How to Communicate and Understand Children’s Worlds By Dr Shehu Sale

1. How to Communicate and Understand Children’s Worlds By DrShehu 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.

2. OUTLINE: 1. Introduction 2. Communicating with children 3. Understanding children’s worlds through interpretation of their drawings and plays 4. Case presentation

3. 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

4. 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)

5. 2. Communicating with children

6. 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

7. Cultural Differences – Avoid ethnocentrism • Be a good listener • Communication is an act • The same information obtained from the adults can be gotten from children

8. 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

9. What could they be discussing???

10. Introduction : Self then child • Create rapport • Confidentiality

11. 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

12. 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

13. Block in communication • Poor communication/ interviewing skills • Language problem • Strong emotional reaction

14. 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)

15. Watch them play Understanding children’s worlds through the interpretation of their plays

16. 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

17. 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

18. Toys used by melanieklein

19. 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

20. Pretend play (around 2yrs): Helps test real life situation in a play manner. E.g. • brushing doll • feeding doll • laying doll in bed • 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.

21. 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

22. Play • Lack of free play may lead to: • anxiety • depression • suicide • feelings of helplessness • narcissism (Peter Gray, 2011)

23. Listen to them draw Understanding children’s worlds through the interpretation of their drawings

24. 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

25. 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.

26. 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)

27. 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

28. 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

29. Expected Developmental Items on HFD by Age Groups

31. Categories of emotional indicators • Quality signs: Reflecting the quality of the HFD, e.g. size of the figure or shading of the drawing • Omission: reflect items that are usually expected and not present, e.g. asymmetry of limbs, short arms, tiny figures and hands cut off • Special features: items that are not usually found on drawings, e.g. genitals, teeth, monster features

32. Emotional Indicators and Possible explanations

33. 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…

34. Interpretation of the style of the KFD

35. Characteristics of individual KFD figures

36. 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

42. 3rd World Congress for Mental Health and Deafness Worcester, South Africa Case Presentation An Adolescent with Congenital Cytomegalovirus Related Deafness and Significant Psychopathology DR SHEHU SALE Division of Child and Adolescent Psychiatry Red Cross Memorial Children Hospital/University of Cape Town October 26th 2005

43. 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.

44. PC = Hearing Impairment Moody Mom: Keeping to self Easily Irritable 3Yrs Fighting Bullied in school

45. HPC = Mother Reports: • 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.

46. 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.

47. Development History • Planned, wanted but out of wedlock, Stressful / Difficult • No known gross physical illness, no psychiatric illness • No alcohol / other psychoactive substance use • NVD B.W=2.7 kg (Weak, Placid, no cry, Deeply Jaundiced) • Temperament: Easy and Weak baby. • Attachment: Well attached to the mother • Grossly retarded physical development and milestones • Bottle fed until 3 years

48. Medical History (after birth): Congenital CMV infection, Diarrhea disease 07/01/94 : Epitaxis 07/07/94 : Hearing Impairment, Post cmv infection 19/08/02 : 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 .

49. 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

50. 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.