Clinical Assessment of the child: Does drawing help children to

talk about their presenting problems?

Research for Master of Health Science: Endorsed in mental health.

Authors; Woolford J., Patterson. T., and Hayne. H..

June ‘Junie’ WoolfordChild and Family Therapist

CAFMHS Dunedin

1.Adverse effects on

development

2.Enduring effects if not addressed.Homotypic/hetrotypic

4.Societal impactLoss of human capitol

(WHO, 2009)

3.Youth issues-

social disengagement

A potential sequence of child psychopathology.

Intervention

• Intervention has the potential to remediate psychopathology.

• Child mental health intervention via specialist services required.

• Cornerstone of therapeutic intervention is a comprehensive assessment.

Clinical assessment of the child.

Historical perspective of clinical assessment for children

• Children subject to physical parameters and behavioral observations.

• Adults as main source of information to clinicians.

• Contemporary Policy demands that services are delivered in a developmentally sensitive way (MOH, 1997).

• In addition it is essential that the child’s voice is heard directly ( UNCRC,1993 NZ).

Now…..

Why hear the child’s voiced directly?

There are a number of reasons…

• “Weak agreement” between parents and children respondents in clinical context (Rutter, 1997; Hawley et al, 2003).

• Parents subject to cognitive dissonance effects

• Parents more inclined to report on externalizing behaviors- related to parenting burden.

• Children more inclined to report on internalizing experiences. Psychological processes are not always easily observable to third parties.

Are children competent enough to self report?

Cognition

Verbal communication

Socio emotional

The challenge for child mental health practitioners.

• To support children to communicate To support children to communicate accurately in clinical interview settings.accurately in clinical interview settings.

• To elicit accurate information - vital to To elicit accurate information - vital to diagnosis and treatment.diagnosis and treatment.

Is drawing a developmentally sensitive Is drawing a developmentally sensitive tool for assessment?tool for assessment?

• Normative developmental stages for drawing.

• Popular with clinicians

• Significant history – focus on what was drawn. Contentious issues about validity and reliability.

A contemporary research paradigm ‘Draw and tell' :

• In the last 2 decades the focus has shifted from:

Child draws Child tells.

• Draw and tell focuses on the child’s narrative.

Hayne and colleagues

• Pioneers in draw and tell research

• Hayne and colleagues have established a series of studies on draw and tell.

Gross and Hayne (1998)Drawing Facilitates Children’s Verbal Reports of

Emotionally Laden Events.

• 40 Children aged 3-6 years of age.

• Children invited to draw and tell or tell about times they had felt happy, sad, scared.

Hayne et al: The draw and tell prototype.

• Children randomly assigned to either a draw or tell interview condition.

• Interviewers use open ended prompts i.e. can you draw and tell (or tell) me about a time when you were …. [happy, sad, angry].

• Interviewers also used follow up prompts. i.e., Is there anything else you can draw and tell about the fight?

• Interviewers also used minimal encouragers, such as…

wow Encouragers e.g. good job

paraphrases

• Interviews are transcribed and the text is broken down into ‘clauses’.

• Total clauses per interview calculated.

Results: Children in draw condition provided almost twice the amount of information regarding emotionally laden events.

• Fire station visit for children aged 5 and 6 years of age.

• Children interviewed at I day and 6 months later.

• Children in the draw condition reported more information.

• No effect on accuracy, with or without temporal delay.

Gross and Hayne (1999)

Drawing facilitates Children’s Verbal Reports After

Long Delays.

Gross, Hayne and Drury (2008) Drawing Facilitates Children’s Reports of Factual

and Narrative Information: Implications for educational contexts.

• Children five and six years of age.

• Museum visit followed by an Interview at 1 or 2 days or 7 months after visit.

• Children in draw condition provide more narrative and factual information during interview at 1 or 2 days.

• Children who drew gave more narrative information at seven month delay interview.

Patterson and Hayne (2009)Does Drawing facilitate older children’s reports of

Emotionally laden events?

• 90 children aged 5 -12 years of age.

• Children invited to draw and tell or tell about a time they had felt happy, sad or scared.

• Children in draw condition reported twice as much information with no effect on accuracy.

• Interviewers used more open or minimal encourager prompts in the draw condition.

Potential Mechanisms

Hypotheses regarding efficacy-

• cognitive• communicative• social support

Consideration of these developmental areas are vital for child consumers.

Does ‘draw and tell’ have a place in the clinical setting?

• Would the use of drawing increase the amount of information yielded from child interviews in a clinical setting?

• No current, existing empirical evidence assessing the use of drawing in the clinical setting.

The questions we asked….

• Does drawing help children talk about their presenting problems?

• Subjective views of child consumers?

-Do children prefer to draw in clinical settings?

-Did children perceive that drawing made the task of talking about their presenting problems easier?

• Is the interviewer behavior different in draw and tell interviews ?

• 33 children, 5-12 years of age were recruited to participate.

• The participants were recruited from four child mental health facilities in Dunedin/Otago region.

The current study:

Procedure as per. Hayne et. al.

Children were randomly assigned to one of two experimental conditions

Tellonly

Draw and tell

Consent sought from children and their caregivers.

• The child interview – embedded in the initial assessment

• Typical assessment protocol was followed during first visit.

• Background data, e.g., school, health, family.

• Some rapport building follows…hobbies, friends, sports etc

The experimental phase: establishing the Presenting

problem (PP).

Do you know why you have come here to see me today?

Yes - Name PP No – Prompt

No- Direct prompt. “I heard that you came along here today because… (PP)”.

Establish and give a name to the presenting problem.

Interview protocol for draw and tell conditions.

1. Open ended free recall, “ Can you draw and tell (or tell) everything you can about .e.g. Sadness?”

2. Direct Prompts. “ You said you don’t go to club anymore, can you draw and tell me more about that?”

3. Encouragers, reflections and minimal responses. “ Wow” , “That sounds tricky” or paraphrases.

4. Are there any other problems that you could draw / tell me about?

5. Repeat question protocol until no further information supplied.

Question Sheet 1.

• Telling me about (Presenting problem PP) is very important. There are two ways of telling me about (______PP____________)

• You can talk to tell me about PP

• You can draw to tell me about PP

• Which one would you rather do when telling about PP?

Question Sheet 2.

• How easy was it for you to tell me about ( PP )?

• Not easy • Very Easy

• Easy

Additional data

Question Sheets • Answers were categorized.

Demographic data collected.• Age• Medication status• Presenting problem• Diagnosis• Ethnicity

Coding protocol

• Transcribed interviews • Coded into clauses• Clinically relevant information i.e.

- About PP - Multi axial information.

• The interviewer prompts were identified and coded.

Results

No association between:

• Age• Interviewer• Gender • Presenting problem

… and the amount of information reported.

Data was collapsed across age, interviewer and gender

Does drawing help children to talk about their presenting problems?

Figure 1. Mean number of clauses (with SE bars) for each experimental condition.

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Tell Draw

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Did the interviewer behavior differ between the draw and tell

conditions?

Interviewer behaviour.

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Open Closed Leading MRE

Prompt Type

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Tell

Draw

The subjective views of children in a clinical setting.

Did children say they would prefer to draw?

Question Sheet 1.

• Telling me about (Presenting problem PP) is very important. There are two ways of telling me about (______PP____________)

• You can talk to tell me about PP

• You can draw to tell me about PP

• Which one would you rather do when telling about PP?

• 53% of children said they would prefer to draw.

• 47% of children said they would prefer to tell only.

• There was no association between the experimental condition the children had been in and their stated preference.

We also wanted to know…

Did children perceive that drawing made the task of reporting easier?

Question Sheet 2.

• How easy was it for you to tell me about ( PP )?

• Not easy • Very Easy

• Easy

• 48% of children reported the task of reporting their presenting problems to be ‘easy/very easy’.

• 52%of the children reported the task of reporting their presenting problems to be ‘not easy’.

• There was no association between the experimental condition the children had been in and their perception of how easy the task was.

Discussion.

• Drawing increases the amount of clinically-relevant information that children report about their presenting problems.

Means: Draw = 99.73 clauses Tell = 50.93 clauses

No findings to suggest children prefer to draw or perceive it to make reporting easier.

Despite this, children provided more clinically relevant information when they

were able to draw.

• Drawing is not associated with any undesirable interviewer prompting.

• In fact…..Interviewers in the draw condition used more Minimal responses and encouragers.

• Drawing is associated with desirable use of interviewer prompting.

Interviewer behaviour.

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Open Closed Leading MRE

Prompt Type

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Tell

Draw

Implications:

1. Draw and tell interviews can be a useful tool in clinical assessment of child.

2. Children provide more, information when they are able to draw.

3. The information they provided was clinically relevant.

4. Interviewers use more, desirable prompts in draw interviews.

Acknowledged with thanks….

The children and families, the centres and the interviewers who took part and

supported this study.

Otago District Health Board

• Award for research project initiative

Discussion