Maurizio Vanelli - Maria Gugliotta

The primary objective of any diabetologic team is to ensure that patients reach and constantly retain a high self-control level in handling the disease. From this point of view, a crucial role is played by doctor-patient communication, which is aimed at getting the patient to know his body and achieve therapeutic self-management; this can however be made ineffective by any incorrect mental processes on the part of the child. This is the same role, “Bottom Up”, played by the doctor, a role that also forces on him the task of obtaining maximum communication effectiveness in the relationship established to assist the patient; it is therefore important for him to have available methods and techniques borrowed from specific branches of learning belonging to developmental psychology, which will make it easier for him to decode the information conveyed by the child. As a rule, the beneficial effects of correct therapeutic communication are immediately evident; there is greater understanding by the patient, who gains knowledge of the doctor’s instructions in a faster and more stable way; a greater therapeutic compliance is established and the patient actively cooperates in controlling his state of health, by reporting more promptly and clearly any events that are unfavourable for the preservation of an optimal control state; this results in a more rapid remission of the decompensation phase and in the preservation of high psychophysical wellbeing standards, with a consequent improvement in the patient’s quality of life. In psychological literature (Zani et al., 1996; Bongiorno, 1996; Zani & Cicognani, 2000), many papers emphasise the most common mistakes undermining doctor-patient communication. Among those that are most frequently reported from the patient’s point of view, are:

1. Insufficient information supplied by the doctor, who, especially in the case of major diseases, is afraid that information may destabilise the patient. On the other hand, it is very useful for the patient to be well informed. It is important to keep in mind that there are significant individual variances in the anxiety levels that patients may experience and that the level of anxiety influences in turn the way in which the information is understood (which may be partial or twisted), leading to incorrect understanding of the therapeutic prescriptions.

2. Difficulty in memorising information and prescriptions, which may be caused by poor understanding of the terminology employed by doctors and by patients’ hesitation in asking for explanations, because afraid either of appearing too ignorant or of wasting the doctor’s time.

3. Low emotional involvement by the doctor in the patients’ problems, which, if detected, may result in lack of punctuality at appointments, underestimation of the doctor’s competence, concealment of the most intimate and personal aspects of one’s health problems or of other psychological problems.

From a medical point of view, the most frequently detected problems relate to:

1. The negative “countertransfert” reactions taking place in doctors when faced with difficult patients. These cause irritation, reactivation of unresolved personal problems and evident impatience with certain patients.

2. Incompleteness of information supplied by the patient, owing to reserve, guilty feeling, opposition to or non-acceptance of the disease.

3. Poor observance of the therapeutic prescriptions supplied, due to distrusts, misunderstanding or a low compliance level.

When the doctor is talking to a child, his communication skills need to be particularly refined, in that he is facing an individual who is on a completely different cognitive and communication competence level, which (what is more) continues to change during the course of development. Lack of knowledge of the child’s actual competence level represents a significant source of communication interferences. Small children, for instance, are unable to effectively represent themselves, let alone communicating to other people how their body works and the feelings that come from it; in addition, they do not have an evolved ego, capable of making a proper analysis of reality and of implementing the necessary strategies to deal with any feelings of anxiety and fear that they may have with regards to diabetes. So we may have the coexistence of apparently inconsistent behaviours, such as the “verbal” acceptance of the disease associated with hetero- or self-aggressive behaviours, which, if properly decoded, communicate in fact a total rejection of diabetes. We also need to take into account that paediatricians also have to face a number of adult interlocutors (parents), who have an enormous cognitive and emotional value for children, whose communicative mediation may produce interferences in the perception and processing of the information conveyed. These cognitive, communicative, developmental and parental sources of interference may make it difficult for the doctor to understand in which way the child has received and processed the information relating to the self-management of his body and of diabetes, transposing in time the implementation of the required corrective actions. In many cases, the doctor’s individual sensitivity is not enough to understand the “hidden” messages that children transmit and it is necessary to resort to a psychologist. Therefore, with a child affected by diabetes, it is necessary to seriously take into account the child’s actual ability to process the information and in turn transmit communication; these skills depend both on the child’s chronological age and on his individual position along an ideal psychological continuum (maximum-minimum level of cognitive and communication competence). Let us direct our attention on drawing as a ”technical” tool, which is regularly employed by psychologists and psychopedagogists, as a communication medium with the “child’s” mental world. Drawing is fun for children, whereas for adults it may also become a “story” that the child tells about himself, about his theories on his inner world and emotions. The professional use of children’s drawings, made by psychologists and psychopedagogists, can be of several different kinds. Among these, the most complex is certainly that of considering them as a “projection” of the child’s emotional and relational life, to be decoded on the basis of specific reference theories on children’s normal and pathologic development. Therefore, there are various psychological tests of a projective nature, whereby the subject is requested to make a drawing on a specific topic, such as for instance “the Family Test” (Corman, 1967). The child is requested to draw a family, after which a semi-structured interview is conducted: this provides for many questions regarding the drawing produced and for an analytical processing of the replies supplied. In order to interpret the family drawing, the expert analyses the graphic level, the formal level and the content, according to specific theoretic criteria, by resorting to the body of reference data available in literature, which have been put together over the years. Regarding the use of the drawing as a projective text, we need to point out that this analysis requires specific psychological professional competence, which has to be very high and refined through years of experience. Furthermore, to reach whatever diagnosis, this is never sufficient on its own; it is necessary for the resulting information to be consistent with other psycho-clinical and psychometric indexes. Another psychological and psychopedagogical use of “thematic” drawings is to view them as indicators of the mental development level reached by the child. For instance the “Draw a Person” test (Goodenough, 1926) consists of asking the child to draw a human figure. Depending on numerous elements (graphic stroke quality, number of parts of the body included and other indexes) it is possible to establish quite accurately the child’s mental age and relate it to his chronological age, thus obtaining an actual numeric I.Q., with related prescriptive data reported in literature. However, again in this case, the “Draw a Person” test on its own is not sufficient to reach an actual diagnosis of cognitive development retardation or deficit. Again, this has to prove consistent with other psychometric or psycho-clinical indexes. However, the drawing may also be viewed from a relatively simpler perspective, that is as a direct representation, which is neither mediated by words nor by adults, of the mental representations that children experience of a specific event. Indeed, graphic activity for a child who has normal cognitive skills is also a classical means of self-awareness, a practical tool to define and express the problems he experiences; the same happens with adults: when we wish to solve a problem or explain something, but words alone do not seem to be sufficient, we resort to sketches, and whilst drawing we find it in fact easier to summarise and clarify the problem we are facing. Graphic representation of an object or event may therefore be viewed as a way of disclosing to ourselves and to others the mental representation that an individual has on such an object or event, and this representation often makes it easier for the individual himself to subsequently supply a verbal explanation on the same subject. We should also take into account that, in children, verbal communicative competence develops more slowly than the cognitive, perceptive and practical skills required to produce a drawing and, furthermore, whilst it is easy to obtain a child’s participation in play, as in fact it happens when asking him to draw, you may obtain little cooperation when you ask him to answer direct questions or to explain what he has understood regarding certain events. In this setting, we have attempted to emphasise the directness of representation and the support to verbal communication that children’s drawings can offer in interacting with medical practitioners. Our hypothesis was that diabetic children who had correctly processed the therapeutic information received would be able to produce more adequate graphic representations of their body’s operation than the children who had processed the same information in a twisted or inaccurate way, and that they would therefore be able to verbally express in a more accurate manner what they had learnt about diabetes and on the functions of insulin. This would have granted the doctor a more detailed overall information feedback as to the real level of understanding acquired on the disease and would have enabled him to conduct individualised educational sessions. In order to verify our hypotheses, we prepared a simple diagnostic set, made up of pencils and paper, on which the doctor asked the patient to draw “The human body as it is made inside” and subsequently asked a number of standard questions: “what is diabetes?” and “where does insulin go?” (Piaget, 1926; Fabbri & Munari, 1985). The test was conducted on a sample of 68 diabetic patients (aged 5-20) who had been affected by diabetes for less than 12 months; HbA1c 7.2 (1.6% 4.2-13). All patients had shown a cognitive development within the normal range and had not developed any complication from the disease. They related to the Regional Interuniversity Paediatric Diabetology Centre of Parma University and had attended our standard therapeutic education programmes (Vanelli, 1995). The sample was then divided into two age brackets: “children” (5-11 year range) and teenagers (12-20 year range). The two subsamples did not differ in cognitive development or glycaemia performance. The drawings produced have been analysed both from a quantity and a quality point of view, based on the number of elements pictured and on the typological relation in which they had been arranged with each other, using different criteria, depending on chronological age, for the patients from the two age brackets under examination. The drawings have been classified into three categories: Correct, Correct but Incomplete and Incorrect. The replies subsequently provided on diabetes have been classified as Correct (all the replies relating to proper function of insulin and of sugar in the body), Incorrect (all replies relating to elimination of sweets from the diet and confused mention to sugar) and Doesn’t Know (no reply). The replies on insulin have been classified as Correct (all replies relating to addition of insulin into the blood or body in general), Incorrect (all replies relating to addition of insulin into the pancreas or into other specific organs) and Doesn’t Know (no reply). In table 1, we list the frequencies and relative percentage frequencies in the drawings classified as mentioned above, produced by our sample divided into the two above- mentioned age brackets. The overall production of correct drawings appears high (83%) and, based on our hypotheses, this means that most part of our sample appears to have adequately acquired and processed the information on how their body works, received through the therapeutic-educational programmes.

The Chi-square value calculated on the frequencies observed in table 1 does not appear to be significant (Chi-square value = 3.83; gl = 2; P =.147). This indicates that the differentiation by age of the criteria whereby drawings were classified was sufficiently consistent, even though we find a higher trend in the production of incorrect drawings by the younger children compared to the older ones (25% vs 10%).

Table 2 and 3 display the frequency of replies supplied on diabetes by the two subsamples of “younger” and “older” children. We note that 100% of the children who have produced a correct drawing has also supplied a correct verbal reply, whereas 100% of the children who have produced an incorrect drawing is unable to supply any information on diabetes. Among those who have produced a correct but incomplete drawing, we find that 30.8% provides in any case a correct reply, whereas 38.5% replies in an incorrect way and 30.8% is unable to provide explanations. The Chi-square value calculated on the frequencies observed in table 2 confirms the existence of a significant correlation between the correctness of the drawings and the correctness of the replies on diabetes supplied by the younger children (Chi-square value = 25.259; gl = 4; P = .0001). Unlike what happens with younger children, all subjects supply in any case a verbal explanation on diabetes. Also among the older children we find that 100% of those who have produced a correct drawing have also supplied a correct verbal reply, whereas 100% of those who have produced an incorrect drawing is unable to provide any explanation on diabetes. Among those who have produced a correct but incomplete drawing, we find that 76.5% replies correctly, whereas 23.5% provides an incorrect reply. Also in this case, the Chi-square value calculated on the frequencies observed confirms the existence of a significant correlation between the correctness of the drawing and the correctness of the replies on diabetes supplied by the older children (Chi-square value = 25.259; gl = 4; P = .0001). It is interesting to note that the correct but incomplete graphic representation appears to correspond to an inadequate knowledge of diabetes only in smaller children (only 30.8% of correct replies), unlike what happens in older subjects who in any case provide a correct reply in 76.5% of cases. This may be due to the greater knowledge acquired by older children on diseases in general, besides diabetes, and to their greater verbal competence.

Table 4 and 5 list the frequency distribution relating to the replies supplied on insulin, by the two subsamples of “younger” and “older” children. In connection with the replies provided on insulin, we find a similar trend compared to our findings on replies on diabetes, that is we find that 100% of the children who have produced a correct drawing have also supplied a correct verbal reply, whereas 100% of those who have produced an incorrect drawing is unable to provide any explanation on insulin. Among those who have produced a correct but incomplete drawing, we find that 23.1% provides in any case a correct reply, whereas 69.2% provides an incorrect reply and 7.7% is unable to reply. The Chi-square value calculated on the frequencies observed in table 2 confirms the existence of a significant correlation between the correctness of the drawings and the correctness of the replies on insulin supplied by the younger children (Chi-square value = 38.280; gl = 4; P = .0001). Also among the older children we find that 100% of those who have produced a correct drawing have also supplied a correct verbal reply, whereas 75% of those who have produced an incorrect drawing provides an incorrect reply on insulin and the remaining 25% is unable to reply. Among those who have produced a correct but incomplete drawing, we find that 17.6% provides in any case a correct reply, whereas 82.4% provides an incorrect reply. Also among the older children, the Chi-square value calculated on the frequencies observed confirms the existence of a significant correlation between the correctness of the drawings and the correctness of the replies supplied on insulin (Chi-square value = 37.93; gl = 4; P = .0001). It is interesting to dwell upon the fact that, unlike what happens with the verbal replies supplied on diabetes, both the younger and older subjects who produce a complete but incorrect drawing appear to have actually misunderstood the action of the insulin therapy (only 23% and 17% of correct replies). In particular, they state that insulin goes directly into the pancreas. Lastly, to provide an example, we are hereby reproducing some of the drawings made and of the verbal replies supplied by pairs of children of a comparable chronological age, who have however mentally processed the information on diabetes and therapy in very different ways.

In picture 1 and 2 you will find the drawings and replies by two children belonging to the 5-11 age bracket and in picture 4 and 5 you will find the drawings and replies by two children belonging to the older age bracket.

Both the comparison between the drawings made by Filippo and Nicola, both aged 7, and the comparison between the drawings made by Maurizio and Luigi, both aged 13, shows the different understanding gained by the children on the internal structure of their body.

The replies they subsequently supplied, using their drawing as reference material and guiding criterion, have then emphasised the close correspondence that existed between the graphic representation and the verbal representation of how the children had processed the information on the disease. The results indicate that thematic drawings on subjects relating to patients’ understanding of their body may be employed by medical practitioners as a tool to elicit the child’s mental representations on diabetes and insulin therapy, especially in those cases in which verbal interaction with the child happens to be particularly difficult. If we dwell on this aspect for a moment, we find that children’s difficulties in effectively interacting with the doctor from a dialogue point of view are in most cases due to their young age (<11 years) and to their low level of communicative competence (both linguistic and pragmatic). Under other circumstances, which also extend to teenagers, the difficulty in dialogue interaction may be due to the patients’ high psychological inhibition in talking about themselves, either because afraid of making mistakes or because of a strong opposition to the disease in general and, hence, also to the medical settings. In conclusion, children’s drawings represent a really precious tool for the medical practitioner in making communicative interaction with the child easier, in that: 1. It stimulates interest and aids the child’s cooperation in the medical settings, being a playful tool children particularly enjoy. 2. It offers a concise and direct interpretation of the actual understanding acquired by the child on how his body works and it enables the doctor to use it as a guideline to start a dialogue on the subject, overcoming any impediments on the part of the child, due to difficulties in verbally expressing himself (especially with very young children) or to opposition. 3. It reduces communication interferences, caused by adults’ (parents’) interpretative mediation in the actual understanding acquired by the child, since it allows the doctor to have a direct dialogue with the child, who, through his graphic representation, expresses only his own, absolutely personal, representation and interpretation of events. From these brief considerations, we infer that the use of graphic settings, as a communication medium with the child, proves an extremely effective aid, especially when the medical practitioner is dealing with very young or extremely inhibited patients, or with patients who reject their disease, or when he wants to check whether the child’s verbal statements are actually the result of his own personal interpretation on diabetes and its therapy, rather than verbal labels that have been dogmatically learnt.

(Translated by Interpres sas giussano)

Maurizio Vanelli
Maria Gugliotta
Dipartimento dell’Età evolutiva,
Centro regionale interuniversitario di Diabetologia pediatrica, Università degli studi di Parma
Parma