Using the write and draw technique with

children
Angela Bradding, Marie Horstman

This article reports on the value and possible uses of the draw and write technique to
further our knowledge and understanding of children's views, thoughts, perceptions and
emotions related to hospitals, health professionals and health information needs of
children.The main focus of the investigation were 6 - 10 year old chronically sick children
(predominantly with cancer). A group of healthy school children were used as a comparison
in order to highlight similarities and differences.The draw and write technique and an open-
ended stimulus task were presented to a total of 99 children (50 hospital, 49 community). A
wealth of valuable qualitative data were collected.The authors conclude that the draw and
write technique in conjunction with the open-ended task and interviewing could be used to
good effect both on an individual level and as an aid to the construction of audit tools.
© 1999 H a r c o u r t Publishers Ltd.
Keywords: d r a w and w r i t e technique, children, paediatric oncology, information needs audit,
research methodology, data collection

Einsatz der Schreib - und Zeichentechnik bei Kindem

Dieser Artikel berichtet fiber Wert und Einsatzmfglichkeiten der Zeichen - und Schreibtechnik zur
Verbesserung unseres Wissens und Verstehens fiber die Ansichten Gedanken,Wahrnehmungen und Geffihle, die
Kinder in bezug auf Krankenh~iuser, Mitarbeiter im Gesundheitswesen und Informationsbedfirfnisse haben. Die
Zielgruppe der Untersuchung waren 6 bis 10Jahre alte, chronisch kranke Kinder (~iberwiegend krebskranke). Eine
Gruppe gesunder Schulkinder diente als Vergleichsgruppe, um Ahnlichkeiten und Unterschiede erkennen zu
k6nnen. Die Zeichen - und Schreibtechnik und eine offene, stimulierende Aufgabe wurden insgesamt 99 Kindern
(50 Krankenhaus, 49 Gemeinde) vorgelegt. Eine groSe Menge wertvoller, qualitativer Daten wurden gesammelt.
Aus den Ergebnissen schliel3en die Autoren, dab die Zeichen - und Schreibtechnik in Kombination mit der offenen
Aufgabe und Interviews einen guten Effekt sowohl auf der individuellen Ebene als auch als Hilfe zur Konstruktion
yon PrLiflnstrumenten haben kann.

Utilizando t~cnicas de dibujo y escritas con ni~os

Este articulo trata sobre los usos posibles y el valor que tiene utilizar t~cnicas escritas y dibujadas en nifios para
aumentar nuestro conocimiento y entendimiento de los puntos de vista, percepciones, pensamientos y
sensaciones qu tienen los nifios respecto a los hospitales. El principal foco de investigacifn fueron nifios que
padecen enfermedad cr6nica (mayoritariamente c~ncer), de edades comprendidas entre 6 y 10 afios. Un grupo de
nifios sanos de las mismas edades que el grupo anterior entraron a formar parte de este estudio comparativo para
ver las diferencias y similitudes entre ellos. Las t~cnicas dibujadas, escritas y una trabajo sin final en el que cada
nifio puede elegir uno, se presentaron a un total de 99 nifios (50 de hospitales y 49 de comunidades). Se us6 una
escala cualitativa para recoger los datos. Los autores en este estudio concluyen que las t~cnicas empleadas podrian
causar un buen efecto en este grupo y podria ser utiiizado para la construccifn de nuevas herramientas de
trabajo.

Angela Bradding MA, BA

(Hons), PGCE, Senior
Lecturer
Marie Horstman Senior
Lecturer MA, RSCN, RGN,
RNT, Adv. Dip Dip Ed.
School of Paediatric
Nursing and Child Health, INTRODUCTION explanation. Further, there is a generally poorly
South Bank University, 103 met need for children to be consulted and have
Borough Road, London SEI
OAA, UK Professionals are constantly seeking ways of their views, opinions and realities taken in to
Correspondence and allowing the child to take the lead in expressing account when they are sick. 'Children hold views,
offprint requests to:
Angela Bradding their need for information, clarification and about health and health-related issues and

EuropeanJoumalofOncologyNursing3 (3), 170-175 ~:~1999Harcourt PublishersLtd

 Using the write and draw technique with children 171

participate in self-care. However, their views are young children and cognitive development the
often ignored as they are not given full status in 'yard stick' by which to judge responses; authors
terms of rights and obligations'(Chevannes such as Donaldson (1978) have questioned these
1995). The child '[has a right] to express views assumptions. More contemporary theories and
freely and have them given due weight; in research suggest that even young children are
particular the right to be heard in any judicial highly sensitive to a variety of social norms,
and administrative proceedings affecting the signals and to what they perceive to be the
child' (Article 12 of the U N Convention 1991). expectations and demands of 'significant others'.
Adults working with children and teenagers in For example, the work on acquiescence by Light
health care are increasingly expected to act as (1986). This subtle, but nonetheless powerful
facilitators. This role can only be successfully social pressure can be a significant hindrance to
achieved if professionals and parents are aware adults involved in gathering data from children.
of a child's perspective. They must also be The responses given may not reflect the child's
prepared to acknowledge children's rights and true opinion but instead the child may be seeking
endeavour to make child-centered changes to to say what they think the adults want to hear
any provision of healthcare and treatment. (Seigal et al. 1988). A young child's perception is
Given then the apparent value and importance that there is a right and a wrong answer. Current
of a child-centred approach, the researchers in thinking views children as very sophisticated
the present study were asked by the commission- transactional 'filters' of their environments. They
ing body, Trent Regional Office, to use the draw selectively extract information from their social
and write technique as a method for collecting world and selectively modify the information
data from, and in the service of children. Action that they, in turn generate. This point is
for Sick Children (ASC formerly NAWCH) developed very convincingly by Backett-Milburn
acted as the conduit between Trent and the and McKie (1999) in their critical review of the
current researchers at South Bank University draw and write technique in health promotion.
London, UK, given their earlier experience with They believe that children's pictorial representa-
the draw and write technique as an exploratory tions will reflect the variety of contexts, settings
tool (Action for Sick Children 1998). This cur- and perceived demands rather than absolute
rent study was requested as a basis on which to 'truths'.
develop a method for gaining auditable informa- In addition to the role played by social factors
tion from young children. The 'draw and write' in children's thought, there is also a growing
technique involves, as its name suggests, the child acknowledgement that a child's understanding of
drawing a picture in response to a theme, topic various domains, including health, appear to be
or research question and writing down any more related to experience than age or level of
associated ideas. Alternatively the researcher cognitive development (Chi et al. 1989). Further,
can write for the child. there is a growing body of knowledge which
The main aim of the present study was to suggests that sick children are highly sensitive
assist in enriching children's views and percep- and receptive to illness related information,
tions about health care professionals, the envir- especially at times of chronic periods of ill health
onment in which they are being cared for, and (Kendrick et al. 1986, Ellis & Leventhal 1993,
their information needs. However, this work Hooker 1997). It is anticipated that the draw and
should also provide an ideal opportunity from write technique will distinguish between the
which to critically evaluate data collection me- hospital and community samples both in terms
thods with chronically sick children. Although of content and specificity of detail within the
'draw and write' (in the standardized format out- data.
lined in this report) is a relatively new technique The draw and write technique is gaining
it has been recommended for its 'innovative popularity amongst health professionals (Wil-
and participatory approach which increases our liams et al. 1984, Pridmore & Bendelow, 1995).
understanding of children and how they see the For example, the study by Williams (1984) used
world' (Pridmore & Bendelow 1995). Techniques it to investigate children's perceptions of five key
such as questionnaires, interviews and specially health issues, namely safety, relationships, eating,
constructed tools often run the risk of being drugs and rest/exercise. The results of this study
ambiguous, misconstrued and adult biased. were used to inform the planning of a health
Conversely, the 'draw and write' technique is curriculum. It showed itself to be a technique
seen as child friendly, non-threatening and with 'natural' appeal and clarity for young
facilitating the expression of views by the child, children and also relatively easy to use in
thus preventing the adult from becoming con- a school environment. Virtually all school age
tinuously involved (Williams et al 1989, Rollings children are very familiar with producing draw-
1990, Pridmore & Bendelow 1995). ings and writing about them. Further support for
Until relatively recently, many Piagetian tasks the technique comes from a review of the use of
were considered to be a 'window to the minds' of children's art in health research by Pridmore and
EuropeanJournalof Ontology Nursing 3 (3), 170-175
 172 European Journal of Oncology Nursing
Bendelow (1995). The draw and write technique
features prominently as an i m p o r t a n t explora-
tory tool. The current researchers certainly
considered it to be a potentially exciting way of
involving children in research, which would
provide rich qualitative data. These also h a d
the a d d e d appeal of being immediately accessible
in their own right. Partly for this reason it was
decided not to use the technique projectively,*
but rather as an overt indication of the children's
views.
Despite the aforementioned growing popular-
ity, no previous reports were found in which the
draw and write technique has been used to gather
information from chronically sick children. It was
anticipated that if administered in a systematic
way that this m a y be a way of obtaining the
opinions o f this vulnerable group without
exposing them to a long drawn out interview
which could prove physically and mentally
exhausting.
A limitation of the draw and write technique
is its lack o f suitability for gaining information
*A projective
about aspects of health care that do not lend
technique is one in
which the subject is themselves well to drawings from the children.
assumed to reveal F o r example, this research aimed to obtain
('project') themselves rather m o r e abstract d a t a about children's
through imaginative information needs (what do they want to know
productions. Examples
and from whom). The researchers commissioned
of projective tests are
the Rorscharch Test an artist to draw four pictures of groups o f
(ink blots to be people involved in the care of children: Doctors,
interpreted) and the nurses, parents and ambulance personnel. These
Thermatic pictures were to act as a specific stimulus for the
Apperception Test
(pictures that elicit child from which to add the written element (or
stories). With regards for the researcher to write for the child). This
drawings, measures of technique uses non-threatening, non-leading
intelligence and questions and therefore could provide a suitable
personality have been complement to the draw and write technique.
assessed via drawings
of the human figure.
See Thomas and Silk
(1990) An Introduction THE CURRENT STUDY
to the Psychology o f
Children's Drawings.
The project was funded through Action for Sick
Harvester Wheatsheaf,
London, for details. Children (ASC formerly N A W C H ) by Trent
*These included Regional Office of the N H S Executive and South
reassurance that this Bank University. A n initial project was con-
was not a test of ducted for A S C to obtain children's views of hos-
intelligence or spelling pitals using a draw and write approach which was
and that no one would
see their work without reported in Pictures o f Health Care - a child's
their permission. Eye View' (Action for Sick Children, 1998).
Sufficient detail of the In order for children's views to be collected in
Tasks was given so a more systematic, standardized way the cur-
that informed verbal rent research was commissioned to collect d a t a
consent could be
gained without leading from two groups, sick children with either cancer
the children's or a chronic illness and a comparison group o f
responses. Children essentially healthy school children.
were also informed of The specific research question were derived,
their right to withdraw with the help of consultation from an advisory
at any time with
penalty. All children team, from the research proposal from Trent
were given a thankyou Regional Office and Action for Sick Children.
and a certificate. These questions addressed the issues o f children's
EuropeanJournalofOntologyNursing3 (3), 170-175
perceptions of health care provision, environ-
ments and health information needs o f sick
children. D a t a were collected in N o r t h e r n
England between November 1997 and M a y 1998.
METHOD
Design
The design of this investigation can be described
as a natural experiment in that two naturally
occurring groups, children of 6-10 years and of
both sexes were sampled from c o m m u n i t y and
hospital settings.
Sample
A total of 99 children aged between 6-10 years
participated in this study, recruited from two
opportunity samples in the Trent region.
• Hospital sample: 50 children suffering from
chronic illness, predominantly cancer, from
four Trent children's hospitals/departments.
D a t a were collected in a quiet side r o o m at
their outpatient's clinic.
• C o m m u n i t y sample: 49 children from three
Trent Primary schools. D a t a were collected in
a quiet room/space outside o f their class-
room.
Procedure
The draw and write technique was used with two
scenarios/questions (Task I and Task II). The
first scenario asked the children to consider 'a
child like them somewhere in a hospital' and
draw a picture of what was in their minds. The
second asked the children to draw what they
'saw' as their 'ideal hospital'.
Task III involved presenting the children with
pre-drawn artist's pictures of four groups of
people involved in their care: M u m m y and
D a d d y , hospitals nurses, doctors, and ambulance
personnel. The children were asked to write or
say (researchers would repeat for the child if
required) what they wanted/needed to know
from these people.
All Tasks reported in this study were piloted at
a j u n i o r school in Colchester. It became apparent
that two of the original three draw and write
tasks were generating very similar d a t a and
hence were merged to form the current two.
This reduced the amount o f concentration and
work required of the children, which was con-
sidered to be advantageous.
Standardized instructions and a prearranged
set o f clarifications and gentle p r o m p t s were
written. * These were also piloted and some

amendments were made which reduced the level
of ambiguity.
The above procedure was used with all
children whose parents had given their written
consent or not opted them out in the case of
the school samples. The standardized instructions
included giving the children sufficient informa-
tion on which to base their verbal consent. They
were also informed of their right to withdraw at
any time without causing problems to the research-
ers or to themselves.
Each child was provided with their own
response booklet for their drawings and their
own copies of the artist's pictures with space
provided for their responses. The meanings and con-
tent of all the drawings and writing were confirmed
with the child before they were collected (to
reduce adult bias and misinterpretation).
Further, all subsequent data analysis required
careful planning and the construction of coding
frames
Coding Frames
Two coding frames were developed from the
data; one for the children's drawings and one for
the responses obtained from the information needs
stimulus material. This involved a systematic
process of coding the individual response 'ingredients'
into what the researchers called Semantic
Categories. Both pictorial and verbal material
from the children's drawings were subjected
to analysis.
For example, all the visual and verbal elements
from the first Task I response were recorded.
These might include: a bed, beside cabinet, light,
clock, leg in plaster, tears and a down-turned
mouth, and the words 'I am sad and lonely, I
wish I could see my friends'. The elements in the
second response would be checked against this
list, new elements added and similar items given
a score of two. This process was completed for
all three Tasks.
The individual elements identified by the
above cumulative tallies were then clustered by
the researchers into the Semantic Categories on
the basis of academic considerations and dic-
tionary definitions. A distinction was made
between the data from the two draw and write
pictures and the information needs task. The
resultant Semantic Categories were as follows:
Tasks I and II (children's drawings)
• Feelings: sad, bored, frustrated, hurt/frigh-
tened, positive
• Environment: rooms and structural aspects,
decoration/comfort, entertainment, medical
equipment.
• Significant others: female nurses, mums, dads
and other family members, others.
Usingthe write and draw technique with children 173
Task llI (information needs)
Diagnosis
Treatment
Prognosis
Supportive
Competency/role.
Data analysis
The Semantic Categories were then used to
recode all the data in order to generate tally
charts of occurrence for the various sample
groups (hospital and community). In this way
it is possible to identify similarities and differ-
ences in frequency of particular aspects of the
data.
RESULTS A N D DISCUSSION
As predicted, the draw and write technique
generated rich, qualitative data that has immedi-
ate impact and value in its own right. The
researchers were very concerned to convey the
children's thoughts, views and perspectives in a
direct uninhibited fashion. In other words, the
drawings were taken at face value and not
analysed projectively. Pridmore and Bendelow
(1995) expressed concern regarding projective
techniques. The drawings produced by the
children in the current study were clarified with
each child to check the content and meaning.
Hence, the researchers were confident that they
had understood what the child meant to say.
This 'face value principle' also held in the
construction of all coding frames, which again
kept interpretation, at this stage to a bare
minimum.
However, Backett-Milburn and Mckie (1999),
in a very thought provoking appraisal of the
draw and write technique, rightly advise us not
to regard even children's drawings as direct
translations of mental states onto paper. These
images will be a product of their social, cultural
and discourse environments. It is believed that
acknowledging this point does not detract from
the benefits of comparing and contrasting the
drawings from the hospital and community
samples.
Using the child's own drawings as a focus for
associated verbal clarification served to reduce
the difficulties in obtaining information from
children with limited verbal skills; given that
verbal skills are not always a true reflection of
the child's cognitive ability (Bryant 1974). Offer-
ing to write (verbatim) for the child reduced
these difficulties further. Verbal limitations are
particularly acute with younger children, which
may help to explain why this group is under
represented in research studies. Innovative
studies such as Kendrick et al's (1986) in which
EuropeanJournalof Ontology Nursing 3 (3), 170-175
 174 EuropeanJournalof OncologyNursing
children aged 2-11 years undergoing cancer
therapy were observed, demonstrated that even
young children seek information from a number
of sources and are very aware of their current
welfare status. We believe that the draw and
write technique was a suitable tool for high-
lighting issues and health concerns that are
considered to be important and relevant to
children in this study.
Through analysing the children's drawings
and their verbal responses in all Tasks it was
clear that children consider and perceive both
health care professionals and parents to be
intimately involved in the physical, emotional
and psychological aspects of their care. After
learning what children had to say about being in
hospital, ideal hospitals and what they wanted
from health professionals, the researchers were
able to identify a number of dominant themes
and issues.
The following represents a very brief summary
of the results, as the main purpose of this article
was to evaluate the draw and write technique.
Full details of the results will be published in a
later paper in this journal.
Most of the children were able to draw a rich
variety of locations, activities, environmental
features (such as lights and windows) and aspects
of personal space (such as 'their' shelves, bedside
cabinet and so on) in their 'ideal hospital'. A
further recurring theme was a preference for a
bright, colorful, cheerful hospital with a very
'home from home' feel. The drawings that
resulted from the 'somewhere in a hospital'
scenario were much more stark and impover-
ished, containing 'the hospital bed' as the central
and often only feature. Sadness, frustration and
anger were all present and expressed in both
visual and verbal ways. Most of these 'negative'
emotions were to do with being ill and the
boredom and inactivity associated with a stay in
hospital. Also the children missed their normal
family lives, friends and sometimes pets featured
in their sad thoughts. Happiness and joy were
also present but in much smaller 'quantities' and
usually related to pleasant surprises, such as the
benefits of a 'wiggly' (central vein access device)
or discovering that 'the hospital was nicer than
[they] thought and the staff are kind'.
With regard to information needs the coding
frame yielded four major domains of informa-
tion: diagnosis, treatment, prognosis and what
we termed supportive. A fifth competency
domain was only relevant to a small number
of children and related to wanting to know
about the qualifications, experience and moti-
vations of hospital personnel. Each domain was
applied to nurses, doctors and parents in order
to search out similarities and differences. All
three groups of potential 'carers' were seen as
important but the profiles were quite distinct.
EuropeanJournalof OncologyNursing3 (3), 170-175
The children wanted nurses to give honest
accurate information about all aspects of illness,
whilst at the same time be supportive, 'nice
kind', humorous 'gofers'. Parents were seen to
be crucial for translating and repeating medical
information and advice from hospital staff.
Doctors were seen as very powerful individuals
who almost had the power to make their level of
personal accessibility and talk more directly to
the children.
The value of the current data analysis relied
heavily on two requirements. Firstly, that the
research questions were carefully constructed
and piloted. The researchers aimed for clarity
and a certain amount of distance (for ethical
reasons) from the issue of illness and hurt ('... a
child like you..'). Secondly, that the coding
frames were constructed with meticulous atten-
tion to detail. This was a relatively complex and
time-consuming process. The current researchers
needed to draw upon well-established traditions
of coding qualitative data. Semantic codes or
categories, such as were developed here for the
draw and write technique have been frequently
used to assist in the organization, quantification
and analysis of data which can usefully be
described as 'rich', 'full' and 'real' (Robson
1997). The type of qualitative data generated
by this study can successfully be dealt with
effectively and systematically by using carefully
creating coding frames as advocated here. In this
way the dangers of information overload can be
reduced if we can construct what has been called
'an objective' reality of the group under study'
(Smith 1996).
We strongly recommend some training in the
use of such methods of data collection in order
to be able to replicate this type of study for the
benefit of hospital audits. We also wish to point
out that in our experience hospital ethics com-
mittees are generally unfamiliar with qualitative
research methods of this type (although much
work is being done to rectify this deficit) which
presents logistical difficulties for researchers,
especially in the very early stages of a study.
For example, most of the ethics forms consisted of
ticking boxes and the current research methods
did not fit easily into this type of framework.
Also, the reliance on coding frames as opposed
to inferential statistical tests created a need for
further discussion and clarification.
Another benefit of the draw and write
technique (used in conjunction with the reflective
type questions about information needs) is that it
was perceived as being ethically sound given that
the children had given informed consent and that
the procedure did not involve any intrusive
intervention. The child discloses as much or as
little as they like with stress and anxiety at a
minimum, and is therefore protected from
unnecessary psychological and emotional upset.

In addition, in this study both of the researchers
were very experienced in working with children
in hospital and community settings; they were
confident of noticing signs of distress or dis-
comfort leading to them bringing the session
gently to a premature end (occurred on two oc-
casions in the hospital sample). Having said this,
many of the children, particularly in the school
environment seemed to enjoy the tasks and were
very keen to produce complete and 'accurate
answers'. Although we believe that the draw and
write technique was more emotionally draining
for sick children, most of them were also very
open about their views, thoughts and often their
own illness. M a n y appeared to appreciate
the tasks as a distraction from their hospital
procedures, although several were quite tired as
a consequence of treatment.
It must be emphasized that even though the
children did not always draw, the write or
spoken aspect of the tool was readily made use
of to voice views and concerns (the children
dictated their thoughts). This m a y prove espe-
cially valuable to those who work with the
younger sick girls who emerged as quite a
vulnerable and passive group.
In conclusion, projects such as this do benefit
children by providing adults with an informed
insight into children's views opinions and values.
We believe that the present research has en-
hanced our understanding of hospitalization and
chronic sickness by attempting to 'look through
the eyes of a child'.
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