Patient-centered care when the patient is a child Martha Driessnack - - PDF document

9/18/2015 1

Patient-centered care when the patient is a child

Martha Driessnack PhD, PPCNP-BC

Patient-centered Care? Crossing the Quality Chasm

• In 2001, the IOM named “patient-centered care” as one of

the 6 fundamental aims of the U.S. health care system.

• Why?

– Orienting health care around the preferences/needs of patients has the potential to improve patients:

• satisfaction with their care
• clinical outcomes
• The challenge arises when the “patient” is a child.

– Is ‘family-centered’ care enough? – How can we ensure children’s voices are heard?

• It turns out that children are perfectly equipped and

totally capable of communicating with us, using art.

9/18/2015 2

Integrating ‘art’ into your practice with children

What are we going to talk about?

• Introduce NPs to:

– the use of art to communicate with children – an overview of different forms of art – evidence to support its use, and – how to integrate art into your practice.

• Emphasis is on …

– increasing the quality of communication with children – the actionable information that results, and – the re-discovery of the artist that lies within all of us.

A little background

• To date, children have typically been viewed:

– Using a deficit-based lens

• Human ‘becomings’ vs human beings

– Adult proxy & observation

• Parents, teachers, health care professionals …

– Little agreement between adult/child

• Traditional methods of self-report are adult-

centered, -directed, and dominated

9/18/2015 3

Because of this…

• Current approaches to self-report are:
• Adult-centered, -developed, and -directed
• With “child-friendly” language/adaptations

Current NIH Initiative

No More

Research http://www.nhlbi.nih.gov/childrenandclinicalstudies/index.php

The challenge…

Can we hear children’s voices without changing existing tools and methods?

9/18/2015 4

Children’s Drawings

• Growing interest in the use of art

– ‘Natural’ medium for children

• Internal, sensory cues for retrieval
• Opportunity to organize
• However, drawings have typically been taken

away from children (‘ectomized’)

– interpreted by adult ‘experts’ – windows vs. doorways

Historical perspective

• The study of children’s art [drawings] has a

long tradition in the fields of psychiatry

• Early work with adults with mental illness,

then children with mental illness

• Measures of ‘mental’ age lead to measures of

intelligence (cognitive development)

• Insights into emotions & feelings gave rise to

‘emotional indicators’

Historical perspective of drawings

• Psychiatry/Psychology

– Mental health/illness

• Cognitive development/Developmental

Psychology

– ‘Mental’ age – Developmental level – Intelligence

• Emotional indicators

9/18/2015 5 Historical progression

(Series of Assessment Tools)

• Draw-A-Man (Goodenough, 1926)
• House-Tree-Person (Buck, 1948)
• Draw-A-Person (Machover, 1949)
• Draw-A-Person (Harris, 1963)
• Emotional indicators (Koppitz, 1968)
• Squiggle (Winnicott, 1971)
• Kinetic Family Drawing (Burns, 1972)
• Draw-A-Story (Silver, 1978)

Drawing progression

• Stage I Scribbling
• Stage II Basic forms
• Stage III Beginning Schemata

– Human forms* (~age 4-5 years)

• Stage IV Visual schemata

– Less egocentric

• Stage V Realism
• Stage VI Adolescence….

Fine motor skill progression….

• Scribbling – eye follows hand

– hand in mouth to grasp progression – hand to paper, hand leads, mark + feedback

• Shapes – eye & hand work together

– mastering form & basic design – line, circle, box, cross

• Pictures – mind guides hand

– Combining shapes – Depicting reality

9/18/2015 6

Human forms (4-12 yrs)

• Tadpoles

– Head, legs

• Facial features

– Eyes, nose, mouth, hair

• Arms
• Body/neck
• Feet
• 2-D, naturalistic placement of arms/legs

9/18/2015 7

9/18/2015 8

“Draw a person”

• Any person you want
• 8 x 11 paper & pencil
• No time limit (~10min)
• No clinician guidance/probing
• Assessment

– Cognitive/intellectual development – Emotional indicators

Emotional indicators

• 30 specific characteristics (Koppitz, 1968)

(DiLeo, 1970; 1973; 1983)

• Quality signs

– Shading, transparencies, lack of integration – Asymmetry, slant

• Omissions
• Special features

– Tiny head, crossed eyes, teeth!, emphasis on hands, legs/arms pressed together, genitals, clouds/rain/snow

9/18/2015 9

NORMAL TINY FIGURE NO INTEGRATION Slant Shading Slant Transparency

Moving away from…

• Art as an ‘assessment’ tool
• To art as a facilitation of communication

– Encourage children to say something about their drawings (Naumburg, 1949)

• Drawings ‘facilitate’ communication
• Meta-analysis (Driessnack, 2005)

– Amount of information

• Mixed methods study (Driessnack, 2006)

– Nature of information

9/18/2015 10

Draw-and-Tell Conversations

Tools & Approaches need to be Child-sensitive

• Child-directed

– Least-adult role

• Capitalize on children’s (not adults’) natural

– Cognitive/developmental capabilities/strengths – Internal, sensory cues

• not words = external semantic cues
• When we do…

– Elicit more information – Information is relevant, accurate, & actionable

Listen…

9/18/2015 11

The stance of ‘not knowing’…

• Never assume that any image always means

something specific

• Stay open to a variety of meanings
• Being careful no to say too much
• Looking for an uncensored view of children’s

thoughts

• Least adult role…

Children’s interpretations

• ften very different than ours

Caution! You will be affected by children’s imagery in personal ways that may/may not be representative of what children are experiencing or trying to communicate

9/18/2015 12

I OFFER EVERY CHILD THE OPPORTUNITY TO DRAW…

9/18/2015 13

So… what does that mean?

• What supplies do I need?
• Do I need to be an artist?
• Will it take too much time?
• What is the value added?
• What do I say?

– Draw a picture of:

• Yourself
• Your family
• You at home
• You at school

Children’s drawings

• Drawings vs. drawing completion

– Impromptu and/or spontaneous – Draw-and-Tell – Draw-and-Write

• Self

– Self-portrait

• Family

– Kinetic Family

• Social network

– Colored Eco-Genetic Relationship Map

9/18/2015 14

9/18/2015 15

9/18/2015 16

Draw your family?

9/18/2015 17 (KINETIC DRAWING)

Draw your family doing something together?

9/18/2015 18

Draw your home?

9/18/2015 19

Here I am This is who I am avoiding

9/18/2015 20

My own exploration…

• f ‘fear’

9/18/2015 21

9/18/2015 22

O CA R C E Primary Experience

Meaning of the experience The end Sequence of events How the situation was solved Who, when, what, where?

Social networks… … support, information, etc.

9/18/2015 23

9/18/2015 24 Often used following ‘trauma’

• 9-11
• Tsunami
• Hurricane Katrina
• Holocaust
• Wars
• Forensic/Abuse interviews

…but that’s not the only time…

9/18/2015 25

9/18/2015 26

9/18/2015 27

9/18/2015 28

9/18/2015 29

Drawing completion

• Inside the body

9/18/2015 30

ART is a powerful medium

• Drawings*

– Person, self, family, home, school

• Sculptures

– Tree vs forrest – Islands to worlds

• Shoe box self
• Collage
• Masks
• Life size tracing
• Storybooks, photo-voice

Most ‘young’ children never hesitate…

9/18/2015 31

But for those who do… we have collage!

Visual ‘kaleidoscope’ of methods

• Children’s drawings*

– self, family, social networks

• Photographs/Media

– photo-elicitation – photo-voice – media diaries

• Graphics

– graphic-elicitation

• Artifacts

– masks

9/18/2015 32

Photographs/Media

• Photographs

– Can be made by child, found, or provided by researcher

• Photo-elicitation

– Photo-elicitation interview (PEI) – Photo diary/collage

• Photo voice

– Social justice/critical theory lens

• Expanding media

– Media/video diaries – Facebook/MySpace

Graphics

• Timelines

– Life course timeline

• Maps

– Body/hand maps – Relational maps – Geographical maps

9/18/2015 33

9/18/2015 34

Artifacts

• Masks
• Shoebox self

9/18/2015 35

9/18/2015 36

Finding the ‘power’ of your

• wn breath!

9/18/2015 37

9/18/2015 38

“There’s an ‘app’ for that!” “There’s an ‘app’ for that!”

9/18/2015 39

• Ready access at the point of care
• Hard copy or digital
• Easy upload
• Easy retrieval
• Ability to send in from home
• Ability to capture/share child’s

accompanying narrative or summary

9/18/2015 40

A ‘knot’ in my stomach

9/18/2015 41

Child talks about drawing Draw with provider Provider annotates and saves drawing Draw in waiting room Draw at home

The importance of materials

• Good quality materials (aka no

broken crayons/used pencils)

• Choices = control

– Too many vs too little

• Tools (active, continuum of control)
• Materials (passive, receptive surface)
• Familiarize yourself with both

– Most adults draw, paint, and sculpt as if they were somewhere between age 4 & 12!

9/18/2015 42

Art ‘tools’

• 10 point continuum

(1=least controlled;10= most controlled Wet clay* Watercolors Soft plasticene Oil pastels Thick markers Collage Hard plasticene Thin markers Colored pencils Pencils 1 2 3 4 5 6 7 8 9 10

Pencil vs Pen

• Pencil

– Gray mark – Emotionally non-committal (vs colors) – Safe, easily erased

• Pen/markers

– Fixed, cannot be undone – Decisive, commitment

Art ‘materials’

• Paper

– Fragile – can be cut, torn – Easily manipulated – folded, wadded up – Responsive, vulnerable, and open to change – Different colors, textures

• paper for learning disabilities, perceptual problems,

visual impairments (high contrast)

• Other ‘surfaces’

– Blackboards, sidewalks, skin – Sand trays – Clay (always says ‘yes’)

9/18/2015 43

Meaning of colors…

• Red ≠ color of hurting, rage, aggression
• Purple/black ≠ unhappiness, depression, death
• Color means different things to different people

– Fads (Ex: purple increased with Barney) – Culture

• Lack of color?
• Developmental considerations

– 3-4 yrs beginning consciousness of color – 4-6 yrs know colors – 6-9 yrs rigid use/rules – >9yrs realistic

Acknowledgements

For the children who shared their art with me, but especially to those who said it was ‘ok’ for me to share it with you

9/18/2015 44

Thank you. Any questions?