Patient Prefer Adherence. 2013 Jun 20;7:595-605.
Perceptions of diabetes obtained through drawing in childhood and adolescence.
Isla Pera P, Palacin Lois M, López Matheu C, Honrubia Pérez M, Gómez Rodriguez AM, Armengol Camps E, Sanchez Villalba C, Insa Soria R, Rigol Cuadra A, Marre D.
Nursing School, University of Barcelona, Barcelona, Spain.
Objective: To examine whether drawing is useful in the detection of problems of psychosocial adaptation in children and adolescents with type 1 diabetes (T1D) and in improving communication with health professionals.
Methods: Exploratory descriptive study in 199 children and adolescents with T1D aged 4–13 years. The variables analyzed were related to the drawing and to clinical and sociodemographic data.
Results: Most participants showed evidence of having a well-balanced personality, but there were also signs of affective or psychosocial difficulties.
Conclusion: Drawing is a useful technique by which to identify children’s and adolescents’ feelings and possible problems in adapting to T1D, as well as to gain information directly from the children themselves.
Keywords: type 1 diabetes mellitus, childhood and adolescence, drawing, psychosocial factors
Children and adolescents with T1D have to tolerate insulin therapy, blood glucose measurement, dietary control, medical visits, and the threat of acute or chronic complications. Numerous studies have identified mental health disturbances in children and adolescents with T1D and their families.Since the 1980s, research into the possible value of drawings as a tool by which to evaluate emotional difficulties has grown. Drawing is also useful in encouraging communication between the child and the health team when relationships are strained by stress and the strong feelings provoked by diagnosis or treatment.
The general aim of this study was to examine whether drawing is useful in detecting problems of psychosocial adaptation in children and adolescents with T1D. Secondary objectives were to determine whether there is a relationship between their drawings and their clinical and sociodemographic variables.
We performed an observational, cross-sectional, exploratory study. Participants were 199 children and adolescents aged between 4 and 13 years with a diagnosis of T1D. To facilitate trust, the person asking the child to produce the drawing was a nurse, who suggested the theme of “diabetes and me” and they were given 30 minutes to complete the drawing. After, the children were asked to talk about their drawings, and their explanations were transcribed literally.
To analyze the drawings, the variables selected as being the most representative were color, stroke, size, and symmetry. In addition, to increase the validity of the study, drawings were classified by their overall impression in relation to their content and structure (joy, sadness, worry, confusion, and self-care); a joint variable for negative emotional indicators (asymmetry, smallness, weak or shaky strokes, and absence of color or only one or two colored strokes) was designed, which grouped drawings into those with no negative emotional indicators, and those with one, two, or three or more of these indicators. Finally, the drawings were grouped into categories according to their theme.
A descriptive analysis was performed of the clinical, sociodemographic, and drawing-related variables. Lastly, a multivariate analysis was performed through simple linear regression. A P-value equal to or less than 0.05 was considered statistically significant.
No significant differences were found by sex, age at disease onset, or current age. HbA1c values were above recommended levels in 61%. Significant differences were found in by age and sex in color (P = 0.032), stroke (P = 0.017), size (P = 0.01), symmetry (P = 0.01), the number of negative emotional indicators (P = 0.009), and themes (P = 0.036); There were no negative emotional indicators in 20.6% of the drawings; one negative indicator in 40.2%; two negative indicators in 31.2%; and three or more negative emotional indicators in 8%. The drawings were grouped in the following thematic categories: suffering (47.7%) (Figure 1); resilience (36.2%) (Figure 2); confusion (8%) (Figure 3); stigma (5%) (Figure 4); and turmoil (3%) (Figure 5). The age range most frequently producing drawings with three or more negative emotional indicators was children aged 10–12 years. HbA1c was directly related to symmetry (P = 0.001) and to the number of negative emotional indicators (P = 0.005). A significant difference was found by the birth order of children with T1D. Younger children with two or more older siblings expressed stronger feelings of stigma (P = 0.037) and sadness (P = 0.42) in their drawings.
Analysis of the drawings and their explanations indicated that most participants had well-balanced personalities with appropriate-for-age objectivity, maturity, self-control, sensitivity and empathy. Some data, nevertheless, could indicate affective or psychosocial difficulties. One-quarter (26.4%) did not include themselves in their drawings, even though the theme of the activity was “diabetes and me,” possibly indicating failure to accept the disease. Importantly, the disproportionately large size of needles and blood drops in many of these drawings indicate the huge impact of these techniques in the participants’ lives. In the present study, in addition to the graphic drawing related variables, analysis of the general impression of the picture was useful as it helped us to consider all the drawing’s dimensions, including the drawer’s age and context.
Although further research is required, drawings and their explanations, in this study, allowed the impact of diabetes on young people and their families to be explored and aided communication with the health team, especially nurses.
In this study, drawings were a useful means by which to capture the emotions and possible difficulties in adapting to T1D, as well as to obtain information directly from the participants themselves. A potential pitfall is interpreting drawings from the interpretative framework of the adult; it is important that young people speak about their drawings, since this aids understanding of the drawings and helps the drawer to communicate difficulties to the health team and the family. Finally, the child’s cultural context and age should be considered when interpreting drawings.
- Fritsch SL, Overton MW, Robbins DR. The interface of child mental health and juvenile diabetes mellitus. Pediatr Clin North Am. 2011;58:937–954.
- Whittemore R, Jaser S, Chao A, Jang M, Grey M. Psychological experience of parents of children with type 1 diabetes: a systematic mixed-studies review. Diabetes Educ. 2012;38:562–579.
- Eno L, Elliot C, Woehlke P. Koppitz emotional indicators in the human-figure drawings of children with learning problems. J Spec Educ. 1981;15:459–470.
- Looman WS. A developmental approach to understanding drawings and narratives from children displaced by Hurricane Katrina. J Pediatr Health Care. 2006;20:158–166.
- Rollins JA. Tell me about it: drawing as a communication tool for children with cancer. J Pediatr Oncol Nurs. 2005;22:203–221.
Pilar Isla Pera Ph D.
Nursing School, Campus Universitario Ciencias de la Salut, University of
Barcelona, Feixa Llarga s/n L’Hospitalet de Llobregat 08907, Barcelona, Spain
Tel +34 93 402 4241