

Cognitive flexibility

Behavioral flexibility

Repetitive behaviors

Effects maintained at 6 weeks

SSIT program including:

→ A puzzle-type computer game (Tatka)

→ Home tasks for generalization

Assessments before, after and at 6 weeks post-intervention

Kyung Hyun Kim 2019 22 Observational study

WISC-R

(Korean version): Total IQ (FSIQ), Verbal IQ (VIQ), Performance IQ (PIQ)

BGT

Total IQ: 110.21 → 113.95 (p = 0.307)

VIQ: 108.92 → 111.54 (p = 0.368)

PIQ: 107.88 → 111.04 (p = 0.152)

Block Design: significant improvement (p = 0.021)

Assessing the impact of arachnoid cyst surgery on neurocognitive functioning in children 24 children (19 boys, 5 girls; mean age: 9.4 years) who underwent arachnoid cyst surgery between June 2009 and August 2012 at Seoul National University Children's Hospital

Total, verbal and performance IQ (WISC-R)

Visual-spatial abilities (Bloc Design)

Comparison by laterality of cyst (left/right) Cyst volume (pre- and post- op)

Location (20 temporal, 4 frontal)

Cerebral imaging to measure cystic volume (calculation by area × slice thickness)

Neuropsychological tests (WISC-R, BGT) performed twice by psychologists within one year of surgery

STRAIT, Julia 2019 23 Psychometric study BGT-II Results not quantified in abstract, but show score invariance between ethnic groups To assess the presence of differential item functioning (DIF) according to ethnicity (African-American vs. Caucasian) for children aged 4 to 7 using BG-II visuomotor scores Children aged 4 to 7; two groups : African-American and Caucasian Differential item functioning (DIF) in figure copying tasks (BG-II) DIF analysis (probably by IRT or Mantel-Haenszel, but not specified here) to determine whether test items discriminate equivalently according to ethnicity
Patrícia Cunha 2019 24 Observational study

WISC-R Wechsler - BGT)

APE

APE tests and lower parental education To study the cognitive profiles of children with specific learning disabilities (SLD), with an assessment of auditory processing 34 children with SLD and 15 control children (aged 7-14) Auditory processing, verbal and spatial reasoning, cognitive performance Auditory tests (tone audiometry, acoustic immittance, brainstem evoked response), Wechsler Scale tests, BGT
Livia de Freitas Keppeke 2018 25 Correlational study BGT Raven's Progressive Matrices Test Visuomotor score measured by the Bender Test and analyzed according to Tanner's pubertal stages To study the relationship between visuomotor development and pubertal changes according to Tanner's scale 134 adolescents aged 10 to 15 Visual-motor development and pubertal changes (Tanner stages), Raven's scores, influence of schooling, grade repetition and developmental problems Bender Visual-Motor Gestalt Test, Raven's Progressive Matrices Test, medical data on pubertal maturity
MUKHERJEE, Soumava 2018 26 Observational study

BKT

BGT

Mean IQ: 85.5 (BKT)

Mean BGT score: 8.6

Significant difference in BGT scores according to mutation location (p = 0.005)

IQ significantly lower in case of cumulative loss of Dp427/Dp260/Dp140utr isoforms (p = 0.011)

Determining the impact of DMD gene mutation localization on cognitive and visuomotor performance in children with Duchenne muscular dystrophy

10 Indian boys with DMD

4 to 9 years old

All carriers of genetic deletions identified by MLPA

Correlation between genetic mutation types (and affected dystrophin isoforms) and cognitive scores (IQ, BGT)

MLPA (Multiplex Ligation-dependent Probe Amplification) for mutation localization

Psychometric tests : BKT for general intelligence, BGT for visuomotor functions

BILDIREN, Ahmet. 2017 27 Psychometric study

CPM

BGT

TONI-3

KR-20 for internal consistency: high (exact values not specified)

Spearman-Brown test- retest: high

Significant positive correlations with Bender- Gestalt and TONI-3 (convergent validity)

Standards established in percentiles by age group (3 to 9 years)

To assess the reliability and validity of the colored progressive matrix test as a diagnostic tool for identifying gifted children in the preschool period (ages 3 to 9) 925 children aged 3 to 9 (433 girls, 492 boys) Internal reliability (KR- 20), test-retest reliability (Spearman- Brown), correlations between scores on colored progressive matrices, Bender- Gestalt test and TONI-3 tests, age norms in percentiles Statistical methods of reliability (Kuder Richardson-20, Spearman-Brown), correlation analysis (Pearson product- moment) between different psychometric tests
LAMÔNICA, Dionísi 2016 28 Single descriptive case study

Peabody test

School performance test

Phonological awareness profile

Raven

Wechsler

BGT

Wisconsin Card Sorting Test

Significant psycholinguistic delay

Poor arithmetic and writing skills

Impaired verbal and executive cognitive performance

Limitations in graphic, perceptual-motor and sequential logical organization skills

Describing oral and written language and cognitive skills in a girl with Moyamoya disease after stroke and surgery

A girl aged 7 years and 7 months

Two strokes in left/right temporo- parietal and left frontal regions

Treated surgically by revascularization and medically

Language skills (oral and written)

General cognitive skills (intellectual, visuo-motor, executive, phonological processing)

Various neuropsychological tests (Peabody, Raven, WISC, Bender, Wisconsin)

Clinical observation and family interviews

Vasanthi Done (2016) 29 Comparative observational cohort Bender Visual Motor Gestalt Test II Psychomotor performance assessed with modified version of the Bender Test; results slightly better with midazolam-N 2O than with ketamine-N 2O Comparing the efficacy of oral sedation with Midazolam-N 2O and Ketamine-N 2O in children during dental treatment 30 healthy children (3-9 years) (ASA I & II) requiring multiple dental extractions Physiological measurements (respiratory rate, pulse rate, oxygen saturation), psychomotor performance Physiological measurements (respiratory rate, pulse rate, oxygen saturation) and psychomotor test (Modified Bender Visual Motor Gestalt Test)

WISC-R (Wechsler Intelligence Scale for Children); SCWT (Stroop Colour and Word Test); BGT (Bender Visual Motor Gestalt); EEG (electrophysiology); RCPM (Raven Colored Progressive Matrices); FEATS (Formal Elements Art Therapy Scale); PPAT (Draw a Person Picking an Apple from a Tree); WCST (Wisconsin Card Sorting Test); APE (Auditory Processing Evaluations); CAPD (Central Auditory Processing Tests); BKT (Binet Kamat Intelligence Test); TONI-3 (Test of Nonverbal Intelligence, 3rd edition).

The quality assessment of the selected studies is presented in Table.

 Discussion

The main aim of this systematic review was to evaluate the use of the Bender Visual-Motor Gestalt Test (BGT) in the identification of visual-motor skills in young subjects, exploring the diversity of clinical, educational and experimental contexts. Results reveal that, while the BGT remains widely used between 2014 and 2024, its use has diversified and become integrated into increasingly complex research protocols, including cognitive, psychometric and neurodevelopmental analyses.

Variability of applications and diagnostic sensitivity

The included studies show that the BGT is frequently mobilized to detect deficits in special-needs groups: autism spectrum disorders, 21 specific learning disabilities 17, 18 ; nocturnal enuresis, 20 and even in the context of rare neurological disorders such as Duchenne muscular dystrophy. 26 Tafti’s (2021) study highlights the complementarity between the BGT and other instruments such as the FEATS and WISC-IV, underlining its usefulness as a screening tool integrated into a multidimensional assessment battery. 18

However, the sensitivity of the test to detect specific disorders remains variable. Orak’s study (2024), for example, showed no significant differences in BGT scores between children with epilepsy (SeLECTS), ADHD or comorbid conditions, despite notable differences in other tests (verbal IQ, sustained attention). This suggests that the BGT, although useful for certain developmental profiles, may lack specificity in complex clinical pictures involving several cognitive impairments. 13

Influence of age and development

As Decker (2008) argues, visuomotor skills become more refined with age, and this is confirmed by several studies reviewed here. 6 Keppeke’s (2018) study, for example, relates BGT scores to pubertal stages according to the Tanner scale, demonstrating an association between biological maturation and visuo-motor performance. 25 Other studies support this trend, notably those showing progressive improvement through adolescence, followed by stabilization or decline in adulthood. 6, 30

Effects of school environment and neurodevelopmental disorders

Concerning the school context, studies by Blazkova (2020) and Cunha (2019) provide relevant evidence of an impact of the level of prenatal exposure to environmental factors (pollution, family conditions) on BGT scores. 19– 24 This corroborates Romi’s (2005) work on the link between school difficulties and poor visuo-motor skills. 5

Finally, children with neurodevelopmental disorders such as high-functioning autism 21 and ADHD 6 consistently perform less well on the BGT, supporting its value in the initial screening and monitoring of atypical developmental trajectories.

 Technological and innovative perspectives

One of the innovative contributions listed in this review is that of Ahmadsaraei (2024), who demonstrates the applicability of BGT in the field of artificial intelligence for the automated analysis of visuo-motor figures. 15 This opens up interesting clinical prospects for low-resource countries or structures requiring mass screening.

 Limitations of included studies

The majority of included studies present moderate sample sizes, often centered on a single geographic region, which limits generalizability. Furthermore, although several studies use the BGT in a combined approach with other tests (WISC-R, Raven, etc.), few rely on longitudinal measures or robust long-term experimental designs. What’s more, the heterogeneity of the test versions used (original BGT, BGT II, modified BGT) makes direct comparison of results difficult.

 Clinical implications

Despite certain methodological limitations, the data collected in this review confirm the value of the BGT as an initial screening tool, particularly in pediatric neuropsychological assessments. It is particularly useful for identifying perceptual- motor deficits in children with neurodevelopmental disorders or academic difficulties. Its integration into multi-tool assessment batteries is recommended to compensate for its lack of isolated specificity.

 Conclusion

This systematic review confirms that the Bender Visual-Motor Gestalt Test (BGT) remains a frequently used tool for assessing visuo-motor skills in children and adolescents, particularly in the context of neurodevelopmental disorders, learning disabilities and neurological impairment. The studies reviewed show that, although the BGT can identify certain perceptual-motor deficits, its diagnostic sensitivity remains uneven across clinical contexts, particularly in the presence of comorbidities or complex disorders.

Integrating the BGT into multidimensional assessment batteries seems to enhance its clinical value, especially when combined with tools such as the WISC, Raven or innovative psychometric approaches. Work exploring the use of the BGT in the context of artificial intelligence also highlights its potential for large-scale automated screening. Nevertheless, the diversity of test versions used, limited sample sizes and lack of robust longitudinal data hamper the comparability of results and limit generalizable conclusions.

With this in mind, future normative and longitudinal research is needed to strengthen the validity and specificity of the BGT, particularly in a variety of educational and clinical contexts, and for different developmental age ranges.

Ethical approval statement

This systematic review did not require the collection of primary data or research involving human or animal participants; therefore, formal ethical approval was not required. All sources included in the review are publicly available and have been properly cited in accordance with academic standards.

 Informed consent statement

Since this research is a systematic review based on previously published studies and does not involve the direct participation of individuals, informed consent was not required.

 Patient consent for publication

Patient consent for publication was not required, as no individual patient data or identifiable information was included in this systematic review.

 Reporting guidelines

The PRISMA-related documents for this systematic review (completed PRISMA 2020 checklist and study selection flow diagram) are available in the Zenodo repository:

Title: PRISMA 2020 Checklist and Flow Diagram – Bender-Gestalt Visual-Motor Test in Young Subjects

DOI: https://doi.org/10.5281/zenodo.16738145 31

License: CC0 1.0 Universal (Public Domain Dedication)

 Data availability statement

The data used in this systematic review are derived exclusively from publicly available publications. All sources of information have been appropriately cited. No original data sets were generated or analyzed specifically for this study.

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