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PROJECTION IN TRAUMATIC ILLNESS THROUGH DRAWING AND T.A.T. IN CHILDREN WITH CHRONIC AND ONCOLOGYCAL CONDITIONS

Autor: Adina Mariș Sandra O'Connor Speranța Popescu
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The study is proposing to analyze variances from mean That Appear in drawings of children with a diagnosis of oncological or chronic illness, through comparison Between Two Population samples Consisting of: one group of healthy children (control group) and one group of children with oncological and chronic illness (experimental group) .There has Significant Differences Between the two sample groups. Through TAT projective test, common themes have been major Identified in the sample group of children with chronic and oncological illness. Even There has Obvious well through Determined the main themes Further study proposes to analyze particularities in the manifestation of Projected trauma in the experimental group.

I.HYPOTHESIS:

The process of drawing is preferred by children playing together to express ideas, feelings, attitudes. The design often reflects the mood of the child and the projection of anxieties, desires or fears. The analysis of drawing is the most accessible way of assessing the child oncology patient in order for the child not to be subjected to lengthy and difficult tests.
It is expected that the projection model in children with oncological illness is different from child to child diagnosed with chronic illness. It is expected to determine noticeable differences between the healthy child assessment , there are certain themes and game design, different from the sick child.
The severity of disease causes certain projections, which have different intensity depending on the pathology;
While the disease appears to present the sick children’s projection with a remarkable intensity, in healthy children the common themes that arise can be determined by other causes related to the personal and family life of the child.

II.MATERIALS AND METHOD

Subjects

Three groups of 15 subjects were chosen. The first group consists of children with oncological diagnosis at baseline, mid-treatment or after hospitalization period when continuous maintenance treatment. Children have the following diagnoses: acute lymphoblastic leukemia, non-Hodgkin lymphoma, abdominal tumor, testicular tumor, retrosternal tumor. The second group consists of children with the following chronic diseases: hemophilia, ITP, microcytic anemia, renal failure, diabetes type B. The third group consists of healthy children.
The groups were chosen to see if there is significant differences in children’s drawings and if there are differences between healthy and sick children’s drawings.
In the group of sick children the differentiate designs the disease may be a variable in this case. Although children with oncological diagnosis drawing may express their trauma and disease as those with chronic illness, the type of project can be different depending on the intensity of the disease. Thus, in the case of oncological medical conditions, the drawings might reflect a higher emotional charge.
A fairly large number of children was chosen in order to to track repeating themes that appear in the drawings. The main theme in traumatic disease children’s drawings is how the disease affects them emotionally, socially and way of life.
However, the study will present a segment that is expected to be found in a higher number of subjects as well, by percentage increase.
A wide range of designs and tests were chosen to capture from different angles the projection of traumatic disease. Each theme drawing and each game has a significance test or the interpretation of trauma and how the child is projecting trauma. Although the child trauma has a different aspect the trauma projection is evident. The sick child’s mental state is reflected in drawings and games. There are certain recurrent themes in drawings and games for sick children. Using drawing, as a test, we can identify sources of conflict, and psychological support resources.
The theme was chosen due to the following aspects: psycho-oncology is an area that needs to be explored more thoroughly. It is important to recognize manifestations such as drawing not just as means of expression but modality of treatment.

1 Drawing themes

1.1. “Drawing of choice”: the child can free draw what they feel and are willing to draw. Design intent: to express feelings or anxieties that they would not normally express verbally.
1.2.”My family”. Purpose: to track how the child views the family; how the child perceives and deals with family disease; how to involve the family in the care of the sick child; aspects of the family hierarchy and whether there are changes in the family after the child fell ill; child’s feelings toward family members and whether others perceive them differently than before his illness; if the family is a support or child neglect; if the child projected on one family member due to illness or disease; if it devalues ​​or overvalues the role of the child; if brotherly jealousy or envy occurred after the disease onset; what value more family members and the child if the person changed after disease onset valued or is all the same; the value of the person that takes care of the child; attitude towards the mother who sits with the child in hospital (depiction of the mother means of maintaining calm or displaying the anger and frustration).
1. 3. “Family spells.” Purpose: detecting child’s feelings toward family members, if these feelings are positive or negative; if the child finds a refuge or escape from the family; if the characters are negative, then the trauma of the disease in these projects.
1.4.”Person / A person of the opposite sex.” Purpose: identifies with his sex or not; who draws first, him or opposite sex; tumor in person projects his drawing; traumatic disease projection as shown in the drawing of the person who is actually to identify himself.
1.5. “10 years from now”. Purpose: to follow if he sees his future in perspective; if you can see a desirable future; where and how it sees the future; future projection is positive or negative; He has thoughts of death / absence of the future; You can see a future so distant as that of 10 years from now.
1. 6. “A fairy fulfills three wishes for me”. Purpose: what the child wants most; What is the interest of the child; if the child is wishing something or not.
Drawing two issues are very important to detect depressive thoughts. If the child can not see in the near future or distant, and if he does not want anything, it might be considered the child is preoccupied with thoughts of death, that the child has negative expectations about the future and the success of treatment, that he has no patience or that can not tolerate the treatment and hospitalization. This can be detected by observing the child’s attitude to the task of making the two drawings. If they refuse to do or say things he does not know or draw strange and unusual, is a clear indication that there is some catastrophic thoughts about his illness. Psychological intervention in this case is essential to monitor and changing dysfunctional thoughts.

Testing method
The used testing method is qualitative.
The utilized testing mean is TAT. It was determined that TAT captures very well the attitude in the face of illness, feelings of depression, sadness, hopelessness, thoughts of death and helplessness in the face of illness. The test includes explicit drawings depicting such situations: the woman who died, the child alone on the doorstep, and the man who sits in the distance the window, the woman on the bridge, scenery by boat, empty sheet. If the child plays or phrases stories can describe anxiety, depression, illness, death, then his thoughts revolve around these concerns.

III. RESULTS AND FINDINGS

1. “Drawing of choice” theme characteristics

1. a The sample of children with oncologic diagnosis:
Wonderful landscape = need to seek a safe environment in which to escape; skull = thoughts about death or thoughts / negative expectations; flowers = tenderness, purity, tranquility and escape desire; trees = substitutes for people wanting to be alone with themselves. Sometimes the flowers and trees are slightly inclined to the left = return to the last bend before the hardships of life; house, clove ,child, car = homesickness, the desire to return home, own projection in the home environment, support objects; retrieval desire self = self, helicopters = desire to fly, to detach the current situation, landscape with sharp teeth underwater with sharks and jellyfish = feels in a foreign environment and feel threatened, rainbow = hope, winter landscape with snowmen and children playing = desire to play with the children in an environment which means “home” healthy, coffee = willingness to get home; abstract drawings= ability to abstract adolescent and see things in perspective, maturity; blooming trees = hope for a better future; no characters means that the child is lonely, self-search.

1. b The sample of children with chronic diseases:
Landscapes sunny sky birds tree = desire of an idyllic environment; tablet padlock = censorship, self-censorship or secret (which is not to see one tablet); sunrise sea = desire a new beginning; insects in water = projection of disease, own name = narcissism; landscape with frogs, birds, butterflies, pond, tree, sun = positivity, designing a secure environment and wonderful, playful spirit

1. c The sample of healthy children:
Balloon flying = self-improvement and personal development desire, black cat = teenager later diagnosed with depression; fairy = desires; hope; Protection desire; fulfillment magic; butterflies = tenderness, purity, desire to fly, to move.

2. “My family” theme characteristics

2. a The sample of children with oncologic diagnosis:
The characters appear in the lower left and lower = inferiority complexes, return to the past; silhouettes only sketchy summary = immature, hastily drawing; cut himself or missing self = devaluation, inconsistency, uncertainty with itself; no family members next to them = and are not emotionally invested; the characters are distant from each other = deconstructed and broken families or who had problems after onset of illness child; appears only himself and his mother = family is reduced to him / her and the person sitting with him / her in the hospital; protective person; characters unstained = devaluation, do not focus on them; some characters have no body, hands or feet = lack common sense, dismantling, feel incomplete; some characters do not have hair (the child or the mother) = explicit projection of the disease; mother has no moving projection hair = another person (defense mechanism); some characters and he / she had feet and hands like filaments and incomplete = immaturity, devaluation, insecurity in relationships and mastery of space around by walking (= grip hands, feet = a move in the environment); others project their own helplessness; some characters have eyes, nose, mouth, ears = depressive scheme; lack of communication; characters with large ears = willingness communication; characters with feet and hands hooked = prohibiting movement of the contact; frustration in relationships; feet segmented in half, folded = self-censorship; family inhibited, characters legs / hands incomplete, blocked = aggression; immaturity, characters fingerless hands = censoring the behavior of a person, characters with fingers sharp as needles = aggression; characters sad, pensive, resigned = negative feelings, depression; drawings do not have a supporting line = feeling that they have a solid support; in some cartoon characters holding hands, smiling = united family, happy; in some drawings appear a natural setting sun, bird house with homesickness road .

2. b The sample of children with chronic diseases:
Characters strands, drawn hastily = no interest or theme is hasty; devaluation; characters who hold hands, colorful, happy family smiling ; drawing placed at the top of the sheet and slightly to the left = idealistic people, past oriented, previous stages; thoughtful details and accessories = Handful narcissistic, obsessive-compulsive tendencies possible; hands / feet like lines = immaturity, sharp lines nervous = nervousness, negligence; placed in frames as paintings, drawings and unstained small border = mean censorship, small books and unstained = devalues ​​family; possible emotional family break

2.b The sample of healthy children:
Family is dew colorful, with significant details, all family members present in the correct order = family relationship is good, functional family; drawing placement is in the top left of the page = idealistic people-oriented past; the characters are smiling and happy = happy family; the child appears in a comic ambient environment or do something specific activity = appears a family, active family.

3. “The family spells” theme characteristics

3.a The sample of children with oncologic diagnosis:
Drawing includes items such as: cabinets, helicopters = affective flattening possible from family members; animals frightening (black beetles) = negative feelings; butterflies, bees = positive feelings, qualities (bee is industrious); cat = “always falls standing” is doing, leaves the situation; half of animals = uncertainty or does not want to turn them into fully; flowers fir tree = tenderness, strength (quality of the characters or positive feelings towards them); body parts (fingers) = critical person; superman, superheroes, fighting cyborg = strong person, a fighter (projection disease), ghosts = negative thoughts of death (illness projection); fairy, queen = need for protection, peace, “everything is possible”; wizard = someone that may harm or has the power to transform every; some designs are colorful, others do not; sometimes the colors are dark, dull, dreary. In some drawings they are omitting drawings themselves, turns only other family members = devaluation or satisfied with it as it is.

3.b The sample of children with chronic diseases:
Drawings main themes included: falling rain cloud: crying inside, sadness; bundling balloons: the desire to rise, to fly, to release, to be relieved, flowers: tenderness, purity; family pet: cute animals, and belts; organized social and affinity; princes: the desire to accede above and be important; butterflies, dragonflies: beautiful animals, graceful, flying ; sun, tree, flower: nature scenes, items relating to each other, united family and communicating.

3.c The sample of healthy children:
Main themes were drawing of: kings, queens, princes, princesses = important persons influences; possible positive perception of family, emotionally investment present in the drawing in form of warm facial features, heart = character (usually the mother); money / euro = father secures the wealth of the family, working abroad; characters appear younger = desire to rejuvenate take much to that person; house pet, cute animals (rabbit, cat, dog, bird) = positive feelings are child’s favorite animals, villain witch = fear, lack of security, priest = father, who reconciles everyone in the family, trees = strong people, vigorous healthy people.

4. “Drawing of the person” theme characteristics

4.a The sample of children with oncologic diagnosis:
The children in the sample drew themselves in the following ways: hairless (projection disease), having drawn points for radiotherapy (projects disease), dressed in robe (the job that they intend to follow), herself without ambient environment (loneliness) strands, or color less (devaluation), small size (devaluation) or colorful, with more details and room home (homesickness, valuing oneself, narcissism), sad smile (sadness, depression), hands in pockets (has something to hide ), with the crown of king (it feels important or wants to feel important inferiority complex), schematic only lines (immaturity, devaluation, inhibition), hands / feet like filaments with fingers spread out like needles (aggressiveness hidden) , hands short fingers sharp (inadequacy to reality, isolation, poor contact with the outside world and aggression), body tilted to the left, with his hands up and his fingers spread out (return to the stages before, early, hope and expectation, defensive, defense, resignation), sad smile with sagging corners of the mouth, eyes devoid of expression (sadness, depression); together with his brother (brother longing for home) and next to a rainbow (desire better).
Opposite sex (investing oneself in a person of the opposite sex) drawn first then another person of the same sex (specifically for children over 12) = sexual identification; the other person is my mother, nurse = person he loves most and is a model; guardian Angel = possible identification / projection of oneself or the need for divine protection and help, the person is placed in the top left, up or down = anchoring in the past.

4.b The sample of children with chronic diseases:
Main themes and afferent symbolic were observed of people drew as incomplete, having only the head with detail and stops at the body, not colored = detail means narcissism; does not feel complete, anxiety, hesitation, denial, suppression of their identity; own identification as physician with details = narcissistic desire to pursue medicine or investing in strong hands that person is her life; opposite sex, not colored, no details = devaluation, the desire to be someone else, misidentification of their own sex; another person (parent, friend, nurse) = dearest person and it takes as a model; opposite sex then self = correct identification with their own sex, specifically drawing children over 13 years; themselves and homesickness house = homesick; teacher, firefighter = profession who want to follow
Placement of drawing and figure is at the bottom left , or without a supporting plan representing devaluation, return to the past, not feeling supported or safe in the given environment.
Items accessories presented in drawings are: belts = self-censorship; ornaments possible representations of narcissism; emphasis on self looks = narcissism, attention to detail = narcissism; hands in his pockets = has something to hide; filaments for hands and feet= insecurity, devaluation, lack common sense; appliances and other items: dog + car; Home + tree = willingness home, family, or go home situation

4.c The sample of healthy children:
Identification of mother as the most important person.
Drawing themselves with details and bright color.

5. “10 years from now” theme characteristics

5.a The sample of children with oncologic diagnosis:
Themes determined before starting treatment: health (4 children) house / home (4 children), school (3 children), material things (2 copies);
Themes determined during treatment: health (6 children), college / workplace (4 children), happiness (6 children), family (5 children);
Themes determined after starting treatment: material things (4 children), health (5 children), family (5 children), happiness (3 children)

5.b The sample of children with chronic diseases:
Health immunity factor VIII (treatment) – 15 children
Drawings include materials tablets, car, laptop, bicycle, dress, necklace, television – 10 children
Drawings include theme of happiness – 9 children; theme of family – 7 children; theme of love – 3 children; theme of house – 3 children; theme of song, music – 2 children

5.c The sample of healthy children
Drawings including material things(15 children)
Happiness theme was presented in 1 child drawing.
Themes determined: to go shopping, to go to the sea (2 children); song, music (2 children), family pet, small dog (1 child).

6. Draft of the future theme characteristics

6.a The sample of children with oncologic diagnosis:
Themes presented idyllic setting with its own positive vision person ; self as a physician = desired profession, making of own Family = want a family; sad figure = sadness; writings , without drawing

6.b The sample of children with chronic diseases:
The drawings presented similar themes in the projection of having own family: “At my house with 2 children”; professor, Ph.D., actress as desired job.

6.c The group of healthy children:
The drawings presented people solitary sad or happy, yet have not reflected the ambient or environment = temperamental child; desired profession: rock star = wish affirmation possible inferiority complex

7. Description of TAT plates

7.a The sample of children with oncologic diagnosis:
3BM: children describe feelings of sadness, anxiety, depressive states: “Woman is sad and crying tired”, “woman received bad news”, “A little hurt and cry”
13B: children describe situations of mourning, loss and loneliness, “A child who thinks of something, the same person who died.” “It’s a single child who pray to him to blame and someone”
12BG: naked children describe situations, loneliness, abandoned place. “It’s an abandoned boat,” “Trees, Water, boat.” (Summary shows strong resistance), “Barca has never had anyone that was broken and then they are gone”

7.b The sample of children with chronic diseases:
3BM: children’s stories appear in feelings of anxiety but not so pronounced “complain that they can give the boy first violin image”, “stumbled and fell”
13B: Children have depressive reactions or loneliness, but more masked “The child is alone and brings ice” (ice cream = gratification), “The family went to the field and he waits.”
12BG: Not so pronounced negative emotions: “Exhibit that has no heart” (defense mechanism), “Somebody went and looked boat but comes after it.”

7.c The sample of healthy children
3BM: Children do not experience negative feelings and instrument approaches with humor: “What entertains me Auntie’s position. Maybe it feels comfortable “,” Is looking for something on the floor?“
13B: Children feel solidarity with the boy alone and want to console him: “His playmates expect”, “Probably late mother at work and he is quiet”
12BG: Children scenery: “What a nice place. I sit in that boat! “” If it were mine I would go with her all day on the lake! “” Dad’s boat is waiting for us to go fishing.

Analysis of children’s drawings show different features in the lots, as it follows:

Children with oncological diagnosis chose topics related to health and disease, but they preferred idyllic landscapes, a sign of insecurity and desire of an idyllic environment. The design presents a family breakup / family fragmentation, the lack of a family member or lack self drawing indicating self devaluing and feelings of worthlessness. The feelings that arise from the enchanted family drawing are generally positive, especially against the person takes care of them, however, appear villains (insects, witches) or objects (cabinets, helicopters), which explains a blunted affect. Drawing disease trauma explains very well the person by drawing themself hairless in preparation for chemotherapy. The faces are sad, expressionless gaze, seem resigned attitude with a posture and bowed to the hardships of life, indicating feelings of sadness, anxiety. Features drawing presents all individuals bring forward immaturity (thin hands-feet), inhibitors (silhouettes drew sketchy), aggression (hands like needles), defensive stance (arms up) impotence and fatigue (hands hanging at his sides). Children’s with oncological diagnostics main desires, as reflected in the drawings are primarily health, and happiness, and the school continued to be home, indicating homesickness and a sense of unhappiness. The person that they view as the most important are the physician and the mother, the person who is represented here as the one that accompanies the course of the disease. The projection of the future is generally positive because depression is prevented through counseling and psychotherapy i support interventions.
The preference for the lower part of the sheet may be indicative of inferiority, insecurity, plan return to the past or the left indicates a period where they feel safer. It often has a line drawing support elements “hover”, which indicates the willingness of a solid support on which to rely. Colors are sometimes rich, sometimes colors appear dull, dreary, dark (negative feelings, sadness) and often appear unstained designs (devaluation, haste, lack of interest in certain topics). The lines are fragmented, poorly drawn, indicating uncertainty or Contoured (obsessive compulsive tendencies), and made with a strong pressing of the drawing utensils (aggressively).
Children with chronic diseases prefer to draw houses, trees, nature scenes with animals, birds, butterflies. These themes may signify a preference for certain topics and / or desire a safe environment and homesickness. Family drawing appears less affected by family problems, or sometimes missing characters are all themselves, which means self devaluation. The family is transformed into elements generally positive (butterflies, kings, princesses). Drawing a person is less endowed with elements of trauma occurring professions they want to follow children (doctor, teacher, fireman) themselves without ambient environment (loneliness), the person is sad or happy, projection disease seen in spots the clothes (purple patches), but also as a person choosing to draw the nurse or mother, grandmother (people that support us and that we take as a model). The wishes of children with chronic disease are related to health, happiness, home, family, to have treatment and future projection is positive: they have wishes, family is present, travel, music, song.
Like oncological diagnosed children, some drawings appear brightly colored and details (narcissism), others are not colored, which indicates either a lack of interest in certain topics or impatience or lack of interest in the character drawing. Lines are drawn and heavily contoured , having weak, but normal structure.
The group of healthy children resented in the drawings only age-specific personal issues pertaining to family, school. Family drawing has generally all family members, is beautifully colored and the characters have a job, usually they do something. Family enchanted animal appears as cute, friendly and profession of parents (priest, mayor) and villains (witch), which explains the negative feelings towards some family members. In some designs new elements compared to the other groups: Dad is a pile of money / euro, the mother is a big heart, a star brother and grandparents are younger. In drawing the person appearing new characters: girlfriend or opposite sex, brother, grandmother, people who are invested emotionally. Himself appears as the profession they want to follow or a more mature person with more details and colorful (narcissism). Desires healthy children are more varied and more abstract than the sick children: they want peace in the world, to go shopping, to go to sea, to have a little brother and material things: tablet, bike, car, laptop. Projection of future children of the same age is specific: to become rock stars, to sing, to go hopping or to have a family. The concept of “health” disappears, but remain those of “happiness” and “love.”
Analysis drawings show a similarity in appearance depressive themes for sick children in groups with a stronger traumatic projection in the sample of children with oncologic diagnosis.
The stories are similar to lots of sick kids by the identification of the statements used. The group of healthy children project no injuries, drawing their own wishes of day to day life situations .

IV. CONCLUSIONS

From the foregoing findings it results that the samples of sick children have a similar thematic approach represented by similarity in :the mode of execution of the design, the colors used in page design and placement of the primordial elements. There are recurrent themes: home, family, health, happiness, rainbow, flowers, medicines, car, balloons, dresses and recurring characters: animals (butterflies, insects, birds, pets), witch. The figures are schematic and have the same characteristics in color or with no color present. Drawings are oriented in the top left or bottom (regression in front of their gates were closed future), and the projection of the future is positive. Desires are related to both health and family and material things.
Repeating features all the characters in the sets of drawings means stereotype behavior, they have lost some of the spontaneity and live under the compulsion of regulation (rules of the hospital), which indicates a neurosis and structure obsessional personality reflected in coloratura lines, elements drawings.
The group of healthy children are similar to the group of chronically ill children execution style and color in the drawings , but issues such as health are not present, being replaced by happiness, and love, detailed by the appearance of new themes such as: shopping trips, peace in the world.
Projection in disease is evidenced by:
1. Analysis of the drawings:
Mode of execution of the drawing lines uncertain, poorly drawn characters not put a line on the ground, drawing on the sheet position: top left or bottom left, chosen themes: hospital, physician, medical, house, car, idyllic setting, comic elements: animals, insects, skull, drip, rain; color: dark colors, dull or lack color; disease in structure design elements: hairless head, points radiotherapy, patches
2. The way subjects express feelings in drawings
Emotion is represented in the following form: sadness, depression: characters sad, passive, do nothing; self devaluing: within the family (the lowest drawing or missing); of oneself (uncolored, drawing small, bottom left); isolation, self-isolation: in the family (drawing isolated separately); It appears alone without a framework of environmental; self-censorship: locks, straps; insecurity: idyllic; socialization and integration problems: short hands, isolated from the rest of the characters drawn; hidden aggression: hands with fingers sharp, scary animals, lines drawn down; obsessive compulsive tendencies: care for details or pressed lines; dismantling lack common sense, inadequacy to reality: characters without body or hands; affective flattening: turning family objects (cabinets, helicopters); feeling that you do not have to lean lack soil line, short legs; negative expectations: skull; hope, expectation: rainbow; homesick: the house, the yard, the dog home; desire to leave and get out of the situation: car, helicopter.
Understanding and analyzing designs in drawings of sick children, will facilitate means of recognizing how they can be can guided successfully to overcome difficult moments during treatment and during admissions, using drawing both as an evaluation tool and as a therapeutic method.
3. The analysis of children stories
The stories described: depressive feelings, sadness; waiting, abandonment, loneliness, longing; guilt; presentation anxiolytic and traumatic circumstances without any possible way out; use of words such as illness, death, cry, wait, is left, wrong, wait, is alone.
Psychological intervention is essential at the following times:
In the process of hospital admissions (for accommodation).
In the process of receiving diagnosis (through the period of denial) , during medical procedures (by playing psychological training and counseling), through the period of treatment (psychotherapy support), in case of death in the environment (psychotherapy to manage grief).
Along with play therapy, cognitive-behavioral psychotherapy and existential positive psychodrama techniques project makes an important addition to achieving therapeutic approach.

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