Elsevier

The Arts in Psychotherapy

Volume 72, February 2021, 101740
The Arts in Psychotherapy

Psychological well-being and graphic representations of self in child victims of violence

https://doi.org/10.1016/j.aip.2020.101740Get rights and content

Highlights

  • Violence during childhood may interfere with child emotional expression.

  • Most studies investigated the consequences of violence in childhood using questionnaire.

  • Drawings might be a useful tool assessment with children victims of violence.

  • Drawings can help children to express thoughts and feelings that may be difficult to communicate.

Abstract

In this study, we had three aims: (a) to investigate whether child maltreatment facilitates the onset of internalizing problems, externalizing problems, and posttraumatic stress symptoms (PTSS); (b) to explore through a standardized projective technique whether the image of the self in maltreated children is related to more inadequate personal resources and more archaic defense mechanisms; (c) to verify the relationship between the presence of internalizing problems, externalizing problems, PTSS, and the key elements of drawings by maltreated children. The study involved 94 children (39 maltreated children and 55 non-maltreated children) aged between 5 and 13 years. We investigated internalizing and externalizing behavioral problems using the Child behavior Check List 4–18, and we investigated PTSS using the Parent Report of Post-Traumatic Symptoms. We used the Draw-a-Child-in-the-Rain activity to investigate mental representations of the self and children’s defense mechanisms. Results indicated a higher rate of internalizing and externalizing problems and of PTSS in maltreated children. Graphic representations by maltreated children differ from those by non-maltreated children in the use of color, amount of detail, and the depiction of an umbrella. Drawings seem to be valid aids for expanding knowledge of the representation of self and the psychological functioning of the child.

Introduction

Violence during childhood is a worrying and widespread phenomenon worldwide. In particular, child maltreatment including physical abuse, sexual abuse, emotional abuse, and neglect impacts a significant number of children around the world. In 2015, about 1.7 billion children and adolescents experienced some form of interpersonal violence. Regarding the European context, the World Health Organization (WHO, 2013, 2016) reported that about 18 million children are victims of sexual abuse, 44 millions of physical abuse, and 55 millions of emotional and psychological abuse. Notably, in Italy a national survey found the following maltreatment rates for minors charged to Social Health Assistance: 47.1 % for neglect and/or affective maltreatment, 19.4 % for witnessing violence, 13.7 % for psychological maltreatment, 8.4 % for in-treatment conditions (i.e., lack of care/hyper-care), 6.9 % for physical abuse, 4.2 % for sexual abuse, and 1.2 % for undefined violence (CISMAI & Terre des Hommes, 2013).

Importantly, different research has suggested that early maltreatment can impact and alter a child’s development, leaving the victim with significant short-term and long-term impairments. For example, it is well known that child maltreatment is generally related to several problems in psychological and physiological functioning (Di Blasio, 2000; Fong, Hawes, & Allen, 2019; Perkins & Graham-Bermann, 2012). Notably, although some children show high resilience after child maltreatment, they may react by developing behavioral and emotional problems and difficulties in the establishment of a coherent self and defense mechanisms (Evans, Davies, & DiLillo, 2008; Jaffe, 2018; Moffitt, 2013). Moreover, different work has suggested that child maltreatment seems to be associated with both internalizing (i.e., anxiety, depression, withdrawal, and somatic and personality disorders) and externalizing problems (i.e., aggressive and delinquent behavior) (Muniz et al., 2019).

Therefore, given the high prevalence and serious potential negative consequences of child maltreatment, it is of crucial importance to understand better the mechanisms that lead to behavioral and emotional maladjustment among maltreated children and to detect its consequences effectively and promptly (Stirling & Amaya-Jackson, 2008; Yoon, Steigerwald, Holmes, & Perzynski, 2016). Notably, as suggested by the developmental traumatology model (De Bellis, 2001), children experiencing posttraumatic stress symptoms (PTSS) have difficulty behaving appropriately and dealing with these symptoms. Therefore, they may display more internalizing and externalizing behavioral problems (De Bellis, 2001, 2002; Fong et al., 2019).

It is well known that questionnaires are among the most widely used methods in clinical and research settings to detect the consequences of child maltreatment, including PTSS and behavioral or emotional problems (Barbozaa & Dominguez, 2017; Fong et al., 2019; Yoon et al., 2016). Nevertheless, it is widely demonstrated that children who experience traumatic events generally have difficulty reporting their concerns regarding themselves and their lived experiences and do not answer well to direct questions. Notably, maltreated children may feel emotions of shame, guilt, and humiliation (Jung & Kim, 2015) that make it more difficult for them to express their feelings. Moreover, when the abuse is perpetrated within the family, children may find it difficult to share personal or family secrets with others (Tanaka, Kakuyama, & Urhausen, 2003).

Therefore, several authors have indicated that artistic expression (i.e., drawings) is a useful tool to assess and elaborate traumatic experiences, including child maltreatment (Backos & Samuelson, 2017; Steele & Kuban, 2003).

Drawings can help children express thoughts and feelings that may be difficult to communicate through other forms of expression, such as oral storytelling or writing (Ionio & Procaccia, 2003, 2006; Lisi, Valentina, Giovanna, Valeria, & Grattagliano, 2013). Moreover, drawing is a sensory mode of expression. Some authors have suggested that drawings may stimulate the expression of sensory memories (Steele, 1997; Steele & Raider, 2001). Traumatic experiences are associated with strong emotional experiences that are encoded by the limbic system as a form of sensory memory (Malchiodi et al., 2001). Sensory media such as drawings can be considered as powerful tools for the detection and elaboration of traumatic events (Steele & Kuban, 2003).

Although many authors have emphasized the importance of drawings as an effective technique to evaluate the effects of traumatic experiences such as child abuse (Callaghan, Fellin, Alexander, Mavrou, & Papathanasiou, 2017; Einarsdottir, Dockett, & Perry, 2009; Lisi et al., 2013), others have indicated that further evidence is needed to demonstrate the reliability and validity of this technique in clinical, legal, and research fields.

Section snippets

Aims

Starting from the abovementioned premises, we aimed in the current study to investigate through questionnaires and drawings the psychological functioning, mental representations of self, and defense mechanisms in child victims of violence. In this paper, we have replicated the results of a previous pilot study (Ionio & Ripamonti, 2016) on a larger sample of maltreated Italian children to evaluate the stability of previous results, trying in this way to overcome one of the limits of the pilot

Participants

Participants included 94 children aged between 5 and 13 years (M = 8.76, SD = 2.34), of whom 49 (51.3 %) were male and 45 (48.7 %) were female. Among the 94 children, the clinical sample consisted of 39 (41.5 %) who had experienced maltreatment, recruited from an Italian child protection community; the control sample consisted of 55 (58.5 %) who had not experienced maltreatment, recruited from Italian primary schools. Recruitment for the clinical and control samples took place between January

Results

The first research objective was to investigate better whether experiences of violence during childhood facilitate the onset of behavioral problems, measured by the CBCL, and of PTSS, measured by the PROPS. We conducted intergroup comparisons between the clinical and control samples using a t-test for an independent sample. Data showed the presence of significant differences between the two groups in both internalization and externalization behaviors (see Table 1). In particular, children in

Discussion

Different psychological research on children’s experiences of various forms of maltreatment has indicated a negative impact on children’s behavioral and socio-emotional development (Meltzer et al., 2009). Since maltreatment during childhood is associated with a high prevalence of severe outcomes for a child’s mental health, including internalizing and externalizing behavioral problems, and PTSS (Grip, Almqvist, & Broberg, 2012), it is necessary to investigate the mechanisms that lead to

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