以動態屋樹人繪圖測驗探討兒童生活經驗之研究：以先天性心臟疾病兒童及健康兒童為例

研究背景及目的：隨著醫療及照護品質的提升，罹患先天性心臟疾病的兒童有更大的信心成長至成人期；然而，不同的疾病類型及嚴重程度對於兒童在生活上的影響有很大的差異。除了生理狀態，我們應該要重視慢性兒童成長過程中所遇到的心理健康問題並適當的介入，避免兒童的心理健康趨向負面的發展。患有先天性疾病或慢性病的兒童其階段性任務發展上有較高機率因疾病受到影響，當兒童面臨危及生命的疾病及治療時，可能會經歷反覆性的創傷，這種創傷可能不會在治療過程中或治療後立即產生影響。透過討論個體在不同成長階段的發展軌跡、角色轉變、事件經歷、社會環境等之間的互動如何影響個人的生命、轉銜以及個體行動是生命歷程理論的價值所在。因此，探討長期面對疾病與治療的兒童在成長過程中的感受及經驗，作為生命軌跡的紀錄，有助於提供照護者、教育者相關訊息並適時地調整個案整體照護及需求。投射性繪畫目前已廣泛應用在不同族群探討人格特質或心理狀態，且證實繪圖投射的有效成果。本研究透過投射性工具動態屋樹人繪圖探討先天性心臟疾病兒童的生命經驗，並比較健康兒童與先天性心臟疾病兒童的繪圖特徵之差異及意涵。研究方法：本研究採混合研究(mixed methods research)方式，採聚合平行混合設計（convergent parallel mixed designs），以動態屋樹人繪圖為媒介，探討先天性心臟疾病兒童對於圖畫元素及生活經驗的闡述，同時藉由量性分析比較健康組兒童及先天性心臟病組兒童在繪圖元素呈現的差異。本研究正式收案期間為2021年2月至2021年7月，收案對象先天性心臟病組兒童16人，健康組兒童14人，共30人。量性資料如人口學特徵及繪圖差異以 IBM SPSS Statics 25.0 版進行處理分析，訪談資料則以主題式分析法進行歸納及分析。研究結果：透過繪圖分析可得知兩組兒童在繪圖時間上無明顯差異，在以年齡的分組探討繪圖發展，先天性心臟疾病兒童與健康兒童的繪圖發展沒有特別差異，但疾病嚴重度較高的先天性心臟疾病兒童在繪圖上有較簡略或退化的情形。透過量性分析，兩組兒童在整體繪圖評估及樹元素的表現上沒有差異；在房屋元素中「整體畫法-快倒或傾斜（H1L）」（p = .005）、「屋頂-頂端未聯合（H4a）」（p = .048）、「屋頂-塗黑、頂上休憩設施（H4c）」（p = .032）有顯著差異；在人物元素中「腿與站姿-朝側面（P9j）」（p = .004）有顯著差異。兩組兒童透過繪圖展現對於家庭關係的緊密以及在人物的描繪皆顯示獨立與依賴的矛盾；先天性心臟疾病兒童針對房屋的繪圖特徵上易表現出退化、沒有安全感、容易焦慮及感受壓力；健康組兒童的繪圖特徵上則是與家庭壓力及人際關係的猶豫與保守。先天性心臟疾病兒童透過動態屋樹人繪圖故事的闡述都符合元素的抽象概念，表現出追求生理、安全、愛與歸屬的需求，而多數兒童無法清楚表達單一事件或繪圖特徵的連結或意義；元素彼此之間「依附」最強的是人與房屋。人物主角在圖畫呈現的「行為」多是個案生活經驗的展現，是孤獨的，其畫法顯示器質性疾患問題、對身體或行動上不滿意、不安全感或焦慮，期待人際的接觸、友善開放，在意他人眼光。由訪談內容，透過先天性心臟疾病兒童確認對於疾病及生活的闡述的主題，分別為「疾病資訊建構不全」以及「生活型態的不穩定性」，部分的繪圖特徵也與生命經歷的事件可相呼應。討論及結論：慢性病兒童的疾病初期即接受妥善的治療合併早期療育，生活功能及身體發展可以尋健康兒童的軌道邁進。疾病較複雜的兒童，早期身心理發展限制可能在未來逐漸展現。隨著認知逐漸成熟，反覆入院治療除了深刻兒童的記憶經驗，影響兒童心理社會功能的發展及生活型態的限制可能更為顯著。透過投射性工具，可以瞭解兒童對於生命經驗的描述，並能呼應繪圖所呈現的心理特徵。即使動態屋樹人繪圖應用於兒童的信效度及適用性有待驗證，臨床仍可善用繪圖探討兒童心理特徵及生活事件連結的線索，以作為轉介或是評估的依據。慢性疾病兒童在學齡期缺乏適當的衛生教育及正確疾病觀念的建立，疾病本身及治療經驗在兒童生命歷程中刻劃痕跡的深淺或好壞，於兒童或許沒有短期的影響，但長久以後有什麼影響仍是未知。

關鍵字

先天性心臟病；學齡兒童；投射性繪畫；動態屋樹人；生命歷程；混合研究

並列摘要

Background: For the improved medical techniques and care, children with congenital heart disease (CHD) could successfully grow into adults. However, there was still great impact on life of children with different types and severity of heart disease. In addition to physical condition, the social mental health should be noticed and be stepped in to avoid from negative affect. Children with CHD have developmentally irrupted in high risk while facing life-threaten treatments or complications. The effect caused by repeating treatment experiences may not be showed up immediately but in the future. The value of life course theory is that the interaction between one’s trajectories, life events, etc., how to affect one’s life, transition, and action. Therefore, it’s important to realize and discover the children ‘s experiences and thoughts with chronic illness which could help caregivers or educators to know what they need. Projective drawing has been widely used in different fields to explore personality traits or psychological states, and it has been proved the effectiveness. This study was aim to explore life experience of children with CHD by Kinetic-House-Tree-Person drawing test and the different characteristics of drawing between children with CHD and healthy group. Methods: This study adopted the mixed-methods research, convergent parallel mixed designs, to explore the elaboration of each drawing feature and life experience in children with CHD by Kinetic-House-Tree-Person drawing test. Quantitative analysis compared the differences in the presentation of drawing features between healthy and children with CHD. The recruited period of this study was from February 2021 to July 2021. There were 16 children with CHD and 14 children in healthy group, total 30 participants. Quantitative data were processed and analyzed by IBM SPSS Statics version 25.0 and interviewed data were summarized and analyzed by thematic analysis method. Results: While there is no significant difference in the drawing time and skills between the two groups, the drawing skills and picture of children with complex CHD were seemed to be simplified and degenerated. There was no difference between the two groups in overall drawing and tree feature but significant difference with house feature: "Overall Drawing - falling or lean (p=.05), "Roof - top unjointed (p=.048), "Roof - painted black, rest facilities on top (p=.032); person feature: "legs and standing - sideways (p=.004)."Both of groups appeared close family relationship and contradiction between independence and dependence through drawing. Children with CHD represented degeneration, insecurity, anxiety, and stress in the house feature characteristics; drawing characteristics of healthy children were related to stress from family and hesitation and reserve while facing interpersonal relationships . The drawing descriptions of children with CHD were in line with the abstract concepts of each feature and showed the needs of physiology, safety, love and belonging. The strongest "attachment" between each feature was Person and House. However, most of children couldn’t clearly express the connection or meaning between life events and drawing features through story telling. The person feature showed loneliness and the "behavior" they drew was the expression of life experience of the case. In CHD group, characteristics of person feature also revealed the organic disease, dissatisfaction with the body or action, insecurity, or anxiety but expectation of interpersonal contact, friendliness and caring how other saw them. This study confirmed the themes of disease and life elaboration, namely "incomplete disease information supply" and “lifestyle instability " as well by interviewing children with CHD. Some of the characteristics drawing features could also be echoed with the life events. Conclusion: The life tract of children with chronic illness receiving proper treatment combination with early treatment in the early stage of the disease is no specifically different from the healthy children, including life functions and physical development. The impact on physical and psychological development caused by complex disease in early stage may gradually appear when children grow up. With the gradual maturity of cognition, repeated hospitalizations may affect the development of children's psychosocial functions and the limitations of life style also create profound memory. Children's descriptions of life experiences through projective tools can be realized, and may echo the meanings presented by the drawing features. Even if the reliability, validity, and applicability of Kinetic-House-Tree-Person drawing test used in children group are yet to be verified, drawing can still be used to explore the clues of children's psychological characteristics connection with life events as a basis for referral or evaluation in clinical use. The disease itself and treatment experience in children's life course may not have short-term effects; however, long-term impact on children with chronic illness, lacking proper health education and the establishment of concept of disease at school-age, will be a question.

並列關鍵字

Congenital heart disease ； school-age children ； projective drawing ； Kinetic-House-Tree-Person drawing test ； life course ； mixed-method research

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