DRAWING AS A DEVELOPMENTAL AND TRANSCULTURAL CLINICAL TOOL IN THE DIAGNOSIS OF PEDIATRIC HEADACHES

F. Cernigliaro¹, E. Correnti², D. Lopes³, R. Nardello⁴, A. Messina⁵, G. Santangelo⁶, C. Balzanelli⁷, V. Raieli⁸ | ¹Servizio Territoriale Azienda Sanitaria Provinciale 6, Palermo, Italy; ²UO NPI Arnas Civico, Palermo, Italy; ³UO NPI Arnas Civico, Palermo, Italy; ⁴Dipartimento Materno Infantile Università di Palermo, Italy; ⁵Libero Professionista Audiologo, Palermo, Italy; ⁶UO NPI Arnas Civico, Palermo, Italy; ⁷Centro Vertigini San Bernardino Poliambulatorio, Salò, Italy; ⁸UO NPI Arnas Civico, Palermo, Italy

Introduction. Pediatric headache is a common neurological disorder in childhood and adolescence, resulting in significant disability. However, the anamnestic process during development can be complex due to children's limited ability to verbally describe the characteristics of the pain. In this context, children's drawings emerge as a valuable nonverbal, projective, and expressive tool that can support clinical assessment, providing information on the subjective experience of pain, including location, intensity, quality, and associated emotional components, often revealing diagnostic clues difficult to obtain through verbal communication alone. The literature suggests the good sensitivity and specificity of drawing for the differential diagnosis of primary headache disorders (1). However, clinical drawing can be influenced by age, gender, and the children's intra- and intercultural contexts. We recently conducted a comprehensive review of the literature on the use of drawing in pediatric headaches (1), now aim of this study is to analyse how drawing in children with headache can be influenced by variables such as gender, age, and geographic area, highlighting both common traits and possible differences.
Methods. This study is based on a literature review of international scientific articles published between 1980 and 2025 on the use of drawing in the assessment of pediatric headaches. Only studies involving children and adolescents (0–18 years) who produced spontaneous drawings of headache or related symptoms were included. The eight selected studies were grouped into five macro cultural geographic areas and analysed by age (4–7, 8–12, 13–18 years) and gender. Both intragroup and comparative analyses were conducted to identify recurring graphic patterns and differences in the graphic representation of pain across cultures, ages, and genders.
Results. Children's headache drawings reveal consistent, universal characteristics, including the depiction of pain location, intensity, and pulsation. However, children's graphic representation of headache is influenced by three main factors: developmental stage (age), gender, and cultural context. Age plays a central role, influencing the level of symbolic complexity, with more structured and detailed representations emerging with the development of cognitive abilities. Gender differences are relatively limited, although boys tend to represent pain more mechanical while girls more frequently express emotional aspects. Cultural background significantly influences the way pain is symbolized and interpreted. Drawing serves different functions across cultural contexts: it appears more expressive in Anglo-Saxon and North American contexts, more communicative in Latin American contexts, more clinically and diagnostically oriented in European contexts, and more phenomenological and perceptive in Eastern European contexts. Table 1 summarizes the main findings.
Conclusions. Overall, the results suggest that the interpretation of children's drawings should take into account the child's developmental level and cultural context to improve understanding of the child's subjective experience and communication between patient, family, and clinician.