How to Communicate and Understand Children’s Worlds

By

Dr Shehu Sale BMBCh (Jos), FMCPsych, Cert Child Psychiatry SA (subspecialty), MPhil (Child and Adolescent Psychiatry) UCT

Department of Psychiatry, Bayero University, Kano/ Aminu Kano Teaching Hospital, Kano, Kano State, Nigeria.

OUTLINE:

1. Introduction

2. Communicating with children

3. Understanding children’s worlds through interpretation of their drawings and plays

4. Case presentation

INTRODUCTION:

CHILDREN AND ADULTS- DIFFERENCES

Children differ from adults in cognitive,

social and physical developments

They have limited capacity for

processing information

They are developing self-concept and

body image

They cannot separate effort from ability

INTRODUCTION CTD….

Children are not little adults (W.H.O. July 2008)

“Children are human beings to whom respect is due, superior to us by reason of innocence and greater possibility of their future”

“When dealing with children there is greater need for observing than of probing” (Maria Montessori)

2. Communicating with children

DEFINITION

Communication is a two-way process. It involves:

Trying to understand the thoughts and feelings the other person is expressing

Responding in a way that is helpful

Cultural Differences – Avoid ethnocentrism

Be a good listener

Communication is an act

The same information obtained from the adults can be gotten from children

Psychiatric disorders seen in adults can

occur in children as well, although they

are expressed differently.

Young children are non-verbal. They

express their unconscious state

differently from adults

WHAT COULD THEY BE DISCUSSING???

Introduction : Self then child

Create rapport

Confidentiality

NON-VERBAL COMMUNICATION

Tone of voice: High-pitched and quieter

Facial expression: Smiles and nodding

Eye contact: Variable

Proximity to the child: Not too close

Jokes and laughter: Relaxes the child

VERBAL COMMUNICATION

Talking together

Open questions with comments:

Open questions e.g.

“Tell me about your family”

“Would you like to tell me more about that?”

Comments e.g.

“That must have been very frightening”

“What happened to you was very sad”

Avoid closed and leading questions

BLOCK IN COMMUNICATION

Poor communication/ interviewing skills

Language problem

Strong emotional reaction

ENDING COMMUNICATION

Thank the child

Stress confidentiality

Give the patient some hope

Ask if he has any question

Something to take home (e.g. behaviour modification)

Watch them play

Understanding children’s worlds through the interpretation of their plays

PLAY

Play is the work of the child while the toys

could be considered the tools

Through play children learn about

themselves, others and the world

Up to 75% of brain development in

children occur after birth

PLAY Play influences the development of :

• fine and gross motor skills

• language

• socialization

• personal awareness

• emotional wellbeing

• creativity and problem solving

Play also helps in maintaining parent - child bond

TOYS USED BY MELANIE KLEIN

TYPES AND FORMS OF PLAY

Solitary play: Playing alone Parallel play: Playing alongside another

child(ren) with no interaction between (among) them Normal in normal children < 3yrs Displayed by autistic children of any age

Group play: Able to share ideas and toys. 3 – 6 yrs

Pretend play (around 2yrs): Helps test real life situation in a play manner. E.g.

brushing doll feeding doll laying doll in bed

o Destructive play: Seen in children exposed to violence/ aggressive behaviour and children with DBD. E.g.

Beating toys or hitting one toy on the other.

Constructive play: Children build towers and cities with blocks or play in sand.

Physical play: gives children the opportunity to express gross and fine motor skills.

Social play: Interacting with others in play setting

PLAY Lack of free play may lead to:

anxiety

depression

suicide

feelings of helplessness

narcissism

(Peter Gray, 2011)

Understanding children’s worlds

through the interpretation

of their drawings

Listen to them draw

MEANING OF CHILDREN’S DRAWINGS

Drawing = form of language which carries specific meanings

Drawing is a constructive process of thinking in action – not an isolated behaviour & forms part of a socially meaningful activity. Meanings are therefore constructed and negotiated within a social context

!! An assessment of a child should thus never be based on one single drawing

CHILDREN’S DRAWINGS AS SCREENING TOOLS

Projective assessment techniques are often used to

help children express emotions, and the use of

drawings are the simplest of these methods.

Children’s drawings are a projection of their

personality; of how they see themselves, their

experiences, and their views of the important

people in their lives.

INSTRUMENTS DEVELOPED TO EVALUATE CHILDREN’S DRAWINGS

FOR EMOTIONAL WELL-BEING

Human Figure Drawing (HFD – Koppitz)

Draw-A-Person: screening procedure for emotional disturbance (Naglieri, McNeish & Bardos)

Draw-A-Person (Goodenough)

Kinetic Family Drawing (Sims)

CONCEPTUAL FRAMEWORK

Ability to draw a human figure – age 3

Toddlers & preschool children struggles – developing fine motor skills

School-aged children – comfortable holding writing and drawing instruments

Age 12 – cognitive skills of reflection are gained, look more self-consciously, critically & aim to capture “reality” in their drawings

HUMAN FIGURE DRAWING (HFD)

“The person a child knows best is himself; his picture of a person becomes, therefore, a portrait of his inner self, of his attitudes”.

Easily administered

Non-threatening

Initial screening tool for depression, anxiety, suicidal ideation

Facilitates conversation during clinical interviews

EXPECTED DEVELOPMENTAL ITEMS ON HFD BY AGE GROUPS

5 years 6 years 7 years 8 years 9 years10

years11

years12

years

Head All/previous

All/previous

All/previous

All/previous

All/previous

All/previous

All/previous

Eyes Arms Arms Arms Arms Arms Arms Arms

Nose Feet Feet Feet Feet Feet Feet

Mouth Arms 2D Arms 2D Arms 2D Arms 2D Arms 2D Arms 2D

Body Legs 2D Legs 2D Legs 2D Legs 2D Legs 2D

Legs Hair Hair Hair

Arms down

Arms down

Arms down

Neck Neck Neck

Arms @ shoulder

CATEGORIES OF EMOTIONAL INDICATORS

1) Quality signs: Reflecting the quality of the HFD, e.g. size of the figure or shading of the drawing

2) Omission: reflect items that are usually expected and not present, e.g. asymmetry of limbs, short arms, tiny figures and hands cut off

3) Special features: items that are not usually found on drawings, e.g. genitals, teeth, monster features

EMOTIONAL INDICATORS AND POSSIBLE EXPLANATIONS

Tiny FigureInsecurity, shyness, extremely insecure, withdrawn, inadequacy, shrunken ego, depression

Omission of the mouthShy, extreme withdrawal, inability or refusal on part of the child to communicate, depression

Omission of the noseShyness, withdrawal, masturbation anxiety, castration fear, passive

Cut off handsShy, aggressive, inadequacy, helplessness, guilt over failure to act correctly (aggression), guilty

Gross asymmetry of limbs

Poor coordination and impulsivity, possible neurological impairment, imbalanced, uncoordinated, physical awkwardness

Teeth Hostile attitude (only with other emotional indicators)

Long armsAggressive reaching out into the environment, ambition for achievement

Big hands Aggressive acting out

KINETIC FAMILY DRAWINGS (KFD)

“The importance of discussing any drawings with children far outweighs the mere drawings itself – don’t jump to any conclusions, use the drawings as signs to assess toward”

“Draw a picture of everyone in the family doing something together…

INTERPRETATION OF THE STYLE OF THE KFD

Style of the Drawing Interpretation / assessment

1) Compartmentalization: Family members in drawing are obviously separated

Unable to express themselves naturally, children close themselves off to others

2) Folding compartmentalization: Paper is folded and family members are on opposite side of page

Severe anxiety and fear

3) Encapsulation: Some family members are enclosed without the other members

Child is able to love some people openly but other bother the child so they encapsulate them

4) Line at Bottom: Family members in drawing are obviously separated

Serves to stabilize the child’s world with a firm foundation as child’s real world is unstable

5) Edging A clever way to stay on the edge without getting involved; tendency to avoid situations

6) Line at Top The child’s world is scary and rapid with storm clouds, darkness, and worry

7) Repetition Obsessive thoughts about something, or perhaps about the area around repetition

CHARACTERISTICS OF INDIVIDUAL KFD FIGURES

Characteristics Interpretations

Arm Extensions Possible aids in controlling the environment

Elevated Figures Perception of dominance or power over those under him/her

Erasures Ambivalence

On Back of Page Conflict

Rotated Figures Feelings about being different

Omission of Body Parts

Anxiety – attempt to gain control

Omission of Figures Anxiety – attempt to gain control

Blocking Out Denying or repressing

CASE STUDY COMPARISON OF DAP & KFD

A case is presented illustrating the diagnostic and therapeutic value of human figure drawings. The case study, and 11-year-old boy recovering from viral encephalitis, compares two projective techniques (DAP & KFD). The tests were admininstered pre- and post-treatment. The relative merit of each technique within the therapeutic context is discussed

3rd World Congress for Mental Health and Deafness Worcester, South Africa

DR SHEHU SALE

An Adolescent with Congenital CytomegalovirusRelated Deafness and Significant

Psychopathology

Case Presentation

Division of Child and Adolescent PsychiatryRed Cross Memorial Children Hospital/University of Cape Town

October 26th 2005

A.L, 12 ½ Boy, Cape Town, G6 (MKSHIC)English & Afrikaans

Mom, Dad & Two sisters (9 & 7)

Referral Source : 22/3/2005 – Red Cross Hosp. (Audiologist)

Reason for Referral : Very moody Fighting

Threatening to killplaymates

Deafness - Complete Right ear - Partial Left ear, Hearing Aid.

PC = Hearing Impairment

Moody

Mom: Keeping to self

Easily Irritable

3Yrs Fighting

Bullied in school

• Easily irritable, withdrawn and less interested in school and social activities• Sad feelings, with low self esteem. Appetite has reduced, slight weight loss, sleep (N)• No guilt feelings but accusing siblings and peers of discussing and teasing him, fighting both at home and in school• School changed, bullied by peers because of his size in new school.• No suicidal thought or attempt, no psychotic features. No features suggestive of conduct disorder.• No treatment given prior to being referring to this unit.

HPC = Mother Reports:

•Collateral from Audiologist: Child hears better with help of hearing aids and parents are committed to making funds available for cochlear implant done

•Collateral from G3 teacher: Child noticed to be declining academically, would not respond to call, and keeping to self most of the time.

•Collateral from Principal (School of Hearing Impaired Children): Child has no problem now, he is well motivated to learning, and obeys school authority, no longer bullied by peers.

DEVELOPMENT HISTORYo oPlanned, wanted but out of wedlock, Stressful / Difficulto No known gross physical illness, no psychiatric illnesso No alcohol / other psychoactive substance useo NVD B.W=2.7 kg (Weak, Placid, no cry, Deeply Jaundiced)o Temperament: Easy and Weak baby. o Attachment: Well attached to the mothero Grossly retarded physical development and milestoneso Bottle fed until 3 years

Medical History (after birth): Congenital CMV infection, Diarrhea disease

07/01/94: Epitaxis07/07/94: Hearing Impairment, Post cmv infection19/08/02: Confirmed Deaf (Right)

Cochlear Damage (Left)Cochlear Implant (???)

Academic and cognitive functioning: - Started Grade 1 at 5 yrs- St James Kalky Bay (G1-5)- MKSHI, CT (G3-6)- Repeated G3

Emotional development and Temperament- Initially quiet and calm, later moody, low self esteem, irritable and easily angered

Peer Relationship: Siblings (9,7), Younger Children of both sexes(cousins) 5-6yrs, Hamsters, Now along with animal toys.

Interest, hobbies, talent: Swimming, Watching wrestling films

Creative, Artistic

Physical Developments and medical condition: Grossly retarded in Height and growth. Fine motor skills Speech and language

Mother - 33 yr, STD 8, unemployed woman. - Determine, positive, hopeful, struggling, - Hopes and expectation of child: -“I wish the child all he wishes for

himself”. -“I want him to achieve in life”. -“I know he will never be normal but I

will like him to be if I could”. - “I pray every morning to get money

for his cochlear implant because I don’t want him to loss the second ear also”.

- Mom was fostered at 7, along with 9,11

siblings. - Severely alcoholic parents.

- Left foster parents at 17 because of physical and emotional abuse by them and went back to her mother who was rehabilitated & had remarried.

- 2 of her sisters are asthmatic

- Father died of Ca prostrate at 60, 5yrs ago.

- Mother, 55, alive, on disability grant.

- Married 11 yrs ago.

- Has 2 other siblings (9,7F) alive and healthy.

- Lives in well ventilated 2 bedroom flat.

- Marriage has been relatively peaceful unless

for the stressful financial difficulty:

* Difficulty in paying house rent.

* Not paid child’s school fees for 2 yrs now.

Psychotic episode

97

Alcoholic 55Alcoholic

Dad/34

Tel/PT12 ½

Mum/33 (AD/UE)

32 36 39 42 41

Ca prostrate, 60

GENOGRAM

MENTAL STATE EXAMINATION

Appearance: A young boy dressed in white shirt and blue jean trouser. Small for his age, with hearing aid attached to his (Lt) pinna. No microcephaly. No dysmorphic features.

Behavior: Initially seated quietly with no exploratory movement, later started playing with animal toys, hitting smaller ones against bigger ones. Smiling and showing what he was doing to Mum, warming up to the doctor, no anxiety separating from mum for individual interview. Drew a shark on the board and whale on a drawing paper.

Mood: Sad, cheerful and happy.Affect: Depressed, warm and reactive,Speech: Reduced tone, coherent and relevant.Thought process: Normal Stream, NFTD, Pre- occupied

with hearing impairment, No perceptual disorder, Average intelligence

Three Wishes:• To have cochlear implant done.• To be a scientist.• Have more pets (Rabbits and Birds).Animal he wants to be – a kilo whale.Favourite T.V Programme - Wrestling

Child’s Review of the problem- “My sisters tease me because I cant hear well”.- “I fight them because they tease me”.- “My friends hit me because they are bigger”.- “One of them is now my friend and the other still hits me.”

DIAGNOSIS : Axis I-309.4 Adjustment Disorder with depressed mood. 291.2 Major Depressive Disorder

300.4 DysthemiaAxis II – NilAxis III – DeafnessAxis IV – Teasing and Bullying.

- Parental Financial difficulties. - Maternal unemployment. - Paternal fear of loosing his job.

Axis V - 71 – 80%

ETIOLOGY:

Predisposing Factors:

- Congenital CMV infection.

- Repeated invasive procedure

(venopucture).

- Early maternal rejection / Abandonment.

- ? Genetic (Parental Psychotic Episode)

Precipitating Factors: Hearing Impairment.

ETIOLOGY CTD….

Perpetuating Factors: -Teasing and Bullying

-Becoming and adolescent.

-Fear of becoming bilaterally deaf.

-Parental financial difficulties.

-Maternal unemployment.

-Inability to raise fee for surgery.

Protective Factors: -Family Support.

-I.Q. and talents

PSYCHODYNAMIC FORMULATION•Child might have felt abandoned by mother at an early developmental stage by being separated from her and lacking containment and bonding which might have made it difficult for him to regulate his affect.•However, being an easy baby coupled with Mom’s loving and affectionate response made it easier for her to make up for these losses.•This is evident by his ability to relate with me. Maternal over-protectiveness might have resulted in learned helplessness, making him unable to depend on himself in conflict.•His world must have been a very frightening place before his deafness was discovered.

Being an adolescent, with such a small body size, made him prone to being bullied by peers with resulting aggressive response , and subsequent displacement reaction at younger ones.

•His frustration was further increased by his“paranoid” feelings of being discussed by siblings and peers resulting in aggressive behavior at them and vice versa. (Dynamics of institutionalization of aggression).

•His unconscious feelings, as manifested in his play and interest in aggressive films, can be seen that he wishes a smaller one can beat a bigger one.

MANAGEMENT

o Ongoing: -Supportive Psychotherapy (Child)

-Anger management (Child) -Counseling (Parents) -Treatment of depression (Mother) -Drug rehabilitation (Father)

o Future: -Antidepressant (Child)

o Medical: -Cochlear Implant.

THANK YOU!

REFERENCES

Peter, G. (2011) American Journal of Play, Volume 3, no: 4

Cox, S. (2005). Intention and Meaning in Young Children’s Drawing. Blackwell Publishing, 2005.

Kaufman, S. H., & Burns, R. (1972). Actions, Styles, and Symbols in Kinetic Family Drawings: An Interpretative Manual. Brunner / Marvel Publications: New York.

Tielsch, A. H., & Allen, P. J. (2005). Listen to Them Draw: Screening Children in Primary Care through the Use of Human Figure Drawings. Paediatric nursing, 2005, 31(4)

Worden, M. (1985). A Case Study Comparison of the Draw-A-Person and Kinetic Family Drawing. Journal of Personality Assessment, 1985, 49(4)