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The Face of Diabetes: the Child's Perspective

Collaborate Cultivate Educate PENS 2015 National Conference

PENS 2015 Platform sessionMay 2015Shari Liesch APNP, CD

Conflict of Interest Disclosure

• NONE

Objectives

• Explore the role of art in pediatric health care

• Discuss the results of review of art collected in routine follow up diabetes visits

• Explore future research


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Review of Literature

Art has been used:

• to make meaning

• facilitate comprehension

• manage stress

• to enhance self‐esteem and life satisfaction.

• integrate creativity (non‐verbal/verbal)

• shape persons through self‐exploration & expression.


Basso & Pelech; Coad, LoomanBasso & Pelech; Brown; Nuvoli et al,Brown; Nuvoli et al. Brown; MatsumoriCoad; RollinsBrown; Basso; RollinsBasso; Carter & Ford; Doldze, Smith Tchanturia.

Literature review, cont.

• Art enables a sense of accomplishment.

• Drawing aids in sorting through feelings & experiences

• It promotes expression of what might be suppressed (words cannot describe).


Art in the literature, cont.

• By reducing stress, coping is facilitated (in general) & when dealing with chronic illness.

• Art allows enhanced communication

• Art allows distancing between “artist” and their “condition”.


Doldze; Nuvoli.Brown; Carter & Ford; Doldze et al; Looman; Matsumori;Looman, WendyBrown.ADA

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Lit review, cont.

• Detail and expression within facial drawings develop in tandem with child development.

• Art is developmentally supportive & can impact neuronal development.

• The process of visualizing & working to achieve the outcome imagined impacts focus‐ability.

• Diabetes care & outcomes are influenced by stress


Limited studies using art in diabetes

Nuvoli et. al. 1989• Youth age 10 to 15 years• Used “draw a sick person”,

• compared to control of well youth “draw a person” test.

• The “diabetic” youth • drew an image of “sick person” having projective elements, depressive signs

& retiring into themselves. • seemed less prone to the cultural stereotype requiring a smiling, happy

image of a “healthy person”, • had symbolic defense which allowed them to adapt & move from

anxiousness to psychological recovery.


Nuvoli, Maioli, Ferrari, Pala,& Chiaretti, 1989

Limited studies, cont.

Basso and Pelech 2008

• Studied creative arts intervention in Diabetes camp

• Used acting and role playing

• Youth had opportunity to decipher the emotional part of diabetes through symbolic play in a secure environment


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Basso & Pelech, 2008.

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Limited studies, cont.Harel et.al in 2013

• Used art therapy for youth with poorly controlled type 1 diabetes• Observed improved glucose control in 56% of the case group • (compared to 23% of the control group)

Nansell, Iannotti, and Liu, in 2012

12 to 14 year old age group studied for clinic intervention

• Clinic-integrated behavioral interventions for family of youth with diabetes had a significant overall effect

Harel, et al 2013Nansel, Iannotti, Liu, 2012 4/23/2015 10

Our Art “event” @ Children’s of WI‐ Fox Valley

• Duration: August to December 2014

• Students given paper, crayons

• While clinic data entered into system, students were asked to draw:

• “If diabetes had a face, what would it look like?”

• As art was collected • Similarities were noted

• Literature review done: • limited data on art/diabetes

• Pictures divided into age groups:• 4‐8, 9‐12, 13‐15, 16‐20

• Nurse researchers evaluated art for complexity, expression, appliances, etc


Results of preliminary study

• Evaluated 212 pictures

• Most common expression: neutral (consistent with mandatory “smile not required in youth with diabetes) Nuvoli, et al 1989

• Other “looks”:• smile• open mouth • frowns, unhappy • tears• corner of mouth tipped• half smile/frown

• All age groups contained expressions from each emotion: Neutral, happy, frown, sad, tears, tools

• Art: simple to complex• Detailed or not

• Common themes:• Eyes off center/uneven• Exaggerated features• Lows• “Devil” features• Non human• Body fluids: vomit, sweat, blood, “snot”

• Tools used for diabetes self‐care: syringe, meter, pump, poker, blood


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Key discovered during art review?

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4‐6 year olds• Was sick that am, drew self vomiting

• Syringe and meter


6 yr. Teeth, angry and smile

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8 years‐one color design


8 yo— “Die‐aBeates” Depicting a low

Sad, body fluids

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Teammates in care

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Many had straight mouths


10 Yr. tools & tears

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10‐11 yr. Non human

The “beard”: “these are all the kids trapped with diabetes”.

Mad, red, angry, see red, it hurts

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11‐12 year old: the neutral look, uneven eyes

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Frown, uneven pupils, tools

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Devil, tears, open mouth

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Simple drawings; intense expressions

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“Tools”, that “smile” & words

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Complex to simple

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Non human: lots of pokes

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More non‐Human

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13 year olds


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13 & 14 yr. Even lips, down cast eyes

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14 yr male: “tools”, blood, tear & ears

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14 yr. Mixed facial features

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PENS second half

Attends special needs school, parents do much of cares.“Diabetes is evil. I hate it.”

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14 years neutral look

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Eye placementVisit 1 of the day:Went from non participation to laughing

Visit 2 of the same day: same off centered eyes, more detail

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Complex to simple in every age group

19 yo male

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Collaborate Cultivate Educate

PENS 2015 National Conference

Diabetes can be both good and badIt depends how you view it And how you handle it.

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The number “rules” her feelings & lifeIs mad

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Both smiled on the outside

Falling “dying” from diabetes

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Age 15 years: whatever

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Non human, Red/black

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17 year male & female

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17 Yr. female: “It’s a big thing you need to take care of. It’s always there, similar to an unwanted pet. When it is happy, nothing bad happens. It is helpless.”

13 Yr. A1c 2% better: Is it a smile?

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Outgoing, joyous on the surface

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Pancreas

Antibodies killing islet cells

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Color or not

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Carrying on

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Or not…

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Smiles?

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Our next step• Exploratory study• Does art in clinic visit

– change over time– change peds QOL‐

diabetes scores– impact willingness to

attend clinic

• Does knowing they would draw at clinic visits impact home discussions about diabetes/feelings

• Does personality type impact peds QOL db, or willingness to attend clinic

• Most important– What do they say about their art?– An interview/evaluation of what their

art means to them

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Thank You

• To fellow nurse researchers:

• Sharron Close PhD, MS, CPNP‐PC

• Dr. Elizabeth Babler, PhD, APNP, CDE, UWM

• Dr. Kathy Elertson, DNP, UWO

• All the artists, who deal with diabetes every minute of every day

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ReferencesBasso, R.; Pelech, J. A creative Arts intervention for children with diabetes Part 2: Evaluation. Journal of Psychosocial Nursing, 2008, 46, 12, 25-26-28Basso, R.; Pelech, W. A creative Arts Intervention for children with diabetes part 1: development . Journal of Psychosocial Nursing, 2008, 46, 10, 25-26-29Brown, C. Facilitating therapeutic expression and communication through play. Medical Principles and Practice, 2007, 16, suppl, 27-28-32Carter, B.; Ford, K. Researching children's health experiences: the place for participatory, child-centered, arts-based approaches. Research in Nursing health, 2013, 36, 95-96-107Coad, J. Using art-based techniques in engaging children and young people in Health care consultations and/or research. Journal of Nursing Research, 2007, 12, 5, 487-488-497Dolidze, K.; Smith, E.; Tchanturia, K. A clinical tool for evaluating emotional well-being: self-drawings of hospitalized children. Journal of Pediatric Nursing, 2013, 28, 470-471-478.Harel, et al. The contribution of art therapy in poorly controlled youth with type 1 diabetes mellitus. Journal of Pediatric Endocrine & Metabolism. 2013; 26(7-8): 669-673.La Guardia, J. Developing who I am: A self-determination theory approach to the establishment of healthy identities. Educational Psychologist, 2009, 44(2), 90-104Looman, W.S. A developmental approach to understanding drawings and narratives from children displaced by hurricane Katrina. Journal of Pediatric Health Care 2006, 20(3), 158-166.Matsumori, N. Use of drawing technique in Nursing assessment. JSPN, 2005; 10(4), 191-195.Nansel, T., Iannotti, R. & Liu, A. Clinic-integrated behavioral intervention for families of youth with type 1 diabetes: randomized clinical trial. Pediatrics, 2012, 129(4), e866-e873.Nuvoli, Maioli, Ferrari, Pala & Chiaretti. Diabetes and illness image: self perception through the draw-a-person test. Psychological Reports, 1989, 65, 83-93.Rollins, J. Tell me about it: drawing as a communication tool for children with cancer. Association of Pediatric Oncology Nurses, 2005, 22, 4, 203-204-221 Snider-Lotz, T. Analysis of the Psychometric Characteristics of the NEW personality insights style assessment. http://www.discoveryreport.com/disc_personality_modle_validation.ht. accessed 1-28-2015.Varni, J. Pediatric Quality of life inventory diabetes module (Peds QL Diabetes Module) accessed 1/28/2014. PROQOLID, the clinical outcome assessment instruments database. (access through CHW)Villani, D.; Gatti, E.; Confalonieri, E.; Riva, G. Am I my Avitar? A tool to investigate virtual body image representation in adolescent. Cyberpsychology, Behavior and social Networking, 2012, 15, 8, 435-436.

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