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PubMed2005

Interrater reliability of scoring of pain drawings in a self-report health survey.

STUDY DESIGN: Study of interrater reliability. OBJECTIVE: To assess the interrater reliability of data from pain drawings scored by multiple raters and the consistency of the subsequent classification of cases of widespread pain. SUMMARY OF BACKGROUND DATA: In large health surveys, pain drawings used to capture self-reported pain, and to classify cases of widespread pain, are often scored by several raters. The reliability of multiple rater scoring of pain drawings has not been investigated. METHODS: As part of a postal survey sent to adults 50 years and older, subjects were asked to shade their pain on a blank body manikin. The first 50 pain drawings in which respondents had shaded pain were selected for this study. Eight nonclinical staff were trained to score pain drawings using transparent templates divided into 50 body areas. Interrater reliability was assessed by comparing the scoring of "pain" or "no pain" for all 50 areas of each pain drawing. RESULTS: Complete scoring agreement among all raters was observed for at least 78% of pain drawings across all body areas (kappa > 0.60). The raters had complete agreement in 42 of 50 areas in 90% or more of pain drawings. From the raters' scoring of pain areas, there was complete agreement on the presence or absence of widespread pain for 49 of 50 pain drawings (98% agreement, Kappa = 0.98). CONCLUSIONS: This study shows that multiple raters, with training and guidelines, can reliably score pain drawings, and high consistency in the subsequent classification of cases of widespread pain can be obtained from such data.

Art↗
PubMed2006

Pain drawing scoring is not improved by inclusion of patient-reported pain sensation.

STUDY DESIGN: This is a retrospective study of 250 patients who describe low back pain with pain drawings. A computer application using artificial neural networks was designed to analyze pain drawings and evaluate the contribution of pain sensation to drawing classification. OBJECTIVE: The primary goal of this study was to assess the contribution of patient recorded pain sensation marks in classifying pain drawings into one of five broadly defined categories. The hypothesis was that including pain sensation would improve classification. SUMMARY OF BACKGROUND DATA: With no perfect diagnostic test for patients with low back pain, many approaches have been proposed and are used. One common diagnostic tool is the pain drawing. Several quantitative methods have been proposed to score the drawings. Some methods use pain sensation in the scoring; however, the contribution of pain sensation has not been defined. METHODS: A custom computer application classified the pain drawing. Data consisted of 250 pain drawings from patients with low back pain. RESULTS: Patient recorded pain sensation is not necessary in computer-based scoring of pain drawings. CONCLUSION: Patient-reported pain sensation does not improve classification when quantitatively scoring pain drawings.

Diagnosis, Computer-Assisted↗
PubMed2002

The usefulness of children's drawings in the diagnosis of headache.

OBJECTIVE: To determine whether drawings can aid in the differential diagnosis of headaches in children. METHODS: Before taking any history, 226 children who were seen consecutively for the evaluation of headache were asked to draw a picture to show how their headache felt. The pictures were then scored as migraine or nonmigraine by pediatric neurologists who were blinded to the clinical history. A clinical diagnosis of headache type was determined independently by another pediatric neurologist using the usual history and examination. The diagnoses of headache type based on the pictures drawn and the clinical findings obtained were then compared to calculate the sensitivity, specificity, and predictive values of the drawings for the diagnosis of migraine. RESULTS: Children produced dramatic and insightful headache drawings. Compared with the clinical diagnosis (gold standard), headache drawings had a sensitivity of 93.1%, a specificity of 82.7%, and a positive predictive value (PPV) of 87.1% for migraine. That is, drawings that contained an artistic feature consistent with migraine (eg, pounding pain, nausea/vomiting, desire to lie down, periorbital pain, photophobia, visual scotoma) predicted the clinical diagnosis of migraine in 87.1% of cases. Predictive values were also calculated for specific migraine-associated features on drawings: artistic depiction of focal neurologic signs, periorbital pain, recumbency, visual symptoms (photophobia, scotomata), or nausea/vomiting had a PPV of >90% for migraine; severe or pounding pain had a PPV of >80% for migraine. Band-like pain was not predictive of migraine (PPV of 11.1%). Features on drawings such as sadness or crying did not differentiate migraine from nonmigraine headaches. CONCLUSIONS: Children's headache drawings are a simple, inexpensive aid in the diagnosis of headache type, with a very high sensitivity, specificity, and predictive value for migraine versus nonmigraine headaches. We encourage the use of drawings in the evaluation of any child with a headache, as an adjunct to the clinical history and physical examination.

Adolescent↗
PubMed2005

Relationship between directionality and orientation in drawings by young children and adults.

The present study examined the relationship between directionality of drawing movements and the orientation of drawn products in right-handed adults and young children for 27 Japanese kindergartners and 29 Japanese university students who were asked to draw with each hand fishes in side view and circles from several starting points. Significant values of chi2 for distributions of frequencies of orientation of the fish drawings and the direction of circular drawing movement indicated that adult right-handers drawing the fish facing to the left tended to draw a circle clock-wise when they drew with the dominant hand, while there was no such significant relationship in young children's drawings. This result may suggest that the reading and writing habits may be implicated in the direction of drawing movements with the dominant hand, and this directional bias of drawing movement in the dominant hand can appear in the orientation of finished drawings.

Adolescent↗
PubMed1994

[On the finger-drawing strategy in recognition of random shapes].

The present study was designed to identify the memory-enhancing factor of finger-drawing strategy, and investigate the relationship between finger-drawing and semantic processing of random shapes. Forty subjects were randomly assigned to one of the five conditions: imagery encoding, verbal encoding, finger-drawing for encoding, finger-drawing for searching, and finger-drawing for both encoding and searching, and performed recognition tasks of random shapes. Results indicated that in the two conditions under which finger-drawing was used for encoding, recognition of complex shapes was superior to that of simple ones. No differences were found for those of high and low associative shapes. Verbal reports of the subjects indicated that finger-drawing for encoding prevented them from naming the shapes. In contrast, in the other three conditions under which finger-drawing was not used for encoding, recognition of simple shapes was superior to that of complex ones. Also, recognition of high associative shapes was superior to that of low ones. These results suggest that kinetic representation, rather than amount of attention, is responsible for the memory-facilitating effect of finger-drawing, and that finger-drawing for encoding inhibits active semantic processing.

Adult↗
PubMed2000

Clock drawing test: correlation with linear measurements of CT studies in demented patients.

OBJECTIVES: To investigate a presumed correlation between clock drawing ratings and linear measurements of computerized tomography (CT) studies in demented patients. DESIGN: Blinded evaluations of clock drawing tests and CT studies of elderly dementia patients were conducted by a geriatric psychiatrist and a neuroradiologist. SUBJECTS: Fifty-one community-dwelling elderly subjects meeting the criteria for DSM-IV diagnosis of dementia (Alzheimer's type dementia: N=31; vascular dementia: N=15; "mixed" type dementia: N=5). MATERIALS: Mini-Mental State Examination (MMSE), Cambridge Cognitive Examination (CAMCOG), Clinical Dementia Rating (CDR). CAMCOG derived scored clock drawings were evaluated using adaptations of Shulman et al.'s and Freedman et al.'s methods. CT studies were evaluated using six different linear measurements of brain atrophy described in the literature. RESULTS: Of the CT linear measurements, only the Cerebro-Ventricular Index-2 (CVI-2; bicaudate index) significantly correlated with clock drawing ratings (CAMCOG's clock r=-0.407, p=0.003; Shulman's method r=0.357, p=0.01, Freedman's method r=-0.413, p=0.003) in the dementia group. There was no significant correlation between CVI-2 with demographic (age), cognitive (MMSE, CAMCOG) and clinical (duration of illness, CDR) ratings. Alzheimer's patients generally maintained a significant correlation between CVI-2 and clock drawings, but vascular dementia patients did not; CVI-2 also correlated significantly with the Praxis subtest of the CAMCOG in dementia and Alzheimer's patients but not in the vascular dementia group. Similarly, multiple stepwise regression analysis showed that only CVI-2 but not the other radiological measures studied, was selected as the significant variable to correlated with clock drawing test ratings in the dementia group and Alzheimer's patients. Partial correlation analysis controlling for demographic and clinical variables shows that controlled variables had no significant effect on the relationship between clock drawing ratings and CVI-2. CONCLUSION: A single and easy to perform measure of caudate atrophy correlates specifically and consistently with impairments revealed in the clock drawing test and with a Praxis subtest, suggesting possible caudate involvement with clock drawings in dementia in general and of the Alzheimer's type in particular.

Aged↗
PubMed2002

Pain-drawing does not predict the outcome of fusion surgery for chronic low-back pain: a report from the Swedish Lumbar Spine Study.

Despite a widespread use of pain drawing in the selection of patients for surgical and non-surgical treatment, its value as a predictor of outcome is still not well documented. In a prospective multicentre randomised controlled trial of surgical and non-surgical treatment for chronic low-back pain (CLBP), two hypotheses were tested: (1). Pain drawing predicts outcome of treatment for CLBP, (2). Pain drawing is associated with psychological characteristics of patients with CLBP. Two hundred and sixty-four patients with severe CLBP of long duration completed pain drawings as part of a battery of questionnaires prior to treatment. They were followed up at 2 years post-treatment, with renewed completion of questionnaires. Outcome was measured in three ways: patient global assessment, change of disability/pain, and work status. The pain drawing was analysed by four different methods. The association between the pain drawings and outcomes was analysed. Personality traits and depressive symptoms were evaluated in the psychological assessment. None of the four methods of interpretation of the pain drawings demonstrated any significant association with outcome, in either the surgical or the non-surgical group. The pain drawing was associated with pre-treatment back pain intensity and depressive symptoms. No predictive value of the pain drawing regarding the outcome of treatment of CLPB was demonstrated. The concept of "organic/non-organic" pain in conjunction with chronic low-back pain is not supported by the results of the present study.

Adult↗
PubMed1999

Relationship of pain drawings to invasive tests assessing intervertebral disc pathology.

It has been found that the pain patterns in pain drawings are related to the presence of herniated disc identified by myelography. The purpose of this study was to determine whether the pattern of pain in the drawings or the type of pain indicated (aching, burning, numbness, pins and needles, stabbing) was related to the presence of symptomatic disc pathology identified by CT/discography. In a subgroup of patients who underwent myelography, the relationship of the drawings to myelographic findings was also investigated. Pain drawings were completed by 187 patients with low back and/or radicular pain who were undergoing CT/discography. The drawings were scored in two ways, first by the system described by Ransford and secondly by visual inspection. They were classified as being indicative, or not, of disc pathology. The CT/discograms were classified as disrupted, or not, and the pain responses were recorded upon injection of each disc, based on the similarity of the pain provoked to clinical symptoms. Among the 133 patients with discogenic pain confirmed by discography, 110 (82.7%) had pain drawings that were classified as indicative. Among the 45 patients without discogenic pain, 29 (64.4%) had pain drawings classified as non-indicative. Patients with discogenic pain used more symbols indicating burning pain and aching pain than did non-discogenic pain patients. Our results confirmed those reported earlier by Uden, who found a relationship between the pattern of pain in the drawings and myelographic findings. Pain drawings may be helpful in the diagnosis of symptomatic disc pathology.

Adult↗
PubMed2004

Quantifying drug-induced dyskinesias in the arms using digitised spiral-drawing tasks.

In this study, we quantify the severity of drug-induced dyskinesias in the arms of Parkinson's disease (PD) patients using digitised spiral-drawing tasks. Two spiral drawings, namely a circular and a square spiral, are designed to, respectively, represent the continuous and discrete arm motions, and the size of the spiral is decided so that both the distal and proximal arm joints are involved. Fifteen PD patients, average disease duration 14.4+/-7.4 years, were assessed 30 min after a levodopa challenge whilst performing circular and square spiral-drawing tasks. The velocity of drawing movements was computed and the amplitude of the involuntary dyskinetic movements was measured as the standard deviation of the drawing velocity (SD-DV). The mean amplitude of dyskinetic movements was compared between arms and tasks and was correlated with clinical measures including the Bain dyskinesia scale and the total unified Parkinson's disease rating scale (UPDRS) score. The results showed that there was no statistically significant difference in the amplitude of dyskinesias either between the arms or between the continuous (circular) and discrete (square) spiral drawings in this group of PD patients, but interestingly the interaction between arm and drawing pattern was significant. Significant correlations were found between the magnitude of dyskinesia measured from the spiral-drawing tasks and both the 'on' or 'off' UPDRS and also the Bain dyskinesia scale. We conclude that the drawing tasks may be used to provide an objective method of quantifying the severity of drug-induced dyskinesias in the arm in PD patients.

Adolescent↗
PubMed2004

Usefulness of pain drawings in identifying real or imagined pain: accuracy of pain professionals, nonprofessionals, and a decision model.

UNLABELLED: The aim of this study was to determine the accuracy of pain specialists, nonprofessionals, and a decision model in judging whether a pain diagram was marked by a patient with chronic pain or by a healthy volunteer. Two hundred twenty-eight pain drawings were shown in random order to 10 pain medicine physicians, 10 pain medicine fellows, 10 nonphysician specialists, and 10 nonprofessionals. One half of the drawings (n = 114) had been produced by patients treated at a pain center and the other half (n = 114) by healthy individuals who were instructed to mark the diagrams as if they had a pain problem. The nonprofessionals were found to be 51.5% accurate, pain medicine fellows 52.7%, nonphysician specialists 54.3%, and pain medicine physicians 55.2 % accurate at distinguishing drawings by actual pain patients from drawings from volunteers without pain. A decision model was able to achieve 68.9% accuracy in determining which drawings were made by pain patients and which drawings were made by healthy individuals. The results suggest that subjective assessment of pain drawings alone is not useful in determining whether someone has real or imagined pain. A decision model that makes decisions on the basis of the number of highlighted squares on the pain diagram can identify real pain drawings with greater accuracy than humans. PERSPECTIVE: Pain drawings are clinically useful but have limitations. This study illustrates some of the benefits of computerized pain assessment and highlights the importance of not judging patients on the basis of one source of information.

Adolescent↗
PubMed1997

Motor control differentiates children's from adults' drawings for child and adult judges.

In two exploratory studies, motor skill as a possible distinctive feature for differentiating drawings made by second-grade children and by college students was tested by having child and adult judges sort drawings made by children and by adults. Adults drew with their preferred (motorically skilled) or nonpreferred (nonmotorically skilled) hand. Children and adults were equally accurate in discriminating children's from adults' preferred-hand drawings, but child judges confused children's and adults' non-preferred-hand drawings. Child, but not adult, judges confused adults' preferred-hand and adults' non-preferred-hand drawings. Thus, children were sensitive to characteristics of drawings that depended on motor skill when it was an additional feature of difference but not when it was the only distinctive feature. Motor control effects in constructing drawings and evidence of motor control in responding to drawings warrant further study and perhaps greater emphasis in theories of drawing development.

Adult↗
PubMed2004

Naïve observers' perceptions of family drawings by 7-year-olds with disorganized attachment histories.

Previous research has succeeded in distinguishing among drawings made by children with histories of organized attachment relationships (secure, avoidant, and resistant); however, drawings of children with histories of disorganized attachment have yet to be systematically investigated. The purpose of this study was to determine whether naïve observers would respond differentially to family drawings of 7-year-olds who were classified in infancy as disorganized vs. organized. Seventy-three undergraduate students from one university and 78 from a second viewed 50 family drawings of 7-year-olds (25 by children with organized infant attachment and 25 by children with disorganized infant attachment). Participants were asked to (1) circle the emotion that best described their reaction to the drawings and (2) rate the drawings on 6 bipolar scales. Drawings from children classified as disorganized in infancy evoked positive emotion labels less often and negative emotion labels more often than those children classified as organized. Furthermore, drawings from children classified as disorganized in infancy received higher ratings on scales for disorganization, carelessness, family chaos, bizarreness, uneasiness, and dysfunction. These data indicate that naive observers are relatively successful in distinguishing selected features of drawings by children with histories of disorganized vs. organized attachment.

Affect↗
PubMed1999

Relation between pain location and disc pathology: a study of pain drawings and CT/discography.

OBJECTIVE: The purpose of this study was to determine whether pain location indicated in pain drawings was related to the specific lumbar disc level(s) that was abnormal in appearance and painful upon discographic injection. DESIGN: Data were collected prospectively. SETTING: This study was conducted in a spine specialty clinic. PATIENTS: The study group consisted of 187 patients (118 men, 69 women; mean age = 37.2 years, range = 18-62 years) with low back pain with or without leg pain. All patients were undergoing computed tomography (CT)/discography at the three lowest lumbar levels for diagnostic purposes. INTERVENTIONS: Pain drawings were completed the day of but prior to undergoing discography. Discographic pain responses were recorded with respect to the similarity to the patient's clinical symptoms. Pain drawings were classified based on the presence or absence of pain in five areas: low back and/or buttocks, posterior thigh, posterior leg, anterior thigh, and anterior leg. The drawings were scored with the system described by Ransford et al. (1976, Spine 1: 127-34), and those likely to be indicative of psychological problems were analyzed separately (n = 43). OUTCOME MEASURES: Results were determined by analyzing the relation between the location of pain in the drawings and the specific lumbar disc level(s) found to be painful and disrupted by discography. RESULTS: There was a significant relation between pain location indicated in the drawing and the lumbar disc level(s) identified as clinically painful and disrupted by CT/discography (p < 0.05, chi-square). Pain limited to the low back and buttocks was frequently associated with the absence of disc pathology (58.3%). When pain in the posterior thigh or leg was present but there was no pain in the anterior drawing, patients frequently had a positive L5-S 1 disc (> or =75%). In patients with anterior thigh pain, with or without posterior thigh or leg pain, the L4-5 disc was frequently symptomatic (>63%). The pattern of no posterior thigh or leg pain but with pain radiating into the leg anteriorly was most commonly associated with the L3-4 disc (71.4%). CONCLUSIONS: The results of this study indicate that pain drawings may be helpful in identifying which specific discs are associated with pain complaints. As with any evaluation, the drawings should be considered in combination with findings from other assessments.

Adolescent↗
PubMed2005

Limited clinical utility of pain drawing in assessing patients with low back pain.

OBJECTIVE: The aim of this study was to assess the use of pain drawing by studying its ability to identify patients with low back pain and abnormal psychological profile. The intraevaluator repeatability of the penalty point method of scoring of pain drawing was also evaluated. METHODS: A total of 331 consecutive patients with low back pain were prospectively recruited. The psychologic profile was assessed using the Hospital Anxiety and Depression Scale. The pain drawings were scored with the penalty point method. The ability of pain drawing to identify patients with significant anxiety and depression was assessed by calculating the sensitivity, specificity, and positive predictive value. The intraevaluator repeatability was calculated for scoring done at an interval of 1 month using the kappa statistic. RESULTS: There were statistically significant differences in the anxiety and depression scores in patients with normal (n = 200) and abnormal (n = 131) pain drawing (anxiety: 9 +/- 4 vs 10.3 +/- 3.7; depression: 8.1 +/- 3.5 vs 8.8 +/- 3.6; P < 0.005). The pain drawing had a low sensitivity for detecting patients with any degree of anxiety (43%) or depression (40%). The positive predictive value of pain drawing for anxiety and depression was 78% and 69%, respectively. The kappa value for intraobserver assessment was 0.6 (P < 0.05). CONCLUSION: Though there are differences in anxiety and depression scores in patients with normal and abnormal pain drawing, the performance characteristics of pain drawing are less than acceptable and therefore limit its use in clinical practice.

Anxiety↗
PubMed2003

Human figure drawing test: validity in assessing intelligence in children aged 3-10 years.

BACKGROUND: Human-figure-drawing abilities are related with cognitive development in children. As cognitive skills progress, drawing abilities also improve in details and sex differentiation. The Goodenough-Harris (G-H) drawing test was developed to score human figure drawing with separate norms for males and females. OBJECTIVES: To evaluate whether the Goodenough-Harris human drawing test is valid to classify intelligence in children aged 3-10 years. MATERIAL AND METHOD: Record files of 528 children aged between 3-10 years who had attended the Child and Adolescent Unit at Queen Sirikit National Institute of Child Health (Children's Hospital), Bangkok, Thailand from January 1999 to December 2001 were retrospectively reviewed. Inclusion criteria included: 1) performing the human figure drawing test and standard intelligence tests on the same day and 2) diagnoses were addressed. RESULTS: The ages of the children ranged from 3 10/12 years to 10 11/12 years with a mean age of 7 9/12 years, 49.5 per cent were males and 50.5 per cent were female. The study group was diagnosed as pervasive development disorder 17 per cent, attention deficit hyperactivity disorder 13 per cent, and mental retardation 11.3 per cent. Overall correlation of full scale intellectual quotient (FSIQ) from the standard intelligence test and standard scores on the Goodenough-Harris system was 0.813 (p < 0.01). The overall validity of the human figure drawing test in classified correct intellectual level was 60.8 per cent but in children with an intellectual quotient (IQ) less than 70, the correct classification was 69.2 per cent. After stratification by age, it was found that the human figure drawing test had validity in predicting IQ below 70 in 88.7 per cent and 68.8 per cent of children aged < 6 years and aged > 6 years respectively. CONCLUSION: The human figure drawing test can be used as an additional measure of assessing intelligence in young children but it should not be substituted for standard tests. The test is not complicated, therefore, trained personnel can use it in combination with other screening tests for cognitive development in children.

Art↗
PubMed1987

Genitalia in children's drawings: an association with sexual abuse.

Many sexual abuse victims have been observed to draw genitalia on human figures. To test the hypothesis that sexually abused children draw genitalia on human figures more often than do nonabused children, drawings from 57 children, 3 through 7 years of age, who were referred to child protective services as alleged sexual abuse victims, were compared with drawings from an age-, sex-, race-, and socioeconomically matched group of 55 nonabused children receiving well-child care in medical settings. A standardized procedure to obtain drawings was followed by a structured interview to collect demographic, past medical, and developmental information. Five evaluators unaware of the children's backgrounds independently examined drawings for the presence or absence of five body parts; there was 94% agreement for all body parts and 93% agreement for genitalia. Eight children were excluded from the analysis because they only scribbled (n = 5) or because evaluators could not agree on whether genitalia were present in their drawings (n = 3). Ten percent (5/52) of the alleged sexual abuse victims and 2% (1/52) of the comparison children drew genitalia (P = .10, one-tailed Fisher exact test). The estimated relative risk was 5.4; that is, alleged sexual abuse victims were 5.4 times more likely to draw genitalia than were comparison children. Children known to have been sexually abused were 6.8 times more likely to draw genitalia than were comparison children (P = .07, one-tailed Fisher exact test).(ABSTRACT TRUNCATED AT 250 WORDS)

Child↗
PubMed1990

Sex, sex role identification, and college students' projective drawings.

A study of 109 undergraduates found that sex and sex role identification, as assessed by the Bem Sex Role Inventory (BSRI), were related significantly to sex sequence, sexual differences, and quality of drawing on the Draw-A-Person (DAP). Specifically, males and masculine persons tended to draw males first, female and feminine persons tended to draw females first, and androgynous persons were equally likely to draw a male or a female first. The greater the sexual differentiation of the female human figure drawing, the lower the subject's degree of masculinity. The single best predictor for identifying a female subject was the quality of the female figure drawing. Results were consistent with Machover's hypothesis that drawings of the human figure reveal facets of the subject's self-image.

Adolescent↗
PubMed2001

Sex differences in children's free drawings: a study on girls with congenital adrenal hyperplasia.

Sex differences are recognized in children's free drawings with respect to motifs, colors, figure compositions, and expression. Boys tend to draw mobile objects and mechanical objects with dark or cold colors and often use bird's-eye-view composition when they draw pictures, whereas girls like to draw human motifs (especially girls and women), flowers, and butterflies with light and warm colors and tend to arrange motifs in a row on the ground. Analyses were made on the drawings of girls with congenital adrenal hyperplasia (CAH) and unaffected boys and girls, using masculine and feminine indexes. Sex difference in masculine and feminine indexes was clear in the drawings by unaffected boys and girls. Their drawings do not or mostly do not contain characteristics typical of the opposite sex. Compared with those of unaffected girls, the pictures of CAH girls more strongly showed masculine characteristics. The feminine index for the pictures of CAH girls was significantly lower than that for unaffected girls, while the masculine index for CAH girls was significantly higher than that for unaffected girls. Furthermore, the masculine index for CAH girls was not significantly different from that of unaffected boys. These results suggest that androgen exposure during fetal life may contribute to shaping masculine characteristics in children's free drawings.

Adrenal Hyperplasia, Congenital↗