*Article* **Visual Expressions of Children's Strengths, Difficulties and Wishes in Person Picking an Apple from a Tree Drawings among Preschoolers Living in Areas of Persistent Political Violence**

**Michal Bat Or 1,\*, Rafi Ishai <sup>2</sup> , Nirit Barkay <sup>3</sup> and Or Shalev <sup>4</sup>**


**Abstract:** The present study sought to inquire into the subjective experience of 156 preschoolers (age 4–6.9 years) living in an area of political violence in Israel (on the border with the Gaza Strip) during a period of massive bombing. Children were invited to draw a Person Picking an Apple from a Tree (PPAT), and were interviewed on their sense of self-potency using the CAMP, a measure of potency. Teachers were asked to report problems in executive functions using a few BRIEF scales; and mothers filled out a questionnaire for maternal distress (BSI), a measure of their child strengths and difficulties (SDQ), and were asked to provide their assessment regarding the extent to which their child was exposed to political violence. Findings reveal associations between mothers' distress, the degree of exposure of their child to trauma, and the child's emotional symptoms. PPAT analysis identified four main factors: Tree Generosity, Person Agency, Vividness, and As-Real-R. Positive associations were found between self-potency and the main factors of the drawings; negative associations were found between the child's difficulties in executive functions and the drawing's four main factors; and two small negative associations were found between the child's emotional symptoms and Tree Generosity and As-Real-R factors. The following associations were found within each gender group: mothers' depression degree was associated with boy's Tree Generosity, and mother's perceptions of their girl's exposure to trauma was related to Person Agency, Tree Generosity, and As-Real-R factors; furthermore, a significant difference was found between the narrative focus of drawings in this sample and the narrative focus of drawings of a sample of the same age group from a non-war zone. In addition, narrative focus was found to be related to children's self-potency. The discussion deals with the study's findings through the prism of developmental psychology, self-agency, object-relations, and art-therapy theories.

**Keywords:** PPAT; children; self-potency; EF; maternal distress; political violence

## **1. Introduction**

*1.1. Civilians Living in Conditions of Persistent Political Violence*

Civilians living in conflict-affected settings, who experience war, terror, military attacks and more, are exposed, as individuals and as a community, to immediate and unforeseen threats and danger. These situations were found to be associated with civilians' reduced sense of safety, heightened anxiety, and post-traumatic stress symptoms—PTSD (e.g., [1–3]). PTSD, according to the DSM-V, appears after an exposure to traumatic event/s, and symptoms include re-experiencing, avoidance, negative mood and cognitions, and hyperarousal [4]. Since ongoing political violence causes an accumulation of stressful events over time, its impact can be explained by the Allostatic Load Framework that shows that the

**Citation:** Bat Or, M.; Ishai, R.; Barkay, N.; Shalev, O. Visual Expressions of Children's Strengths, Difficulties and Wishes in Person Picking an Apple from a Tree Drawings among Preschoolers Living in Areas of Persistent Political Violence. *Children* **2022**, *9*, 1387. https://doi.org/ 10.3390/children9091387

Academic Editor: Brian Littlechild

Received: 14 August 2022 Accepted: 11 September 2022 Published: 14 September 2022

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**Copyright:** © 2022 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https:// creativecommons.org/licenses/by/ 4.0/).

more people are exposed to stressful or traumatic events, the more they are at risk [5]. Diamond et al. [6] described the phenomenon of Ongoing Traumatic Stress Response (OTSR) as a unique outcome for some people who live for years in conditions of political violence. OTSR is different from PTSD in four aspects: (a) clients describe their anxiety symptoms as the cumulative result of repeated ongoing stressful events, and not as related to a marked traumatic event; (b) fewer re-experiencing symptoms appear; instead, the fear is focused more on daily life routines such as those that require leaving the house (for examplepicking up the children); (c) Client's patterns of fear and avoidance are reality-based, and thus can be considered reasonable; and (d) clients report a marked decrease of symptoms when they are away from the war zone.

The present study focused on preschool children who were born into a situation of persistent political violence that began in the area where they reside about 12 years before they were born. It may be thus assumed that their parents, who were about to serve as a protective envelope to their children, experienced their safety as compromised, due to constant uncertainty and alertness. It is well known that young children's development, health, and well-being depend on their caregivers; for example, research showed that the mother's well-being serves as a resilience factor [7–9], while maternal stress was associated with children's internalizing and externalizing disorders [10]. In a systematic review on the effects of political violence on young children [11], parental care was found as a moderator of the associations between exposure to violence and children's outcomes. For this reason, we included in the current study a measure of the degree of maternal stress, as this maternal aspect may have a significant impact on the child. Since the missile attacks occur suddenly in the child's daily life, and are uncontrollable, there is a high risk that these children's development and resiliency will be impacted by the trauma in these living conditions (e.g., [12,13]).

#### *1.2. Children's Emotional-Behavioral Aspects in Political Violence Settings*

Since events of political violence mainly function as threats and stressors in the children's daily life, they can elicit fear and anxiety and other overwhelming feelings that arouse a sense of helplessness. These emotional states may be seen as a normal reaction to an abnormal situation [12]. However, prolonged exposure to political violence in childhood may limit children's adaptation [14]. Research shows that children who live in an environment of political violence tend to suffer more from clinical behavioral and emotional distress [15–17]; PTSD; psychosomatic symptoms; sleep disorders; and disturbed play [11]. Wessells and Kostelny [18] recently coined the term Violence In Childhood (VIC), that also refers to how children who witness violence are impacted [19]. VIC may occur in home, school, community, social and cultural settings.

The impact of prolonged political violence may be devastating to children's wellbeing and development; however, its continued appearance may prompt civilians under fire and the community at large to be proactive; develop solutions for coping with the challenges; and provide children, families, and educational institutions suitable preventive resources, therapeutic interventions, and resiliency building routines [20] to support health and recovery, and bolster children's sense of self-agency.

The sense of potency among children living in environments of political violence

Self-agency is the perception that the individual's actions have an impact and influence the physical and relational environment [21]. Research shows that self-agency is shaped by the repeated behavior of the caregiver toward the infant or child (e.g., [22]). Specifically, when the infant experiences sensitive and good-enough parenting, he or she internalizes a sense of self agency, by which non-verbal cues bring positive changes (for example, a cry of hunger, will result in feeding). Two concepts related to self-agency, the first is self-efficacy [23], that describes the belief in one's ability to fulfill tasks and goals, and the second is the concept of self-locus of control [24], which is the assumption that one can change reality. Self-efficacy was found as associated with motivation and cognitive achievements (e.g., [25,26]), as well as with social relationship aspects (e.g., [26,27]); In accordance

with Ben-Sira [28], self-potency includes the dimensions of self-efficacy, and self-locus of control, and, in addition, one's understanding that one's social surroundings can be an important and significant anchor. To summarize, the sense of self-potency indicates the individuals' sense of competency, based on various abilities and potential support from others. Self-potency may thus be regarded as a protective element that can support children's successful adaptation and handling of aversive conditions, such as living in war zones. The concept is important from the aspects of health and self-resourcefulness; nevertheless, very few systematic study of self-potency has been undertaken [29], particularly in the context of war zones. Amongst the challenges of studying children's self-potency is their limited ability to express themselves verbally.

#### *1.3. Children's Drawings as Communicating Their Experiences*

Since most of the research-tools for assessing preschoolers' emotional state and subjective experiences are verbal ones, and raters are mainly stakeholders such as parents and teachers, the present body of research in this field lacks the child's perspective and voice [30]. The child's perspective can be included by incorporating children's non-verbal expressions, such as drawings. Drawings are a natural activity for children and engages them in exploration, communication, fun, and learning [31]. From a realistic perspective, children's drawings progress gradually from scribbling to schematic and realistic images [32].

The current research included the drawings of children ages 4–6.9 years, a period of life which incorporates two developmental stages in drawing according to Lowenfeld and Brittain [33]. The first is the Preschematic stage, characterized by a conscious and clearly recognizable creation of form and objects, The child continually searches for new concepts and engages in problem solving, so symbols constantly change. The second developmental stage is the schematic stage, which characterizes the drawings of five- to six-year-old children, who draw schemas of specific objects in a repeated form, add a baseline [34], and emphasis objects by enlarging them. They also consider the space, demonstrated through variations in distance and how objects are organized [31]. Since the present study focuses on self-potency and emotional and cognitive aspects, the drawing task of a "Person Picking an Apple from a Tree" (PPAT: Gantt, [35]) was chosen, as it invites the child to depict a person that is in the process of reaching a goal. This drawing was found in previous studies to be related with children's motivation, and executive functions [36], and with emotional and relational aspects [37]. For example, preschoolers' executive functions problems were found to be related with a drawn person that was less active, while girls' self-potency was associated with a successful apple picking [38]. The PPAT has reliable rating systems for form, content, and narrative aspects, and thus it can be incorporated in quantitative research format. The present study's aim was to broaden our knowledge about children who live in areas of prolonged political violence by examining associations between children's variables (cognitive and emotional) and maternal stress and their PPAT drawings (form, content, and narrative layers). The inclusion of the children's drawings in this study incorporates their voices while enabling a closer inquiry into the explicit and implicit aspects of their subjective experience in relation to other data that was collected from their caregivers. This data triangulation may also strengthen and enrich the study's results, and further deepen our understanding of how preschoolers communicate via their drawings subjective experience, strengths and difficulties that may need to be addressed.

#### *1.4. Research Hypotheses*

Hypotheses of background variables:

1. Significant negative correlations were expected to be found between children's selfpotency, and emotional symptoms; executive functions (EFs) difficulties; and maternal stress.

2. Significant correlations were expected to be found between mothers' assessments as to degree of exposure of their children to events of political violence, maternal stress, and child's emotional symptoms.

Hypotheses regarding the child's PPAT drawings

Since the child's gender was found to be an intervening variable in previous studies, all the following hypotheses were also examined in relation to gender.


#### **2. Method**

*2.1. Participants*

156 preschool children (the age range of 122 children was: 4–6.9 years; Mean 5.32; SD = 0.75) who were recruited from randomly selected Israeli kindergartens located in an area affected by chronic political violence. Table 1 presents participants' demographic variables.

**Table 1.** Demographic Data: Means, SDs (in Parentheses), and Percentages.


Table 1 about here.

As described in Table 1, 107 mothers (96% married; about 80% with an academic degree and 20% with a high-school education or diploma; 41% reported an average economic status; 34% an average plus economic status, and 19% a high economic status), and 15 kindergarten teachers participated in the study. This sample was recruited from an area near the Gaza strip, affected by political violence, mainly in the form of rocket attacks since the year 2001. Participants were mainly from small villages and kibbutzim (81%), while the minority were from the city of Sderot. The gender distribution of the children was equal.

#### *2.2. Instruments*

#### 2.2.1. Mother's Questionnaires

SDQ: Strengths and Difficulties Questionnaire [40]—Parent Version

A brief behavioral screening questionnaire assessing children's (age 3–16 years) mental health, and social functioning. The questionnaire was translated to about 40 languages. The 25 items measure 5 scales: emotional symptoms, e.g., "Many fears, easily scared;" behavioral problems, e.g., "Often lies, and cheats;" hyperactivity/inattention, e.g., "Restless, overactive, cannot stay still for long;" peer relationship problems, e.g., "Rather solitary, tends to play alone;" and prosocial behaviors, e.g., "Considerate of other people's feelings." The items are coded on a three point scale: 0 = Not true, 1—Somewhat true, and 2 = Certainly true. The item's score is calculated according to the online SDQ manual. In an extensive study of the psychometric characteristics of this tool, the measure was validated with DSM-IV diagnoses, and the five subscales were found as having a sufficient internal consistency (of 0.73) [41]. In the present study, only two scales had adequate internal consistency: the hyperactivity scale (Cronbach = 0.82), and the emotional problem scale, after omitting item no. 3 (Cronbach = 0.76). The internal consistency for the 19 items (omitting item no. 3, and the prosocial scale) was sufficient (Cronbach = 0.77). Scores were computed for each of the two scales and a total measure was computed, without the prosocial scale, and item no. 3.

#### BSI-18: Brief Symptom Inventory-18 [42]

An 18-item self-report questionnaire on psychological distress that was experienced in the previous week. The items are rated on a 5-point Likert scale ranging from 0 (not at all) to 4 (extremely). In the present study we used Canetti, et al. [43] in its Hebrew translation. The items covering three dimensions are measured through the subscales: somatization (e.g., "Pains in heart/chest"); depression (e.g., "Lonely"); and anxiety (e.g., "Scared for no reason"). Additionally, a Global Severity Index (GSI) score is also calculated [44]. Prior studies confirm that the BSI-18 has good internal consistency, as reflected in a Cronbach's alpha of 0.89 [44,45]. There is adequate internal consistency for each of the scales: anxiety (0.71–0.79); depression (0.84–0.88); and somatization (0.74–0.80) [44,45]. The scales have adequate convergent and discriminant validity, constructing a three-factor structure (e.g., [44,46,47]). Adequate internal consistency was found in the current study for each scale: anxiety (Cronbach = 0.86); depression (Cronbach = 0.77); and somatization (Cronbach = 0.80). The internal consistency of the 18 items was high (Cronbach = 0.91). Scores were computed to each scale and for the total score.

#### The Child's Exposure to Trauma [15]

The questionnaire included 7 items (yes/no answers) that refer to missile attacks and exposure to political violence (e.g., the child saw a missile fall, etc.), and two items that refer to nonpolitical trauma (e.g., the child was exposed to other dangerous/traumatic events). The sum of the total scores of political violence categories was used for further analysis.

#### 2.2.2. Teacher's Questionnaires

Five Scales of the BRIEF Questionnaire [48], for Assessing EF Problems.

The children's teachers rated 46 items relating to the child's functioning during a time period of three weeks before and after the PPAT drawing, using a three—point scale (*N* = never, S = Sometimes, O = Often). The five scales that teachers evaluated included: initiating (e.g., "Needs to be told to begin a task even when willing."); planning and organizing (e.g., "Has trouble concentrating on chores, schoolwork, etc."); monitoring (e.g., "Has good ideas but cannot get them on paper."); working memory (e.g., "When given three things to do, remembers only the first or last."); and emotional control (e.g., "Erupts in rage for an insignificant reason"). The scales have high internal consistency (Cronbach = 0.90–0.93) and validity (*p* < 0.001) [48]. In the current study, the scales had high internal consistency (Cronbach = 0.88–0.95), and the global consistency was high

as well (Cronbach = 0.98). A general score of the difficulties in executive functions was calculated as the total sum of these five scales.

#### 2.2.3. Children's Questionnaires

#### The CAMP: The Child Adaptation and Measure of Potency [49]

An interview-administered questionnaire, involves 19 potency statements which are answered orally by a yes or a no. The instrument's statements were adapted from the adult's Potency Scale [28], and were modified for children, by adding an opening question: "Which child resembles you?". Each statement was formulated as positive and a negative, for instance: "A child who tries and succeeds" versus "A child who does not succeed even if he/she tries." In cases when a child did not understand the statements, the researcher supplied examples for clarification. The measure has high internal consistency (Cronbach = 0.81), and a global score was computed.

#### PPAT—Person Picking an Apple from a Tree Drawing [35]

Children were provided with white sheets of paper (21 cm × 29.5 cm) and 12 scented Sanford Mr. Sketch colors: red, orange, blue, turquoise, green, dark green, hot pink, magenta, purple, brown, yellow, and black. Each child was asked, separately, to draw a person picking an apple from a tree; no time limitation was set for the assignment. The PPAT drawings were scored based on three rating systems:

#### PPAT Drawings Analyses

*FEATS*—*Formal Elements Art Therapy Scale* [50]. This rating system is designed to measure the drawing's form features. It uses twelve 5-point Likert scales: Prominence of Color; Color Fit; Implied Energy; Space; Integration; Logic; Realism; Problem-Solving; Developmental Stage; Details of Objects and Environment; Line Quality; and Person. A low score (0) on the Space scale represents a non-existent phenomenon, e.g., the absence of any drawing. A high score (5) reflects the prominence of this phenomenon, e.g., 100% of the space was used.

Two art therapy graduate students underwent training in which they learned to rate PPAT drawings based on the FEATS Rating Manual [50]; Each of the students individually rated 40 PPAT drawings (which were not part of this study), and they reached a high inter-rater reliability calculated by ICC scores ranging between 0.72 to 0.95.

*SC-PPAT/c*—*Symbolic Content in PPAT drawings of children* [51]. The SC-PPAT/c comprises of 9 Likert scales for ranking the content-related characteristics of the tree, the person, and the relationship between them. The scales measure the quantity of apples on the tree; a tree's strength vs. its weakness; the degree to which the person is active or passive in the apple-picking; the degree of success in picking the apple; amount of contact between the person and the tree; the height ratio between the person and the tree; the position of the tree trunk in relation to the person; the proximity of the branches to the person; and the proximity of the tree's apples to the person. The Likert scales each have five to six points, depending on the scale. A low score (0) reflects a non-existent phenomenon, e.g., one of the objects is missing, while a high score (5 or 6) reflects the strong prominence of this phenomenon, e.g., a person with an apple in hand, which demonstrates success in the picking task. A previous study [38] revealed high inter-rater agreement and Interclass Correlations Coefficients (ICC) ranged from 0.78 to 0.96. In the current study ICC scores ranged between 0.84 to 0.99 (*n* = 35). After reaching inter-rater agreement, the rest of the drawings were divided between them for scoring.

*The Narrative Focus Degree Scale* [52]. A 6-point Likert scale measures the narrative focus of PPAT drawings. Narrative focus varies and ranges from drawings focusing only on the picking theme to drawings that contain a competing narrative that steers attention away from the picking theme. Drawings featuring the PPAT as the main theme receives a score of 1 to 4 that reflect an increasing PPAT narrative emphasis and richness. A score of (5) reflects the presence of a competing narrative, and a score of (0) reflects the absence of a picking narrative. Two art therapy students who were asked to rank 35 drawings reached high inter-rater reliability (ICC = 0.84).

#### *2.3. Procedure*

The Israeli Ministry of Education and the ethical committee of the University of Haifa's Faculty of Social Welfare and Health Sciences approved the study. First, kindergarten teachers were invited to take part in this research, and then the children's parents were contacted. Data was collected during 2018 and 2019. PPAT drawings [35], and the CAMP [49], were administered individually in the presence of a researcher. The children's mothers completed the SDQ [40], which measures the child's strengths and difficulties, the BSI-18 [44], which measures maternal stress, and a measure that assesses the degree to which their children were exposed to events of political violence [15]. Finally, the children's teachers responded to five scales of the BRIEF questionnaire [48] that measures children's problems in executive functions.

#### **3. Results**
