A Developmental Approach to Understanding Drawings and Narratives From Children Displaced by Hurricane Katrina by tee4cute


									Original Article


A Developmental Approach to Understanding Drawings and Narratives From Children Displaced by Hurricane Katrina
Wendy Sue Looman, PhD, RN, CNP
ABSTRACT Using art as a process to help children externalize complex feelings can add another layer of assessment in the primary care setting. In the face of trauma, drawing may help children gain symbolic control over events that are confusing and frightening. Through examples of children who were affected by Hurricane Katrina, this article describes the use of drawings and narratives to understand children’s experiences related to traumatic displacement. Recommendations include using a developmental lens to understanding children’s art, asking children to talk about their drawings, and considering the significance of place for children who have been traumatically displaced. J Pediatr Health Care. (2006) 20, 158-166.

Wendy S. Looman is Assistant Professor, University of Minnesota School of Nursing, Minneapolis. Reprint requests: Wendy S. Looman, PhD, RN, CNP, University of Minnesota, School of Nursing, 5-160 WDH, 308 Harvard SE, Minneapolis, MN 55455; e-mail: looma003@umn.edu. 0891-5245/$32.00 Copyright © 2006 by the National Association of Pediatric Nurse Practitioners. doi:10.1016/j.pedhc.2006.01.008

Children’s drawings and narratives can provide a unique window into their inner experiences, particularly when they have experienced trauma. While much has been written about the science of interpreting children’s drawings, there are limitations to formulaic approaches that seek to diagnose pathology or measure cognition. Goodenough (1926) emphasized that children’s drawings are not easily categorized by singular characteristics and warned against clinicians’ using drawings to diagnose psychopathic tendencies. Instead, understanding children’s drawings in context and using art as a process to help children externalize complex feelings can serve to add another layer of assessment in the primary care setting. Using a developmental lens, this article describes the use of drawings and narratives to understand children’s experiences related to traumatic displacement. Hurricane Katrina and the resulting flooding from the levee breech in New Orleans, Louisiana, displaced nearly half a million people from the affected areas. According to U.S. Census Bureau (2005) estimates, 9.7 million people living in Alabama, Louisiana, and Mississippi experienced hurricane force winds as Katrina made landfall in the Gulf Coast. In the weeks after the hurricane, evacuees remained in makeshift shelters in churches, recreation centers, and massive sports domes. These shelters became home to thousands of children and their families who remained homeless either because their homes were destroyed in the storm or because residents were not allowed to return to the storm-ravaged area until several weeks later. One in five Louisiana residents (19.36%) and one in four residents of the city of New Orleans (23.2%) live in poverty (U.S. Census Bureau). Because persons
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In the face of trauma, drawing may help children gain symbolic control over events that are confusing and frightening.

living in poverty were less likely to have a means of transportation to evacuate before the hurricane, the families who remained in shelters usually were those who experienced poverty before the storm. In response to a need for primary care and assessment of individuals living in temporary shelters immediately following Hurricane Katrina, teams of health care professionals from around the United States traveled to Louisiana and the surrounding states. Minnesota Lifeline was a collaborative effort between the University of Minnesota Medical Reserve Corps, Mayo Clinic, the College of St. Catherine, and American Refugee Committee. This collaborative effort recruited health care teams and quickly mobilized to provide health care in Louisiana. Members of these teams traveled to western Louisiana to provide primary care and public health services to evacuees in the shelters in the area. Four teams of advance practice nurses, physicians, infectious disease experts, and mental health providers each spent 2 weeks there, traveling to shelters and the Louisiana Health Department Clinics to care for more than 5200 displaced victims of the hurricane. In addition to needing treatment for acute and chronic health conditions, many of the evacuees needed an opportunity to share their stories and talk about events related to the hurricane and flooding. Evacuees told of experiences, including “swimming out of New Orleans,” leaving cherished pets behind, and being rescued from rooftops by strangers. Family members were separated, homes were destroyed, and lives were
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lost in the days immediately following the hurricane. Children who were evacuated during the storm or flooding witnessed physical, social, and emotional chaos. Children who were evacuated with their families before the storm watched these events unfold on television as the nation’s attention was focused on this natural disaster of unprecedented proportions. As pediatric nurse practitioners, we realized that many of these children, while physically unharmed, were struggling to comprehend “life after Katrina” and needed a safe way share their own stories with us. Natural disasters such as hurricanes, tornadoes, and earthquakes can have a powerful impact on children. The trauma of a natural disaster is “a line of demarcation distinguishing a time of relative safety and a time of distress, fear, anxiety, and other concerns associated with experiencing the trauma” (Malchiodi, 1998, p. 137). The children and families were living in shelters, and at the time there was no plan for returning to their homes. Long-term difficulties following natural disasters are most likely to be seen when children have to relocate or are unable to return to their schools or communities following disasters (National Association of School Psychologists, 2005). For children

who lack the ability to communicate emotions verbally, art expression is a way to bring order and containment to feelings that may be contradictory, confusing, or difficult to say with words (Malchiodi). A primary benefit of using art with children is that it increases the amount of information a child reports about past experiences. In the face of trauma, drawing may help children gain symbolic control over events that are confusing and frightening. In the clinical setting, drawing and storytelling can facilitate young children’s ability to talk about emotionally laden experiences (Gross & Hayne, 1998). In two experiments, Gross and Hayne found that drawing increased the amount of information that young children reported about their past experiences. In the first experiment, 40 children between the ages of 3 and 6 years were asked to describe a time when they were happy, a time when they were sad, and a time when they were scared. Half the children were asked to tell the experimenter about each of these experiences (the tell group) and the remaining half were asked to draw each of the experiences and to describe the drawing as he or she did so (the draw group). Gross and Hayne found that children in the draw group reported significantly more (more than twice as much) information about their emotional experiences than did children in the tell group. In the second experiment with 20 children ages 5 to 6 years, the procedures of the first experiment were followed with the exception that each child was interviewed using both the draw

A primary benefit of using art with children is that it increases the amount of information a child reports about past experiences.
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and tell procedures. The accuracy of children’s accounts were assessed through interviews with parents, who were asked to indicate whether the event actually happened and whether details about the event were accurate. Gross and Hayne found that, as in the first experiment, drawing increased the amount of information the child reported, and that this increase did not occur at the expense of accuracy. Gross and Hayne (1998) propose that drawing increases the amount of information that children report about past experiences through a number of potential mechanisms. First, drawing may reduce the perceived demands of an interview with a clinician. Drawing may facilitate memory retrieval; children allowed to draw during an interview may remember more about the event as they draw. Drawing also may help children organize their narratives, allowing them to tell a better story. Finally, drawing may facilitate children’s interview performance simply because it extends the duration of the actual interview (Gross & Hayne). The process of drawing can help children put distance between themselves and their problems by making these tangible and visible. Children’s art expressions, like children themselves, are individual and must be considered as such within the larger context of their developmental, emotional, social, and cultural experiences. Malchiodi (1998) used a phenomenologic approach to understanding children and their drawing. This approach is important because it emphasizes an openness to a variety of meanings, the context in which they were created, and the maker’s way of viewing the world. It is important to encourage children to say something about their drawings; this acknowledges the importance of the child’s perspective and the personal meaning that
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is expressed in the drawing. According to Karnick (2005), art is an opportunity for expression that can help children describe the meaning of life situations; “bearing witness to children as they use art and words to describe their feelings encourages and fosters new ways of becoming for the nurse and the child and the child’s family” (p. 221). As Gross and Hayne (1998) found, using drawing when interviewing children can help the child tell more of his or her story; the pediatric nurse who incorporates drawing into assessment further enhances the quality of the interview by considering this story within the child’s developmental,

emotional, social, and cultural contexts. THE PSYCHOLOGY OF PLACE Using art with children is helpful in both normative and nonnormative situations. In the case of trauma, particular attention to the type of trauma a child has experienced is important. For the children who were forced to leave their homes during Hurricane Katrina, displacement was a significant source of trauma. Fullilove (1996) wrote about the psychology of place and its implications for understanding the behavior of individuals who are

FIGURE 1. Ten-year-old child’s drawing: “It is sad to leave your home and know your house is under water or might be on fire. I will miss New Orleans.” This figure is in color online at www.jpedhc.org.

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FIGURE 2. Certain features of children’s drawings—such as the lack of color in an object that most would use color and a shaded, sad face—may indicate existing depression. This figure is in color online at www.jpedhc.org.

displaced from their homes. The psychology of place is based on the assumption that individuals strive for a sense of belonging to a place. This sense of belonging, according to Fullilove, arises from the psychological processes of familiarity, attachment, and identity. Displacement can lead to feelings of disorientation that can affect one’s well-being and sense of belonging. One feeling that results from displacement is nostalgia. From the Greek nostos, meaning “a return home,” and algos, meaning pain, the term nostalgia was used by physicians hundreds of years ago. When travel was more of an ordeal than it is now, physicians recognized “nostalgia” as a life-threatening
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condition that afflicted those far from home (Fullilove). Feelings associated with the loss of home include sadness and longing. These feelings are likely enhanced when displacement is traumatic and when there is much uncertainty. Case’s (1996) research on the dynamic between “home” and “away” suggests that being away from one’s

residence causes those things, people, and activities that are associated with it to become more apparent through their absence. A 10-year-old child who left New Orleans before the flooding occurred described the sadness she felt and the difficulty of not knowing whether her home survived (Figure 1). For adolescents, who are in a stage of identity versus role confusion, identity is a dynamic process that balances rootedness and uprootedness (Manzo, 2003). In the following statement, an adolescent describes a sense of uprootedness as manifest in the absence of routine, explaining what was most difficult for her: “Moving from school to school. Not seeing the usual people always at your house. Friends gone. Misplaced aggression for the things that happened in the Super Dome. No help being offered when really needed.” This child’s sense of loss of those things that were familiar and that were part of her identity was compounded by her struggle to comprehend the injustices that accompanied the chaos after the hurricane and flooding. Drawing may be helpful for children who have experienced trauma, because it provides them a way to express their feelings of sadness as well as the anger, anxiety, and frustration that may accompany it (Malchiodi, 1998). A 5-year-old child who was displaced with her large extended family was living in a shelter. This family was forced to leave their fishing village on the gulf when

It is important to consider children’s drawings within the larger context of their developmental, emotional, social, and cultural experiences and to be open to a variety of meanings.
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Table 1. Stages of children’s artistic and cognitive development
Stage of artistic development Stage of cognitive development (Piaget) Approximate age range Implications for expression through drawings* Recommendations related to using art in the primary care setting with displaced children

Scribbling stage (I)

Latter part of sensorimotor period, beginning of preoperational

18 months to 3 years

Child thinks kinesthetically, begins to improve eye hand coordination, likes to imitate speech and actions of others; later, begins to recognize the edge of the paper and draw shapes Child enjoys naming and inventing stories about drawings, will actively seek to talk about the drawings; symbolic thought is emerging; developmental landmark: child can connect marks on paper to the world around them; shapes, designs, and beginning human figures appear Child has increased symbolic thought, ability to classify and see relationships; child conceives space as primarily being related to his/her own body; “tadpole” drawings of people appear; often draws houses, sun, flowers, trees (common things in environment) Child develops visual symbols/ true schemata for human figures, animals, houses—often fairly standard to most children’s drawings (house with triangular roof, person with hairstyle, arms and legs); groundline appears; may exaggerate size to emphasize something to the viewer Child begins to shift away from egocentric thinking and considers thoughts, feelings of others; understands relationships, cause and effect; increasingly aware of the world around him or her Child thinks about large systems of events, can reason about ideas, impossibilities, probabilities, and broad abstract concepts; child’s drawings are less free due to a need for perfection/photogenic effect; may not draw at all at this stage

Basic forms (II)

Preoperational/ Preconceptual

2–4 years

Provide materials that are easy for a very young child to use (i.e., large, sturdy crayons, paper with space for scribbling); use art as a way to engage the child; at this stage children may not cognitively connect marks on paper to the world around them. Focus on child’s description rather than actual lines or shapes on the paper, because child’s interpretation of what he or she drew may change; encourage the child to tell a story about the drawing

Human forms and early schemata (III)


4–6 years

See Stage II, above

Emergence of visual schema (IV)

Concrete operations

7–9 years

Encourage the child to draw a picture of his or her home or a favorite place; as the child describes the drawing, use phrases such as “say more about that” or “and then what?” Avoid asking the child why he or she drew something; focus on the story told by the artist See Stage IV, above

Interest in realistic drawing (V)

Concrete operations

9–12 years

Adolescent artistic development (VI)

Formal operations



Provide alternate materials for art expression, including those that allow more abstract expression (such as clay, watercolor, or chalk); offer the adolescent an opportunity to direct his or her art or narrative to an audience (actual or imagined) of children of the same age

*Based on Malchiodi (1998).

Hurricane Katrina moved through the area. She drew a picture of a sad person beneath a colorless rainbow, despite the availability of
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additional colors (Figure 2). This child’s drawing suggests intense sadness, given the lack of color in an object usually associated with

color, and the shaded, sad face without a body (Malchiodi). For this child, drawing provided a way to express her sadness; it was
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FIGURE 3. Five-year-old child’s drawing of a house (center) and the “hurgercane” (C). Inside the house, the child can be seen smiling (A) and sad (B). This figure is in color online at www.jpedhc.org.

through this drawing that the provider was able to identify the emotional significance of loss for the child. In situations where depression is suspected, it is important for the practitioner to refer the child and family to an appropriate mental health provider. ARTISTIC AND COGNITIVE DEVELOPMENT In addition to considering psychology of place, it is important to consider children’s level of cognitive and artistic development, because these have implications for the their ability to symbolize their experiences and provide cues about the their understanding of events around him or her. Lowenfeld (1947) stated that children’s growth through art was analogous to the process of organizing thoughts and the development of cognitive abilities. Lowenfeld described six major stages of artistic development during which a child moves from scribbling to creating realistic images on paper. Stages of artistic development correspond roughly to Piaget’s (1959) theory of
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cognitive development (see the Table). Understanding the significance of these stages will help the practitioner gain insight into the processes behind a child’s artistic expression. This framework of artistic and cognitive development will be used in the following sections to discuss drawings by children who experienced Hurricane Katrina and its aftermath. PRESCHOOL/KINDERGARTEN For children ages 4 to 6 years, drawing can facilitate discussions about traumatic experiences by providing a link between children’s internal thoughts and their perceived reality. According to Malchiodi (1998), children in this age group are at stage III of artistic development, in which human forms and early schemata begin to appear. In what Piaget (1959) terms the preoperational stage of cognitive development, children’s mental processes are governed by their own perceptions of events; there is little separation between internal and external reality. There is an emphasis on transductive rea-

soning, egocentrism, and animism in children’s thoughts and behaviors. Lowenfeld (1947) refers to this stage of artistic development as pre-schematic, where children begin to make connections between drawing, thinking, and reality. Using more symbolic thought than at earlier stages, children conceive space primarily as being related to themselves and often draw common things in their environment such as houses, trees, and people. Animism may be evident as children ascribe human motives to nonhuman objects in the environment. Preschool or kindergarten-aged children’s use of animism to explain events in the environment is evident in the drawings of displaced children; they depict the hurricane as human with human motives of destruction. This attribution of human qualities to a natural event may be reinforced by the fact that the media and adults give human names to tropical storms and hurricanes. Discussions of Katrina and “her approach” likely supported the child’s notion that the storm had human motives, and egocentrism would lead the child to believe the he or she is the target of destructive intentions. For example, a 5-year-old child drew a picture of a “hurgercane” with a human face approaching his house (Figure 3). He told the following story about his picture: “This is me smiling and this is me sad. I’m sad because of the hurgercane. It wants to break stuff down. It won’t break me down ’cause I’m too big.” Having this child tell his story through drawing helped the nurse practitioner understand his fear related to the “hurgercane” and his conflicting feelings of sadness (because it wants to “break stuff down”) and security (“can’t break me down ’cause I’m too big”). The facial features on the “hurgercane” remind the observer that this child considered the storm to be anthropomorphic.
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FIGURE 4. “This is a house. It’s Hurricane Day. They ran out of the house. The poodle came, too.” This figure is in color online at www.jpedhc.org.

story about their experiences to identify potential sources of fear and anxiety. In this case, the child’s assumption that rain may always be followed by catastrophic destruction was discussed and anticipatory guidance was provided to the parent. ELEMENTARY SCHOOL Between the ages of 7 and 12 years, children are less egocentric and are able to represent objects in relation to one another (as opposed to in relation to themselves). Children seek to find order in the environment and to develop rules for behavior and structure in their lives. In stages IV and V of artistic development, children develop visual symbols and true schemata for human figures, animals, and houses. These symbols and schemata often are fairly standard to most children’s drawings (such as the house with a triangular roof, or a person with a hairstyle, arms, and legs). The groundline appears in drawings at this stage. There may be exaggeration of size to emphasize something to the viewer or as a result of some experience of trauma (Malchiodi, 1998). In Piaget’s (1959) concrete operations stage of cognitive development, children can reason through real and mental actions on real objects, can reverse changes to the world mentally to gain understanding, and can reason using a stable rule system. The child whose drawing is shown in Figure 4 told a story of people who ran out of a house on “Hurricane Day”; her drawing includes some standard elements and tells a straightforward story of her experience. A common situation depicted by elementary-aged children who experienced Hurricane Katrina was people standing on the rooftops of submerged houses. One 9-year-old child drew such a scene and told the following story: “People are on top of houses, and the water was flowing beneath the people of the house. And the peoJournal of Pediatric Health Care

An example of transductive reasoning in these children’s drawings and stories was their descriptions of the sun’s power sun to “cause” the hurricane and to make it go away, as well. For these children, their experience was that the sun went away before the storm and returned after the storm. A 6-year-old girl told this story about her drawing: “The hurricane: It rained, it knocked everything down. Then it rained all day. Then the place was destroyed. The sun
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made it go away.” Because many children experienced a sequence of events that included the sun “going away,” the rain and wind all day, and the appearance of calm weather when the sun returned, young children who experienced the storm may have anxiety or fear in the future when a storm, though not a hurricane, approaches. Providers who work with children who have experienced trauma, such as displacement, can use the process of drawing or telling a

ple say, ‘Help me Lord’ and the Lord lifted his hand and said, ‘I will help you.’” This child’s story and its positive ending suggests he was able to synthesize messages of hope from his support systems into his drawing. In the case of this 9-year-old child’s drawing, asking the child to tell a story about his drawing revealed important information that would not have been evident from the drawing itself. The way adults ask children to talk about their drawings can have either a positive or negative effect on the quality of information gained. For example, asking, “Why did you draw those people there?” or, “Why is the house under water?” may not be as helpful as saying to the child, “I see three people on top of a house” or, “I wonder what those people are feeling.” Asking “Why?” may discourage the child who does not really know why he drew what he did, while commenting on what is present in the drawing can encourage the child to tell a story about the experience using the drawing as a safe means of expression. ADOLESCENT By the age of about 12 years, children enter a stage of artistic and cognitive development in which they can think about ideas and broad abstract concepts. In Piaget’s stage of formal operations, adolescents think about large systems of events. According to Dixon and Stein (1992), adolescents “practice the physical and mental schema they possess, almost to exhaustion and without the necessity of reinforcement from the external environment” (p. 22). At this age, schematic representations no longer satisfy children’s needs to represent their perceptions in their drawings. The desire for drawings to accurately reflect reality may lead adolescents to not draw at all, opting for words to express abstractions. The adolescent children who experienced the trauma of Hurricane Katrina and its aftermath
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were more likely to express themselves in words than in drawings. The words they shared suggested a struggle to understand the reality of a catastrophe and the social unrest that ensued in the days after the levee breech. “My experience from hurricane Rita and Katrina is devastating,” wrote a 14-year-old girl. “Life feels so, strange, all days are different now.” This child added a small picture of the Earth to her narrative. Unlike the younger children who depicted the experience as it affected their immediate surroundings, this adolescent focused on the enormity of the event, physically as well as emotionally. CONCLUSIONS Children’s drawings and narratives provide clues to adults wishing to explore the unique and shared experiences of children who were evacuated from their homes after Hurricane Katrina. Encouraging children to tell their stories through drawings enables practitioners to obtain a more complete perspective on children’s experiences, reactions, and coping. Having these children draw provided them an opportunity to share their experience through an activity that was familiar and nonthreatening. It also enabled the practitioners to understand more fully the range of experiences and reactions of the children who were displaced by Hurricane Katrina. RECOMMENDATIONS Apply a developmental lens when using drawing as a tool for assessment in the primary care setting in order to tailor the assessment process and discussion during the drawing activity. Depending on children’s ages and developmental levels, different approaches may be used to help children express themselves through artwork. Children in the Basic Forms stage of artistic development (stage II), for exam-

ple, may benefit more from telling a story about the drawing than through drawing as a process itself. Older children who are able to depict themselves in relation to the environment can be encouraged to “say more” in the drawing, because this may help them remember more aspects of an experience than they would just talking about the experience. Adolescents who may feel that drawings cannot capture the complexity of their thoughts and feelings may wish to write about their experience, with an intended audience of peers, parents, or the provider in mind. Children should be asked to provide an explanation for their drawings when possible, because it acknowledges the importance of their perspectives and the personal meaning that is expressed in the drawing. More information can add context to children’s artwork and may help providers understand their perception of the important aspects of the drawing. It is important to consider children’s drawings within the larger context of their developmental, emotional, social, and cultural experiences and to be open to a variety of meanings. When children’s drawings or stories suggest depression or other serious emotional difficulties, it is important to refer to appropriate mental health professionals. Finally, consider the meanings that are attached to place, because any kind of displacement is potentially traumatic, including moves that are planned. The environment is a central part of one’s life, identity, and ability to manage feelings and maintain a sense of well-being (Manzo, 2003). Children and adults who are displaced by natural disasters, such as those affected by Hurricane Katrina and the resulting flooding of Louisiana, may experience a profound sense of loss that is difficult to articulate and may not be identified as sigMay/June 2006 165

nificant by health care providers. The advance practice nurse can facilitate healing for individuals who experience displacement by encouraging them to share their experiences through narratives, artwork, or both. REFERENCES
Case, D. (1996). Contributions of journeys away to the definition of home: An empirical study of a dialectical process. Journal of Environmental Psychology, 16, 1-15. Dixon, S. D., & Stein, M. T. (1992). Encounters with children: Pediatric behavior and development (2nd ed.). St. Louis: Mosby.

Fullilove, M. T. (1996). Psychiatric implications of displacement: Contributions from the psychology of place. American Journal of Psychiatry, 153, 1516-1623. Goodenough, F. (1926). Measurement of intelligence by drawings. New York: Harcourt, Brace, & World. Gross, J. & Hayne, H. (1998). Drawing facilitates children’s verbal reports of emotionally laden events. Journal of Experimental Psychology, 4, 163-179. Karnick, P. M. (2005). Human becoming theory with children. Nursing Science Quarterly, 18, 221-226. Lowenfeld. V. (1947). Creative and mental growth. New York: Macmillan. Malchiodi, C. A. (1998). Understanding children’s drawings. New York: Guilford. Manzo, L. C. (2003). Beyond house and haven: Toward a revisioning of emotional

relationships with places. Journal of Environmental Psychology, 23, 47-61. National Association of School Psychologists. (2005). Responding to Hurricane Katrina: Information for school crisis teams. Retrieved November 2, 2005 from http://nasponline.org/ NEAT/katrina.html Piaget, J. (1959). Judgment and reasoning in the child. Patterson, NJ: Littlefield, Adams. U.S. Census Bureau. (2005 November 2). Census bureau estimates nearly 10 million residents along gulf coast hit by Hurricane Katrina (press release). Retrieved November 2, 2005 from www.census.gov/Press-Release/www/ releases/archives/hurricanes_tropical_ storms/005673.html.

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