SUNGDO DAVID HONG, M.D.

S. PETER KIM, M.D.

Self-concept and body-imageof children during physical illness

Dr. Hong, assistant prOfessor ofpsychiatry at the University ofSouth Florida Collegeof Medicine, was a fellow in child psychiatry at New York University, BellevueMedical Center, at the time ofthis study. Dr. Kim is associate prOfessor ofpsychiatryat New York University School ofMedicine. Reprint requests to Dr. Hong, Universityof South Florida, Medical Center, Department of Psychiatry, Box 14, 12901 North30th Street, Tampa FL 33612.

ABSTRACT: The authors explored children's understanding oftheir physical illnesses and their effects on body-image and self­concept. A majority of 19 hospitalized boys oflatency age realis­tically understood the nature of their illness and their treatmentwhen health care personnel provided them with adequate infor­mation. Interviews and psychological tests showed that acutephysical illness did not have a significant impact on general self­concept but did alter body-image in 37% of the children duringthe period of acute illness.

Even the best cared for and health­iest children develop physical ill­nesses or sustain injuries, which in­variably draw attention to thebody. During the latency period thehealthy child takes the body forgranted, but illness enforces anawareness of physiologic eventsthat would otherwise go unnoticed.This new perception evokes re­pressed infantile experiences. Par­ticularly, the inside of the body­the gastrointestinal tract and

joints, for example-may becomeinvested with increased oral, anal,and oedipal fantasies. I

The illness produces change inthe child as well as in his or herenvironment. The sequelae of thischallenge for the ego may be tran­sient or result in long-lasting re­gression, tendency toward maso­chism, proneness toward or denialof illness, depression, self-devalua­tion, or aggression. On the otherhand, experiencing illness or injury

may lead to growth through an in­tegrative process,a widened hori­zon, heightened sensitivity, deep­ened feelings, and a broadened ca­pacity for empathy as well as forsublimation"

The term "body-image" refers tohow the body is experienced psy­chologically and to the feelings andattitudes toward one's body. Itdenotes a person's subjective expe­riences of his or her body and theirorganization. Each person has thedifficult task of meaningfully orga­nizing the body's sensations as heor she develops.2

Noble and associates,3 in theirstudy of war amputees, found evi­dence ofcastration anxiety, aggres­sive feelings, and wishes for depen­dency; they concluded that denialwas the most prominent defense,although displacement and projec­tion were also manifested. Further,those amputees who were judged tobe adapting poorly to loss of theirlimbs tended, in a drawing exercise,to depict the absent limb as largerthan the other one or with empha­sized markings.

Centers and Cente1's4 compared

128 PSYCHOSOMATICS

the body images of children whowere amputees and children whowere not. Contrary to the findingsof Noble and associates, theirstudy, using Draw-A-Person tests,showed that most amputees repre­sent their bodies and those ofothersrealistically and, on the whole,nondefensively.

Meisner and associatesS com­pared the impact of obvious physi­cal handicaps on self-concept inmale and female adolescents. Theyconcluded that the greatest impacton self-concept occurred in girlswith physical problems of high im­pact and visibility.

Weininger and associates2 com­pared body-image between groupsof institutionalized physicallyhandicapped children, noninstitu­tionalized physically handicappedchildren, and physically normalchildren and found that institu­tionalizedhandicapped children dohave a way ofregarding themselvesthat differs from that of the otherchildren. The authors concludedthat lack of consistency in parentalfigures and limited life experiencesare important variables underlyingthe underdeveloped body-imageschema of institutionalized physi­cally handicapped children.

Schecter6 stated that the ortho­pedically handicapped child notonly withdraws cathexis from theouter world but, because of de­creased motility, tests reality inade­quately. Consequently, the handi­capped child's ability to develop anadequate self-concept and self­image is lessened. Reduced mobil­ity, especially ifit develops betweenthe ages of two and six, severelyrestricts all other ego functions, andthe child's conception of himselfand the way he relates to the outerworld are affected by his distortedbody-image.

FEBRUARY 1981 • VOL 22 • NO 2

In addition to impairment of egostrength through such physicalconditions as fever and metabolicdisturbances, many other factors,mere by-products of illness, canalter self-image by jeopardizing theintactness of the body. Examplesinclude injections, operations,physical examinations, and thechange-from wearing regular cloth­ing, which forms part of one's egoimage, to wearing unfamiliar,anonymous hospital garments.

Being suddenly different frompeers, with the concomitant loss ofgroup identification, further altersthe self image. I Change in self- andbody-image may also stem from

Elements oftreatment, withtheir highly emotiolUllsignificance, may be thedetennining factors incausing a child'spsychological breakdown.

the libidinization of the diseasedorgan or the symptoms and mayproduce various somatic and psy­chological problems.

Although a significant number ofstudies have examined children'svarious reactions to chronic illness,there have been few studies on theirreactions to acute illness. This studyexplores children's understandingof their illness and the changes inbody-image and self-concept thatoccur during acute illness.

Study sampleThe patients in this study included19 boys (18 Puerto Rican and oneblack) who were admitted to thepediatric ward of a metropolitanmunicipal hospital. The subjectswere randomly chosen, althoughthose children with chronic ill-

nesses or psychiatric illness requir­ing attention were excluded. Agesranged from 6 years. 2 months to 12years, II months, with a mean ageof to years, 2 months.

The patients were interviewedand tested soon after the acutemedical/surgical crisis was overand when the patients were rela­tively stable and comfortable andable to perform the testing tasks.The duration of each child's hospi­talization, as of the day of the test­ing, ranged from one to 13 days.

Procedure

One of the authors (SH) inter­viewed the children to determinetheir understanding about their ill­nesses. In addition to engaging thechildren in verbal discussions, theinterviewer asked them to depictthe nature of their illnesses bydrawing pictures. They were askedto draw the organ involved andshow its change and also to indicatewith one of several colored pencilsthe location of the lesion involvedon a pre-printed silhouette of aperson.

Later in the interview. each pa­tient was provided with three sheetsof white. unlined paper (one sheetat a time) and a pencil with aneraser. The instructions were todraw "a whole person," "a personof the opposite sex" (explained tothe younger children as boy/manor girl/woman). and "a picture ofyourself." After the interview wasover, the children were tested onthe Piers-Harris Children's Self­Concept Scale.

ResultsUnderstanding of illness. Most ofthe children had a relatively goodgrasp of the nature of their illnessesand the therapeutic procedureseven though their explanations

119

Illness and self-concept

were sometimes concrete and dis­torted. A ten-year-old boy who hadperitonitis and had a poor under­standing of micro-organisms said,"Some bugs-roaches-entered tomy stomach and caused the prob­lems." Another ten-year-old boywho had recently developed a sei­zure disorder explained his condi­tion by saying, "When I am upset,my brain shrinks and it sendssomething to my arms and legs andthey move by themselves." A nine­year-old boy who had a surgicalprocedure for meatal stenosis of hispenis revealed his fear and fantasy:"I'm glad that the doctors did thisoperation for me to have a biggeropening in my penis. If they didn'tdo it my urine would not come outand would stay inside my body,and when the urine reached mybrain, I would die."

All the children located their le­sions on the silhouetted person cor­rectly, except for confusing rightand left. Eight children representedthe lesion with shading, seven witha line, and four with a dot. Fourpatients used black pencils, threeused brown ones, three used pinkones, and the rest used pencils ofother colors.Human figure draWing tests. Of the19 boys, six were trauma and or­thopedic patients. Five of thesewere immobilized or restricted inmovement by casts or other ortho­pedic devices. Three patients in thisgroup drew pictures of movementor performance of an exercise.

There were no significant dif­ferences between the figures ob­tained with the Draw-A-Person testand a self-portrait test, except fortwo drawings of the patients in thehospital setting.

Two patients emphasized the le­sion, two simplified or minimizedit, and the other two did not include

130

it in their human-figure drawings.Of the five general and urosur­

gery patients, none ofwhose move­ment was completely restricted,only one drew a figure in motion.There were no significant dif­ferences between the figures in theDraw-A-Person tests and in theself-portrait tests of the other pa­tients. One patient accentuated thelesion, one minimized it, and threeomitted it.

Of the eight medical patients, sixdid not show any significant dif­ferences between the figures ob­tained in the Draw-A-Person testand in the self-portrait test. Onepatient minimized the area of the

Most ofthe childrell IuuJ arelatively good grasp ofthe1IIlture oftheir illnesses arulthe therapeutic procedures.

lesion, and seven did not representit in their drawings.Piers-Harris Children's Self-Con­cept Scale. The Piers-Harris Chil­dren's Self-Concept Scale is a self­report instrument designed pri­marily for research on the develop­ment of children's attitudes aboutthemselves and on correlates ofthese attitudes.' High scores indi­cate high self-esteem and a positiveself-concept. Average scoresusually are considered to rangefrom 46 to 60. For the total group of19 boys, scores ranged from 43 to72, with a mean score of56.3. Meanscores for the orthopedic andtrauma patients, surgical patients,and medical patients were 56.7,55.8, and 56.9, respectively.

Discussion

Anna Freud8 stated that the child isunable to distinguish between feel-

ings of suffering caused by the dis­ease and suffering imposed by ex­ternal sources intended to cure thechild, and that the child must sub­mit uncomprehendingly, help­lessly, and passively to both formsof experience. In certain instances,elements of treatment, with theirhigh emotional significance, maybe the determining factors in caus­ing a child's psychological break­down during illness or in determin­ing its after-effects.

However, the majority of chil­dren in this study realistically un­derstood the nature of their ill­nesses and of the therapeutic pro­cedures because pediatricians andnurses had provided careful expla­nations and adequate information.Their efforts prevented or reducedconfusion, feelings of helplessness,bewilderment, and psychologicalbreakdowns in the children.

Wagenheim9 proposed that inearly childhood, illness is viewed asa punishment for hostile feelings.The "attack" by the disease pro­vides evidence that the child is "nogood" and is subject to punishmentby unknown forces. While this maybe true in young children, none ofthe physically ill children in thepresent study made a connectionbetween illness and punishment.However, the concept of punish­ment was revealed in the cases ofinjuries due to accidents.

Two 12-year-old boys who sus­tained multiple fractures in acci­dents-one with an elevator, theother with an automobile-re­ported that their injuries wereGod's punishment. One of themsaid, "I smoked once, stole somemoney, and played hooky severaltimes. God was mad and punishedme because I was bad."

Machover lO stated that the"human figure drawn by an indi-

(continued)

PSYCHOSO~TICS

vidual who is directed to draw aperson relates intimately to the im­pulses, anxieties, conflicts, andcompensations characteristic ofthat individual. In some sense thefigure drawn is the person and thepaper corresponds to the environ­ment." The human figure drawingsobtained in the Draw-A-Persontests of 14 children in our studywere essentially the same as theirself-portraits; this supports Mach­over's self-image hypothesis.

Acute physical illness and injurydo not interfere with general self­concept including self-esteem, asevidenced by the scores of oursample on the Piers-Harris Self­Concept Scale.7 There is no signifi­cant difference between the scoresof our sample and those of thegeneral population. However, ill­ness and injury significantly alterthe child's body-image as evi­denced by their figure drawings. Inour study, seven out of 19 patients(37%) emphasized or minimizedthe lesion in their drawings. Thisemphasis or minimization wasmore apparent in trauma, orthope­dic, or surgical patients (six out ofII) than in medical patients (oneout of eight),

The human figure drawings alsoreveal the wishful thoughts or fan­tasies of the children. Three of thefive immobilized children drew

FEBRUARY 1981 • VOL 22 • NO 2

pictures of movement. A child whowas not permitted to take foodorally drew a picture of a personeating candy. And the child whohad a .genital surgical proceduredrew a person holding a largebaseball bat, which some psychia­trists consider a phallic symbol.

Since there are so many variablesthat influence children's reactionsto physical illness,II and since thesample of this study is small andrestricted to a narrow social seg­ment, the findings may not be rep­resentative of the population atlarge. However, it is probable thatthe impact of acute physical illnesson self-concept and body-imagewould be minimal for children withadequately developed personalitiesbefore their illnesses, positiveparent-child relationships, andsupportive hospital environmentsin which they receive realistic in­formation concerning their illnessand treatment.

Conclusion

Contrary to prevalent psychoana­lytic concepts, at least in the case ofacute physical illness, the majorityof children realistically understandthe nature of illness and therapeu­tic procedures when they are pro­vided with adequate information tofacilitate their adaptation to theseexperiences.

Illness and self-concept

Human figure drawing tests ap­pear to be efficient measures ofchildren's fantasies and wishfulthoughts in addition to body-image.Acute physical illness in childrendoes not have a significant impacton general self-concept but doesalter body-image during the acuteillness. 0

REFERENCES1. Jessner L: Some observations on children

hospilalized during latency, in Jessner L, Pa­venstedt E (eds): Dynamic Psychopathologyin Childhood. New York, Grune & Stranon,1959, pp 257-268.

2. Weininger 0, Rotenberg G, Henry A: BOdyimage of handicapped children. PersonalityAssess 38:248-253, 1972.

3. Nobel 0, Price D. Gilder R: Psychiatric distur­bances following amputation. Psychiatry110:609-613, 1954.

4. Centers L, Genters R: A comparison of thebOdy images of amputee and non-amputeechildren as revealed in figure drawing. J Pro·ject Techniques 27:158-165, 1963.

5. Meisner A, Thoreson R. Butler A: Relation ofself-concept to impact and obviousness ofdisability among male and female adoles­cents. Percept Mot Skills 24:1099-1105,1967.

6. Schechter M: Orthopedically handicappedchild. Arch Gen Psychiatry 4:247-253, 1961.

7. Piers E, Harris P: The Piers·Harris Children'sSelf Concept SCafe. Nashville, Tenn., Coun­selor Recordings and Tests. 1969.

8. Freud A: The role ·of bOdily illness in themental life of children. Psychoanal StudyChild 7:69-81, 1952.

9. Wagenheim L: Learning problems associatedwith childhoOd diseases contracted at agetwo. Am J Orthopsychiatry 21:102-109,1959.

10. Machover K: Personality Projection in theDrawings of the Human Figure. Springfield, III,Charles C Thomas, 1949.

11. Nagera H: Children'S reactions to hospilal­ization and illness. Child Psychiatry Hum Dev1:3·19, 1978.