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Art and Children's Perceptions of Physicians .. study continued
.... Previous studies have led to conflicting findings regarding the demographic and illness-related variables that are of interest to this study. Regarding age, Bachanas (1995) found that younger children tended to rate health care personnel, procedures, and settings as more approachable and reported liking them more than older children. Simonian (1993), by contrast, found that older children expressed greater satisfaction with their providers than did younger children. Regarding gender, some studies have suggested that girls display higher levels of satisfaction with their providers than boys while other studies have found no significant difference between gender (Simonian, 1993). The effects of type and duration of illness have not previously been studied in depth.
Sixty subjects, aged 5-16 years, were recruited during routine outpatient clinic visits at a tertiary care university hospital. Fifteen subjects each were recruited from the Cystic Fibrosis, Diabetes, Oncology, and Orthopedic clinics. Subjects were required to have at least a two-month history with their current doctor, and orthopedic patients were restricted to those with bone fractures or other reparable ailments (corns, rotator cuff). Patients were required to understand and speak English for consent and instructional purposes. Two methods were used to assess children's perceptions of their doctors:
1. projective art exercises, and
2. a self-report questionnaire.

Subjects were asked to complete two projective art measures routinely used in child assessment: the "madala" (Color-Feeling Wheel), first described by psychotherapist Carl Jung (Slegelis, 1987), and the "Draw A Person" test, developed by Karen Machover (1949). The mandala involves the subject choosing feelings that correspond with how they feel lmost when they are with their doctor, assigning each a color, and using markers to fill in a circle with these colors in proportion to the strength of each emotion. Emotions were printed on index cards from which subjects could choose, including 8 positive (safe, thankful, happy, understood, excited, important, hopeful, and strong/confident) and 8 negative (bored, confused, scared, invisible, vulnerable, angry, helpless, and guilty). Each subject was allowed to select between 1 and 6 emotions. Mandalas were used to quantify emotional states toward doctors. Next, the subject was given a standard 8.5"x11" piece of paper and asked to use colored markers to draw a picture of their doctor showing their whole body. Lastly, subjects were asked to complete two previously validated measures, the Metro Assessment of Child Satisfaction (MACS; Simonian, 1993) and the Physician Attribute Checklist (PAC; Rifkin, 1988). MACS consists of eight Y/N questions used to assess child satisfaction with their doctor, and has shown internal consistency. The PAC is a 7-item checklist used to assess children's perceptions of the positive and negative attributes of their doctor (a=.70). All recruiting and interviews were conducted by the primary investigator. Subjects were generally able to complete most of the exercises during the interval in the waiting room and during the time in the examination room before the doctor arrived. Approximately 75% of patients and parents who were approached agreed to participate in the study. Of those who did not, the overwhelming majority were due to time constraints.

Six second year students (3 male, 3 female) from the Stanford School of Medicine acted as graders for the mandala and "Draw-Your-Doctor". For each art exercise, graders selected on a Likert-type scale what they thought the overall emotional response or attitude the subject had toward their doctor. Mandalas were unlabeled, and graders were not given specific guidelines or a feature checklist. The intent was to record first global impressions. Each person graded 60 mandalas and 60 "Draw-Your-Doctors. Interrater reliability was demonstrated between external graders for both the mandalas (a=.89) and "Draw-Your-Doctor" (a=.81).

Eigenvalues were used to extract 9 items from the combined MACS and PAC to create a measure of "positive regard". Significant associations (p<.05) were found between self-reported "positive regard" and subjective grading of "Draw-Your-Doctor" as well as with an objective count of positive emotions selected on mandalas.

The major findings of the study are as follows. Age was correlated with positive attitude as demonstrated by emotion count on mandalas (p<.01) Specifically, age was positively correlated with feeling "understood" (p<.001) and negatively correlated with feeling "scared" (p<.05) and confused (p<.001). Duration of illness correlated negatively with presence of smile (p<.05) and overall score in "Draw-Your-Doctor" (p=.051) as well as with the report of feeling "strong/confident" as recorded through mandalas.

Although not statistically significant, the questionnaire-derived "positive regard" score suggests a trend that orthopedic patients have more negative attitudes toward their doctors than other clinic patients. A trend was also found in the use of curvy vs. straight/jagged lines in the mandala. In the field of art therapy, curvy lines are interpreted to be indicative of relaxation and trust while straight/jagged lines are interpreted as a sign of anger or frustration. Oncology patients were more likely to use curvy lines (3:1) whereas for orthopedics, the ratio was reversed (3:7) in favor of straight/jagged lines. The selection of feeling "important" was significantly correlated (p<05) to clinic with oncology patients feeling the most important and orthopedic patients feeling the least important. The selection of "hopeful" was also significantly correlated (p<.05) to clinic with cystic fibrosis (CF) patients feeling the most hopeful and oncology patients feeling the least hopeful.

Projective art measures are a useful adjunct to examine children's perceptions of physicians and offer a richer, more open-ended perspective. Slegelis (1987) even describes the mandala as a "personal Rorschach". The results of our study suggest that younger age, longer duration of illness, and orthopedic injuries are variables associated with more negative attitudes. We offer the following explanations for our finding on age. First, younger children may not often understand the medical situation or what the doctor tells them. In addition, doctors tend to communicate more with the parent than with the child and may be more intimidating to younger patients.

Regarding duration of illness, one might think a prolonged course of illness would result in a longer, more intimate relationship with a doctor, and thus more positive regard toward them. However, data from our study indicate that patients are less likely to draw their doctor in a positive light and also less likely to feel "strong/confident" when with their doctor. This may reflect the nature of their illness and the inability of doctors to cure their ailment.

The more negative attitudes of orthopedic patients may be explained by the fact that these patients are accustomed to being healthy. They are unfamiliar with the medical environment and may see their injury as a nuisance or hindrance to their normal daily routine. The finding that orthopedic patients do not feel as "important" as other clinic patients may perhaps reflect the "benign" nature of their injuries as well as the behaviors and attitudes of their physicians. Because the injuries of recruited orthopedic subjects were amenable to treatment and not life-threatening, some orthopedists may underestimate the impact the situation has on their patients and may not invest themselves as much into understanding the patient and their concerns. On the other hand, oncology patients reported feeling the most important. This again may reflect the severity of condition and thus the amount of empathy physicians show their patients. Unlike otherwise healthy orthopedic patients, children with cystic fibrosis practically grow up with doctors as part of their family. Despite the average lifespan of CF being around 32 years, patients reported being "hopeful" more than any other clinic group. This may reflect the close relationship and trust that CF children have in their doctors and their subsequent hope that they will find a way to cure them.

This study was a rare opportunity for pediatric patients to give their side of the doctor-patient relationship. Knowledge of variables affecting children's attitudes toward physicians may lead to improvements in treatment compliance, subjective distress, and pro-health behaviors of these clinical populations.


Bachanas PJ, Roberts MC. Factors affecting children's attitudes toward health care and responses to stressful medical procedures. Journal of Pediatric Psychology. June 1995;20(3): 261-75.

Machover, K. Personality projection in the drawing of the human figure. Springfield, Ill.: Thomas, 1949

Rifkin L, Wolf M, Lewis C, Pantell R. Children's Perceptions of Physicians and Medical Care: Two Measures. Journal of Pediatric Psychology. 1988;13(2):247-254.

Simonian SJ, Tarnowski KJ, Park A, Bekeny P. Child, parent, and physician perceived satisfaction with pediatric outpatient visits. Journal of Developmental and Behavioral Pediatrics. Feb. 1993; 14(1):8-12

Slegelis, Maralynn H. A Study of Jung's Mandala and its Relationship to Art Psychotherapy. The Arts in Psychotherapy, 1987;14:301-311

The Healing Nature of Mandalas: Empirical Study of Active Imagination
Patti Henderson, Nathan Mascaro, David Rosen and Tiffany Skillern
Texas A&M University

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