Abstract
Objective
Attention deficit hyperactivity disorder (ADHD) is the most common behavioral problem during childhood and in school-aged children. Various projection drawings have been designed for assessing children’s personality and psychological disorders including the tests of draw a person (DAP) and draw a family (DAF). We aimed to compare the differences between typically developing children and children with ADHD using these tests.
Methods
In this case-control study, all the 9-10 year-old boy students studying at the third and fourth grades were enrolled from schools in the 2nd educational district of Shiraz, south of Iran. Eighty students were then selected and enrolled into the ADHD group and the control group. The Diagnostic and Statistical Manual of Mental Disorders, 4th edition- text Revised (DSM-IV-TR), and the Child Symptoms Inventory were used to diagnose the children with ADHD. We evaluated and analyzed impulsiveness, non-impulsiveness, emotional problems and incompatibility indices in the DAP and DAF tests in each group.
Results
A significant difference was found in the indices of incompatibility and emotional problems, impulsiveness, non-impulsiveness and DAF between typically developing children and those with ADHD. The mean (±SD) total scores of the above mentioned indices in the ADHD group were 19.79(±2.94), 12.31(±1.84), 5.26(±2.29) and 5.89(±2.13), respectively (P<0.001). The corresponding figures for these indices in the normal group were 12.11(±4.74), 5.63(±2), 10.36± (2.33) and 2.88(±2.13), respectively (P<0.001).
Conclusion
Significant differences were obtained between the control group and children with ADHD using these two drawing tests. The rate of impulsivity and emotional problems indices in drawings of children with ADHD was markedly more common than those of the typically developing children. This suggests the need for further assessment to screen ADHD.
Keywords: Attention Deficit Hyperactivity Disorder, Draw a Person Test, Draw a Family Test, Child Symptom Inventory
Children should be able to freely express what is in their minds and souls, and drawing is a way for open expression. Children’s drawing may be the perfect reflection of their simple or complex problems and their relationship with family members (1).
Draw a person (DAP) and draw a family (DAF) tests are suitable for assessing the mental, emotional and familial aspects of all children (2). The DAP test has been widely used in various studies for cognitive, emotional and impulsivity evaluation (3-8). The DAP is used for evaluating indices such as impulsiveness, non-impulsiveness and incompatibility problems as well (2, 8).
Oas showed that impulsivity indices in the DAP test are higher in impulsive children than non-impulsive children. Moreover, non-impulsivity indices were at a lower level (7). The validity and reliability of the DAP test is satisfactory (9-11). The DAF test assesses 11 variables (12). This test was invented by Hulse in 1951 (13), and has been evaluated by various studies (14-15).
Moreover, Zaback (1994) and Rachel (1999) assessed the application of the DAP test in sexual disorders and sexual abuse (16-17). Furthermore, Rachel and coworkers (2000) used the DAP test for predicting aggressive behavior in prisoners (18). Wendy and colleagues (2004) studied the group differences between individuals with obsession, hyperactivity and Tourette’s syndrome and normal individuals using the DAP test (19).
Attention deficit hyperactivity disorder (ADHD) is the most common behavioral problem during childhood (20). Therefore, we decided to evaluate drawing test performances in children with ADHD. This study compared the drawing of ADHD children with that of the typically developing children.
Material and Methods
In this case-control study, all the 9-10 year-old boy students studying at third and fourth grades in boy schools in the 2nd educational district of Shiraz, south of Iran, were enrolled. Among the 800 enrolled boys, 40 students were selected as the case group for they were diagnosed as having ADHD. They did not have any history of chronic diseases such as diabetes or hypothyroidism. Further, nothing abnormal was found in the participants’ physical examinations. Moreover, the laboratory tests evaluation of the children with ADHD did not show any significant finding. We also selected 40 boys for the control group among the remaining children without ADHD. All children lived with their parents.
At first, all the students were evaluated using the Child Symptom Inventory-Teacher’s form (CSI-4) developed by Gadow and Spafkin (21, 22) based on the DSM-IV ADHD criterion (21); its Farsi version has enough validity and reliability (23). The mothers of those children who were diagnosed as having ADHD were invited to complete the Parent’s form of CSI-4 questionnaire (23).
If the Parent and Teacher forms matched, then the student underwent the final screening stage which was a face-to-face interview with the parents. This interview was conducted to confirm the ADHD diagnosis according to DSM-IV-Text Revised diagnostic criteria. Forty children with ADHD were matched with 40 children without ADHD by age and gender.
Children in both groups performed the Draw-A-Person (DAP) and Draw-A-Family (DAF) tests in a silent environment. They were provided with a white A4 paper, a black pencil and an eraser and were asked to draw a person. The time taken to draw a person was recorded. Then they were asked about the gender of the drawn person. After finishing the test, the children were given another A4 paper and were told to imagine a family and then draw that family. If any of the emotional problems or the incompatibility variables such as deleting the important components of the body (such as hand or leg), simplifying the head or body, distortion and lack of proportion (such as inappropriate arm size) were shown, score of 1 was given, and if not, the score of 0 was given, except for score 1 to 9 for the weak quality of the drawing and sexual differentiation If any of the DAF variables were presented, score of 1 was given, if not, the score of 0 was given.
Impulsivity and non- impulsivity indices have 13 variables separately; for example, if the signs which were suggestive of aggressiveness such as (knife, gun, blood), deleting important parts of the body for impulsivity index and shading, emphasis on the eyes and mouth for non- impulsivity index were detected, the score of 1 was given; for the existence of two components or more, the score of 2 was given, and if not, then the score of 0 was given.
Statistical Analysis
Data were analyzed using SPSS software, version 11.5. The mean scores of impulsiveness, non-impulsiveness, indices in the DAP and DAF were compared between the two groups using the independent t-tests. P value less than 0.05 was considered as significant.
Results
The maximum and minimum total scores of incompatibility and emotional problem indices in the ADHD group were 23 and 12, respectively, with a mean (±SD) of 19.79 (±2.94). The corresponding figures for the normal group were 22 and 3, respectively, with a mean (±SD) of 12.11(±4.74) (P<0.001, Table 1).
Table 1.
Mean scores of incompatibility and emotional problems in both groups
| Incompatibility and emotional problem indices | Group | Minimum | Maximum | Mean | P value |
|---|---|---|---|---|---|
| 1-Simplifying the head | ADHD | 0 | 1 | 0.94 | <0.001 |
| Normal | 0 | 1 | 0.38 | ||
| 2-Simplifying the body | ADHD | 0 | 1 | 0.94 | <0.001 |
| Normal | 0 | 1 | 0.50 | ||
| 3- Deleting the important components of the drawing | ADHD | 0 | 1 | 0.76 | <0.001 |
| Normal | 0 | 1 | 0.22 | ||
| 4- Distortion and lack of proportion | ADHD | 1 | 1 | 1 | <0.001 |
| Normal | 0 | 1 | 0.83 | ||
| 5-Weak quality of the drawing | ADHD | 4 | 9 | 7.78 | <0.001 |
| Normal | 1 | 8 | 4.58 | ||
| 6-Clarity of the drawing | ADHD | 0 | 0 | 0 | Not calculat |
| Normal | 0 | 0 | 0 | ||
| 7-Sexual differentiation | ADHD | 1 | 9 | 8.07 | <0.001 |
| Normal | 1 | 9 | 5.55 | ||
| 8-Lack of balance in standing | ADHD | 0 | 1 | 0.26 | <0.001 |
| Normal | 0 | 1 | 0.03 | ||
| 9-Sexual details | ADHD | 0 | 0 | 0 | Not canculat |
| Normal | 0 | 0 | 0 |
The maximum and minimum total scores of impulsiveness in the ADHD group were 21 and 7, respectively, with a mean (±SD) of 12.31 (±1.84). The corresponding figures for the normal group were 10 and 2, respectively, with a mean (±SD) of 5.63 (±2) (P<0.001, Table 2). The maximum and minimum total scores of non-impulsiveness in the ADHD group were 11 and 1, respectively, with a mean (±SD) of 5.26 (±2.29). The corresponding figures for the normal group were 16 and 6, respectively, with a mean (±SD) of 10.36 (±2.33) (P<0.001, Table 3). The maximum and minimum total scores of DAF indices in the ADHD group were 10 and 0, respectively, with a mean (±SD) of 5.89 (±2.13). The corresponding figures for the normal group were 7 and 60, respectively, with a mean (±SD) of 2.88 (±2.13) (P<0.001, Table 4). Table 5 demonstrates the mean total scores of the four variables and their comparison between the two groups.
Table 2.
Mean scores of impulsiveness indices in both groups
| Impulsiveness indices | Group | Minimum | Maximum | Mean | P value |
|---|---|---|---|---|---|
| 1-Consumed time | ADHD | 0 | 2 | 0.47 | <0.001 |
| Normal | 0 | 0 | 0 | ||
| 2-Disconnected lines | ADHD | 0 | 2 | 1.57 | <0.001 |
| Normal | 0 | 2 | 0.33 | ||
| 3-Omitting specific features | ADHD | 0 | 2 | 1.78 | <0.001 |
| Normal | 0 | 2 | 0.83 | ||
| 4- Shoulders | ADHD | 0 | 1 | 0.81 | <0.001 |
| Normal | 0 | 1 | 0.11 | ||
| 5-Aggressiveness | ADHD | 0 | 2 | 0.31 | 0.037 |
| Normal | 0 | 2 | 0.16 | ||
| 6-Deleting important parts of the image | ADHD | 2 | 2 | 2 | <0.001 |
| Normal | 0 | 2 | 0.88 | ||
| 7-General quality of the image | ADHD | 0 | 2 | 1.21 | <0.001 |
| Normal | 0 | 2 | 0.22 | ||
| 8-Tendency to the left | ADHD | 0 | 1 | 0.52 | <0.001 |
| Normal | 0 | 1 | 0.30 | ||
| 9-Increasing the drawing surface | ADHD | 0 | 2 | 0.36 | <0.001 |
| Normal | 0 | 2 | 0.88 | ||
| 10-Neck | ADHD | 0 | 1 | 0.57 | <0.001 |
| Normal | 0 | 1 | 0.13 | ||
| 11-Weak planning | ADHD | 0 | 1 | 0.36 | <0.001 |
| Normal | 0 | 1 | 0.06 | ||
| 12-Posture | ADHD | 0 | 1 | 0.28 | <0.001 |
| Normal | 0 | 1 | 0.08 | ||
| 13-Proportions | ADHD | 2 | 2 | 2 | <0.001 |
| Normal | 0 | 2 | 1.61 |
Table 3.
Mean scores of non-impulsiveness indices in the groups
| Non-impulsiveness indices | Group | Minimum | Maximum | Mean | P value |
|---|---|---|---|---|---|
| 1-Symmetry | ADHD | 0 | 1 | 0.26 | 0.0013 |
| Normal | 0 | 1 | 0.38 | ||
| 2-Consumed time | ADHD | 0 | 2 | 1.36 | <0.001 |
| Normal | 2 | 2 | 2 | ||
| 3-Emphasis on the eyes | ADHD | 0 | 2 | 0.15 | <0.001 |
| Normal | 0 | 2 | 1.05 | ||
| 4- Design | ADHD | 0 | 0 | 0 | <0.001 |
| Normal | 0 | 2 | 1.05 | ||
| 6-Paying attention to details | ADHD | 0 | 0 | 0 | <0.001 |
| Normal | 0 | 2 | 0.61 | ||
| 6-Erasing mistakes | ADHD | 0 | 1 | 0.34 | <0.001 |
| Normal | 0 | 1 | 0.88 | ||
| 7-Size | ADHD | 0 | 1 | 0.55 | <0.001 |
| Normal | 0 | 1 | 0.41 | ||
| 8-Place of drawing | ADHD | 0 | 1 | 0.42 | 0.175 |
| Normal | 0 | 1 | 0.36 | ||
| 9- Sexual identity | ADHD | 0 | 1 | 0.03 | 0.161 |
| Normal | 0 | 1 | 0.08 | ||
| 10- Features of the mouth | ADHD | 0 | 2 | 0.47 | <0.001 |
| Normal | 0 | 2 | 1.11 | ||
| 11- Scenery and landscapes | ADHD | 0 | 1 | 0.03 | 0.345 |
| Normal | 0 | 0 | 0 | ||
| 12- Tendency to the right | ADHD | 0 | 1 | 0.36 | <0.001 |
| Normal | 0 | 1 | 0.50 | ||
| 13- Shading | ADHD | 0 | 2 | 1.26 | <0.001 |
| Normal | 0 | 2 | 1.88 |
Table 4.
The mean scores of DAF variables in the groups
| DAF indices | Group | Minimum | Maximum | Mean | P value |
|---|---|---|---|---|---|
| 1-Very weak organization | ADHD | 0 | 1 | 0.78 | <0.001 |
| Normal | 0 | 1 | 0.25 | ||
| 2- Smallness of the total drawing space | ADHD | 0 | 1 | 0.48 | <0.001 |
| Normal | 0 | 1 | 0.13 | ||
| 3-Drawing oneself smaller than other | ADHD | 0 | 1 | 0.59 | <0.001 |
| Normal | 0 | 1 | 0.44 | ||
| 4-Very simple image without any details | ADHD | 0 | 1 | 0.67 | <0.001 |
| Normal | 0 | 1 | 0.16 | ||
| 5-Drawing oneself distant and separated from others | ADHD | 0 | 1 | 0.51 | <0.001 |
| Normal | 0 | 1 | 0.38 | ||
| 6-Weak sexual differentiation between the drawn members | ADHD | 0 | 1 | 0.64 | <0.001 |
| Normal | 0 | 1 | 0.22 | ||
| 7-Lots of empty spaces in the drawing | ADHD | 0 | 1 | 0.54 | <0.001 |
| Normal | 0 | 1 | 0.27 | ||
| 8-Omitting a member of the family from the drawing | ADHD | 0 | 1 | 0.59 | <0.001 |
| Normal | 0 | 1 | 0.44 | ||
| 9-Deleting important features of the drawing | ADHD | 0 | 1 | 0.81 | <0.001 |
| Normal | 0 | 1 | 0.38 | ||
| 10- Drawing the parents undesirably | ADHD | 0 | 1 | 0.24 | <0.001 |
| Normal | 0 | 1 | 0.16 | ||
| 11- Drawing the male sex undesirably | ADHD | 0 | 0 | 0 | Not calculate |
| Normal | 0 | 0 | 0 |
Table 5.
The mean total scores of the four variables and their comparison between the two groups
| Variables | Group | Minimum | Maximum | Mean | SD | P value |
|---|---|---|---|---|---|---|
| Incompatibility and emotional problems | ADHD | 12 | 23 | 19.79 | 2.94 | 0.001 |
| Normal | 3 | 22 | 12.11 | 4.74 | ||
| Impulsiveness index | ADHD | 7 | 21 | 12.31 | 1.84 | 0.001 |
| Normal | 2 | 10 | 5.63 | 2.00 | ||
| Non-impulsiveness index | ADHD | 1 | 11 | 5.26 | 2.29 | 0.001 |
| Normal | 6 | 16 | 10.36 | 2.33 | ||
| DAF | ADHD | 1 | 10 | 5.89 | 2.22 | 0.001 |
| Normal | 0 | 7 | 2.88 | 2.13 |
Discussion
ADHD is the most common behavioral disorder in children. Therefore, the accurate diagnosis of children with ADHD in its primary stages is of prime importance. So far, various methods have been used to evaluate and diagnose this disorder such as related questionnaires, clinical interviews with parents and teachers and monitoring the child in different situations. Various projection drawings regarding child personality and mental disorders have been designed. We used the DAP test to evaluate and identify students with ADHD, and we also used the DAF test to assess the interpersonal relationship of the children with ADHD and their families.
Many of these students were identified at school and were then evaluated and treated.
The DAP test has been widely used in many emotional-cognitive disorders. Some studies have shown a correlation between the indices of the DAP test and children’s verbal intelligence score (4, 24). This test has been used as an initial screening tool for evaluating intelligence; however, it should not replace the standard intelligence tests (2).
Naglieri and colleagues used the DAP test for the initial screening and assessment of emotional disorders and found a significant difference between the drawings of exceptional and normal students (5).
A significant relationship existed between the conflict indices in the DAP test and mental pathologies (6). To assess a conflict in a child, Groth-Marnat has suggested to determine 9 indices in the DAP test (2). We found a significant difference between the case and control groups with respect to conflict indices in the DAP test, with a mean of 19.79(±2.94) in ADHD and 12.11 (±4.74) in normal children.
In two other studies, using the indices of the DAP test that assessed impulsivity, the researchers found that people with ADHD draw a part of the person out of the border of the page (3, 4). Drawing items such as zipper, pocket, or belt shows a tendency to control impulses, and the lack of consistency and organization in the image and drawing, thin shoulders and wide arms depicts a tendency to be impulsive (3).
Currently, Oas’s study (7) is considered as the most successful formulation for evaluating impulsivity (2). Oas showed that impulsivity indices in the DAP test are higher in impulsive children than non-impulsive children. Moreover, non-impulsivity indices were at a lower level. Consistently, in our study, the comparison of these indices between the two groups was highly significant. Impulsiveness scores were 12.31(±1.84), 5.63(±2) in ADHD and normal children, and non-impulsiveness scores were 5.26(±2.29), 10.36(±2.33) in ADHD and normal children.
Zaback and colleagues (1994) found that in normal individuals, 92% of men and 64% of women draw their same sex first in the DAP test (16). In a study of 1500 people, Leibowitz (1999) observed that 78% of normal people draw the image of the same sex while 81% of homosexuals draw the picture of their opposite sex first (3).
Rachel (1999) found that the DAP results differed significantly in the four general indices of the facial, eye, hand and arm and genital organs in adults who were sexually abused in childhood compared with those who were not (17). The results of Rachel’s study were highly effective in discovering and identifying adults who had been sexually abused in childhood, and they suggested that the DAP test be used as a clinical tool. Moreover, Rachel and coworkers (2000) used the DAP test to predict aggressive behaviors in prisoners (18). The results showed that the eyebrows, shoulder, hair, mustache and eye indices significantly differed in aggressive prisoners compared to non-aggressive ones. These recent (16, 3, 17, 18) studies are other samples for DAP test usage in psychological problem detection. Human Figure Drawings were found to be a time/cost-effective, sensitive and culturally appropriate means for measuring emotional well-being in Debiasie,s study (25).
There were significant differences between depressive patients and normal individuals in DAF test variables (14). Also, comparing the results of this test between children from divorced and non-divorced families revealed significant differences (15). In our study, the same result was obtained. DAF scores were 5.89(±2.13), 2.88(±2.13) in ADHD and normal children, respectively.
If children with ADHD are not recognized at the right time, their disorder might be left untreated and their performance will weaken. Moreover, it would lead to personality disorders, delinquency, drug addiction, alcohol use and depression in adulthood. Hyperactivity, immaturity in social behavior, impulsiveness and interference with teacher’s educational strategies severely affect the learning of these children.
We aimed to introduce the DAP and DAF tests as primary screening tests. The simplicity and applicability of these tests are beneficial in the primary detection of high risk children at schools. These tests can be easily taught to the health teachers. Detected children can be referred to physicians, their parents can be interviewed and the rest of the diagnosis and treatment process can begin. Using a set of methods and techniques for diagnosis leads to better diagnosis of the disorder and therefore these tests can be added to the previous diagnostic tools.
Conclusion
Significant differences were found between normal children and ADHD children using these two drawing tests. The rate of impulsivity and emotional problems indices in ADHD children’s drawing was markedly more common than that of the typically developing children. This suggests the need for further assessment to screen ADHD.
Footnotes
Contributors
1.Main concept, 2. design, 3. data gathering and Interview, 4. Data analysis, 5. Interpretation of the results, 6. preparing the first of the manuscript, 7. Revision of the manuscript.
MH1, 2, 3, 4, 5, 6, 7
M.K. 1, 2, 3, 4,
G.C. 1, 2, 3, 4, 5, 6, 7
S.T. 4, 5, 6, 7
A.G. 5, 6, 7
References
- 1.Dadsetan P. Child’s personality assessment based on drawing tests. 1. Tehran: Roshd; 1994. [Google Scholar]
- 2.Groth-Marnat G. Handbook of psychological assessment. 3. New York: John Wiley and sons; 1997. [Google Scholar]
- 3.Leibowitz M. Interpreting Projective Drawings: A Self Psychological Approach. 6. Philadelphia, PA: Brunner/Mazel; 1999. [Google Scholar]
- 4.Naglieri JA, Draw A Person. A quantitative scoring system. San Antonio, TX: The Psychological Corporation; 1988. [Google Scholar]
- 5.Naglieri JA, Mcneish TJ, Bardos AN. Draw -A-Person: Screening procedure for Emotional Disturbance. Austin, TX: Pro-Ed; 1991. [Google Scholar]
- 6.Maloney MP, Glasser A. An evaluation of the clinical utility of the Draw-a-Person Test. J Clin Psychol. 1982;38:183–190. doi: 10.1002/1097-4679(198201)38:1<183::aid-jclp2270380132>3.0.co;2-8. [DOI] [PubMed] [Google Scholar]
- 7.Oas P. Validity of the draw-a-person and Bender Gestalt tests as measures of impulsivity with adolescents. J Consult Clin Psychol. 1984;52:1011–1019. doi: 10.1037//0022-006x.52.6.1011. [DOI] [PubMed] [Google Scholar]
- 8.Gustafson JL, Waehler CA. Assessing concrete and abstract thinking with the Draw-a-Person technique. J Pers Assess. 1992;59:439–447. doi: 10.1207/s15327752jpa5903_2. [DOI] [PubMed] [Google Scholar]
- 9.Lilienfeld SO, Wood JM, Garb HN. The scientific status of projective techniques. Psychol Sci Public Interest. 2000;1:27–66. doi: 10.1111/1529-1006.002. [DOI] [PubMed] [Google Scholar]
- 10.Rawley S. Aggression and depression assessed through art: Using draw-a-story to identify children and adolescents at risk. New York: Brunner-Routledge and Hove; 2005. [Google Scholar]
- 11.Thomas O, Williams JR. The reliability of scores for the draw-a-person intellectual ability test for children, adolescents, adults. Psycho educational assessment. 2006;24:137–144. [Google Scholar]
- 12.Corman L. Family Drawing Test (Animal Symbolization of Forbidden Tendencies) Canadian Psychiatric Association journal. 1964;136:417–430. doi: 10.1177/070674376400900508. [DOI] [PubMed] [Google Scholar]
- 13.Hulse WC. The emotionally disturbed child draws his family. Quartery Journal of Child behavior. 1951;3:152–174. [Google Scholar]
- 14.Wright JH, Mcintyre MP. The family drawing depression scale. J Clin Psychol. 1982;38:853–861. doi: 10.1002/1097-4679(198210)38:4<853::aid-jclp2270380428>3.0.co;2-r. [DOI] [PubMed] [Google Scholar]
- 15.Spigelman G, Spigelman A, Englesson I. Analysis of family drawings:A comparsion between children from divorce and non divorce families. Journal of Divorce and re marriage. 1992;18:31–54. [Google Scholar]
- 16.Zaback TP, Weather CA. Se x of human figure drawing and sex-role orientation. J Pers Assess. 1994;62:552–558. doi: 10.1207/s15327752jpa6203_14. [DOI] [PubMed] [Google Scholar]
- 17.Rachel LW. The use of the Mach over Draw-A-Person test in detecting adult survivors of sexual abuse: A pilot study. Am J Art Ther. 1999;37:106–107. [Google Scholar]
- 18.Rachel LW, Hershkovitz D. Detecting violent aggressive behavior among male prisoners through the Mach over draw-a-person test. The Arts in Psychotherapy. 2000;27:171–177. [Google Scholar]
- 19.Wendy A, Burch BA. The draw-a-person: Group differences among individuals with obsessive-compulsive disorder, attention deficit hyperactivity disorder, toilette syndrome, and normal controls. New York: Buffalo; 2004. [Google Scholar]
- 20.Kaplan HI, Sadock BJ. Concise textbook of clinical psychiatry. 8. Philadelphia: Lippincott Williams & Wilkins; 2005. [Google Scholar]
- 21.Gadow KD, Sprafkin J. Child sysmptom inventoriy-4screening and manual. Stony Brook, Ny: Checkmate Plus; 2002. [Google Scholar]
- 22.Gadow KD, Sprafkin J. Adelescent Symptom Inventory-4screening manual. Stony Brook, Ny: Checkmate Plus; 1997. [Google Scholar]
- 23.Ghanizadeh A, Jafari P. Cultural structures of the Persian parents’ ratings of ADHD. J Atten Disord. 2010;13:369–373. doi: 10.1177/1087054709332421. [DOI] [PubMed] [Google Scholar]
- 24.Harris DB. Children’s Drawings as Measures of Intellectual Maturity. New York: Harcourt, Brace and World; 1963. [Google Scholar]
- 25.Debiasi LB, Reynolds A, Buckner EB. Assessing Emotional Well-being of Children in a Honduran Orphanage. Pediatr Nurs. 2012;38:169–176. [PubMed] [Google Scholar]