June Woolford, Clinical Assessment of the Child

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  • 1. 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. .
  • 2. June ‘Junie’ Woolford Child and Family Therapist CAFMHS Dunedin
  • 3. 1.Adverse effects on development 2.Enduring effects if not addressed. Homotypic/hetrotypic 4.Societal impact Loss of human capitol (WHO, 2009) 3.Youth issues- social disengagement A potential sequence of child psychopathology.
  • 4. Intervention
    • Intervention has the potential to remediate psychopathology.
    • Child mental health intervention via specialist services required.
  • 5.
    • Cornerstone of therapeutic intervention is a comprehensive assessment.
    Clinical assessment of the child.
  • 6. Historical perspective of clinical assessment for children
    • Children subject to physical parameters and behavioral observations.
    • Adults as main source of information to clinicians.
  • 7.
    • 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…..
  • 8.
    • Why hear the child’s voiced directly?
    • There are a number of reasons…
  • 9.
    • “ 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.
  • 10. Are children competent enough to self report? Cognition Verbal communication Socio emotional
  • 11. The challenge for child mental health practitioners.
    • To support children to communicate accurately in clinical interview settings.
    • To elicit accurate information - vital to diagnosis and treatment.
  • 12. Is drawing a developmentally sensitive tool for assessment?
    • Normative developmental stages for drawing.
    • Popular with clinicians
    • Significant history – focus on what was drawn. Contentious issues about validity and reliability.
  • 13. 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.
  • 14. Hayne and colleagues
    • Pioneers in draw and tell research
    • Hayne and colleagues have established a series of studies on draw and tell.
  • 15. 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.
  • 16.
    • 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
  • 17.
    • 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.
  • 18.
    • 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.
  • 19. 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.
  • 20. 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.
  • 21. Potential Mechanisms
    • Hypotheses regarding efficacy-
    • cognitive
    • communicative
    • social support
    • Consideration of these developmental areas are vital for child consumers.
  • 22. 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.
  • 23. 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 ?
  • 24.
    • 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.
  • 25. Children were randomly assigned to one of two experimental conditions Tell only Draw and tell Consent sought from children and their caregivers.
  • 26.
    • 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
  • 27. 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.
  • 28. 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.
  • 29. 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?
  • 30. Question Sheet 2.
    • How easy was it for you to tell me about ( PP )?
    • Not easy
    • Very Easy
    • Easy
  • 31. Additional data
    • Question Sheets
    • Answers were categorized.
    • Demographic data collected.
    • Age
    • Medication status
    • Presenting problem
    • Diagnosis
    • Ethnicity
  • 32. Coding protocol
    • Transcribed interviews
    • Coded into clauses
    • Clinically relevant information i.e.
    • - About PP
    • - Multi axial information.
    • The interviewer prompts were identified and coded.
  • 33. Results
    • No association between:
    • Age
    • Interviewer
    • Gender
    • Presenting problem
    • … and the amount of information reported.
    • Data was collapsed across age, interviewer and gender
  • 34. Does drawing help children to talk about their presenting problems?
  • 35. Figure 1 . Mean number of clauses (with SE bars) for each experimental condition.
  • 36. Did the interviewer behavior differ between the draw and tell conditions?
  • 37. Interviewer behaviour.
  • 38. The subjective views of children in a clinical setting. Did children say they would prefer to draw?
  • 39. 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?
  • 40.
    • 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.
  • 41. We also wanted to know… Did children perceive that drawing made the task of reporting easier?
  • 42. Question Sheet 2.
    • How easy was it for you to tell me about ( PP )?
    • Not easy
    • Very Easy
    • Easy
  • 43.
    • 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.
  • 44. Discussion.
  • 45.
    • Drawing increases the amount of clinically-relevant information that children report about their presenting problems.
    • Means: Draw = 99.73 clauses
    • Tell = 50.93 clauses
  • 46. 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.
  • 47.
    • 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.
  • 48. Interviewer behaviour.
  • 49.
    • Implications:
    • Draw and tell interviews can be a useful tool in clinical assessment of child.
    • 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.
  • 50. Acknowledged with thanks….
    • The children and families, the centres and the interviewers who took part and supported this study.
  • 51. Otago District Health Board
    • Award for research project initiative
  • 52. Discussion