An Autistic Child Drawing in an Emotion Training :Case Report
الموضوعات :Vahid Moradi 1 , Saged Yaghoobnezhad 2 , Haghani Shima 3 , Marzieh Hasanpour 4
1 - Tabas school of nursing, Birjand University of Medical Sciences, Southern Khorasan, Iran.
2 - Assistant Professor, Department of Psychology and Counseling, Farhangian University, Tehran, Iran.
3 - Instructor, Nursing and Midwifery Care Research Center, Iran University of Medical Sciences, Tehran, Iran
4 - Professor of Nursing, NIDCAP Professional, Pediatric and Neonatal Intensive Care Nursing Department, School of Nursing and Midwifery, Tehran University of Medical Sciences, Tehran, Iran.
الکلمات المفتاحية: Case Report, Autism, Emotion, Child,
ملخص المقالة :
Background and Aim: There are different types of data collection tools, such as questionnaires and drawings, which are common in autism studies. This case, which was reported, presents a boy who didn't score significantly on the Labeling of Emotions Training (LET), indicating no growth in the mother-child relationship according to the questionnaire; however, his drawings showed otherwise. Materials and Methods: An 8-year-old boy with high-functioning autism with an IQ of 92 who was studied in elementary school is the case reported. During an RCT study, he had drawn 2 different drawings. Results: However, the data from the main study showed that specifically, there was no significant improvement in the child's LET scores, indicating no effect on enhancing emotion perception in situations, including the mother-child relationship. Nevertheless, the child's drawings show signs of improvement in the mother-child relationship, as evidenced by features such as drawing his figure near his parent. Conclusion: Based on the findings, it is recommended that researchers pay closer attention to the comparative interpretation of autism drawings and data collected from other common tools in their research, and conduct further similar studies in this field.
1. Baron-Cohen S, Golan O, Ashwin E. Can emotion recognition be taught to children with autism spectrum conditions? Philosophical Transactions of the Royal Society B: Biological Sciences. 2009;364(1535):3567-74.
2. Girard EI, Wallace NM, Kohlho JR, Morgan SS, McNeil CB. Parent-Child Interaction Therapy with Toddlers: Springer; 2018. 84 p.
3. Torre JB, Lieberman MD. Putting feelings into words: Affect labeling as implicit emotion regulation. Emotion Review. 2018;10(2):116-24.
4. Conallen K, Reed P. A teaching procedure to help children with autism spectrum disorder label emotions. Research in Autism Spectrum Disorders. 2016;23:63-72.
5. Skybo T, Ryan-Wenger N, Su Y-h. Human figure drawings as a measure of children's emotional status: Critical review for practice. Journal of Pediatric Nursing. 2007;22(1):15-28.
6. Bowen C, Ross E, Leitão S. Informal Assessment of Communication Skills. United Kingdom: Black Sheep Press Ltd; 2011 [Available from: https://www.blacksheeppress.co.uk/product/informal-assessment-communication-skills/.
7. Hanai F, Narama M, Tamakoshi K. The Self of Adolescents with Autism Spectrum Disorder or Attention Deficit Hyperactivity Disorder: A Qualitative Study. Journal of Autism and Developmental Disorders. 2021;51(5):1668-77.
8. King MC, Williams EI, Gleeson K. Using photographs to explore self-understanding in adolescent boys with an autism spectrum condition. Journal of Intellectual & Developmental Disability. 2019;44(2):232-43.
9. Farokhi M, Hashemi M. The analysis of children's drawings: social, emotional, physical, and psychological aspects. Procedia-Social and Behavioral Sciences. 2011;30:2219-24.
10. Wesson M, Salmon K. Drawing and showing: Helping children to report emotionally laden events. Applied Cognitive Psychology: The Official Journal of the Society for Applied Research in Memory and Cognition. 2001;15(3):301-19.
11. Kotroni P, Bonoti F, Mavropoulou S. Children with autism can express social emotions in their drawings. International Journal of Developmental Disabilities. 2019;65(4):248-56.
12. Thomas GV, Silk AM. An introduction to the psychology of children's drawings. New York: NYU Press; 1990.
13. Malchiodi CA. Understanding children's drawings. 1 ed: Guilford Press; 1998.
14. Lee A, Peter Hobson R. Drawing self and others: How do children with autism differ from those with learning difficulties? British Journal of Developmental Psychology. 2006;24(3):547-65.
15. Zlateva A. How to read children's drawings. 1 ed. University of Malta: Centre for Resilience & Socio-Emotional Health; 2020;5.
16. Saneei A, Haghayegh SA. Family drawings of Iranian children with autism and their family members. The Arts in Psychotherapy. 2011;38(5):333-9.
17. Peterson LW, Hardin ME. Children in distress: A guide for screening children's art: WW Norton, 1997.
18. Kaufman S, Burns RC. Actions, styles, and symbols in kinetic family drawings (KFD):
https://sanad.iau.ir/journal/hsp
HSP
Health Services Promotion
An Autistic Child Drawing in an Emotion Training
:Case Report
Vahid Moradi 1, Sajed Yaghoobnezhad2, Shima Haghani3, Marzieh Hasanpour4*
1.Tabas school of nursing, Birjand University of Medical Sciences, Southern Khorasan, Iran.
2.Assistant Professor, Department of Psychology and Counseling, Farhangian University, Tehran, Iran.
3.Instructor, Nursing and Midwifery Care Research Center, Iran University of Medical Sciences, Tehran, Iran.
4.Professor of Nursing, NIDCAP Professional, Pediatric and Neonatal Intensive Care Nursing Department, School of Nursing and Midwifery, Tehran University of Medical Sciences, Tehran, Iran.
*.Corresponding Author: E-mail: m-hasanpour@tums.ac.ir
Citation: Moradi V, Yaghoobnezhad S, Haghani SH, Hasanpour M. Case Report: An Autistic Child Drawing in an Emotion Training. Health Services Promotion. 2025; 1(2): 33-37.
Received: 24 August 2025;Accepted: 29 September 2025; ePublished: 6 October 2025.
Abstract
Background and Aim: There are different types of data collection tools, such as questionnaires and drawings, which are common in autism studies. This case, which was reported, presents a boy who didn't score significantly on the Labeling of Emotions Training (LET), indicating no growth in the mother-child relationship according to the questionnaire; however, his drawings showed otherwise.
Materials and Methods: An 8-year-old boy with high-functioning autism with an IQ of 92 who was studied in elementary school is the case reported. During an RCT study, he had drawn 2 different drawings.
Results: However, the data from the main study showed that specifically, there was no significant improvement in the child's LET scores, indicating no effect on enhancing emotion perception in situations, including the mother-child relationship. Nevertheless, the child's drawings show signs of improvement in the mother-child relationship, as evidenced by features such as drawing his figure near his parent.
Conclusion: Based on the findings, it is recommended that researchers pay closer attention to the comparative interpretation of autism drawings and data collected from other common tools in their research, and conduct further similar studies in this field.
Keywords: Case Report, Autism, Emotion, Child.
Introduction
This case report follows the CARE Guidelines (1) and describes an autistic boy who was one of the participants in a semi-experimental study with a single-subject design (2). In the description, no significant progress was made in his condition of emotion understanding according to his scores, so there was no effect on his mother-child relationship; however, one of his drawings changed the affair noticeably. Compared to his drawings, there are signs of improved emotion perception after label emotion training (LET) and better relationships.
Regarding the characteristics of autism children, they have difficulty in recognizing and evoking their correct emotional responses, so training can help them (1). LET uses basic emotions to improve the range of words, cognition, and perception of emotions (2). Perceiving emotions as words and accurately labeling them could be lower intensity in emotional experience, as well as correct the expression of emotions into appropriate responses (3). That fundamentally increases a person's understanding of social situations, such as: "happiness (emotion) in: receiving a gift from a friend (situation)" (4). Tools are usually used for data collection of studies; one of which is the analysis of children's drawings (5). Hence, we describe changes in a case drawn during a train.
Patient Information Clinical and Diagnostic Findings
The case is going to be reported is an 8-year-old boy with autism (High Function) who was diagnosed at age 6 years old by a pediatric psychiatrist using DSM criteria (IV Edition). The child was educated in 1st class in an elementary autism school (Peike Honar). The child's IQ was 92 and had no problem in the five main senses (visual, etc.). He's diet regimen was different from healthy youngsters but was using Vit C (25 mg/day), Vit E (7 mg/day), and a Gluten and casein-free regimen (CF/GF); His parent and siblings had a healthy diet regimen.
The child's laboratory tests were normal, and takes no medication. Brief clinical findings can be seen below:
Graph 1: Clinical findings
Therapeutic Intervention
During the formal education and before LET, the child had received some education in previous studies, such as play therapy for 4 weeks and emotion recognition training in which was appropriate revenue. Also, he had been participating in school routine occupational therapy once a week.
The main goal of the main intervention was to investigate the effect of LET on children's emotional understanding of situations, including situations related to the mother, which was expected to have an effect on the mother-child relationship. The consent was obtained from the child and his parent to use the drawings in this study.
Main intervention
In the main intervention (approved by the Ethics Committee of the School of Nursing in Tehran University of Medical Sciences, no: IR.TUMS.FNM.REC.1397.185), LET with three basic emotions (happiness, sadness, and anger) and related emotion-based situations (30 relationship situations) was performed to 5 high-functioning autism in 6 sessions individually. It was administered in 3 weeks (two sessions per week and each session in 30 minutes).
All emotion cards had a valid status (6). Occasionally, during the training, participants were asked to draw their favorite subjects or family draws. For the case reported, a letter of satisfaction was obtained from the parent and the child (participant 4).
Management
In some sessions, the child had complex behaviors; in these sessions, these behaviors were reported to the school counselor, and the trainee did not continue. In this situation and when the child didn't want to participate in the research, he was asked to do what he wanted according to his common daily programs, such as drawing or returning to the classroom for education. It should be noted that the train times did not interfere with his school education, and the trainer and teachers coordinated the programs in attention to the child's class times.
Follow-Up and Outcomes
The mother-child relationship questionnaire was completed by the mother. Drawing in the first session was consistent with the findings by questionnaires, but in the second drawing in follow-up (8th session), there were different and considerable details. Also, it is noted that the mother had no stigma toward her child, and she's rejection level score based on the Mother-Child Relationship Evaluation Questionnaire (MCRE) was low.
Fig 1. Draw
Fig 2. Draw 2
Discussion
Based on evidence, when teenagers with autism spectrum conditions started interacting with others, they had distinct feelings about themselves (7). A review of past literature on self-perception in autism reveals important points: 1- children with high-functioning autism who have higher IQ, have higher self-perceptions than other children in their group, 2- deficiency in self-perception in people with autism is selected by the individual 3- the range of denial to accept self-existence, often positively correlated with how child function socially (8). Drawing can be used to interfere child's social and emotional changes and direct in the square of their relationships (9). So, it is one of the best tools for interpreting children's emotions (10). Generally, Children with autism can express social emotions in their drawings (11). Drawings of human figures state their importance in life (12). According to that, children's responses to relationships with parents can be seen in their drawings, which is part of the emotional content of their drawings (13).
Discussing of draw breakdown, known that children with autism draw people with little details (14); while healthy children aged 7-9 years old see the world as real and pay attention to details in the drawing (15). Studying families with autism children, findings showed that children's drawings were different from healthy children, and autism's main feature was the elimination of human characters (16). The removal of the human figure indicates that he/she is denied by the drawer (17). In a drawing, being close to another person means the painter (oneself) has/had good or bad emotions towards that figure (another person) (18). Drawing the basic emotions by autistic children is significant and is not random or habitual. Based on the comment of Cannoni et al. (2021), the most popular emotion that children depict in their drawings is happiness (19). In general, children like to see positive emotions in those they love, and declare positive or negative feelings in something/someone they are drawing (20).
Children with autism are more affected by objects than people (21). For this reason Coloring object has meanings and shows a great impact on autism child perception and relation level (22). All of the foregoing can be seen in the drawings of the reported case.
Limitation & Suggestion
The limitations included the absence of other drawings from the child, also the child didn’t agree to paint the second drawing to better analyze the changes. It is suggested that other researchers use drawing in parallel with questionnaires in similar studies and have obtain the child to draw more drawings for more data and better comparison.
Conclusion
Based on the observations and report drawings as well as the discussion about them, the researchers recommend that drawing should be given more attention, especially in children with autism. For example, drawings and their interpretation could be evaluated in more studies, or drawings used in several studies to confirm the results of the data, whether the results of the drawings and other tools were the same in those studies or not.
Author statement
Dr. Hasanpour was in charge of guiding the main study, reviewing, and revising the generalities and details of articles. Dr. Yaghoobnezhad supervised the implementation of the main training within the single-subject method and the correct training of participants. Ms. Haghani was the statistical consultant of the present study. Mr. Moradi, carrying out the training, prepared the article and obtained parental permission to use the drawings.
Acknowledgment
The authors would like to extend their gratitude to all in the Deputy of Research and Technology in the School of Nursing and Midwifery and Tehran University of Medical Sciences for the approval and financial support of the project. Grant Number: 97-03-28-39648 and Ethical Code: IR.TUMS.FNM.REC.1397.185). The
authors would also like to express their sincere thanks to all the school authorities, the child, and his family who participated in this study.
Conflict of Interest
Authors declare no conflicts of interest.
|
Variables/Train Sessions |
1 |
2 |
3 |
4* |
5 |
Crowd/ Mean |
Sex / Age | Male/7 | Male/8.3 | Male/7.6 | Male/6.8 | Male/7.5 | 7.44 |
Diagnosis | HFA** | HFA | HFA | HFA | HFA | - |
Child's educational level (elementary) |
1
| 3 | 2 | 1 | 2 |
- |
Mother educational level | diploma | diploma | licentiate | MD | licentiate | - |
Session 1- Week 1 | 160 | 130 | 100 | 30 | 100 | 520 |
Session 2- Week 1 | 190 | 180 | 160 | 70 | 120 | 650 |
Session 3- Week 1 | 250 | 250 | 180 | 70 | 150 | 900 |
Session 4- Week 2 | 200 | 210 | 140 | 50 | 120 | 720 |
Session 5- Week 2 | 240 | 240 | 160 | 70 | 150 | 860 |
Session 6- Week 2 | 300 | 270 | 200 | 100 | 170 | 1040 |
Crowd | 1340 | 1280 | 940 | 390 | 810 | 4760 |
Total Score Ratio (100%) | %28/15 | %26/89 | %19/74 | %8/19 | %17/01 | %100 |
* Case reported - **HFA: High Function Autism
Refrences
1. Baron-Cohen S, Golan O, Ashwin E. Can emotion recognition be taught to children with autism spectrum conditions? Philosophical Transactions of the Royal Society B: Biological Sciences. 2009;364(1535):3567-74.
2. Girard EI, Wallace NM, Kohlho JR, Morgan SS, McNeil CB. Parent-Child Interaction Therapy with Toddlers: Springer; 2018. 84 p.
3. Torre JB, Lieberman MD. Putting feelings into words: Affect labeling as implicit emotion regulation. Emotion Review. 2018;10(2):116-24.
4. Conallen K, Reed P. A teaching procedure to help children with autism spectrum disorder label emotions. Research in Autism Spectrum Disorders. 2016;23:63-72.
5. Skybo T, Ryan-Wenger N, Su Y-h. Human figure drawings as a measure of children's emotional status: Critical review for practice. Journal of Pediatric Nursing. 2007;22(1):15-28.
6. Bowen C, Ross E, Leitão S. Informal Assessment of Communication Skills. United Kingdom: Black Sheep Press Ltd; 2011 [Available from: https://www.blacksheeppress.co.uk/product/informal-assessment-communication-skills/.
7. Hanai F, Narama M, Tamakoshi K. The Self of Adolescents with Autism Spectrum Disorder or Attention Deficit Hyperactivity Disorder: A Qualitative Study. Journal of Autism and Developmental Disorders. 2021;51(5):1668-77.
8. King MC, Williams EI, Gleeson K. Using photographs to explore self-understanding in adolescent boys with an autism spectrum condition. Journal of Intellectual & Developmental Disability. 2019;44(2):232-43.
9. Farokhi M, Hashemi M. The analysis of children's drawings: social, emotional, physical, and psychological aspects. Procedia-Social and Behavioral Sciences. 2011;30:2219-24.
10. Wesson M, Salmon K. Drawing and showing: Helping children to report emotionally laden events. Applied Cognitive Psychology: The Official Journal of the Society for Applied Research in Memory and Cognition. 2001;15(3):301-19.
11. Kotroni P, Bonoti F, Mavropoulou S. Children with autism can express social emotions in their drawings. International Journal of Developmental Disabilities. 2019;65(4):248-56.
12. Thomas GV, Silk AM. An introduction to the psychology of children's drawings. New York: NYU Press; 1990.
13. Malchiodi CA. Understanding children's drawings. 1 ed: Guilford Press; 1998.
14. Lee A, Peter Hobson R. Drawing self and others: How do children with autism differ from those with learning difficulties? British Journal of Developmental Psychology. 2006;24(3):547-65.
15. Zlateva A. How to read children's drawings. 1 ed. University of Malta: Centre for Resilience & Socio-Emotional Health; 2020;5.
16. Saneei A, Haghayegh SA. Family drawings of Iranian children with autism and their family members. The Arts in Psychotherapy. 2011;38(5):333-9.
17. Peterson LW, Hardin ME. Children in distress: A guide for screening children's art: WW Norton, 1997.
18. Kaufman S, Burns RC. Actions, styles, and symbols in kinetic family drawings (KFD): An interpretive manual: Brunner/Mazel; 1972.
19. Cannoni E, Pinto G, Bombi AS. Typical emotional expression in children’s drawings of the human face. Current Psychology. 2021:1-7.
20. Burkitt E, Barrett M, Davis A. The effect of affective characterizations on the size of children's drawings. British Journal of Developmental Psychology. 2003;21(4):565-83.
21. White RC, Remington A. Object personification in autism: This paper will be very sad if you don’t read it. Autism. 2019;23(4):1042-5.
22. Burkitt E, Barrett M, Davis A. Drawings of emotionally characterised figures by children from different educational backgrounds. International Journal of Art & Design Education. 2005;24(1):71-83.
