Todos

Outcome-Based Evaluation of a Social Skills
Program Using Art Therapy and Group

Therapy for Children on the Autism Spectrum
Kathleen Marie Epp
There is a paucity of literature on social skills therapy for students on the autism spectrum,
revealing an urgent need for additional research. Past research has focused on the use of
small groups or single-case study designs. The present study examines the effectiveness of a
social skills therapy program for school-age children ages 11 through 18.The program uses
art therapy and cognitive-hehavioral techniques in a group therapy format to broaden and
deepen the state-of-the-art techniques used in helping children with social developmental
disorders to improve their social skills. Pre- and posttest instruments were distributed to
parents and teachers in October and May of the 2004-2005 school year. Scores revealed a
significant improvement in assertion scores, coupled with decreased internalizing behaviors,
hyperactivity scores, and problem behavior scores in the students. Implications for social
work and policy are discussed.
KEY WORDS: art therapy; autism spectrum disorder;group therapy;

social developmental delays; social skills
T
he need for intervention for children LITERATURE REVIEW
with autistic spectrum disorder (ASD), The "autism spectrum" is a phrase that pres-
also referred to as pervasive develop- ently includes several specific diagnoses, each
mental disorder (PDD),is becoming increasingly with its own particular characteristics and
apparent. Social skills classes, individual therapy, symptoms. The autistic spectrum comprises
and professional workshops for clinicians are a broad range of disorders characterized by
expanding at an exponential rate. It is the con- interference with communication and social
sensus among professionals that children with interactions and circular patterns of interest,
PDD are in need of services to guide them along activities, and behavior. PDD is a diagnostic
their path while they develop peer relationships. category, according to the DSM—/K (American
School social workers and psychologists are Psychiatric Association, 1994), which includes
fmding more ways to help these children in the the ASDs. According to Gargiulo (2003) the
school setting, and more independent profes- conditions included in the diagnostic category
sional services are becoming available. of PDD are autism, Rett syndrome, childhood
Many curriculums being tried within therapy disintegrative disorder,Asperger's syndrome, and
programs have not been tested or examined to pervasive developmental disorder not otherwise
determine which is the most effective for chil- specified (PDD-NOS).
dren with ASDs; however, the evaluation of such Because the awareness of these conditions
programs is needed for evidence-based practice. within the medical field is still growing, many
This study is a response to the necessity for an cases continue to go undiagnosed. Therefore it
increase of outcome-based research that analyzes is difficult to document what percentage of the
the effectiveness of therapeutic programs for population suffers from these disorders. A report
children on the autism spectrum. released in 2007 by the Centers for Disease
CCC Code: 1532-8759/08 $3.00 ©2008 National Association of 5ocial Workers 27

Control and Prevention (CDC, 2007a) states bullying. Children with autism are more likely
that 1 in 150 children in the United States has to suffer from depression, and 20 percent of
an ASD. It is the fastest growing developmental children and adolescents with developmental
disability, with 10 percent to 17 percent annual delays attempt suicide (Gargiulo, 2003).
growth. CDC statistics show that the number Children with ASD are not able to under-
of children ages six to 21 years who received stand that other people have thoughts, ideas,
services for ASD increased from 22,664 cases and ways of thinking that are different from
in 1994 to 193,637 in 2005. At least 300,000 theirs; in this way they have difficulty under-
school-age children were diagnosed with ASD standing the attitudes, actions, and emotions of
in 2004, according to a survey of parents (CDC, others. This grouping of behavioral actions is
2007b). known as theory of mind (Winter, 2003). Accord-
ing to theory of mind, individuals who suffer
Characteristics of the Population from autistic disorders are not able to connect
The characteristics of ASD are difficult to emotionally, through empathy, with others. As
identify because the exact mechanism of social a result, children with ASD do not act appro-
interaction skills is not known. Characteristics priately for their age, and they are unable to
of children with autistic disorders vary, but reciprocate in social interactions to participate
some of the qualities include a tendency to in cooperative play. These children are often
withdraw from social contact and an increased described as socially stiff, awkward, emotionally
sensitivity to crowds as well as an increased flat, socially unaware, self-absorbed, lacking in
sensitivity to stimuli in general, such as sounds, empathy, prone to show socially unacceptable
smells, and tactile materials,These children have behavior, and insensitive or unaware of verbal
more difficulty developing conversational skills. and nonverbal social cues.
Eye contact, facial expression, and tonal vocal The theory of mind has been particularly
variation in speaking may be restricted. Their helpful in identifying the neurological com-
vocabulary and form ofspeaking can come across ponent, rather than relying on family dynamic
as "stiff" and "unnatural" compared with that theory, in the assessment of PDD. The Autism
of their peers. Often they relate to adults better Society ofAmerica (2007) recognizes that autism
than to peers. They seem to be victimized by is the result of a neurological disorder rather
children with aggressive tendencies more than than a psychological impairment due to lack
are other children. of healthy nurturing.
Psychological Theories that Present Intervention Practice Models

Underlie Intervention Research studies have documented that the
People with ASD live in individual worlds of brain systems that control communications and
their own, in which they are socially disen- social skills do not function normally in children
gaged froni others. They are often stressed by with autism.Therefore,it is deemed necessary to
demands fdr social interaction or intimacy that train other parts ofthe brain to take over these
they cannot give or manage. This mental and functions. Teaching social and communication
emotional stress can be so great as to cause a skills to children gives them the ability and the
state of chronic anxiety. opportunity to fulfill their need for friendship
Communication disorders on this spectrum and companionship.
become progressively debilitating as children Presently, a combination of behavior training
grow olden The loneliness and confusion that and cognitive teaching is used for this popula-
these children feel becomes accentuated when tion. A variety of instructional techniques such
they reach ages of socialization in later elemen- as social storytelling and chunking have been
tary school and even more so as they become developed to teach children how to deal with
adolescents. They are considered "different" social situations and social cues. Children are
and "eccentric" and experience rejection and taught by means of role modeling and model-
28 Children &Schools VOLUME 30, NUMBER I JANUARY 2008

ing two-way interactions. Documentation for ers, special education staff, and teachers, some
evaluative research is usually gathered through of whom are not qualified to make behavioral
frequency counts of particular behaviors such diagnoses. Clearly, correct diagnoses are impor-
as eye contact, interrupting, and staying on tant when grouping children if significant posi-
subject. tive outcomes are to be expected. Overall the
greatest reason that children are not diagnosed
The Use of Group Therapy to Improve adequately enough to form therapy groups is
Social Skills that PDD is only lately being studied; thus,
One of the reasons that individual therapy has treatments are only in the beginning stages of
been used most often thus far is the lack of being proven effective.
available groups of children suffering firom PDD The use of group therapy in school settings
with whom to work. PDD is a spectrum condi- is increasing. One example of this practice is
tion in which children who are low functioning illustrated in a study by Mishna and Muskat
are often diagnosed early and are often given (2004), in which the researchers studied four
separate classroom environments. Conversely, school-based groups of four to six members
children at the high end of the spectrum may each, all of whom received direct interventions
never he diagnosed; thus treatment may not in social skills from the school social worker
be sought. Because the diagnostics category is along with indirect interventions consisting of
a relatively new one, many doctors, teachers, consultation for teachers, parents, and peers.The
social workers, and psychologists are unfamiliar goals were improvement of the students' psycho-
with the diagnosis or are not able or willing to social functioning and increased understanding
discern which students need additional help of the disorders for students, school staff, and
with social skills. parents. The evaluation showed some attain-
To complicate matters, many social skills ment of these goals (Mishna & Muskat). Group
deficits are due to emotional or behavioral therapy for children on the autism spectrum
causes, not neurological conditions. Therefore not only has great potential to improve social
it is contraindicated to group children with skills in a way that can be generalized to other
emotional disturbances (ED) with children with environments in the children's world, but also
ASD. Although the issue being addressed for helps them form friendships by teaching them
both groups may be social skills, the origins of the social skills in groups.
deficits are different. Children with ASD have
a neurological condition that makes it difficult The Use of Art Therapy to Improve
for them to read and intuit social cues, whereas Social Skills
children with ED have a psychological impair- Another form of therapy for this particular
ment but are able to read social cues. Grouping population that has not been extensively ex-
these children together can result in a situation plored is art therapy. According to Cooper and
in which social "aggressors" (those with ED) are Widdows (2004), art therapy is particularly ap-
grouped with social "victims" (those with ASD), propriate for children on the autism spectrum
making it difficult, if not impossible, to create because they are often visual, concrete thinkers.
a safe environment for therapy and learning. Art therapy as a component to social skills train-
Because school staff know that grouping chil- ing may increase the willingness of children to
dren with ED with children with ASD would participate because art is an activity that they
be detrimental to the latter population, they fmd acceptable (Julian, 2004).
are likely to undertreat autism rather than to Art therapy offers a way to solve problems
risk subjecting a child with ASD to an abusive visually. It forces children with autism to be
environment. This situation leads to increased less literal and concrete in self-expression, and
confusion, considering that many children are it offers a nonthreatening way to deal with
assigned to school social skills therapy groups rejection. It replaces the need for tantrums or
on the recommendation of school social work- acting-out behaviors because it offers a more
E P P / Evaluation of a Social Skills Program Using Art Therapy and Group Therapy for Children on the Autism Spectrum 29
sual characteristics of art help these children,
Through the child's art, the therapist who often experience anxiety in social situ-
can gain insight into what the child is ations, to relax and enjoy themselves while
experiencing, which is information that is they are learning social skills in the carefully
controlled environment of the therapeutic
not readily available through verbal means.
group setting.
acceptable means of discharging aggression PROGRAM DESCRIPTION

and enables the child to self-soothe (Henley, Location and History
2000). The program for this study is SuperKids, which
Use of icons, symbols, and social stories help is located in Ridgefield, Connecticut, a small
the children to remember what they were town in the southwest corner of the state.
taught. When children and therapists collabo- Demand has been so high for services that a
rate to custom make these symbols, icons, and satellite program opened in 2004 in Hamden,
stories for each child's unique challenges and Connecticut, just north of New Haven. The
goals, the children take ownership of them and location ofthe program is ideal for developing
integrate them into their internal experience curriculums and therapeutic techniques for
(Gray, 1994). students on the autism spectrum for several rea-
A technique already widely used among sons. Fairfield County, a bedroom community
therapists who teach social skills to children with to New York City, is a relatively affluent area
autistic tendencies is the use of comic strips as of the country. This community represents a
teaching tools. Comic strips are drawn by the wealthy socioeconomic stratum where parents
teacher and then "taught" to the children, with have the financial means, education, access to
discussion and analysis ofthe portrayed events. state-of-the-art therapy, and interest in social
Children who are visual learners take in this skills development in their children.
information in a way that stays with them. For The SuperKids social skills program began in
example, learning about conflict between people 1999 in response to the need among individual
by seeing it drawn in a comic strip is more ef- therapy clients (children and teenagers) in local
fective with children on the autism spectrum private practices. Each practice had a number
than is learning about it through a theoretical of children who had social and communica-
discussion, and it is less threatening than role tion difficulties, including Asperger's syndrome,
playing. high-functioning autism, or P D D - N O S .
Program staff involved in the present study Therapists in local private practices found that
have developed the use of therapeutic comic working in individual therapy with children
art in a converse application, in which the who had difficulties with their peers offered
therapist invites the children to draw the comic limited opportunity for the development of
strip.This act of creation becomes an avenue of social skills.
expression for children with practical language
skills difficulties. The children are then able to Program Model
intellectually and emotionally integrate their The SuperKids therapeutic model uses group
personal experiences by viewing and reflecting therapy with groups of approximately six chil-
on the art that their own creativity has mirrored dren of similar age and social communication
for them. In addition, through the child's art, the ability. Each leadership team has at least one
therapist can gain insight into what the child is therapist with a master's degree. Leaders are
experiencing, which is information that is not selectively paired to offer diversity of expertise.
readily available through verbal means. Professional backgrounds include art therapy,
Art therapy need not be restricted to comic drama therapy, school counseling, and special
strips. Art can be explored in many forms, education.The groups meet weekly during the
including drama and music. The concrete, vi- school year, from September to May.
30 Children &Schoots VOLUME 30, NUMBER I JANUARY 2008

Cognitive—behavioral strategies are used other side draw or write something about
throughout the group therapy session. An yourself that you wish you could change."
example of this would be a therapist asking a Another instruction might be "Draw a
student, "When you're frustrated/happy, what picture of what animal you would be if
do you say to yourself? What's your self-talk?" you were an animal." This activity is fol-
Artwork solicited by the therapist often shows a lowed by creating a zoo or jungle over the
deeper level of meaning than words can deliver subsequent weeks in which all animals can
because these students have communication dis- live together. In such a project the students
orders. Usually the group is led in a brainstorm- explore sharing space and materials as well
ing exercise to discover ways to change self-talk as dealing with issues like sensory overload
to improve feelings or make better choices \vith and frustration.
difficult feelings. • Unstructured free time (20 minutes) in
The specific social skills addressed at Su- which the students can choose an activ-
perKids include compromise, graciously win- ity, such as play a game or create art, with
ning or losing a game, conversation skills, eye the one rule that they cannot do it alone.
contact, voice modulation, friendship skills, Group leaders stand back and coach the
understanding nonverbal cues, awareness of children in skills such as communicating,
the environment, learning to identify and brainstorming, initiating play, joining into
express feelings, awareness of others' feelings, existing play, and compromising about
and modulating intense emotions. Social skills rules.
are "taught" by therapists who carefully watch
how children approach or do not approach each SuperKids staff keep parents informed of
other, intervening in a helpful, nonthreatening, their child's progress through two meetings per
concrete manner so that the children learn year. Likewise, staff encourage other profes-
how to structure their own play time in a so- sionals who treat the children and adolescents
cial context. Each group is assessed by its own to collaborate. This peer collaboration includes
therapist team in weekly clinical supervision to school teachers and allied professionals such
determine which skills intervention is needed. as psychiatrists, psychologists, social workers,
As each group progresses, the individual teams psychotherapists, and speech and occupational
of therapists make decisions on how to best therapists.
use the group therapeutic experience for their The SuperKids staff also respond to requests
particular students. to share their expertise with school districts in
A typical hour-long group therapy session for an effort to help school personnel learn ways
ages six through 12 is as follows: to help this population.They conduct seminars
and furnish ongoing supervision of school staff
• Children come into the room and are when needed.
greeted by the therapists with a snack and
drinks. METHOD
• Conversation skills are practiced in an Recruitment of Participants
unstructured manner (10 minutes), with Seventy-nine primary and secondary school
leading questions such as "What's the children were enrolled by their parents in
best thing (or worst thing) that happened September 2004 for one-hour group therapy
today?" and "Does anyone have any news sessions held once a week after school at the
to share with the group?" SuperKids program. A nonprobability conve-
• Structured activity (30 minutes), with nience sample was used for this study. All chil-
instructions such as "Fold the paper in dren were considered eligible for participation
half and on one side draw a picture or in the study.
write something about yourself that you Introductory letters were sent to all parents
love and would never change, and on the in October because the Social Skills Rating
System (SSRS) (Gresham & Elliott, 1990) was questions for each characteristic behavior, so a
created to be used at least two months after a score of 12 signifies difficulty with all problem
teacher has begun to observe the student in his behaviors, and a score of zero signifies absence
or her classroom. Letters informed the parents of any problem behaviors. Problem behavior
of the proposed grant-based research study, total is a summative score of aU the problem
explained the protocol, requested written per- behavior categories. The category of hyperac-
mission to enroll their child in the study, and tivity does not appear on the secondary school
requested the name and address of the child's questionnaires. Internal consistency has been
school teacher or special education teacher who reported from .83 to .94 for the social skills
had the most exposure to the student's behavior questionnaire and .73 to .88 for the problem
around peers. behaviors questionnaire, representing a high
Ofthe 79 parents notified, 70 gave permission level of homogeneity among items (Conoley
for their children to participate. Of these 70, four & Impara, 1995).
withdrew their children from the program some This instrument was selected by the re-
time during the year for varying reasons, mostly searcher for several reasons. First a child's dem-
because of family relocation. Sixty-six children onstrated social skills may vary between school
were eligible to participate in the study. The and home, so an instrument that measures both
children were not aware that the research study is preferable. Second the SSRS is a standard-
was being carried out; therefore, they were not ized, norm-referenced instrument intended for
asked to complete any surveys for their partici- use with typical school children or those with
pation in the study. mild disabilities related to social skills, which
makes it well suited for the sample at Super-
Data Source and Instrumentation Kids program. Although many rating scales
The SSRS, developed by Gresham and EUiott have been developed for autistic children, most
(1990), was used in this study. The SSRS was ofthe students enrolled at SuperKids function
constructed to screen and classify children in a mainstream classroom and many of them
suspected of having social behavior problems attend public schools. Some of them have not
(Conoley & Impara, 1995). received a D5M-/Fdiagnosis.The therapists at
Questionnaires were designed separately SuperKids do not accept students whose be-
for parents and teachers. The questionnaire havior is violent or disturbing, and they screen
is divided into two sections, social skills and for a level of verbal and cognitive skill that will
problem behaviors. The social skills section enable students to benefit from the program.
measures positive social behaviors in the fol- Third SSRS uses a strengths-based approach to
lowing four categories: cooperation, assertion, assessment in the wording ofthe questions and
self-control, and responsibility. The problem in the intention of the measurements. Other
behaviors section measures negative behaviors social skills rating instruments measure social
in the following three categories: externaliz- skills deficits more directly through the ways in
ing problems, such as aggressive acts and poor which the questions are worded and the scores
temper control; internalizing problems, such as are recorded. Finally, the SSRS is widely used
sadness and anxiety; and hyperactivity, such as and accessible.
fidgeting and impulsive acts. Scoring for each
behavior is as follows: 0 = never, 1 = sometimes, Data Collection
and 2 = always. In the social skills section, there The first phase of the research study was to
are 10 questions for each characteristic behav- contact all parents, explain the research study,
ior, so a score of 20 signifies mastery of social request written permission for their child to
skills, and a score of zero signifies absence of participate in the study, and request the name
any social skills. Social skills total is a summa- and contact information for the student's
tive score of all ofthe social skills categories. school classroom teacher or special education
In the problem behaviors section, there are six teacher. These letters were sent and returned in
32 Children &Schoob VOLUME 30, NUMBER I JANUARY 2008

October. Parents on the list of unreturned letters Of the 44 students who made up the study
were contacted by phone. October was chosen sample, all were white, except for one Hispanic
because the recommendation is for teachers secondary school male student and one biracial
to have observed the student for two months primary school male student. Six were female
before filling out the questionnaire (Gresham secondary school students, 12 were male second-
& Elliott, 1990).With school beginning in late ary school students, and the other 29 were male
August, late October was the first time pretests primary school students. The socioeconomic
could be carried out without compromising the range of the students was mainly upper middle
accuracy of the results. to upper class. The homogeneity of the sample
The second phase of the study was to send is the result of both the high cost of living of the
out SSR.S pretest questionnaires to the parents study location and the high cost of the group
and teachers of all participating students. Sev- therapy program.
eral parents did not give the names of teach-
ers because they felt that no one teacher had Data Analysis
enough class time to assess their child accurately I hypothesized the following: Participation in
(especially high school students) or because they the SuperKids program would improve social
wished to avoid having their child identified as skills and the social skills frequency ratings be-
developmentally disabled by school staff. This tween pre- and posttests, and participation in
mailing was done in late October. Every few the SuperKids program would decrease ratings
weeks thereafter, teachers or parents who had of the frequency of problem behaviors between
not returned questionnaires were contacted by pre- and posttests.
phone until most of the questionnaires were Descriptive statistics for the SSRS at both
received. pre- and posttest are presented in Table 1. The
The third phase of the study was to send out table shows matched pairs for 44 students at both
identical, blank SSRS questionnaires as posttest pre- and posttest. Paired samples ( tests were
surveys in late May Every few weeks thereafter, conducted on these 44 students to determine
teachers or parents who had not returned ques- change over time.
tionnaires were contacted by phone until most Four categories of behavior showed change
of the questionnaires were received. toward improvement of statistical significance.
Of the social skills measured, there was a statisti-
RESULTS cally significant change in mean assertion scores
Sample Characteristics between pre- and posttest, with an increase in
For the 66 students eligible to participate in scores at posttest (9.30 and 10.32, respectively).
the study, pre-and posttests were received from Of the three problem behaviors measured,
a total of 44 parents. Thirty pre- and posttests there were statistically significant mean changes
were received from teachers. All responses were between pre- and posttest in internalizing
used for analyses purposes. Because of the small behaviors (6.64 and 5.89, respectively) and
number of pairs, power analysis did not allow for in hyperactivity (8.77 and 7.81, respectively).
the use of paired parent and teacher comparisons Both showed a decrease in internalizing scores
for each child. at posttest. In addition, there was a statistically
Of the 44 paired pre- and posttest parent significant change in the mean of all problem
responses, mothers fiUed out the paired tests in behaviors (summative) between pre- and posttest
all cases except four. A father fiUed out one pair, (16.70 and 15.43, respectively), with a decrease
and three paired tests were filled out by mother in problem behaviors at posttest.
and father together. Of the 30 paired pre- and All other behaviors also showed improve-
posttest teacher responses, 18 were fiUed out by ment between pre- and posttest; however, the
regular classroom teachers, 12 were filled out by measurements were not statistically significant.
resource teachers, and three were filled out by The one exception was responsibility, which
school psychologists. showed no change in mean scores between
Table 1: Pretest and Posttest DISCUSSION
Scores on the SSRS Importance of the Study
fflS a® G The evaluation shows a statistically significant
Social Skills' improvement in assertion scores coupled with
Cooperation -1.14 decreased internalizing behaviors, hyperactivity
Pretest 9.07 3.61 scores, and problem behavior scores. AU other
Posttest 9.55 3.76 social skills and problem behaviors also showed
Assertion -2.55* improvement, although the measurements were
Pretest 9.30 3.42 not statistically significant (with the exception
Posttest 10.32 3.17 of responsibility, which showed no change).
Responsibility 0.00 These behavioral improvements are particularly
Ptetest 12.14 3.29 important to note with this population that
Posctest 12.14 3.97 suffers from delayed social skills development.
Self-control -0.90 The SSRS instrument, used in a pre- and post-
Pretest 10.59 3.60 test study, shows a change in behaviors that are
Posttest 10.95 3.38 relatively difficult to teach. Generally a student
Total -1.29 would score similarly year after year on the
SSRS, remaining at a somewhat stable level
•
Pretest 41.09 10.20

Posttest 42.95 11.47 of social effectiveness, altering slightly with
circumstances. It is significant for a behavioral
Problem Bebaviors b program to produce such consistent results in
Externalizing 0.21 improving social skills.
Pretest 4.98 2.31
To make the significance of this outcome
Posttest 4.93 2.20
Internalizing 2.50*
measurement even more clear, another aspect
Pretest 6.64 2.23 of this population should be considered. De-
Posttest 5.89 2.06 velopmentally delayed children are not diag-
Hyperactivity 2.57* nosed as infants because they must first enter
Pretest 8.77 2.20 into age-appropriate social interaction; delays
Posttest 7.81 1.77 in social development may become apparent
at any age thereafter. What tends to happen
Total 2.50*
for these children is that their social develop-
Pretest 16.70 6.28
ment begins to fall behind that of their peers.
Posttest 15.43 5.61
Note: SSRS = Social Skills Rating System (Gresham & Eiliott 1990). Resulting anxiety, poor self-esteem, frustration,
*A score increase indicates improvement.
"A score decrease indicates improvement,
and depression compound the problem. These
•p < .05. children are at risk of falling farther and farther
behind in development over time as their social
attempts are met with rejection. From a statisti-
cal perspective, the scores of these children on
social skills tests are more likely to fall than they
pre- and posttest.The mean scores for coopera- are to remain the same.
tion increased from 9.07 to 9.55. For self-control
the scores increased from 10.59 to 10.95. The Implications of the Study
responsibility scores remained at 12.14 for both Implications of the study are that social skills
pre- and posttest.The summative scores of mean can be taught in therapeutic group settings that
change for all social skills increased from 41.09 sufficiently meet the needs of this special popula-
to 42.95.The only problem behavior change that tion.The study suggests that group therapy and
was not statistically significant was in external- art therapy very likely lend themselves well to
izing behaviors, which was 4.98 at pretest and this kind of intervention. The study also shows
4.93 at posttest. that outcome measurements can be gathered to
34 Children S-Schools VOLUME 30, NUMBER i JANUARY 2008

statistically prove the demonstrable effectiveness the private and public sectors will likely (and
of the program. should) develop. School social workers can be
key instigators in this movement by staying ac-
Recommendations for School quainted with current information on treatment
Social Workers and outcomes of social skills programs.
School social workers are often the professionals
most likely to first encounter and recognize the Limitations of the Study
characteristics of autism spectrum behaviors. The study has several limitations. First, a con-
As a result, in many cases they provide the venience sample with a single program from an
first referral to psychiatrists or psychologists affluent community was used, thereby limiting
for diagnosis. A social worker is distinctive in generalizability. Second, a control group would
many ways from other professionals when a have been useful to control for improvement
child presents behaviors that are indicative of that might occur through age-related matura-
the autism spectrum. Specifically, they provide tion. No control group was available.
an interface between school staff and parents, Other factors that were not addressed be-
they have access to confidential information cause of the small sample size are variations in
about families and school behavior records, psychological development, economic factors,
they are trained in recognizing emotional and parenting styles, age at which intervention began,
behavioral problems, and they are the profes- level of disability, and range of diagnoses.
sionals to whom parents and teachers first turn Another limitation is that there is no statistical
for help. evidence that art therapy or even group therapy
In school systems that have the resources were vitally important ingredients in the success
to support social skills interventions, school of this intervention. Any assumption that these
social workers can use the study findings in modalities enhance the social skills learning leans
several ways.The findings add to the wealth of heavily on the personal experience and expertise
information that a school social worker must of the professional therapists who designed and
sort through in regard to recognizing the pres- implemented the classes.
ence of autism behaviors and recognizing the
difficulties these social skills difficulties pose in Recommendations for Further Study
their students.The findings also discuss some of Similar evaluative research will be more gen-
the current interventions that are being used to eralizable when students from a greater variety
treat PDD. If the school system can support the of socioeconomic groups can be evaluated.
social worker in creating social skills groups, this Control groups would confirm the reliability
article provides information that can be used in of the results, but comparison groups would be
the design and programming of curriculums. In preferable to the use of control groups in which
addition, the report gives pertinent information no intervention is used so that no child who
that can be passed on to interested parents who suffers from ASD would go untreated.
are looking for resources and available programs To better control for maturation variables,
or therapies that could possibly be beneficial to fliture research should track both the specific age
their children. groups that receive treatment as well as when
Because this study addresses a private therapy treatment began. Concurrent psychological test-
program held outside the public school system, ing could give greater accuracy to evaluations
the report opens doors for school social work- of outcomes.
ers to become more aware of opportunities for Future studies would benefit from data collec-
referring parents to private therapy programs tion that uses triangulation. Although this study
for their children. As the number of programs used two sources of data, it was not possible to
outside the school system grows and they be- compare the data because of the small number
come more recognized, the possibility of con- of teacher—parent pairs at both pre- and posttest.
sultations and cooperative programs between This indicates that a larger number of children
E P P / Evaluation of a Social Skills Program Using Art Therapy and Croup Therapy for Children on the Autism Spectrum 35
would be needed to increase the number of Centers for Disease Control and Prevention. (2007a).
Autism community report. Retrieved March 10,
teacher-parent pairs for triangulation analysis. 2007, from http://www.cdc.gov/ncbddd/autism/
Use of multiple groups and a variety of thera- documents/AutismCommunityReport.pdf
Centers for Disease Controi and Prevention. (2007b).
peutic techniques would help to isolate whether Autism overview. Retrieved March 10, 2007, from
art therapy and group therapy are more effective http://www.cdc.gov/ncbddd/autism/overview.
htm#who
than are other interventions. Conoiey,J. C , & Impara, J. C. (Eds.). (1995). Ttie twelfth
mental measurements yearbook. Lincoln, NE: Buros
Institute of Mental Measurements.
CONCLUSION
Cooper,B.,& Widdows, N. (2004). Knowing yourself
There is a growing need for treatment for in- knowing others: Activities that teach social skills (p. vi).
dividuals who suffer from social developmental Norwalic, CT: Instant Heip Press.
Gargiulo, R. M. (2003). Special education in contempo-
delays and a parallel need for outcome-based rary society. Beimont, CA:Wadsworth/Thomson
research to analyze the effectiveness of these Learning.
Gray, C. (1994) The original social story book. Arlington,
interventions. This research study provides TX: Future Horizons.
evidence of improvement in social skills and Gresham, F., & Elliott, S. (1990). Social skills rating system
manual. Circle Pines, MN: American Guidance
resolution of problem behaviors through com- Services.
parison of pre-and posttest results in school-age Henley, D. (2000).Blessings in disguise: Idiomatic expres-
sion as a stimulus in group art therapy with chil-
children attending a social skills group therapy dren./!r( TTierapy.'JoHrMu/ of the American Art Ttjerapy
program. Association, 17,210-215.
Julian, S. (2004). The efficacy of art therapy based social skills
The study compares primary and secondary training in the treatment of children with Asperger's syn-
school students on the autism spectrum who drome, tjnpublished master's thesis, Albertus Magnus
College.
were enrolled in the 2004-2005 after-school Mishna, E, & Muskat, B. (2004). School-based group
group therapy classes at SuperKids. Significant treatment for students with learning disabilities:
A collaborative approach. Children & Schools, 26,
statistical evidence based on questionnaires filled 135-150.
out by teachers and parents shows that both at Winter, M. (2003). Asperger syndrome: WItat teachers need to
know. London:Jessica Kingsley Publishers.
home and at school the frequency of assertive
social skills increased, whereas internalizing Kathleen Marie Epp, MSVf{ is in private practice and is
behaviors, hyperactivity, and problem behaviors a research subcontractor for SuperKids, Ridgefield, CT. Ad-
decreased.This is particularly important for chil- dress all correspondence concerning this article to Kathleen
dren who are developmentally delayed in social Marie Epp, 13 High Street, Bethel, CT 06801; e-mail:
kathleenmarieepp@gobrainstorm.net. Fundingfor this research
skills because they are at a higher risk of social
study was provided by a grant from the Leonard Milton
maladjustment and resulting emotional stress. Foundation.
The SuperKids program incorporates group
AcceptedMay 16, 2007
therapy and art therapy to translate abstract
social—emotional concepts into a curriculum
that reaches children who function more easily
in a visual/kinesthetic orientation than in the
social/intuitive environment.The improvements
seen by comparing means of test scores on the
SSRS show that children who suffer from ASD
can improve at a faster rate than would otherwise
be expected when given specific intervention
such as that which the SuperKids program
provides. S
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and statistical manual of mental disorders (4th ed.).
Washington, DC: Author.
Autism Society of America. (2007). Tiie voice of autism.
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autisni-society.org/site/PageServer
36 Children drSchools VOLUME 30, NUMBER I JANUARY 2008

The Arts in Psychotherapy 37 (2010) 97–105
Contents lists available at ScienceDirect
The Arts in Psychotherapy
The contribution of art therapy to the social, emotional, and academic

adjustment of children with learning disabilities
Rita Freilich, PhD, Zipora Shechtman, PhD ∗
University of Haifa, Counseling and Human Development, Haifa, Israel
a r t i c l e i n f o a b s t r a c t
Keywords: The study conducted in Israel, investigates the contribution of art therapy to the adjustment of children
Art therapy with learning disability and assesses interventions and their association with outcomes. Art therapy
Children as an adjunct to academic assistance (i.e., experimental group) was compared to academic assistance
Learning disabilities
only (control group) in one counseling center, which treated 93 children with learning disability (42
in the experimental and 51 in the control group). Results indicated more favorable outcomes in adjust-
ment under art therapy conditions and similar progress in academic achievement under either condition.
Although children in the control group scored higher on the process variables (bonding and impression
of therapy), bonding was associated with outcomes only in the therapy condition. A session-by-session
evaluation revealed that the two interventions were very different: the academic intervention focused on
improved learning experiences, whereas the art therapy intervention focused on emotional exploration
and awareness-insight development.
© 2010 Elsevier Inc. All rights reserved.
Introduction difficulties than do children without LD (Auerbach, Gross-Tsur,

Manor, & Shalev, 2008; Klassen & Lynch, 2007; Sideridis, 2007).
The purpose of the study was to examine the impact of art ther- Research indicates that between 38 and 78% of children with emo-
apy on the socio-emotional and academic achievements of children tional difficulties also have learning disabilities (Fessler, Rosenberg,
with learning disabilities (LD). In addition, the study examined & Rosenberg, 1991; Fristad, Topolosky, Weller, & Weller, 1992).
processes that might impact on gains following the two kinds of Specifically, the characteristics of these children include difficulties
intervention. Academic difficulties by children with learning dis- in social information processing (Bauminger & Kimhi-Kind, 2008),
abilities are to be expected, and they are usually treated through low interpersonal skills (Ladd & Troop-Gordon, 2003; Wiener,
academic assistance by expert teachers. However, many children 2004), high levels of social rejection and loneliness (Estell et al.,
with LD also present social and emotional difficulties, and these are 2008; Margalit & Efrati, 1996), mood disturbance and depression
often ignored in the school. The current study, which focuses on (Sideridis, 2007; Wiener & Schneider, 2002), and adjustment diffi-
socio-emotional assistance, examines art therapy as one possible culties of both an internalizing and externalizing nature (Al-Yagon
type of intervention with these children. & Mikulincer, 2004; Auerbach et al., 2008; Sharma, 2004; Wiener,
2004). Because adjustment problems comprise many of the socio-
emotional difficulties reviewed above (Achenbach & McConaughy,
Literature review
1987), this will be our major dependent variable. The question is,
therefore, does art therapy improve the adjustment of children with
The definition of LD that is now accepted by most researchers
LD?
was suggested by the National Joint Committee on Learning Disabil-
ities (NJCLD, 1998). Accordingly, LD is perceived as a neurological
dysfunction and may be reflected in cognitive difficulties, such as Treatment of children with LD
comprehension, reading, writing, and doing math. Social difficulties
are not part of this definition, yet a vast literature has been dedi- The most frequent way of treating children with LD is through
cated to the social and emotional difficulties of children with LD. assistance with their academic difficulties, under the assumption
Overall, children with LD present a higher rate of socio-emotional that improved academic achievement will have a positive impact
on children’s self-esteem, improve interpersonal relationships and
social status, and lead to fewer emotional difficulties (Morgan,
∗ Corresponding author. Tel.: +972 4 8249722; fax: +972 4 8240911. Farkas, Tufis, & Sperling, 2008). The association between academic
E-mail address: ziporas@construct.haifa.ac.il (Z. Shechtman). success and socio-emotional well-being is well known and widely
0197-4556/$ – see front matter © 2010 Elsevier Inc. All rights reserved.
doi:10.1016/j.aip.2010.02.003
98 R. Freilich, Z. Shechtman / The Arts in Psychotherapy 37 (2010) 97–105
documented (Bakker, Denessen, Bosman, Krijger, & Bouts, 2007; Based on the literature reviewed, we pose three questions:
Elias & Arnold, 2006). Researchers have shown, too, that a pos- (a) Will the addition of an art therapy unit to academic assis-
itive classroom climate and school support help children with tance result in more favorable outcomes than academic assistance
LD function more constructively in school (Margalit, 2004). Even alone? (b) Will differences emerge in the process of the two
when treatment directly addresses the socio-emotional difficulties treatments—art therapy and academic assistance? (c) Will the
of children with LD, it is most often cognitive-behavioral oriented process variables explain the outcomes of each treatment? We
(Kavale & Mostert, 2004; Kazdin & Weisz, 2003), based on the hypothesized the following: (1) Children treated with art ther-
assumption that cognitive disorders leading to learning disabilities apy will show more favorable outcomes on adjustment than will
produce social difficulties, as well. children treated only through academic assistance. In contrast, chil-
Recently, however, more humanistic treatments, focusing on dren treated in academic assistance will show better outcomes in
emotions, have been suggested for treating children with LD. Con- academic achievement. (2) Differences in process variables will be
necting to one’s feelings, by exploring and reflecting on them, seem found between the two treatments: scores in bonding and impres-
to offer the key in treatment, Greenberg (2001) argues. Similarly sion of therapy will be higher with art therapy treatment than
Hill (2005) contends that the cognitive and affective exploration with academic assistance. (3) Process variables will be associated
of feelings leads to insight and eventually to behavior change. with outcomes following each of the two kinds of treatments: the
Indeed, in a meta-analysis of humanistic treatment of children with higher the scores on the process variables, the better will be the
LD, Elliott (2001) showed that an emotional focus in treatment outcomes.
improved children’s functioning. Several other studies have used
humanistic group treatment with children with LD to show that
Method
such treatment improved children with a variety of social and emo-
tional difficulties compared to control groups (Shechtman, Gilat,
Population
Fos, & Flasher, 1996; Shechtman & Katz, 2007; Shechtman & Pastor,
2005).
The study included 93 children, 42 who were in art therapy and
Using the arts in therapy is one type of humanistic treatment
51 in academic assistance. They came to the LD treatment center
(Metzl, 2008) found to be appropriate for the treatment of chil-
from 19 schools located in three different cities. Ages ranged from 7
dren (Gladding, 2005; Shechtman, 2009). Art therapy is defined as
to 15 (M = 10.48, SD = 2.42). Participants, all of whom had been iden-
a treatment based on the interaction of the creator, the creation,
tified formally as having LD, were referred by their school personnel
and the therapist. It brings to awareness repressed emotions and
for assistance. Each year, the center accepts over 350 children diag-
permits their exploration through the images created. Art therapy
nosed with LD, about 100 of whom are recommended, in addition,
is particularly suitable for working with children, as they connect
for socio-emotional treatment; because of budget constraints, how-
spontaneously to art. Being a non-verbal method of treatment, it
ever, only half of these receive such assistance. The demographic
has the advantage of appealing to children who experience lan-
characteristics of the children, by treatment condition, were sim-
guage difficulties (Liebmann, 1990). Moreover, the creation of art
ilar: the majority was male (70%), had married parents (69%), and
helps children to visualize their difficulties and, thus, to under-
came from middle-class families (father’s mean education was
stand them more fully (Safran, 2002). The use of art to effect
12.72 years, SD = 2.52; there were 2.52 children per family on aver-
treatment, moreover, has been found to decrease resistance to ther-
age, SD = .98). Most of the students were enrolled in elementary
apy, encourage the expression of feelings and personal experiences
school (81%); a few were identified as having ADHD (26%). No group
(McMurray & Schwartz-Mirman, 2001), and increase the therapeu-
differences were found: age – t(91) = 1.68, elementary vs. junior
tic alliance with the therapist (Eaton, Doherty, & Widrick, 2007). It
high – Z = .59, gender – Z = .74, parental status – Z = .46, father’s
makes sense, therefore, that art therapy will be helpful in treating
education – t(73) = .32, mother’s education – t(76) = .40, number of
children with LD; however, there is little research to support such
children per family – t(80) = 1.18, ADHD + LD vs. LD − Z = 1.82.
a claim. Thus, the current study seeks to explore this issue and, in
The professional staff comprised 10 art therapists and 17 expert
addition, to shed light on the process of art therapy with children in
teachers, all certified and experienced in their professions. Their
order eventually to explain the outcomes. Process research on the
ages ranged from 31 to 57 (M = 46.48, SD = 7.12), and experience
treatment of children is particularly scarce (Barlow, Burlingame, &
from 3 to 24 years (M = 14.48, SD = 6.12). No difference in age or
Fuhriman, 2000).
experience was found for therapists vs. teachers in age or years
of experience: t(25) = .16 and t(25) = 1.38, respectively; p > .05 for
both.
Processes in treatment
Two common process variables are the therapeutic relation- The intervention
ship and the impression of the therapy. Therapeutic relationship is
now accepted as the “common factor” in therapy (Horvath, 2005; Art therapy was conducted in a special room equipped with
Norcross & Lambert, 2006). It serves as the confidence base from materials needed for art projects, such as paper, paints, pictures,
which to start self-exploration. The impression of therapy (Stiles, journals, etc. The child undergoing such therapy usually selects a
2002) refers to the depth and the satisfaction with the therapy. topic, and the materials, for a project of interest, and the therapist
Depth was associated with the improved condition of patients assists and supports the youngster in carrying it out. The assump-
(Cummings, Martin, Hallberg, & Slemon, 1992; Hill, Beutler, & tion in art therapy is that the project selected is never incidental;
Daldrup, 1989). The rare research on child treatment that does exist rather, it is a reflection of important issues in the child’s life that
indicates that bonding with the therapist is related to outcomes cannot be expressed directly. The therapist’s role is to help the child
(Shechtman & Katz, 2007; Shechtman & Leichtentritt, in press). identify a meaningful experience, a difficulty, or a conflict. In the
Impression of therapy emerged as one of the best predictors of other process of working on the art piece, the therapist encourages the
process variables and of outcomes (Shechtman & Leichtentritt, in child to express related feelings and concerns, to explore them, and
press). These studies on child treatment, however, were conducted to reflect on them. The reflection often leads to the development
on group treatment. The current study explores outcomes and pro- of insight and, sometimes, also to the selection of goals for change.
cesses in individual treatment through art therapy. When appropriate, the project is directed to encourage the child
R. Freilich, Z. Shechtman / The Arts in Psychotherapy 37 (2010) 97–105 99
to reach his or her goal; when necessary, role-playing and guided The Session Evaluation Questionnaire (Stiles et al., 1994) mea-
discussions are conducted to increase efficacy. sures clients’ responses in two categories: an evaluation, including
Academic assistance is provided to increase knowledge, improve the factors of depth and smoothness (e.g., empty-full, relaxed-
basic skills, and develop learning strategies. Material learned in tense), and post-session mood, including the factors of positivity
class is usually used as the basis for academic assistance but is and arousal (e.g., happy-sad, excited-calm). Participants respond
adjusted to the child’s personal needs and abilities. to each of 20 items (10 in each category) on a 6-point scale.
Test of validity and reliability was based on 218 participants and
Dependent variables and instruments 2414 sessions. Internal consistency ranged from .80 to .92. Validity
was based on correlation with a similar questionnaire, the Session
Outcomes Impact Scale (SIS; Elliott & Wexler, 1994; r = .61 and .79, for session
Adjustment was measured by means of the Child Behavior Check- evaluation and session mood, respectively; Stiles et al., 1994). In
list (CBCL) and the Teacher Evaluation Form (TRF), both developed related research with children, validity was based on a comparison
by Achenbach (1991a and 1991b, respectively). These are widely with the Transgression-Related Interpersonal Motivations Inventory
used questionnaires (including in Israel) with good psychometric (TRIM; McCullough et al., 1998), indicating positive correlations
properties (Achenbach, Howell, McConnaughy, & Stranger, 1995). with empathy, no revenge, and forgiveness. Internal consistency in
For example, the CBCL scale was validated in comparison with the the current study ranged from .66 (meaningfulness–child report)
Conners Parent Questionnaire (r = .71–.92). The TRF was validated to .87 (mood–therapist report). This measure was completed by
in comparison to Conners Revised Teacher Rating Scale (Goyette, participants five times during the intervention, or after every other
Conners, & Ulrich, 1978) (r = .83). Test-retest reliability ranged from session.
.82 to .90, and internal consistency from .44 to .84. For the TRF, test- The Critical Incident was used to check adherence to each inter-
retest reliability ranged from .66 to .87, and internal consistency vention. Following each session, children were asked to report in
from .48 to .96. writing about their most meaningful experience. A total of 922
The questionnaires consisted 113 items measuring 8 specific reports was gathered and analyzed through the Client Behavior
sub-scales: withdrawal (“I refrain from being involved with other System (Hill & O’Brien, 1999). The scale includes four constructive
people”), psychosomatic difficulties (“I am often too tired”), anxi- behaviors (cognitive exploration, affective exploration, insight, and
ety/depression (“I feel that others tend to hurt me”), social problems change) and four less-constructive behaviors (resistance, agree-
(“Children often make fun of me”), troubling thoughts (“Some ment, appropriate request, and recounting). These eight behaviors
thoughts I cannot get rid of”), delinquency (“I don’t regret after are expected to cover all client responses in therapy. The scale
I do something wrong”), attention (“I act before I think”), and showed high validity, based on a comparison with relevant scales,
aggressive behavior (“I often get into fights”). The two scales are and high inter-rater agreement (Hill, 2001). Although the scale was
identical; only the wording is different. Response was on a scale of developed for individual therapy, it has been used in group ther-
0 (never) to 2 (very often). The first three sub-scales created one apy studies, as well, and there, too, has shown high inter-rater
score for Internalizing behavior. The aggression and delinquency agreement (Kappa = .99) (e.g., Shechtman & Pastor, 2005). In the
sub-scales created a second score, for Externalizing behavior. All present study, we used six behaviors: Resistance, Simple response
eight sub-scales create the Total Adjustment score. In addition, (composed of agreement, appropriate request, and recounting),
the instrument permits establishing clinical scores based on group and the four constructive behaviors of Cognitive exploration,
norms (Achenbach, 1991a, 1991b). Affective exploration, Insight, and Therapeutic change. Because
academic assistance is not therapy, an additional category was
added—learning. Sample responses for art therapy and academic
Academic achievements assistance, respectively: “I have understood why children get angry
Scores on academic achievements were based on national nor- at me on the playground”; “I have learned to multiply two-digit
mative tests in three subjects (language, history, and math) and numbers.” The written reports were coded by two independent
ranged from 4 (extremely low) to 10 (extremely high). Because the raters; agreement (Kappa) between them ranged from .83 to .99.
three scores highly correlate (r = .80–.60), an average score was used
for each child.
Procedure
Process variables and instruments
Bonding was measured with the Working Alliance Inventory The children had been diagnosed with LD prior to referral to the
(Horvath & Greenberg, 1989). This scale contains 36 items, mea- learning center by professionals in or out of school. Often, the eval-
suring three dimensions: agreement on tasks, agreement on goals, uation of a psychologist or psychiatrist was added. At the center,
and bonding with the therapist. In the present study, we used only all the children received three weekly hours of assistance: children
the third dimension, consisting of 12 items (e.g., “Therapist and I in the academic assistance group (control) received 3 h of teaching
understand each other”). In addition, we modified this scale to mea- while children in the art therapy group (experimental) received 2 h
sure bonding with group members. The items were identical, only of academic assistance and 1 h of art therapy. Both groups under-
they were reworded to address group members rather than a ther- went a total of 22 weeks of treatment. The center accepts over 350
apist (e.g., “Group members and I understand each other”). Validity students diagnosed with LD every year; about 100 of whom also
was based on a comparison with the Relationships Inventory (RI) and require socio-emotional assistance. However, this treatment was
the Counselor Rating Form (CRF). Internal consistency was .88. The given to only 42 of the students, on the basis of first come, first
scale has been used in its shortened form with children (Shechtman served, because of a shortage of therapists (only 10 were available).
& Katz, 2007; Shechtman & Leichtentritt, in press). Validity for chil- The remaining children were placed on a waiting list for receiv-
dren was supported by the association between scores on bonding ing emotional assistance the following year. The 10 art therapists
and on outcomes (social competence; r = .42; Shechtman & Katz, treated between 1 and 7 children (M = 4.20, SD = 1.93). The 17 spe-
2007). Responses are given on a 5-point scale, with the higher cial teachers also treated between 1 and 7 children each (M = 3,
scores representing higher bonding. Internal consistency in this SD = 2.00). All the participating therapists and teachers were super-
study was .86 (child report) and .78 (therapist report). The scale vised in group meetings throughout the treatment to ensure fidelity
was completed five times in the course of treatment. to the program.
Outcome measures were completed at 3 points in time: pre-, In summary, no pre-score differences were found between the
post-, and follow-up (3 months later). Because some children could experimental and control children; therefore, the examination was
not be traced after the conclusion of the intervention, pre–post and based on 2 × 2 MANOVAs, with repeated measures for adjust-
post-follow-up measurements were conducted separately in order ment (child and teacher reports), and a 2 × 2 ANOVA for Academic
to avoid the loss of too many children from the analyses. However, Achievements (group by time interaction), controlling for chil-
an examination of differences between children who dropped out dren’s age (and gender, too, but only for process variables). As
before follow-up and those who remained showed no differences some of the children dropped out before follow-up, the interac-
either on demographic variables or on pre–post-scores (see Prelim- tion of groups by time was performed twice, pre to post and post
inary results below). Process variables were completed five times to follow-up, in order to save all subjects initially included in the
over the course of the intervention. Critical incidents were com- study.
pleted following each session. Coding was performed by trained
students and showed high inter-rater agreement (see Instrument Main results
section).
Outcomes
The first hypothesis suggested that gains in adjustment mea-
Results sures (internalizing behavior, externalizing behavior, and total
score) would be higher in the therapy group than in the aca-
Preliminary analyses demic assistance group. In contrast, gains on AA were expected
to be higher in the latter. Means, SD, and Fs (Group by Time
First, the criteria for the normalcy of the distribution of the study differences for pre–post) are presented in Table 1. Differences
variables were examined. Skewness and Kurtosis were assessed on pre–post gains (child self-report) were revealed between the
and found to be within the acceptable range (the coefficient art therapy and academic assistance groups in internalizing and
less than twice its standard error) for Academic achievement, externalizing behavior and the total score (child report); how-
Adjustment-child report, and the Process variables of Feeling, ever, no group by time difference was revealed in AA or in
Meaning, and Bonding. Adjustment-teacher report was found to adjustment (teacher report) (see Table 1). In the adjustment
deviate from a normal distribution. Thus, parametric analyses variables, there was a pre–post reduction in symptoms (child
are appropriate for most of the variables. They were used with report) in the therapy group, with no change in the control
Adjustment-teacher report as well, in order to maintain the uni- group (internalizing: therapy – F(1,90) = 9.76, p < .01, !2 = .11 vs.
formity of the analyses, yet results for Adjustment-teacher report teaching – F(1,90) = .40, p = ns, !2 = .01; externalizing: therapy –
should be interpreted with caution. An exception is the Client F(1,90) = 3.80, p < .05, !2 = .04 vs. teaching – F(1,90) = 1.41, p = ns,
Behavior System (Hill & O’Brien, 1999), including the variables !2 = .02; total score: therapy – F(1,90) = 8.21, p < .01, !2 = .09 vs.
of Resistance, Simple response, Cognitive exploration, Affective teaching – F(1,90) = .05, p = ns, !2 = .001). These differences were
exploration, Insight, and Therapeutic change. These are not sup- not reported by teachers. No post-follow-up differences were
posed to distribute normally, and were thus analyzed with found.
non-parametric statistics. Clinical differences are presented in Tables 2 and 3. Table 3
Second, the relationships between background variables suggests a pre–post clinical change in internalizing behavior-
(assessment – LD/ADHD, gender, and age) and dependent vari- self-report for children treated in therapy, with no change in
ables (academic achievement – AA, adjustment – child and teacher the teaching group (Z = 2.82, p < .01 vs. Z = .11, p = ns). More chil-
reports) were examined. Only age correlated with some of the dren in therapy improved clinically, moving out of the clinical
dependent variables; therefore, the hypotheses were examined level, than did children treated in the teaching group. The dif-
controlling for age (correlations with age: academic achievement ference is significant for externalizing behavior, as well (Z = 2.02,
at follow-up – r = −.33, p < .05; adjustment-child report at pre-test p < .05 vs. Z = 1.13, p = ns). About 20% of the children in the
– r = −.23 to r = −.26, p < .05; adjustment-child report at follow-up – therapy group moved out of the clinical level, whereas no sig-
r = −.31 to r = −.32, p < .05; adjustment-teacher report at follow-up nificant change was detected in the teaching group. This trend
– r = −.28 to r = −.34, p < .05). also emerged from an examination of the total score for behav-
Third, differences between the experimental and the control ior problems (therapy group – Z = 2.77, p < .01; teaching group –
group on the initial scores were examined. No significant difference Z = .36, p = ns). Similar results were found for teacher report on
was found on any of the variables. both internalizing and externalizing behavior (Table 3). Signifi-
Fourth, the difference on all pre-scores and post-scores was cant clinical changes were found only in the therapy group (for
examined between children who dropped out before follow-up and internalizing – Z = 2.38, p < .05 vs. Z = 1.33, p = ns; for externaliz-
those who remained. No differences were found on pre-scores; ing – Z = 1.98, p < .05 vs. Z = 1.70, p = ns). In terms of internalizing
the post-scores were higher only on two variables for those who and externalizing problems, children in the therapy group moved
remained until follow-up: internalizing problems [F(1,90) = 4.51, out of the clinical level, whereas their percentage in the teaching
p < .05, !2 = .05] and the total adjustment score [F(1,90) = 7.75, group did not change significantly (even increased). No differences
p < .01, !2 = .09]. between groups were found in regard to the total score (teacher
Fifth, a difference was found on child vs. teacher report on report) (therapy group – Z = .57, p = ns; teaching group – Z = 1.81,
pre-treatment adjustment scores, with higher scores reported by p = ns).
children (internalizing problems – F(1,88) = 12.22, p < .001, !2 = .12, Hence, although teachers did not report progress based on either
and total score – F(1,88) = 6.41, p < .05, !2 = .07). These differences, the continuous variable or the clinical total score, clinical differ-
however, were eliminated at post-treatment. ences in children’s internalizing and externalizing problems were
Sixth, process variables were correlated with gender (r = −.38, observed. This leads to the conclusion that children treated in ther-
p < .01 to r = .28, p < .05) and age (r = −.29 to r = .30, p < .05); there- apy showed better outcomes, as expected.
fore, the pre–post differences in process variables were examined, On academic achievements, the expected outcome did not
controlling for gender and age. Finally, since correlations among occur. No time by group difference was found on this vari-
all dependent variables were lower than r = .50 (p < .001), this ruled able between the treatment and teaching formats. Both groups
out the possibility of multicolinearity. improved significantly and similarly in AA.
Table 1
Means, standard deviations and F-values for outcome variables, by group and time (N = 52–93).
Therapy Teaching Pre–post group × time

difference
Pre (N = 42) Post (N = 42) Follow-up Pre (N = 51) Post (N = 51) Follow-up
(N = 21) (N = 31)
M SD M SD M SD M SD M SD M SD
Academic achievement 6.45 1.29 7.12 1.14 6.94 1.15 5.96 1.15 6.51 1.11 6.43 1.34 F(1,82) = .07 (!2 = .001)
Adjustment-child report
Internalizing .69 .24 .57 .26 .66 .25 .57 .29 .59 .34 .51 .28 F(1,90) = 7.47**
(!2 = .09)
Externalizing .52 .22 .45 .25 .48 .2 .44 .24 .48 .25 .42 .24 F(1,90) = 4.89*
(!2 = .06)
Total score .56 .17 .47 .22 .52 .16 .5 .22 .5 .23 .44 .19 F(1,90) = 5.18*
(!2 = .06)
Adjustment-teacher report
Internalizing .4 .24 .44 .33 .62 .35 .39 .24 .37 .22 .28 .19 F(1, 83) = 1.15 (!2 = .02)
Externalizing .34 .33 .36 .36 .54 .39 .29 .28 .28 .26 .21 .25 F(1, 83) = .68 (!2 = .01)
Total score .4 .2 .41 .26 .58 .3 .39 .19 .38 .19 .28 .17 F(1, 83) = .39 (!2 = .01)
Range: AA – 4–10; Achenbach – 0–2.

*p < .05; **p < .01.
Table 2
Distribution of clinical categories of internalizing and externalizing behaviors, by group and time–child evaluation (N = 93).
Art therapy Academic assistance
Pre Post Pre Post
N % N % N % N %
Internalizing problems
Below clinical level 7 16.7 15 35.7 23 45.1 21 41.2
Marginally clinical 10 23.8 10 23.8 7 13.7 12 23.5
At clinical level 25 59.5 17 40.5 21 41.2 18 35.3
Externalizing problems
Total score
In sum, there are more favorable gains for the experimental therapist, and bonding with the therapist, also as evaluated by child
group than for the control, and note should particularly be made of and therapist. Results were analyzed through repeated MANOVA,
the clinical differences. controlling for age and gender. The hypothesis suggested that chil-
dren in therapy would score higher on all process variables than
Process variables would children in the teaching group.
Means, standard deviations, and F-values for session impression
The process variables included in this study were as follows: and bonding with therapist are presented in Table 4. They suggest
session impression (feeling and meaning), evaluated by child and higher scores on feeling, meaningfulness, and bonding in the teach-
Table 3
Distribution of clinical categories of internalizing and externalizing behaviors, by group and time–teacher evaluation (N = 93).
Art therapy Academic assistance
Pre Post Pre Post
N % N % N % N %
Internalizing problems
Externalizing problems
Total score
Table 4
Means, standard deviations, and F-tests for session impression and bonding, by group and evaluator (N = 73).
Child (N = 63) Therapist (N = 73) Group Evaluator Group × Evaluator

2 2
Therapy Teaching Therapy Teaching F(1,70) (! ) F(1,70) (! ) F(1,70) (!2 )
M (SD) M (SD) M (SD) M (SD)
Feeling 4.70 (.51) 5.50 (.38) 4.59 (.52) 5.36 (.44) 59.92*** (.46) .38 (.01) .31 (.004)
Meaning 4.71 (.45) 5.25 (.46) 4.58 (.46) 5.11 (.45) 25.83*** (.27) 2.90 (.04) .01 (.001)
Bonding 5.66 (.70) 6.42 (.66) 5.76 (.62) 6.30 (.55) 19.05*** (.21) 2.01 (.03) 6.70* (.08)
*p < .05, **p < .01, ***p < .001.
Table 5
Means, standard deviations, and Z-tests for client verbal behavior, by group (N = 73).
Therapy (N = 33) Teaching (N = 40) Group

M (SD) M (SD) MW Z-tests
Simple response .11 (.15) .10 (.14) .09

Learning .00 (.00) .66 (.18) 7.68***
Cognitive exploration .07 (.13) .12 (.14) 2.17*
Affective exploration/catharsis .59 (.20) .04 (.07) 7.51***
Emotional awareness/insight .13 (.12) .04 (.07) 3.52***
Problem solving/change .08 (.09) .02 (.04) 3.18**
Resistance .02 (.05) .02 (.05) .73
*p < .05, **p < .01, ***p < .001.
ing group, in contrast to our expectations. No difference was found ond, how unique are processes of art therapy compared to academic
between child and therapist, and only one group by source differ- assistance? Third, are process variables associated with outcomes?
ence was found on bonding, with therapist evaluation being higher
than child evaluation in the teaching group [F(1,70) = 4.38, !2 = .06, Validity of the intervention
p < .05], but not in the therapy group [F(1,70) = 2.64, !2 = .04, p = ns].
When one looks at the process of change, it appears that children To answer the first question, scores on adjustment and academic
started and ended with lower scores in the therapy group (feel- achievements for children treated in art therapy, in addition to
ing – F(1,70) = 59.92, p < .001, !2 = .46; meaning – F(1,70) = 25.83, having academic assistance, were compared to scores for children
p < .001, !2 = .27; bonding – F(1,70) = 19.05, p < .001, !2 = .21); how- treated only by way of academic assistance. Results indicated sig-
ever, the process in the experimental group showed a tendency to nificant differences in gains between the two groups when based
increase with time. The difference between time 1 and 5 was signifi- on the child report; but a positive and significant pre–post change
cant in the therapy group for feeling and bonding (child assessment was revealed only in the experimental group. Based on the teacher
of feeling – M1 = 4.48, SD1 = .67, M5 = 4.80, SD5 = .76, F(1,32) = 5.72, report, on the other hand, such differences were not confirmed,
p < .05, !2 = .15; teacher assessment of feeling – M1 = 4.32, SD1 = .72, perhaps due to the low scores and non-normal distribution of the
M5 = 4.76, SD5 = .82, F(1,32) = 7.50, p < .01, !2 = .19; child assess- teacher evaluations. Moreover, on the basis of the clinical mea-
ment of bonding – M1 = 5.16, SD1 = 1.02, M5 = 5.99, SD5 = .66, sures, significantly more positive gains were found among children
F(1,32) = 34.25, p < .001, !2 = .52; teacher assessment of bonding – in the experimental group. More children moved from a clinical to
M1 = 5.27, SD1 = 1.03, M5 = 6.06, SD5 = .61, F(1,32) = 27.62, p < .001, a non-clinical level of adjustment compared to children in the con-
!2 = .46), whereas the change was non-significant in the teaching trol group, and these results were based on both child and teacher
group. Difference in meaning was non-significant in both groups. reports. Hence, the hypothesis referring to improved adjustment of
Regressions of process variables (the mean of 5 times) on resid- children with LD who receive art therapy treatment in addition to
ual gains in adjustment suggested that bonding was the only academic assistance was mostly supported.
variable to affect outcomes on internalizing as reported by the The second part of the outcome hypothesis suggested that
child (child report of bonding: ˇ = −.47, p < .05; therapist report of children in the control condition would gain more in academic
bonding: ˇ = −.58, p < .05). Similarly, bonding was the only variable achievement because they received more hours of academic assis-
to affect outcomes on externalizing according to the child report tance. This hypothesis was rejected; both groups progressed in
(child report of bonding: ˇ = −.58, p < .05; therapist report of bond- academic achievements, regardless of the treatment condition.
ing: ˇ = −.64, p < .01). Bonding did not predict teacher evaluation The more favorable outcomes in adjustment for the children
of behavior problems, nor was it significant in the teaching group. treated in art therapy are not surprising. We expected that art
Similar results were found for process variables measured at time therapy would contribute to improved adjustment based on the
5. unique characteristics of the intervention. Children in art therapy
Client Verbal Behavior was studied to examine the adherence focus mostly on emotional exploration of their difficulties. They
of the processes in each type of intervention. The critical incidents identify problems, share them with the therapist, and go through
reported by the children were coded based on the Client Behav- cathartic experiences that lead to an increase in self-awareness
ior System (Hill, 2005). The results, presented in Table 5, suggest and insight. This result was evident in the critical incidents the
that two very different processes are involved. In the teaching children provided following each session; the control children, in
conditions, learning was the most frequent behavior; in therapy, contrast, focused mainly on academic success experiences. The
participants found affective exploration, insight, and change to be basic assumption of humanistic therapies, including art therapy,
more meaningful (see Table 5). is that focusing on an exploration of emotions and reflecting on
them provide a key to personal change (Greenberg, 2001; Hill,
Discussion 2005; Prochaska, 1999). In earlier studies on children with LD who
were treated in group, humanistic therapies proved to be effective
The current study focused on three major questions: First, does (Shechtman et al., 1996; Shechtman & Katz, 2007), even more so
art therapy contribute to the adjustment of children with LD? Sec- than cognitive-behavioral therapies (Shechtman & Pastor, 2005).
Fig. 1. Change process.
The current study, which examined individual art therapy, supports difficulties that is meaningful. Allowing children to express their
these earlier findings. creative selves may help them deal with academic issues on their
The following case illustrates the art therapy process. Dina is a own.
third grade student, extremely withdrawn. She hardly communi- In summary, one weekly session of art therapy, in addition
cates with peers as well as with adults, and seems to be fearful of to academic assistance, was effective in improving the children’s
her social surrounding. She is constantly worried about her aca- adjustment, and gains were sustained over the following several
demic achievements and her parents’ reaction to her academic months. This should provide evidence for using art therapy with
failure. When she started her work with clay, her figures had no children with LD. When an evidence-base is sought for any ther-
clear shape. At that point she talked about her confusion, fears, and apy (Norcross & Lambert, 2006), our finding makes an important
sense of helplessness. During the therapy process her clay figures contribution to the knowledge of treating children with LD. In this
became more clearly shaped and she expressed more trust in oth- study, we measured the contribution of art therapy in addition to
ers and herself (see Fig. 1). She felt more control over her life and academic assistance. Future studies should investigate its contribu-
was more optimistic. Indeed, her academic achievement and social tion without such assistance. In the Shechtman and Pastor (2005)
life improved substantially. study, the group that received only group treatment showed more
Not only was there a difference between the two groups, but favorable outcomes than the group that received both group ther-
children in the experimental condition improved over time both apy and academic assistance. Perhaps art therapy alone is capable
statistically and clinically, unlike those in the control condition. of improving a child’s adjustment.
This finding contradicts the argument that academic improvement
influences socio-emotional progress. Our finding suggests, rather, Processes of treatment
that improving academic achievement in itself is not enough to
change the adjustment level of children. Children’s emotional and The hypothesis pertaining to treatment processes suggested
social difficulties must be directly addressed in order to improve that both bonding and impression of therapy would score higher
their situation. An earlier study (Shechtman & Pastor, 2005) indi- in the art therapy group than in the control group. The assumption
cated that even one weekly session of group therapy contributed to was that the focus of art therapy on emotions and the sharing of
the adjustment of children with LD more than did additional hours personal experiences would lead to a more intimate relationship
of academic assistance. Another study showed that four weekly between the child and the therapist, and the cathartic experiences
hours of academic assistance was less effective than 1 h of group would lead to a strong impression of therapy. The results actually
therapy (Shechtman et al., 1996). Moreover, although in the current pointed to a contrasting picture: bonding and impression of the
study the experimental group of children received fewer hours of treatment were overall higher in the academic assistance condi-
academic assistance than did the control group, they nevertheless tion, where significantly they started with higher scores. However,
improved in academic achievements no less than did their counter- scores on some of the process variables improved with time only
parts. This finding again suggests that it is not the amount of time in the experimental group, whereas in the control group they
devoted to academic assistance but the exploration of emotional remained fairly stable.
One possible explanation for these unexpected results is the Despite its limitations, this study makes an important contribu-
unknown nature of therapy compared to academic assistance. Chil- tion to the literature on children with LD. First, it provides some
dren and teachers feel on familiar ground in the teaching-learning evidence of the efficacy of using art therapy with children with LD.
process; furthermore, as all the teachers in this study were experts These children suffer from many social, emotional, and learning
in working with children with LD, they more easily created a bond difficulties. Finding ways to assist them to cope with their difficul-
with the children and knew how to provide each child with a sense ties is of most importance. In the current study, we showed that art
of accomplishment. In contrast, the art therapy process is less struc- therapy can be used safely with such children without the addition
tured, and both the therapist and the child may feel less secure. The of time for academic assistance. The findings highlight a neglected
children might have been particularly puzzled, as they apparently area of assistance that can be used in centers for these children,
did not understand what therapy had to do with school. They were as well as in school. Second, the study combines process with out-
expected to self-disclose, which may have raised some resistance come study, closely tracing session after session. Such research,
to treatment. Moreover, children may have been intimidated by the particularly rare, is highly sought after (Greenwood, Leach, Lucock,
referral to “a shrink” and feared being labeled. In therapy, a bond & Noble, 2007). The study also bears practical implications. Know-
has to be developed based on trust, which takes time, as noticed ing that bonding is a meaningful variable in art therapy treatment
in the present results. The impression of the session may also have it is crucial to finding ways to encourage the development of bond-
been limited because of the lack of clarity of expectations. Most ing. Children may require the application of unique techniques to
participants were young clients (of elementary-school age), which increase this beneficial emotional act. Moreover, the reality that
may have generated confusion, even embarrassment, in regard to made it possible for only less than half of the children in our study
therapy. This raises questions regarding individual psychological to obtain the help they needed with socio-emotional difficulties,
treatment with young children, as the two variables examined, in addition to the difficulties in bonding that were observed in the
bonding and impression, had been found to be associated with out- therapy process, raises the need to look for more cost-effective and
comes in previous studies with adults (Horvath, 2005; Stiles, 2002). clinical-effective experiences. Past research has supported the use
In the group research literature, furthermore, both variables have of group therapy with children with LD (Shechtman & Katz, 2007;
been found to be related to outcomes (Shechtman & Katz, 2007; Shechtman & Pastor, 2005); perhaps art therapy in a group format
Shechtman & Leichtentritt, in press). This leads to the next ques- may more effectively help redress their problems.
tion, What impact do these variables have on the outcomes of art
therapy?
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Open Journal of Social Sciences, 2017, 5, 90-108
http://www.scirp.org/journal/jss
ISSN Online: 2327-5960
ISSN Print: 2327-5952
Using Visual Arts to Encourage Children with

Autism Spectrum Disorder to Communicate
Their Feelings and Emotions
Alicia Round, William J. Baker, Christopher Rayner
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TLJMMT JO SU NBLJOH BOE FYQSFTTJOH FNPUJPO BT SBQQPSU BT CVJMU PWFS UIF
TUVEZ QFSJPE WBSJFUZ PG SJDI EBUB FSF DPMMFDUFE EVSJOH UIF TUVEZ IJDI JO
DMVEFE RVFTUJPOOBJSFT JOUFSWJF T WJEFP SFDPSE JOHT PCTFSWBUJPO OPUFT BOE
QBSUJDJQBOU SU PSLT 5IJT QSFTFOUBUJPO TIP DBTFT UIF SU PSLT PG UIF QBS
UJDJQBUJOH CPZT GFBUVSJOH B WBSJFUZ PG NFEJVNT UP DPNNVOJDBUF UIFJS
UIPVHIUT GFFMJOHT BOE FNPUJPOT EFTDSJQUJPO PG UIF WJTVBM SU BT UIFSBQZ
FYQFSJFODFT BOE UIF JNQBDUT VQPO TUVEFOUT DPNNVOJDBUJPO TPDJBM JOUFSBD
UJPO BOE TFMG FTUFFN BSF EJTDVTTFE
DOI: 10.4236/jss.2017.510009 Oct. 13, 2017 90 Open Journal of Social Sciences

A. Round et al.
Keywords
VUJTN 4QFDUSVN %JTPSEFS 7JTVBM SUT IJMESFO PNNVOJDBUJPO
'FFMJOHT NPUJPOT
1. Introduction
5IJT QBQFS SFQPSUT UIF GJOEJOHT PG B #BDIFMPS PG EVDBUJPO )POPVST UIFTJT DPO
EVDUFE JO POF VTUSBMJBO 6OJWFSTJUZ BOE DPNQMFUFE JO 5IF BJN PG UIF SF
TFBSDI BT UP UFMM JO EFQUI TUPSJFT PG UIF MJWFT PG U P DIJMESFO MJWJOH JUI VUJTN
BOE UIF BZT JO IJDI UIFJS SU NBLJOH JNQBDUFE PO UIF DPNNVOJDBUJPO PG
UIFJS GFFMJOHT BOE FNPUJPOT
OJUJBMMZ UIF JOTQJSBUJPO GPS UIJT SFTFBSDI JT QSFTFOUFE BMPOH JUI B CSJFG SFWJF
PG QFSUJOFOU MJUFSBUVSF BO PVUMJOF PG UIF NFUIPEPMPHJDBM BQQSPBDI UBLFO BOE UIF
QBSBNFUFST GPS UIF FUIJDBM DPMMFDUJPO PG EBUB T EBUB JODMVEJOH EFUBJMFE PCTFSWB
UJPOT PG FMFWFO SU NBLJOH TFTTJPOT BOE NBOZ EP[FOT PG QIPUPT PG QBSUJDJQBOU
SU PSLT FSF TP FYUFOTJWF JU JT OPU QPTTJCMF UP QSFTFOU UIFTF JO UIFJS FOUJSFUZ
IFSF 3BUIFS EBUB GSPN GJWF TFMFDUFE TFTTJPOT UIPTF JUI UIF NPTU QP FSGVM PC
TFSWBUJPOT PG QBSUJDJQBOUT BOE UIFJS BTTPDJBUFE SU PSLT BSF QSFTFOUFE BOE EJT
DVTTFE IFSF 5IFTF EBUB BOE UIF CSPBEFS GJOEJOHT PG UIF SFTFBSDI BSF TVCTF
RVFOUMZ SFGMFDUFE VQPO BOE EJTDVTTFE
5IF JEFB GPS UIJT SFTFBSDI QSPKFDU EFWFMPQFE IFO U P PG NZ GJSTU BVUIPS T
TPO T GSJFOET EJFE JO 5IJT BT IJT GJSTU FYQFSJFODF JUI EFBUI BOE IBWJOH
TFWFSF VUJTN IF GPVOE UIJT EJGGJDVMU UP VOEFSTUBOE /VNFSPVT WJTJUT UP B QTZ
DIJBUSJTU BOE QTZDIPMPHJTU EJE OPU BQQFBS UP IFMQ CFDBVTF IF OFFEFE B BZ UP FY
QSFTT IJT HSJFG BOE TBEOFTT JUIPVU SFMZJOH PO WFSCBM NFBOT UP DPNNVOJDBUF 4P
F CFHBO ESB JOH BCPVU IJT GFFMJOHT SU PSL BOE SU PSL UPHFUIFS BT B
BZ PG IFBMJOH )F BMTP FYQSFTTFE UIJT HSJFG JO IJT i.JOFDSBGUw 5.
PSME SU PSL
SU PSL .JTTJOH NZ GSJFOET 3ZBO
DOI: 10.4236/jss.2017.510009 91 Open Journal of Social Sciences

A. Round et al.
SU PSL N JO IFBWFO 3ZBO
SU PSL O UIF WJSUVBM PSME PG .JOFDSBGU™ WJTJUJOH CPOZ

BOE NJMZ JO IFBWFO JUI B MBEEFS TUSVDUVSF UIBU BMMP FE IJN UP
SFUVSO IPNF IFO IF JT SFBEZ 4PO PG UIF GJSTU OBNFE BVUIPS
2. Literature
5IF NFSJDBO 1TZDIJBUSJD TTPDJBUJPO 1 EFTDSJCFT VUJTN BT B OFVSPMPHJDBM
EJTPSEFS DIBSBDUFSJTFE CZ JNQBJSNFOUT JO TPDJBM JOUFSBDUJPOT DPNNVOJDBUJPO
BOE SFTUSJDUFE SFQFUJUJWF CFIBWJPVS JOUFSFTUT BOE BDUJWJUJFT VUJTN BMTP BGGFDUT B
QFSTPO T TFOTPSZ QSPDFTTJOH DBQBCJMJUJFT UIFJS DPHOJUJWF GVODUJPOJOH BOE FNP
UJPOBM SFHVMBUJPO 5IF %JBHOPTUJD BOE TUBUJTUJDBM NBOVBM PG NFOUBM EJTPSEFST
UI FE JEFOUJGJFT MFWFMT PG VUJTN SBOHJOH GSPN MFWFM SFRVJSJOH UIF MP FTU
MFWFM PG TVQQPSU UP MFWFM SFRVJSJOH UIF NPTU TVQQPSU 8JUIPVU TVQQPSU GSPN
GBNJMZ BOE UFBDIFST JOEJWJEVBMT BU -FWFM JMM IBWF OPUJDFBCMF JNQBJSNFOUT JO
TPDJBM DPNNVOJDBUJPO BOE FYQSFTTJOH FNPUJPOT BOE DPVME FYQFSJFODF EJGGJDVM

A. Round et al.
UJFT JO JOJUJBUJOH PS NBJOUBJOJOH TPDJBM JOUFSBDUJPOT BOE VOEFSTUBOEJOH TPDJBM DVFT

5IF JNQMJDBUJPOT GPS UIFJS FEVDBUJPOBM FYQFSJFODFT NFBOT UIFZ NBZ GFFM JTP
MBUFE GSPN UIFJS QFFST DPOGVTFE BOE PWFS IFMNFE CZ IBU FYQSFTTJPOT BSF FY
QFDUFE BOE JO UVSO NBZ CF WVMOFSBCMF UP EFQSFTTJPO
OEJWJEVBMT BU -FWFM IBWF NBSLFE EFGJDJUT JO TPDJBM DPNNVOJDBUJPO JODMVE
JOH WFSCBM BOE OPO WFSCBM TLJMMT WFO JUI TVQQPSUT JO QMBDF UIFTF JOEJWJEVBMT
UZQJDBMMZ TUSVHHMF JUI OPSNBM CBDL BOE GPSUI DPOWFSTBUJPOT IBWF MJNJUFE TIBS
JOH PG JOUFSFTUT BOE FNPUJPOT MJNJUFE JOJUJBUJPO PG TPDJBM JOUFSBDUJPO BOE QPPS
TPDJBM JNJUBUJPO 5IF DPOTFRVFODF UP UIJT NBZ SFTVMU JO UIF DIJME DPNNVOJ
DBUJOH UIFJS GSVTUSBUJPOT UISPVHI JOBQQSPQSJBUF CFIBWJPVST TVDI BT PVUCVSTUT PS
UBOUSVNT
OEJWJEVBMT BU -FWFM IBWF TFWFSF EFGJDJUT JO TPDJBM DPNNVOJDBUJPO BOE JO FY
QSFTTJOH FNPUJPOT IJDI JNQBDU PO BMM BTQFDUT PG UIFJS GVODUJPOJOH 5IFTF JOEJ
WJEVBMT TFMEPN JOJUJBUF TPDJBM JOUFSBDUJPO BOE IBWF WFSZ QPPS TPDJBM JNJUBUJPO
TLJMMT 5IF JNQMJDBUJPOT GPS UIFJS FEVDBUJPO NFBOT UIFZ NBZ OFWFS EFWFMPQ
PSET UP EFTDSJCF IP UIFZ BSF GFFMJOH 5IF DPOTFRVFODF PG UIJT NBZ MFBE UP
GSVTUSBUJPO BHHSFTTJPO PS TFMG JOKVSZ
5IF VTUSBMJBO #VSFBV PG 4UBUJTUJDT #4 IBT DPODMVEFE UIBU UIFSF BT B
JODSFBTF PG QFPQMF JUI VUJTN GSPN UP FRVBUJOH UP B EJBHOPTJT PG
VUJTN GPS POF JO FWFSZ VTUSBMJBOT VUJTN JT B MJGFMPOH EJTBCJMJUZ JUI
OP LOP O DBVTF 4UVEJFT IBWF JOEJDBUFE UIBU FBSMZ JOUFSWFOUJPO JMM JNQSPWF UIF
PVUDPNF BOE RVBMJUZ PG MJGF GPS JOEJWJEVBMT PO UIF VUJTN TQFDUSVN
5PEBZ UIFSF BSF BO BCVOEBODF PG FNQJSJDBMMZ TVQQPSUFE JOUFSWFOUJPOT JO
VTF GPS 4% JODMVEJOH UIPTF VTFE UP BTTJTU UIF EFWFMPQNFOU PG DPNNVOJDBUJPO
TLJMMT JO JOEJWJEVBMT PO UIF VUJTN TQFDUSVN BOE SU UIFSBQZ BMUIPVHI OPU B
FMM FTUBCMJTIFE JOUFSWFOUJPO JT POF PG UIFTF
SU UIFSBQZ DBO CF EFTDSJCFE BT VTJOH UIF DSFBUJWF QSPDFTT UP FYQMPSF JOOFS
GFFMJOHT GPTUFS TFMG B BSFOFTT NBOBHF CFIBWJPVST BOE SFEVDF BOYJFUZ 5IF
NBJO QVSQPTF PG SU UIFSBQZ JT UP FOBCMF JOEJWJEVBMT UP FYQSFTT IBU UIFZ DBOOPU
TBZ WFSCBMMZ UISPVHI QBJOUJOHT ESB JOHT PS PUIFS SU GPSNT 3FTFBSDI IBT
JOEJDBUFE UIBU SU UIFSBQZ DBO CF FGGFDUJWF GPS DIJMESFO PO UIF VUJTN TQFDUSVN
BT JU DBO CF UBJMPSFE UP UIF JOEJWJEVBM T QSFGFSFODF GPS WJTVBM JOGPSNBUJPO EJGGJ
DVMUJFT JUI WFSCBM DPNNVOJDBUJPO CFIBWJPVS BOE TFOTPSZ TFOTJUJWJUJFT CVU DBO
BMTP EFWFMPQ QPTJUJWF SFMBUJPOTIJQT SU UIFSBQZ JT QBSUJDVMBSMZ VTFGVM GPS JOEJ
WJEVBMT JUI VUJTN CFDBVTF JU JT B GPSN PG TFMG FYQSFTTJPO UIBU SFRVJSFT MJUUMF PS
OP WFSCBM JOUFSBDUJPO
WFO UIPVHI UIF BQQMJDBUJPO PG SU UIFSBQZ GPS JOEJWJEVBMT JUI 4% JT OPU OF
UIFSF JT WFSZ MJUUMF SFTFBSDI JO UIJT BSFB IP FWFS IBT BDLOP MFEHFE B TNBMM CVU
TUFBEZ JODSFBTF PG SFTFBSDI JO UIJT GJFME BJNFE UP VTF iQSF SFQSFTFOUBUJPOBM
ESB JOH BDUJWJUJFTyBT B GPVOEBUJPO GPS UIF EFWFMPQNFOU PG DPNNVOJDBUJPO
TLJMMTw Q TPVHIU UP EFWFMPQ DPNNVOJDBUJPO TLJMMT UISPVHI
DP DPOTUSVDUJWF FYQFSJFODFT PG QPTJUJWF SFMBUJPOTIJQT BOE TPDJBM JOUFSBDUJPO CZ
SFJOUSPEVDJOH TQPOUBOFJUZ BOE JNQSPWJTBUJPO JO TIBSFE SU NBLJOH TFTTJPOT
5IFZ GPVOE UIF TVCKFDUJWF SPMF PG UIF UIFSBQJTU BEEFE BO JOUFSBDUJWF FMFNFOU UP

A. Round et al.
UIF SU NBLJOH TFTTJPOT SFGFSSJOH UP UIJT BT UIF i OUFSBDUJWF 4RVBSFw NPEFM 5IJT
NPEFM JT BO BQQSPBDI UP BSU UIFSBQZ UIBU iTIJGUT UIF UIFSBQJTU SPMF GSPN TQFDUBUPS
PS PCTFSWFS UP BO BDUJWF QBSUJDJQBOUw JUIJO BO BSU NBLJOH TFTTJPO U BT
PVS JOUFOUJPO UIBU UIJT SFTFBSDI QSPKFDU TQFDJGZ BOE TUVEZ POMZ UIF BSFB PG DPN
NVOJDBUJOH FNPUJPOT BOE GFFMJOHT CZ BEBQUJOH BOE EFWFMPQJOH #SBHHF BOE 'FO
OFS T DP DSFBUJWF BQQSPBDI JUI WBOT BOE %VCP TLJ T GPVOEBUJPOBM NPEFM
GPS EFWFMPQJOH DPNNVOJDBUJPO TLJMMT GPS DIJMESFO JUI VUJTN
3. Methods
5IF JOUFOUJPO PG UIJT SFTFBSDI BT UP UFMM JO EFQUI TUPSJFT PG UIF MJWFT PG U P
DIJMESFO MJWJOH JUI VUJTN BOE IP SU NBLJOH JNQBDUFE PO UIFJS DPNNVOJDB
UJPO PG GFFMJOHT BOE FNPUJPOT O MJOF JUI UIJT BJN BOE UIF PCTFSWBUJPO PG
UIBU SU UIFSBQZ SFTFBSDI UZQJDBMMZ VTFT RVBMJUBUJWF NFUIPET B DBTF TUVEZ EFTJHO
BT FNQMPZFE SJUFT UIBU DBTF TUVEZ JT BQQMJDBCMF IFO B TUVEZ SFRVJSFT B
iDMPTF FYBNJOBUJPO PG QFPQMFw Q HBUIFSFE GSPN NVMUJQMF QFSTQFDUJWFT 5IF
SFTVMUT BSF QSFTFOUFE JO B OBSSBUJWF GPSN UFMMJOH B TUPSZ CZ JOUFSQSFUJOH UIF
DIJMESFO T FEVDBUJPOBM FYQFSJFODFT BOE JODPSQPSBUJOH GJSTU QFSTPO BDDPVOUT JUI
SFGFSFODF UP UIF JNBHFT DSFBUFE MM QBSUJDJQBOUT JO UIJT SFTFBSDI IBWF CFFO QSP
WJEFE JUI QTFVEPOZNT JO PSEFS UP QSPUFDU UIFJS JEFOUJUZ
QQSPWBM UP DPOEVDU UIF SFTFBSDI BT HSBOUFE CZ UIF 5BTNBOJBO 4PDJBM
4DJFODFT )VNBO 3FTFBSDI UIJDT PNNJUUFF 44)3 POTFOU GPS QBSUJDJQB
UJPO BT HJWFO CZ UIF DIJME IFO UIFZ IBE UIF DBQBDJUZ UP NBLF UIBU EFDJTJPO
BOE BMTP GSPN UIF QBSFOUT PS HVBSEJBOT PO UIFJS DIJME T CFIBMG 'PS UIF EVSBUJPO
PG UIF QSPKFDU POHPJOH DPNNVOJDBUJPO JUI UIF QBSFOUT BT GBDJMJUBUFE UP FOTVSF
UIF WPMVOUBSZ OBUVSF PG UIFJS DIJME T QBSUJDJQBUJPO BOE UP FOTVSF UIFZ FSF DPN
GPSUBCMF JUI UIF QSPDFTT 1BSFOUT FSF HJWFO UIF PQUJPO PG BUUFOEJOH UIF SU
NBLJOH TFTTJPOT
5IJT SFTFBSDI VTFE QVSQPTJWF TBNQMJOH UP SFDSVJU UIF U P DIJME
QBSUJDJQBOUT 5P CF FMJHJCMF QBSUJDJQBOUT OFFEFE UP
)BWF IBE B GPSNBM EJBHOPTJT PG 4% QSJPS UP UIF TUVEZ
#F BHFE CFU FFO TJY BOE U FMWF ZFBST PME JODMVTJWF 1SFQ UP :FBS TJY
#F BUUFOEJOH B 5BTNBOJBO QSJNBSZ TDIPPM 4PVUI
)BWF EFNPOTUSBUFE B JMMJOHOFTT UP CF JOWPMWFE JO SU NBLJOH J F OP
TUSPOH TFOTPSZ BWFSTJPO UP SU NBUFSJBMT DPMPVST TNFMMT FUD SFHBSEMFTT PG UIFJS
UFDIOJDBM BCJMJUZ BOE
)BWF UIF QIZTJDBM DBQBDJUZ J F TJHIU NPUPS DPPSEJOBUJPO JO IBOET OFDFT
TBSZ UP FOHBHF JO SU NBLJOH
5 P CPZT 3ZBO BOE BNFT QBSUJDJQBUFE JO UIJT TUVEZ U UIF UJNF PG UIJT TUVEZ
3ZBO BT B TFWFO ZFBS PME CPZ JUI -FWFM 4% MJWJOH JUI IJT GBUIFS NPUIFS BOE
PMEFS CSPUIFS 5IF NPUIFS BT B QBSU UJNF MFDUVSFS BU UIF 6OJWFSTJUZ 3ZBO BU
UFOEFE BO BMM CPZT JOEFQFOEFOU TDIPPM TJUVBUFE JO B IJHI TPDJP FDPOPNJD BSFB
BOE BT JO B 1SFQ DMBTT QBSU UJNF JUI B UFBDIFS BJEF .T BNFT BT B
ZFBS PME CPZ MJWJOH JUI IJT NPUIFS BOE ZPVOHFS CSPUIFS )JT NPUIFS PSLFE

A. Round et al.
BT B WPMVOUFFS GPS B ISJTUJBO TPDJBM FMGBSF PSHBOJTBUJPO BOE DBSFE GPS IFS
DIJMESFO GVMM UJNF BOE IJT GBUIFS IBE GSFRVFOU BDDFTT UP CPUI CPZT BNFT BT
EFTDSJCFE CZ IJT NPUIFS BT IBWJOH -FWFM 4% NJME FSFCSBM 1BMTZ NPUPS EZ
TQSBYJB BOE B ISPNPTPNF COPSNBMJUZ U UIF UJNF PG UIJT TUVEZ BNFT BU
UFOEFE WBSJPVT JOUFSWFOUJPOT BOE UIFSBQJFT JODMVEJOH TQFFDI UIFSBQZ PDDVQB
UJPOBM UIFSBQZ QIZTJPUIFSBQZ BOE B QTZDIPMPHJTU BNFT BT BCMF UP BEFRVBUFMZ
DPNNVOJDBUF IJT GFFMJOHT UISPVHI WFSCBM NFBOT CVU FJUIFS iLFQU IJT FNPUJPOT
CPUUMFE VQ PS PVME DMBN VQw BNFT .PUIFS
5ISPVHIPVU 0DUPCFS UIF GJSTU BVUIPS BUUFOEFE UIF QBSUJDJQBOUT DMBTT
SPPNT BT B iIFMQFSw UP FTUBCMJTI B SBQQPSU JUI UIFN 5IFTF TFTTJPOT FSF BQ
QSPYJNBUFMZ POF IPVS JO EVSBUJPO U JDF B FFL GPS U P FFLT BOE FSF OPU SU
UIFSBQZ SFMBUFE O /PWFNCFS UIF GJSTU BVUIPS CFHBO GJFME PSL DPNNFODJOH SU
NBLJOH TFTTJPOT BOE DPMMFDUJOH EBUB 5IFSF FSF B UPUBM PG FMFWFO SU NBLJOH
TFTTJPOT GJWF JUI 3ZBO BOE TJY JUI BNFT BOE GPS TPNF PG UIFTF TFTTJPOT
DP DSFBUJPO PG SU UPPL QMBDF JUI UIF QBSUJDJQBOU BOE UIF GJSTU BVUIPS BOE TPNF
UJNFT JUI UIF 5FBDIFS T JEF 5IJT DP DSFBUJWF BQQSPBDI BT CBTFE PO #SBHHF
BOE 'FOOFS T NPEFM PG UIF i OUFSBDUJWF 4RVBSFw
4. The Art Making Experiences

T EJTDVTTFE FBSMJFS JU JT OPU QPTTJCMF UP QSFTFOU BMM EBUB GSPN UIF U P QBSUJDJ
QBOUT BOE JOEFFE UP TVNNBSJTF EBUB PVME PWFS TJNQMJGZ UIF DPNQMFYJUZ BOE
JOEJWJEVBMJUZ PG FBDI SU NBLJOH FYQFSJFODF 5IVT UIF U P NPTU QP FSGVM BOE
DSFBUJWFMZ MJOLFE TFTTJPOT GSPN 3ZBO BSF QSFTFOUFE IFSFoIJT TFDPOE BOE UIJSE SU
NBLJOH TFTTJPOT BOE UISFF MJOLFE BOE QP FSGVM TFTTJPOT GSPN BNFT BSF QSF
TFOUFEoIJT UIJSE GPVSUI BOE GJGUI BMM JO FEJUFE BOE SFEVDFE GPSNBU
4.1. Ryan
#FGPSF UIF TFTTJPO .T IBE JOGPSNFE NF UIBU 3ZBO IBE IBE BOPUIFS iVQ BOE
EP Ow NPSOJOH 5IFZ IBE KVTU GJOJTIFE SFIFBSTBMT GPS UIF FOE PG ZFBS ISJTUNBT
QFSGPSNBODF QQBSFOUMZ UIF OPJTF BOE FYDJUFNFOU IBE i JSFEw 3ZBO VQ BOE IF
BT GJOEJOH JU EJGGJDVMU UP TJU BOE DPODFOUSBUF 3ZBO BT FBHFS UP HFU TUBSUFE BOE
EFDJEFE UP VTF WJTVBM QSPNQUT JO UIJT TFTTJPO JO PSEFS UP FOBCMF IJT DPNNVOJDB
UJPO 'JHVSF
i8IBU T EJT w IF BTLFE BT IF QPJOUFE UP UIF FNPUJPOT IFFM i U T B IFFM JUI
QJDUVSFT PG GFFMJOHT PO JU TP UIBU ZPV DBO TIP NF IP ZPV GFFM IFO ZPV MPPL BU
UIFTF QJDUVSFT IFSF w TIP FE IJN B WJTVBM QSPNQU PG B CPZ IPMEJOH IJT IBOET UP
IJT FBST 'JHVSF FYQMBJOFE UIBU IJT FBST FSF IVSUJOH GSPN MPVE OPJTFT
UIFO BTLFE IP MPVE OPJTFT NBEF 3ZBO GFFM )F UVSOFE UIF IFFM UP TBE )F
QJDLFE VQ UIF CMBDL NBSLFS BOE ESF IJNTFMG JO UIF DFOUSF BOE OPJTFT UIBU EJT
USFTT IJN SU PSL 0O UIF SJHIU IBOE TJEF BT B NFHBQIPOF BOE BCPWF IJT
IFBE BT B HVO JO SFGFSFODF UP UIF BUIMFUJDT DBSOJWBM IF IBE QBSUJDJQBUFE JO UIF
FFL CFGPSF )F ESF TVOHMBTTFT PWFS IJT FZFT JUI UFBST ESJQQJOH EP O IJT
GBDF )F BTTVSFE NF UIBU IJT NPVUI BT OPU TNJMJOH CVU DMFODIJOH GSPN UIF
OPJTFT

A. Round et al.
'JHVSF 7JTVBM QSPNQU NPUJPOT IFFM
'JHVSF 7JTVBM QSPNQU -PVE OPJTF SFTQPOTF
SU PSL 'FFMJOH TBE GSPN MPVE OPJTFT 3ZBO
5IF OFYU WJTVBM QSPNQU QJDUVSF TIP FE 3ZBO BT B DSP EFE FOWJSPONFOU
'JHVSF
.T DPNNFOUFE PO UIF QJDUVSF BOE TBJE JU MPPLFE B MPU MJLF UIF SFDFOU TDIPPM
GVO GBJS )F JNNFEJBUFMZ QJDLFE VQ UIF FNPUJPOT IFFM BOE UVSOFE UP UIF IBQQZ
GBDF BT FMM BT UIF TBE GBDF T IF BT ESB JOH UIF KVNQJOH DBTUMF IF QSPDMBJNFE
UIBU IF MJLFE SJEFT CVU EJE OPU MJLF UIF DSP ET SU PSL

A. Round et al.
'JHVSF 7JTVBM QSPNQU SP EFE FOWJSPONFOU
SU PSL 'FFMJOH IBQQZ BOE TBE JO B DSP EFE FOWJSPONFOU 3ZBO
3ZBO TB UIF WJTVBM QSPNQU QJDUVSF PG B CPZ QMBZJOH JUI UPZT 'JHVSF
i%IBU UIBU POFw IF TBJE QPJOUJOH UP UIF QJDUVSF
i)P EPFT JU NBLF ZPV GFFM UP QMBZ JUI ZPVS UPZT 3ZBO w BTLFE i)BQQZ w
)F CFHBO ESB JOH B TNBMM GJHVSF JO UIF DFOUSF i%IBU T NF w )JT GBDF IBE B MBSHF
TNJMF BOE UIF FZFT FSF MPPLJOH VQ BU IJT UPZ IJDI BT U JDF UIF TJ[F PG IJN
i8IP JT UIBU w BTLFE i0QUJNVT 1SJNFw B 5SBOTGPSNFS UPZ IF TBJE BT IF
KVNQFE PVU PG IJT TFBU 0QUJNVT 1SJNF BT IJT DVSSFOU GBWPVSJUF UPZ BOE QMBZJOH
JUI IJN NBEF IJN IBQQZ SU PSL
5IF MBTU WJTVBM QSPNQU TIP FE 3ZBO BT B CPZ JUI TPNFPOF JOTJEF B
UIPVHIU CVCCMF UP SFQSFTFOU NJTTJOH B QFSTPO 'JHVSF BT B BSF UIBU 3ZBO T
NPUIFS BT DVSSFOUMZ PWFSTFBT BU B DPOGFSFODF
i.VNNZ NJTT NVNNZ w IF ZFMMFE i BO ZPV TIP NF IP ZPV GFFM IFO
ZPV NJTT NVNNZ w RVFSJFE 3ZBO MFBOFE IJT IFBE POUP IJT MFGU BSN BOE CFHBO
UP ESB IJNTFMG PO UIF SJHIU IBOE TJEF PG UIF QJDUVSF SU PSL
)F GPVOE UIF TUJDLFS FZFT UIBU CFTU SFQSFTFOUFE TBE BOE TUVDL UIFN EP O PO
UP IJT GBDF )F EJE UIF TBNF GPS IJT CSPUIFS GBS MFGU IBOE TJEF 5IF GJHVSF JO UIF
NJEEMF JT IJT GBUIFS BOE IBT POF PG IJT BSNT PO IJT CSPUIFS T TIPVMEFS BQQFBSJOH

A. Round et al.
'JHVSF 7JTVBM QSPNQU 1MBZJOH JUI UPZT
'JHVSF 7JTVBM QSPNQU NJTTJOH QFSTPO
SU PSL 'FFMJOH IBQQZ QMBZJOH JUI PQUJNVT QSJNF 3ZBO
SU PSL .JTTJOH NVN BOE GFFMJOH TBE 3ZBO

A. Round et al.
IBQQZ -JLF JTF JUI UIF EPH JO UIF CPUUPN SJHIU IBOE DPSOFS i:PV BOE ZPVS
CSPUIFS NJTT NVNNZ 3ZBO w i:FTw IF IJTQFSFE
O UIF GPMMP JOH TFTTJPO 3ZBO SFRVFTUFE UP QBJOU PO BO QJFDF PG QBQFS )F
TUPPE VQ PVU PG IJT DIBJS BOE PSHBOJTFE UIF QBJOU QPUT JO B SP 8JUI JOUFOTF
DPODFOUSBUJPO IF CFHBO UP QBJOU MBSHF DJSDMFT JUI PSBOHF i5IJT JT EBE IBQQZ
CFDBVTF NVN JT IPNFw IF TBJE BT IF QMBDFE UIF TUJDLFST JO UIF NJEEMF PG UIF QB
QFS SU PSL )F DPOUJOVFE UP BEE NPSF QFPQMF i8IP BSF BMM UIFTF QFPQMF
3ZBO w BTLFE i5IJT JT NVN UPQ SJHIU UIJT JT NF UPQ MFGU UIJT JT NZ CSPUIFS
CPUUPN MFGU BOE UIF SFTU BSF NZ HSBOEBET BOE HSBOENBTw IF SFQMJFE
T IF BT BQQMZJOH UIF GJOJTIJOH UPVDIFT UP IJT QBJOUJOH 3ZBO UPPL B TUFQ
CBDL IBE B MPPL BU UIF QJDUVSF IF DSFBUFE BOE TBJE i.Z GBNJMZ JT IBQQZw
4.2. James
T F FSF BMLJOH PWFS UP UIF SU SPPN BTLFE BNFT IP IJT NPSOJOH IBE
CFFO )F TJHIFE BOE TBJE i8FMM OPU TP HPPE BOE BT SFBMMZ BOHSZ BU POF QPJOU
BT QMBZJOH 0DUPQVT B CBMM HBNF JUI UIF DMBTT BOE BM BZT HFU UBSHFUFE CZ
(BWJO QTFVEPOZN CFDBVTF N TMP JNNFEJBUFMZ GFMU BOHSZ CVU EJEO U BOU
UP HFU JOUP B GJHIU TP UPME .S 4w BTLFE BNFT IFUIFS IF DPVME iTIBLF PGGw UIF
DPNNFOUT (BWJO NBEF 5P IJDI IF SFQMJFE i/P OPU BU BMM BOE JMM HP UP CFE
UIJOLJOH BCPVU JU UPOJHIU IJDI JT IZ MJLF 5VFTEBZT BOE 'SJEBZT CFDBVTF HFU
UP EP QBJOUJOH JUI ZPV BOE JU NBLFT NF GFFM CFUUFS w BNFT BOUFE UP TUBSU JUI
B TFMG QPSUSBJU PG CFJOH BOHSZ )F QJDLFE VQ UIF TNBMMFTU CSVTI JO UIF QJMF BOE
DIPTF UP QBJOU UIF QMBTUFS GBDF SFE BNFT BOHSZ DPMPVS SU PSL 8JUI UJOZ
TUSPLFT IF CFHBO UP DPWFS UIF GBDF MUIPVHI IF BT TUJMM UBMLJOH UP NF BCPVU UIF
JODJEFOU IF TBU WFSZ TUJMM
SU PSL 5IF IPMF GBNJMZ JT IBQQZ CFDBVTF NVN JT CBDL 3ZBO

A. Round et al.
SU PSL #FJOH UIF UBSHFU BOE GFFMJOH BOHSZ BNFT
'PS UIF OFYU BDUJWJUZ BNFT CFHBO CZ TLFUDIJOH PVU BO JOUSJDBUF NBQ PG BO JN
BHJOBSZ DJUZ JUI MFBE QFODJM SU PSL )F TUBUFE UIBU CFDBVTF UIF PSME BT
PWFSQPQVMBUFE IF PVME MJLF UP FTDBQF BOE HP UP UIF NPPO BOE TUBZ UIFSF 5IF
NBQ JODMVEFE B SPDLFU MBOEJOH QBE BO VOEFSHSPVOE NFUSP TZTUFN B SBJM BZ
UIBU DPOOFDUFE JUI UIF NFUSP BO JOEVTUSJBM BOE SFTJEFOUJBM BSFB B UIFNF QBSL
BOE UIF UP O DFOUSF GPS FWFSZPOF UP HBUIFS
8IJMF QBJOUJOH JUI UIF MBSHFTU CSVTI IF DPVME GJOE BNFT PVME TUBOE VQ
BOE QBDF IJMF IF BT UIJOLJOH PG IJT JEFBT O PSEFS UP DPNNVOJDBUF UIF TUSVD
UVSF PG IJT JEFBT IF DIPTF UP UBML UP NF VTJOH IJT QFSJQIFSBM WJTJPO PS IF BT VO
BCMF UP GPDVT T UIF ESB JOH PG UIF UP O FNFSHFE IF EJTDVTTFE DPNQMFY JTTVFT
TVSSPVOEJOH UIF SJDI BOE QPPS i5IJT JT UIF JOEVTUSJBM BSFBw IF TBJE BT IF QPJOUFE
UP UIF PSBOHF BSFB PO UIF SJHIU IBOE TJEF i IJDI JT IZ BN QVUUJOH UIF QPPS
QFPQMF IFSF CFDBVTF SJDI QFPQMF EPO U MJLF TNPLF BOE EJSU 5IF QPPS QFPQMF
PO U IBWF BOZ USBJO DPOOFDUJPOT FJUIFS CFDBVTF UIFZ EPO U IBWF BOZ NPOFZ BO
Z BZ TP UIFZ DBO KVTU BML FWFSZ IFSF 3JDI QFPQMF MJLF UP CF FOUFSUBJOFE TP
JMM QVU B UIFNF QBSL OFBS UIF SJDI SFTJEFOUJBM BSFBw UIF HPME HMJUUFS BSFB PO UIF
MP FS MFGU IBOE TJEF i8IZ EP ZPV UIJOL UIFTF QFPQMF BSF QPPS BNFT w BTLFE
BT QPJOUFE UP UIF PSBOHF BSFB i#FDBVTF UIFZ VTFE BMM PG UIFJS TBWJOHT UP USZ UP
HFU IFSF UP UIF NPPO BOE OP UIFZ IBWF OPUIJOHw IF SFQMJFE )F DPOUJOVFE UIF
DPOWFSTBUJPO JUI SFGFSFODF UP SFGVHFFT BOE UIF GPSNFS VTUSBMJBO 1SJNF .JOJT
UFS 5POZ CCPUU T QPMJDZ JO UIJT BSFB UIF SFGVHFFT JO 4ZSJB BOE TMBNJD 4UBUF
i4P BNFT IP BSF ZPV GFFMJOH UPEBZ w BTLFE BU UIF TUBSU PG UIF OFYU TFTTJPO
i(SFBU CFDBVTF EJEO U IBWF 1 TP IBWFO U CFFO B UBSHFU UPEBZw IF SFQMJFE )F
MPPLFE VQ BOE IJT FZFT BQQFBSFE UP IBWF EBSL DJSDMFT i SF ZPV GFFMJOH UJSFE
BNFT w BTLFE i:FT IBWF CFFO VQ BMM OJHIU A:PV 5VCJOH BOE EJEO U HP UP
TMFFQ VOUJM BN .Z .FMBUPOJO BTO U PSLJOHw

A. Round et al.
SU PSL (FUUJOH PVU PG IFSF BOE HPJOH UP UIF NPPO BNFT
BNFT FYQSFTTFE BO JOUFSFTU JO DPOUJOVJOH JUI UIF TBNF UIFNF GSPN UIF MBTU
SU TFTTJPO )P FWFS UIJT UJNF JOTUFBE PG QBJOUJOH IVNBOT DPMPOJTJOH UIF
NPPO JU BT SPCPU TDJFOUJTUT JOWBEJOH UIF E BSG QMBOFU i4FEOBw )F CFHBO
TLFUDIJOH PVU UIF UP O QMBO JO MFBE QFODJM SU PSL BNFT BT TJUUJOH TUJMM
BQBSU GSPN UIF PDDBTJPOBM NPWFNFOU PG CJUJOH IJT UPOHVF IFO DPODFOUSBUJOH
MUIPVHI IF BT DBMN IJT FZFT FSF EBSUJOH CBDL BOE GPSUI T IF BT UBMLJOH UP
NF IF BT GJEEMJOH JUI UIF CVUUPOT PO IJT TIJSU 5IFSF BQQFBSFE UP CF UPP NVDI
JOGPSNBUJPO UIBU IF OFFEFE UP HFU PVU )F CFHBO UP TQFBL BCPVU IBU PVME
IBQQFO JG DIBPT CSPLF PVU PO 4FEOB QQBSFOUMZ JG UIJT SFE E BSG QMBOFU IBE
QSPCMFNT JUI CVMMZ SPCPUT UIFJS NJDSPDIJQT PVME CF SFNPWFE BOE UIFZ PVME
CF SF QSPHSBNNFE VOUJM UIFZ i FSF OJDF UP PUIFSTw
'PS QBSU PG UIF OFYU TFTTJPO POF PG NZ HPBMT BT GPS NF UP DP DSFBUF JUI
BNFT BOE UP FOBCMF IJN UP FYQSFTT IJT GFFMJOHT BCPVU CFJOH CVMMJFE JO 1 BTLFE
BNFT JG IF UIPVHIU JU BT B HPPE JEFB JG F QBJOUFE B QJDUVSF UPHFUIFS SU PSL
)F BHSFFE BOE TIVGGMFE IJT DIBJS DMPTFS i%P ZPV SFNFNCFS UIF PUIFS EBZ
BNFT IFO ZPV UPME NF BCPVU IP ZPV GFMU ZPV FSF CFJOH UBSHFUFE JO 1 w
TBJE i-FU T ESB IBU IBQQFOFE UIBU EBZ BOE UIJOL PG IBU ZPV DPVME EP OFYU
UJNF JU IBQQFOTw DPOUJOVFE CFHBO TLFUDIJOH QFPQMF JO UIF GBS MFGU IBOE TJEF
PG UIF QJDUVSF BNFT MFBOFE PWFS BOE ESF GBDFT PO U P PG UIFN i5IFSF BSF BM
BZT U P UIBU UBSHFU NFw IF TBJE BT IF ESF BHHSFTTJWF GBDFT PO UIFN )F DPO
UJOVFE UP QBJOU IJT GBDF JO CMVF 5FYUB BNFT TBE DPMPVS OPUJDFE IJN TJUUJOH PO
UIF FEHF PG UIF TFBU BT UIPVHI IF BT USZJOH UP SFNPWF IJNTFMG GSPN UIF TJUVB
UJPO 4P EFDJEFE UP DIBOHF UBDUJDT i8IBU DPVME ZPV EP UP NBLF ZPVSTFMG GFFM
CFUUFS w BTLFE i5FMM .S 4w IF SFQMJFE CFHBO TLFUDIJOH IJT UFBDIFS IFO IF
SFNJOEFE NF UIBU IF PSF HMBTTFT BOE EJE OPU IBWF NVDI IBJS i-JLF UIJT w
TPVHIU BQQSPWBM GPS B .S 4 MPPL B MJLF BNFT MBVHIFE IZTUFSJDBMMZ i:FT FYBDUMZ
MJLF UIBUw IF TBJE BT IF NPWFE DMPTFS UP UIF UBCMF i MM ESB NZTFMG EP O IFSF
UBMLJOH UP IJN PL w IF TBJE BNFT JOGPSNFE NF UIBU BGUFS UFMMJOH .S 4 IF GFMU
BOHSZ BOE UIFO TJDL UIF SFE BOE HSFFO DJSDMFT

A. Round et al.
SU PSL 5IF ZFBS 4FEOB JMM CF DPMPOJTFE IBMG DPNQMFUF BNFT
SU PSL 8BZT UP GFFM CFUUFS BNFT DP DPOTUSVDUJPO JUI GJSTU BVUIPS
i4P IP DBO ZPV HFU CBDL UP CFJOH IBQQZ w BTLFE BNFT BNFT QSPDFFEFE UP
NBLF B iIBQQZ MJTUw PO UIF GBS SJHIU IBOE TJEF PG UIF QBHF GUFS IF SPUF iMFBW
JOH UIF SPPNw JU USJHHFSFE B NFNPSZ GSPN UIF PUIFS FFL IFO IJT DMBTT IBE B
SFMJFG UFBDIFS i MM BOUFE UP EP BT SVO PVU PG UIF SPPN CFDBVTF FWFSZPOF BT
TP MPVEw IF TBJE )F UIFO DPOUJOVFE JO HSFBU EFQUI BCPVU IJT UISFF MFWFMT PG OPJTF
UPMFSBODF i BT EFGJOJUFMZ BU MFWFM UISFF UIJT EBZ 5IBU T IFO DBO U DPQF BOE
NZ CSBJO MJUFSBMMZ TIVUT EP O DBO U UBML DBO U UIJOL DBO U UFMM BOZPOF IP
GFFMw i8P BNFTw TBJE BDLOP MFEHJOH IJT QBJO i8IZ DBO U ZPV FBS IFBE
QIPOFT JO UIBU JOTUBODF w BTLFE i N OPU BMMP FE UPw IF TBJE BT IF TUBSFE JOUP
TQBDF )F TMVNQFE JO IJT DIBJS BHBJO )F TBJE IF BT UIJOLJOH BCPVU UIF U P
CPZT UIBU UBSHFU IJN BHBJO
i8PVME ZPV MJLF UP QBJOU IBU UIFZ MPPL MJLF w BTLFE BNFT CFHBO JUI
ESB JOH B MBSHF DJSDMF JO UIF DFOUSF JUI CMBDL 5FYUB SU PSL )JT UFFUI
FSF UJHIUMZ DMFODIFE POUP IJT UPOHVF BNFT IBE NPSQIFE U P QFPQMF JOUP IBU
MPPLFE MJLF POF NPOTUFS i)P BSF ZPV GFFMJOH BNFT w BTLFE RVJFUMZ i4BE
CFDBVTF LOP UIFZ JMM BM BZT UBSHFU NFw IF SFQMJFE DPVME TFOTF IJT VOIBQ
QJOFTT CZ IP RVJFU IF BT SFNFNCFSFE SFBEJOH BO SU TUSBUFHZ IJDI DPVME
IFMQ WJDUJNT PG CVMMZJOH HBJO B TFOTF PG DPOUSPM PWFS UIFJS TJUVBUJPO BOE SFMJFWF
BOYJFUJFT 4P TVHHFTUFE ESB JOH UPYJD TMJNF TQF JOH PG PS UIFJS NPVUI T )F
IBMG MBVHIFE

A. Round et al.
SU PSL 5IF #VMMJFT BNFT DP DPOTUSVDUJPO JUI GJSTU BVUIPS
4VEEFOMZ BNFT T GBDF DIBOHFE )F BT CFDPNJOH VODPNGPSUBCMF i8IZ EPO U

ZPV GJOJTI ZPVS 4FEOB QBJOUJOH w TVHHFTUFE BNFT JNNFEJBUFMZ TIPU VQ JO IJT
DIBJS BOE TUBSUFE UBMLJOH BCPVU 4QBDF BHBJO T IF BT ESB JOH UIF iQPSUBM DP
MPVSTw PSBOHF BOE CMVF IJT NJOE BT FTDBQJOH UP QMBOFU 4FEOB SU PSL
BT SFMJFWFE IFO IJT FYDFTTJWF UBMLJOH SFUVSOFE JOGPSNFE UIF TDIPPM BCPVU UIF
CVMMZJOH UIBU UIF SU NBLJOH IBE TVSGBDFE UIFZ FSF BMSFBEZ EFBMJOH JUI JU
5. Reflections and Discussion

3ZBO BOE BNFT SU NBLJOH TFTTJPOT DPOUSJCVUF UP UIF BSHVNFOU UIBU UIF QSPD
FTTFT PG SU NBLJOH DBO CF BO FGGFDUJWF JOUFSWFOUJPO GPS DIJMESFO PO UIF VUJTN
TQFDUSVN BT JU DBO CF UBJMPSFE UP UIF JOEJWJEVBM T QSFGFSFODF GPS WJTVBM JOGPSNB
UJPO EJGGJDVMUJFT JUI WFSCBM DPNNVOJDBUJPO CFIBWJPVS BOE TFOTPSZ TFOTJUJWJUJFT
CVU DBO BMTP EFWFMPQ QPTJUJWF SFMBUJPOTIJQT 4JNJMBS UP QSFWJPVT SFTFBSDI JO
UIJT GJFME JODMVEJOH BOE F GPVOE UIBU UIF SU NBLJOH
QSPDFTT BT BTTPDJBUFE JUI JNQSPWFE TQFFDI DPNNVOJDBUJPO BOE TPDJBM JOUFS
BDUJPO ,FZ UIFNFT IJDI FSF OPU BOUJDJQBUFE JO UIJT SFTFBSDI JODMVEFE JOEJDB
UJPOT PG JODSFBTFE TFMG FTUFFN BOE HFOFSBM FMMCFJOH BOE JODSFBTFE DPO
DFOUSBUJPO TFOTPSZ SFHVMBUJPO BOE GMFYJCJMJUZ UP DIBOHF MTP CPUI QBSUJDJQBOUT
FYQFSJFODFE UIF QSPDFTT JO NBSLFEMZ EJGGFSFOU BZT JODMVEJOH BO JODSFBTF JO
BOYJFUZ MFWFMT BTTPDJBUFE JUI UIF DP DSFBUJOH QSPDFTT GPS BNFT
5IF GJOEJOHT GSPN UIJT SFTFBSDI TUVEZ TVHHFTU UIBU UIF SU NBLJOH TFTTJPOT
FSF BO FOKPZBCMF BOE CFOFGJDJBM FYQFSJFODF GPS CPUI 3ZBO BOE BNFT (JWFO UIF
EJWFSTJUZ PG QFSTPOBMJUJFT BDSPTT UIF VUJTN TQFDUSVN OPU TVSQSJTJOHMZ UIF PVU
DPNFT GSPN UIJT TUVEZ FSF WFSZ EJGGFSFOU GPS UIF U P QBSUJDJQBOUT %SB JOH
GSPN UIF PSL PG JU JT QPTTJCMF UIBU OVNFSPVT GBDUPST NBZ IBWF DPOUSJCVUFE
UP UIFTF EJGGFSFODFT TVDI BT UIFJS EFWFMPQNFOUBM BHFT QFSTPOBM DJSDVNTUBODFT
BOE MFWFMT PG EJBHOPTFT
3ZBO BT POMZ TJY BU UIF UJNF PG UIJT TUVEZ BOE BMUIPVHI IF IBE B -FWFM EJ
BHOPTJT PG VUJTN IF BMTP IBE QSBYJB PG TQFFDI 5IJT DPNNVOJDBUJPO EJTPSEFS

A. Round et al.
SU PSL 5IF :FBS DPNQMFUF BNFT
BGGFDUFE IJT BCJMJUZ UP QSPEVDF PSET DPSSFDUMZ IFO DPNNVOJDBUJOH 5IF SU

NBLJOH TFTTJPOT QSPWJEFE UIF PQQPSUVOJUZ GPS IJN UP QSBDUJDF IJT TPVOET IJMF
QBJOUJOH JO B OPO UISFBUFOJOH FOWJSPONFOU U UIF UJNF PG UIJT TUVEZ 3ZBO T
NPUIFS BT BMTP B BZ BUUFOEJOH B DPOGFSFODF PWFSTFBT O QSFWJPVT ZFBST IFO
UIJT PDDVSSFE IJT UFBDIFS T BJEF TUBUFE UIBU IJT NPUIFS T BCTFODF PVME MFBWF IJN
iRVJFU BOE JUIESB Ow )P FWFS UISPVHI UIF SU NBLJOH TFTTJPOT 3ZBO BT
BCMF UP FYQSFTT IJT TBEOFTT UISPVHI IJT QBJOUJOHT CVU BMTP QBJOU BZT UIBU IF
DPVME GFFM CFUUFS
O DPOUSBTU UP 3ZBO T FYQFSJFODF BNFT BT QSF QVCFTDFOU BU UIF UJNF PG UIJT
TUVEZ BOE IJT TJUVBUJPO BT GBS NPSF DPNQMFY JUI UIF TPDJBM EZOBNJDT TVS
SPVOEJOH IJT QFFST BU TDIPPM )F BT WFSZ NVDI B BSF PG IJT VUJTN BOE JO QBS
UJDVMBS IJT FSFCSBM 1BMTZ BNFT JEFOUJGJFE IJT FSFCSBM 1BMTZ JO PSEFS UP FYQMBJO
IZ IF BT CVMMJFE BOE BENJUUFE UIBU IF BT VOBCMF UP WFSCBMJTF IJT GFFMJOHT
IFO IF GFMU EJTUSFTTFE 5IF SU NBLJOH TFTTJPOT QSPWJEFE UIF PQQPSUVOJUZ GPS
BNFT UP FTDBQF UIF SFBMJUJFT PG IJT EJBHOPTJT BOE IJT CVMMJFT 5IJT BT FWJEFOU JO
SFNBSLT IF NBEF BCPVU IP FMM IF BT TMFFQJOH CFDBVTF IF BT BCMF UP iHFU JU
IJT GFFMJOHT PVUw WFO UIPVHI 3ZBO BOE BNFT IBE WFSCBM MBOHVBHF JO UJNFT PG
EJTUSFTT UIFZ FSF VOBCMF UP QIZTJDBMMZ GJOE UIF PSET UP FYQSFTT UIFJS GFFMJOHT
5IFTF SU NBLJOH TFTTJPOT QSPWJEFE CPUI CPZT UIF PQQPSUVOJUZ UP FYQSFTT
IBU UIFZ DPVME OPU TBZ JO PSET
MUIPVHI BNFT EJE OPU FYQMJDJUMZ TUBUF UIBU IF BT EFQSFTTFE CZ CFJOH CVMMJFE
IF DPOTUBOUMZ NFOUJPOFE IJT TMFFQ BT BGGFDUFE CZ UIF OFHBUJWF UIPVHIUT BOE
BOYJFUJFT TVSSPVOEJOH IJT UPSNFOUPST 0O TFWFSBM PDDBTJPOT BNFT SFQPSUFE B
QPTJUJWF BUUJUVEF UP BSET UIF BZ IF GFMU BCPVU IJNTFMG BOE UIBU IJT TMFFQJOH JN
QSPWFE BT B SFTVMU PG UIF SU NBLJOH TFTTJPOT 5IJT GJOEJOH JT TJNJMBS UP MJU
FSBUVSF SFWJF JO IJDI TIF TUBUFE UIF SU NBLJOH QSPDFTT FOIBODFE UIF MJWFT PG
JOEJWJEVBMT JUI 4% CZ JODSFBTJOH UIFJS HFOFSBM FMMCFJOH
3ZBO BOE BNFT FSF CPUI JEFOUJGJFE BT IBWJOH TFOTPSZ JTTVFT 5IJT JO UVSO BG

A. Round et al.
GFDUFE UIFJS BCJMJUZ UP TJU TUJMM BOE DPODFOUSBUF 'PS 3ZBO UIJT NFBOU T BZJOH IJT
IFBE GSPN TJEF UP TJEF JG IF OFFEFE B CSFBL PS BT CFDPNJOH BHJUBUFE )F BT
BMTP PWFSMZ SFTQPOTJWF UP MPVE EFFQ TPVOET BNFT BT PWFSMZ SFTQPOTJWF UP DFS
UBJO PCKFDUT BOE TPVOET BOE PVME QBDF CBDL BOE GPSUI JG IF GFMU PWFS IFMNFE
T UIF SU NBLJOH TFTTJPOT QSPHSFTTFE UISPVHI UIF FFLT CPUI QBSUJDJQBOUT
TIP FE BO JODSFBTF JO DPODFOUSBUJPO BOE BT TVDI B SFEVDUJPO PG UIF TUFSFP
UZQJDBM CFIBWJPVST PG QBDJOH PS T BZJOH 5IJT BT TJNJMBS UP DBTF TUVEZ BOE
MJUFSBUVSF SFWJF UIF GJOEJOHT PG IJDI JOEJDBUFE QPTJUJWF CFIBWJPVST BTTP
DJBUFE JUI TFOTPSZ EJGGJDVMUJFT EVSJOH BOE BGUFS SU NBLJOH TFTTJPOT
'PS 3ZBO UIF SU NBLJOH QSPDFTT TUJNVMBUFE DIBOHFT PG CFIBWJPVS TJNJMBS UP
UIPTF SFQPSUFE CZ JO UIFJS DMJOJDBM DBTF TUVEZ SFWJF T JOUP SU UIFSBQZ JUI
DIJMESFO JUI 4% 5IF DSFBUJWF QSPDFTT JODSFBTFE IJT GMFYJCJMJUZ UP RVJDLMZ BM
UFSOBUF CFU FFO BDUJWJUJFT 3ZBO WFSCBMJTFE UP .T BOE UIF GJSTU BVUIPS UIBU IF
GPVOE UIF DP DSFBUJOH QSPDFTT FYDJUJOH 'VSUIFSNPSF GPVOE UIJT BQQSPBDI
JODSFBTFE MBOHVBHF BOE DPOGJEFODF BT FMM BT GBDJMJUBUFE UIF VTF PG IVNPVS 1FS
IBQT UIF GPDVT PO QPTJUJWF GPSNBUJWF FYQFSJFODFT BOE CFJOH UPHFUIFS JUI GBNJMZ
QSPWJEFE BO JEFBM SFGFSFODF QPJOU GPS B DP DSFBUJOH SU NBLJOH QSPDFTT
6OGPSUVOBUFMZ GPS BNFT UIF DP DSFBUJWF QSPDFTT QSPWFE UP CF UPP JOUSVTJWF
BOE JNQFEFE UIF SU NBLJOH QSPDFTT O DPOUSBTU UP T SFTFBSDI PSLJOH
BMPOHTJEF BNFT JO B DP DSFBUJWF BZ JODSFBTFE IJT BOYJFUZ MFWFMT 8IJMTU DSFBUJOH
UIF CVMMZ QBJOUJOHT UPHFUIFS JUI UIF GJSTU BVUIPS IF CFDBNF RVJFU BOE JUI
ESB O 4FOTJOH UIJT BOYJFUZ JNNFEJBUFMZ DFBTFE DP DSFBUJOH BOE PGGFSFE IJN
UIF DIPJDF PG SFUVSOJOH UP IJT iFTDBQF QBJOUJOHw BNFT SFTQPOTF UP DP DSFBUJPO
BT QSPCBCMZ FYQMBJOFE CZ UIF FNPUJPOBM JNQBDU PG UIF UPQJD CFJOH FYQMPSFE UIF
SFDFOU FYQFSJFODFT PG CVMMZJOH U TFFNFE UIBU DSFBUJOH BSU PSLT CZ IJNTFMG IJMTU
TJNVMUBOFPVTMZ UBMLJOH UP NF QSPWFE UP CF NPSF CFOFGJDJBM GPS BNFT BOE EVSJOH
UIJT DSFBUJOH POMZ TFFNFE UP OFFE BO FNQBUIJD QSFTFODF GSPN NF 5IF VOFY
QFDUFE JODSFBTF JO BOYJFUZ MFWFMT GPS BNFT IJMTU DP DSFBUJOH EFNPOTUSBUFT UIBU
DBVUJPO NVTU CF UBLFO JUI QSBDUJDFT TVSSPVOEJOH DIJMESFO JUI VUJTN BOE
JOEFFE OFVSP UZQJDBM DIJMESFO BOE DPNQMFY DBTFT TVDI BT CVMMZJOH
5IF SU NBLJOH QSPDFTT QSPWJEFE BO BMUFSOBUJWF PVUMFU GPS TFMG FYQSFTTJPO BU
TDIPPM 5IJT QSPDFTT NBZ SFEVDF UIF DIBMMFOHFT JOEJWJEVBMT JUI VUJTN GBDF
UIFSFGPSF JNQSPWJOH UIF RVBMJUZ PG MJGF GPS UIFN BT FMM BT UIFJS GBNJMJFT BOE
UFBDIFST 5IF NBJO JTTVF UIBU UIJT TUVEZ BEESFTTFE BT UIF DPNNVOJDBUJPO EJG
GJDVMUZ DIJMESFO JUI 4% FOEVSF BU TDIPPM BOE BU IPNF 5IF EJWFSTJUZ PG UIF
VUJTN TQFDUSVN NFBOT OP U P JOEJWJEVBMT BSF BMJLF BOE VOTVSQSJTJOHMZ UIF
PVUDPNFT GSPN UIJT TUVEZ FSF WFSZ EJGGFSFOU GPS UIF U P QBSUJDJQBOUT 3FGMFD
UJPOT PO UIF SU NBLJOH QSPDFTT JO UIJT TUVEZ EJE IP FWFS MFOE TVQQPSU UP UIF
JEFB UIBU UIF QSPDFTTFT PG SU NBLJOH DBO FBTJMZ CF EJWFSTJGJFE UP TVJU JOEJWJEVBMT
JUI VUJTN SFHBSEMFTT PG UIFJS MFWFM PG EJBHOPTJT 5IJT NFBOT UIF JODMVTJPO PG
BO SU NBLJOH QSPHSBN DPVME CF JNQMFNFOUFE JO TDIPPMT CZ TPDJBM PSLFST SU
UIFSBQJTUT PS TDIPPM QTZDIPMPHJTUT UP SFEVDF CFIBWJPVSBM JTTVFT BTTPDJBUFE JUI
DPNNVOJDBUJPO EJGGJDVMUJFT GPS DIJMESFO JUI VUJTN 'VSUIFSNPSF UIF (VOB
JSSB QSPHSBN JO SVSBM /F 4PVUI 8BMFT TUBUF JU JT QPTTJCMF UIBU B TQF

A. Round et al.
DJGJD SU NBLJOH QSPHSBN JO B QSF TDIPPM PS TDIPPM TFUUJOH DPVME BMTP NFFU UIF
JODSFBTJOH OFFET PG PUIFS DIJMESFO IP SFRVJSF NPSF BTTJTUBODF UIBO UIF DMBTT
SPPN UFBDIFS DBO SFBTPOBCMZ CF FYQFDUFE QSPWJEF GPS FYBNQMF JUI DIJMESFO
IP BSF FNPUJPOBMMZ EJTUVSCFE TVGGFS GSPN USBVNB NFOUBM IFBMUI PS BSF FYQPTFE
UP BCVTF PS EPNFTUJD WJPMFODF #VU UIFSF NBZ BMTP CF PQQPSUVOJUJFT GPS DMBTTSPPN
UFBDIFST UP FNCFE TJNJMBS SU NBLJOH GPS BMM UIFJS TUVEFOUT TVDI BT IFO EF
TJHOJOH BDUJWJUJFT UP EFWFMPQ TUVEFOUT i1FSTPOBM BOE 4PDJBM BQBCJMJUJFTw GPS
IJDI JEFOUJGZJOH DPNNVOJDBUJOH BOE NBOBHJOH FNPUJPOT JT DFOUSBM
PNNVOJDBUJPO BOE TFMG FYQSFTTJPO BSF B GVOEBNFOUBM QBSU PG IP F FYJTU
BOE JOUFSBDU JUI UIF PSME BSPVOE VT 3ZBO BOE BNFT FSF HJWFO UIF PQ
QPSUVOJUZ UP FYQSFTT UIFJS FNPUJPOT UP PUIFST BCPVU IBU NBLFT UIFN IBQQZ BOE
TBE G BO JOEJWJEVBM BT VOBCMF UP DPNNVOJDBUF UIFJS GFFMJOHT BOE FNPUJPOT B
DIBOHF JO CFIBWJPVS NBZ FTDBMBUF VOUJM B UFBDIFS PS B QBSFOU EPFT UBLF OPUJDF
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Psychology and Behavioral Sciences
2019; 8(3): 79-84
http://www.sciencepublishinggroup.com/j/pbs
doi: 10.11648/j.pbs.20190803.14
ISSN: 2328-7837 (Print); ISSN: 2328-7845 (Online)
Painting Therapy in Improvement of the Symptoms of

Children with Autism Spectrum Disorder
Kaveh Moghaddam1, *, Aida Ravarian2, Farhoud Saied Ershadi3
1
Department of Exceptional Children Psychology, Islamic Azad University, Tehran, Iran
2
Pediatrics Neurorehabilitation Center, University of Social Welfare and Rehabilitation Sciences, Tehran, Iran
3
Department of Orthosis and Prosthesis, University of Social Welfare and Rehabilitation Sciences, Tehran, Iran
Email address:
*
Corresponding author
To cite this article:

Kaveh Moghaddam, Aida Ravarian, Farhoud Saied Ershadi. Painting Therapy in Improvement of the Symptoms of Children with Autism
Spectrum Disorder. Psychology and Behavioral Sciences. Vol. 8, No. 3, 2019, pp. 79-84. doi: 10.11648/j.pbs.20190803.14
Received: December 27, 2018; Accepted: April 1, 2019; Published: July 8, 2019
Abstract: Objective: Children with autism spectrum disorder suffer from problems such as qualitative impairment in the
social interactions and stereotypical behaviors and the purpose of many interventions is the dynamic involvement of the
families in the treatment and rehabilitation of these children. Therefore, the purpose of this study was to investigate the effect
of educational application of family-centered painting techniques on social interactions and stereotypical behaviors of children
with autism spectrum disorder. Methods: This applied experimental study was conducted using the pre-test-posttest with
follow-up and control group design. In this study, 20children with autism spectrum disorder and their parents were selected by
the available sampling method and then, they were randomly divided into experimental and control groups. Then, the Gilliam
Autism Rating Scale-I questionnaire was applied at pre-test, posttest and follow-up stages and educational application of
family-centered painting techniques was applied just for the experimental group. Then the data were analyzed by the
ANCOVA and the repeated measures as statistical methods. Results: An alpha of 0.05 was considered as the significance level
and the results showed a significant difference between experimental and control groups in social interactions and stereotypical
behaviors of the children. Follow-up tests showed a significant difference and durability, as well. Conclusions: The results
showed that educational application of family-centered painting techniques can play an effective and durable role in
improvement of social interactions and stereotypical behaviors of the children with autism spectrum disorder.
Keywords: Family-centered, Social Interactions, Stereotypical Behaviors, Autism Spectrum Disorder
ego ". Drawing lines are a reflection of the emotional world,

1. Introduction and painting is solely as a world that is transforming parallel
Painting is a mental association that teenagers, adults and to increase in the alertness and transformation of the child
especially children, can interact with others. That is why can [2]). Painting is very important in the formation of character
understand the child's mood, desires and personality using and mind of the child, not only to enable the child to identify
their paintings and of course, this orientation is effective in environment and company in it as well as raising questions,
their educational guidance, because by painting, children but also allows child formulates issues that are irregularly
experience discipline in thought and psychomotor skills in raised from all sides. In the drawings, like dreams and
the hands [1, 2]. Child's painting is a message and moves us visions, child will release ego from the ban and speaks us in
what he cannot verbalize, and to review and understand the the subconscious state of the issues, discoveries and
"language" of painting, offers useful information for the apprehensions. Therefore, it must be said that children
parents, educators, psychologists and all those who want to painting is not merely fostering creativity and sophistication
understand and get the mysteries of the child's world. Child of the child and or an index of evolution, and it should be
experiences all of issues by painting; tests and builds the" considered as a medium of research and exchange with the
social environment - with the world of adults who are around
80 Kaveh Moghaddam et al.: Painting Therapy in Improvement of the Symptoms of
the child- and as a sign of the child's emotional states [3, 4- retardation, due to the lack of sufficient attention and focus,
7]. In addition, the painting is considered as a means to and relatively low learning and IQ, are not able to portray the
measure intelligence, spatial perception and the projection of issues surrounding themselves and fail projection in their
feelings, emotions and personality of the child; furthermore, paintings and feel powerless for drawing what is in their
all studies in the field of paintings of children show the immediate environment. A variety of colors and shape in
importance of this art's role in the cohesion and the formation most of their paintings are low, and symbols, objects, and
of the child's character; in addition, painting adjusts and images in their paintings are stereotypical and uniform [21].
improves their information exchange and communication Furthermore, art therapy studies show that these children pay
with the environment, and also highly help children for more attention to sensory stimuli, such as color and shape
intellectual development and learning, and in general all that are the main elements, rather than human stimuli, in the
people use paintings to convey their thoughts and fantasies or painting; moreover, clinical studies and research in the field
feelings and perceptions to others. [8, 9-12]. There is another of education of painting and art therapy among the children
important point that visual painting as an art in which the show that by painting we can reduce somewhat the
aesthetic element is completely evident, can cause discharge stereotypical behaviors and movements in this group of
and release children's feelings, emotions and sentiments by children and improve interpersonal communication among
affecting the limbic system of the brain; furthermore, based them; in fact, in some ways these children, however with a
on other studies in the art neuropsychology field, elements limited manner, express their thoughts and feelings through
such as colors, shapes, sizes and penumbra that are seen in painting [22-29].
painting, are interpreted and processed as visual data and In fact, fundamental problems in drawing and painting of
information in the occipital lobe of the right hemisphere, children with autism spectrum disorder that create particular
where is place of interpretation, processing and finally the problems in the educational environment for them and along
perception of visual data; then, by the activation of the brain their main symptoms, i.e. the deficiency in interpersonal
lobe it causes improvement of the visual perception skills communication, poor verbal skills, and stereotypical
such as eye-hand coordination, understanding spatial behaviors cause the family, especially the parents of the
relationships, visual memory, understanding the shape children face many challenges and the various aspects of life
stability and visual accuracy in children, and therefore are overshadowed [30, 31]. To alleviate such specific
increases their learning and perception [13, 14-17]. problems that there are in families of the children, extensive
In the paintings of children with autism spectrum disorder studies have been conducted. The purpose of many of these
or ASD, who suffer difficulties in social interaction, verbal studies has been applying the so-called family-centered
communication, and stereotypical behaviors, when human interventions and approaches that by using them and by
image is displayed, always is small in size, and details of the involving the parent in these programs actively and
face and extremities are rarely shown. For example, if dynamically, we can reduce not only problems of these
dummies drawn by a child, have the eye, the eye is children, but also create greater interaction between family
thoughtful with a look at remote or completely devoid of a members, especially their parents in order to more
look. If the child has high performance and or wholly he or satisfaction with life in the existing conditions for them and
she can paint, while drawing several dummy, he or she paints preserve the mental health of the family [31-34]. However,
all of them uniformly and the same. Sometimes also, this study sought to address this issue that educational
aggression is seen in their paintings [18, 19]. Usually due to application of family-centered painting techniques to what
touch defensive in the limbs, especially hands and fingers, extent can improve the symptoms of autism spectrum
children with autism spectrum disorders cannot look colored disorder, i.e. stereotypical behaviors and social interactions
pencils, pens, crayons and other drawing and painting in the among the children with autism spectrum disorder and
hands for a long time that is why parents and teachers are whether the impact of this program on these symptoms can
complaining of poor handwriting, lack of attention to be durable?
drawing and lack of focus on writing and drawing for a long
time. Hence, most of these children do not have much 2. Methodology
interest in drawing and painting and their paintings are
frequently uniform and in some cases, appear garbled and 2.1. Participants and Methods
scrawl and it seems that they have been fixed in the early
stages of the evolution of painting, i.e. scrawl. Free painting In this applied and experimental research, a pre-test- post-
it is a stereotype among them, and always they paint only a test and control group, and follow-up design has been used
picture [20]. These children, unlike the normal children, for conducting it. The study population included all children
cannot reflect their feelings, emotions, fears, happiness and with autism spectrum disorder, along with their parents, who
generally, emotions in their paintings. For example, normal were refered to the rehabilitation centers and exceptional
children can describe the events that had happened to them, schools in Tehran in order to receive the educational and
and can project their feelings and emotions towards a friend, rehabilitation services. The sample consisted of 6-11-year-old
parent, or peers in his paintings. While children with the children with autism spectrum disorder (N=20) along with
autism spectrum disorder, such as children with mental their parents. The subjects were selected from among the
Psychology and Behavioral Sciences 2019; 8(3): 79-84 81
children in the school for children with autism spectrum 2.3. Procedure
disorder by a convenience sampling method. Importantly
diagnosis of autism spectrum disorder for these children was In educational application of family-centered painting
done by special education and training organization and techniques, which is derived from studies and clinical trials
using the ADI-R test. After random selection, the subjects conducted by Case & Dalley (2008), Silvers (2008),
were divided into two groups: experimental and control; Zadehmohamdi and Rajabi (2011), Landgartn (2003), Martin
then, all 20 children with autism spectrum disorder and their (2009) and kamkar Yazdannezhad (2006), a combination of a
parents were taken pre-test and then, for 10 children in the variety of painting ways such as free painting, painting based
experimental group together with their parents, the family- on the evolution of painting, copying the shapes of the
centered painting techniques program was conducted in 15 patterns and images, coloring pictures and shapes, painting of
sessions of 45 minutes to an hour in the center. family, drawing of the homunculus and painting with
Simultaneously, the parents conducted 15 training sessions in contrasting colors (green, red, yellow and purple, blue and
touch with their children at home. After finishing 30 orange, black and white, red and black, pink and gray) were
sessions, all groups of children and their parents were taken used; and tools of painting and drawing also were diverse and
the post - test. And after post-test, follow-up program also included colored pencils, crayons, gouache and finger paint.
was done in a three month and after completion of a three- Furthermore, in this application, the main symptoms of
month follow-up period, children and parents of two groups children with autism spectrum disorders, namely the
were follow-up. existence of stereotypical behaviors and the qualitative
defects in social interactions as the two sets of main
2.2. Materials and Measures symptoms consistent with the DSM V (2013) have been
considered. In the training sessions with the children, this
In this study, to assess symptoms of autism spectrum application was instructed to parents, so that they observe
disorder or ASD, the GARS- I questionnaire was used. In a them and then, they run and follow it themselves for children
study to validate the Gilliam Autism Rating Scale (GARS) by at home. To analyze research data, descriptive indicators such
Ahmadi et al. (2011) on children and adolescents with ASD as mean and standard deviation were used, and also,
in the Isfahan, the study population consisted of all children according to the number of dependent variables and follow-
and adolescents with ASD Isfahan province, of these 100 up courses, analysis of covariance (ANCOVA) and the
subjects were selected by simple random sampling (12). In repeated measures tests with the help of SPSS software were
this study, descriptive and analytical methods were used and used. An ANCOVA was used because for determining
data were collected using GARS and the Childhood Autism normality of scores, if the number of participants is 40 or
Rating Scale (CARS). The face validity and content validity less, Kolmogorov-Smirnov and Shapiro-Wilk tests are used.
of these scales were confirmed by the Esfahan Autism Otherwise, report of values of a distribution index: tilt and
Center's experts. To estimate the construct validity, the CARS strain or visual depiction of score chart will suffice. Because
was used simultaneously that the correlation coefficient of the sample size of the study groups is less than 40 people and
these two questionnaires was 0.80. The reliability of this based on the results of the Shapiro-Wilk test, because the
scale using Cronbach's alpha coefficient was 0.89. Results values obtained from these tests in a group at a 0.05 level is
showed that the GARS is a reliable tool for diagnosing and not significant, so, the condition of equality of intragroup
screening ASDs. Furthermore, the results obtained from this variances and normality distribution of data is met.
study are consistent with previous research and according to
good reliability and validity of this scale, it can be used in
research and clinical settings. The results also showed that 3. Results
there is no a significant correlation between age and overall First hypothesis: educational application of family-
score of autism, and only stereotypes have a significant centered painting techniques is effective in the social
relationship with age. The results also showed that the GARS interactions of children with ASD.
test is not gender- sensitive [24].
Table 1. A summary of the results of ANCOA of the first hypothesis.
Indicator
Sum of squares DF MS F Significance level Coefficients for ETA Power of Test
Sources of changes
Effect of pre-test 1014.959 1 1014.959 185.437 0.000 0.925 1.000
Effect of group 76.135 1 76.135 13.910 0.002 0.481 0.936
Error 82.100 15 5.473
Total 1107.000 17
According to the data in Table 1, the value of F = 13.910 the amount of the effect of the application in the social
with degrees of freedom. (1 and 15) in the studied variable at interactions of these children is 1.48%. So, the research
the level of α = 0.05 is significant. Therefore, we can hypothesis is confirmed with 95% confidence.
conclude that the application has a significant effect on the The second hypothesis. The effectiveness of family-
social interactions of children with ASD. ETA showed that centered painting application in the social interactions of
children with ASD remained stable after three months.

Table 2. Results of the four characteristics of the F related to the analysis of the repeated measurements of the test of follow-up - social interactions
(experimental group).
Indicator
Sum of square DF MS F Significance level
Sources of changes
Sphericity assumed 62.600 2 31.300 12.982 0.000
Effect of Greenhouse-Geisser 62.600 1.310 47.773 12.982 0.002
time Hewitt- Flett 62.600 1.444 43.352 12.982 0.002
High band 62.600 1.000 62.600 12.982 0.006
Sphericity assumed 43.400 18 2.411
Greenhouse-Geisser 43.400 11.793 3.680
Error
Hewitt- Flett 43.400 12.996 3.340
High band 43.400 9.000 4.822
As it can be concluded from the above table, the statistical characteristic of F with a value of 12.982 of the time factor at a
significance level of α =0. 05 is significant, i.e. it can be concluded that the change (increase) at the various stages of the test is
significant. Also in table 3, results of different stages of Bonferroni post-hoc test in the test group showed that the means of the
three stages of the pre-test, post-test and follow-up are significantly different. So, the effectiveness of the application in these
children's social interactions after three months has remained stable.
Table 3. Results of Bonferroni follow-up test of the results of analysis of repeated measurements in the test of follow-up- social interactions.
J-I Mean difference (I – J) SD Significance level

Post-test 2.200* 0.512 0.006
Pre-test
Follow-up 3.500* 0.910 0.012
Pre-test -2.200* 0.512 0.006
Post-test
Follow-up 1.300 0.597 0.172
Pre-test -3.500* 0.910 0.012
Follow-up
Post-test -1.300 0.597 0.172
The third hypothesis. The educational application of family-centered painting is effective in the stereotypical behaviors of
children with ASD.
Table 4. Summary of results of ANCOA of the third hypothesis.
Indicator
Sum of squares DF MS F Significance level Coefficients of ETA Power of test
Sources of changes
Effect of pre-test 643.382 1 643.382 84.286 0.000 0.849 1.000
Effect of group 50.441 1 50.441 6.608 0.021 0.306 0.671
Error 114.500 15 7.633
Total 765.000 17
According to the data in Table 4, the value of F = degrees of freedom (1 and 15) in the variables studied at a level of α =0.
05 is significant. Therefore, it can be concluded that the application has a significant effect on the stereotypical behavior of
children with ASD. And the value of the ETA indicates that the effect of the educational application of family-centered
painting on the stereotypical behavior of these children is 30.6%. So, the research hypothesis is confirmed at 95% level of
confidence.
The fourth hypothesis. The effectiveness of the educational application of family-centered painting in the stereotypical
behavior of children with ASD after three months remains stable.
Table 5. Results of the four characteristics of the F related to the analysis of repeated measurements related to the test of follow-up - stereotypical behaviors
(experimental group).
Indicator
Sum of squares DF MS F Significance level
Sources of changes
Sphericity assumed 88.867 2 44.433 31.822 0.000
Effect of Greenhouse-Geisser 88.867 1.743 50.976 31.822 0.000
time Hewitt- Flett 88.867 2.000 44.433 31.822 0.000
High band 88.867 1.000 88.867 31.822 0.000
Sphericity assumed 25.133 18 1.396
Greenhouse- Geisser 25.133 15.690 1.602
Error
Hewitt- Flett 25.133 18.000 1.396
High band 25.133 9.000 2.793
As It can be concluded from the above table, the statistical characteristic of F with a value of 31.822 of the time factor at a
Psychology and Behavioral Sciences 2019; 8(3): 79-84 83
significance level of α =0. 05 is significant, i.e. with 95% probability, it can be concluded that the change (increase) at the
various stages of the test is significant. Also in table 6, results of Bonferroni post-hoc test in different stages in the test group
showed that the means of the three stages of the pre-test, post-test and follow-up are significantly different. So, the
effectiveness of the application in the stereotypical behavior of these children after three months has remained stable.
Table 6. Results of Bonferroni follow-up test of the results of analysis of repeated measurements in the follow-up- stereotypical behaviors test.
J-I Mean difference (I – J) SD Significance level

Post-test 4.100* 0.526 0.000
Pre-test
Follow-up 2.900* 0.433 0.000
Pre-test -4.100* 0.526 0.000
Post-test
Follow-up -1.200 0.611 0.243
Pre-test -2.900* 0.433 0.000
Follow-up
Post-test 1.200 0.611 0.243
the environment. But change and diversity in practices of the

4. Discussion application, especially the practices such as painting with
contrasting colors and step by step drawing of the
According to the data analysis and findings obtained from homunculus helped the children to create a flexible and
the present study, the effect of the educational application of gradual change in their movement, and compromise the
family-centered painting on improvement of the symptoms of changes made. These findings are consistent with the
children with autism spectrum disorder or ASD can be findings of Landgartn (2003), Silvers (2008), Case & Dalley
associated with primarily to the durability of the art's effects (2006), Kamkar Yazdannezhad (2006) and American
in the brain and the cerebral hemispheres. Because repeat of Association of Art Therapy (2009) is consistent coordination.
this application's exercise can strengthen In this study, paintings of educational application of family-
neuropsychologically performance of perceptual, linguistic, centered painting was run in such a way that the main
cognitive, emotional and motor parts of the brain and activate symptoms of ASD. i.e. stereotypical behaviors and social
it. Secondly, these exercises helped the children with autism interactions will be affected. The results and findings of this
spectrum disorder using painting, as long as due to speech study showed that the presence of a sense of flexibility and
and language problems they cannot entirely use the word in aesthetics of art can create diversity and fundamental changes
order to express their feelings and purposes, fill this vacuum and more relation with the environment of the children.
and transfer their feelings and emotions to the opposite side Children with ASD with sensory stimuli such as color and
in order to take a step towards the desired social interaction. shape establish better relationships and to combine these
stimuli with human drivers because parents can fill and
5. Conclusion improve the communicative, social, behavioral and affective
gaps in them. In addition, the active participation of parents
However, the start of teaching drawing to these children as the two important members of the family in the research
empowers their cerebral hemispheres and accelerates the indicated that tools of an art such as painting, can have a
transformation of painting among the children. These constructive effect in the relationship between the children
findings are consistent with the findings of Landgartn (2003), and their family members (parents in the study) facilitate
Silvers (2008), Case & Dalley (2008), Zaidel (2006), Rajabi their social and communication skills with their parents,
and Zadehmohammadi (2011) and the American Association increase sense of psychological security and comfort in them
of Art Therapy (2009). Furthermore, features of being and change and target their stereotypes.
stereotyped, repetitive and pointless in paintings are However, some of the fathers of the children somewhat
completely evident and in fact, one of the main symptoms of had working poor in this study, and the most cooperation was
ASD is the same as being stereotyped behaviors and done by mothers, but, as a final point, it is suggested that the
movements. In fact, one of the main symptoms of autism application of the family-centered painting, alongside other
spectrum disorders so stereotyped behavior and movements. therapeutic and educational approaches and interventions of
But to use practices of the application of family-centered children with ASD, be instructed to parents of these children
paintings, particularly free painting, education of painting and be run as a palliative - supportive approach in
based on the stages of its development, copies of the pictures, environment such as homes, special schools, and
coloring images and painting with contrasting colors in terms rehabilitation clinics in conjunction with these children.
of diversity, and its attractive and flexible and beautiful
structure, and by attracting child's attention, can make a Acknowledgements
gradual change in their routine and stereotyped behaviors and
movements, especially the movements of hands and fingers. The authors would like to acknowledge the assistance of
In fact, one-dimensional, restricted and stereotyped look of staff in Aieen Mehrvarzi School (School for children with
these children limits them in isolation and stereotypes with a autism spectrum disorder), Tehran, Iran.
higher rate, and does not allow them to communicate with
[20] Anderson B. M, Schnetz- Boutaud N, Bartlett J, Wright H. H,

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INTERNATIONAL JOURNAL OF ART THERAPY
https://doi.org/10.1080/17454832.2019.1574845
The effectiveness and contribution of art therapy work with children in 2018
-what progress has been made so far? A systematic review
Liat Cohen-Yatziv and Dafna Regev
The School of Creative Arts Therapies, University of Haifa, Israel
ABSTRACT ARTICLE HISTORY

This systematic literature review is a companion to our review of the effectiveness of art therapy Received 11 August 2018
with adult clients (Regev & Cohen-Yatziv, 2018) and aims to contribute towards the ongoing Accepted 22 January 2019
discussion in the field of art therapy on the effectiveness of art therapy in a wide range of
KEYWORDS
child-aged clients. Art therapy; children;
For this purpose, four major electronic databases were searched for quantitative articles systematic review;
relating to outcome measures in the field of art therapy with children from 2000 to 2017. A effectiveness evaluation;
total of 13 articles responding to the inclusion criteria were identified and divided into three clinical populations
levels of evidence (Case-Smith, 2013). The results are organised into five clinical categories:
trauma, special education and disabilities, non-specific difficulties, medical conditions and
juvenile offenders. The potential benefits of art therapy in these five clinical populations is
discussed and suggest that art therapy can be effective with children of the described
categories.
The limitations of this review and the current state of affairs are presented, alongside
recommendations for future research to promote art therapy effectiveness research.
Plain-language summary
This article brings together all the research studies conducted so far on how helpful art therapy
is for children. We use electronic databases to look at all the research published from 2000 to
2017. We found 13 articles which were relevant and classified under the following 5 headings:
(1) Art therapy with children dealing with traumatic events in their past. Four studies
examining effectiveness have been conducted since 2002. These studies strengthen the
claim that art therapy may help alleviate post-traumatic symptoms in children.
(2) Art therapy with children with special educational needs and disabilities. Four studies on
effectiveness have been conducted since 2001. Most of the studies in this category
suggest that art therapy has a positive effect on children with special educational needs
and disabilities.
(3) Art therapy with children with no specific diagnosed difficulty. Three studies on
effectiveness have been conducted since 2000. All three articles support the claim that
art therapy may help children who are not diagnosed with specific difficulties but are
faced with a variety of challenges in life.
(4) Art therapy with children dealing with medical conditions. Only one study fell into this
category and addressed children coping with persistent asthma. This article lends some
weight to the claim that art therapy may help children dealing with medical conditions,
and specifically persistent asthma.
(5) Art therapy with juvenile offenders. Only one study fell into this category. This article
supports the claim that art therapy may help juvenile offenders.
In comparison to our recent review of research on how well art therapy works with adult clients
(Regev & Cohen-Yatziv, 2018), we found far few studies in relation to children. Thus, we
recommend further research on how well art therapy works with children.
Almost two decades have passed since Reynolds, Nabors, of art therapy. Our first publication on the matter,
and Quinlan (2000) published the first paper on the effec- which reviewed the effectiveness of art therapy with
tiveness of art therapy. In 2010, Slayton, D’Archer and adults, was recently published (Regev & Cohen-Yatziv,
Kaplan published another article in the field covering 2018). This article is one of several reviews specifically
studies conducted in 1999-2007. Both articles concluded related to working with adults (for example Huet,
that although there had been a revival in this field of 2015; Schouten, de Niet, Knipscheer, Kleber, & Hutsche-
research, there was still a long way to go. maekers, 2015; Uttley, Scope, et al., 2015; Uttley, Ste-
Almost 20 years later, we decided to conduct a new venson, Scope, Rawdin, & Sutton, 2015). However,
review, collecting the latest articles on the effectiveness this disproportionate interest in art therapy with
CONTACT Liat Cohen-Yatziv Liatyatziv@gmail.com

© 2019 British Association of Art Therapists
2 L. COHEN-YATZIV AND D. REGEV
adults does not accurately represent the fact that art categorisation, that divides studies into three levels of
therapists treat a much larger proportion of children evidence. Level 1 refers to randomised controlled
(Eaton, Doherty, & Widrick, 2007). The current article trials (RCTs), level 2 refers to nonrandomized two-
thus focuses on the effectiveness of art therapy with group studies, and level 3 refers to nonrandomized
children. one-group studies.
Most reviews that have addressed art therapy in The second challenge has to do with the definition
children have considered children who experienced of art therapy. We applied the standard definition pro-
traumatic events, such as one by Eaton et al. (2007) vided by the British Association of Art Therapists:
that summarises the literature in the field and covers
Art therapy is a form of psychotherapy that uses art
ten case studies and two quantitative studies. They media as its primary mode of expression and com-
discuss the difficulties involved in generalising these munication. Within this context, art is not used as diag-
studies. First, half of the studies had fewer than ten par- nostic tool but as a medium to address emotional
ticipants. Second, many articles did not specify the issues which may be confusing and distressing … .
length of the therapeutic intervention although Although influenced by psychoanalysis, art therapists
have been inspired by theories such as attachment-
therapy did not appear to last for more than a few
based psychotherapy and have developed a broad
weeks. Third, the diagnoses were not always clearly range of client-centered approaches such as psycho-
stated in the articles reviewed. More recently, van educational, mindfulness and mentalization-based
Westrhenen and Fritz (2014) reviewed all research treatments, compassion-focused and cognitive ana-
related to arts therapies on children with traumatic lytic therapies, and socially engaged practice (The
life experiences and reported that 73% utilised visual British Association of Art Therapy [BAAT], 2018).
art therapy. Although their search identified 38 publi- This definition makes it clear that art therapy is a
cations between 2002 and 2012, they noted that it process that takes place in the presence of a certified
was still difficult to generalise the contribution of art art therapist, and indicates different areas where an
therapy to this population because the vast majority effect or outcome in therapy can be expected as a
of these articles involved case studies rather than quan- result of this form of treatment.
titative research. Thus, the research question was formulated accord-
A very recent article published by McDonald and ing to ‘PICOS’ components (Participants, Interventions,
Drey (2018) examined primary-school-based art Comparisons, Outcomes, and Study design) (Moher,
therapy. This article reviewed two controlled (non-ran- Liberati, Tetzlaff, & Altman, 2009): is art therapy
domised) studies and two randomised controlled effective for children as measured in results published
studies (RCT). Three of these were composed of from 2000 to 2017, in various quantitative studies cor-
sample groups of approximately 30 participants (includ- responding to Levels 1, 2, 3 (Case-Smith, 2013)? These
ing the experimental group and the control group). studies assessed the effectiveness of art therapy on
Although the authors concluded that these interven- variety of indices including symptoms, quality of life,
tions appear to positively assist clients, they raised health or mental health assessments. These indices
serious questions about the lack of research in this were typically evaluated through questionnaires and
field, particularly since the demand for child emotional occasionally by projective drawings. By posing this
therapy is high; for example in Israel (Snir et al., 2018), question, this systematic review aims to contribute to
the UK (McDonald & Drey, 2018) and other countries. the ongoing discussion in the field on the degree of
This review, and its companion – our review on the effectiveness of art therapy with children. This forms
effectiveness of art therapy with adult clients (Regev & part of the academization process in the field of art
Cohen-Yatziv, 2018), deals with research measuring the therapy, which involves attempting to relate interven-
effectiveness of art therapy. It addresses two major tion techniques in the field to their significance for
challenges, the first of which is the definition of the theoretical research.
term ‘effectiveness’. Hill, Frappier-Davignon, and Morri-
son (1979) defined effectiveness as ‘the attribute of an
Method
intervention or maneuver that results in more good
than harm to those to whom it is offered’ (p. 1203). Searches were conducted in January 2017 by accessing
This review adheres to the positivist perspective four main electronic databases: Medline, PsycInfo,
(Holton, 1993) to examine the assessment of effective- Scopus and Web of Science. The term ‘art therapy’
ness reported in quantitative studies conducted in the combined with the terms ‘Effectiveness’, ‘Efficacy’,
field. Since the field of art therapy is still relatively new, ‘Outcome’, ‘Measurement’, ‘Treatment’ and ‘Interven-
there are only a small number of studies of differing tion’ was searched. The search was restricted to articles
quality. This makes it hard to generate a comparative published in English from the year 2000 onward, for
review that presents the state of the art in the field reasons of relevancy and recency. We also consulted
and draw exhaustive conclusions. For these reasons, other reviews (such as the ones addressed above) to
this review implements the Case-Smith (2013) locate additional articles applicable to this study.
INTERNATIONAL JOURNAL OF ART THERAPY 3
In the initial screening stage, both authors (who are and literature reviews that did not meet this cri-
certified art therapists) reviewed the abstracts to elimin- terion were rejected. A total of 80 articles were elimi-
ate those that did not meet the research objectives. This nated at this stage.
resulted in 151 articles (see Figure 1). Then, these articles . They assessed the specific impact of art therapy. All
were read completely. Articles were selected for this articles that described a combination of therapeutic
study if they met the following criteria (Figure 1): intervention techniques, or a variety of art modal-
ities simultaneously were eliminated. A total of 14
. They utilised a quantitative measure of the effective- articles were eliminated at this stage.
ness of art therapy on a sample of clients. All case . Art therapy took place in an ongoing manner and in
studies, method descriptions, qualitative analyses, the presence of a qualified art therapist. Articles
Figure 1. flow diagram of the studies identified, excluded and included in the systematic review.
describing artistic intervention techniques that were Chemtob, 2007; Pretorius & Pfeifer, 2010) included
not implemented in a therapeutic context or were control groups and random allocation (Level 1). Two
implemented in a single art therapy session, or of these dealt with children and adolescents, one exclu-
during sessions in which a qualified art therapist sively with children and one exclusively with adoles-
was not present were omitted. A total of 17 articles cents. One article focused on female participants
were eliminated at this stage. alone. The total sample sizes ranged from 13 to 41
clients, all of whom received short-term therapy
All the articles that met the inclusion criteria were lasting eight to 16 sessions in group therapy settings.
defined as articles that examined ‘effectiveness’ and The studies made use of questionnaires that assessed
quantified the impact of art therapy in a measurable the children’s symptoms of trauma. In one study,
way. In total, 37 studies were identified in 40 articles researchers also used a drawing of a human figure. All
(three studies were published in two different articles). these studies strengthen the claim that art therapy
Of these 40, 13 articles related to art therapy with chil- may help alleviate post-traumatic symptoms in children.
dren. This article categorises these 13 articles in terms
of the levels of evidence proposed by Case-Smith
(2013). Category 2: children with special educational
needs and disabilities
The second category consists of children who had
Findings
special educational needs or disabilities (see Table 2).
The findings described in this article emerge from the Four studies on effectiveness have been conducted
13 studies that met the inclusion criteria. The decision since 2001, two of which (Epp, 2008; Pachalska et al.,
to present these studies as a review rather than as a 2001) without a control group (Level 3) and the other
meta-analysis is due to the emergent nature of the two (Freilich & Shechtman, 2010; Regev & Guttmann,
field of art therapy. There is little research in the field, 2005) which included control groups and random allo-
and the differences between studies and the indices cation (Level 1). Two articles focused solely on children
are so great that it would have been impossible to and two other articles on both children and adolescents.
produce a meta-analysis that would yield meaningful The total sample sizes ranged from 14 to 109 clients in
results (a conclusion also reached by Uttley, Scope, different experimental groups. Three studies described
et al., 2015). group therapy and the fourth one individual therapy.
The authors discussed the clinical categorisation of The therapeutic process lasted four to eight months.
each article until full agreement was reached. This cat- Most of the studies in this category suggest that art
egorisation was chosen to enable the reader to access therapy has a positive effect on children with special
knowledge in the field in a way that would allow and educational needs and disabilities. There was a wide
encourage researchers to conduct further research. variety of research instruments used in these studies
The next section presents the findings classified into including the Auditory Dysarthria Scale, and question-
five clinical categories. naires evaluating self-esteem, and behavioural and
Different research methods were used in the 13 social measures. However, one study in this category
articles reviewed: five used a randomised comparison (Regev & Guttmann, 2005) found no effect of art
group (Level 1), two included a comparison group therapy on the sample that was tested; namely, chil-
without randomised allocation (Level 2), and six used dren with learning disorders. This study administered
an intervention group without a comparison group validated questionnaires in which the children
(Level 3). Ten of the 13 articles did not define the reported their emotional state. It is possible that
research population by gender, and the remaining these research indices were not sufficiently sensitive
three studies only included female participants. No to the changes that occurred during the 25-session
studies were found that exclusively addressed male period. Alternatively, it is also possible that it is
participants, among the studies that met this article’s difficult for children to look closely enough at the
inclusion criteria. process they underwent during this period. The
authors concluded: ‘Obviously, there are countless
possible relevant dependent variables, and some may
Category 1: children dealing with traumatic
prove more affected by art activity than others. It is
events
for further research to examine these.’ (p. 310).
The first category consists of art therapy with children
dealing with traumatic events in their past (see Table
Category 3: children with no specific diagnosed
1). Four studies examining effectiveness have been
difficulty
conducted since 2002 of which two (Pifalo, 2002;
Pifalo, 2006) were conducted without a control group The third category consists of children who received art
(Level 3) and two (Lyshak-Stelzer, Singer, Patricia, & therapy but were not diagnosed with any specific
difficulty (see Table 3). Three studies on effectiveness Discussion

have been conducted since 2000, one of which (Saun-
The purpose of this review was to assess whether art
ders & Saunders, 2000) without a control group (Level
therapy is effective in a wide range of child-aged
3), one (Wallace et al., 2014) with a control group
clients, as documented in quantitative studies pub-
(Level 2), and one (Bazargan & Pakdaman, 2016) with
lished from 2000 to 2017. Since the review conducted
a control group and random allocation into groups
by Reynolds et al. (2000), research on adults has
(Level 1). Two studies had a sample of both children
made significant progress and there has been an
and adolescents, and one only examined adolescents.
increase in the number of high quality studies (Level
One article dealt solely with female participants. The
1) and the number of participants in such studies
total sample sizes ranged from 30 to 94 clients in
(Regev & Cohen-Yatziv, 2018). However, there is still a
various experimental groups; some clients received
dearth of studies on children: we only located 13
individual therapy and others group therapy. The
studies conducted since 2000 that have examined
therapeutic process was very short, ranging from
the effectiveness of art therapy with children and met
three to an average of 16 sessions.
this article’s inclusion criteria. Most had small samples
The measurement indices that were selected for
and only five included randomised allocation to an
these studies included a variety of questionnaires
experimental group and a control group (Level 1).
measuring symptoms, psychological and social func-
The advantage of such RCT studies lies in the likelihood
tioning, and aspects of the therapeutic relationship.
of fewer errors than in studies that do not include a
All three articles reinforce the claim that art therapy
control group, or studies that have a control group
may help children who are not diagnosed with
but lack random allocation to groups. The use of ran-
specific difficulties but are faced with a variety of
domisation is the best way to ensure that differences
challenges in life, as reflected in the indices examined.
in outcome measures between the experimental
group and the control group result from the interven-
Category 4: children dealing with medical tion itself and not from other factors, thereby decreas-
conditions ing biases.
Analogous to our conclusion in our review of the
The fourth category consists of children suffering effectiveness of art therapy with adult clients (Regev
from various medical conditions (see Table 4). Only & Cohen-Yatziv, 2018), the shortage of studies that
one study fell into this category (Beebe, Gelfand, & relate to each population and the considerable discre-
Bender, 2010) and addressed children coping with pancies in the duration and nature of the therapeutic
persistent asthma. The study was conducted with ran- process, the proposed interventions and the indices
domised participants in a trial group and a control make it difficult to draw conclusions or create a data-
group (Level 1), and covered seven weeks of group base from which a meaningful meta-analysis could be
art therapy. The study implemented questionnaires carried out. Thus, more research needs to be con-
that dealt with subjects such as quality of life and ducted on art therapy for children to examine and
the emotional state of the participants, as well as evaluate its effectiveness.
the ‘Person Picking an Apple from a Tree’ (PPAT; This raises many questions in that art therapy clearly
Gantt & Tabone, 1998) art-based assessment tool. emerges as pertinent and highly suitable for working
This article lends weight to the claim that art with children; in many countries, children constitute
therapy may help children dealing with medical con- the majority of the clients (Eaton et al., 2007).
ditions, and specifically persistent asthma, as reflected However, the challenge may be associated with the
in the indices examined. difficulty of evaluating children as research participants
since they cannot always complete questionnaires, and
it may also be connected to the onerous ethical con-
Category 5: juvenile offenders
siderations involved in research with children.
The fifth and final category consists of juvenile An important issue the arose is the necessity to
offenders who received art therapy (see Table 5). define the profession, in order to evaluate therapeutic
Only one study fell into this category (Hartz & Thick, interventions. Despite major differences between cul-
2005). It implemented two approaches to art therapy – tures in relation to the status of the art therapy pro-
art psychotherapy and art therapy, but had no control fession and the legislation in the field, in order to
group (Level 3). The research tools included question- maintain standards we need to define, clarify and
naires that assessed self-perception and self-esteem. specify what art therapy is and what it is not; and
This article supports the claim that art therapy may specifically to clarify that this type of therapy must be
help juvenile offenders, as reflected in the indices composed of ongoing sessions and be conducted by
examined. a certified art therapist who meets the criteria
6
L. COHEN-YATZIV AND D. REGEV
Table 1. Children dealing with traumatic events.
Amount and
Author Sample (size and duration of Assessment Outcome
Article (year) groups) Group Description Intervention & Treatment therapy Points measured Results
Pulling Out the Thorns: Pifalo Only intervention Sexually abused children and An approach that integrates art therapy 10-week group Baseline, The Trauma On 3 of the 10 clinical subscales, the
Art Therapy with (2002) group (N = 13). adolescents – 8-10, 11-13, and 14– and group process to target areas of cycle. immediately Symptom Child difference reached sufficient magnitude
Sexually Abused 16 years of age. need when working with child and after. Checklist (TSCC). to yield a statistically significant Fisher t-
Children and adolescent victims of sexual abuse. value. Level 3
Adolescents
Art Therapy with Pifalo Only intervention Sexually abused children and Trauma-focused group treatment using One hour weekly Baseline, The Trauma There was a statistically significant
Sexually Abused (2006) group (N = 41). adolescents – 8-10, 11-13, and 14– the combined modalities of AT and for eight weeks. immediately Symptom Child reduction in symptomatology scores on
Children and 16 years of age. CBT. after. Checklist (TSCC). nine of the ten clinical subscales (Anxiety,
Adolescents: Depression, Anger, Posttraumatic Stress,
Extended Research Dissociation, Dissociation-Overt, Sexual
Study Concerns, Sexual Preoccupation, and
Sexual Distress) in the direction of
reduced pathology. Level 3
Art Therapy for Lyshak- N = 29 Adolescents with Posttraumatic Stress Groups consisted of 2–5 participants. One hour group Baseline, The UCLA PTSD There was a significant effect of treatment
Adolescents with Stelzer Randomly assigned Disorder Symptoms. Inclusion sessions over 16 immediately Reaction Index over time for both groups across
Posttraumatic Stress et al. to A trauma-focused criteria: Ages 13-18, were able to weeks. after. for DSM-IV, Child treatment conditions. There was a
Disorder Symptoms: (2007) expressive art sustain a school programme for 2 Version. significant treatment by condition
A Pilot Study therapy protocol (TF- weeks running, and were expected interaction showing that TF-ART was
ART) (n = 14) to stay at the hospital for at least 16 significantly more effective in reducing
A treatment-as-usual weeks. trauma symptoms from pre-treatment to
(TAU) (n = 15). post-treatment.
Level 1
Group art therapy with (Pretorius & N = 25 Sexually abused girls aged 8–11 years. A group art therapy intervention The programme Baseline, The Trauma The results indicated that the experimental
sexually abused girls Pfeifer, The Solomon four- designed by the authors aimed at consisted of immediately Symptom groups improved significantly compared
2010) group design was reducing depression, anxiety, sexual four themes after. Checklist for to the control groups with regard to
used to investigate trauma and low self-esteem. The with eight Children (TSCC), anxiety and depression.
the efficacy of the programme was based on existential- sessions. The Human Level 1
intervention. humanistic, Gestalt, client-centered Figure Drawing
and abuse focused principles. (HFD).
Table 2. Children with special educational needs and disabilities.
Intervention & Amount and
Article Author (year) Sample (size and groups) Group Description Treatment duration of therapy Assessment Points Outcome measured Results
The impact of art Pachalska et al. Only intervention group Children with Art therapy with 4-month art therapy Baseline, immediately The Auditory Dysarthria On the Auditory Dysarthria
therapy on the (2001) (N = 14 children – 9 cerebral palsy (CP). elements of programme. after. Scale. Scale, the largest
intelligibility of boys and 5 girls) Average age 15.3, logopedic improvements were noted
speech in children who showed therapy. in overall intelligibility; less
with cerebral severe dysarthria improvement, though still
palsy. at admission statistically significant took
without other place with respect to
language or volume, tempo, and
cognitive control of pauses. The least
disturbances. improvement was noted in
the pronunciation of
vowels and consonants
(the most purely motor of
the measured parameters).
All the children also
exhibited significant
improvement in fluency of
speech.
Level 3
The psychological (Regev & N = 109 Primary-school Groups – as The intervention Baseline, immediately CSCS – The Piers – Harris Children in the art-therapy
benefits of Guttmann, Randomly assigned to children with described. programme after. Children’s Self-Concept group did not score better
artwork: The case 2005) Experimental (art) learning disorders. included 25 weekly Scale, IARQ – The than those in any other
of children with group (n = 25) Control encounters, each Intellectual Achievement group on any of the
learning disorders group A (games group) of 45 min. Responsibility dependent variables.
(n = 25) Control group Questionnaire, CS – The Level 1
B (art therapy group) (n Children’s Sense of
= 29) Control group C Coherence Scale, LSDQ –
(no intervention group) The Loneliness and Social
(n = 25) Dissatisfaction
Questionnaire.

Outcome-Based (Epp, 2008) Only intervention group – Children ages 6–12 Group of One-hour group Baseline, immediately The Social Skills Rating Scores revealed a significant
evaluation of a (N = 66) with ASD. approximately six therapy sessions after. System (SSRS) – was improvement in assertion
Social Skills children of similar held once a week – constructed to screen and scores, coupled with
Programme using age and social October till Mai. classify children suspected decreased internalising
Art Therapy and communication of having social behaviour behaviours, hyperactivity
Group Therapy for ability. problems. scores, and problem
children on the behaviour scores in the
autism spectrum students. Level 3
(Continued )
7
8
Table 2. Continued.
Intervention & Amount and
Article Author (year) Sample (size and groups) Group Description Treatment duration of therapy Assessment Points Outcome measured Results
The contribution of (Freilich & N = 93 Randomly Children aged 7–15 Individual art Children in the art Outcome measures – Outcome measures – Child Results indicated more
art therapy to the Shechtman, assigned to with learning therapy with therapy group Baseline, Behaviour Checklist (CBCL), favourable outcomes in
social, emotional, 2010) Experimental group (n disabilities experienced art (experimental) immediately after, The Teacher Evaluation adjustment under art
and academic = 42). Control group (n therapists. received 2 h of and follow-up (3 Form (TRF), Scores on therapy conditions and
adjustment of = 51). academic months later). academic achievement. similar progress in
children with assistance and 1 h Process measures – Process measures – academic achievement
learning of art therapy per five times over the Working Alliance Inventory, under either condition.
disabilities week. course of the The Session Evaluation Although children in the
Children in the intervention. Critical Questionnaire. The Critical control group scored
academic incidents – following Incident (after each session) higher on the process
assistance group each session. variables (bonding and
(control) received impression of therapy),
3 h of teaching per bonding was associated
week; for 22 weeks with outcomes only in the
therapy condition.
A session-by-session
evaluation revealed that
the two interventions were
very different: the
academic intervention
focused on improved
learning experiences,
whereas the art therapy
intervention focused on
emotional exploration and
awareness-insight
development. Level 1
Table 3 . Children with no specific diagnosed difficulty.
Amount and
Sample (size and duration of
Article Author (year) groups) Group Description Intervention & Treatment therapy Assessment Points Outcome measured Results
Evaluating the Saunders N = 94 Children between Art therapy programme An average of Baseline, Each client was rated on 24 Symptomatic Behaviour – the
effectiveness of art and Only intervention the ages of 2 and which operates in a large 16.8 sessions. immediately behaviours typically change in scores, suggesting a
therapy through Saunders group. 16 multi-programme, The range of after. identified as symptomatic of decline in frequency, was
quantitative, (2000) private, nonprofit human the number of individual and family statistically significant.
outcomes-focused service agency in Des sessions was dysfunction. The therapist Therapeutic Relationship – This
study. Moines, Iowa quite large (2– rated each positive change in scores from
96). client on seven indicators of Intake to exit was statistically
a positive therapeutic significant for each item.
relationship. Level 3
Psychosocial Changes Wallace et al. N = 30 Children (ages 6–18 Individual art therapy with 3 sessions – 90– Three times – 1 Participant Demographics Results showed improvements in
Associated with (2014) Intervention group years) – Siblings of experienced art 120 min each week after the (parent), Medical sibling psychosocial
Participation in Art (n = 20) Pediatric therapists, working in a HSCT procedure, Characteristics (parent), functioning associated with
Therapy Interventions Control group (n = Hematopoietic pediatric hospital setting 1 month post- Revised Children’s Manifest participation in the art therapy
for Siblings of Pediatric 10) Stem Cell HSCT, 3 months Anxiety Scale (RCMAS), interventions. Compared to a
Hematopoietic Stem Transplant Patients post-HSCT Piers-Harris Children’s Self- control group, the intervention
Cell Transplant Concept Scale, UCLA PTSD group showed lower levels of
Patients Index for DSM-IV, McMaster posttraumatic stress symptoms
Family Assessment Device. at the final session.
There was no intervention
versus control group difference
for self-concept, anxiety, family
functioning, or parent-
reported PTSS.
Level 2
The Effectiveness of Art (Bazargan & N = 60 Female adolescent Experimental groups Six sessions, 1.5 Baseline, The history of artistic interest Data were analysed using mixed

Therapy in Reducing Pakdaman, 30 students with students (14-18 participated in painting h each. immediately and activities scale, ANOVA. The results showed
Internalising and 2016) internalising years old) of one of sessions designed based after. Achenbach System of that Art Therapy significantly
Externalising Problems problems – art schools in on Art therapy theories Empirically Based reduced internalising
of Female Adolescents randomly assigned district 3 of Tehran. and previous studies Assessment (ASEBA), problems; however, its effect in
to experimental and (specific topic for each Intervention package of Art reducing externalising
control groups. session).15 min – therapy problems was not significant.
Similarly, 30 explanation, 45 min – Level 1
students with drawing, 15 min –
externalizing reflecting.
problems –
randomly assigned
to experimental and
control groups.
9
Table 4. Children dealing with medical conditions.
10
Article Author Sample (size and Group Description Intervention & Treatment Amount and Assessment Outcome measured Results
(year) groups) duration of Points
therapy

A randomised trial to (Beebe N = 22 Children 7–14 Group art therapy included 60-minute art Baseline, The Pediatric Quality of Life Immediately after art therapy there was a
test the et al., Randomly assigned years old. specific art therapy tasks therapy immediately (PedsQL) – Asthma Module reduction in parent-reported and child-
effectiveness of art 2010) to Intervention Diagnosis of designed to encourage sessions after, and 6 (child and parent report), The reported worry scores from the PedsQL
therapy for group (n = 11) persistent expression, discussion, and once a week months after Beck Youth Inventories – questionnaires, a reduction in the
children with Control group (n = asthma requiring problem-solving in response for 7 weeks. the final art Second Edition, The Draw a anxiety score and an increase in the self-
asthma 11) daily treatment to the emotional burden of therapy. Person Picking an Apple from a concept score from the child-reported
chronic illness. Tree evaluation – (FEATS). Beck Inventories, and improvements in
the colour, logic, and details scores from
the FEATS in the intervention group
compared with the control group.
Six months after completion of the
therapy there was improved parent-
reported and child-reported worry and
total scores from the PedsQL
questionnaires, a lower anxiety score
from the Beck Inventories, and higher
colour and detail scores from the FEATS
persisted remained in the intervention
group.
Level 1
Table 5. Juvenile offenders.

Article Author Sample (size and Group Intervention & Amount and Assessment Outcome measured Results
(year) groups) Description Treatment duration of Points
therapy
Art Therapy Strategies to (Hartz & N = 27 Female Juvenile Six core groups were Ten 1-1/2-hour Baseline, The Self-Perception Profile for The art psychotherapy group showed a
Raise Self-Esteem in Female Thick, Only intervention Offenders randomly divided so art therapy immediately Adolescents (SPPA) + The significant increase in the domains of
Juvenile Offenders: A 2005) groups (12 art ranging from that half of them sessions were after. Hartz Art Therapy Self- close friendship and behavioural conduct
Comparison of Art psychotherapy 13 to 18 received one type of conducted Esteem Questionnaire (Hartz whereas the art as therapy group did so in
Psychotherapy 15 art as therapy). years old. art therapy and half with each AT-SEQ). the domain of social acceptance.
and Art as Therapy received the other. group during a Level 3
Approaches 12-week
period.
defined for the profession (BAAT, 2018). This process that art therapy interventions had a beneficial effect
could reduce the large number of articles conducted on this population, as shown by the indices measured.
in the field by uncertified art therapists or in a single It is surprising that there are so few quantitative studies
therapeutic session, as found in this review and pre- in the field. By comparison, in our review on the effec-
viously documented on its companion on the effective- tiveness of art therapy with adult clients (Regev &
ness of art therapy with adult clients (Regev & Cohen- Cohen-Yatziv, 2018), six works (published in seven
Yatziv, 2018). different articles) were found on clients who have
The first category presented here covered art cancer (Bar-Sela, Atid, Danos, Gabay, & Epelbaum,
therapy for children dealing with traumatic events. 2007; Monti et al., 2006; Monti et al., 2012; Öster
There is a growing body of research indicating that et al., 2006; Öster, Magnusson, Thyme, Lindh, &
art therapy can benefit these children, and that art Åström, 2007; Svensk et al., 2009; Thyme et al., 2009)
therapists play a significant role in helping them cope and three others on clients coping with a variety of
with a variety of traumatic experiences and can con- other medical conditions (Feldman, Betts, & Blausey,
tribute to improving their quality of life and their 2014; Sela et al., 2011; Sudres et al., 2013). Since the
ability to cope with a variety of emotional issues. Our field of art therapy with clients dealing with various
review complements previous ones (Eaton et al., medical conditions is of vital significance and research
2007; van Westrhenen & Fritz, 2014) which have conducted with adults clearly points to its contribution
shown that art therapy with children dealing with trau- (Regev & Cohen-Yatziv, 2018), it is important to con-
matic events is one of the most frequently studied tinue developing research in this field.
topics in this field. The fifth and final category covered art therapy with
The second category covered art therapy with chil- juvenile offenders. Only one study was found and indi-
dren with special educational needs and disabilities. cated that art therapy interventions had a beneficial
In some countries, children with special needs are effect for this population, as expressed in the indices
legally entitled to art therapy within the education measured. This result extends the important work of
system (Snir et al., 2018). The findings in most of David Gussak who has investigated the effectiveness
these studies indicate an improvement in a variety of of art therapy with adult prison inmates (Gussak,
measures resulting from art therapy interventions. 2004, 2006, 2009a, 2009b) and reported its beneficial
However, the differences between participants and effects. Nevertheless, conclusions concerning this cat-
assessment tools make it difficult to summarise and egory should be treated carefully since it is based on
generalise the findings. a single level 3 study.
The third category covered art therapy with children
with no specific diagnosis. The decision to examine
Conclusion
clients in the general population reflects the unique
nature of art therapy and its suitability for individuals This review is a companion to our review of the effec-
who are dealing with a wide range of difficulties, or tiveness of art therapy with adult clients (Regev &
as mentioned in the definition of the profession by Cohen-Yatziv, 2018) and documents research con-
the British Association of Art Therapists: ‘Art therapists ducted in recent years. Similar to the conclusions
work with children, young people, adults and the drawn in earlier reviews (for example McDonald &
elderly. Clients may have a wide range of difficulties, Drey, 2018), we only found a small number of quanti-
disabilities or diagnoses. These include emotional, tative studies that relate to the effectiveness of art
behavioural or mental health problems, learning or therapy with children, despite the growing need for
physical disabilities, life-limiting conditions, neurologi- this type of therapy. This review did not include quali-
cal conditions and physical illnesses.’ (BAAT, 2018). In tative studies, which are very common and acceptable
the reality of everyday life, there are many frameworks in this field. Applying diverse approaches and a variety
in which therapy is offered to a wide variety of children of research methods as a dependent measure of the
who are coping with an array of different difficulties research purpose and question, can help expand
and who remain undiagnosed. However, the vast knowledge and understanding in this interdisciplinary
differences between such clients make it difficult to field (Kapitan, 2017).
find relevant indicators for evaluation, and as such The current review has several limitations. First,
there are considerable variations in the indices similar to other reviews in the field (for example:
between studies. Regev & Cohen-Yatziv, 2018), due to the small
The fourth category covered art therapy clients number of studies, various levels of quantitative
dealing with various medical conditions. It was striking studies were included. This variability makes it
that there was only one study on effectiveness, dealing difficult to generalise across findings, but not mention-
with children coping with persistent asthma, ing these studies would have led to a total sample of an
suggesting that conclusions relating to this category even smaller number of studies. Second, in many
should be made with caution. The findings indicated studies several indices of varying types (questionnaires,
drawings) were used and on some occasions only some Disclosure statement
of these indices led to demonstrable indications of the
No potential conflict of interest was reported by the authors.
effectiveness of art therapy. This complex picture of the
findings, which is well reflected in the tables, only auth-
orises partial conclusions at this stage. Further research Notes on contributors
in the field should make it possible to examine changes Liat Cohen-Yatziv, The School of Creative Arts Therapies, Uni-
in similar research indices and draw more far-reaching versity of Haifa, Israel
conclusions. In so doing, future researchers should Dafna Regev, The School of Creative Arts Therapies and the
examine these specific studies closely before conduct- Emili Sagol Creative Arts Therapies Research Center, Univer-
ing further research on the same types of populations. sity of Haifa, Israel
In addition, due to the small number of studies in this
field, we needed to combine various subjects in
ORCID
certain cases, make decisions and create artificial cat-
egories based on our professional knowledge and Dafna Regev http://orcid.org/0000-0001-8192-6152
judgment. Future reviews, including a broader scope
of research, could employ a different, possibly more References
specific, categorisation.
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2020
Extended Abstract Journal of Psychiatry Research and Treatment
Vol.2 No.1
A Landscape of Art Therapy and Psychodrama in Children and Adults with Autism
Spectrum Disorders in Iran
1
Kaveh Moghaddam, 2Aida Ravarian , 3Farhoud Saeid Ershadi , 4Ali Gorji , 5Saleh Mirzaaghaei and 6Theresa
Van lith
1
Exceptional Children Psychology, Tehran, Iran
2
University of Social welfare and Rehabilitation Sciences, Tehran, Iran
3
Assistant Professor of University of Social welfare and Rehabilitation Sciences, Tehran, Iran
4
Khatam Alanbia Hospital, Tehran, Iran
5
Artist and Actor, Tehran, Iran
6
Department of Art Education, Florida State University, USA
Autism spectrum disorder (ASD) is one of the severest psychological this disorder, but also any exact interventions have not been explored
disorders in children and adolescents in which symptoms such as yet. Therefore, the above- mentioned interventions and modalities
stereotypical behaviors, impairments of social skills and dysfunction just can help to improve these symptoms not treatment (Samadi 2011,
of verbal skills can affect all of their life aspects. Also, they suffer from Autism Association, 2015; Moghaddam, 2016).
sensory dysfunction. This disorder has a high incidence around the
world and it is seen in Iran as well. For improvement of these problems, Nowadays, because of the validity and reliability of the diagnostic
a lot of interventions such as Applied Behavioral Analysis (ABA), Picture criteria and scales, the incidence of ASD is high (1 in 66 newborn infants)
Exchange Communication System (PECS), Treatment and Education of in the United States of America. Also, it is high in Iran (only 4000 children
Autistic and related Communication Handicapped Children (TEACCH), in Tehran) and 10 in 10000 for boys and 2/4 in 10000 for girls (Social
Family Therapy and etc. are applied, but recently, studies show that Welfare organization, 2017; Samadi et al., 2011; Moghaddam, 2016).
the application of supportive interventions via beautiful arts such as Art Therapy as a new approach
drawing and painting, music, clay work, and theatre can lead to better
results in the improvement of these symptoms. Art therapy techniques, According to the American Art Therapy Association, "Art therapy employs
especially painting, fine arts such as drawing and theatre are performed the creative process of art-making to perfect the physical, mental, and
in an environment in which all sensory stimuli like light, sound, and emotional well-being among people of all ages, so that the process
color can be observed and according to art therapy researches and helps people to resolve their conflicts and problems; it also causes to
studies these sensory stimuli can lead to better sensory integration in develop interpersonal skills, manage behavior, reduce stress, increase
these children. Also, they can have better eye-contact, motivation, self- self-esteem, and self-awareness, and achieve insight "(American Art
esteem. and interpersonal interaction and verbal skills via role-playing Therapy Association, 2018).
at the scene. Therefore, this article discusses a landscape of art therapy
and psychodrama on the improvement of symptoms of children and No single way exists to present art therapy; consequently, it can appear
adults with autism spectrum disorder in Iran. especially distinctive when performed using and alongside various
persons. Art therapy can be a steady stream or organized, unrestricted
Introduction: Children and adolescents with autism spectrum disorder or goal-directed and can be an amazing approach to create opportunities
(ASD) are a group of children with special needs who suffer from for self-expression and engagement for children and adults with autism
symptoms such as stereotyped behaviors and interests, impairments in (American Art Therapy Association, 2016).
social interactions and poor and strange verbal skills. These problems
have negative effects on their family lifestyles and sometimes these The reasons for using art therapy for treatment of ASD?
symptoms and problems can lead to secondary psychological problems A sign of ASD is a problem with verbal and social language. Occasionally,
and issues in their family, especially their parents (Moghaddam, 2016; individuals with ASD are exactly nonverbal and incapable to utilize
Moghaddam & Sarabi, 2016; Samadi, 2011). spoken language to converse at all. On other occasions, individuals
Unfortunately, besides a lot of scientific researches and studies, the with ASD have a challenging time that processes language and turns it
main reasons and etiology of this disorder have not been known yet, but into a soft, easy dialogue. Individuals with ASD may also have a difficult
according to the research findings and results, it is shown that a complex time reading facial expressions and body language. So, they may have a
of genetic, biological, environmental and psychological factors can lead problem of joke-telling from a statement or sarcasm from sincerity.
to the emergence of this neuropsychological disorder (American Autism In the meantime, numerous individuals with ASD have an unusual
Association, 2014 & 2016). capacity to visualize "in pictures." Lots of people can convert that capacity
Recently, all of the symptoms of ASD were classified into two groups to appropriate usage in handling memories, recording images and visual
as social interaction and communication skills and also, stereotypical information, and stating ideas via drawing or other artistic media. Art is
interests and behaviors in the Diagnostic and Statistical Manual of considered as an appearance of expression necessitating little or body
Mental Disorders, Fifth Edition (DSM-V). Although, in the previous DSM language that can create an opportunity for communication.
(III and IV) these symptoms just have been classified into three groups Regularly, a nonverbal autism individual or an individual with limited
(DSM V, 2013 translated by Ganji, 2014). language ability is supposed to be incapable of other subjects. So,
Besides etiology, all of the psychological, psychiatrical and rehabilitational individuals with ASD cannot be exposed to chances to use artistic media,
practitioners have been studied for the best interventions and or the chances can be excessively exciting in additional methods (in large
therapeutic modalities since 1980. Not only Applied Behavioral Analysis classrooms, for example). Art therapy allows therapists to work alone
(ABA), Picture Exchange Communication System (PECS), Treatment and with people with autism spectrum to design a wide range of skills in a
Education of Autistic and related Communication Handicapped Children sense that can be more convenient, and therefore more efficient than
(TEACCH), family therapy, sensory integration, and massage therapy have spoken language (Jo Rudy, 2018).
been known as the best and most effective therapeutic interventions in
2nd World Congress on Mental Health, February 01-02, 2021 | Paris, France
2020
Vol.2 No.1
Among the therapeutic interventions mentioned above, practitioners

have found that some of the palliative interventions such as art
Advantages of Art Therapy for Pupils with ASD therapy, including visual arts, music, and drama have the potential for
If you are a teacher in a teaching space, you may wonder if you have the improvement and treatment (CATA, 2011; Case and Dally, 2008; Dally,
artistic capability to use art therapy in this teaching space. Do not worry! 2005; Moghaddam et al., 2016).
If you have pupils with ASD, you do not need artistic skill and capability They have found that flexibility and sensibility of the art elements can
to use strategies of art therapy with them. lead to better sensory integration in the children with ASD because
Consider using art therapy to help your pupils: the most of their problems are due to sensory defensiveness and
dysfunction (Moghaddam et al., 2016; Zadeh Mohammadi, 2013; Case
• Investigate and comprehend their feelings and Daley, 2008; Hajloo, 2017). The combination of artistic elements
such as paintings, music, clay works, drawings, and drama or applying
• Be in contact with their feelings, needs and wants all of them separately can help these children to be improved, and
• Improve their self-awareness and confidence art therapists have studied about these benefits since 1990 (Case
& Daley,2008; Case & Daley, 2005; Daley, 2000; Moghaddam, 2016;
• Reduce their behavioral problems Moghaddam et al., 2016; American Art Therapy Association, 2012). In art
therapy, these children can be observed as persons with a lot of abilities
• Improve their social skills and not only art therapy techniques can help them to improve their
A lot of pupils with ASD have sensory problems, this means that they impairments, but also they can help these children to reinforce their
are sensitive to certain sights, sounds, textures, and so on. In contrast, abilities and potentials. According to studies, art therapy can change
some students with ASD are sensory seeking, implying they are looking people’s viewpoints about children with ASD. Therefore, applying art
for specific things to stimulate their senses that can occasionally cause therapy techniques has been used in Iran since 2004 (Moghaddam and
them to act impulsively. It is important to know about any sensory issues Zadeh Mohammadi, 2016; Zadeh Mohammadi, 2012).
your students have when you select art strategies. You do not want Painting and Drawing as Therapeutic Art in Children with ASD
the student to either turn off or fix upon a certain medium and not the
strategic aim. Painting is a mental association that teenagers, adults and especially
children, can interact with others. For this reason, we can understand the
If you want the student to really engage in art therapy, it is best to start child's mood, desires, and personality using their paintings and of course,
with non-messy projects that are short in duration. You might have to this orientation is effective in their educational guidance because, by
just start by introducing materials while keeping the students’ sensory painting, children experience the discipline in thought and psychomotor
issues and preference in mind. Let the students touch the materials and skills in the hands (Kamkar Yazdannezhad, 2006; Oliverio Ferraris, 1996).
get used to them; then come back later and start the project. A child's painting is a message and moves us what he or she cannot
Art therapy helps clients to access their feelings. On the contrary, art verbalize, and to review and understand the "language" of painting,
classes are planned to provide students with instruction on how to offers useful information for the parents, educators, psychologists and
achieve specific artistic effects or goals. Despite the fact art classes can all those who want to understand and get the mysteries of the child's
be applied for persons with autism, they are not an alternative to art world. A child experiences all his or her issues by painting, and tests
therapy. himself or herself, as well as builds his or her ego. Drawing lines are a
reflection of his or her emotional world, and painting is solely a world that
The study is rather sketchy about the art therapy effect in individuals is transforming parallel to increase the alertness and the transformation
with autism. The literature contains mostly of case studies and papers of the child. Painting is very important in the formation of character and
expressing the observed effect of art therapy programs. Yet, some of mind of the child, not only to enable the child to identify environment
the papers on the subject indicate that art therapy can do very much. and his or her company in it as well as raising questions for him or her,
Occasionally, it has opened up a whole world of the chance to a person but also allows he or she formulates issues that are irregularly raised
with autism who has significant artistic talent. from all sides for him or her. In the drawings, like dreams and visions,
the child will release himself or herself from the ban and speaks us in the
On other occasions, it has generated an exceptional chance for personal subconscious state of his or her issues, discoveries and apprehensions.
bonding. Further probable results contain: Therefore, it must be said that children painting is not merely fostering
creativity and sophistication of the child and or an index of evolution,
• enhanced capability to imagine and think symbolically
and it should be considered as a medium of research and exchange
• enhanced capability to recognize and respond to facial expressions with the social environment - with the world of adults who are around
the child- and as a sign of the child's emotional states (Dadsetan, 2011;
• enhanced capacity to manage sensory issues (problems with Oliverio Ferraris,1996). In addition, painting is considered as a means to
stickiness, and so on ) measure intelligence, spatial perception, and the projection of feelings,
emotions, and personality of the child; furthermore, all studies in the
• enhanced fine motor skills (Moghaddam, 2015).
field of paintings of children show the importance of this art's role in the
Art Therapy as a Palliative Intervention for ASD cohesion and the formation of the child's character; in addition, painting
adjusts and improves their information exchange and communication
According to studies and researches, the therapeutic intervention with the environment, and also highly help children for intellectual
objectives for ASD are as followings: improving the verbal skills, development and learning, and in general, all people use paintings to
increasing communication with the environment, decreasing the convey their thoughts and fantasies or feelings and perceptions to the
stereotypical behaviors and interests, reinforcing the relationship others (Ozonoff, 2008; Association AAT, 2009; Case and Dalley, 2008).
between the child and his or her parents and family, and improving
the eye-contact. Furthermore, there are therapeutic goals such as There is another important point that visual painting as an art in which
the facilitation of social interaction and sensory integration, better the aesthetic element is completely evident, can cause discharge and
adaptation to the environment and better neuropsychological function release children's feelings, emotions and sentiments by affecting
and learning (American Autism Association, 2016; Amiri Majd, 2013; the limbic system of the brain; furthermore, based on other studies
Rafeii, 2010). in the art neuropsychology field, elements such as colors, shapes,
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sizes and penumbra that are seen in painting, are interpreted and In educational application of family-centered painting techniques,
processed as visual data and information in the occipital lobe of the derived from some studies and clinical trials conducted by Case and
right hemisphere, where is place of interpretation, processing and Dalley (2008), Silvers (2008), Zadeh Mohammadi and Rajabi (2011),
finally the perception of visual data; then, by the activation of the brain Landgartn (2003), Martin (2009), Moghaddam et al. (2015) and kamkar
lobe, it causes improvement of the visual perception skills such as eye- Yazdannezhad (2006), a combination of a variety of painting ways was
hand coordination, understanding spatial relationships, visual memory, used. These combination of a variety of painting ways included free
understanding the shape stability and visual accuracy in children, and painting, painting based on the evolution of painting, copying the shapes
therefore increases their learning and perception (Landgartn, 2003). of the patterns and images, coloring pictures and shapes, painting of
family, drawing of the homunculus and painting with contrasting colors
In the paintings of children with ASD, who suffer difficulties in social (green, red, yellow and purple, blue and orange, black and white, red
interaction, verbal communication, and stereotypical behaviors, when and black, pink and gray); in addition, tools for painting and drawing
a human image is displayed, it always is small in size, and details of the have also been diverse and included colored pencils, crayons, gouache
face and extremities are rarely shown. For example, if dummies drawn and finger paint. Additionally, the two sets of main symptoms consistent
by a child, have the eye, the eye is thoughtful with a look at remote or with the DSM V (2013), i.e., stereotypical behaviors and the qualitative
completely devoid of a look. If the child has high performance and or defects in social interactions, which are the main symptoms of children
wholly he or she can paint, while drawing several dummies, he or she with ASD, have been considered in this application. All of these
paints all of them uniformly and the same. Sometimes also, aggression techniques have been applied at family and art therapy research center
is seen in their paintings (Ganji, 2013; Poorheidar, 2011). Usually due to at Shahid Beheshti University in Tehran, Iran since 2011.
touch defensive in the limbs, especially hands and fingers, children with
ASD cannot look colored pencils, pens, crayons, and other drawing and Psychodrama (Theatre Therapy)
painting in the hands for a long time that is why parents and teachers
are complaining of poor handwriting, lack of attention to drawing and Besides art therapy studies, researches and practitioners have studied
lack of focus on writing and drawing for a long time. Hence, most of this issue that can theatre (drama) be applied to children with ASD
these children do not have much interest in drawing, and painting and or not? At first, for answers to this question, we have to review the
their paintings are frequently uniform. Also, in some cases, they appear psychodrama history. Drama (theatre) has been applied for improving
garbled and scrawl, and it seems that they have been fixed in the medical and psychological disorders by Jacob Moreno and others since
early stages of the evolution of painting, i.e., scrawl. Free painting is a 1930. According to the scientific studies, the dramatic language, which is
stereotype among them, and always they paint only a picture. applied for some of the psychological interventions is “Play of Gestalt”.
In gestalt, the drama is applied for the investigation of “Ego” in “Here”
These children, unlike normal children, cannot reflect their feelings, and “Now”. Other psychologists believe that some of the psychological
emotions, fears, happiness and generally, emotions in their paintings. interventions such as psychoanalysis are dramatic, too. Therefore, they
For example, normal children can describe the events that had happened can show the main aspects of psychoanalysis or psychotherapy at a
to them and can project their feelings and emotions towards a friend, dramatic framework (Jones, 1996, Translated by Yasrebi, 2005; Akbari,
parent, or peers in his paintings. While children with the ASD, such as 2008; Moghaddam and Sarabi, 2016).
children with mental retardation, due to the lack of sufficient attention
and focus, and relatively low learning and IQ, are not able to portray According to the psychological researches and studies, psychodrama
the issues surrounding themselves and fail projection in their paintings or theatre therapy is a scientific approach in which the psychotherapist
and feel powerless for drawing what is in their immediate environment. applies the different drama methods such as the scenic, dolly and
A variety of colors and shape in most of their paintings are low, and nonverbal drama (theatre) for helping the improvement of cognitive,
symbols, objects, and images in their paintings are stereotypical and emotional, verbal, perceptual, behavioral and emotional problems
uniform (Chitgarzadeh, 2010). Furthermore, art therapy studies show in the clients. Indeed, theatre or drama is an effective method in
that these children pay more attention to sensory stimuli, such as color the rehabilitation of clients who suffer from cognitive, perceptual,
and shape that are the main elements, rather than human stimuli, in the behavioral, emotional and other psychological disorders, because the
painting; moreover, clinical studies and research in the field of education best situation which is the creation of scenes will be happening and the
of painting and art therapy among the children show that by painting client can express himself or herself in theatre. (Amraei, 2010; Kianian;
we can reduce somewhat the stereotypical behaviors and movements in 2011; Moghaddam, 2016; Case and Dalley, 2008). Role-playing is one of
this group of children and improve interpersonal communication among the drama techniques in which clients can show themselves inside and
them; in fact, in some ways these children, however with a limited express the characters which is like or opposite of them. Therefore, not
manner, express their thoughts and feelings through painting (Wall, only this technique can help the expression of “ego” but also can lead
2004, 2006; Ahmadi, 2011). to better self-esteem and motivation. Also, confrontation techniques
can be applied because their goals and objectives are like role-playing
In fact, fundamental problems in drawing and painting of children with techniques (same resources).
ASD that create particular problems in the educational environment for
them and along their main symptoms, i.e., the deficiency in interpersonal Psychodrama in ASD
communication, poor verbal skills, and stereotypical behaviors cause As noted above psychodrama can be applied for some clients with
the family, especially the parents of the children face many challenges psychological disorders. According to studies, this approach can be
and the various aspects of life are overshadowed (Samadi, 2011). To applied for ASD, too (American Autism Association, 2014; Moghaddam
alleviate such specific problems that there are in families of the children, and Sarabi, 2016).
extensive studies have been conducted. Many of these studies were
aiming for applying the so-called family-centered interventions and The best benefits and outcomes of psychodrama in ASD are as the
approaches that by using them and by involving the parent in these followings: increase of motivation, improvement of self-esteem, social
programs actively and dynamically, we can reduce not only problems interaction, verbal skills, the perception of the environment, attention
of these children, but also create greater interaction between family and concentration, objective movements, release of tensions and self-
members, especially their parents in order to more satisfaction with life expression.
in the existing conditions for them and preserve the mental health of the
family and art therapy and painting techniques are applied, too (Samadi, Application of role-playing and confrontation techniques along with the
2011; Waters, 2012). scene, light, decoration, effect, and attendance of people can cause a
better social interaction and verbal skills in children and adults with ASD.
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Vol.2 No.1
Also, sensory integration, which is necessary for their improvement, will

happen.
Clients with ASD can communicate with objects better than persons and
this can lead to better attention and concentration in the environment. A
psychotherapist and director can use this characteristic for the invitation
of clients with ASD in peer groups at the scene. At first around the
decoration, they have applied warm-up techniques which involve music
and motion.
Sometimes they can repeat poems via simple role-playings. Also, they
can benefit from pantomime (especially the clients with ASD who have
severe verbal problems). Confrontation techniques can be applied by
the attendance of two clients with ASD and the psychotherapist.
Attendance of psychotherapist can help the management of the
scene and the director. After improvement of clients with ASD in the
psychodrama techniques some short theatres can be performed by
them.
Psychodrama in ASD is as a new therapeutic approach in Iran since 2015
and some little artistic groups and associations can apply it (Moghaddam,
2016, Moghaddam & Sarabi, 2016). Recently a new artistic theatre group
called “kind sound” have involved children and adolescents with ASD in
music and theatre (Moghaddam, 2017).
Sheida, a 7-year-old girl with ASD
The following pictures are the results of psychodrama in children with
ASD for 3 years. We have a little drama and music group consists of
12 children with ASD who can learn and perform role-playing and
confrontation techniques by myself and other practitioners. We have
worked in theatre since 2015 and performed 4 times in amphitheaters
and art halls in Iran.
At first, these children could not communicate with each other and
just can watch themselves and didn’t show any relationship, but after
months they could learn verbal and nonverbal communication with each
other. They show better self-esteem and self-confidence. Now they like
to play on the scene and can be watched by other audiences.
Drama can help them to play and work together. Now they can play
simple roles and have better eye-contact and talking with each other.
They can sing poems in theatre and also draw pictures via theatre.
A painting by Maziar as an ASD boy
Maziar, a 15-year-old boy with ASD
A theatre performed by students with ASD

Sepehr, a 10-year-old boy with ASD
2020
Vol.2 No.1
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University of Groningen
Evaluation of ‘Images of Self', an art therapy program for children diagnosed with Autism
Spectrum Disorders (ASD)
Schweizer, Celine; Knorth, Erik J.; Van Yperen, Tom A.; Spreen, Marinus
Published in:
Children and Youth Services Review
DOI:
10.1016/j.childyouth.2020.105207
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Schweizer, C., Knorth, E. J., Van Yperen, T. A., & Spreen, M. (2020). Evaluation of ‘Images of Self', an art
therapy program for children diagnosed with Autism Spectrum Disorders (ASD). Children and Youth
Services Review, 116, Article 105207. https://doi.org/10.1016/j.childyouth.2020.105207
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Children and Youth Services Review 116 (2020) 105207
Contents lists available at ScienceDirect
Children and Youth Services Review

journal homepage: www.elsevier.com/locate/childyouth
Evaluation of ‘Images of Self,’ an art therapy program for children diagnosed T

with autism spectrum disorders (ASD)
Celine Schweizera, , Erik J. Knorthb, Tom A. van Yperenb, Marinus Spreena
⁎
a
NHL Stenden University of Applied Sciences, The Netherlands
b
University of Groningen, The Netherlands
A RT ICLE INFO ABSTRACT
Keywords: The art therapy (AT) program for children diagnosed with Autism Spectrum Disorders (ASD), ‘Images of Self’,
Art therapy program has been evaluated with repeated single case studies (n = 12) in a mixed-methods design. The program focuses
Children on children’s diAculties with their ‘sense of self’, ‘emotion regulation’, ‘flexibility’ and ‘social behavior’. Parents,
Autism Spectrum Disorder teachers and art therapists scored the BRIEF and CSBQ, instruments for rating child behavior. Children filled out
Evaluation
the SPPC, a self-image scale. To evaluate the quality of the program, therapists used a child observation scale
Small-N methodology
(OAT-A) and a therapists’ self-evaluation scale (EAT-A). All instruments were applied three to five times per case,
depending on the corresponding measurement objectives: one week before the start of the program (T0), during
session 3 (T1), session 8 (T2), session 15 (T3), and 15 weeks after termination of the treatment (T4). Parents and
teachers were invited to complete a form for qualitative comments which was structured around the four pro-
blem areas. Therapists video-recorded three sessions and evaluated these with parents and - during training
sessions - with the principal investigator. At the end of the treatment parents, teachers and art therapists gave a
rating for their overall satisfaction with the treatment. Main improvements after treatment were seen in chil-
dren’s flexible and social behavior. Overall satisfaction regarding the program showed averages between 7.1 and
7.7. Implications of our study for the AT-practice and future research are discussed.
1. Introduction Schweizer, Haeyen, Henskens, Rutten-Saris, & Visser, 2009). Art

therapists facilitate the emotional, social, physical and creative pro-
‘Images of Self’ is a recently developed art therapy (AT) treatment cesses in a systematic cycle of observing, formulating treatment aims,
program for children with problems related to Autism Spectrum treating and evaluating children’s progress (Smeijsters, 2008; Visser,
Disorders (ASD). The program is designed on the basis of a series of 2009). A defining characteristic of this experiential way of treatment is
practice-based studies (Schweizer, Knorth, & Spreen, 2014; Schweizer, the so-called triangular relationship; communication between therapist
Spreen, & Knorth, 2017; Schweizer, Knorth, Van Yperen, & Spreen, and client goes indirectly via the art-making. This way of treatment
2019a, 2019b). In this series, consensus was reached among 32 art provides opportunities for fresh experiences and for the development
therapists and 28 referrers about what they considered to be typical and training of new skills for children with communication problems.
elements of AT for children with ASD. Two instruments (I. Observation Working with art materials o)ers a focus on tactile and sensory motor
of a Child with ASD in Art Therapy: OAT-A; II. Evaluation of the Art experiences. Such a process may contribute to new behavior (Bergs-
Therapist working with a child with ASD: EAT-A) were also developed Lusebrink, 2013; Case & Dalley, 1990; Gilroy, 2006; Hinz, 2009;
to enable program evaluation, including studying the treatment in- Malchiodi, 2003). For example, a child with ASD often has diAculties
tegrity of the art therapist (Schweizer et al., 2019b). with perceiving his/her own feelings and experiences. During art-
Children diagnosed with ASD are characterized by their restricted making, the child may explore and develop preferences and new skills,
social and communicative skills and repetitive and obsessive behaviors based on a better processing of feelings and experiences (Ben Itzchak,
(APA, 2013). In AT, children’s experiences during the art -making Abutbul, Bela, Shai, & Zachor, 2016; Betts, Harmer, & Schmulevich,
processes and the ‘art product’ they create are assumed to reduce or 2014; Martin, 2009).
stabilize problematic behavior and/or support children in dealing with Four main problem areas of children with ASD in AT were defined.
and accepting these problems (Malchiodi, 2003; Rubin, 2001; These were ‘sense of self’, ‘emotion regulation’, ‘flexibility’, and ‘social
⁎
Corresponding author at: Academy of Health, NHL Stenden University of Applied Sciences, Rengerslaan 8, NL-8917 DD Leeuwarden, The Netherlands.
E-mail address: Celine.Schweizer@nhlstenden.com (C. Schweizer).
https://doi.org/10.1016/j.childyouth.2020.105207
Received 2 March 2020; Received in revised form 22 June 2020; Accepted 24 June 2020
Available online 29 June 2020
0190-7409/ © 2020 Elsevier Ltd. All rights reserved.
C. Schweizer, et al. Children and Youth Services Review 116 (2020) 105207
Fig. 1. Hypothetical influence from art therapy on the behavior of the child with autism.
communication’ problems (Schweizer et al., 2019b). Development of create art products which make him/her happy and which generate
sense of self starts with a focus on personal experiences, i.e. the child’s success experiences. In the next 12 sessions, the child is stimulated to
self-perception (what do I feel, like or dislike?) (Schweizer et al., vary experiences and develop di)erent skills, to become more aware of
2019a). A better self-perception and awareness of success during art- experiences, preferences and resistances, and to connect words to these
making are expected to contribute to an improved self-image and self- experiences. For instance, a boy who participated in this study was
concept. Greater self-esteem is considered to be a final result of these referred to art therapy with a very negative self-image. He created a
developmental stages of ‘sense of self’ (cf. Stern, 1985). Problems with bird house with support from the art therapist and sawed, hammered,
emotion regulation are related to a strong or weak reactivity and can painted and made a cosy place with soft fabric inside the little house.
appear as anger outbursts (Konstantareas & Stewart, 2006; Samson Every new technique was a real challenge for him. In the beginning he
et al., 2013). Flexibility problems appear as diAculties that arise be- told the art therapist several times that he was not skilled enough to
cause of the child’s rigid behavior patterns (APA, 2013). Social com- create anything. Over time he began to express anger during ham-
municative behavior problems often manifest themselves as troubles of mering, enjoyed the smell of the wood, and he caressed the fabric for
the child with adaptation to other people and new situations, and as the nest. With help from the art therapist he practiced to stop telling
diAculties with expressing themselves verbally (APA, 2013). Fig. 1 that he wasn’t able to make anything and he began talking about what
shows how the ‘Images of Self’ program is assumed to contribute to he liked about creating the bird house. During these activities he also
change in these problem areas of the child. began telling about his diAculties at school with other children and
The central aim of this study was the evaluation of the ‘Images of with his teacher who didn’t understand him. Meanwhile, at home and
Self’ AT-program for children with ASD. This involved monitoring the at school, he began expressing what was on his mind.
child during the therapy sessions, at school, and at home. The con- The therapist records the sessions through video, and watches and
tribution of the art therapist was also monitored. Desired outcomes evaluates the recordings afterwards with the parents. In addition, par-
included changes in children’s ‘sense of self’, ‘emotion regulation’, ents are o)ered a psycho-education training to improve their under-
‘flexibility’ and ‘social behavior, thereby showing a movement in the standing of ASD. Parents who did not receive this training had their
direction of behavior that is better accommodated to the child’s social child treated in a special educational setting.
environment; behavior that helps the child to function better in his/her
social environment (Boer & Van der Gaag, 2016; Van der Doef, 1992).
2. Method
1.1. The program
The program was evaluated with a sample of 12 single case studies
The ‘Images of Self’ program consists of 15 weekly, individual AT in a pretest–posttest design. At five specific moments in time, members
sessions (each lasting 45 min) and is standardized as much as possible. of the child’s network (i.e., parents, teacher, art therapist), completed
It is to be executed in accordance to the child’s preferences in themes, several questionnaires (Fig. 2). Possible change in behavioral aspects of
type of art materials, skills, techniques and individual needs, thereby ‘sense of self’, ‘emotion regulation’, ‘flexibility’ and ‘social commu-
taking into account the variety of problems for each individual child nication’ were measured with these questionnaires. Additional com-
with ASD (Fein, 2011; Feinstein, 2010; Waterhouse & Gillberg, 2014). A ments were noted during the same five measuring moments by the
prerequisite for conducting the program is that the AT room must o)er network members in an evaluation form and during training sessions
a quiet safe space with a broad spectrum of art materials that o)er with the art therapists and the principal investigator. This mixed-
opportunities to vary with di)erent experiences. The art therapist must methods design provides a multiple perspectives approach of quanti-
take an active and supportive role in creating a safe and inviting place, tative and qualitative data, leading to an improved understanding of the
so the child is stimulated to express him/herself through art. The first topic being studied (Creswell, 2015; Tashakkori and Teddlie, 2010).
three sessions are focused on getting used to the situation and exploring The study design was approved by the METC, the Dutch Medical
the preferences and resistances of the child relating to the type of art Ethical Assessment Committee (Centrale Coördinatie Mensgebonden
materials and the art therapist. The child is stimulated and supported to Onderzoek – CCMO) in 2017.
2
Fig. 2. Measurements.
2.1. Participants of mouth. As a result, initially 17 art therapists signed up. During
preparation in the training phase, 10 of them decided not to join the
Included were children diagnosed with ASD between the ages of research because it appeared to be too time consuming. Moreover, for
6–12 years and having an IQ z 80. Children were signed up through eight of them who worked in a private practice, it was an unpaid work.
the usual referral procedures from the collaborating organizations, i.e. Both parents and teachers of the included children contributed to
the art therapists employed there (N = 7). Based on the professional the evaluation of ‘Images of Self’ by filling out questionnaires, obser-
judgements of these therapists, children were excluded if they were ving the child’s daily behavior, and reporting possible behavior
evaluated as showing too much resistance to or fear of art-making. With changes. Further participation of parents was achieved by discussing
the help of the collaborators, initially 15 children were found who and evaluating video recordings from selected sessions with the art
fulfilled the inclusion criteria. However, three children dropped out therapist.
before session 8 because of a highly problematic and disturbing school
situation. As a result, 12 children fully participated in this study. 2.2. Instruments
Seven art therapists finally joined the study. All participating
therapists had a Bachelor’s degree in art therapy, which is the general The parents and the teachers completed two questionnaires. The
professional qualification in the Netherlands. They had at least two first instrument was the (Dutch version of the) Behavior Rating
years’ experience of working in AT with the target group. They were Inventory of Executive Functioning (BRIEF; Gioia, Isquith, Guy, &
included with the help of convenience sampling (Lavrakas, 2008), i.e. by Kenworthy, 2000; Huizinga and Smidts, 2012), measuring executive
using newsletters from professional organizations, Facebook, and word functioning of children. Consistency and test–retest reliability for
3
parents and teachers (in the Dutch version) are high (Cronbach’s k 2.3. Procedure
0.78-0.97). Content and construct validity are well established. The 75
items of the BRIEF are rated on a 3-point scale ranging from 1 (never) to The first measurements (T0) were planned one week before the
2 (sometimes) or 3 (often). actual treatment program for a child began. The parent/s and teacher of
The second questionnaire was the Children’s Social Behavior the child completed two questionnaires at T0: BRIEF and CSBQ. At
Questionnaire (CSBQ), in a Dutch version (VISK), which measures so- session 3 (T1) the art therapist completed OAT and EAT, while the child
cial behavior of children with ASD (Hartman, Luteijn, Serra, & completed SPPC. From the viewpoint of the art therapist this was before
Minderaa, 2006; Hartman, Luteijn, Moorlag, De Bildt, & Minderaa, ‘real treatment’, because the first three sessions were for observation.
2007). Internal consistency of this questionnaire is suAcient (Cron- i.e. to get a first impression of developmental opportunities in art-
bach’s k z 0.70) for descriptive and research aims. The 49 items in the making and the behavior of the child. At session 8 (T2), the art therapist
CSBQ are rated with a 3-point scale ranging from 0 (never) to 1 again completed OAT-A and EAT-A and made a video recording to be
(sometimes) or 2 (often). watched and evaluated with the parents. After session 15 (T3), the
The children completed the Dutch version (CBSK) of the Self- parents and the teacher completed the BRIEF and CSBQ, the child the
Perception Profile for Children (SPPC; Harter, 2012; Veerman, SPPC, and the art therapist the OAT and EAT. Also in session 15, the art
Straathof, Tre)ers, Van den Bergh, & Ten Brink, 2004). This instrument therapist made a video recording and selected representative parts to
measures self-perception and has 36 items with four rating options. watch and evaluate with the parents. In addition, all participants were
Cronbach’s k for internal consistency of the subscale 'behavior attitude’ asked for an overall satisfaction rating (scale 1–10) of the whole
is poor (Cronbach’s k J 0.70). The subscales 'social acceptance’ and treatment program. The follow up (T4) was 15 weeks after terminating
'self-esteem’ show a Cronbach’s k z 0.70, which is acceptable. Test- the treatment. This art-making session was again recorded by video and
retest reliability of the scales 'social acceptance’ and 'self-esteem’ are evaluated, and afterwards the relevant questionnaires were completed
acceptable (Cronbach’s k > 0.70); that of the subscale ‘behavior at- by all participants. At all five timepoints (T0-T4), parents, teachers and
titude’ is poor J 0.70. art therapists completed an evaluation form to collect more detailed
Expected behavioral changes were measured with subscales in the qualitative data on processes at home, at school and during treatment.
following questionnaires: To support and control the research process, small groups of three or
four art therapists were trained by the PI (who is also an experienced art
- ‘Self-perception’ was measured by the ‘evaluation of behavior’ therapist). This training comprised five meetings: one before the
(BRIEF), and ‘behavior attitude’ and ‘self-esteem’ subscales (SPPC). treatment, and four during and after treatment. During the training
- ‘Emotion regulation’ was measured by the ‘emotion regulation’ sessions, the treatment and research procedures were discussed, and
subscale (BRIEF). video fragments of ‘old cases’ were watched and evaluated with OAT-A
- ‘Flexibility’ was measured by the ‘flexibility’ (BRIEF), and ‘stereo- and EAT-A. This was done to enhance the reliability of the ‘real’ scoring
type behavior’ and ‘resistance for change’ subscales (CBSQ). later on (Schweizer et al., 2019b).
- ‘Social behavior’ was measured by the ‘not attuned’, ‘diminished
contact’ and ‘social understanding of problems’ (CBSQ), and ‘social 2.4. Data analysis
acceptance’ subscales (SPPC).
Severity of ASD-related problem behaviors were calculated based on
The art therapists evaluated the progress of the child during treat- norms in the BRIEF-, CSBQ- and SPPC-Manuals. To detect whether a
ment with the ‘Observation in Art Therapy of a child diagnosed with single child had improved, the Reliable Change Index (RCI) (Jacobson
ASD’ (OAT-A, Schweizer et al., 2019b). This instrument has 22 items & Truax, 1991; Veerman & Bijl, 2017; Wise, 2004) was computed be-
covering four subscales: ‘sense of self’, ‘emotion regulation’, ‘flexibility’ tween T0 and T3 and between T0 and T4. Criteria to assess meaningful
and ‘social behavior’. change between two measurements are: strong improvement:
The therapeutic behavior of the art therapist was evaluated with the RCI z 1.96; some improvement: 1.65 J RCI < 1.96; stable:
‘Evaluation of the actions of the Art Therapist working with a child 1.65 > RCI > -1.65; some decline: .1.65 z RCI > -1.96; strong
diagnosed with ASD’ (EAT-A, Schweizer et al., 2019b). This instrument decline: RCI J -1.96.
has 24 items and measures the professional behavior of the art therapist Qualitative data from the evaluation form filled out by parents,
when working with a child. The four subscales are 'supporting the de- teachers and art therapists were analyzed according to the four out-
velopment of sense of self’, 'supporting the improvement of flexibility’, come domains (Fig. 1). Next, they were organized in two categories:
‘stimulating emotion regulation’ and ‘stimulating social behavior’. Both ‘reasons for referral’ and ‘treatment results’.
instruments were tested on interrater reliability and showed moderate Art therapists’ comments were noted by the researcher during
to substantial reliability1 with art therapists being trained in their use training sessions. These were then grouped under the following topics:
(Schweizer et al., 2019b). a) How is the child’s behavior at home, in the classroom, and in AT
Parents, teacher and art therapists indicated their satisfaction with related to the outcome domains? b) (How) does watching a video re-
the treatment using a rating scale ranging from 1 (completely un- cording with the parents contribute to (a better) understanding of the
satisfied) to 10 (completely satisfied). child by the art therapist and the parents? c) (How) does the use of the
Additional comments were noted by parents, teachers and art instruments OAT and EAT contribute to (a better) understanding of the
therapists in an evaluation form and during training sessions with the child? d) What are the art therapist’s most noticeable and hardly seen
art therapists and the researcher. They were invited to briefly write actions? e) (How) does the training contribute to the art therapist’s
down their comments about (intermediate) results and expectations understanding and performance during AT? Qualitative data analysis
concerning the child’s behavior. The researcher extracted extra in- was checked by and discussed with a peer researcher.
formation from the art therapists about the treatment and evaluation
moments with the parents and teachers, during training sessions (see 3. Results
below).
Table 1 gives an overview of some characteristics of the children
and their context at the beginning of the treatment process, including
the reasons for referral to AT. In addition, some facts on the engaged
1
Moderate interrater reliability means: 0.40 < κ J 0.60; substantial inter- therapists are provided.
rater reliability means: 0.60 < κ J 0.80. Some children not only showed ASD-symptoms, but also had to cope
4
C. Schweizer, et al.
Table 1
Overview of participating children, art therapists, treatment settings, reasons for referral, use of medication, and context information.
Child Gender Age Art Therapist Experience of art Treatment setting Reason for referral Medication Context information
therapist (years)
1 F 6 1 13 Ambulant mental health Not going to school at start AT.Heavy emotion regulation Vitamin B injections After eight weeks she is part-time visiting
care organization problems and inflexible behavior in classroom. school. Mother tells that the teacher does
not understand her child.
2 F 9 2 40 (Semi)residential Social communication problems: isolated; what is she thinking / No Philippine background with Asian values
psychiatric center for feeling? about behavior and education. Mother has
children and youth a burn-out and is in a divorce.
3 F 12 3 8 School for special Emotion regulation problems in classroom (crying); negative self- Methyl phenidate for Extra psycho- education for child, to
education image;Oversensitivity. oversensitivity improve her understanding of ASD.
4 M 10 4 13 (Semi)residential Child shows severe depressed feelings at home. Negative self- Methyl phenidate Parent training to improve understanding
psychiatric center for image.Emotion regulation problems in classroom (anxiety of ASD.
children and youth problems and anger outbursts).
5 F 11 5 40 School for special Negative self-image.Severe depressed feelings at home.Emotion No At the end of AT she went to a lower class
education regulation problems in classroom (anxiety problems).Social grade.
communication problems at home and in school (hardly talks).
5
6 M 9 5 40 School for special Negative self-image.Emotion regulation problems at home and in Yes, for the anxiety and emotion After 10 weeks, mother severely ill. Child
education classroom (anxiety problems and anger outbursts). regulation, but no specific has problems with teacher.
information what it is.
7 M 10 5 40 School for special Negative self-image.Flexibility problems at home. No
education
8 M 12 6 20 (Semi)residential Negative self-image.Flexibility problems. Social communication No Parent training to improve understanding
psychiatric center for problems (what is she thinking / feeling?).Anxiety problems. of ASD.
children and youth
9 M 12 6 20 (Semi)residential Negative self-image.Emotion regulation problems at home and in No Parent training to improve understanding
psychiatric center for classroom (anger outbursts). of ASD.Stop-think-do method is used in
children and youth school.
10 M 11 1 13 Ambulant mental health Negative self-image.Emotion regulation problems at home (anger No Parent training to improve understanding
care organization outbursts).Social communication problems (what is he thinking / of ASD.
Children and Youth Services Review 116 (2020) 105207

feeling?).
11 F 11 7 9 Ambulant mental health Negative self-image.Social communication problems. Methyl phenidate for ADHD
care organization
12 M 12 1 13 Ambulant mental health Negative self-image. Very depressed feelings.Social No Parent training to improve understanding
care organization communication problems (what is he thinking / feeling?). of ASD.Divorce of parents during
treatment.
Table 2
Overview of Reliable Change indexes (RCis) regarding BRIEF-, CSBQ-, and SPPS-scores of parents, teachers and children (N = 12 children).
with other issues like anxiety problems, depressed feelings, over- norms of a child psychiatric population). According to the professional
sensitivity, and ADHD. Looking at the standards for problematic be- judgments of the art therapists, all children had varied problems with
havior of the BRIEF, nearly all included children (n = 11) showed high ‘self-perception’, ‘flexibility’, ‘emotion regulation’, and ‘social beha-
scores in severity of problems regarding ‘emotion regulation’, ‘flex- vior’.
ibility’ and ‘behavior evaluation’ (T-scores > 60) at the start of the The overview in table 2 shows the degree of improvement according
treatment. Also, the CSBQ data show high scores in severity of problems to the RCIs computed between T0-T3 and T0-T4.
of the child, particularly in the areas of ‘social acceptance’, ‘self-esteem’ Strong improvement is visible in cases 1, 2, 4, 7, 8, 9 and 11
and ‘behavior-attitude’ (generally, scores are very high according to the (n = 7), specifically at T4 in the areas of ‘flexibility’ and ‘social
Table 3
0verview 0f OAT-A and EAT-A di)erence scores by art therapists, indicating a change between T1 and T3, and between T1 and T4 respectively (N = 12
children).
6
behavior’. A (strong) decline is visible in cases 5, 6 and 10, mainly in T4 for cases 4, 5, 9 and 11 shows improvement regarding ‘self-esteem’.
the areas of ‘flexibility’ and ‘social behavior’. Cases 3, 5, 6, and 12 show Decreased scores are remarkable because in the qualitative comments
mixed results of strong improvement and (strong) decline spread over from all participants it was reported that children are happier and more
di)erent outcome measures. Notably, all cases show items with stable stable after completing the treatment. OAT-A results supported the
RCI’s, and on closer examination, the majority of these ‘stable’ results outcomes obtained from the SPPC, and in most cases particularly
appeared to show some improvement. showed improvement in the areas of ‘sense of self’ and ‘emotion reg-
T3 scores are often equal to T4 scores. In five cases (1, 2, 7, 8, 12) T4 ulation’. However, the improvement in the OAT-A ‘sense of self’ scores
scores are mainly higher than T3 scores. In nearly all cases (except case (inside the AT-setting) was not always in agreement with the BRIEF and
2 and 6) the SPPC child scores have improved during the follow up CSBQ results (observations at home and in the classroom).
(T4). T4 scores in cases 2, 3, 5, 6 and 10 are less favorable for ‘flex-
ibility’ and ‘social behavior’. 4. Discussion
Scores from teachers are often di)erent from those of the parents.
Sometimes there is more behavioral change observed in the school si- Results from our treatment evaluation inidciate that ‘Images of Self’
tuation, sometimes more at home. is partly helpful for children su)ering from ASD related problems
Scores of cases with RCIs that indicate strong improvement are (Barlow, Nock, & Hersen, 2009). In the majority of children (58%), the
accompanied by positive OAT-A scores, especially for an improved expected improvements (according to Fig. 1) were confirmed by the
‘sense of self’ and ‘social behavior’ (Table 3). measurements with BRIEF and CSBQ regarding ‘flexibility’ and ‘social
Case 8 improved on all outcomes of the OAT-A. Improvement at T4 behavior’. Positive change in the direction of behavior that is more
regarding ‘sense of self’ is observed in cases 4, 5, 7, 8, 9, 10, 11 (n = 7), socially acceptable in the child’s social environment was also described
regarding ‘emotion regulation’ in cases 1, 2, 5, 6, 8, 9, 11, 12 (n = 8), in the comments of teachers, parents, children and therapists after
regarding ‘flexibility’ in cases 1, 2, 3, 8, 9, 10, 12 (n = 7), and regarding terminating the program: the children were more able to communicate,
‘social behavior’ in cases 1, 2, 4, 5, 6, 7, 8, 11, 12 (n = 9). Decline to ask for help, and they showed more self-confidence. In the qualitative
regarding ‘flexibility’ at T4 is observed in cases 4, 5 and 6. comments, it appeared that children were happier and more stable
The EAT-A results are showing a stable behavioral pattern of the art (n = 11) and had an improved ‘sense of self’ (n = 9) and were better at
therapists in ‘supporting development of sense of self’ (n = 11). ‘emotion regulation’ (n = 8). Involvement of parents and psychoedu-
Increased ‘stimulation emotion regulation’ by the art therapist at T4 can cation were recognized as valuable building blocks in ‘Images of Self’
be reported in cases 1, 4, 5, 6, 8, 9, 10 and 12 (n = 8); increased (cf. Van Rooyen & Rietveld, 2017).
‘stimulating flexibility’ is observed in cases 1, 2, 3, 10, and 11 (n = 5); Our positive results are confirmed by a very recently published
increased ‘supporting social behavior’ is seen in cases 1, 2, 4, 5, 6, 7, 8, experimental study about e)ects of AT with children diagnosed with
9 and 12 (n = 9). ASD (Koo & Thomas, 2019); five out of nine children in that study
Parents scored the highest average rating for overall satisfaction of improved significantly in cognitive, motor and social skills. A positive
the treatment: 7.7 (min 6, max 10). The teachers’ average was 7.2 (min development was also assessed in their drawings.
5, max 9), and the art therapists’ average was 7.1 (min 6, max 8). Three There are some noticeable di)erences in reasons and aims for re-
parents commented spontaneously: “If my child was asked to score, this ferral (Table 1) and treatment outcomes: the main reasons for referral
would have been a 10.” Art therapists reported that all parents were to AT were a ‘negative self-image’, ‘emotion regulation problems’ and
motivated to join the research. For teachers, it was sometimes hard to ‘social behavior problems’ in the children, while main positive results
find time for scoring the tests, due to a heavy workload. Teachers from the measurements were improvement of children’s ‘flexibility’ and
scored lower when having a problematic relationship with the child. ‘social behavior’. All children were referred with ‘self-image’ problems.
In all cases (except case 11), parents, teachers and art therapists To understand the relatively low SPPC child-scores in the ‘sense of self’
wrote comments about main improvements in the areas of ‘self-esteem’ area – which are contrary to the reported positive comments about
and ‘social behavior’ at T4. Children were perceived as happier and improvement in ‘sense of self’ from parents, teachers, and art therapists
more stable, and more able to give words to their experiences. (n = 11) – it could be hypothesized that children scored their self-
Improvements in ‘emotion regulation’ were also reported in eight cases image more ‘realistically’ after treatment. This may indicate that AT
(1, 3, 4, 5, 8, 9, 10, 12) and improvements in ‘flexibility’ in four cases had contributed to an improved but not necessarily more positive ‘sense
(4, 8, 11, 12). In addition, it was reported by parents that ‘over-sensi- of self’.
tivity’ decreased (cases 1 and 3), and that some children showed ‘an- In one case (10) it was diAcult to understand why the scores on
xieties’ (cases 4, 5, 6 and 8). BRIEF and CSBQ did not improve, because the video observations and
For parents and art therapists, watching videos was an extra way in the additional comments of the child, the parents and the teacher were
which to improve their understanding of their child’s behavior. Parents positive. The art therapist presumed that this could be related to a more
evaluated this as supportive; they were relieved and content to see their valid understanding of the ASD related problems, expressed by parents,
child functioning in such a positive way. teacher and the child in standardized instruments.
A combination of quantitative results and qualitative comments It is striking that in some cases that seem to benefit from the AT-
provided a better understanding of scores but also generated questions. program (1, 2, 6 and 12) there were substantial problems in the child’s
Cases with the highest scores seemed to have quite stable situations at personal context (like divorce of the parents, illness of the mother, and
home and a good working relationship with the teacher. Problems at problems at school). Contrary to our expectations, this did not seem to
home (divorced parents and/or illness of the mother) seemed to have a influence the scores in a negative direction.
negative impact for cases 6 and 12 (see BRIEF and CSBQ scores at T3). A combination of results in Table 2 (BRIEF, CSBQ and SPPC) and
The same seemed true regarding problems at school (a poor match Table 3 (OAT-A and EAT-A) supports insights in behavioral changes at
between child and teacher) for cases 5, 6 and 12. Case 10 was re- home and at school and in AT. It is plausible to assume that the AT
markable: comments by parents and the art therapist regarding the less situation o)ers other opportunities for the child’s development than
positive development of the child are contrary to the (positive) RCIs. daily life situations. Di)erences in the results in Tables 2 and 3 indicate
The video at T4 also shows a happy, self-confident and relaxed boy. di)erences in the child’s behaviors during art-making processes on the
‘Sense of self’ items in the SPPC (scored by the child) are not one hand and the child’s behaviors in daily life and at school on the
showing strong improvement in most cases. But ‘social acceptance’ at other hand.
7
4.1. Strenghts and limitations observed with the OAT-A and EAT-A. In a further analysis of our data
we will take a closer look at these aspects (see also below).
Strengths. This study concerns a first evaluation of the ‘Images of
Self’ AT program for children diagnosed with ASD. ‘Images of Self’ 4.2. Recommendations
seems promising for these children showing problems with ‘sense of
self’, ‘emotion regulation’, ‘flexibility’ and ‘social behavior’. We believe An analysis of more detailed results is expected to provide more
our study has generated a valuable contribution to scientific evidence insight into the opportunities ‘Images of Self’ can o)er children with
by combining results from daily practices about various problems of ASD. For further research, we recommend exploring treatment fidelity
ASD diagnosed children in AT at home, at school and in di)erent set- (King & Bosworth, 2014). This might support a deeper understanding of
tings (American Psychological Association, 2006; Chambless et al., the outcomes. For instance, investigating the relationship between what
1998). exactly is going on during AT and how this a)ects the problematic
In our study, the repeated single case study methodology facilitated behavior of children may shed further light on interaction processes and
a focus on individual children, thereby using the perspectives of mul- working mechanisms (McLeroy, Bibeau, Steckler, & Glanz, 1988;
tiple informants (Bartholomew et al., 2012; Spek, 2012; Spreen, 2009, Bartholomew et al., 2001; Koole & Tschacher, 2016). Also, an expanded
2013). The Cochrane Collaboration regards outcomes from single case series of single case studies with micro-analyses of video-stimulated
designs as contributing to research evidence if a RCT is not relevant or recall of art therapists while treating a child with ASD can contribute to
not (yet) doable for evaluating practice (Higgins & Green, 2011). The further insight in art-making processes and results. Nearly all treated
approach o)ered opportunities to explore, develop and map insights in children had severe ASD related problems. It would be interesting to see
the progress and development of a sample of children in their personal what the results would be in a group of children with less severe pro-
situations on a detailed level (Reeves, Deeks, Higgins, & Wells, 2008; blems. With the results of the proposed research lines, the ‘Images of
Fein, 2011; Kern Koegel & Brown, 2007; Snir & Regev, 2013; Aalbers, Self’ program may be optimized further, thereby creating a solid base
Spreen, Bosveld-Van Haandel, & Bogaerts, 2017). for experimental studies to test the e)ectiveness of the program (see
According to the multiple informants’ approach, parents and tea- also Betts et al., 2014; Martin, 2009).
chers of the children were involved in the research procedure. From a Our results could be useful for the referral policy of professionals in
research perspective, the involvement of parents by watching and dis- the field because of the positive outcomes that were seen in the children
cussing videos from AT sessions might also be interpreted as a form of who benefited most from the program. For AT practice, the results of
action research at a micro-level (Reason & Bradbury, 2006). From a the evaluation of ‘Images of Self’ program must be seen as a first step in
treatment perspective, the involvement of parents is strongly re- providing insight into the program and its e)ects. It can also serve as a
commended (Steiner, Koegel, Koegel, & Ence, 2012). Their engagement source of inspiration for those who have the ambition to contribute to a
and the joint forces of therapist, teacher and parents contribute to an more evidence-based AT practice.
improved level of care (cf. Hurt et al., 2017; Schothorst et al., 2009).
Our design enabled comparison of data gathered from di)erent 4.3. Conclusion
sources. In the majority of cases, results were (rather) consistent; in a
minority they were not always. It stimulated us to explore reasons be- The promising results after evaluation of the ‘Images of Self’ AT
hind these di)erences and contributed to a deeper understanding of the program for children diagnosed with ASD may encourage parents,
results of the ‘Images of Self’ program. schools, child welfare agencies and mental health services to refer to
Validity and reliability of the BRIEF, CSBQ and SPPC were sa- and make more use of AT. Learning from the strengths and limitations
tisfactory to good; reliability of the OAT-A and EAT-A was moderate to of the study and following our recommendations can contribute to
substantial with trained raters. We therefore believe the results do re- further improvements and implementation of the program as next steps.
present the reality fairly well.
Limitations. There were also some limitations. In this study, we ap-
CRediT authorship contribution statement
plied a ‘convenience sample’ which, in combination with the repeated
single case approach, limits the opportunity for generalization of the
Celine Schweizer: Conceptualization, Formal analysis,
treatment results (Barlow et al., 2009). Exclusion of children with too
Investigation, Resources, Data curation, Writing - original draft,
high levels of fear and resistance for art-making might have created a
Visualization, Project administration. Erik J. Knorth:
bias in analysis of the results.
Conceptualization, Writing - review & editing, Supervision. Tom A.
In addition, it was not possible to monitor the referred children for a
Yperen: Conceptualization, Writing - review & editing, Supervision.
longer period before treatment with the aim to assess a baseline of their
Marinus Spreen: Conceptualization, Methodology, Formal analysis,
functioning; their referral to AT was surrounded by a sense of urgency
Writing - review & editing, Supervision.
and following the children without treating them was not an option.
However, a baseline would have enabled us to assess with more pre-
Declaration of Competing Interest
cision what the impact was for the child of starting a treatment program
like ‘Images of Self’ (Delsing & Van Yperen, 2017).
Nearly all participating children (n = 11) had co-morbidity pro- The authors declared that there is no conflict of interest.
blems (Table 1). The severity of ASD-related problems scored highly on
most items for most cases according to the norms of the BRIEF, CSBQ Acknowledgements
and SPPC. This may have impacted the results in a negative way. Three
children dropped out before the 8th session. They also dropped out of This research could not have taken place without all our partici-
school. Apparently ‘Images of Self’ did not o)er enough support. pants. We are grateful to all the children, their parents, teachers and art
Although the treatment program was tailored to the individual cli- therapists who contributed to this research. Our gratitude for facil-
ents, it was not possible to show all detailed results in this article. We itating the research goes out to NHL Stenden University of Applied
focused on the behavior of the child and not on the art -making process Sciences, Leeuwarden and the cooperating centers for child and youth
or the behavior of the art therapist, although aspects of both were psychology and psychiatry (Accare, Bascule, GGZ Centraal,
8
Therapeutisch Centrum GGZ, Focus: School for Special Education), and Clinical Psychology, 59(1), 12–19. https://doi.org/10.1037/0022-006X.59.1.12.
to the Art Therapy Practice of Mirjam van Houwelingen. Kern Koegel, L., & Brown, F. (2007). Autism spectrum disorders: Trends, treatments, and
diversity. Research and Practice for Persons with Severe Disabilities, 32(2), 87–88.
https://doi.org/10.2511/rpsd.32.2.87.
Appendix A. Supplementary material King, H. A., & Bosworth, H. (2014). Treatment fidelity in health services research. In L. M.
Hagermoser Sanetti, & T. R. Kratochwill (Eds.). Treatment integrity: A foundation for
evidence-based practice in applied psychology (pp. 15–33). Washington, DC: American
Supplementary data to this article can be found online at https:// Psychological Association (School Psychology Book Series). https://doi.org/10.
doi.org/10.1016/j.childyouth.2020.105207. 1037/14275-003.
Konstantareas, M. M., & Stewart, K. (2006). A)ect regulation and temperament in chil-
dren with Autism Spectrum Disorder. Journal of Autism and Developmental Disorders,
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10
children
Article
Exploring Change in Children’s and Art Therapists’ Behavior
during ‘Images of Self’, an Art Therapy Program for Children
Diagnosed with Autism Spectrum Disorders: A Repeated Case
Study Design
Celine Schweizer 1, *, Erik J. Knorth 2 , Tom A. Van Yperen 2 and Marinus Spreen 1
1 Research Centre for Small n-Designs, NHL-Stenden University of Applied Sciences, 8917 DD Leeuwarden,
The Netherlands; marinus.spreen@nhlstenden.com
2 Faculty of Behavioral and Social Sciences, Groningen University, 9712 CP Groningen, The Netherlands;
ej@knorth.nl (E.J.K.); t.vanyperen@nji.nl (T.A.V.Y.)
* Correspondence: celine.schweizer@nhlstenden.com
Abstract: (1) Background: ‘Images of Self’ (IOS) is a recently developed and evaluated art therapy
program of 15 sessions to reduce difficulties in ‘sense of self’, ‘emotion regulation’, ‘flexibility’, and
‘social behavior’ of children diagnosed with Autism Spectrum Disorders (ASD). In this paper, it
is explored whether change in the child’s behaviors corresponds to the therapist’s actions during
IOS and 15 weeks later. (2) Method: In a repeated case study design, twelve children and seven
therapists participated. Art therapists monitored their own and the children’s behavior by applying
two observation instruments: the OAT (Observation of a child with autism in Art Therapy) and EAT
(Evaluation of Art Therapist’s behavior when working with a child with autism). Child behaviors
Citation: Schweizer, C.; Knorth, E.J.; during art making were—individually and as a group—compared with therapist’s actions at three
Van Yperen, T.A.; Spreen, M. moments during the program. (3) Results: Ten of twelve children showed a substantial or moderate
Exploring Change in Children’s and positive behavior change considering all OAT subscales at the end of the program and 15 weeks
Art Therapists’ Behavior during after treatment. Improvement of ‘social behavior’ stood out. Halfway treatment art therapists
‘Images of Self’, an Art Therapy
most prominently showed support of ‘emotion regulation’, ‘flexibility’, and ‘social behavior’. Clear
Program for Children Diagnosed
one-on-one relationships between changes in children’s behavior and actions of therapists could
with Autism Spectrum Disorders:
not be identified. (4) Conclusion: The study provides new insights in the AT treatment process by
A Repeated Case Study Design.
monitoring children’s and therapists’ behavior. The art making itself and the art therapy triangle
Children 2022, 9, 1036. https://
doi.org/10.3390/children9071036
(child, art making, therapist) offer opportunities to improve verbal and nonverbal communication
skills of the child.
Academic Editor: Dafna Regev
Received: 6 June 2022 Keywords: art therapy; children; autism spectrum disorders; change processes; OAT; EAT
Accepted: 6 July 2022
Published: 12 July 2022
Publisher’s Note: MDPI stays neutral

1. Introduction
with regard to jurisdictional claims in
published maps and institutional affil- Children with autism-related problems are often referred to art therapy (AT) in the
iations. Netherlands [1]. Art therapies are recommended in the Dutch Guidelines for Mental
Health [2]. The American Art Therapy Association [3] states that people with autism are an
important target group for (research into) AT.
In the DSM-5 [4], persons with Autism Spectrum Disorders (ASD) frequently have
Copyright: © 2022 by the authors. social-communicative deficits and repetitive/restricted behaviors and interests.
Licensee MDPI, Basel, Switzerland. Recently, several studies have indicated that AT can provide a successful treatment for
This article is an open access article children with ASD-related problems. In a systematic review [5], two single group studies
distributed under the terms and reported improvement of the children to engage in social situations and improve ability
conditions of the Creative Commons
to focus attention. The review also included an RCT that showed some favorable but not
Attribution (CC BY) license (https://
significant outcomes for the treatment group, compared to the control group. The lack in
creativecommons.org/licenses/by/
the RCT is not unexpected, because of the variety of ASD features in children [6–9], which
4.0/).
Children 2022, 9, 1036. https://doi.org/10.3390/children9071036 https://www.mdpi.com/journal/children

Children 2022, 9, 1036 2 of 17
makes it hard to form a comparable treatment and control group. An extensive practice-
and theory-based study evaluated the contribution of sensory experiences when touching
art materials. This resulted in improvement of communication with the therapist [10].
Art making in AT supports the pleasure of the child and contributes to an improved
therapeutic relationship. It also increases the range of patterns in the child’s behavior and
art expressions [11,12].
Until recently, there was a gap in the knowledge regarding behavioral changes of
children with ASD in AT, the activities of the art therapist, and the relationship between
the two [1,13,14]. To address this challenge, a series of studies was performed, resulting
in the AT program ‘Images of Self’ (IOS). This title refers to the important role of art
making in the triangular relationship between client, art work, and art therapist. Every art
making process and every art product mirrors the experiences of the maker within this
triangular relationship.
IOS was developed firstly with two studies examining knowledge from experienced art
therapists as well as literature about AT practices with children diagnosed with ASD [15,16].
Based on these studies, the building blocks of the IOS program were further articulated as
consensus-based typical elements of AT [17]. IOS consists of 15 individual sessions with an
art therapist who has been intensively trained to apply the program. Characteristics of the
treatment and the relevant actions of the art therapist are described in a manual [18]. The
starting point of the treatment is attunement to the needs and art expressions of the child.
The IOS program offers a frame that allows adjustments to individual needs, because
every child with autism has different interests, skills and varied reasons for being referred
to art therapy. For instance, an 11-year-old girl and her environment suffered from her
emotional outbursts. An important step during her IOS treatment was to make a colorful
felt blanket that she wanted to use to comfort herself. During the creation of this blanket,
she moved the soft wool with soap and water until it turned into felt. She enjoyed the
creation of the blanket. During this process, she talked with the art therapist and became
more aware of what gives her (emotional) stress and what brings relaxation. The girl
became aware that sensory experiences helped her to relax. She also made a small plastic
bag with smooth glue in it, for keeping in her pocket. Whenever she became aware that her
tension grew, it helped her to relax by touching the smooth bag.
The IOS program yielded promising results in a multiple case study among 12 children
diagnosed with ASD, aged 6–12 years, with normal/high intelligence profiles [19]. Children
were referred to IOS because of difficulties with their ‘sense of self’ (difficulties with
reflecting on their own feelings and behaviors), ‘self-esteem’ (strongly negative senses
about ‘being different’ but not understanding why), ‘emotion regulation problems’ (being
very depressed; emotional outbursts), ‘flexibility problems’ (being upset when something
unexpected happens) and/or ‘social problems’ (difficulties in expressing themselves and
troubles with understanding others). Nearly all participating children (n = 11) started the
program with severe problems in these areas according to the norms of the Child Social
Behavior Questionnaire (CSBQ) [20].
During the program, the children were monitored on the outcomes ‘sense of self’,
‘emotion regulation’, ‘flexibility’, and ‘social behavior’ by therapists, but also by their
parents and teachers [18]. The outcome ‘sense of self’ is a concept that includes a continuum
regarding self-development: self-perception, self-image, self-concept, and self-esteem [21].
Seven of the 12 children significantly improved in ‘flexibility’ and ‘social behavior’,
both during treatment and also 15 weeks after termination of the treatment [19]. These
results can be interpreted as positive, because in general, the reduction rate of problems by
psychosocial interventions in children and youth lies between 35 and 62 percent a year after
the start of a treatment [22,23]. According to the qualitative analysis of the evaluation of
IOS, all children were reported by their parents, teachers, and therapists to be happier and
more stable, and better able to give words to their experiences. Additionally, improvements
in ‘emotion regulation’ (n = 8) and ‘flexibility’ (n = 4) were reported.
Children 2022, 9, 1036 3 of 17
In our evaluation study, the focus was primarily on the outcomes: do the children
improve or not? However, AT is characterized by a triangular relationship between client,
art, and therapist [24,25]. In this relationship, it is supposed that communication of the
children with the art therapist will be easier and feel safer for the child, because of the
component of art making. This especially applies to children with communication chal-
lenges such as children diagnosed with ASD [17]. In this paper, we explore the process of
therapeutic change, thereby directing the attention to the development of children’s and
therapists’ behavior in relation to each other. The research question in the current study
is: To what extent are changes in the behaviors of the children and the art therapists’ activities
concerning (supporting) ‘sense of self’, ‘emotion regulation’, ‘flexibility’ related?
2. Methods
2.1. Participants
The repeated case study design makes it possible to monitor individual patterns of
results in different contexts. In our design, we included children, their parents, teachers and
their art therapists. The multiple perspectives and the pre-test/post-test provide insight in
changes in AT as well as in the contexts of home and school. Twelve children and seven
therapists participated in this study. Children aged 6–12 years with an ASD diagnosis and
an IQ 80 were included in the sample [19] (Table A1 in Appendix A). Children were
excluded if they were evaluated by their art therapists as showing amounts of resistance
that were too high or fear of art making. All therapists had a Bachelor’s degree in art
therapy, which is the required professional qualification in the Netherlands for working
as an art therapist. They also had at least two years of work experience in AT with the
target group. Parents and teachers of the participating children completed questionnaires,
observed daily behavior, and reported possible behavior changes of the child in a form.
Parents participated by discussing and evaluating video recordings of selected IOS sessions
with the art therapist. All participants signed informed consent forms.
2.2. Measurement Instruments

In this study, two instruments were used to monitor and describe the children’s and the
therapists’ behaviors during the IOS program [26]. (In the evaluative multiple case study
three other instruments were also applied: the Behavior Rating Inventory of Executive
Functioning (BRIEF; [27,28]), the Children’s Social Behavior Questionnaire (CSBQ) [20,29],
and the Self-Perception Profile for Children (SPPC) [21,30]. With the first two instruments,
parents’ and teachers’ findings were measured, and with the third instrument, the child’s
findings were mapped). The first instrument in the recent study is the so-called ‘Observation
in Art Therapy with a child diagnosed with ASD’ (abbreviated as OAT. (In our former
studies, the names of the instruments were OAT-A and EAT-A, with ‘-A’ referring to ASD.
However, the titles without the suffix ‘-A’ are more compact). The OAT is an instrument
that is intended to observe and measure the behavior of the child during art making
in the sessions on four subscales: ‘sense of self’, ‘emotion regulation’, ‘flexibility’, and
‘social behavior’.
‘Sense of self’ refers to a theory-based continuum of concepts that represents a devel-
opment of ‘self skills’: self-perception, self-image, self-concept, and self-esteem [21,31,32].
Improvement of ‘sense of self’ is one of the main aims of AT for children diagnosed with
ASD [15,18,33]. In studies about AT for children with ASD the importance of development
of the lowest level in the continuum, ‘sense of self’ is often mentioned as a treatment
goal [10–12]. An example of an item in the OAT subscale ‘sense of self’ is: “The child is
connected with his/her experiences during art making”.
‘Emotion regulation’ is a complex concept that concerns perception of internal and
external stimuli within a complexity of mechanisms: physiological arousal, motivation,
and cognitive evaluation. The ability of regulating emotions is based on recognition of
inner sensations, feelings, and behavior, relating these to their causes [34]. Initiating, main-
taining, inhibiting, or moderating emotional reactions may lead to ‘emotion regulation’ in
Children 2022, 9, 1036 4 of 17
association with processes that influence experience and the expression of emotions [35–37].
‘Emotion regulation’ refers to the downregulation of negative affects or the upregulation
of positive affects [37]. For children with ASD, it is often hard to recognize their own
emotions. In art work, inner feelings can be expressed by, for example, drawing cruel
fights or monsters. Difficulties with ‘emotion regulation’ can behaviorally be expressed, for
instance, by becoming angry when something disappointing happens during art making,
or by lack of emotion expression when it is expected. An example of an OAT item of this
subscale is: “The child is expressing emotions/experiences in art making/symbols”.
‘Flexibility’ is about adaptation to unexpected situations. Cognitive ‘flexibility’ (the
ability to find new solutions to a problem) is distinguished from flexible behavior (adapta-
tive skills to unexpected situations) [38]. An example of an OAT item of this subscale is:
“The child uses varied art materials and/or techniques”.
‘Social behavior’ is one of the main difficulties for children diagnosed with ASD [4].
These children are often hardly or not skilled in reciprocity, to adapt to others, to adapt to
play, and in working together [6,29]. In art therapy, some social skills can be developed,
for instance task-oriented collaboration, asking for help, and connecting words to experi-
ences [24]. The child may enjoy working together, and joint attention skills may also be
developed during art making [39–41]. An example of an item in the OAT subscale ‘social
behavior’ is: “The child shows enjoyment during art making with the art therapist”.
The second instrument is the so-called ‘Evaluation of the Art Therapist’s behavior
working with a child diagnosed with ASD’ (abbreviated as EAT); an instrument that is
intended to observe and measure art therapeutic behavior in IOS sessions. This instrument
has subscales corresponding with those in the OAT: ‘supporting the development of sense
of self’, ‘stimulating emotion regulation’, ‘supporting the improvement of flexibility’, and
‘supporting social behavior’. A (corresponding) example of the EAT subscale ‘supporting
social behavior’ is: “The art therapist supports the child to follow directions of the therapist”.
Items of both instruments have a 5-point Likert scale with values 1 = not observable,
2 = a bit observable, 3 = to some extent observable, 4 = well observable, 5 = strongly
observable. Both instruments are filled out by the therapists (see further below). The
reliability of the OAT and EAT is ‘moderate’ to ‘substantial’ [26]. Inter-rater reliability of
both instruments were determined with pairs of raters (trained art therapists and Bachelor
students) who scored selected video fragments of AT sessions collected during a pilot
study. Interrater reliability has been computed per item and per subscale of the instruments.
Because of the ordinal level of the scores (5-point Likert scale) the degree of agreement was
computed per item using quadratic weighted Kappas (Kw ). Kw may be influenced by a
restriction of the range of scores, resulting in an inflated high or low value. For that reason
also Gower indices (G) were computed to interpret values of Kw for items with very low or
high absolute agreement [42]. In addition: 0.40  Kw < 0.60 means ‘moderate’ agreement;
0.60  Kw  0.80 means ‘substantial’ agreement.) Training of raters was still proved to
enhance the inter-rater agreement regarding the instrument’s scales [26].
2.3. Procedure
To include art therapists, a convenience sample [41] was drawn using newsletters from
the national professional organization of art therapists, calls on Facebook, and word of
mouth advertisement. Participating children followed the usual referral procedure from the
seven collaborating institutions. Based on the professional judgements of the art therapists,
children were excluded if they were assessed as having levels of resistance that were too
high or fear of art making.
Both instruments, OAT and EAT, were scored by the art therapist at all of the measure-
ment moments. The use of both instruments was intensively trained and supervised by the
PI during the IOS program.
Details regarding the monitoring of treatment were described in our previous publica-
tion about IOS evaluation [17].
cation about IOS evaluation [17].
2.4. Analysis
The data were analyzed in two steps. In the first step, the behaviors of each
Children 2022, 9, 1036 during the session at the measurement moments T1, T2 and T3 were visually 5 of 17 comp
with the acts of the corresponding therapists (EAT). The aim was to explore wh
changes in the child’s behaviors corresponded to the therapist’s actions. Excel (ve
2.4.
2016Analysis
for Windows) was used to analyze the data. As a decision rule, we considered
The data
ferences were analyzed
between in two steps. In
two measurement the first step,
moments equaltheto
behaviors of each
or larger thanchild
−1 ordur-
+1 as sub
ing the session at the measurement moments T1, T2 and T3 were visually
tial. Differences between −1 and −0.5 or +0.5 and +1 were seen as minor or moderatecompared with
the acts of the corresponding therapists (EAT). The aim was to explore whether changes in
ferences smaller than −0.5 or +0.5 were defined as negligible.
the child’s behaviors corresponded to the therapist’s actions. Excel (version 2016 for Win-
dows) Inwasthe second
used step,the
to analyze fordata.
eachAssubscale,
a decision arule,
nonparametric
we consideredFriedman test was perfor
differences between
on the
two four measurement
measurement moments equalmoments for the
to or larger thangroup1 orof
+112
as children.
substantial.The aim of this test
Differences
between
to explore whether there was a consistent pattern of change over time. smaller
1 and 0.5 or +0.5 and +1 were seen as minor or moderate. Differences This enabled
than
parison0.5 or
of +0.5
the were defined
scores as negligible.
at different measurement moments and visual exploration o
In the second step, for each subscale, a nonparametric Friedman test was performed
development in children’s and therapists’ behaviors.
on the four measurement moments for the group of 12 children. The aim of this test
was to explore whether there was a consistent pattern of change over time. This enabled
3. Results of the scores at different measurement moments and visual exploration of the
comparison
development in children’s
3.1. Individual Analyses and therapists’ behaviors.
Detailed information about changes in child behaviors is shown in Figures 1, 3
3. Results
5; in
3.1. FiguresAnalyses
Individual 2, 4, and 6, the corresponding information is depicted regarding ther
behaviors.
Detailed information about changes in child behaviors is shown in Figures 1, 3, and 5; in
FiguresFigure
2, 4, and1 6,shows
the corresponding
the developmentinformation of isthe
depicted regarding
individual therapistat
children behaviors.
session 8, hal
Figure 1 shows the development of the individual children at
through the treatment (T2), compared to T1. Substantial positive developments (≥+1session 8, halfway
through the in
identified treatment
one or (T2),
morecompared
subscales to for
T1. eight
Substantial positive
children (casesdevelopments
1, 2, 3, 5, 6,(7,+1)
8, 9), and
are identified in one or more subscales for eight children (cases 1, 2, 3, 5, 6, 7, 8, 9), and
stantial negative developments (≤−1) in one or more subscales for two children (cas
substantial negative developments ( 1) in one or more subscales for two children (cases
4,7).
7).Four
Four children (cases
children (cases 2,6,5,9)6,developed
2, 5, 9) developed on at
on at least twoleast two subscales
subscales substantiallysubstantially
in a
positive
positive direction.
direction.
OAT T2–T1 means of all subscales

per case
3.0
2.0
1.0
0.0
1 2 3 4 5 6 7 8 9 10 11 12
-1.0
-2.0
sense of self emotion regulation

flexibility social behavior
Figure Means
Figure1. 1. of all
Means ofsubscales per case,
all subscales perT2–T1.
case, T2–T1.
In Figure 2, we see four therapists (cases 1, 5, 7, 11) being most active during the time
In Figure 2, we see four therapists (cases 1, 5, 7, 11) being most active during the
period T1–T2 on the dimension ‘emotion regulation’. Two therapists were substantially
period
active on T1–T2 on (cases
‘flexibility’ the dimension ‘emotion
5, 12), and one regulation’.
on ‘social Two9).therapists were substan
behavior’ (case
active
Figure 3 compares the OAT subscales’ means between the end (T3) and(case
on ‘flexibility’ (cases 5, 12), and one on ‘social behavior’ 9). (T1) of
the start
treatment. Inspecting all four subscales, we see substantial positive change in one or more
subscales for ten children (cases 2, 3, 4, 5, 6, 7, 8, 9, 11, and 12) and substantial negative
developments in one or more subscales for one child (case 7). Five children (cases 2, 5, 6, 8,
and 9) developed substantially on at least two subscales in a positive direction.
EAT T2–T1 means of all subscales
per case
3.0
Children 2022,
Children 9,9,x 1036
2022, FOR PEER REVIEW 6 of 17 6
2.0
1.0
0.0 per case
3.0 1 2 3 4 5 6 7 8 9 10 11 12
-1.0
2.0
-2.0
1.0
0.0 flexibility social behavior
1 2 3 4 5 6 7 8 9 10 11 12
Figure
-1.0 2. Means of all subscales per case, T2–T1.
-2.0 Figure 3 compares the OAT subscales’ means between the end (T3) and the start
of treatment. Inspecting all four subscales, we see substantial positive change in on
sense of self
more subscales for ten children emotion
(casesregulation
2, 3, 4, 5, 6, 7, 8, 9, 11, and 12) and substantial n
tive developments in one or more subscales for one child (case 7). Five children (cas
Figure
5, Means
6, 8,2. and
Figure 2. 9)ofdeveloped
Means all
ofsubscales per
all subscalescase,
perT2–T1.
case, T2–T1.
substantially on at least two subscales in a positive direction
Figure 3 compares the OAT subscales’ means between the end (T3) and the start
of treatment. Inspecting all four subscales, we see substantial positive change in o
per case
more subscales for ten children (cases 2, 3, 4, 5, 6, 7, 8, 9, 11, and 12) and substantial n
3.0
5,2.0
6, 8, and 9) developed substantially on at least two subscales in a positive directio
1.0
0.0 per case
3.0 1 2 3 4 5 6 7 8 9 10 11 12
-1.0
2.0
-2.0
1.0
1
Figure3.3.Means
Figure Means 2
of all
3 4
of subscales 5 6
per case,
all subscales 7
perT3–T1. 8 9 10 11 12
case, T3–T1.
-1.0
The most substantial positive change can be observed on the dimension ‘emotion
-2.0 The most substantial positive change can be observed on the dimension ‘emo
regulation’ (cases 2, 4, 5, 6, 7, 8, 9, 11, and 12). For the other three subscales, we ascertain
regulation’positive
substantial (cases 2, 4, 5, 6, 7, 8, 9,of11, and‘social
12). For the other and three subscales,
in fourwe asce
sense of self change in ‘sense emotion self’,
regulation behavior’ ‘flexibility’
substantial
(cases positive
5, flexibility
6, 8, and change
9), three (casesinsocial
2,‘sense
8, and of
9),self’, ‘social
and again behavior’
three childrenand ‘flexibility’
(cases 2, 3, and 8),in four (c
behavior
respectively.
5, 6, 8, and 9), Forthree
two children
(cases 2,(cases8, and 1 and 10), again
9), and we hardlythree observe
children change,
(cases while
2, 3,also
and 8), res
observing
Figure 3.
tively. some
For twonegative
Means children tendencies.
of all subscales
(casesper case,10),
1 and T3–T1.
we hardly observe change, while also obser
Figures 4 and 5 show that the art therapists are most actively supportive on ‘social
some negative tendencies.
behavior’.
TheFor mostthe time period T1–T3,
substantial positivethis concerns
change cases
can be8 and 9. For T1–T4,
observed on the this dimension
concerns ‘em
Figures 4 and 5 show that the art therapists are most
cases 1, 5, 8, 9 and 11. Additionally, for the same time period T1–T4, the art therapist was
actively supportive on ‘s
regulation’
behavior’. For (cases 2,
theintime 4, 5, 6, 7, 8, 9, 11, and 12). For the other three subscales, we asce
substantially active two period T1–T3,
cases (cases this12)
11 and concerns casesto8 ‘stimulating
with respect and 9. For T1–T4, emotionthis conc
substantial
regulation’. positive change in ‘sense of self’, ‘social behavior’
cases 1, 5, 8, 9 and 11. Additionally, for the same time period T1–T4, the art therapist and ‘flexibility’ in four (
5, 6,The
8, and 9),active
three
IOS results
substantially (cases
15 weeks 2,cases
in twoafter 8,termination
and 9), and
(cases 11ofagain three
the treatment
and 12) with children
(T4) (cases
compared
respect to2,T1
3,are
to ‘stimulatingand 8),emo
re
graphically
tively. For
regulation’. displayed
two in
children Figure
(cases6. For
1 ten
and children
10), we (cases
hardly 1, 2, 5,
observe6, 7, 8, 9,
change,10, 11, and
while 12),
also obser
substantial
someThe or minor
negative positive change is shown in one or more subscales. Substantial positive
tendencies.
IOS results 15 weeks after termination of the treatment (T4) compared to T
changeFigures
in one or4 more
and 5subscales
show is shown
that theFor fortherapists
art six childrenare (cases
most1, 2,actively
5, 7, 8, and 9); sub- on ‘s
supportive
graphically displayed in Figure 6. ten children (cases
stantial negative change in one or more subscales is shown for two children (cases 4 and 1, 2, 5, 6, 7, 8, 9, 10,
7). 11, and
behavior’.
substantial
Looking
For
at allor
the time
minor positive
subscales,
period
we ascertain
T1–T3,
change this concerns
is shown
substantial in one
positive
cases 8
or more
change
and 9. For
subscales.
in ‘emotion
T1–T4, this con
Substantial
regulation’
caseschange
tive 1, 5, 8,in
9 and
one 11. Additionally,
or more subscalesfor
is the samefor
shown time
six period
childrenT1–T4,
(casesthe1, art
2, 5,therapis
7, 8, an
substantially
substantial active in
negative two cases
change in one(cases 11 and
or more 12) with
subscales respectfor
is shown to two
‘stimulating
children em (ca
regulation’.
The IOS results 15 weeks after termination of the treatment (T4) compared to T
Children
Children 2022,
2022, 9,
9, xx FOR
FOR PEER
PEER REVIEW
REVIEW 77
Children 2022, 9, 1036 7 of 17
and
and 7).
7). Looking
Looking at at all
all subscales,
subscales, we we ascertain
ascertain substantial
substantial positive
positive change
change in in ‘emotion
‘emotion
ulation’
ulation’ at T4 compared to T1 in five children (cases 1, 2, 5, 7, and 9). For ‘sense of
at T4 compared to T1 in five children (cases 1, 2, 5, 7, and 9). For ‘sense of self
self
at
seeT4 compared
substantial to T1 in
positive five children
change in (cases
three 1, 2, 5,
children 7, and
(cases 9).
5, For
8, 9).‘sense of
Regarding self’, we
‘social beha
seesubstantial
see substantial positive
positive change
change in three
in three children
children (cases (cases
5, 8, 9).5,Regarding
8, 9). Regarding ‘social beha
‘social behav-
and
and ‘flexibility’,
‘flexibility’, substantial
positive development
development can
can be
be identified
identified
ior’ and ‘flexibility’, substantial positive development can be identified in two children
in
in two
two children
children (c(
1 and
(cases 8).
1 and1 8). Child
andChild 4
8). Child showed a substantial
4 showeda asubstantial
4 showed negative
substantial negative
negative development
development
development in ‘emotion
in ‘emotion regulation
regulation’
‘flexibility’.
‘flexibility’. In addition, one child (case 7) developed substantially positive results
and In
‘flexibility’. addition,
In addition, one
one child
child (case
(case 7)
7) developed
developed substantially
substantially positive
positive results in
results in
in ‘e
‘
‘emotion
tion regulation’,
tion regulation’,
regulation’, and and substantially
and substantially negative
substantially negative results
negative resultsin ‘flexibility’.
results in
in ‘flexibility’.
‘flexibility’.
EAT
EAT T3-T1
T3-T1 means
means of
of all
all subscales
subscales
per
per case
case
3.0
3.0
2.0
2.0
1.0
1.0
0.0
0.0
11 22 33 44 55 66 77 88 99 10
10 11
11 12
12
-1.0
-1.0
-2.0
-2.0
sense
sense of
of self
self emotion
emotion regulation
regulation
flexibility
flexibility social
social behavior
behavior
Figure Means
Figure4. 4.
Figure 4. of all
Means
Means ofsubscales
of all per case,
all subscales
subscales perT3–T1.
per case,
case, T3–T1.
T3–T1.
EAT
EAT T4–T1
T4–T1 means
means of
of all
all subscales
subscales
per
per case
case
3.0
3.0
2.0
2.0
1.0
1.0
0.0
0.0
11 22 33 44 55 66 77 88 99 10
10 11
11 12
12
-1.0
-1.0
-2.0
-2.0
sense
sense of
of self
self emotion
emotion regulation
regulation
flexibility
flexibility social
social behavior
behavior
Figure
Figure5. 5.
Figure Means
Means
5. of
of all
Means all
all subscales
ofsubscales per
per case,
subscales case,
case, T4–T1.
perT4–T1. T4–T1.
Children 2022, 9, 1036 8 of 17
Figure 6. Means of all subscales per case, T4–T1.
3.2. Change in Children’s Behavior with Respect to Therapists’ Behavior

One purpose of our analysis was to explore whether childrens’ behavior changed
during the IOS program, and if and how this was related to the behavior of the therapist.
We take a look at this question, thereby focusing on three groups of children: children who
seemed to take the most (four cases) or least (one case) advantage of the treatment, and a
group that did not exhibit much change (three cases).
Most profit. Substantial enduring positive change in more than one subscale is shown
in Figure 5 (time period T1–T4) for four children (cases 1, 5, 8, 9). These changes appeared
in varied (combinations of) behavior areas. Related to therapist’s behavior mean scores,
we saw in these cases that the therapist showed most actions in the ‘supporting social
behavior’ area and hardly offered support on developing a ‘sense of self’. Additionally,
during the therapy sessions (T1–T3), most support from the therapists was directed at the
‘social behavior’ of these children.
Least profit. Child 4 showed relatively flat and substantial negative scores for both
the time period T1–T2 (Figure 1) and the time period T1–T4 (Figure 5). The profiles
(Figures 2, 4 and 6) also show a therapist who is relatively inactive in supporting the child.
Not much change. For one dyad (case 10), the profile is quite flat in all compared
measurement moments; both the child’s and therapist’s behaviors hardly show any change.
Another child (case 3) shows some change on one dimension, ‘flexibility’, during therapy
(Figures 1 and 3), but the change is not persistent (Figure 5). In this case, the support
of the therapist is at a low level of activity (Figure 2), or even substantially diminished
(Figure 4). Child 12 shows some change during the time period T1–T3 in ‘emotion regu-
lation’ (Figure 3); but, looking at the other comparisons of time moments, it is difficult to
observe change. The art therapist is surprisingly active in supporting ‘emotion regulation’
at T4 compared to T1 (Figure 6), but this is not associated with positive scores for the child
with respect to this behavior (Figure 5).
3.3. Group Analyses

The mean ranks of the OAT and EAT of the four measurement moments are shown in
Figures 7 and 8. These two figures also make it possible to perform a visual inspection of
the change in child behaviors with reference to therapist behaviors as a group.
Children 2022,
Children 2022,9,9,x1036
FOR PEER REVIEW 9 of 17 9 of
OAT, mean ranks of 12 cases at

the four measurement moments
5
1
T1 T2 T3 T4

Figure7. 7.
Figure Mean
Mean ranks
ranks of OAT.
of OAT.
EAT, mean ranks of 12 cases at

5
1
T1 T2 T3 T4
Figure Mean
Figure8. 8. ranks
Mean of EAT.
ranks of EAT.
With respect to the development of the children, in Figure 7, it can be observed that
With respect to the development of the children, in Figure 7, it can be observed th
the subscales ‘sense of self’, ‘emotion regulation’ and ‘social behavior’ seem to have a linear
the subscales‘Sense
development. ‘senseofofself’
self’,
( 2‘emotion
(3) = 9.72;regulation’
p = 0.02) andand ‘social
‘social behavior’
behavior’ seem
( 2 (3) to have a l
= 13.72;
ear development. ‘Sense of self’ (χ 2(3) = 9.72; p = 0.02) and ‘social behavior’ (χ2(3) = 13.
p = 0.004) increase significantly, while the linear development in ‘emotion regulation’ is
visually apparent,
p = 0.004) increase but statistically
significantly,not while
significant 2 (3) = development
the (linear 4.70; p = 0.20). ‘Flexibility’
in ‘emotion shows
regulation
avisually
constant apparent, 2
line ( (3) =but 4.32; p = 0.23).
statistically not significant (χ (3) = 4.70; p = 0.20). ‘Flexibility’ sho
2
As to the
a constant behavior
line (χ2(3) =of4.32;
the therapists,
p = 0.23). in Figure 8, it can be observed that the sub-
scale ‘stimulating emotion regulation’
As to the behavior seems toin
of the therapists, have a linear
Figure 8, itdevelopment
can be observed ( 2 (3) = 13.50;
that the subsc
p = 0.004). ‘Supporting sense of self’ also has a significant different pattern from the2situa-
‘stimulating emotion regulation’ seems to have a linear development (χ (3) = 13.50; p
tion that all measurements moments are the same ( 2 (3) = 8.52; p = 0.04). In this pattern,
0.004).
we ‘Supporting
observe that after a sense of self’
dip at T2, also hasincreased
the subscale a significant different
substantially pattern
at T3, from the situati
but decreased
that somewhat
again all measurements moments
at T4. However, are the
the mean ranksame
at T4 (χ
2 (3) higher
is still = 8.52;than
p = at0.04). In this
T1. The pattern,
devel-
opment
observe of that
‘stimulating
after asocial
dip atbehavior’
T2, theissubscale
partly linear; from T1substantially
increased to T2, this behavior
at T3, among
but decreas
therapists received more 2 (3) = 2.64; p = 0.45).
again somewhat at T4.emphasis,
However, which remained
the mean rankatatT3T4 and T4 ( higher
is still than at T1. The dev
However,
opment of this pattern wassocial
‘stimulating not significant.
behavior’‘Supporting flexibility’
is partly linear; fromalsoT1 toshows a constant
T2, this behavior amo
line in this figure ( 2 (3) = 2.21; p = 0.53).
therapists received more emphasis, which remained at T3 and T4 (χ (3) = 2.64; p = 0.4 2
However, this pattern was not significant. ‘Supporting flexibility’ also shows a consta
line in this figure (χ2(3) = 2.21; p = 0.53).
Children 2022, 9, 1036 10 of 17
3.4. Patterns in Mean Ranks

The gradients for all four subscales—‘sense of self’, ‘emotion regulation’, ‘flexibility’,
and ‘social behavior’—show an upward development between T1 and T2 for the children
as well as the therapists, except for one of the therapists’ dimensions: ‘supporting sense of
self’ (Figure 8). This indicates that halfway through the treatment, it may be expected that
an ‘average child’ would show improvement in all subscales.
Improvement of the children’s behaviors continued at T3 (end of treatment) and even
at T4 (15 weeks after ending treatment), with the exception of the dimension ‘flexibility’.
The gradients of the EAT scores for ‘supporting sense of self’ show a decrease at T2,
an upward development at T3, and again a decrease at T4. Therefore, especially during
the first half of the treatment sessions, the art therapists do not seem to be very active with
respect to the ‘sense of self’ dimension.
When comparing the OAT and EAT scores at T2, a comparable pattern can be observed:
an increase in mean scores for (supporting) ‘sense of self’, ‘emotion regulation’, ‘flexibility’,
and ‘social behavior’. In particular, the heightened EAT scores at T2 are remarkable; the
therapists clearly seem to increase their support efforts halfway treatment on ‘emotion
regulation’, ‘flexibility’, and ‘social behavior’.
After treatment, only the EAT scores for ‘supporting sense of self’ decreased.
Regarding ‘emotion regulation’, the art therapists’ supportive behavior appeared to
be more strongly represented compared to the other three dimensions.
At the end of the treatment, the therapists’ scores seemed to be higher than at the start
for the subscales ‘stimulating emotion regulation’ and ‘supporting social behavior’.
4. Discussion
In this study, the changes in behavior of children during the IOS program were
explored in four dimensions, i.e., ‘sense of self’, ‘emotion regulation’, ‘flexibility’, and
‘social behavior’. Art therapists evaluated the behavior of their young clients and their own
behavior by repeatedly completing the OAT and EAT, respectively. Besides descriptive
results using each instrument, we also visually explored whether and how changes in the
behavior of children were associated with the behavior of therapists.
Looking at the individual children, the change in behavior represented by the subscales
‘sense of self’, ‘emotion regulation’, ‘flexibility’, and ‘social behavior’ was highly varied.
It is plausible to firstly explain this variation on the basis of the diversity of problems in
children diagnosed with ASD [7,43]. Despite this variation, we see that ten of the twelve
children showed moderate to substantial positive behavior changes during art making
considering all OAT subscales—at the end of the program and fifteen weeks after treatment
termination. This confirms our expectation that the ‘art therapy triangle’ may offer an
important contribution; the triangular relationship between the child, the art making, and
the therapist seems to give opportunities to improve verbal and nonverbal communication
skills [10]. In general, it has been shown that AT is a promising treatment for patients/clients
who have difficulties in identifying and expressing their emotions verbally [44]. Interactions
with a therapist via artistic means are indicated as being supportive for children with
autism-related problems in order to improve their social communication skills [5,27].
Qualitative comments by art therapists can be helpful in better understanding cases
with negative changes and those with quite a flat profile (cases 4 and 10, respectively). The
art therapists reported that both children improved on most outcomes, but at the same
time, they were young persons who remained dependent on a supportive environment.
This is a realistic prospect for children diagnosed with ASD [45]. With respect to the child
with the flat profile (case 10), the art therapist reported that she observed a development in
the art making. Nevertheless, the child kept on saying: “Please explain to me what is the
point about this art making?”. This result may indicate that not every child with ASD may
develop skills and positive behaviors during art making.
Additionally, some other patterns emerged. For the OAT subscales, the highest amount
of substantial and moderate positive change in behavior was established for ‘emotion
Children 2022, 9, 1036 11 of 17
regulation’: between T1 and T3 for nine children, and between T1 and T4 also for nine
children, with an overlap of seven children. This result corresponds with improvement
of ‘emotion regulation’ in 50–55% of AT treatment cases, which is in line with a recently
published review [5].
In the mean ranks of scores, it is possible to observe an improvement in children’s
behaviors, even 15 weeks after treatment, albeit with the exception of the ‘flexibility’
subscale. We notice here that the results regarding children’s behavior during art making
differ in some respects from the observations supplied by parents and teachers at home
and in the classroom; see also [19]. It may be assumed that the art therapy triangle offers
other opportunities for the children’s behavior and expressions during art making and for
interacting with the art therapist via the art making [24,46]. Another explanation may be
found in the different perspectives and situations of observation of therapists compared to
teachers and parents [47].
For the ‘social behavior’ subscale, the moderate or substantial development of eight
cases, 15 weeks after treatment, was compared to that of seven cases directly after treatment.
The improvement 15 weeks after treatment may indicate an ‘after effect’. Improvement of
‘social behavior’ in 75% of AT treatment cases is in line with a recently published review [5].
For children with ASD, improvement of ‘social behavior’ is often described as one of the
most important AT aims [11,12,48].
The EAT ‘supporting sense of self’ scores showed a decrease at T2 compared to T1, an
increase at T3, and again a decrease at T4. This may mean that the therapists—in line with
the literature—adhere at different moments to varying intensities of actions while offering
the child opportunities to learn from tactile experiences. In the literature, it has been found
that art therapists presume sensory experiences to be the most supportive element for the
child in developing a ‘sense of self’ [10–12,15,16]. Improvement of self-esteem, which is
part of the ‘sense of self’ continuum, seems to be observed in 50–55% of the AT treatments
to be observed [5].
Comparison of mean ranks of observed children’s behaviors with mean ranks of
therapists’ behaviors hardly shows a clear relationship between the two behaviors. For
instance, we saw little change in efforts in ‘supporting sense of self’ by therapists. An
explanation might be that, according to the therapist’s view, the handling and touching
of art materials is the main source contributing to improvement of ‘sense of self’ for these
children. In other words, and considering the ‘art therapy triangle’ and the communication
difficulties of children with ASD, it might be assumed that psychological processes involved
in the ‘sense of self’ are not directly influenced by the therapist’s behavior.
The mapping of the first and second IOS phases showed a remarkable positive change
in children’s behaviors halfway through treatment. This might indicate that during the first
eight sessions, one could already expect positive developments in some or all behavioral
dimensions. Additionally, we found an increased activity of the therapists’ halfway treat-
ment on the dimensions of stimulation or supporting ‘emotion regulation’, ‘flexibility’, and
‘social behavior’. It seems plausible that the therapist does not start with full effort, because
at the start, it takes time to get acquainted, build a safe situation, etc. When the therapeutic
relationship is more or less set, the therapist may increase efforts at T2 and invite the child
to share new experiences. At T3, the therapists become again a bit less active in their
support, thereby anticipating the moment at which the child needs to further develop
without being supported by a therapist and should integrate his/her new experiences,
skills and behaviors into daily life. This pattern reminds us of a model of promoting change
in people’s behavior, already conceptualized in 1947 by the psychologist Dr. Kurt Lewin in
a three-step frame with the phases ‘unfreezing’, ‘moving’, and ‘freezing’. The steps refer to
helping someone to orient him/herself to new behavior, to (tentatively) practice it, and to
stabilize it with diminishing external support, respectively [49]. Therapists might apply the
model even without being professionally aware of its existence.
In their qualitative reported comments, art therapists mentioned that the clearly
designed treatment program was helpful. Feedback informed treatment is supportive
Children 2022, 9, 1036 12 of 17
for therapist’s working in a child psychiatric setting [50]. This contributes to improved
quality of life in children with ASD and also supports parents’ expectations. Participating
therapists mentioned being surprised that they did not see further change after 15 sessions,
because most of them were used to applying art therapy for a period of around a year.
Evaluation moments combined with the use of videos is understood to be supportive
for helpers working with ASD patients/clients [51]. Additionally, parents and others who
have to communicate with ASD children (teachers) feel supported by the opportunities
that video-recordings offers [52].
Our study confirms that working in the ‘art therapy triangle’ allows children with
communication problems to develop their sense of self, emotion regulation skills and
communication skills, and sometimes also flexibility.
4.1. Strengths and Limitations

This study provides new insights into the treatment process by monitoring children’s
and therapists’ behavior with respect to the 12 cases that were part of the research. The
‘Images of Self’ program is—as far as we know—the first empirically studied art therapy
program, specifically for children diagnosed with ASD. The intervention, with its ‘built-in’
monitoring system, creates opportunities to explore characteristics of the processes of
change in the ‘art therapeutic triangle’ of child, art (making), and therapist. The program
provides a manual that allows attunement to the client’s needs during art making, in order
to build a strong therapeutic alliance via art making.
The combination of the IOS program with the measurement instruments OAT and
EAT provided a focus in the treatment for the participating art therapists. The instruments
that were applied for observing the children’s and therapists’ behavior were intensively
tested on aspects of validity and reliability [26]. The design of the study—a multiple case
study with repeated measurements, with a combination of quantitative and qualitative
data—allowed us to profile the child’s as well as the therapist’s developments in behavior,
and to compare both—case by case and on the level of the whole sample—in our search for
associations and patterns.
We also notice some limitations. Although we have confidence in the observation
scales OAT and EAT, it cannot be denied that the study mostly leans on the perspective
of professionals, i.e., the art therapists. Missing is especially the perspective of the child.
While spontaneous utterances of the participating children were mapped, a child-oriented
method including ‘their voices’ (like, for instance, by interviewing them) was lacking.
This holds less true for the parents and teachers, because they were asked to report their
observations at home and at school, respectively.
In addition, there are indications that therapists in some situations might overestimate
their competences in therapeutic settings [53]. Contrary to this kind of ‘bias’, we found that
participating therapists did not always report their behavior to be as active as might be
expected in a therapeutic context. Especially regarding the dimension ‘supporting sense
of self’, the level of input by the therapists was relatively low. This did not seem to be
evaluated by them as a ‘failure’ of engagement and might argue against bias. Nevertheless,
it would be profitable in further research to include neutral, trained observers in order to
fill out the OAT and EAT forms—in addition to the observations by the therapists.
The design prohibits the possibility of making causal inferences. If we would like
to deepen our insights regarding the question as to what in the therapeutic processes
‘causes’ progress with children, another type of design, i.e., a (quasi-)experimental one,
would be needed [54]. This means that a sample of children receiving AT according to the
IOS program would be compared to a sample that does were receiving AT, or that were
receiving another treatment. Considering the necessary ‘power’ to make valid inferences, a
bigger sample than the current one is required.
As indicated up here we found some differences between the results of this study
compared to our former study [18]. This may indicate that the observed behaviors of the
children during art making are different from the behaviors at home and in the classroom.
Children 2022, 9, 1036 13 of 17
For that reason we suggest to include all relevant contexts (therapy, home, school, leisure
time) in future research.
4.2. Recommendations
We recommend continuing the research on art therapy by applying the IOS program
on a larger scale and carefully monitoring the results. Above, we already argued in favor
of a (quasi-)experimental design to gain further insight into the effectiveness of IOS. More
detailed insights into children’s and therapists’ behavior during AT and how these relate to
each other can be gained from a larger pool of n = 1 studies with repeated measurements.
In these studies, the ‘voice of the child’ should be included—more than was the case in the
current research.
Special attention should be paid to the working mechanisms of art making as an instru-
ment to improve specific behaviors: what exactly is the role of making art and expressing
oneself in an artistic way for the child’s development and behavior? A combination of
narrative methods (interview, diary, focus group) and content analysis of ‘art products’
might be helpful in further clarifying the dynamics during AT.
In a more practical sense, we propose to improve the IOS program by gathering
feedback from experienced therapists and trainees, as well as from parents or other network
members like teachers. As was already indicated, the use of video-recordings, together
with analyzing and discussing these afterwards, has proven to be very valuable. For that
reason, we consider the instruments OAT and EAT that have been used in this study to
systematically observe children’s and therapists’ behavior, as an integral part of the IOS
program. The implication is that AT therapists using IOS should be thoroughly trained in
the implementation of these instruments.
Until now, the IOS program has only been applied and studied in the context of mental
health care services for children with ASD. Recently, a pilot study started to broaden the
field in which IOS could be applied. An empirical study to investigate the possibilities and
opportunities to apply the program in a school context, thereby studying the preventive
qualities of AT for children with ASD and other psychosocial problems: is participation of
vulnerable children in IOS during school hours helpful in preventing their referral to more
‘heavy’ psychosocial services or treatments? In addition, in what way does IOS, applied in
an educational environment for teachers, support expanded possibilities for accompanying
children with ASD [9].
Author Contributions: Conceptualization, C.S., E.J.K., T.A.V.Y. and M.S.; Formal analysis, C.S., E.J.K.
and M.S.; Investigation, C.S.; Methodology, M.S.; Supervision, E.J.K. and T.A.V.Y.; Visualization, C.S.;
Writing—original draft, C.S.; Writing—review and editing, E.J.K., T.A.V.Y. and M.S. All authors have
read and agreed to the published version of the manuscript.
Funding: This research received no external funding.
Institutional Review Board Statement: The study was conducted according to the guidelines of
the Declaration of Helsinki, and approved by the Regionale Toetsingscommissie (RTPO 1026a,
9 January 2018).
Informed Consent Statement: Written informed consent was obtained from all subjects involved in
the study.
Data Availability Statement: The data presented in this study are available on request from the
corresponding author.
Acknowledgments: Our gratitude goes out to the children, their parents, teachers and art therapists
who participated in this study.
Conflicts of Interest: The authors declare no conflict of interest.
Children 2022, 9, 1036 14 of 17
Appendix A
Table A1. Overview of participating children, art therapists, treatment settings, reasons for referral, use of medication, and context information [19]
Reprinted/adapted with permission from Elsevier Rights and Permissions, http://s100.copyright.com/mycount/viewrightslinkorders; accessed on 6 July 2022).
Experience of
Child. Gender Age Art Therapist Treatment Setting Reason for Referral Medication Context Information
Art Therapist (years)
After eight weeks she is
Ambulant mental Not going to school at start AT. part-time visiting school.
1 F 6 1 13 health care Heavy emotion regulation problems and Vitamin B injections Mother tells that the teacher
organization inflexible behavior in classroom. does not understand
her child.
Philippine background with
(Semi)residential Asian values about
Social communication problems: isolated;
2 F 9 2 40 psychiatric center for No behavior and education.
what is she thinking/feeling?
children and youth Mother has a burn-out and
is in a divorce.
Extra psycho- education for
Emotion regulation problems in classroom
School for special Methyl phenidate for child, to improve her
3 F 12 3 8 (crying); negative self-image;
education oversensitivity understanding of ASD.
oversensitivity.
Child shows severe depressed feelings at

(Semi)residential
home. Negative self-image. Parent training to improve
4 M 10 4 13 psychiatric center for Methyl phenidate
Emotion regulation problems in classroom understanding of ASD.
children and youth
(anxiety problems and anger outbursts).
Negative self-image.
Severe depressed feelings at home.
At the end of AT she went
School for special Emotion regulation problems in classroom
5 F 11 5 40 No to a lower class grade.
education (anxiety problems).
Social communication problems at home
and in school (hardly talks).
Children 2022, 9, 1036 15 of 17
Table A1. Cont.
Experience of
Yes, for the anxiety
and emotion After 10 weeks, mother
School for special Emotion regulation problems at home and in
6 M 9 5 40 regulation, but no severely ill. Child has
education classroom (anxiety problems and anger
specific information problems with teacher.
outbursts).
what it is.
School for special Negative self-image.
7 M 10 5 40 No
education Flexibility problems at home.
(Semi)residential Parent training to
Flexibility problems. Social communication
8 M 12 6 20 psychiatric center for No improve understanding
problems (what is she thinking/feeling?).
children and youth of ASD.
Anxiety problems.
Parent training to
(Semi)residential Negative self-image. improve understanding
9 M 12 6 20 psychiatric center for Emotion regulation problems at home and in No of ASD.
children and youth classroom (anger outbursts). Stop-think-do method is
used in school.
Ambulant mental Emotion regulation problems at home Parent training to
10 M 11 1 13 health care (anger outbursts). No improve understanding
organization Social communication problems (what is he of ASD.
thinking/feeling?).
Ambulant mental
health care Negative self-image. Methyl phenidate
11 F 11 7 9
organization Social communication problems. for ADHD
Parent training to
Ambulant mental Negative self-image. Very depressed feelings. improve understanding
12 M 12 1 13 health care Social communication problems (what is he No of ASD.
organization thinking/feeling?). Divorce of parents
during treatment.
Children 2022, 9, 1036 16 of 17
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REVIEW
published: 12 August 2021
doi: 10.3389/fpsyg.2021.686005
Art Therapy: A Complementary

Treatment for Mental Disorders
Jingxuan Hu 1 , Jinhuan Zhang 2,3 , Liyu Hu 2 , Haibo Yu 2 and Jinping Xu 3*
1
College of Creative Design, Shenzhen Technology University, Shenzhen, China, 2 The Fourth Clinical Medical College
of Guangzhou University of Chinese Medicine, Shenzhen, China, 3 Institute of Biomedical and Health Engineering, Shenzhen
Institutes of Advanced Technology, Chinese Academy of Sciences, Shenzhen, China
Art therapy, as a non-pharmacological medical complementary and alternative therapy,

has been used as one of medical interventions with good clinical effects on mental
disorders. However, systematically reviewed in detail in clinical situations is lacking.
Here, we searched on PubMed for art therapy in an attempt to explore its theoretical
basis, clinical applications, and future perspectives to summary its global pictures.
Since drawings and paintings have been historically recognized as a useful part of
therapeutic processes in art therapy, we focused on studies of art therapy which mainly
includes painting and drawing as media. As a result, a total of 413 literature were
identified. After carefully reading full articles, we found that art therapy has been gradually
Edited by: and successfully used for patients with mental disorders with positive outcomes,
Stephen Clift, mainly reducing suffering from mental symptoms. These disorders mainly include
Canterbury Christ Church University,
United Kingdom
depression disorders and anxiety, cognitive impairment and dementias, Alzheimer’s
Reviewed by:
disease, schizophrenia, and autism. These findings suggest that art therapy can not
Rachel Brandoff, only be served as an useful therapeutic method to assist patients to open up and share
Thomas Jefferson University, their feelings, views, and experiences, but also as an auxiliary treatment for diagnosing
United States
Juliet L. King, diseases to help medical specialists obtain complementary information different from
George Washington University, conventional tests. We humbly believe that art therapy has great potential in clinical
United States
applications on mental disorders to be further explored.
*Correspondence:
Jinping Xu Keywords: painting, art therapy, mental disorders, clinical applications, medical interventions
jp.xu@siat.ac.cn
Specialty section: INTRODUCTION

This article was submitted to
Health Psychology, Mental disorders constitute a huge social and economic burden for health care systems worldwide
a section of the journal (Zschucke et al., 2013; Kenbubpha et al., 2018). In China, the lifetime prevalence of mental
Frontiers in Psychology
disorders was 24.20%, and 1-month prevalence of mental disorders was 14.27% (Xu et al., 2017).
Received: 26 March 2021 The situation is more severely in other countries, especially for developing ones. Given the large
numbers of people in need and the humanitarian imperative to reduce suffering, there is an
Published: 12 August 2021
urgent need to implement scalable mental health interventions to address this burden. While
Citation: pharmacological treatment is the first choice for mental disorders to alleviate the major symptoms,
Hu J, Zhang J, Hu L, Yu H and
many antipsychotics contribute to poor quality of life and debilitating adverse effects. Therefore,
Xu J (2021) Art Therapy:
A Complementary Treatment
clinicians have turned toward to complementary treatments, such as art therapy in addressing the
for Mental Disorders. health needs of patients more than half a century ago.
Front. Psychol. 12:686005. Art therapy, is defined by the British Association of Art Therapists as: “a form of psychotherapy
doi: 10.3389/fpsyg.2021.686005 that uses art media as its primary mode of expression and communication. Clients referred to
Frontiers in Psychology | www.frontiersin.org 1 August 2021 | Volume 12 | Article 686005

Hu et al. AT for Mental Disorders
art therapists are not required to have experience or skills in the PUBLICATIONS OF ART THERAPY
arts. The art therapist’s primary concern is not to make an esthetic
or diagnostic assessment of the client’s image. The overall goal The literatures about “art therapy” published from January 2006
of its practitioners is to enable clients to change and grow on a to December 2020 were searched in the PubMed database. The
personal level through the use of artistic materials in a safe and following topics were used: Title/Abstract = “art therapy,” Indexes
convenient environment” (British Association of Art Therapists, Timespan = 2006–2020.
2015), whereas as: “an integrative mental health and human A total of 652 records were found. Then, we manually screened
services profession that enriches the lives of individuals, families, out the literatures that contained the word “art” but was not
and communities through active art-making, creative process, relevant with the subject of this study, such as state of the art
applied psychological theory, and human experience within therapy, antiretroviral therapy (ART), and assisted reproductive
a psycho-therapeutic relationship” (American Art Therapy technology (ART). Finally, 479 records about art therapy were
Association, 2018) according to the American Art Association. identified. Since we aimed to focus on art therapy included
It has gradually become a well-known form of spiritual support painting and drawing as major media, we screened out literatures
and complementary therapy (Faller and Schmidt, 2004; Nainis deeper, and identified 413 (84%) literatures involved in painting
et al., 2006). During the therapy, art therapists can utilize many and drawing (Figure 1).
different art materials as media (i.e., visual art, painting, drawing, As we can see, the number of literature about art therapy is
music, dance, drama, and writing) (Deshmukh et al., 2018; increasing slowly in the last 15 years, reaching a peak in 2020.
Chiang et al., 2019). Among them, drawings and paintings have This indicates that more effort was made on this topic in recent
been historically recognized as the most useful part of therapeutic years (Figure 1).
processes within psychiatric and psychological specialties (British
Association of Art Therapists, 2015). Moreover, many other art
forms gradually fall under the prevue of their own professions OVERVIEW OF ART THERAPY
(e.g., music therapy, dance/movement therapy, and drama
therapy) (Deshmukh et al., 2018). Thus, we excluded these As defined by the British Association of Art Therapists, art
studies and only focused on studies of art therapy which therapy is a form of psychotherapy that uses art media as its
mainly includes painting and drawing as media. Specifically, primary mode of communication. Based on above literature,
it focuses on capturing psychodynamic processes by means several highlights need to be summarized. (1) The main media
of “inner pictures,” which become visible by the creative of art therapy include painting, drawing, music, drama, dance,
process (Steinbauer et al., 1999). These pictures reflect the drama, and writing (Chiang et al., 2019). (2) Main contents
psychopathology of different psychiatric disorders and even their of painting and drawing include blind drawing, spiral drawing,
corresponding therapeutic process based on specific rules and drawing moods and self-portraits (Legrand et al., 2017; Abbing
criterion (Steinbauer and Taucher, 2001). It has been gradually et al., 2018; Papangelo et al., 2020). (3) Art therapy is mainly
recognized and used as an alternative treatment for therapeutic used for cancer, depression and anxiety, autism, dementia and
processes within psychiatric and psychological specialties, as cognitive impairment, as these patients are reluctant to express
well as medical and neurology-based scientific audiences themselves in words (Attard and Larkin, 2016; Deshmukh et al.,
(Burton, 2009). 2018; Chiang et al., 2019). It plays an important role in facilitating
The development of art therapy comes partly from the engagement when direct verbal interaction becomes difficult, and
artistic expression of the belief in unspoken things, and provides a safe and indirect way to connect oneself with others
partly from the clinical work of art therapists in the medical (Papangelo et al., 2020). Moreover, we found that art therapy
setting with various groups of patients (Malchiodi, 2013). has been gradually and successfully used for patients with mental
It is defined as the application of artistic expressions and disorders with positive outcomes, mainly reducing suffering from
images to individuals who are physically ill, undergoing mental symptoms. These findings suggest that art therapy can not
invasive medical procedures, such as surgery or chemotherapy only be served as an useful therapeutic method to assist patients
for clinical usage (Bar-Sela et al., 2007; Forzoni et al., to open up and share their feelings, views, and experiences, but
2010; Liebmann and Weston, 2015). The American Art also as an auxiliary treatment for diagnosing diseases to help
Therapy Association describes its main functions as improving medical specialists obtain complementary information different
cognitive and sensorimotor functions, fostering self-esteem from conventional tests.
and self-awareness, cultivating emotional resilience, promoting
insight, enhancing social skills, reducing and resolving conflicts
and distress, and promoting societal and ecological changes ART THERAPY FOR MENTAL
(American Art Therapy Association, 2018). DISORDERS
However, despite the above advantages, published
systematically review on this topic is lacking. Therefore, Based on the 413 searched literatures, we further limited them
this review aims to explore its clinical applications and future to mental disorders using the following key words, respectively:
perspectives to summary its global pictures, so as to provide more Depression OR anxiety OR Cognitive impairment OR dementia
clinical treatment options and research directions for therapists OR Alzheimer’s disease OR Autism OR Schizophrenia OR mental
and researchers. disorder. As a result, a total of 23 studies (5%) (Table 1) were

FIGURE 1 | Number of publications about art therapy.
included and classified after reading the abstract and the full (Runde, 2008; Zhenhai and Yunhua, 2011) have shown that
text carefully. These studies include 9 articles on depression art therapy also significantly reduces depressive symptoms in
and anxiety, 4 articles on cognitive impairment and dementia, 3 students. For example, Wang et al. (2011) conducted group
articles on Alzheimer’s disease, 3 articles on autism, and 4 articles painting therapy on 30 patients with depression for 3 months,
on schizophrenia. In addition to the English literature, in fact, and found that painting therapy could promote their social
some Chinese literatures also described the application of art function recovery, improve their social adaptability and quality of
therapy in mental diseases, which were not listed but referred to life. Another randomized clinical trial also showed that it could
in the following specific literatures. decrease mean anxiety scores in the 3–12 year painting group
(Forouzandeh et al., 2020).
Depression Disorders and Anxiety Studies have shown that distress, including anxiety and
Depression and anxiety disorders are highly prevalent, depression, is related to poorer health-related quality of life and
affecting individuals, their families and the individual’s role in satisfaction to medical services (Hamer et al., 2009). Painting can
society (Birgitta et al., 2018). Depression is a disabling and costly be employed to express patients’ anxiety and fear, vent negative
condition associated with a significant reduction in quality of emotions by applying projection, thereby significantly improve
life, medical comorbidities and mortality (Demyttenaere et al., the mood and reduce symptoms of depression and anxiety of
2004; Whiteford et al., 2013; Cuijpers et al., 2014). Anxiety is cancer patients. A number of studies (Bar-Sela et al., 2007; Thyme
associated with lower quality of life and negative effects on et al., 2009; Lin et al., 2012; Abdulah and Abdulla, 2018) showed
psychosocial functioning (Cramer et al., 2005). Medication is that art therapy for cancer patients could enhance the vitality of
the most commonly used effective way to relieve symptoms patients and participation in social activities, significantly reduce
of depression and anxiety. However, nonadherence are crucial depression, anxiety, and reduce stressful feelings. Importantly,
shortcomings in using antidepressant to treat depression and even in the follow-up period, art therapy still has a lasting effect
anxiety (van Geffen et al., 2007; Nielsen et al., 2019). on cancer patients (Thyme et al., 2009). Interestingly, art therapy
In recent years, many studies have shown that art therapy based on famous painting appreciation could also significantly
plays a significant role in alleviating depression symptoms and reduce anxiety and depression associated with cancer (Lee et al.,
anxiety. Gussak (2007) performed an observational survey about 2017). Among cancer patients treated in outpatient health care,
populations in prison of northern Florida and identified that art therapy also plays an important role in alleviating their
art therapy significantly reduces depressive symptoms. Similarly, physical symptoms and mental health (Götze et al., 2009).
a randomized, controlled, and single-blind study about art Therefore, art therapy as an auxiliary treatment of cancer is of
therapy for depression with the elderly showed that painting great value in improving quality of life.
as an adjuvant treatment for depression can reduce depressive Overall, art painting therapy permits patients to express
and anxiety symptoms (Ciasca et al., 2018). In addition, art themselves in a manner acceptable to the inside and outside
therapy is also widely used among students, and several studies culture, thereby diminishing depressed and anxiety symptoms.

TABLE 1 | Studies of art therapy in mental diseases.
Frontiers in Psychology | www.frontiersin.org
Hu et al.
Type of diseases/ Country Number Treatment Subjects Main results
author and year (painting)
Depression and anxiety

Bar-Sela et al., 2007 Israel 19/41 once-weekly, 4w/2w Cancer patients with In the intervention group, the median Hospital Anxiety and Depression
depression and anxiety Scale score for depression was 9 at the beginning and 7 after the fourth
appointment.
Gussak, 2007 Unite States 48 4-week period, two group Depression The results reflected a significant decrease in depressive symptoms in
American sessions per week those inmates who participated in the program.
Geue et al., 2013 Germany 54 22 sessions Cancer patients with Anxiety scores decreased in a pre–post comparison.
psychological distress
Crone et al., 2013 United Kingdom 202 10-week intervention Patients with anxiety, There was a significant improvement in well-being.
depression, or stress
Montag et al., 2014 Germany 58 12 twice-weekly sessions Acute psychotic episodes with Patients in the ART group showed significant improvement in levels of
depression emotional awareness.
Armstrong and United Kingdom 6 mothers/ 12 consecutive weeks Postpartum depression The responses of the questionnaires were more positive after the
Howatson, 2015 8 infants intervention, and 8 of the 10 mothers showed an improvement in
postpartum depression and in the relationship with their children.
Lefèvre et al., 2016 France 28 63 art therapy sessions, Cancer patients with There was a significant reduction in all of the symptoms: pain, anxiety,
1 h/session depression and anxiety evil, fatigue, sadness, and depression.
Ciasca et al., 2018 Brazil 31/25 20 weekly art therapy sessions Depression Art therapy as an adjunctive treatment for MDD in the elderly can
(90 min/session) improve depressive and anxiety symptoms.
Forouzandeh et al., Iran 55 NA Anxiety Nurses should collaborate with medical teams to routinely use
2020 non-pharmacological methods such as the painting and the interactive
4
games to alleviate preoperative anxiety in children.

Cognitive impairment, and dementia
Rusted et al., 2016 United Kingdom 45 1 h each week for 40 Dementia Art therapy is beneficial and appropriate interventions for older people
successive weeks with dementia.
Pike, 2013 Unite States 91 10-week art therapy Cognitive impairment Art therapy treatment was associated with significantly improved
American cognitive performance.
Heymann et al., 2018 Germany 32 analysis of tree drawings on a Mild cognitive impairment (MCI) MCI group shows a higher recognition rate.
digitizing tablet
Yu et al., 2021 Singapore 22 weekly 45-min sessions were MCI Significant gains in immediate memory and working memory span were
carried out across 3 months. observed.
Alzheimer’s disease
Witkoski and Chaves, Brazil 11 31 months Alzheimer’s disease The selection of drawing or modeling showed significant association
August 2021 | Volume 12 | Article 686005
2007 with severity of cognitive deficit.

Mimica and Kaliniæ, Croatia 1 case report not available Alzheimer’s disease The art therapy was shown to be an excellent add-on
2011 non-pharmacological intervention, beneficial for reducing stress-related
behaviors.
Hattori et al., 2011 Japan 39 once weekly for 12 weeks Alzheimer’s disease Significant improvement in the quality of life was observed in the art
AT for Mental Disorders

therapy
Autism
Low et al., 2009 New Zealand 27 four 0.5 to 1 h sessions that Autism There is an important relationship between generativity and imagination.
were approximately 1 week
apart
(Continued)
Cognitive Impairment, and Dementia
imagination and children with autism employ a unique cognitive strategy in
social and life function problems, and promote the recovery of individuals
Group art therapy can improve self-efficacy and social function, reducing
Art therapy produced a statistically significant positive effect on negative
Dementia, a progressive clinical syndrome, is characterized
The patient’s drawings show clinical improvement from the reduction of

The positive effect of art therapy is mainly due to a strengthening of the
depressive themes and an increase in the frequency of human figure

by widespread cognitive impairment in memory, thinking,
Autistic children showed more adaptive behaviors and emotions.

behavior, emotion and performance, leading to worse daily
There are changes in the type of cognitive processes involved in living (Deshmukh et al., 2018). According to the Alzheimer’s
Disease International 2015, there is 46.8 million people suffered
from dementia, and numbers almost doubling every 20 years,
rising to 131.5 million by 2050. Although art therapy has
been used as an alternative treatment for the dementia for
long time, the positive effects of painting therapy on cognitive
function remain largely unknown. One intervention assigned
Schizophrenia’ minimal sense of self. older adults patients with dementia to a group-based art therapy
diagnosed with schizophrenia.

drawings and self-confidence.
(including painting) observed significant improvements in the
clock drawing test (Pike, 2013), whereas two other randomized
controlled trials (Hattori et al., 2011; Rusted et al., 2016) on
imaginative drawing.
patients with dementia have failed to obtain significant cognitive

improvement in the painting group. Moreover, a cochrane
Main results
symptoms.
systematic review (Deshmukh et al., 2018) included two clinical

studies of art therapy for dementia revealed that there is no
sufficient evidence about the efficacy of art therapy for dementia.
This may be because patients with severely cognitive impairment,
who was unable to accurately remember or assess their own
behavior or mental state, might lose the ability to enjoy the
Schizophrenia
Schizophrenia
Schizophrenia
Schizophrenia
benefits of art therapy.

Subjects
In summary, we should intervene earlier in patients with mild

Autism
Autism
cognitive impairment, an intermediate stage between normal

aging and dementia, in order to prevent further transformation
into dementia. To date, mild cognitive impairment is drawing
much attention to the importance of painting intervening at
90 min for a total of 30 times in
12 weekly sessions of one and
this stage in order to alter the course of subsequent cognitive

once a week, two months
decline as soon as possible (Petersen et al., 2014). Recently, a

randomized controlled trial (Yu et al., 2021) showed significant
relationship between improvement immediate memory/working
1.5-h session
memory span and increased cortical thickness in right middle

12 sessions
a half hours
Treatment
2 h a week
15 weeks
frontal gyrus in the painting art group. With the long-term

cognitive stimulation and engagement from multiple sessions of
painting therapy, it is likely that painting therapy could lead to
enhanced cognitive functioning for these patients.
(painting)
Number
104
Alzheimer’s Disease
22
48
43
Alzheimer’s disease (AD) is a sub-type of dementia, which is

usually associated with chronic pain. Previous studies suggested
that art therapy could be used as a complementary treatment
to relief pain for these patients since medication might induce
United Kingdom
severely side effects. In a multicenter randomized controlled

Denmark
Country
Canada
Serbian
China
Iran
trial, 28 mild AD patients showed significant pain reduction,

reduced anxiety, improved quality of life, improved digit span,
and inhibitory processes, as well as reduced depression symptoms
after 12-week painting (Pongan et al., 2017; Alvarenga et al.,
2018). Further study also suggested that individual therapy rather
Richardson et al., 2009
Mannheim et al., 2013
than group therapy could be more optimal since neuroticism can

TABLE 1 | Continued
Ten and Muller, 2018

Type of diseases/
Jalambadani, 2020
decrease efficacy of painting intervention on pain in patients with

author and year
Tong et al., 2020

Teglbjaerg, 2011
Schizophrenia
mild AD. In addition to release chronic pain, art therapy has been
reported to show positive effects on cognitive and psychological
symptoms in patients with mild AD. For example, a controlled
study revealed significant improvement in the apathy scale and

quality of life after 12 weeks of painting treatment mainly Art therapy is a form of expression that opens the door to
including color abstract patterns with pastel crayons or water- communication without verbal interaction. It provides therapists
based paint (Hattori et al., 2011). Another study also revealed with the opportunity to interact one-on-one with individuals
that AD patients showed improvement in facial expression, with autism, and make broad connections in a more comfortable
discourse content and mood after 3-weeks painting intervention and effective way (Babaei et al., 2020). Emery (2004) did a
(Narme et al., 2012). case study about a 6-year-old boy diagnosed with autism and
found that art therapy is of great value to the development,
growth and communication skills of the boy. Recently, one study
Schizophrenia
(Jalambadani, 2020) using 40 children with ASD participating in
Schizophrenia is a complex functional psychotic mental illness
painting therapy showed that painting therapy had a significant
that affects about 1% of the population at some point in their
improvement in the social interactions, adaptive behaviors and
life (Kolliakou et al., 2011). Not only do sufferers experience
emotions. Therefore, encouraging children with ASD to express
“positive” symptoms such as hallucinations, delusions, but
their experience by using nonverbal expressions is crucial to their
also experience negative symptoms such as varying degrees
development. Evans and Dubowski (2001) believed that creating
of anhedonia and asociality, impaired working memory and
images on paper could help children express their internal
attention, poverty of speech, and lack of motivation (Andreasen
images, thereby enhance their imagination and abstract thinking.
and Olsen, 1982). Many patients with schizophrenia remain
Painting can also help autistic children express and vent negative
symptomatic despite pharmacotherapy, and even attempts to
emotions and thereby bring positive emotional experience and
suicide with a rate of 10 to 50% (De Sousa et al., 2020).
promote their self-consciousness (Martin, 2009). According to
For these patients, art therapy is highly recommended to
two studies (Wen and Zhaoming, 2009; Jianhua and Xiaolu,
process emotional, cognitive and psychotic experiences to release
2013) in China, Art therapy could also improve the language and
symptoms. Indeed, many forms of art therapy have been
communication skills, cognitive and behavioral performance of
successfully used in schizophrenia, whether and how painting
children with ASD.
may interfere with psychopathology to release symptoms remains
Moreover, art therapy could be used to investigate the
largely unknown.
relationship between cognitive processes and imagination in
A recent review including 20 studies overall was performed to
children with ASD. One study (Wen and Zhaoming, 2009;
summary findings, however, concluded that it is not clear whether
Jianhua and Xiaolu, 2013) suggested that children with ASD
art therapy leads to clinical improvement in schizophrenia with
apply a unique cognitive strategy in imaginative drawing.
low (Ruiz et al., 2017). Anyway, many randomized clinical
Another study (Low et al., 2009) examined the cognitive
trials reported positive outcomes. For example, Richardson
underpinnings of spontaneous imagination in children with ASD
et al. (2007) conducted painting therapy for six months in
and showed that ASD group lacks imagination, generative ability,
patients with chronic schizophrenia and found that art therapy
planning ability and good consistency in their drawings. In
had a positive effect on negative symptoms. Teglbjaerg (2011)
addition, several studies (Leevers and Harris, 1998; Craig and
examined experience of each patient using interviews and written
Baron-Cohen, 1999; Craig et al., 2001) have been performed
evaluations before and after painting therapy and at a 1-year
to investigate imagination and creativity of autism via drawing
follow-up and found that group painting therapy in patients with
tasks, and showed impairments of autism in imagination and
schizophrenia could not only reduce psychotic symptoms, but
creativity via drawing tasks.
also boost self-esteem and improve social function.
In a word, art therapy plays a significant role in children
What’s more, the characteristics of the painting can also be
with ASD, not only as a method of treatment, but also in
used to judge the health condition in patients with schizophrenia.
understanding and investigating patients’ problems.
For example, Hongxia et al. (2013) explored the correlation
between psychological health condition and characteristics of
House-Tree-Person tests for patients with schizophrenia, and
Other Applications
showed that the detail characteristic of the test results can be
In addition to the above mentioned diseases, art therapy
used to judge the patient’s anxiety, depression, and obsessive-
has also been adopted in other applications. Dysarthia is a
compulsive symptoms.
common sequela of cerebral palsy (CP), which directly affects
Most importantly, several other studies showed that drug
children’s language intelligibility and psycho-social adjustment.
plus painting therapy significantly enhanced patient compliance
Speech therapy does not always help CP children to speak
and self-cognition than drug therapy alone in patients with
more intelligibly. Interestingly, the art therapy can significantly
schizophrenia (Hongyan and JinJie, 2010; Min, 2010).
improve the language intelligibility and their social skills for
children with CP (Wilk et al., 2010).
Autism In brief, these studies suggest that art therapy is meaningful
Autism spectrum disorder (ASD) is a heterogeneous and accepted by both patients and therapists. Most often, art
neurodevelopmental syndrome with no unified pathological or therapy could strengthen patient’s emotional expression, self-
neurobiological etiology, which is characterized by difficulties in esteem, and self-awareness. However, our findings are based on
social interaction, communication problems, and a tendency to relatively small samples and few good-quality qualitative studies,
engage in repetitive behaviors (Geschwind and Levitt, 2007). and require cautious interpretation.

THE APPLICATION PROSPECTS OF ART paints, storage of paints, and toxins of allergens in the paint),
THERAPY insufficient space for the artwork to dry without getting in the
way or getting damaged, and negative medical settings and family
With the development of modern medical technology, life environments. Nevertheless, these difficulties can be overcome
expectancy is also increasing. At the same time, it also due to great benefits of the art therapy. We thus humbly believe
brings some side effects and psychological problems during the that art therapy has great potential for mental disorders.
treatment process, especially for patients with mental illness. In the future, art therapy may be more thoroughly investigated
Therefore, there is an increasing demand for finding appropriate in the following directions. First, more high-quality clinical
complementary therapies to improve life quality of patients trials should be carried out to gain more reliable and rigorous
and psychological health. Art therapy is primarily offered as evidence. Second, the evaluation methods for the effectiveness of
individual art therapy, in this review, we found that art therapy art therapy need to be as diverse as possible. It is necessary for
was most commonly used for depression and anxiety. the investigation to include not only subjective scale evaluations,
Based on the above findings, art therapy, as a non-verbal but also objective means such as brain imaging and hematological
psychotherapy method, not only serves as an auxiliary tool for examinations to be more convincing. Third, it will be helpful to
diagnosing diseases, which helps medical specialists obtain much specify the details of the art therapy and patients for objective
information that is difficult to gain from conventional tests, comparisons, including types of diseases, painting methods,
judge the severity and progression of diseases, and understand required qualifications of the therapist to perform the art therapy,
patients’ psychological state from painting characteristics, but and the theoretical basis and mechanism of the therapy. This
also is an useful therapeutic method, which helps patients practice should be continuously promoted in both hospitals and
open up and share their feelings, views, and experiences. communities. Fourth, guidelines about art therapy should be
Additionally, the implementation of art therapy is not limited gradually formed on the basis of accumulated evidence. Finally,
by age, language, diseases or environment, and is easy to be mechanism of art therapy should be further investigated in
accepted by patients. a variety of ways, such as at the neurological, cellular, and
Art therapy in hospitals and clinical settings could be molecular levels.
very helpful to aid treatment and therapy, and to enhance
communications between patients and on-site medical staffs in
a non-verbal way. Moreover, art therapy could be more effective AUTHOR CONTRIBUTIONS
when combined with other forms of therapy such as music, dance
and other sensory stimuli. JH designed the whole study, analyzed the data, and wrote the
The medical mechanism underlying art therapy using painting manuscript. JZ searched for selected the studies. LH participated
as the medium for intervention remains largely unclear in the in the interpretation of data. HY and JX offered good suggestions.
literature (Salmon, 1993; Broadbent et al., 2004; Guillemin, 2004), All authors read and approved the final manuscript.
and the evidence for effectiveness is insufficient (Mirabella, 2015).
Although a number of studies have shown that art therapy could
improve the quality of life and mental health of patients, standard FUNDING
and rigorous clinical trials with large samples are still lacking.
Moreover, the long-term effect is yet to be assessed due to the lack This study was financially supported by the National Key R&D
of follow-up assessment of art therapy. Program of China (2019YFC1712200), International standards
In some cases, art therapy using painting as the medium research on clinical research and service of Acupuncture-
may be difficult to be implemented in hospitals, due to medical Moxibustion (2019YFC1712205), the National Natural Science
and health regulations (may be partly due to potential of Foundation of China (62006220), and Shenzhen Science and
messes, lack of sink and cleaning space for proper disposal of Technology Research Program (No. JCYJ20200109114816594).
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Wiadomości Lekarskie, VOLUME LXXIV, ISSUE 10 PART 1, OCTOBER 2021 © Aluna Publishing
ORIGINAL ARTICLE
OPINIONS OF PARENTS OF CHILDREN WITH AUTISM SPECTRUM

DISORDERS ON ART THERAPY IN THE IMPROVEMENT OF THEIR
FUNCTIONING
DOI: 10.36740/WLek202110116
Julia Wypyszyńska1, Natalia Zaboklicka1, Maria Stachura1, Zuzanna Sito1, Tomasz Męcik-Kronenberg2
1
STUDENT RESEARCH GROUP AT THE CHAIR AND DEPARTMENT OF PATHOMORPHOLOGY FACULTY OF MEDICAL SCIENCES IN ZABRZE, ZABRZE, POLAND
2
CHAIR AND DEPARTMENT OF PATHOMORPHOLOGY, FACULTY OF MEDICAL SCIENCES IN ZABRZE MEDICAL UNIVERSITY OF SILESIA, ZABRZE, POLAND
ABSTRACT
The aim: Our work aims to investigate the therapeutic effect of art on children and adolescents with autism spectrum disorder (ASD) up to the age of 18 and to disseminate
knowledge about its use as a part of therapy.
Materials and methods: The authors created an anonymous online questionnaire addressed to parents and legal guardians of children and adolescents with and without ASD. The
studied population comprised 190 subjects, of which 108 were a control group (children and adolescents without ASD) and 82 – a study group (children and adolescents with ASD).
Results: Most respondents did not hear about the therapeutic use of art (59.5%). 20.73% of respondents with ASD participated in therapy using artistic activities. 82.4%
participated in music therapy, 23.5% – in theater therapy, and 70.6% – in art therapy. These forms of therapy effectively improved disorders related to social relationships,
speech, and atypical behavior.
Conclusions: There is a positive therapeutic effect of art on children and adolescents with ASD. The therapeutic use of art among the respondents is not very widespread.
Artistic activities have a positive impact on social relations, speech, and unusual behavior. Music and visual arts activities seem to positively impact social relationship disorders,
while theater activities seem to impact speech disorders positively. Combining several arts in therapy is more beneficial than using just one. Art therapy is most often used at
the age of 13 and older.
KEY WORDS: music therapy, autism spectrum disorder, art therapy
Wiad Lek. 2021;74(9 p.II):2452-2459
INTRODUCTION of the British Society of Art Therapists (BAAT). He is also

Autism spectrum disorder (ASD) is a comprehensive de- considered one of the pioneers of this type of therapy [9].
velopmental disorder that includes abnormalities in social Artistic activities can be a complementary form of treat-
interaction, communication, and restricted and repetitive ment in children and adolescents with autism spectrum
behavior patterns. It typically appears in early childhood disorders. They are based on non-verbal communication,
but can also be diagnosed at later stages of development which makes them appropriate for them [10]. However,
[1, 2]. The World Health Organization estimates the prev- despite the increasing number of reports on the positive
alence of ASD among children and adolescents at 1: 160 impact of art on patients, its use is not widespread [11-15].
(0.63%) worldwide [3]. In Poland, the number of disabled One of the forms of art therapy is music therapy. It takes
people up to 16 years of age with diagnosed ASD is 44,302, the form of improvising, singing, vocalizing, or listening to
which stands for 1: 115 (0.87%) [4]. Autism spectrum music. It is carried out by the therapist individually or in
disorders are more common in boys than girls [1, 5-7]. groups, o%en in the presence of the family [11]. It involves
Currently, the ratio is 3: 1 [5]. using music to improve communication, social skills,
Already in antiquity, people were aware of the beneficial sharing, and recognizing emotions [16, 17]. In addition, it
effects of contact with art on human health and psyche. increases the sense of security and self-esteem [18]. Many
Aristotle acknowledged this phenomenon by defining studies show a clearly beneficial effect of music therapy on
catharsis (Greek for purification) in his work Poetics [8]. children and adolescents with ASD [11, 16, 19, 20].
However, it was not until the 20th century that the painter Another form of art therapy is theater therapy. It
Adrian Hill introduced the concept of art therapy. He no- deals with using elements of the performing arts, such
ticed the positive influence of art on the healing process and as role-playing, pantomime, puppetry, and theatrical
human psyche on himself and other sanatorium patients performances for psychotherapeutic purposes [12]. It is
where he was struggling with tuberculosis. In the following successfully used in children and adolescents with ASD by
years, he was employed as the first art therapist in one of influencing their imagination [13]. In addition, it allows for
the British psychiatric hospitals and became the president the development of social skills, reducing anxiety, limiting
2452
OPINIONS OF PARENTS OF CHILDREN WITH AUTISM SPECTRUM DISORDERS ON ART THERAPY...
Table I. Characteristics of the study population.*

Respondents Control group Study group
n(%) n(%) n(%)
girl 74 (38.9) 53 (71.6) 21 (28.4)
Sex
boy 116 (61.1) 55 (47.4) 61 (52.6)
0 - 3 yrs 2 (1.1) 2 (1.1) 0 (0)
4 - 6 yrs 5 (2.6) 0 (0) 5 (2.6)
Age 7 - 9 yrs 49 (25.8) 33 (17.4) 16 (8.4)
10 -13 yrs 75 (39.5) 45 (23.7) 30 (15.8)
> 13 yrs 59 (31.1) 28 (14.7) 31 (16.3)
up to 50,000 106 (55.8) 76 (40) 30 (15.8)
Population in the up to 100,000 18 (9.5) 8 (4.2) 10 (5.3)

inhabited town
up to 250,000 46 (24.2) 21 (11.05) 25 (13.15)
above 250,000 20 (10.5) 3 (1.6) 17 (8.9)
* data obtained from parents and legal guardians of children and adolescents up to 18 years of age.
problem behaviors, and establishing interpersonal relation- ASD and children and adolescents up to 18 years of age
ships, especially family relationships [21, 22]. without such disorders. Each respondent represented one
Another form of art therapy is artetherapy. It is a type of family. The respondents came from all Polish voivodships.
psychotherapy in which art materials are the main form of We obtained 190 responses, of which 108 were the con-
communication. Thanks to the mediation of an image or trol group (children and adolescents with no diagnosed
other object, it is easier for people who have problems with ASD), and 82 were the study group (children and adoles-
communication and verbal expression of their feelings to cents with diagnosed ASD). The number of boys was 116
communicate with the therapist [15, 23]. In addition, the (61.1%), and the number of girls was 74 (38.9%), of which
analysis of the colors and shapes used by the child allows 55 boys and 53 girls were in the control group, and 61 boys
for the analysis of the progress of therapy [24]. Artetherapy and 21 girls were in the study group. The analysis distin-
in children with ASD aims to alleviate symptoms related guished the following age ranges: 0 to 3 years old, 4 to 6
to difficulties with social communication and limited, years old, 7 to 9 years old, 10 to 13 years old, and more than
repetitive behavior patterns [15]. 13 years old. The respondents also provided information
Every year we observe a 20% increase in the ASD frequency on the population in the inhabited town, based on which
among children and adolescents in Poland [4]. This is related we distinguished ranges: up to 50,000, up to 100,000, up to
to the increased demand for the introduction of additional, 250,000, and over 250,000 inhabitants. The characteristics
effective methods supporting the psychosocial development of the respondents are presented in Table I.
of children and adolescents with ASD. One of them may The study group distinguished children and adolescents
be the use of art, which is why we focus on comparing the in whom artistic activities were an element of essential ther-
effectiveness of various forms of artistic activity in our work. apy (17 subjects). To analyze the effects of various fields of
art, we distinguished three groups of artistic activities based
on: music, theater, and art classes, hereina%er referred to
THE AIM as music therapy, theater therapy, and artetherapy. Their
The study aimed to assess the impact of broadly understood numbers were 14, 4, 12 subjects, respectively.
art on children and adolescents with ASD. Unfortunately, We conducted the study in the form of a voluntary,
there are still many inaccuracies regarding its document- anonymous, online survey addressed to parents and legal
ed impact and influence on improving health in children guardians of children and adolescents with ASD (study
with ASD. Therapy with the use of elements of art is also group) and without such disorders (control group). The
little known by many specialists, and our activities were questionnaire was widely available on internet forums
associated with little dissemination of knowledge about it and in educational institutions throughout Poland. The
among interested parties. questionnaire consisted of a demographic part, general
questions about the interests of children and adolescents
in the field of art and the knowledge of the concept of
MATERIALS AND METHODS its therapeutic application, questions about the type and
The voluntary study involved parents and legal guardians of scope of disorders, and a part about therapy with the use
children and adolescents up to 18 years of age with diagnosed of art elements.
2453
Julia Wypyszyńska et al.
RESULTS
Parents and legal guardians completed an electronic ques- and adolescents with comprehensive development disorders
tionnaire entitled: Therapeutic impact of art on children (autism spectrum disorders) and children and adolescents
without diagnosed developmental disorders.
One hundred ninety parents and legal guardians of chil-
Table II. The impact of artistic activities on the well-being and behavior dren and adolescents participated in the study, of which
of children and adolescents with diagnosed disorders from the autism 43% (82 subjects) were parents and legal guardians of
spectrum and without such disorders. children and adolescents with ASD.
Type of impact n (%)
Children and positive 82 (76)
adolescents without negative 1 (1)
RESULTS CONCERNING THE INTERESTS OF
autism spectrum CHILDREN AND ADOLESCENTS IN THE FIELD OF
disorders no impact 25 (23) ART AND THE KNOWLEDGE OF THE CONCEPT
Children and positive 63 (77) OF ITS THERAPEUTIC APPLICATION
adolescents with negative 0 (0) Respondents described the impact of artistic activities
autism spectrum on the well-being and behavior of their children. We di-
disorders no impact 19 (23) vided the answers into positive, negative, and no impact.
The results are presented in Table II. In both groups, we
Table III. Have you experienced the therapeutic application of art? noticed a clear predominance of responses proving the
Respondents Control group Study group positive impact of artistic activities on the well-being and
Yes 77 people (40.5%) 36 people (33.3%) 41 people (50%) behavior of children and adolescents with diagnosed ASD
(the study group – 77%) and without such disorders (the
No 113 people (59.5%) 72 people (66.7%) 41 people (50%)
control group – 76%). As examples of the positive impact,
parents and legal guardians mentioned, among others,
Table IV. When was your child diagnosed? calming and reassuring children, improving concentration,
The age of diagnosis n (%) and increasing self-esteem.
below the age of 3 20 (24.4) For the respondents from the control group, artistic class-
3 - 6 years old 33 (40.2) es were most o%en a form of additional classes in which
they participated to develop their interests and passions
7 - 8 years old 17 (20.7)
and improve relations with their peers. Thus, within the
after the age of 10 12 (14.6) study group, we could distinguish children and adolescents
Table V. Symptoms in terms of social relations, speech disorders, and atypical behavior in children and adolescents with ASD.
Symptoms n (%)
difficulties in establishing relationships with peers 64 (78)
not making eye contact 41 (50)
no spontaneous need to share emotions 30 (36.6)
in terms of social relations
impaired or different reaction to other people’s emotions 40 (48.8)
none of the above 4 (4.9)
other 5 (6)
delayed or complete absence of speech development 41 (50)
lack of willingness to start and sustain a conversation 29 (35.4)
stereotypical and repetitive use of words and phrases 26 (31.7)
Speech disorders
lack of spontaneous variety in pretend play or social role play 42 (51.2)
other 4 (4.8)
absorbing one or more stereotypical interests, e.g., a form of play is to
44 (53.7)
arrange objects (blocks, cars) in a row, in a specific order
attachment to specific, non-functional routines 38 (46.3)
Atypical behavior stereotypical and repetitive movement patterns, including tapping or
36 (43.9)
twirling your fingers, or complex whole-body movements
other 6 (7.2)
2454
Table VI. Reasons for not using the elements of art in the therapy of children were in the control group, and 50% (41 subjects) were in
and adolescents with ASD. the study group.
Reasons for not using the elements of art
in the therapy of children and adolescents n (%)
with ASD RESULTS ON THE TYPE
I haven’t heard about art therapy 38 (58.5) AND EXTENT OF DISORDERS
It is not possible to participate in this form of
Parents and guardians of children and adolescents with
therapy in the immediate vicinity
10 (15.4) ASD provided information on the age at which their chil-
dren were diagnosed with ASD. The results are presented in
I believe that the effectiveness of art therapy
is low
3 (4.6) Table IV. Among the respondents, the largest group of chil-
dren was diagnosed between the ages of 3 and 6 (40.2%).
Financial issues 4 (6.15) The next questions concerned the symptoms of children
Nobody recommended this form of therapy 2 (3.1) and adolescents diagnosed with ASD. We asked the re-
Child disinterest 4 (6.15) spondents to list the symptoms occurring in their charges
This form of therapy is not suitable for my regarding social relations, speech disorders, and unusual
1 (1.5) behavior. The obtained results are presented in Table V.
child
The most common symptoms in children and adolescents
Others 3 (4.6)
with ASD regarding social relations were difficulties in
establishing relationships with peers (78%). In terms of
Table VII. The relationship between the child’s age and the use of art therapy.
speech disorders, it was the lack of spontaneous variety of
Children taking part in art therapy playing pretend or playing imitating social roles (51.2%)
The child’s age
n (%) and delayed or complete lack of speech development (50%).
0-3 years old 0 (0) However, in terms of atypical behaviors, it was absorbed
4-6 years old 2 (11.8) in one or more stereotypical interests (53.7%).
7-9 years old 2 (11.8)
10-13 years old 3 (17.6)
RESULTS OF THERAPY WITH THE USE
above the age of 13 10 (58.8) OF ART ELEMENTS
Then we asked the study participants about the use of
with ASD who received therapy using elements of art and elements of art in the therapy of their charges. Some chil-
those who had contact with artistic activities that were not dren combined more than one type of artistic activity. The
elements of therapy in the home and school environment. results are presented in Figure 1. Art therapy was used in
Then we asked the respondents if they had encountered 20.7% (n = 17) of children and adolescents with ASD, of
a therapeutic application of art. The results are presented which 14 subjects (82.4%) received music therapy, four
in Table III. 40.5% (77 subjects) of the respondents expe- subjects (23.5%) received theater therapy, and 12 subjects
rienced its therapeutic use, of which 33.3% (36 subjects) (70.6%) – artetherapy.
Fig. 1. Percentage of each form

of art therapy used with children
and adolescents with ASD.
2455
Fig. 2. The correlation between

the type of art therapy used and
the improvement achieved, by ASD
symptoms category.
Fig. 3. The correlation between the

use of a single form of art therapy
and a combination of several forms
of art therapy and the improvement
obtained, taking into account each
category of ASD symptoms.
Fig. 4. The relationship between the

therapy used and the population of
the respondents locality.
Parents and legal guardians of children and adolescents symptoms (social relations, speech, atypical behavior) oc-
with ASD who underwent art therapy assessed the effec- curring in their charges. For this purpose, the respondents
tiveness of this type of therapy on the improvement of marked the scope of improvement on the axis consisting
2456
of a 5-point scale, where 1 was no visible effects, and 5 was of art. It was 50% (41 subjects) within the study group,
the improvement to a large extent. Based on the obtained and in the control group, it was only 33.3% (36 subjects).
results, we calculated the means (M), considering the type This proves that art therapy is not very widespread among
of therapy (music therapy, theater therapy, artetherapy) and the respondents. Still, there is a noticeable slightly greater
the category of ASD symptoms (social relations, speech, knowledge of this form of therapy among parents and
unusual behavior). Detailed results are presented in Figure guardians of children and adolescents with ASD.
2. Among the respondents, music therapy (M = 3.43) and
artetherapy (M = 3.42) had the most positive effect on
disorders in social relations. In contrast, theater therapy THE PART ON THE TYPE AND SCOPE OF
had the most positive effect on speech disorders (M = 3.5). DISORDERS
We also analyzed the effects of using only one form of art Children and adolescents with ASD struggle with problems
therapy and the effects of combining several of their forms related to various spheres of life. They o%en have a higher
with each other. 58.8% (10 subjects) received more than one level of anxiety [25, 26]. Moreover, there are gastrointes-
form of therapy, while 41.2% (7 subjects) received single tinal symptoms, sleep problems, and seizures [1, 27]. We
therapy. In the analysis, we considered the average of the categorized the basic symptoms of children and adoles-
obtained data in the field of disorders in social relations, cents with ASD into three main groups. Within disorders
speech, and atypical behavior. The obtained results are of social relations, there are, among others, difficulties in
presented in Figure 3. understanding roles and social situations [28]. In terms
We asked the parents and legal guardians of children and of speech, disorders refer to a delay or complete lack of
adolescents with ASD who did not use the elements of art development [29]. They are most likely one of the causes
in therapy why this form of treatment was not used in their of irregularities in functional play [30]. Repetitive atypical
charges. Detailed results are presented in Table VI. Among behaviors such as clapping hands, spinning in circles, and
the respondents, the most common reason for not using the swaying belong to the last category of symptoms [31].
elements of art in the therapy of children and adolescents The questionnaire showed that the most common symp-
with ASD was the lack of knowledge about the existence toms in terms of social relationships are difficulties in estab-
of such a form of therapy (58.5%). lishing relationships (78%), lack of making eye contact, and
We also analyzed the relationship between the child’s impaired or different response to other people’s emotions.
age and the type of art therapy used. The obtained results Regarding speech disorders, 51.2% of the respondents
are presented in Table VII. Children participating in art pointed to the lack of spontaneous variety of play in their
therapy were most o%en over 13 (58.8%). charges and half of the delayed or complete lack of speech
We also analyzed the relationship between the therapy development. Finally, among atypical behaviors, the most
used and the size of the town inhabited by the respondents. common (52.7%) mentioning was a preoccupation with
The results are presented in Figure 4. Most of the respon- one or more stereotypical interests.
dents who received art therapy came from towns of up to
50,000 inhabitants.
THE PART ON THERAPY WITH
THE USE OF ART ELEMENTS
DISCUSSION Based on the questionnaire, we compared music therapy,
artetherapy, and theater therapy. The groups of subjects
THE PART CONCERNING THE INTERESTS OF who received music therapy and artetherapy were compa-
CHILDREN AND ADOLESCENTS IN THE FIELD OF rable (14 and 12 subjects), while the participants of theater
ART AND THE KNOWLEDGE OF THE CONCEPT therapy were definitely fewer (4 subjects). Moreover, the-
OF ITS THERAPEUTIC APPLICATION ater therapy was in each case combined with a different
Based on the respondents’ answers, we concluded that in form of art therapy (Fig. 4).
our population, activities related to art showed a positive The most frequently chosen form of art therapy among
impact on the well-being and development of children and the surveyed parents and legal guardians (82.4%) was
adolescents, both without and with diagnosed ASD. Within music therapy. Available data indicates its impact on the
the control group, 76% of parents and guardians noticed improvement of social relations [32]. Our study confirms
the positive impact of artistic activities on their children, this, and in addition, its impact on this category of ASD
and in the study group, it was 77%. The most frequently symptoms turned out to be the greatest (M = 3.43). To a
reported positive effects were silence, calming down, re- lesser extent, it positively affects the improvement of speech
laxation, joy, improvement of manual dexterity under the disorders (M = 3) and unusual behavior (M = 3).
influence of art, and in children and adolescents with ASD, Theatre therapy was the least frequently used form of
additionally improvement of concentration and speech. therapy among children and adolescents with ASD. Our
Thanks to the positive influence of art on the development survey showed its most significant impact on speech dis-
of children and adolescents, it was used as a complementary orders (M = 3.5), slightly less on atypical behavior (M =
therapy, among others, in ASD [13, 14, 18, 20]. 40.5% (77 3.25), and the least on social relations (M = 3). The respon-
subjects) of respondents heard about the therapeutic use dents indicated that artetherapy had the most significant
2457
impact on social relationship disorders (M = 3.42), less the effects of therapy.

on atypical behavior (M = 3.25), and the least on speech 4. Music and visual arts activities seem to positively impact
disorders (M = 2.58). social relationship disorders, while drama activities seem
The above data showed that music therapy and arteth- to impact speech disorders positively.
erapy have a comparable and the most significant impact 5. Combining several arts in therapy is more beneficial
on disorders in the field of social relations. However, in than using just one.
terms of speech disorders, theater therapy brought the most 6. Therapy with elements of art is most o%en used in chil-
significant improvement. On the other hand, artetherapy dren and adolescents over 13 years of age.
had the most positive impact on atypical behavior. We plan to continue the research thanks to the promising
More than one form of art therapy was used among results and the profound interest of both the authors and
our respondents more o%en (58.8%). Combining several families of subjects with ASD. Soon, we plan to significantly
forms had a much more significant impact on improving increase the number of subjects surveyed by establishing
speech than using single therapy. The ratio of means (M:M) cooperation with foundations supporting people with
expressing improvement was 3.39:2.71. In terms of social autism spectrum disorders. This will allow for detailed
relations, the effect of the therapy was similar (M:M = analysis and increasing the credibility of the results. We
3.39:3.29). On the other hand, the use of an independent hope that our work will help to broaden the knowledge on
form of art therapy (M = 3.43) seems to be more beneficial the use of art in therapy and contribute to its dissemination.
in improving atypical behaviors than combining several The authors declare that they have no ties or financial
forms with each other (M = 3.04). dependence on any organization or anyone with a direct
The respondents said that the main reason for not using financial contribution to the research subject or materials
art therapy was that they had not heard about this form of studied in this work (through employment, consulting,
treatment (58.5%). In addition, 15.4% of the respondents indi- shareholding, fees). At the same time, they declare that
cated the inability to participate in this form of therapy in the they do not show any conflict of interest.
immediate vicinity as the main reason. Other responses that
emerged were financial reasons and the lack of recommen- REFERENCES
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2459
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children
Article
Exploring Change in Children’s and Art Therapists’ Behavior
during ‘Images of Self’, an Art Therapy Program for Children
Diagnosed with Autism Spectrum Disorders: A Repeated Case
Study Design
Celine Schweizer 1, *, Erik J. Knorth 2 , Tom A. Van Yperen 2 and Marinus Spreen 1
1 Research Centre for Small n-Designs, NHL-Stenden University of Applied Sciences, 8917 DD Leeuwarden,
The Netherlands; marinus.spreen@nhlstenden.com
2 Faculty of Behavioral and Social Sciences, Groningen University, 9712 CP Groningen, The Netherlands;
ej@knorth.nl (E.J.K.); t.vanyperen@nji.nl (T.A.V.Y.)
* Correspondence: celine.schweizer@nhlstenden.com
Abstract: (1) Background: ‘Images of Self’ (IOS) is a recently developed and evaluated art therapy
program of 15 sessions to reduce difficulties in ‘sense of self’, ‘emotion regulation’, ‘flexibility’, and
‘social behavior’ of children diagnosed with Autism Spectrum Disorders (ASD). In this paper, it
is explored whether change in the child’s behaviors corresponds to the therapist’s actions during
IOS and 15 weeks later. (2) Method: In a repeated case study design, twelve children and seven
therapists participated. Art therapists monitored their own and the children’s behavior by applying
two observation instruments: the OAT (Observation of a child with autism in Art Therapy) and EAT
(Evaluation of Art Therapist’s behavior when working with a child with autism). Child behaviors
Citation: Schweizer, C.; Knorth, E.J.; during art making were—individually and as a group—compared with therapist’s actions at three
Van Yperen, T.A.; Spreen, M. moments during the program. (3) Results: Ten of twelve children showed a substantial or moderate
Exploring Change in Children’s and positive behavior change considering all OAT subscales at the end of the program and 15 weeks
Art Therapists’ Behavior during after treatment. Improvement of ‘social behavior’ stood out. Halfway treatment art therapists
‘Images of Self’, an Art Therapy
most prominently showed support of ‘emotion regulation’, ‘flexibility’, and ‘social behavior’. Clear
Program for Children Diagnosed
one-on-one relationships between changes in children’s behavior and actions of therapists could
with Autism Spectrum Disorders:
not be identified. (4) Conclusion: The study provides new insights in the AT treatment process by
A Repeated Case Study Design.
monitoring children’s and therapists’ behavior. The art making itself and the art therapy triangle
Children 2022, 9, 1036. https://
doi.org/10.3390/children9071036
(child, art making, therapist) offer opportunities to improve verbal and nonverbal communication
skills of the child.
Academic Editor: Dafna Regev
Received: 6 June 2022 Keywords: art therapy; children; autism spectrum disorders; change processes; OAT; EAT
Published: 12 July 2022
Publisher’s Note: MDPI stays neutral

1. Introduction
with regard to jurisdictional claims in
published maps and institutional affil- Children with autism-related problems are often referred to art therapy (AT) in the
iations. Netherlands [1]. Art therapies are recommended in the Dutch Guidelines for Mental
Health [2]. The American Art Therapy Association [3] states that people with autism are an
important target group for (research into) AT.
In the DSM-5 [4], persons with Autism Spectrum Disorders (ASD) frequently have
Copyright: © 2022 by the authors. social-communicative deficits and repetitive/restricted behaviors and interests.
Licensee MDPI, Basel, Switzerland. Recently, several studies have indicated that AT can provide a successful treatment for
This article is an open access article children with ASD-related problems. In a systematic review [5], two single group studies
distributed under the terms and reported improvement of the children to engage in social situations and improve ability
conditions of the Creative Commons
to focus attention. The review also included an RCT that showed some favorable but not
Attribution (CC BY) license (https://
significant outcomes for the treatment group, compared to the control group. The lack in
creativecommons.org/licenses/by/
the RCT is not unexpected, because of the variety of ASD features in children [6–9], which
4.0/).
Children 2022, 9, 1036. https://doi.org/10.3390/children9071036 https://www.mdpi.com/journal/children

Children 2022, 9, 1036 2 of 17
makes it hard to form a comparable treatment and control group. An extensive practice-
and theory-based study evaluated the contribution of sensory experiences when touching
art materials. This resulted in improvement of communication with the therapist [10].
Art making in AT supports the pleasure of the child and contributes to an improved
therapeutic relationship. It also increases the range of patterns in the child’s behavior and
art expressions [11,12].
Until recently, there was a gap in the knowledge regarding behavioral changes of
children with ASD in AT, the activities of the art therapist, and the relationship between
the two [1,13,14]. To address this challenge, a series of studies was performed, resulting
in the AT program ‘Images of Self’ (IOS). This title refers to the important role of art
making in the triangular relationship between client, art work, and art therapist. Every art
making process and every art product mirrors the experiences of the maker within this
triangular relationship.
IOS was developed firstly with two studies examining knowledge from experienced art
therapists as well as literature about AT practices with children diagnosed with ASD [15,16].
Based on these studies, the building blocks of the IOS program were further articulated as
consensus-based typical elements of AT [17]. IOS consists of 15 individual sessions with an
art therapist who has been intensively trained to apply the program. Characteristics of the
treatment and the relevant actions of the art therapist are described in a manual [18]. The
starting point of the treatment is attunement to the needs and art expressions of the child.
The IOS program offers a frame that allows adjustments to individual needs, because
every child with autism has different interests, skills and varied reasons for being referred
to art therapy. For instance, an 11-year-old girl and her environment suffered from her
emotional outbursts. An important step during her IOS treatment was to make a colorful
felt blanket that she wanted to use to comfort herself. During the creation of this blanket,
she moved the soft wool with soap and water until it turned into felt. She enjoyed the
creation of the blanket. During this process, she talked with the art therapist and became
more aware of what gives her (emotional) stress and what brings relaxation. The girl
became aware that sensory experiences helped her to relax. She also made a small plastic
bag with smooth glue in it, for keeping in her pocket. Whenever she became aware that her
tension grew, it helped her to relax by touching the smooth bag.
The IOS program yielded promising results in a multiple case study among 12 children
diagnosed with ASD, aged 6–12 years, with normal/high intelligence profiles [19]. Children
were referred to IOS because of difficulties with their ‘sense of self’ (difficulties with
reflecting on their own feelings and behaviors), ‘self-esteem’ (strongly negative senses
about ‘being different’ but not understanding why), ‘emotion regulation problems’ (being
very depressed; emotional outbursts), ‘flexibility problems’ (being upset when something
unexpected happens) and/or ‘social problems’ (difficulties in expressing themselves and
troubles with understanding others). Nearly all participating children (n = 11) started the
program with severe problems in these areas according to the norms of the Child Social
Behavior Questionnaire (CSBQ) [20].
During the program, the children were monitored on the outcomes ‘sense of self’,
‘emotion regulation’, ‘flexibility’, and ‘social behavior’ by therapists, but also by their
parents and teachers [18]. The outcome ‘sense of self’ is a concept that includes a continuum
regarding self-development: self-perception, self-image, self-concept, and self-esteem [21].
Seven of the 12 children significantly improved in ‘flexibility’ and ‘social behavior’,
both during treatment and also 15 weeks after termination of the treatment [19]. These
results can be interpreted as positive, because in general, the reduction rate of problems by
psychosocial interventions in children and youth lies between 35 and 62 percent a year after
the start of a treatment [22,23]. According to the qualitative analysis of the evaluation of
IOS, all children were reported by their parents, teachers, and therapists to be happier and
more stable, and better able to give words to their experiences. Additionally, improvements
in ‘emotion regulation’ (n = 8) and ‘flexibility’ (n = 4) were reported.
Children 2022, 9, 1036 3 of 17
In our evaluation study, the focus was primarily on the outcomes: do the children
improve or not? However, AT is characterized by a triangular relationship between client,
art, and therapist [24,25]. In this relationship, it is supposed that communication of the
children with the art therapist will be easier and feel safer for the child, because of the
component of art making. This especially applies to children with communication chal-
lenges such as children diagnosed with ASD [17]. In this paper, we explore the process of
therapeutic change, thereby directing the attention to the development of children’s and
therapists’ behavior in relation to each other. The research question in the current study
is: To what extent are changes in the behaviors of the children and the art therapists’ activities
concerning (supporting) ‘sense of self’, ‘emotion regulation’, ‘flexibility’ related?
2. Methods
2.1. Participants
The repeated case study design makes it possible to monitor individual patterns of
results in different contexts. In our design, we included children, their parents, teachers and
their art therapists. The multiple perspectives and the pre-test/post-test provide insight in
changes in AT as well as in the contexts of home and school. Twelve children and seven
therapists participated in this study. Children aged 6–12 years with an ASD diagnosis and
an IQ 80 were included in the sample [19] (Table A1 in Appendix A). Children were
excluded if they were evaluated by their art therapists as showing amounts of resistance
that were too high or fear of art making. All therapists had a Bachelor’s degree in art
therapy, which is the required professional qualification in the Netherlands for working
as an art therapist. They also had at least two years of work experience in AT with the
target group. Parents and teachers of the participating children completed questionnaires,
observed daily behavior, and reported possible behavior changes of the child in a form.
Parents participated by discussing and evaluating video recordings of selected IOS sessions
with the art therapist. All participants signed informed consent forms.
2.2. Measurement Instruments

In this study, two instruments were used to monitor and describe the children’s and the
therapists’ behaviors during the IOS program [26]. (In the evaluative multiple case study
three other instruments were also applied: the Behavior Rating Inventory of Executive
Functioning (BRIEF; [27,28]), the Children’s Social Behavior Questionnaire (CSBQ) [20,29],
and the Self-Perception Profile for Children (SPPC) [21,30]. With the first two instruments,
parents’ and teachers’ findings were measured, and with the third instrument, the child’s
findings were mapped). The first instrument in the recent study is the so-called ‘Observation
in Art Therapy with a child diagnosed with ASD’ (abbreviated as OAT. (In our former
studies, the names of the instruments were OAT-A and EAT-A, with ‘-A’ referring to ASD.
However, the titles without the suffix ‘-A’ are more compact). The OAT is an instrument
that is intended to observe and measure the behavior of the child during art making
in the sessions on four subscales: ‘sense of self’, ‘emotion regulation’, ‘flexibility’, and
‘social behavior’.
‘Sense of self’ refers to a theory-based continuum of concepts that represents a devel-
opment of ‘self skills’: self-perception, self-image, self-concept, and self-esteem [21,31,32].
Improvement of ‘sense of self’ is one of the main aims of AT for children diagnosed with
ASD [15,18,33]. In studies about AT for children with ASD the importance of development
of the lowest level in the continuum, ‘sense of self’ is often mentioned as a treatment
goal [10–12]. An example of an item in the OAT subscale ‘sense of self’ is: “The child is
connected with his/her experiences during art making”.
‘Emotion regulation’ is a complex concept that concerns perception of internal and
external stimuli within a complexity of mechanisms: physiological arousal, motivation,
and cognitive evaluation. The ability of regulating emotions is based on recognition of
inner sensations, feelings, and behavior, relating these to their causes [34]. Initiating, main-
taining, inhibiting, or moderating emotional reactions may lead to ‘emotion regulation’ in
Children 2022, 9, 1036 4 of 17
association with processes that influence experience and the expression of emotions [35–37].
‘Emotion regulation’ refers to the downregulation of negative affects or the upregulation
of positive affects [37]. For children with ASD, it is often hard to recognize their own
emotions. In art work, inner feelings can be expressed by, for example, drawing cruel
fights or monsters. Difficulties with ‘emotion regulation’ can behaviorally be expressed, for
instance, by becoming angry when something disappointing happens during art making,
or by lack of emotion expression when it is expected. An example of an OAT item of this
subscale is: “The child is expressing emotions/experiences in art making/symbols”.
‘Flexibility’ is about adaptation to unexpected situations. Cognitive ‘flexibility’ (the
ability to find new solutions to a problem) is distinguished from flexible behavior (adapta-
tive skills to unexpected situations) [38]. An example of an OAT item of this subscale is:
“The child uses varied art materials and/or techniques”.
‘Social behavior’ is one of the main difficulties for children diagnosed with ASD [4].
These children are often hardly or not skilled in reciprocity, to adapt to others, to adapt to
play, and in working together [6,29]. In art therapy, some social skills can be developed,
for instance task-oriented collaboration, asking for help, and connecting words to experi-
ences [24]. The child may enjoy working together, and joint attention skills may also be
developed during art making [39–41]. An example of an item in the OAT subscale ‘social
behavior’ is: “The child shows enjoyment during art making with the art therapist”.
The second instrument is the so-called ‘Evaluation of the Art Therapist’s behavior
working with a child diagnosed with ASD’ (abbreviated as EAT); an instrument that is
intended to observe and measure art therapeutic behavior in IOS sessions. This instrument
has subscales corresponding with those in the OAT: ‘supporting the development of sense
of self’, ‘stimulating emotion regulation’, ‘supporting the improvement of flexibility’, and
‘supporting social behavior’. A (corresponding) example of the EAT subscale ‘supporting
social behavior’ is: “The art therapist supports the child to follow directions of the therapist”.
Items of both instruments have a 5-point Likert scale with values 1 = not observable,
2 = a bit observable, 3 = to some extent observable, 4 = well observable, 5 = strongly
observable. Both instruments are filled out by the therapists (see further below). The
reliability of the OAT and EAT is ‘moderate’ to ‘substantial’ [26]. Inter-rater reliability of
both instruments were determined with pairs of raters (trained art therapists and Bachelor
students) who scored selected video fragments of AT sessions collected during a pilot
study. Interrater reliability has been computed per item and per subscale of the instruments.
Because of the ordinal level of the scores (5-point Likert scale) the degree of agreement was
computed per item using quadratic weighted Kappas (Kw ). Kw may be influenced by a
restriction of the range of scores, resulting in an inflated high or low value. For that reason
also Gower indices (G) were computed to interpret values of Kw for items with very low or
high absolute agreement [42]. In addition: 0.40  Kw < 0.60 means ‘moderate’ agreement;
0.60  Kw  0.80 means ‘substantial’ agreement.) Training of raters was still proved to
enhance the inter-rater agreement regarding the instrument’s scales [26].
2.3. Procedure
To include art therapists, a convenience sample [41] was drawn using newsletters from
the national professional organization of art therapists, calls on Facebook, and word of
mouth advertisement. Participating children followed the usual referral procedure from the
seven collaborating institutions. Based on the professional judgements of the art therapists,
children were excluded if they were assessed as having levels of resistance that were too
high or fear of art making.
Both instruments, OAT and EAT, were scored by the art therapist at all of the measure-
ment moments. The use of both instruments was intensively trained and supervised by the
PI during the IOS program.
Details regarding the monitoring of treatment were described in our previous publica-
tion about IOS evaluation [17].
cation about IOS evaluation [17].
2.4. Analysis
The data were analyzed in two steps. In the first step, the behaviors of each
Children 2022, 9, 1036 during the session at the measurement moments T1, T2 and T3 were visually 5 of 17 comp
with the acts of the corresponding therapists (EAT). The aim was to explore wh
changes in the child’s behaviors corresponded to the therapist’s actions. Excel (ve
2.4.
2016Analysis
for Windows) was used to analyze the data. As a decision rule, we considered
The data
ferences were analyzed
between in two steps. In
two measurement the first step,
moments equaltheto
behaviors of each
or larger thanchild
−1 ordur-
+1 as sub
ing the session at the measurement moments T1, T2 and T3 were visually
tial. Differences between −1 and −0.5 or +0.5 and +1 were seen as minor or moderatecompared with
the acts of the corresponding therapists (EAT). The aim was to explore whether changes in
ferences smaller than −0.5 or +0.5 were defined as negligible.
the child’s behaviors corresponded to the therapist’s actions. Excel (version 2016 for Win-
dows) Inwasthe second
used step,the
to analyze fordata.
eachAssubscale,
a decision arule,
nonparametric
we consideredFriedman test was perfor
differences between
on the
two four measurement
measurement moments equalmoments for the
to or larger thangroup1 orof
+112
as children.
substantial.The aim of this test
Differences
between
to explore whether there was a consistent pattern of change over time. smaller
1 and 0.5 or +0.5 and +1 were seen as minor or moderate. Differences This enabled
than
parison0.5 or
of +0.5
the were defined
scores as negligible.
at different measurement moments and visual exploration o
In the second step, for each subscale, a nonparametric Friedman test was performed
development in children’s and therapists’ behaviors.
on the four measurement moments for the group of 12 children. The aim of this test
was to explore whether there was a consistent pattern of change over time. This enabled
3. Results of the scores at different measurement moments and visual exploration of the
comparison
development in children’s
3.1. Individual Analyses and therapists’ behaviors.
Detailed information about changes in child behaviors is shown in Figures 1, 3
3. Results
5; in
3.1. FiguresAnalyses
Individual 2, 4, and 6, the corresponding information is depicted regarding ther
behaviors.
Detailed information about changes in child behaviors is shown in Figures 1, 3, and 5; in
FiguresFigure
2, 4, and1 6,shows
the corresponding
the developmentinformation of isthe
depicted regarding
individual therapistat
children behaviors.
session 8, hal
Figure 1 shows the development of the individual children at
through the treatment (T2), compared to T1. Substantial positive developments (≥+1session 8, halfway
through the in
identified treatment
one or (T2),
morecompared
subscales to for
T1. eight
Substantial positive
children (casesdevelopments
1, 2, 3, 5, 6,(7,+1)
8, 9), and
are identified in one or more subscales for eight children (cases 1, 2, 3, 5, 6, 7, 8, 9), and
stantial negative developments (≤−1) in one or more subscales for two children (cas
substantial negative developments ( 1) in one or more subscales for two children (cases
4,7).
7).Four
Four children (cases
children (cases 2,6,5,9)6,developed
2, 5, 9) developed on at
on at least twoleast two subscales
subscales substantiallysubstantially
in a
positive
positive direction.
direction.

per case
3.0
2.0
1.0
0.0
1 2 3 4 5 6 7 8 9 10 11 12
-1.0
-2.0

Figure Means
Figure1. 1. of all
Means ofsubscales per case,
all subscales perT2–T1.
case, T2–T1.
In Figure 2, we see four therapists (cases 1, 5, 7, 11) being most active during the time
In Figure 2, we see four therapists (cases 1, 5, 7, 11) being most active during the
period T1–T2 on the dimension ‘emotion regulation’. Two therapists were substantially
period
active on T1–T2 on (cases
‘flexibility’ the dimension ‘emotion
5, 12), and one regulation’.
on ‘social Two9).therapists were substan
behavior’ (case
active
Figure 3 compares the OAT subscales’ means between the end (T3) and(case
on ‘flexibility’ (cases 5, 12), and one on ‘social behavior’ 9). (T1) of
the start
treatment. Inspecting all four subscales, we see substantial positive change in one or more
subscales for ten children (cases 2, 3, 4, 5, 6, 7, 8, 9, 11, and 12) and substantial negative
developments in one or more subscales for one child (case 7). Five children (cases 2, 5, 6, 8,
and 9) developed substantially on at least two subscales in a positive direction.
per case
3.0
Children 2022,
Children 9,9,x 1036
2022, FOR PEER REVIEW 6 of 17 6
2.0
1.0
0.0 per case
3.0 1 2 3 4 5 6 7 8 9 10 11 12
-1.0
2.0
-2.0
1.0
1 2 3 4 5 6 7 8 9 10 11 12
Figure
-1.0 2. Means of all subscales per case, T2–T1.
-2.0 Figure 3 compares the OAT subscales’ means between the end (T3) and the start
of treatment. Inspecting all four subscales, we see substantial positive change in on
sense of self
more subscales for ten children emotion
(casesregulation
2, 3, 4, 5, 6, 7, 8, 9, 11, and 12) and substantial n
Figure
5, Means
6, 8,2. and
Figure 2. 9)ofdeveloped
Means all
ofsubscales per
all subscalescase,
perT2–T1.
case, T2–T1.
substantially on at least two subscales in a positive direction
Figure 3 compares the OAT subscales’ means between the end (T3) and the start
of treatment. Inspecting all four subscales, we see substantial positive change in o
per case
more subscales for ten children (cases 2, 3, 4, 5, 6, 7, 8, 9, 11, and 12) and substantial n
3.0
5,2.0
6, 8, and 9) developed substantially on at least two subscales in a positive directio
1.0
0.0 per case
3.0 1 2 3 4 5 6 7 8 9 10 11 12
-1.0
2.0
-2.0
1.0
1
Figure3.3.Means
Figure Means 2
of all
3 4
of subscales 5 6
per case,
all subscales 7
perT3–T1. 8 9 10 11 12
case, T3–T1.
-1.0
The most substantial positive change can be observed on the dimension ‘emotion
-2.0 The most substantial positive change can be observed on the dimension ‘emo
regulation’ (cases 2, 4, 5, 6, 7, 8, 9, 11, and 12). For the other three subscales, we ascertain
regulation’positive
substantial (cases 2, 4, 5, 6, 7, 8, 9,of11, and‘social
12). For the other and three subscales,
in fourwe asce
sense of self change in ‘sense emotion self’,
regulation behavior’ ‘flexibility’
substantial
(cases positive
5, flexibility
6, 8, and change
9), three (casesinsocial
2,‘sense
8, and of
9),self’, ‘social
and again behavior’
three childrenand ‘flexibility’
(cases 2, 3, and 8),in four (c
behavior
respectively.
5, 6, 8, and 9), Forthree
two children
(cases 2,(cases8, and 1 and 10), again
9), and we hardlythree observe
children change,
(cases while
2, 3,also
and 8), res
observing
Figure 3.
tively. some
For twonegative
Means children tendencies.
of all subscales
(casesper case,10),
1 and T3–T1.
we hardly observe change, while also obser
Figures 4 and 5 show that the art therapists are most actively supportive on ‘social
some negative tendencies.
behavior’.
TheFor mostthe time period T1–T3,
substantial positivethis concerns
change cases
can be8 and 9. For T1–T4,
observed on the this dimension
concerns ‘em
Figures 4 and 5 show that the art therapists are most
cases 1, 5, 8, 9 and 11. Additionally, for the same time period T1–T4, the art therapist was
actively supportive on ‘s
regulation’
behavior’. For (cases 2,
theintime 4, 5, 6, 7, 8, 9, 11, and 12). For the other three subscales, we asce
substantially active two period T1–T3,
cases (cases this12)
11 and concerns casesto8 ‘stimulating
with respect and 9. For T1–T4, emotionthis conc
substantial
regulation’. positive change in ‘sense of self’, ‘social behavior’
cases 1, 5, 8, 9 and 11. Additionally, for the same time period T1–T4, the art therapist and ‘flexibility’ in four (
5, 6,The
8, and 9),active
three
IOS results
substantially (cases
15 weeks 2,cases
in twoafter 8,termination
and 9), and
(cases 11ofagain three
the treatment
and 12) with children
(T4) (cases
compared
respect to2,T1
3,are
to ‘stimulatingand 8),emo
re
graphically
tively. For
regulation’. displayed
two in
children Figure
(cases6. For
1 ten
and children
10), we (cases
hardly 1, 2, 5,
observe6, 7, 8, 9,
change,10, 11, and
while 12),
also obser
substantial
someThe or minor
negative positive change is shown in one or more subscales. Substantial positive
tendencies.
IOS results 15 weeks after termination of the treatment (T4) compared to T
changeFigures
in one or4 more
and 5subscales
show is shown
that theFor fortherapists
art six childrenare (cases
most1, 2,actively
5, 7, 8, and 9); sub- on ‘s
supportive
graphically displayed in Figure 6. ten children (cases
stantial negative change in one or more subscales is shown for two children (cases 4 and 1, 2, 5, 6, 7, 8, 9, 10,
7). 11, and
behavior’.
substantial
Looking
For
at allor
the time
minor positive
subscales,
period
we ascertain
T1–T3,
change this concerns
is shown
substantial in one
positive
cases 8
or more
change
and 9. For
subscales.
in ‘emotion
T1–T4, this con
Substantial
regulation’
caseschange
tive 1, 5, 8,in
9 and
one 11. Additionally,
or more subscalesfor
is the samefor
shown time
six period
childrenT1–T4,
(casesthe1, art
2, 5,therapis
7, 8, an
substantially
substantial active in
negative two cases
change in one(cases 11 and
or more 12) with
subscales respectfor
is shown to two
‘stimulating
children em (ca
regulation’.
The IOS results 15 weeks after termination of the treatment (T4) compared to T
Children
Children 2022,
2022, 9,
9, xx FOR
FOR PEER
PEER REVIEW
REVIEW 77
Children 2022, 9, 1036 7 of 17
and
and 7).
7). Looking
Looking at at all
all subscales,
subscales, we we ascertain
ascertain substantial
positive change
change in in ‘emotion
‘emotion
ulation’
ulation’ at T4 compared to T1 in five children (cases 1, 2, 5, 7, and 9). For ‘sense of
at T4 compared to T1 in five children (cases 1, 2, 5, 7, and 9). For ‘sense of self
self
at
seeT4 compared
substantial to T1 in
positive five children
change in (cases
three 1, 2, 5,
children 7, and
(cases 9).
5, For
8, 9).‘sense of
Regarding self’, we
‘social beha
seesubstantial
see substantial positive
positive change
change in three
in three children
children (cases (cases
5, 8, 9).5,Regarding
8, 9). Regarding ‘social beha
‘social behav-
and
and ‘flexibility’,
‘flexibility’, substantial
positive development
development can
can be
be identified
identified
ior’ and ‘flexibility’, substantial positive development can be identified in two children
in
in two
two children
children (c(
1 and
(cases 8).
1 and1 8). Child
andChild 4
8). Child showed a substantial
4 showeda asubstantial
4 showed negative
substantial negative
negative development
development
development in ‘emotion
regulation’
‘flexibility’.
‘flexibility’. In addition, one child (case 7) developed substantially positive results
and In
‘flexibility’. addition,
In addition, one
one child
child (case
(case 7)
7) developed
developed substantially
substantially positive
positive results in
results in
in ‘e
‘
‘emotion
tion regulation’,
tion regulation’,
regulation’, and and substantially
and substantially negative
substantially negative results
negative resultsin ‘flexibility’.
results in
in ‘flexibility’.
‘flexibility’.
EAT
EAT T3-T1
T3-T1 means
means of
of all
all subscales
subscales
per
per case
case
3.0
3.0
2.0
2.0
1.0
1.0
0.0
0.0
11 22 33 44 55 66 77 88 99 10
10 11
11 12
12
-1.0
-1.0
-2.0
-2.0
sense
sense of
of self
self emotion
emotion regulation
regulation
flexibility
flexibility social
social behavior
behavior
Figure Means
Figure4. 4.
Figure 4. of all
Means
Means ofsubscales
of all per case,
all subscales
subscales perT3–T1.
per case,
case, T3–T1.
T3–T1.
EAT
EAT T4–T1
T4–T1 means
means of
of all
all subscales
subscales
per
per case
case
3.0
3.0
2.0
2.0
1.0
1.0
0.0
0.0
11 22 33 44 55 66 77 88 99 10
10 11
11 12
12
-1.0
-1.0
-2.0
-2.0
sense
sense of
of self
self emotion
emotion regulation
regulation
flexibility
flexibility social
social behavior
behavior
Figure
Figure5. 5.
Figure Means
Means
5. of
of all
Means all
all subscales
ofsubscales per
per case,
subscales case,
case, T4–T1.
perT4–T1. T4–T1.
Children 2022, 9, 1036 8 of 17
Figure 6. Means of all subscales per case, T4–T1.
3.2. Change in Children’s Behavior with Respect to Therapists’ Behavior

One purpose of our analysis was to explore whether childrens’ behavior changed
during the IOS program, and if and how this was related to the behavior of the therapist.
We take a look at this question, thereby focusing on three groups of children: children who
seemed to take the most (four cases) or least (one case) advantage of the treatment, and a
group that did not exhibit much change (three cases).
Most profit. Substantial enduring positive change in more than one subscale is shown
in Figure 5 (time period T1–T4) for four children (cases 1, 5, 8, 9). These changes appeared
in varied (combinations of) behavior areas. Related to therapist’s behavior mean scores,
we saw in these cases that the therapist showed most actions in the ‘supporting social
behavior’ area and hardly offered support on developing a ‘sense of self’. Additionally,
during the therapy sessions (T1–T3), most support from the therapists was directed at the
‘social behavior’ of these children.
Least profit. Child 4 showed relatively flat and substantial negative scores for both
the time period T1–T2 (Figure 1) and the time period T1–T4 (Figure 5). The profiles
(Figures 2, 4 and 6) also show a therapist who is relatively inactive in supporting the child.
Not much change. For one dyad (case 10), the profile is quite flat in all compared
measurement moments; both the child’s and therapist’s behaviors hardly show any change.
Another child (case 3) shows some change on one dimension, ‘flexibility’, during therapy
(Figures 1 and 3), but the change is not persistent (Figure 5). In this case, the support
of the therapist is at a low level of activity (Figure 2), or even substantially diminished
(Figure 4). Child 12 shows some change during the time period T1–T3 in ‘emotion regu-
lation’ (Figure 3); but, looking at the other comparisons of time moments, it is difficult to
observe change. The art therapist is surprisingly active in supporting ‘emotion regulation’
at T4 compared to T1 (Figure 6), but this is not associated with positive scores for the child
with respect to this behavior (Figure 5).
3.3. Group Analyses

The mean ranks of the OAT and EAT of the four measurement moments are shown in
Figures 7 and 8. These two figures also make it possible to perform a visual inspection of
the change in child behaviors with reference to therapist behaviors as a group.
Children 2022,
Children 2022,9,9,x1036
FOR PEER REVIEW 9 of 17 9 of
OAT, mean ranks of 12 cases at

5
1
T1 T2 T3 T4

Figure7. 7.
Figure Mean
Mean ranks
ranks of OAT.
of OAT.
EAT, mean ranks of 12 cases at

5
1
T1 T2 T3 T4
Figure Mean
Figure8. 8. ranks
Mean of EAT.
ranks of EAT.
With respect to the development of the children, in Figure 7, it can be observed that
With respect to the development of the children, in Figure 7, it can be observed th
the subscales ‘sense of self’, ‘emotion regulation’ and ‘social behavior’ seem to have a linear
the subscales‘Sense
development. ‘senseofofself’
self’,
( 2‘emotion
(3) = 9.72;regulation’
p = 0.02) andand ‘social
‘social behavior’
behavior’ seem
( 2 (3) to have a l
= 13.72;
ear development. ‘Sense of self’ (χ 2(3) = 9.72; p = 0.02) and ‘social behavior’ (χ2(3) = 13.
p = 0.004) increase significantly, while the linear development in ‘emotion regulation’ is
visually apparent,
p = 0.004) increase but statistically
significantly,not while
significant 2 (3) = development
the (linear 4.70; p = 0.20). ‘Flexibility’
in ‘emotion shows
regulation
avisually
constant apparent, 2
line ( (3) =but 4.32; p = 0.23).
statistically not significant (χ (3) = 4.70; p = 0.20). ‘Flexibility’ sho
2
As to the
a constant behavior
line (χ2(3) =of4.32;
the therapists,
p = 0.23). in Figure 8, it can be observed that the sub-
scale ‘stimulating emotion regulation’
As to the behavior seems toin
of the therapists, have a linear
Figure 8, itdevelopment
can be observed ( 2 (3) = 13.50;
that the subsc
p = 0.004). ‘Supporting sense of self’ also has a significant different pattern from the2situa-
‘stimulating emotion regulation’ seems to have a linear development (χ (3) = 13.50; p
tion that all measurements moments are the same ( 2 (3) = 8.52; p = 0.04). In this pattern,
0.004).
we ‘Supporting
observe that after a sense of self’
dip at T2, also hasincreased
the subscale a significant different
substantially pattern
at T3, from the situati
but decreased
that somewhat
again all measurements moments
at T4. However, are the
the mean ranksame
at T4 (χ
2 (3) higher
is still = 8.52;than
p = at0.04). In this
T1. The pattern,
devel-
opment
observe of that
‘stimulating
after asocial
dip atbehavior’
T2, theissubscale
partly linear; from T1substantially
increased to T2, this behavior
at T3, among
but decreas
therapists received more 2 (3) = 2.64; p = 0.45).
again somewhat at T4.emphasis,
However, which remained
the mean rankatatT3T4 and T4 ( higher
is still than at T1. The dev
However,
opment of this pattern wassocial
‘stimulating not significant.
behavior’‘Supporting flexibility’
is partly linear; fromalsoT1 toshows a constant
T2, this behavior amo
line in this figure ( 2 (3) = 2.21; p = 0.53).
therapists received more emphasis, which remained at T3 and T4 (χ (3) = 2.64; p = 0.4 2
However, this pattern was not significant. ‘Supporting flexibility’ also shows a consta
line in this figure (χ2(3) = 2.21; p = 0.53).
Children 2022, 9, 1036 10 of 17
3.4. Patterns in Mean Ranks

The gradients for all four subscales—‘sense of self’, ‘emotion regulation’, ‘flexibility’,
and ‘social behavior’—show an upward development between T1 and T2 for the children
as well as the therapists, except for one of the therapists’ dimensions: ‘supporting sense of
self’ (Figure 8). This indicates that halfway through the treatment, it may be expected that
an ‘average child’ would show improvement in all subscales.
Improvement of the children’s behaviors continued at T3 (end of treatment) and even
at T4 (15 weeks after ending treatment), with the exception of the dimension ‘flexibility’.
The gradients of the EAT scores for ‘supporting sense of self’ show a decrease at T2,
an upward development at T3, and again a decrease at T4. Therefore, especially during
the first half of the treatment sessions, the art therapists do not seem to be very active with
respect to the ‘sense of self’ dimension.
When comparing the OAT and EAT scores at T2, a comparable pattern can be observed:
an increase in mean scores for (supporting) ‘sense of self’, ‘emotion regulation’, ‘flexibility’,
and ‘social behavior’. In particular, the heightened EAT scores at T2 are remarkable; the
therapists clearly seem to increase their support efforts halfway treatment on ‘emotion
regulation’, ‘flexibility’, and ‘social behavior’.
After treatment, only the EAT scores for ‘supporting sense of self’ decreased.
Regarding ‘emotion regulation’, the art therapists’ supportive behavior appeared to
be more strongly represented compared to the other three dimensions.
At the end of the treatment, the therapists’ scores seemed to be higher than at the start
for the subscales ‘stimulating emotion regulation’ and ‘supporting social behavior’.
4. Discussion
In this study, the changes in behavior of children during the IOS program were
explored in four dimensions, i.e., ‘sense of self’, ‘emotion regulation’, ‘flexibility’, and
‘social behavior’. Art therapists evaluated the behavior of their young clients and their own
behavior by repeatedly completing the OAT and EAT, respectively. Besides descriptive
results using each instrument, we also visually explored whether and how changes in the
behavior of children were associated with the behavior of therapists.
Looking at the individual children, the change in behavior represented by the subscales
‘sense of self’, ‘emotion regulation’, ‘flexibility’, and ‘social behavior’ was highly varied.
It is plausible to firstly explain this variation on the basis of the diversity of problems in
children diagnosed with ASD [7,43]. Despite this variation, we see that ten of the twelve
children showed moderate to substantial positive behavior changes during art making
considering all OAT subscales—at the end of the program and fifteen weeks after treatment
termination. This confirms our expectation that the ‘art therapy triangle’ may offer an
important contribution; the triangular relationship between the child, the art making, and
the therapist seems to give opportunities to improve verbal and nonverbal communication
skills [10]. In general, it has been shown that AT is a promising treatment for patients/clients
who have difficulties in identifying and expressing their emotions verbally [44]. Interactions
with a therapist via artistic means are indicated as being supportive for children with
autism-related problems in order to improve their social communication skills [5,27].
Qualitative comments by art therapists can be helpful in better understanding cases
with negative changes and those with quite a flat profile (cases 4 and 10, respectively). The
art therapists reported that both children improved on most outcomes, but at the same
time, they were young persons who remained dependent on a supportive environment.
This is a realistic prospect for children diagnosed with ASD [45]. With respect to the child
with the flat profile (case 10), the art therapist reported that she observed a development in
the art making. Nevertheless, the child kept on saying: “Please explain to me what is the
point about this art making?”. This result may indicate that not every child with ASD may
develop skills and positive behaviors during art making.
Additionally, some other patterns emerged. For the OAT subscales, the highest amount
of substantial and moderate positive change in behavior was established for ‘emotion
Children 2022, 9, 1036 11 of 17
regulation’: between T1 and T3 for nine children, and between T1 and T4 also for nine
children, with an overlap of seven children. This result corresponds with improvement
of ‘emotion regulation’ in 50–55% of AT treatment cases, which is in line with a recently
published review [5].
In the mean ranks of scores, it is possible to observe an improvement in children’s
behaviors, even 15 weeks after treatment, albeit with the exception of the ‘flexibility’
subscale. We notice here that the results regarding children’s behavior during art making
differ in some respects from the observations supplied by parents and teachers at home
and in the classroom; see also [19]. It may be assumed that the art therapy triangle offers
other opportunities for the children’s behavior and expressions during art making and for
interacting with the art therapist via the art making [24,46]. Another explanation may be
found in the different perspectives and situations of observation of therapists compared to
teachers and parents [47].
For the ‘social behavior’ subscale, the moderate or substantial development of eight
cases, 15 weeks after treatment, was compared to that of seven cases directly after treatment.
The improvement 15 weeks after treatment may indicate an ‘after effect’. Improvement of
‘social behavior’ in 75% of AT treatment cases is in line with a recently published review [5].
For children with ASD, improvement of ‘social behavior’ is often described as one of the
most important AT aims [11,12,48].
The EAT ‘supporting sense of self’ scores showed a decrease at T2 compared to T1, an
increase at T3, and again a decrease at T4. This may mean that the therapists—in line with
the literature—adhere at different moments to varying intensities of actions while offering
the child opportunities to learn from tactile experiences. In the literature, it has been found
that art therapists presume sensory experiences to be the most supportive element for the
child in developing a ‘sense of self’ [10–12,15,16]. Improvement of self-esteem, which is
part of the ‘sense of self’ continuum, seems to be observed in 50–55% of the AT treatments
to be observed [5].
Comparison of mean ranks of observed children’s behaviors with mean ranks of
therapists’ behaviors hardly shows a clear relationship between the two behaviors. For
instance, we saw little change in efforts in ‘supporting sense of self’ by therapists. An
explanation might be that, according to the therapist’s view, the handling and touching
of art materials is the main source contributing to improvement of ‘sense of self’ for these
children. In other words, and considering the ‘art therapy triangle’ and the communication
difficulties of children with ASD, it might be assumed that psychological processes involved
in the ‘sense of self’ are not directly influenced by the therapist’s behavior.
The mapping of the first and second IOS phases showed a remarkable positive change
in children’s behaviors halfway through treatment. This might indicate that during the first
eight sessions, one could already expect positive developments in some or all behavioral
dimensions. Additionally, we found an increased activity of the therapists’ halfway treat-
ment on the dimensions of stimulation or supporting ‘emotion regulation’, ‘flexibility’, and
‘social behavior’. It seems plausible that the therapist does not start with full effort, because
at the start, it takes time to get acquainted, build a safe situation, etc. When the therapeutic
relationship is more or less set, the therapist may increase efforts at T2 and invite the child
to share new experiences. At T3, the therapists become again a bit less active in their
support, thereby anticipating the moment at which the child needs to further develop
without being supported by a therapist and should integrate his/her new experiences,
skills and behaviors into daily life. This pattern reminds us of a model of promoting change
in people’s behavior, already conceptualized in 1947 by the psychologist Dr. Kurt Lewin in
a three-step frame with the phases ‘unfreezing’, ‘moving’, and ‘freezing’. The steps refer to
helping someone to orient him/herself to new behavior, to (tentatively) practice it, and to
stabilize it with diminishing external support, respectively [49]. Therapists might apply the
model even without being professionally aware of its existence.
In their qualitative reported comments, art therapists mentioned that the clearly
designed treatment program was helpful. Feedback informed treatment is supportive
Children 2022, 9, 1036 12 of 17
for therapist’s working in a child psychiatric setting [50]. This contributes to improved
quality of life in children with ASD and also supports parents’ expectations. Participating
therapists mentioned being surprised that they did not see further change after 15 sessions,
because most of them were used to applying art therapy for a period of around a year.
Evaluation moments combined with the use of videos is understood to be supportive
for helpers working with ASD patients/clients [51]. Additionally, parents and others who
have to communicate with ASD children (teachers) feel supported by the opportunities
that video-recordings offers [52].
Our study confirms that working in the ‘art therapy triangle’ allows children with
communication problems to develop their sense of self, emotion regulation skills and
communication skills, and sometimes also flexibility.
4.1. Strengths and Limitations

This study provides new insights into the treatment process by monitoring children’s
and therapists’ behavior with respect to the 12 cases that were part of the research. The
‘Images of Self’ program is—as far as we know—the first empirically studied art therapy
program, specifically for children diagnosed with ASD. The intervention, with its ‘built-in’
monitoring system, creates opportunities to explore characteristics of the processes of
change in the ‘art therapeutic triangle’ of child, art (making), and therapist. The program
provides a manual that allows attunement to the client’s needs during art making, in order
to build a strong therapeutic alliance via art making.
The combination of the IOS program with the measurement instruments OAT and
EAT provided a focus in the treatment for the participating art therapists. The instruments
that were applied for observing the children’s and therapists’ behavior were intensively
tested on aspects of validity and reliability [26]. The design of the study—a multiple case
study with repeated measurements, with a combination of quantitative and qualitative
data—allowed us to profile the child’s as well as the therapist’s developments in behavior,
and to compare both—case by case and on the level of the whole sample—in our search for
associations and patterns.
We also notice some limitations. Although we have confidence in the observation
scales OAT and EAT, it cannot be denied that the study mostly leans on the perspective
of professionals, i.e., the art therapists. Missing is especially the perspective of the child.
While spontaneous utterances of the participating children were mapped, a child-oriented
method including ‘their voices’ (like, for instance, by interviewing them) was lacking.
This holds less true for the parents and teachers, because they were asked to report their
observations at home and at school, respectively.
In addition, there are indications that therapists in some situations might overestimate
their competences in therapeutic settings [53]. Contrary to this kind of ‘bias’, we found that
participating therapists did not always report their behavior to be as active as might be
expected in a therapeutic context. Especially regarding the dimension ‘supporting sense
of self’, the level of input by the therapists was relatively low. This did not seem to be
evaluated by them as a ‘failure’ of engagement and might argue against bias. Nevertheless,
it would be profitable in further research to include neutral, trained observers in order to
fill out the OAT and EAT forms—in addition to the observations by the therapists.
The design prohibits the possibility of making causal inferences. If we would like
to deepen our insights regarding the question as to what in the therapeutic processes
‘causes’ progress with children, another type of design, i.e., a (quasi-)experimental one,
would be needed [54]. This means that a sample of children receiving AT according to the
IOS program would be compared to a sample that does were receiving AT, or that were
receiving another treatment. Considering the necessary ‘power’ to make valid inferences, a
bigger sample than the current one is required.
As indicated up here we found some differences between the results of this study
compared to our former study [18]. This may indicate that the observed behaviors of the
children during art making are different from the behaviors at home and in the classroom.
Children 2022, 9, 1036 13 of 17
For that reason we suggest to include all relevant contexts (therapy, home, school, leisure
time) in future research.
4.2. Recommendations
We recommend continuing the research on art therapy by applying the IOS program
on a larger scale and carefully monitoring the results. Above, we already argued in favor
of a (quasi-)experimental design to gain further insight into the effectiveness of IOS. More
detailed insights into children’s and therapists’ behavior during AT and how these relate to
each other can be gained from a larger pool of n = 1 studies with repeated measurements.
In these studies, the ‘voice of the child’ should be included—more than was the case in the
current research.
Special attention should be paid to the working mechanisms of art making as an instru-
ment to improve specific behaviors: what exactly is the role of making art and expressing
oneself in an artistic way for the child’s development and behavior? A combination of
narrative methods (interview, diary, focus group) and content analysis of ‘art products’
might be helpful in further clarifying the dynamics during AT.
In a more practical sense, we propose to improve the IOS program by gathering
feedback from experienced therapists and trainees, as well as from parents or other network
members like teachers. As was already indicated, the use of video-recordings, together
with analyzing and discussing these afterwards, has proven to be very valuable. For that
reason, we consider the instruments OAT and EAT that have been used in this study to
systematically observe children’s and therapists’ behavior, as an integral part of the IOS
program. The implication is that AT therapists using IOS should be thoroughly trained in
the implementation of these instruments.
Until now, the IOS program has only been applied and studied in the context of mental
health care services for children with ASD. Recently, a pilot study started to broaden the
field in which IOS could be applied. An empirical study to investigate the possibilities and
opportunities to apply the program in a school context, thereby studying the preventive
qualities of AT for children with ASD and other psychosocial problems: is participation of
vulnerable children in IOS during school hours helpful in preventing their referral to more
‘heavy’ psychosocial services or treatments? In addition, in what way does IOS, applied in
an educational environment for teachers, support expanded possibilities for accompanying
children with ASD [9].
Author Contributions: Conceptualization, C.S., E.J.K., T.A.V.Y. and M.S.; Formal analysis, C.S., E.J.K.
and M.S.; Investigation, C.S.; Methodology, M.S.; Supervision, E.J.K. and T.A.V.Y.; Visualization, C.S.;
Writing—original draft, C.S.; Writing—review and editing, E.J.K., T.A.V.Y. and M.S. All authors have
read and agreed to the published version of the manuscript.
Institutional Review Board Statement: The study was conducted according to the guidelines of
the Declaration of Helsinki, and approved by the Regionale Toetsingscommissie (RTPO 1026a,
9 January 2018).
Informed Consent Statement: Written informed consent was obtained from all subjects involved in
the study.
Data Availability Statement: The data presented in this study are available on request from the
corresponding author.
Acknowledgments: Our gratitude goes out to the children, their parents, teachers and art therapists
who participated in this study.
Conflicts of Interest: The authors declare no conflict of interest.
Children 2022, 9, 1036 14 of 17
Appendix A
Table A1. Overview of participating children, art therapists, treatment settings, reasons for referral, use of medication, and context information [19]
Reprinted/adapted with permission from Elsevier Rights and Permissions, http://s100.copyright.com/mycount/viewrightslinkorders; accessed on 6 July 2022).
Experience of
After eight weeks she is
Ambulant mental Not going to school at start AT. part-time visiting school.
1 F 6 1 13 health care Heavy emotion regulation problems and Vitamin B injections Mother tells that the teacher
organization inflexible behavior in classroom. does not understand
her child.
Philippine background with
(Semi)residential Asian values about
Social communication problems: isolated;
2 F 9 2 40 psychiatric center for No behavior and education.
what is she thinking/feeling?
children and youth Mother has a burn-out and
is in a divorce.
Extra psycho- education for
Emotion regulation problems in classroom
School for special Methyl phenidate for child, to improve her
3 F 12 3 8 (crying); negative self-image;
education oversensitivity understanding of ASD.
oversensitivity.
Child shows severe depressed feelings at

(Semi)residential
home. Negative self-image. Parent training to improve
4 M 10 4 13 psychiatric center for Methyl phenidate
Emotion regulation problems in classroom understanding of ASD.
children and youth
(anxiety problems and anger outbursts).
Severe depressed feelings at home.
At the end of AT she went
School for special Emotion regulation problems in classroom
5 F 11 5 40 No to a lower class grade.
education (anxiety problems).
Social communication problems at home
and in school (hardly talks).
Children 2022, 9, 1036 15 of 17
Table A1. Cont.
Experience of
Yes, for the anxiety
and emotion After 10 weeks, mother
School for special Emotion regulation problems at home and in
6 M 9 5 40 regulation, but no severely ill. Child has
education classroom (anxiety problems and anger
specific information problems with teacher.
outbursts).
what it is.
School for special Negative self-image.
7 M 10 5 40 No
education Flexibility problems at home.
(Semi)residential Parent training to
Flexibility problems. Social communication
8 M 12 6 20 psychiatric center for No improve understanding
problems (what is she thinking/feeling?).
children and youth of ASD.
Anxiety problems.
Parent training to
(Semi)residential Negative self-image. improve understanding
9 M 12 6 20 psychiatric center for Emotion regulation problems at home and in No of ASD.
children and youth classroom (anger outbursts). Stop-think-do method is
used in school.
Ambulant mental Emotion regulation problems at home Parent training to
10 M 11 1 13 health care (anger outbursts). No improve understanding
organization Social communication problems (what is he of ASD.
thinking/feeling?).
Ambulant mental
health care Negative self-image. Methyl phenidate
11 F 11 7 9
organization Social communication problems. for ADHD
Parent training to
Ambulant mental Negative self-image. Very depressed feelings. improve understanding
12 M 12 1 13 health care Social communication problems (what is he No of ASD.
organization thinking/feeling?). Divorce of parents
during treatment.
Children 2022, 9, 1036 16 of 17
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International Journal for Multidisciplinary Research (IJFMR)
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Effectiveness of Art Therapy in Autism

Spectrum Disorders Focusing on Sensory and
Motor Aspects: Review of Literature
Lokeshwari Balaramamurugan1, Dr.N.Balakrishnan2
1
M.SC Clinical Psychology, Annamalai University
2
Assistant professor, Department of Psychology, Annamalai University, Annamalai nagar.
Abstract:
Background and Objective: Autism Spectrum Disorder is a group of neurodevelopmental disorders
characterized by impaired verbal and non-verbal communication in addition to repetitive stereotypical
behaviour. The Art therapy intervention is a performance based intervention that is used as a treatment for
vast categories of mental health problems. Autism spectrum disorder (ASD) refers any one of a group of
disorders with an onset typically occurring during the preschool years and characterized by difficulties
with social communication and social interaction and restricted and repetitive patterns in behaviours,
interests, and activities. The Effectiveness of the art therapy is proved in treating vast categories of mental
health problems. The Aim of this study is to review and summarize the Severity of Autism Spectrum
Disorder and Effectiveness of Art therapy in reducing the Symptoms of Art therapy. Methods: An
electronic search was made through published scholarly articles in Goggle scholar and Semantic Scholar.
The Studies were filtered to last 15 years and with the following key words Art therapy, Autism spectrum
disorder, Sensory and motor aspects 22 articles were sorted according to the selection criteria.
Conclusions: Art based therapies were widely used in the recent times. Art therapy can be used for the
reduction of symptoms of ASD and develop sensory and motor aspects. Based on the results of the
available literature, Art therapy interventions can be useful in reducing the symptoms of Autism spectrum
disorder and in developing the sensory and motor aspects.
Keywords: Autism Spectrum Disorder, Art therapy, Sensory aspects and Motor aspect
INTRODUCTION
Autism spectrum disorder (ASD) refers any one of a group of disorders with an onset typically occurring
during the preschool years and characterized by difficulties with social communication and social
interaction and restricted and repetitive patterns in behaviours, interests, and activities [1]. The term
“spectrum” is used because of the heterogeneity in the presentation and severity of ASD symptoms, as
well as in the skills and level of functioning of individuals who have ASD [2]. Autism is a
neurodevelopmental disorder characterized by markedly impaired social interactions, verbal and
nonverbal communication; narrow interests; and repetitive behaviour. Manifestations and features of the
disorder appear before age 3 but vary greatly across children according to developmental level, language
skills, and chronological age. They may include a lack of awareness of the feelings of others, impaired
IJFMR23033116 Volume 5, Issue 3, May-June 2023 1

ability to imitate, absence of social play, abnormal speech, abnormal nonverbal communication, and a
preference for maintaining environmental sameness. Classified in DSM–IV–TR as a pervasive
developmental disorder, autism has been subsumed into autism spectrum disorder in DSM–5 and is no
longer considered a distinct diagnosis. Also called autistic disorder; childhood autism; early infantile
autism; infantile autism; Kanner’s syndrome [3]. The etiology of ASD is likely to be multifactorial, with
both genetic and non-genetic factors playing a role. ASD can be syndromic or non-syndromic. Syndromic
ASD is often associated with chromosomal abnormalities or monogenic alterations like Rett’s Syndrome
[4]. Contrary to syndromic ASD, the etiology of non-syndromic ASD is still relatively undefined due to
its genetic heterogeneity. A collaboration of de novo mutations and prenatal plus postnatal environmental
factors are likely to play a role. There is correlation between the environmental factors during fetal
development proving that environmental factors may have role in causing ASD [5]. Art therapy is a mental
health profession that enriches the lives of individuals, families, and communities through active art-
making, creative process, applied psychological theory, and human experience within a psychotherapeutic
relationship [6]. Art therapy serves as t5he treatment of wide verities of mental health problems. In recent
days, Art therapy is considered to be a definite treatment for pervasive development disorder
Review of literature is the written overview of major writings, publications and other sources on a selected
topic. It is the overview of previously published work related to a specific topic or research question. It is
often written as the part of dissertation, thesis or research paper which provides context to our study. The
present study was attempted to identify effectiveness of art therapy among the children with ASD and in
the reduction of sensory and motor aspects.
STUDIES RELATED TO ART THERAPY

Laura A. Clapp, E. Taylor, S. Di Folco, V. Mackinnon (September 2019) examined effectiveness
of art therapy with paediatric populations affected by medical health conditions: a systematic review 12
studies with the combined sample of 722 children and young people aging from 2 to 19 years who have
chronic disorders or hospitalized in which 404 children received art therapy and 318 subjects in
comparison groups. The study concluded that Art therapy has a significant difference in the psychological
wellbeing of the children with chronic illness or prolonged hospitalization which in turn improved their
recovery.
Jingxuan Hu, Jinhuan Zhang, Liyu Hu, Haibo Yu and Jinping Xu (2021) studied art therapy as a
complementary treatment for mental disorders. This study is about the effectiveness of art therapy for
various mental health problems such as Depression, Anxiety, Schizophrenia, Dementia, Cognitive
impairment and Autism spectrum disorder. 479 records about art therapy were identified, this study is
aimed to focus on art therapy included painting and drawing as major media, the literatures were screened
out deeper, and identified 413 (84%) literatures involved in painting and drawing. The research study
concluded that art therapy is effective for all the type of mental disorders.
Biyun Zhang, Jingyao Chen, Xiaoyan Huang and Wenhao Xu (2021) studied Chinese Flower and
Bird Painting as a New Form of Art Therapy for Depression. Total of 110 people affected by depression
were selected in which 58 were males and 52 were females, EEG was done to observe the brain
neurotransmission. Three stages of art therapy intervention for 24 weeks combined with breathing
exercises and relaxation therapy was given to 56 people with mild and moderate depression according to

Hamilton rating scale for Depression (HAM-D). EEG and Psychometrics (HAM-D) is done after the
therapy process which proves the significant improvement of the patients of experimental group. This
study concludes that art therapy helps to alleviate the symptoms of depression.
Dafna Regev* and Liat Cohen-Yatziv (2018) studied effectiveness of art therapy with adult clients. This
paper analyse 27 latest art therapy studies and concludes the effectiveness of art therapy. This review study
has been made by seven clinical categories such as cancer patients, person with medical illness, adult
patients, post traumatic patients, prison inmates, elderly and people who face daily challenges (burnout
and stress). It is concluded that the art therapy is effective to all the seven clinical categories.
MojtabaGholamzade Khadar, Jalil Babapour, Hassan Sabourimoghaddam studied Effect of art

therapy based painting therapy in reducing symptoms of Oppositional Defiant Disorder (ODD). This
research was done by selecting 30 elementary school children with the symptoms of ODD aging between
7 to 12 years. The children were selected on the basis of Child symptom inventory and by DSM IV criteria.
12 sessions of therapy was given as twice a week, each session lasted for 40 minutes. This is an
experimental and a pre-test, post-test control group design method were applied. The data were analysed
using descriptive statistics as well as ANCOVA. The finding showed that experimental group did have a
significant decrease in the symptoms of odd while the control group showed no significant difference.
Annemarie Abbing, Erik W. Baars, Leo de Sonneville, Anne S. Ponstein and Hanna Swaab (2019)
studied the effectiveness of art therapy on anxiety for adult women in a randomized control trial. The aim
of this research is to study the effectiveness of specific art therapy treatment, Anthroposophic art therapy
technique to reduce the anxiety of adult women. Participants were women, aged 18-65 years, diagnosed
with generalized anxiety disorder, social anxiety disorder or panic disorder, with moderate to severe
anxiety symptoms. The trial was registered in the Dutch Trial Registration (NTR28143). It aims on quality
of life and emotional regulation. 59 women were included of which 49 completed the trial and the pre-
protocol and intension to treat analysis resulted that there is reduction in Anxiety level of the participants
and there is evidence of increase in quality of life and emotional regulation. These improvements are seen
after 3 months of follow up as 2 times a week and the research is concluded that there is improved
acceptance of emotions and improved goal-oriented action are aspects of emotion regulation that are
associated with the decrease in anxiety level.
Kristina Geue, Heide Goetze, Marianne Buttstaedt, Evelyn Kleinert, Diana Richter, Susanne Sing
er (2010) studied art therapy intervention for cancer patients. The intention and goal of this article is to
determine whether art therapy may decrease psychological distress and increase coping ability of the
cancer patients. HDRS is used to measure psychological distress. This study consists of total 48
participants in which 18 belong to experimental group. The results are as follows, there is a significant
decrease in the psychological distress of the experimental group, there is no significant or notable
difference in the depression and coping abilities of the experimental group. The study is concluded that
art therapy can make an important contribution in the aftercare recovery of cancer patients and this study
also lime lighted the need for psycho-oncological after care for cancer patients.

Studies related to Autism Spectrum Disorder (ASD)

Rajalakshmi Ramu and Radhakrishnan (2022) conducted nursing professional’s understanding and
screening practices in the identification of children with autism spectrum disorder: a scoping review. Early
identification and intervention of childhood autism spectrum disorder is recognised to have a valuable
impact on a child’s life. Nurses who are adequately prepared with the necessary screening practices to do
early intervention. The scoping review approach was adopted for the present study utilized by reviewing
electronic databases from inception to 2021 Data accomplished by searching 160 related studies from
above said database and found only 10 full- text studies based on the research question. Data concluded
that effective training programmes and continuing nursing education would hasten the early identification
and intervention process in the arena.
Holly Hodges, Casey Fealko, and Neelkamal Soares (Feb 2020) researched on Autism spectrum
disorder: definition, epidemiology, causes, and clinical evaluation. Autism spectrum disorder (ASD) is a
neurodevelopmental disorder characterized by deficits in social communication and the presence of
restricted interests and repetitive behaviours. This study explains about the classification of ASD as In
DSM-5, the concept of a “spectrum” ASD diagnosis was created, combining the DSM-IV’s separate
pervasive developmental disorder (PDD) diagnoses: autistic disorder, Asperger’s disorder, childhood
disintegrative disorder, and pervasive developmental disorder not otherwise specified (PDD-NOS), into
one. The prevalence of ASD is presented as 1 of 59 US children and this study also extended the causes
of ASD as biological, genetic and neurological factors. This study suggested 5 different measuring tools
to measure ASD, they are Modified checklist for autism in toddlers- revised or follow-up (M-CHART r/f);
Survey of well-being of young children; Social Communication Questionnaire (SCQ); Social
Responsiveness Scale (SRS); Autism Spectrum Screening Questionnaire (ASSQ).
Bir Singh Chavan and Priti Arun (2022) conducted a Survey of autism spectrum disorder in chandigarh,
India. This study was a two-stage survey of representative child population of chandigarh using stratified
random sampling technique covering 8820 children between the ages 1.5 and 10 years. Data accomplished
by administering Chandigarh autism screening instrument (CASI), detailed assessment was done using
Autism diagnostic Interview-Revised and Childhood Autism Rating Scale-2. Data concluded that the
prevalence of ASD was found to be 2.25 per 1000 children in chandigarh, no children below the cut-off
on the screening instrument was diagnosed as ASD, and it suggests that the prevalence of ASD in India is
lower than western countries.
Khadija Saleemet al., (2021) examined Diagnostic evaluation of Autism Spectrum Disorders, A health
professional survey. Descriptive cross sectional survey design was conducted from October 2017 till
March 2018 to find out the diagnostic practices of ASD among different health professionals. Data was
collected from 126 health care professionals Data was accomplished by yoga or control group. The
participants in the yoga group received an 8 week (24 session) yoga training program (YTP). Data was
accomplished by administering ATEC. Data was concluded with this study provides support for the
implementation of a yoga training program and identifies specific procedural enhancements to reduce the
severity of symptoms in children with Autism.

Meng-Chuan Laiet al., (2017) conducted Quantifying and exploring camouflaging in men and women
with autism. Undoubtedly, one of the most frequently studied conditions in the field of mental health today
is the autism spectrum disorders (ASD). One of the most controversial topics with respect to this
population is the prevalence of this spectrum of disorders. Autobiographical descriptions and clinician
observations suggest that some individuals with autism. particularly females, 'camouflage! their social
communication difficulties, which may require considerable cognitive effort and lead to increased stress,
anxiety and depression. Using data from 60 age- and IQ-matched men and women with autism (without
intellectual disability), we operationalized camouflaging in adults with autism for the first time as the
quantitative discrepancy between the person's "external" behavioural presentation in social-interpersonal
contexts. Data was accomplished by administering (Autism Diagnostic Observation Schedule) and the
person's "internal status (dispositional traits measured by the Autism Spectrum Quotient and social
cognitive capability measured by the "Reading the Mind in the Eyes Test). We found that the
operationalized camouflaging measure was not significantly correlated with age or 10. On average, women
with autism had higher camouflaging scores than men with autism (Cohen's d=0.98), with substantial
variability in both groups. Data concluded that greater camouflaging was associated with more depressive
symptoms in men and better signal-detection sensitivity in women with autism. The neuroanatomical
association with camouflaging score was largely sex/gender-dependent and significant only in women:
from reverse inference, the most correlated cognitive terms were about emotion and memory. The
underlying constructs, measurement, mechanisms, consequences and heterogeneity of camouflaging in
autism warrant further investigation.
Yuko Yoshimuraet al., (2019) investigated Early intervention and perspectives for children with Autism
Spectrum disorders in Japan Data accomplished by administering the differences of development between
before and after the Early Start Denver Model intervention using the Kyoto Scale of Psychological
Development, the Vineland Adaptive Behaviour Scales-Second Edition, the Autism Diagnostic
Observation Schedule-2. Data concluded the differences in brain responses evoked by human voices
between typically developing children and children with ASD, the relationship between language
development and brain activity in young children, and the different developmental patterns of auditory
response to voice between typically developing children and children with ASD. In the future, we would
like to evaluate the effects of ESDM intervention in terms of behavioural indicators and in terms of
physiological indicators in Japan.
Emilio Salgueiroet al., (2012) conducted a study on Effects of a dolphin interaction program on Children
with autism spectrum disorders - an exploratory research. Data were collected with ten children, registered
in December 2002 as ASD at The Regional Education Authority of the Algarve (South-Ern Portugal) The
age of these children at the time of their first evaluation ranged. From 3 years and 6 months to 13 years
and 6 months. Mean age was 6 years and 9 months. Data was accomplished by administering CARS. This
scale (Childhood Autism Rating Scale, PEP-R- This psycho-educational developmental test. For ASD
children, ATEC-This tool (Autism Treatment Evaluation Checklist. A custom-designed developmental
protocol to evaluate the child's capacity for a "Theory of Mind (TOM). A custom-designed Interaction
Evaluation Grid'. Data was concluded with The ATEC, TOM Tasks and CARS results Show no benefits
of the dolphin interaction program. Interestingly, the PEP-R suggests some statistically Significant effects
on Overall development score', as well as on their 'Fine motor development, Cognitive Performance' and

'Cognitive verbal development. Also, a significant evolution in behavioural complexity was shown by the
IEG.
Satabdi Chakrabortyet al., (2015) Conducted Assessment of Severity of Autism Using the Indian Scale
for Assessment of Autism. Indian children with ICD 10 diagnoses of Autistic disorder (AD, n = 50),
Intellectual Disability (ID, n = 50). Attention Deficit Hyperactivity Disorder (ADHD, n = 26), other
psychiatric disorders (PD-N-25) and control children without psychiatric disorders (n 65) 29 were
Evaluated using the ISAA, DD-CGAS and the CARS (total n-216) The study evaluated the ISAA in
relation to the Childhood Autism Rating Scale (CARS) and the Developmental Disability- Children Global
Assessment Scale (DD-CGAS). The Indian Scale for Assessment of Autism (ISAA) was developed to
assess the severity of autism among Indian cases Data concluded that Total ISAA scores were significantly
higher among children diagnosed with autistic Disorder compared to four other diagnostic groups. Total
ISAA scores were significantly correlated with CARS scores And DD-CGAS scores. Groups sub- divided
on the basis of recommended ISAA cutoff points of severity showed significant Differences in CARS
scores. Conclusion: The ISAA can thus be used to assess severity of AD among Indian children.
Studies related to effectiveness of art therapy on ASD

K. Moghaddam, A. Ravarian, Farhoud Saeid Ershadi, A. Gorji, Saleh Mirzaaghaei, T. Lith(2020)
Studied a Landscape of Art Therapy and Psychodrama in Children and Adults with Autism Spectrum
Disorders in Iran. 12 children who has autism for more than 3 years has been selected as the subject. 4
sessions of Art therapy (Painting medium) and Psychodrama therapy was given. The study is concluded
that In Iran, this approach is very new and can be applied besides the other therapeutic approaches for
ASD, and the art therapy and techniques of psychodrama should be designed in which the sensory
integration occurs for clients with ASD. This study explains the improvement of ASD children in social
interaction and sensory integration, better adaptation to the environment and better neuropsychological
function and learning after art therapy and psychodrama treatment.
Allison Bernier, Karen Ratcliff, Claudia Hilton, Patricia Fingerhut, and Chi-Ying Li (2022) studied
Art Interventions for Children with Autism Spectrum Disorder: A Scoping Review. The objective of this
study is to provide occupational therapists evidence of the benefit of creative arts interventions for children
with ASD by evaluating treatment efficacy and connecting the evidence with the Occupational Therapy
Practice Framework: Domain and Process. For this study the 18 articles from 6 different databases
as CINAHL, Cochrane, PubMed, Ovid, Psyc-Info, and Scopus from 2000 to 2020, from which 15 articles
were considered for scoping review. The study is concluded and provides evidence for the efficacy of
creative arts interventions to enhance occupation-based outcomes for children with ASD.
Celine Schweizer MA et al., (2014) has conducted the study of Art therapy with children with Autism
Spectrum Disorders: A review of clinical case descriptions on ‘what works’. For this study a systematic
review was undertaken covering the period 1985–2012. Eighteen descriptive case-studies were found and
analysed according to the Context Outcomes Art Therapy (COAT) model. The target group of this study
is up-to 18 years. The results indicate that art therapy may add to a more flexible and relaxed attitude, a
better self-image, and improved communicative and learning skills in children with ASD. Art therapy
might be able to contribute in mitigating two main problem areas: social communicative problems, and

restricted and repetitive behaviour patterns. Typical art therapeutic elements such as sensory experiences
with sight and touch may improve social behaviour, flexibility and attention-abilities of autistic children.
This study concludes that the art therapy is effective in improving various skills of children diagnosed
with ASD.
Miranda D'Amico et al., (2017) has studied on the Effectiveness of Art Therapy for Teaching Social
Skills to Children with Autism Spectrum Disorder. This is a Quasi-experimental study in a therapeutic
setting. In a therapeutic setting the social problems faced by the ASD children was discussed and then a
group setting was designed to enhance the social interaction with the peers facing same or similar
problems. Techniques of art therapy is provided in the group therapeutic setting. The research study is
concluded and the findings revealed that art therapy enhanced the ability of children with ASD to engage
and assert themselves in their social interactions, while reducing hyperactivity and inattention.
Elisandra Lopes (2021) has conducted the research on Effectiveness of Art Therapy with Children with
Both Attention-deficit/hyperactivity and Autism Spectrum Disorder. The population focus of this research
is pre-school and grade schooling children from 4 years to 12 years. This research reviews current art
therapy methods and studies. This study demonstrates that art therapy can be used as an intervention tool
for treatment with this population to promote positive social skill and increase academic achievement and
expression of emotions.
Kathleen Marie Epp (2008) has studied the Outcome-Based Evaluation of a Social Skills Program Using
Art Therapy and Group Therapy for Children on the Autism Spectrum Disorder. This study has examined
the effectiveness of a social skills therapy program for school-age children of age from 11 to 18. The
program used art therapy and cognitive-behavioural techniques in a group therapy format to broaden and
deepen the state-of-the-art techniques used in helping children with social developmental disorders to
improve their social skills. Pre-test and post-test instruments were distributed to parents and teachers in
October and May of the 2004—2005 school year. Scores revealed a significant improvement in assertion
scores, coupled with decreased internalizing behaviours, hyperactivity scores, and problem behaviour
scores in the students.
CONCLUSION:
There is a large amount of literature available in the internet providing clear understanding about Autism
Spectrum Disorder and Art therapy. The closely related articles were sorted and studied to conclude that
the Art therapy is effective for treating and reducing the symptoms of Autism Spectrum Disorder and
improving the sensory and motor aspects.
FINANCIAL SUPPORT AND SPONSERSHIP:

NIL
CONFLICTS OF INTEREST:
There are no conflicts of interest

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Original article
CEP Clin Exp Pediatr Vol. 66, No. 10, 447–454, 2023
https://doi.org/10.3345/cep.2023.00640
Impact of short and intensive art-based intervention on

symptomatology and social interactions among children
with autism spectrum disorder
Deldar Morad Abdulah, MSc1, Bayar Mohammed Omar Abdulla, MFA2, Pranee Liamputtong, PhD3
1
Community and Maternity Health Nursing Unit, College of Nursing, University of Duhok, Duhok, Iraq; 2Administration of Institutes, Ministry of Education, Duhok,
Iraq; 3College of Health Sciences, VinUniversity, Hanoi, Vietnam
Background: Consensus on the effectiveness of art therapy Key words: Autism spectrum disorder, Social cognition,
in children with autism spectrum disorders (ASDs) is lacking Social interaction
in the literature.
Purpose: Here, we examined the effectiveness of a short and Key message
intensive art-based intervention on autistic symptomatology Question: Does a short and intensive art-based intervention
and social skills among children with ASD levels 2 and 3. affect symptoms and social interactions among children with
Methods: This pre- and postexperimental investigation in- autism spectrum disorder (ASD)?
cluded 13 children previously diagnosed with ASD levels 2 Finding: The short and intensive art-based intervention did not
and 3 in Kurdistan Region in 2019. They completed the art- affect symptoms in children with ASD level 2 or 3, including
social awareness, social cognition, social communication,
based intervention 2 hours/day for 3 days/week for 1 month.
social motivation, and autistic mannerisms.
The activities included cutting and pasting squares and trian-
Meaning: The short and intensive art-based intervention did
gles, coloring black-and-white images, and recognizing and not improve the symptoms of patients with ASD.
coloring shapes. Children used wooden and aquatic pens and
scissors under guidance. Symptom severity was measured
using the Social Responsiveness Scale (SRS-2), a validated tool
for measuring the severity of autistic traits and symptoms that Introduction
features subscales of social awareness, social cognition, social
communication, social motivation, and autistic mannerisms. Autism spectrum disorder (ASD), also known as a pervasive
Children with ASD level 2 require significant support and developmental disorder, is one of the diagnostic developmental
experience notable difficulties in verbal and social communi- disabilities. It has 4 distinct disorders including autistic disorder,
cation, while those with ASD level 3 require extensive support Asperger syndrome, childhood disintegrative disorder, and per-
and have the most severe form of autism. The outcome was vasive development disorder not otherwise specified. Persons
measured one day before the course commenced and one who are diagnosed with ASD experience the following health
week after completion. issues; difficulty in social interaction, and communication, and
Results: The mean patient age (n=13) was 8.15 years (stan- issues of repetitive and self-stimulatory behaviors. ASD persons
dard deviation, 1.95; range, 5–11 years). Most patients were commonly experience sensory issues; experiencing a severe
male (n=11, 84.62%). The mean SRS-2 score did not change sensitivity or desensitivity to special auditory, visual, and tactile
significantly pre- to postexperiment (159 vs. 157, P=0.601). sensations. These symptoms limit the individuals’ ability in
Similarly, we found no significant changes in social awareness engaging and interact with their environment.1) However, these
(19 vs. 19, P=0.779); social cognition (28 vs. 27, P=0.199); symptoms may not be recognized until later childhood ages.
social communication (56 vs. 54, P=0.600); social motivation Impairments in social interactions are in the following ways;
(26 vs. 24, P=0.684); and autistic mannerisms (33 vs. 32; P= impairments in using or comprehending eye contact, facial ex-
0.780), respectively. pression, and body postures. These symptoms can happen
Conclusion: The art-based intervention did not improve among children despite a lack of social and emotional responsi-
autism symptoms or social interactions among children with veness among ASD children.2)
ASD levels 2 and 3. According to the estimates of the trend in the burden of ASD
at global, regional, and national levels from 1990 to 2019 of the
Corresponding author: Deldar Morad Abdulah, MA. Community and Maternity Health Nursing Unit, College of Nursing, University of Duhok, Kurdistan Region 42001,
Iraq
Email: deldarmorad@gmail.com, https://orcid.org/0000-0002-8986-5793
Received: 29 April 2023, Revised: 29 June 2023, Accepted: 9 August 2023
This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-
nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
Copyright © 2023 by The Korean Pediatric Society
Global Burden of Disease, the global incidence, prevalence, and we need more robust and high-quality experimental studies to
disability-adjusted life year rates of ASD among children under investigate this issue, particularly in Iraq where we know little
5 years were 91.09 per 100,000, 439.39 per 100,000, and about the effectiveness of the therapy on children with ASD. In
68.67 per 100,000 in 2019, respectively. The global incidence this regard, we aimed to examine the effectiveness of a short
rate of ASD has decreased, but the prevalence and DALY have and intensive art-based intervention on autistic symptomatology
raised between 1990 and 2019. The regions with low among children with ASD levels 2 and 3. We hypothesized that
sociodemographic index had the highest prevalence of cases social interaction will be improved after completing with the
(80.26%) and DALYs (81.24 %). Also, male children under 5 art-based intervention.
years have roughly 3 times ASD compared to female children.
North Africa and the Middle East had 75.36 (61.72–90.27) and
prevalence rates of 363.75 (298.26–435.12) per 100,000 Methods
population in 2019.3) A similar pattern was found in another
systematic review.4) 1. Study design and sampling
Expressive arts therapy, particularly art-based therapeutic in- This paper is based on a pre and postexperimental research
terventions presents a unique and comprehensive approach to design. To our knowledge, this study was the first project that
dealing with autism symptoms among children. The art-based examined the effectiveness of art-based intervention among
interventions could be effective to improve the relational capa- ASD children in Iraq. In the study, we included children aged 6
city of ASD patients and to solve tactile and sensory integration, and 16 years old who were previously diagnosed with ASD in a
communication, emotion, and regulation, as well as social 1-month art-based course. We recruited the ASD patients from
skills.5) These interventions are important because ASD children the list of children who were previously diagnosed by a physi-
suffer from difficulties in overall development, particularly cian and were registered in the Mental Health Center in Duhok
issues in interpersonal relations, language, and behavior owing city. The patients were included in a 1-month art-based inter-
to brain damage. Scholars have tried to find out the internal vention course and were followed up by 1 month. The patients
aspect of autistic children through different therapeutic techni- received the art-based intervention 2 hours per day for 3 days/
ques. However, it seems that the children are more conformable wk. To recruit the patients, we contacted the Mental Health
to art-based interventions such as painting because art is the Center in Duhok city. Patients who are diagnosed with mental
most simple and familiar language for children to express their disorders are referred to this center for the next medical care
minds.6) ASD children are regularly referred to art therapy by and follow-up. In this regard, the center has all patients who
clinicians7) in coping with their communication and behavior were diagnosed with ASD across the Duhok governorate. We
issues and low self-esteem.8) checked the medical records of the patients with ASD for the
The effectiveness of art therapy and art-based interventions eligibility criteria. The children who were diagnosed with ASD
on symptoms among children with ASD has been examined in and met the eligibility criteria were separated and others were
the literature. The current systematic reviews have recommend- crossed accordingly. We found that 56 children met the initial
ed that art therapy may help ASD children in their social com- eligibility criteria of the total 125 patients with ASD. The
munication and interaction, and limited and repetitive behavior children with ASD levels 2 and 3 met the initial eligibility criteria
patterns.8) ASD is a neurodevelopmental medical condition in in this study. The center then contacted the parents of the
which children have a reduction in social aspects. In other patients. Of the total 56 patients with ASD, the parents of 28
words, impairment in social communication is the main issue children accepted to take part in this study. Out of 28 children,
among ASD children. This impairment in social interaction and the parents of 15 children registered for the course on the first
atypical attention of ASD children impacts cognition and be- day. The remaining 13 children did not register for the course
havior impairment.9,10) Although the literature has paid the owing to unknown reasons. We determined the dates and times
attention to the effectiveness of art therapy and art-based in- of the course at a meeting before the course. We presented 11
terventions on symptoms in children with ASD, there is no two-hour sessions to the children within a month. In session 12,
consensus on the effectiveness of art therapy on symptoms in we conducted an exhibition of the artworks made by the child-
children with ASD in the systematic reviews.8) Also, many of ren. The parents of the children participated in the art course as
these experimental studies have included ASD children with well.
level 1. Due to the long-term and chronic nature of ASD, treat-
ing patients within a short period of time presents challenges. 2. Study setting and intervention area
The effectiveness of intensive art-based intervention has not The children who were included in this study were recruited
been evaluated in children with ASD. Therefore, we attempted from the Mental Health Center in Duhok city. This center has
to examine the effectiveness of a short-term, intensive art-based been established to provide diagnostic and therapeutic care to
intervention. Both children with ASD and their parents require children with psychiatric disorders in the Duhok governorate.
a short and highly effective technique for alleviating symptoms. In addition, this center presents some psychiatric and psycho-
Consequently, this study holds double importance. Therefore, logical interventions to the children. The Mental Health Center
448 Abdulah DM, et al. Group art-based intervention and children with autism spectrum disorder www.e-cep.org
is the only center for the provision of psychiatric health to child- in focus or location, and engaging in repetitive behaviors. They
ren. The Duhok General Directorate of Health administers the have too many limitations to speak evidently. They start inter-
center. A convenient calm and large hall was devoted by the acting with other people and speak so awkwardly. Also, they
center for the art-based intervention. The hall was located on respond to only very direct social approaches from other peo-
the second floor of the Mental Health Center. It was a calm hall ple.11) The ASD level was detected from the medical records of
afar from the victors of the center. the patients and their parents.
3. Diagnosis of autism 4. Inclusion and exclusion criteria

We included ASD children with levels 2 and 3 in this study. We included ASD with any type in this study. The ASD types
The patients with ASD level 2 require substantial support and were autistic disorder, Asperser syndrome, pervasive develop-
have more evident verbal and social communication issues com- mental disorders (PDD-NOS [not otherwise specified]), Rett
pared to those children with ASD level 1. Also, these patients syndrome, and childhood disintegrative disorder. We included
have difficulties changing their concentrations from one activity both genders in this study. The patients with other severe mental
to another one. These children have very narrow interests and disorders that made difficulty in communication were not
engage in repetitive behaviors leading to difficulty in function in included in the study. Also, we included patients from different
certain states and tend to speak in sentences and struggle with sociodemographic characteristics.
nonverbal forms of communication.
ASD children with level 3 need very substantial support. ASD 5. Art therapy intervention
level 3 is considered the most severe form of autism and has We provided some art-based templates to the children in each
many same behaviors as levels 1 and 2. Despite these children session. The templates were different for each session to avoid
expressing themselves verbally and nonverbally, they have diffi- boredom amongst the children. We presented some of these
culties functioning, interacting socially, and deal with a change templates in Fig. 1. In one of these templates, there were 3 dif-
Fig. 1. A sample of templates given to children with autism in the art-based intervention.
www.e-cep.org https://doi.org/10.3345/cep.2023.00640 449

ferent size squares on the bottom page. On the top side of the vities. The children were trained on how to keep and use the
paper, there were 3 empty squares the same as size the bottom pen and scissors taking into account safety considerations. Some
squares. We asked the children to cut the squares and locate of these activities were shown in Figs. 2 and 3.
them in the suitable empty squares and stick them on the paper. In the course, 1 artist and 1 psychologist helped the intervenor
This template was repeated with triangles in another session. In in this study. We trained these 2 persons on how to help the
another template, there were 2 colorful bees on the top side of intervenor during the course because controlling the ASD child-
the paper. The bees were not colored on the bottom side of the ren without help is not possible especially since we included the
paper. We asked the children to color the black-and-white ASD children with levels 2 and 3 only. Also, the parents of the
images. Also, we gave a template of a black-and-white house to children assisted the intervenor and trainer in controlling the
color as they like. We gave the required wooden pen colors to children in the course because a few children did not follow the
the children to color the house and other templates as required. instructions of the intervenor. The trainers were the staff of the
In another assignment, there were one colorful square, one Mental Health Center and had 5 and 8 years experience of
circle, and one trainable. There were some noncolored triangles, working with children in the center. The art-based intervention
squares, and circles on the bottom side of the paper. We asked was performed between September 14, 2019, and October 7,
the children to color the same as the color of the triangles, cir- 2019, in Duhok city. Community involvement: not applicable
cles, and squares. This assignment helped the children to search
for the colors and recognize them for use in convenient places. 6. Techniques of bias reduction
Apart from these templates, we gave some wooden handwork We tried to include a representative sample of the ASD
to the children to play with them during the course. We gave population from this region. In this regard, we asked the center
some templates to the parents of the children to repeat the art- to call all eligible parents of the children. In addition, only 1 re-
working at home (Fig. 1). searcher with the cooperation of 2 trainers applied the interven-
During the art-based intervention, the children used a pen tion and the outcomes were measured by another researcher. In
(wooden and aquatic) and scissors for performing these acti- terms of the allocation bias, we had not any problem because
Fig. 2. A sample of tasks given to children with autism during the art-based intervention.
we did not include any control group in this study. Also, we did psychiatric conditions. Higher total and subscale scores indicat-
not have any family with 2 or more children with ASD in this ed worse severity of social impairments.
study. Each question on this scale rates the severity of behaviors
rated on a 4-point Likert scale as not true, sometimes true, often
7. Measurement criteria true, and almost always true for children aged 4 to 18 years.
We recorded the children’s information in a predesigned The subscales of this scale are:
questionnaire. The general information was recorded in the first (1) Social awareness: Social awareness is defined as the ability
part of the questionnaire. The general information was age, sex, to pick up on social assignments. The following items are
sleeping hours, current disease, medicine use, parents’ educa- included in the social awareness are the sensory aspects of
tion, and the number of family members. The autism severity reciprocal social behavior.
items were recorded in the second part of the questionnaire. (2) Social cognition: Social cognition is defined as the ability
to analyze social missions. The following items are included in
8. Autistic symptomatology social cognition; the cognitive-interpretive aspects of reciprocal
The symptoms were measured using the parent version of the social behavior.
Social Responsiveness Scale (SRS)-2. The SRS-2 has 65 items (3) Social communication: Social communication is defined
for the measurement of ASD severity. The scale emphasizes as expressive social communication and reflects the motoric
social impairment the items are rated from 0 to 4 and added to- aspects of reciprocal social behavior.
gether to obtain the overall score. The scale measures 5 sub- (4) Social motivation: Social motivation is defined as the
scales including social motivation, social cognition, social aware- extent to which a person is generally motivated to engage in
ness, social communication, and repetitive behavior).12) The social-interpersonal behavior. Social motivation presents ele-
scale is used for children with ASD and general pupations. The ments of social anxiety, inhibition, and empathic orientation is
scale can be filled out by a parent, teacher, spouse, or another included among these items.
adult informant. The scale measures the children with natural (5) Autistic mannerisms: Autistic mannerisms are defined as
social context and reflects what has been consistently observed stereotypical behaviors or highly restricted interests characte-
over weeks or months. The scale measures the severity of auti- ristic of autism.13)
stic traits and symptoms, and distinguishes ASD from other
Fig. 3. Images of children with autism completing the art-based intervention.

9. Statistical analysis 10. Ethical statement
The general characteristic of the children was presented in We obtained ethical approval from the Duhok General
descriptive statistics. The uncertainty was determined in a 95% Directorate of Health in Duhok city in 2018. The written
confidence interval (CI). The comparisons of ASD severity and consent forms were obtained from the parents of the children
its subscales between pre and postcourse in children were before inclusion in the course. The participants had the right to
examined in a Wilcoxon signed-rank test. The difference reject the participation to leave the course whenever they way.
between pre and postcourse was determined by mean difference The art-based intervention had not any risk to the children. The
and 95% CI. The null hypothesis was rejected in a P<0.05. The protocol of this study was registered on 12th March, 2019 as
statistical calculations were performed in JMP Pro 14.3.0 the reference number 12032019-2 by the Scientific Research
(https://www.jmp.com/en_us/home.html). Divison, Department of Planning of Duhok Directorate Gene-
ral of Health in Duhok city.
Table 1. General characteristics of children with autism spec- Results

trum disorders (n=13)
Statistics
Characteristic The mean age of the patients was 8.15 (standard deviation,
Estimate 95% CI
1.95) aged 5 and 11 years old. Most patients were males (11,
Age, 5–11 yr 8.15±1.95 6.97±1.40–9.33±3.22
84.62%). The patients slept between 8 and 11 years. Three
Sex
patients had epilepsy and only 2 patients used medicines. The
Male 11 (84.62) 57.77–95.67
educations of mothers and fathers were most in under high
Female 2 (15.39) 4.33–42.23
school and college. The patients had family members between 4
Sleeping hours, 8–11 hr 8.88±0.92 8.33±0.66–9.44±1.51
and 16 people (Table 1).
Current disease
The study showed that the mean score of autism was not
Yes (epilepsy) 3 (23.08) 8.18–50.26
changed significantly from pre to postcourse (159 vs. 157;
No 10 (76.92) 49.74–91.82
Medicine
mean diff [95% CI], -3.38 [-15.74 to 8.97]; P=0.601). Similar-
No 11 (84.62) 57.77–95.67
ly, we did not find any significant change in social awareness (19
Yes 2 (15.39) 4.33–42.23 vs. 19, P=0.779); social cognition (28 vs. 27; P=0.1992); social
Father education communication (56 vs. 54, P=0.600); social motivation (26 vs.
Illiterate 3 (23.08) 8.18–50.26 24, P=0.684), and autistic mannerisms (33 vs. 32, P=0.780),
Under high school 4 (30.77) 12.68–57.63 respectively (Table 2, Fig. 4).
College 6 (46.15) 23.21–70.86
Mother education
Illiterate 6 (46.15) 23.21–70.86 Discussion
Under high school 1 (7.69) 1.37–33.31
College 6 (46.15) 23.21–70.86 This study showed that art-based intervention was not effec-
Family number (5–16 members), 5 (2.5) 4.88–9.12 tive in improving autism symptoms and social skills (social
median (IQR) awareness, social cognition, social communication, social moti-
Family member vation, and autistic mannerisms) among children with ASD
4–6 Members 9 (69.23) 42.37–87.32 levels 2 and 3 after one month. Children diagnosed with ASD
>6 Members 4 (30.77) 12.68–57.63 have qualitative limitations in social communication skills. They
Values are presented as mean±standard deviation or number (%) unless
often have stereotypic and repetitive patterns in behavior, inter-
otherwise indicated.
CI, confidence interval; IQR, interquartile range. ests, and activities.14) In the literature, there is no consensus on
Table 2. Autism symptomatology and subscale scores before and after the art-based intervention (n=13)
Time, median (IQR)
Autistic symptom subscale Man diff (95% CI) P value (2-tailed)
Before course After course
SRS score 159 (21.5) 157 (33) -3.38 (-15.74 to 8.97) 0.601
Social awareness scale 19 (7.0) 19 (3.0) 0.54 (-2.19 to 3.27) 0.779
Social cognition scale 28 (6.5) 27 (5.5) -1.54 (-4.17 to 1.09) 0.199
Social communication scale 56 (13.5) 54 (14.5) -1.77 (-8.04 to 4.50) 0.600
Social motivation 26 (5.5) 24 (7.5) -0.69 (-3.13 to 1.74) 0.684
Autistic mannerisms 33 (9.0) 32 (7.0) 0.46 (-2.94 to 3.87) 0.780
IQR, interquartile range; CI, confidence interval; SRS, Social Responsiveness Scale.
Wilcoxon signed-rank tese was used for statistical analyses.
the effectiveness of art-based interventions on symptoms in tivity to the world. Gabriels17) approved that learning motor
children with ASD. For example, a systematic review of 18 coordination is considered the preliminary step to taking part in
descriptive studies identified the main elements of art therapy a multistep project and art group activities. The longer art-based
for children up to 18 years. The systematic review reported that sessions may help the children to establish a better relationship
art therapy could be effective in assisting a more flexible and with autistic children in the environment because an intensive
relaxed perception, improved communication and learning short course may not provide sufficient opportunities for the
skills, and better imagination in ASD children. The study report- children to make this kind of relationship and experience their
ed that the art therapy may reduce social communicative issues senses for better communication.
and restricted and repetitive behavior patterns. Also, they found Lee et al.18) applied for an art program on two 6-year-old
that typical art therapeutic elements (e.g., sensory experiences children with ASD in an educational setting. They provided
with sight and touch) improve social behavior, flexibility, and opportunities for the children to raise their social communi-
attention abilities of children with ASD.8) In another attempt, cation skills through a behavior-analytic instructional methodo-
the researchers showed that drawing is an effective technique to logy once a week for 17 sessions. They reported that the art
improve participants’ cognitive, social, and motor skills.15) intervention facilitated the children’s expression of their own
It seems that the art establishes a unique bridge for a relation- emotions and social interactions with each other during the art
ship between ASD children and the world. Emery16) suggested sessions. An analysis of the findings of the study claimed that the
that creative art-making activities help children with ASD to be children learn on how to use images as a means of communica-
mindful of themselves and to make an association with their tion (creating), to present their artwork in the classroom (pre-
environment because the children observe, recognize, and find senting), to describe their works (responding), and to associate
out the world as observed in their art. In the art-based interven- themselves to others and their surrounding environment (relat-
tions, the children choose their favorite materials and take part ing).
in the artworks leading to the expression of their thoughts and In this study, we tried to avoid measurement bias as much as
feelings. But in this study, we selected the materials for the possible. The art-based intervention and measures of outcomes
children because ASD children with levels 2 and 3 were unable were performed by 2 independent researchers. But the out-
to choose their favorite art materials. Koo and Thomas15) comes reported in this study may not be comparable to the
claimed that basic anticipation from an art therapy or art-based findings reported in other studies because we included ASD
intervention could be an improvement in motor skills and sen- children with levels 2 and 3 in this study. Other studies have not
sory integration through media and different art creative acti- reported the severity of ASD. Also, we did not include an art
vities. Also, the improvement in motor skills can be occurred by therapist in this study as our region has no art therapist. Also,
using coping skills, and eye-hand coordination in art activities the majority of the patients who were included in this study
like tearing, cutting, drawing, and touching new materials. The were males because boys are at higher risk for autism compared
activities made for the sensory aspects of humans are effective in to girls.19)
managing and adjusting new materials and reducing oversensi- We could not include an art therapist in this study, but we
SRS Score
Social Social Social Social Autistic Social Social Social Social Autistic
awareness cognition Commu- motivation Mannerisms awareness cognition Commu- motivation Mannerisms
scale scale nication scale scale nication
A B scale scale
Fig. 4. Pre- and postintervention comparisons of total autistic symptomatology score (A) and autistic symptom subscales (B). SRS, Social
Responsiveness Scale

recommend other researchers include an art therapist as much 2. Richard DA, More W, Joy SP. Recognizing emotions: testing an inter-
as possible. Also, we recommend longer and more sessions of vention for children with autism spectrum disorders. Art Ther 2015;32:
13-9.
art-working for the children because an intensive and short art- 3. Kang L, Liu J, Liu Y, Liang W, Yang F, Liu M. Global, regional, and
based intervention may not be adequate to improve the autism national disease burden of autism spectrum disorder among children
symptoms among children. We recommend the role of family- under 5 years from 1990 to 2019: an analysis for the Global Burden of
based art therapies on symptoms in patients with ASD for the Disease 2019 Study. Asian J Psychiatr 2023;79:103359.
4. Li YA, Chen ZJ, Li XD, Gu MH, Xia N, Gong C, et al. Epidemiology of
next attempts. There were insufficient studies on family-based autism spectrum disorders: Global burden of disease 2019 and biblio-
art therapy in the literature.20) metric analysis of risk factors. Front Pediatr 2022;10:972809.
In conclusion, this study showed that art-based intervention is 5. Holmes H. The use of art therapy to address attachment in autism
not an effective technique to improve autism symptoms and spectrum disorder. Expressive Therapies Capstone Theses 316. Cam-
bridge (MA): Lesley University, 2020.
social interactions (social awareness, social cognition, social 6. Bi W, Wu J, Lin R. Research on the case of art therapy and cognition of
communication, social motivation, and autistic mannerisms) autistic children. World J Soc Sci Res 2018;5:172.
among children with ASD levels 2 and 3. We recommend more 7. Martin N. Art therapy and autism: overview and recommendations. Art
sessions of art-based interventions for a longer period for the Ther 2009;26:187-90.
8. Schweizer C, Knorth EJ, Spreen M. Art therapy with children with
improvement of symptoms and social interactions for children
autism spectrum disorders: a review of clinical case descriptions on ‘what
with ASD. works’. Arts Psychother 2014;41:577-93.
9. Allen G, Courchesne E. Attention function and dysfunction in autism.
Front Biosci 2001;6:D105-19.
10. Keehn B, Müller RA, Townsend J. Atypical attentional networks and the
Footnotes
emergence of autism. Neurosci Biobehav Rev 2013;37:164-83.
11. Masi A, DeMayo MM, Glozier N, Guastella AJ. An overview of autism
Conflicts of interest: No potential conflict of interest relevant to spectrum disorder, heterogeneity and treatment options. Neurosci Bull
this article was reported. 2017;33:183-93.
12. Constantino JN, Gruber CP. Social responsiveness scale second edition
(SRS-2): manual. Torrance (CA): Western Psychological Services (WPS),
Funding: This study was funded by the Duhok General Direc- 2012.
torate of Health as a health promotion activity for children with 13. Constantino J, Gruber C. Social responsiveness scale. Los Angeles (CA):
autism spectrum disorders. Western Psychological Services; 2012.
14. Carter MJ. Diagnostic and statistical manual of mental disorders. Ther
Recreat J 2014;48:275.
Acknowledgments: The authors of this study would like to 15. Koo J, Thomas E. Art therapy for children with autism spectrum disor-
present their deep thanks to the Mental Health Center and der in India. Art Ther 2019;36:209-14.
Duhok General Directorate of Health in Duhok city, specifically 16. Emery MJ. Art therapy as an intervention for autism. Art Ther 2004;
Dr Nezar Ismet Taib who agreed to fund this project. In addi- 21:143-47.
17. Gabriels RL. Art therapy with children who have autism and their
tion, we would like to give our deep gratitude to the parents of
families. In: Malchiodi CA, editor. Handbook of art therapy. New York:
the children. Guilford Press, 2003:193-206.
18. Lee GT, Chou WC, Feng H. Social engagements through art activities for
Author Contribution: Conceptualization: DMA, BMA; Formal two children with autism spectrum disorders. Int J Educ Through Art
2017;13:217-33.
analysis: DMA, PL; Funding acquisition: BMA; Methodology:
19. Posserud MB, Skretting Solberg B, Engeland A, Haavik J, Klungsøyr K.
DMA; Project administration: DMA; Visualization: DMA, BMA; Male to female ratios in autism spectrum disorders by age, intellectual
Writing- original draft: DMA; Writing- review & editing: BMA, disability and attention-deficit/hyperactivity disorder. Acta Psychiatr
PL Scand 2021;144:635-46.
20. Moghaddam K, Zadeh Mohammadi A, Sharifi Daramadi P, Afrooz G.
Effect of the family-based art therapy program on the social interactions,
ORCID: verbal skills and stereotypic behaviors of children with autism spectrum
Deldar Morad Abdulah iD https://orcid.org/0000-0002-8986- disorders (ASD). Iran J Public Health 2016;45:830-2.
5793
Bayar Mohammed Omar Abdulla iD https://orcid.org/0000- How to cite this article: Abdulah DM, Abdulla BMO,
0002-0950-8439 Liamputtong P. Impact of short and intensive art-based interven-
Pranee Liamputtong iD https://orcid.org/0000-0003-0673-4497 tion on symptomatology and social interactions among children
with autism spectrum disorder. Clin Exp Pediatr 2023;66:447-
54.
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Journal of Education, Humanities and Social Sciences RETPS 2023
Volume 22 (2023)
The Effectiveness of Art Therapy on Social Development in

Children with Autism Spectrum Disorders
Xiaoxi Jia *
The High School Affiliated to Renmin University of China, Beijing, China
* Corresponding author: zhangyanfang@baiccl.com
Abstract. People with Autism Spectrum Disorder (ASD) are characterized by having problems with
communication, behaviors, and social interactions. Art therapy (AT) is recognized as an effective
way to deal with the difficulties of ASD since it is accessible and applicable. The application of AT at
an early age can raise the possibility that one with ASD can improve the symptoms. Past studies
suggested that two main deficits of ASD are psychosocial problems and social-reward processing
problems. The mechanisms that make AT effective are still unclear. Communication, sense of self,
eye contact, tolerance of unexpected consequences, establishing of social relationships, and
decrease in anxiety level can support the development of social skills. Incorporating behavioral
techniques into AT can exert a greater influence on the enhancement of problem behaviors. The
means, goals, outcomes, and factors that work for AT are discussed and become essential elements
of AT. The application of art materials, the artwork of children, and the attachment of art therapists
can contribute to the progress of forming relationships, facilitating interactions, and alleviating self-
stimulatory behaviors as well as anxiety levels. Follow-up observations and transformations of AT
are recommended to be completed in future research. This review can provide some suggestions
for the development of intervention programs at schools.
Keywords: Autistic Spectrum Disorder, art therapy, social development.
1. Introduction
Autism spectrum disorder (ASD) is marked by difficulties with social interaction, verbal and
nonverbal communication, and stereotypical or compulsive patterns of behavior [1]. Children with
ASD have problems with flexibility and self-stimulatory behaviors. These problems prevent them
from normally socializing. Flexibility refers to how naturally and flexibly people behave. Self-
stimulatory behaviors represent behaviors that can stimulate the sense organs to make individuals
satisfied. ASD includes high-functioning autism (HFA) and low-functioning autism (LFA). Children
with HFA have regular intelligence and linguistic ability, but children with LFA don’t. Art therapy
(AT) is applied as a treatment for autistic children because it can mitigate their symptoms and is an
affordable and accessible approach. It is essential to develop social skills at an early age, as some
crucial values can be formed during certain phases of growth, which is irreplaceable for social
development [2]. If children are not exposed to the social environment enough, obstacles will be
established in childhood, thus preventing them from further social development and hindering them
from obtaining social support. Since ASD cannot be completely cured, it is vital to insert interventions
at an early age for children with ASD to reduce their symptoms. Therefore, studies on the
effectiveness of art therapy become particularly important. Explanations of effective mechanisms of
AT can contribute to more effective intervention, resulting in more effective intervention, resulting
in better application in education and daily life to improve the social development of children with
ASD.
In the systematic review of Bosgraaf et al., the author claimed that children with ASD had
psychosocial problems that hindered their psychological and social functioning of children [3]. The
biopsychosocial theory held that a confluence of genetic and environmental factors led to mental
illness. Attachment theories paid attention to the relationship between children and their caregivers.
AT was applied as a favorable treatment as it was capable of improving various mechanisms beneath
psychosocial problems and allowed people with autism to indirectly communicate. The behaviors of
therapists could be divided into directive, non-directive, and eclectic behaviors. Researchers found
512
Volume 22 (2023)
that directive therapist behaviors were considerably effective in externalizing problems, while they
were relatively weak in other kinds of psychosocial difficulties. Non-directive therapist behaviors
have remarkable effects on internalizing, externalizing, and social problems. Eclectic therapist
behaviors do best in reducing externalizing as well as internalizing problems. The approaches and
forms of expression and behaviors of therapists could be applied flexibly according to the conditions
and demands of clients to yield the best effects on psychosocial problems.
Various theories including environmental, neurobiological, neuropsychological, mental, and so on
triggered the social motivation theory. This theory was introduced in a recent systematic review,
which contended that social deficiencies in ASD were brought on by underlying brain problems in
processing the reward value of social cues [4]. Past studies tended to focus on the motivators that
could cause social impairment. The author claimed that social functioning would emerge with
deficiencies in the processing of social reward. Most past studies paid attention to the potential causes
and the analysis of social issues in ASD. The mechanism of social impairment was about different
parts of the brain with respect to their functions. Therefore, neural abnormalities could lead to social
interaction issues. Low willingness and orientation to engage in social activities and other weaknesses
collectively constitute the underlying cause of social impairments. A majority of research used
graphical social stimuli, such as pictures of faces and monetary nonsocial stimuli as its comparison.
The methodological approaches used in the investigations differed widely. The author contended that
it might be crucial to investigate particular reward processing sub-dimensions in order to elaborate
ASD impairments. Many studies suggest deficiencies in social and nonsocial reward processing or
individual differences in social reward processing.
Recent research confirmed that art therapy was useful in improving various aspects of individuals,
such as social interactions, communications, and so on. Nevertheless, mechanisms working in the
process of art therapy in relation to the enhancement of patient with ASD is still blurry. This review
paper is designed to identify the mechanisms of effectiveness in AT through recent research. The
demonstration related to the effectiveness of AT will be discussed with respect to the methodology,
which is the elaboration of the AT applied and experimental procedures, and their conclusions about
the impact AT brings on autistic people.
2. The Effectiveness of AT on Various Abilities Related to Social Development

in ASD
2.1. Quantitative Evidence
Communication is essential to basic social engagement and is an important indicator of social
development. AT is responsible for the improvement of vocal behaviors, thus enhancing autistic
children’s ability to engage in social activities and promote their social development. In a previous
experiment, participants included four autistic children, their parents, and the same number of normal
children and their parents as the experimental group were given AT sessions [5]. In the AT sessions,
participants started with painting basic color shifts, lines, and shapes and then transitioned to
depicting objects. The performances of children were tested before and after the therapy. The
researcher indicated that AT had a substantial impact on children with autism particularly in vocal
behavior, and improved and activated neuropsychological functions in the perceptual, linguistic,
cognitive, affective, and motor regions of the brain. Assessments were completed by the children’s
parents or teachers. The improvement of scores regarding self-care, sensibility, communication, and
language ability of assessments suggests that AT contributed to vocal-behavior promotion.
A sense of self is significant in one’s social development since individuals can be aware of their
positions, values, and effects in society. AT is capable of enhancing the sense of self of children with
ASD. A previous study assessed the impact of AT on the image of self [6]. Participants included
autistic children and their parents or teachers. The first three AT sessions were to familiarize children
with the materials and therapist. The therapist could explore their preferences by creating artwork. In
the next 12 sessions, children developed varied skills and connected their experiences to words. The
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therapist realized the children’s resistances and preferences. Different participants filled out particular
scales one week before the treatment and fifteen weeks after the treatment. They were also tested
during the treatment at sessions three, eight, and fifteen. Researchers found out that the image of self
could partially improve difficulties in ASD, especially flexibility and social behaviors. The sense of
self was facilitated and more stable and positive emotions of the children were expressed. The
research could plausibly support the argument as scores from scales of different cases showed more
improvements than worsening, which might be caused by the low baseline of the autistic children
recruited.
Nevertheless, the application of only AT may not be enough for autistic individuals with high-
barrier problems, behavioral interventions may be incorporated to reduce the barriers to problem
behaviors. Only when behavior obstacles are reduced can social development be improved. In a recent
study about behavioral art programs, researchers stipulated a series of measuring standards and
communicated with two children, and recorded marks according to how they reacted [7]. Promotions
reported by teachers and parents of two children were measured by a scale of adaptive behaviors.
Researchers recorded each measurement of the children before and after the sessions. The results
indicated that art therapy combined with behavioral instruction could effectively facilitate the eye
contact, presentation, and verbal communication of autistic children with a low level of social
behaviors. Both children became more expressive, formed interpersonal relationships, had more
leisure time, and developed coping skills. Since similar enhancements of children can also be
observed in previous AT without behavioral interventions, the comparisons of whether behavioral
controls are included are recommended to figure out if behavior intervention is more useful in AT.
2.2. Qualitative Evidence
Eye contact can assist communication, and enduring unexpected consequences can make people
more adaptive to the social environment. They are both counted as the factors affecting social
development and can be practiced during AT. A previous study investigated art activities on social
engagement in children with ASD [8]. AT sessions included specifically three sessions for baseline,
eleven sessions for intervention, and two sessions for generalization were given to two children. The
art sessions began with spontaneous artistic expression. The kids then took part in guided art activities
with social skills education built in. Children participated in free art activities during the baseline and
generalization sessions. They were told to give a presentation at the end of every session. The study
revealed that children could more frequently use eye contact, communicate, and endure some
unexpected consequences after sessions. Both children showed more complexities in their artworks,
interactions with peers, willingness to try new materials, and intense interest in art activities. The
results were demonstrated by assessing their artworks in different phases in AT. The progress of their
artwork, the feedback from their parents, and the therapist’s observation could support the statement
that children’s ability of eye contact and unintended-consequence toleration could be motivated by
AT.
Establishing social relationships can partially account for social development because one is able
to find social support or develop further interactions with people. AT is responsible for the
enhancement of building relationships by applying art materials as mediums. A recent study presented
a framework for the sensory-based relational art therapy approach (S-BRATA) [9]. Guardians of the
children engaged in informal interviews to assess the social-emotional behaviors and sensory profile
of the children before and after the AT. The researcher used various forms of art, different structures
of interventions, and boundary establishment to treat different children. Analytic tables were made
for each participant. The study revealed seven themes, which corresponded with the role of art
materials, the significance of forming relationships with autistic children, and children’s sensory
profiles. The therapist and children could implicitly communicate with art materials, which were
mediums of children’s engagement. By applying attuning and mirroring, social interactions were
improved, specifically longer eye contact, more active attitudes toward activities, and more balanced
relationships between the therapist and children. By comparing and coding the information generated
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from gestalt from analytic tables, the study supports that art materials were implemented to
communicate and interact because the process of children asking for help to get or learn the usage of
materials makes interactions and relationships necessary.
The anxiety level determines the extent one would engage in social activity. Self-stimulatory
behaviors can satisfy autistic individuals to decrease their anxiety levels. The social development of
children with ASD is considerably related to the anxiety level and self-stimulatory behaviors, and
those two can be promoted by AT. A case study about attachment facilitating with a boy was
documented [10]. Initially, the therapist drew in front of the boy to implicitly edify him. When the
child became familiar with the environment and tried to use art materials, the therapist began to
imitate what the child did till the sessions ended. The researcher concluded the frequency of his eye
contact increased as well as his communication, while his self-stimulatory behaviors and anxiety level
decreased. Attachment and attunement were formed between the boy and his artworks or therapist.
His self-regulation and sensory modulations both improved after the therapy. By observing the
transformation of the kid’s behaviors during and after the art therapy, the outcomes of the study
sustain the thesis, because artwork and attachment to the therapist can distract him from performing
self-stimulatory behaviors or directly replace this behavior to make him satisfied, thus reducing the
anxiety level of children.
3. Essential Elements in AT for ASD

The means, goals, and outcomes therapists observe are similar since the consensus of elements is
established. In a previous study, participants including referrers and art therapists assessed the
feasibility and pertinence and added their qualitative comments on items appearing in AT in two
consecutive rounds in the Delphi study [11]. The context category (C), outcomes category (O), art
therapeutical materials and expressions category (A), and therapeutic behavior category (T)
comprised the COAT framework, which was the base of the research. Different professionals
discussed and clarified the outcomes of the Delphi study. Researchers concluded that therapists
reached an agreement about 46 typical elements of AT, which revealed that the inner calm, mood,
and sense of self were improved by the AT. Children with ASD are thought to present the chances
for growth in the management and expression of feelings, thoughts, and emotions. The study may
ascertain some elements of consensus in AT, but the sample size is too small to generalize the
consensus in AT. COAT framework is the basis of this study, while other professionals who do not
approve of this framework may have other opinions about AT.
Different from the last research, the factors that work in AT are also explored. In another research,
the art therapists were engaged in an interview and shared their tacit expertise [12]. Each participant
was asked about the factors causing art therapy to be an appropriate or inappropriate approach to
treating autistic children. Eventually, respondents were asked to provide evidence and clarification of
their claims. The outcome stated that art therapy may have an impact on reducing autism-related
behavioral issues in particular problem areas, such as flexibility, social communication, and self-
image. Children’s improvements in flexibility could be reflected by increased frequency of flexible
behavior, a more relaxed attitude toward making decisions, and promotion of planning. Progressive
social communication was indicated by problems expressing in verbal forms, more expressive
communication, and more personal artwork. The clearer cognition of self-image was inferred by the
management of emotions, considerations of better functions and behaviors, directions of attention,
and improvements in self-confidence and self-esteem. The improvement of behaviors,
communications, and self-image are three mechanisms that are affected by AT and work for social
development.
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4. Conclusion
The salient change of pre- and post-intervention results reveal the positive effect AT exerts on the
vocal behaviors of children with ASD. Quantitative evidence suggests the AT’s effectiveness in
stimulating the sense of self. Incorporation of AT and behavioral interventions can yield a more
effective influence on the problem behaviors of autistic children. Children’s increasing frequency of
eye contact is examined by differences in artwork. The application of art materials helps connect
children with therapists, thus increasing interactions and forming relationships. Children’s artwork
and interactions with therapists can distract them from or replace their self-stimulatory behaviors and
make their anxiety levels fall. COAT framework and improvements of children brought by AT require
more professionals to examine the consensual elements. AT improves social development by
facilitating three elements, which are behavior, communication, and self-image.
Most studies conduct AT sessions and record the children’s variation before and after the program,
while few studies do the follow-up recording of children’s social development to explore whether the
effect of AT is long-term or transitory. If the effect of AT is not long-lasting, studies of the duration
of AT’s improvement after the sessions are helpful in figuring out the period of AT applied. Whether
AT’s effectiveness can be generalized to real life is required to be clarified. Further comparisons
between AT and AT with behavioral intervention are recommended. More research is needed to
confirm whether the baseline of children will affect the impact of treatment. The study area of AT for
LFA children is recommended to be broadened in the future since the intellectual and linguistic
barriers of children may prevent them from achieving the goals of AT and weaken the effectiveness
of AT.
References
[1] Sealey L. A., Hughes B. W., Sriskanda A. N., Guest J. R., Gibson A. D., Johnson-Williams L., Bagasra
O. Environmental factors in the development of autism spectrum disorders. Environment international,
2016, 88: 288 - 298.
[2] Cieciuch J., Davidov E., Algesheimer, R. The stability and change of value structure and priorities in
childhood: A longitudinal study. Social Development, 2016, 25 (3): 503 - 527.
[3] Bosgraaf L., Spreen M., Pattiselanno K., Hooren S. V. Art therapy for psychosocial problems in children
and adolescents: A systematic narrative review on art therapeutic means and forms of expression, therapist
behavior, and supposed mechanisms of change. Frontiers in psychology, 2020, 11: 2389.
[4] Bottini S. Social reward processing in individuals with autism spectrum disorder: A systematic review of
the social motivation hypothesis. Research in Autism Spectrum Disorders, 2018, 45: 9 - 26.
[5] Wang S. The Effect of Art Therapy on Children with Autism. Social Science and Natural Science, 2020.
[6] Schweizer C., Knorth E. J., Van Yperen T. A., Spreen M. Evaluation of ‘Images of Self,’an art therapy
program for children diagnosed with autism spectrum disorders (ASD). Children and Youth Services
Review, 2020, 116: 105207.
[7] Chou W. C., Lee G. T., Feng H. Use of a behavioral art program to improve social skills of two children
with autism spectrum disorders. Education and Training in Autism and Developmental Disabilities, 2016,
195 - 210.
[8] Lee G. T., Chou W. C., Feng H. Social engagements through art activities for two children with autism
spectrum disorders. International Journal of Education Through Art, 2017, 13 (2): 217 - 233.
[9] Durrani H. Sensory-based relational art therapy approach (S-BRATA): A framework for art therapy with
children with ASD. Art Therapy, 2021, 38 (2): 78 - 86.
[10] Durrani H. Facilitating attachment in children with autism through art therapy: A case study. Journal of
Psychotherapy Integration, 2014, 24 (2): 99.
[11] Schweizer C., Knorth E. J., Van Yperen T. A., Spreen, M. Consensus-based typical elements of art therapy
with children with autism spectrum disorders. International Journal of Art Therapy, 2019, 24 (4): 181 -
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[12] Schweizer C., Spreen M., Knorth E. J. Exploring what works in art therapy with children with autism:
Tacit knowledge of art therapists. Art therapy, 2017, 34 (4): 183 - 191.
517
Systematic Review
Interventions through Art Therapy and Music Therapy in

Autism Spectrum Disorder, ADHD, Language Disorders, and
Learning Disabilities in Pediatric-Aged Children:
A Systematic Review
Victoria Martínez-Vérez 1, Paula Gil-Ruíz 2 and Sara Domínguez-Lloria 3,*
1 Department of Didactics of Musical Expression, Art and Dance, Faculty of Education, University of
Valladolid, 34004 Palencia, Spain; vita.martinez@uva.es
2 Department of Corporal and Musical Artistic Expression, Faculty of Education Sciences, Universidad CES
Don Bosco, Attached to the Complutense University of Madrid, 28040 Madrid, Spain;
pgil@cesdonbosco.com
3 Department of Special Didactics, Faculty of Education and Sport Sciences, University of Vigo,
36005 Pontevedra, Spain

* Correspondence: saradominguez.lloria@uvigo.es; Tel.: +34-986-801-700
Abstract: Traditional pharmacological treatments, although effective, often carry potential side ef-
fects, which positions art therapy and music therapy as promising non-pharmacological alternatives
to alleviate symptoms and improve social, cognitive, and emotional skills without the associated
risks. Through a review in the SCOPUS and WOS databases following the PRISMA protocol, a total
of 80 articles were analyzed through a series of determined categories and subcategories of analysis.
The aim of this study is to evaluate and synthesize the existing evidence on the efficacy and applica-
bility of art therapy and music therapy in the treatment of children with autism spectrum disorder
(ASD), hyperactivity disorder (HSDD), developmental language disorders, and language learning
Citation: Martínez-Vérez, V.;
difficulties, identifying best practices and key areas for future research. Among the main findings is
Gil-Ruíz, P.; Domínguez-Lloria, S.
that art therapy and music therapy have a significant impact on symptomatology, behavior, and
Interventions through Art Therapy
communication as well as social, cognitive, and emotional skills in the pediatric populations stud-
and Music Therapy in Au-Tism
Spectrum Disorder, ADHD,
ied. These therapies are highly valued by the participants with a large majority recognizing their
Language Disorders, and Learning adaptability to different educational and clinical contexts. It is concluded that these therapies have
Disabilities in Pediatric-Aged a high potential as viable alternatives or complements to traditional pharmacological treatments,
Children: A Systematic Review. justifying their application and further study in broader therapeutic contexts.
Children 2024, 11, 706.
https://doi.org/10.3390/ Keywords: art therapy; autism; ADHD; systematic review; music therapy; ADHD
children11060706
Academic Editor: Michal Bat Or
Received: 12 May 2024

1. Introduction
Revised: 1 June 2024
Accepted: 5 June 2024
The prevalence of disorders such as attention deficit hyperactivity disorder (ADHD),
Published: 7 June 2024 autism spectrum disorder (ASD), developmental language disorders (SLD), and specific
learning difficulties (SLD) has increased in recent years. This upward trend is complex
and multivariable, and it includes factors such as evolving diagnostic criteria, increased
knowledge and awareness of these conditions, and improved screening methodologies
Copyright: © 2024 by the authors. Li-
censee MDPI, Basel, Switzerland.
and removal of previous barriers in the diagnostic process [1].
This article is an open access article
Cybulski et al. [2] report an increase in ADHD and ASD diagnoses based on medical
distributed under the terms and con- records and parental reports in the United Kingdom, suggesting increased awareness and
ditions of the Creative Commons At- recognition of these disorders. Similarly, Norbury et al. [3] note that following the removal
tribution (CC BY) license (https://cre- of certain diagnostic access requirements, the prevalence of TDL is estimated at 7.58%
ativecommons.org/licenses/by/4.0/). with a 1.22:1 male to female ratio. Specific learning disorders (SLDs) are a group of
Children 2024, 11, 706. https://doi.org/10.3390/children11060706 www.mdpi.com/journal/children

Children 2024, 11, 706 2 of 17
neurobiological disorders manifested by significant and persistent difficulties in the ac-

quisition and use of academic skills, such as reading, writing, and mathematics. These
disorders are not the result of sensory, intellectual, emotional deficits, or an inadequate
educational environment. It is noteworthy that these types of disorders frequently co-oc-
cur with emotional and behavioral problems [4], oppositional behaviors and socialization
difficulties [5], and comorbidities [6]. Furthermore, Zablotsky et al. [7] report a notable
9.5% increase in ASD prevalence among U.S. children aged 3–17 years. The influence of
environmental, educational, and sociocultural factors has also been significant.
Art therapy and music therapy have emerged as key interventions in the treatment
of disorders such as autism spectrum disorder (ASD), attention deficit hyperactivity dis-
order (ADHD), Tourette disorder (TDL), and ASD. These therapeutic approaches have
gained popularity due to the demand for more personalized and individually tailored
treatments, which is crucial in managing the varied manifestations of these disorders [8].
Art therapy offers an alternative means of communication and expression that allows in-
dividuals to explore their emotions, develop social skills, reduce anxiety, and increase self-
esteem [9]. This approach is particularly useful for children and adolescents with ASD,
ADHD, TDL, and ASD, where conventional communication channels are often compro-
mised [10,11]. In contrast, music therapy employs the impact of music on the brain to
facilitate communication and expression in addition to improving motor, social, and emo-
tional functions. It can assist in improving behavior regulation and concentration in chil-
dren with ADHD and promotes verbal and nonverbal communication, potentially mini-
mizing delays in language development and improving the quality of interaction in ASD
[8–12].
Recent studies have demonstrated the efficacy of art therapy and music therapy in
the treatment of the disorders, emphasizing the need to customize treatments to meet the
specific needs of this population [13]. Authors such as López-Hernández et al. [14] propose
a music therapy intervention protocol to improve attention, memory, and language in
children with dyslalia in the context of TDL and report positive results in this type of
intervention. In contrast, art therapies have been demonstrated to enhance attention in
children with intellectual disabilities, improve language skills in children with specific
language disorders, and contribute to the improvement of reading accuracy and speed in
children with learning disabilities [15].
Art therapy and music therapy have emerged as key interventions not only in the
management of disorders such as ASD and ADHD but also in the treatment of develop-
mental language disorders and auditory spectrum disorders. They offer significant bene-
fits in improving language articulation and communicative skills, as evidenced by the
findings of Livengood-Ordóñez [16] and Guanoluisa [17]. Music therapy has been shown
to have a positive effect on language development and communication with notable im-
provements in language processing and memory observed in patients with dyslalia. Fur-
thermore, specific methodological strategies have been identified as effective in improving
speech clarity and fluency. Furthermore, [9] presents a case study that demonstrates how
music therapy, when implemented in a community setting, can facilitate emotional ex-
pression and reinforce social connections, which are crucial for effective communication.
In light of these considerations, the rising prevalence of these disorders, coupled with the
advancements in art therapy and music therapy, underscores the necessity for a system-
atic review to update the scientific information gleaned from the most recent research to
the greatest extent possible, given the considerable heterogeneity in the results and re-
search methods employed. A systematic review will enable the synthesis of existing data
in a rigorous manner and the assessment of the quality and reliability of studies conducted
to date. This will not only provide a solid basis for more informed clinical recommenda-
tions but will also identify gaps in the existing literature, directing future research to areas
of greatest need and potential. Furthermore, the systematic review will facilitate a more
profound comprehension of the potential for these interventions to be optimized and
Children 2024, 11, 706 3 of 17
customized for different patient subgroups, thereby maximizing their therapeutic effects
in children and adolescents with ASD, ADHD, TDL, and ASD.
2. Materials and Methods

For the analysis, we followed the PRISMA protocol that has been registered in the
open science framework platform. Following the methodology established by Shaheen et
al. [18], our aim is to synthesize existing research and assess its applicability and efficacy
in these clinical settings.
We adopted an interpretive approach, allowing a thorough understanding of existing
studies, in accordance with the principles described by Page et al. [19]. This approach
guided us in the selection and analysis of academic literature, using an observational and
retrospective method that is both descriptively and analytically oriented [20].
The literature search was conducted between January and May 2024, using the SCO-
PUS and Web of Science databases. The most effective search equation used combinations
of specific terms applied to the titles, abstracts, and keywords of the documents: (“Art
therapy” OR “Music therapy”) AND (“autism spectrum disorder” OR “ASD” OR
“ADHD” OR “learning difficulties” OR “language disorders”) AND “children”. This
search generated a total of 349 documents in SCOPUS and 406 documents in Web of Sci-
ence. To reduce the number of documents, a search filter was applied to the period be-
tween 2019 and 2023 with the purpose of accessing the most updated information availa-
ble in both databases, yielding a total of 157 and 133 documents, respectively.
2.1. Inclusion and Exclusion Criteria

An inclusion criterion was applied that limited the selection to papers that were re-
search articles only. After this filter, the SCOPUS database submitted 113 papers, while
WOS provided a total of 109 papers, resulting in a total of 222 papers. Duplicates were
removed, thus reducing the document pool to 176 (n = 176), combining the two databases.
The inclusion criteria focused on interventions using art therapy and music therapy
in the treatment of disorders such as autism (ASD), attention deficit hyperactivity disorder
(ADHD), as well as language development disorders and learning difficulties in the pedi-
atric population, aged 0–14 years.
During the analysis of the documents, those that did not meet the established criteria
were excluded. Specifically, 29 articles were eliminated because they did not address the
desired age range, 44 papers that did not constitute interventions, including 27 systematic
reviews, and 17 studies that presented the design but not the results of the intervention.
In addition, 21 papers were excluded because they did not use art therapy or music ther-
apy in the interventions, and two were excluded because they were validations of instru-
ments. As a result, a total of 96 articles were excluded. Finally, a total of 80 articles that
met the previously established inclusion criteria were included in the study.
According to the above, the following flow chart was drawn up according to PRISMA
standards (Figure 1).
Children 2024, 11, 706 4 of 17
Figure 1. Flow chart according to PRISMA for inclusion and exclusion criteria.
2.2. Procedure and Data Analysis

Following an analysis of the identified studies, we proceeded to divide them into four
main categories of analysis, which collectively gathered the data from all the selected ar-
ticles. This is illustrated in Table 1. To mitigate the potential for bias, this analysis process
was carried out independently by three researchers.
Table 1. Categories and subcategories of analysis.
Categories Subcategories
Geographic location.
Productivity.
Bibliometric indicators
Publication.
Authors.
Method.
Age range.
Intervention modality.
Methodological aspects
Participants.
Instrument.
Context.
Type of pathology.
Pathologies and impacts
Improvements detected.
Results of interventions Participants perception.
The analysis of the articles was conducted in accordance with the guidelines estab-
lished by Para Mayer-Benarous et al. [8] and Geretsegger et al. [21], which indicate that
Children 2024, 11, 706 5 of 17
art therapy and music therapy have a significant impact on the pathologies of ASD,
ADHD, language development disorders, and learning difficulties. About the age range,
the standardized pediatrics age classification was employed, which is determined as fol-
lows: newborn (0–6 days), neonate (7–29 days), infant (1–2 years), pre-school (3–5 years),
school (6–11 years) and adolescent (12–14 years). Regarding the results of the intervention,
the following terms were employed: “high value”, “appropriate value”, and “low value”.
The term “high value” was employed when participants perceived that the intervention
yielded substantial benefits in relation to the effort invested. The term “appropriate value”
was employed when the benefits were deemed to be commensurate with the resources
invested. Finally, the term “low value” was employed when participants perceived that
the benefits did not justify the resources or time invested.
3. Results
3.1. Bibliometric Results
As for the geographical location of the studies, Table 2 shows those countries identi-
fied in this systematic review
Table 2. Geographical location of the analyzed articles.
Number of Items Countries Percentage

11 South Korea and the United States 13.75%
8 China 10%
5 India and Israel 6.25%
4 Iran 5%
3 Italy, Netherlands and United Kingdom 5.08%
2 Spain, France, Cyprus and the Czech Republic 3.75%
Kurdistan, Nigeria, Saudi Arabia, Lebanon, Germany, Thailand, Romania, Canada, Egypt, Finland,
1 0.8%
Taiwan, Ecuador, Norway, South Africa, Denmark, Australia, Poland, Turkey
Upon analysis of the data by continent, it was found that 41 articles were from Asian
countries, representing 51.25% of the total. Europe followed with 22 articles, constituting
27.5%, while America contributed 13 articles, which was equivalent to 16.25%. As for the
other continents, Africa was represented with three articles, corresponding to 3.75%, and
finally Oceania with one article, representing 1.25%.
With respect to productivity, it is observed that the year with the highest number of
articles published on this topic was 2020 (n = 20), representing a total of 25% of the articles.
This was followed by 2022 (n = 19), which contributed 23.75% of the articles. The next most
productive year was the year 2021 (n = 11), contributing 20% of the total production, while
the years with the lowest number of articles published on this topic were 2019 (n = 14) and
2023 (n = 11), representing 17.5% and 13.75% of the total, respectively.
About the journals that host these investigations, a total of 61 different publications
can be identified. The Nordic Journal of Music Therapy stands out with six articles (n = 6),
representing 7.5% of the total. The next most prolific journals are Art Therapy, Arts in
Psychotherapy, and The Journal of Music and Human Behavior, which have each contrib-
uted four articles (n = 4), representing 5% each. Furthermore, the International Journal of
Environmental Research and Public Health has three contributions (n = 3), representing
3.75%. Finally, and with the least representation, several journals have two articles each
(n = 2), including Children and Youth Services Review, Frontiers in Psychology, Journal
of Music Therapy, Psychiatry Research, and Research in Developmental Disabilities,
which collectively represent 2.5% of the total. The remaining journals with only one par-
ticipation (n = 1) represent 61.25%. There is a notable diversity among the authors contrib-
uting to academic research. However, a select few have distinguished themselves through
their prolific scientific production in specific areas. For instance, Kim Mi-kyung and Lee
Esther, both from South Korea, have collaborated on two articles examining the efficacy
Children 2024, 11, 706 6 of 17
of art therapy in children with ADHD and ASD. In the Netherlands, Schweizer et al. [22]
have published two studies in 2019 that examine the benefits of art therapy on flexibility
and social behavior in children with ASD. In the United States, LaGasse et al. [23] made
significant contributions to the field of music therapy in the same year, exploring the po-
tential for cognitive improvements in children with ASD. In Italy, Saladino et al. [24,25]
have conducted two studies in 2020 and 2021, respectively, investigating the efficacy of
art therapy in the context of ASD.
3.2. Methodological Aspects

About the methodological approach, 40 studies employed quantitative methodology
(50%), 23 utilized qualitative methods (28.75%), and 17 employed a mixed approach
(21.25%).
Regarding the age range of the participants, 53 studies were conducted with school-
children (66.25%), 17 with preschoolers (21.25%), eight with adolescents (10%), and only
one study involved infants and neonates (1.25% each; Figure 2).
Neonate (7–29 days) Infant (1–2 years )

Preschool (3–5 years) School Age (6–11 years)
Preadolescent (12–14 years)
Figure 2. Distribution of participants in the studies according to age range.
Regarding the intervention modality, 53 studies employed music therapy (66.25%),

while 27 studies utilized art therapy (33.75%).
With respect to the number of participants, two studies with more than 200 partici-
pants stand out in the results. One of these studies included 251 participants, while an-
other included 205. Additionally, four studies exceeded 100 participants. Most of the arti-
cles analyzed samples of fewer than 100 individuals, representing 91.03% of the total. A
noteworthy observation is that thirteen studies with a single participant account for
16.67% of the overall total. In the quantitative approach, questionnaires were employed
as the primary instrument in 18 of the 40 interventions, representing 45% of the total. Ad-
ditionally, systematic recording was employed in 10 studies, representing 25% of the total.
Twenty cases involved the use of evaluation instruments and scales, representing 8% of
the total number of cases. The medical tests constituted only 10% of the total with only
four cases. Regarding qualitative approaches, observation was employed as an instrument
in 14 studies (60.86%), interviews in two studies (8.6%), and systematic records in seven
cases (30.43%). In mixed studies, questionnaires and observational records were em-
ployed as instruments in six studies (35.29%), while assessment tools and scales were used
in ten studies (58.82%), and questionnaires and medical tests were used in conjunction
with questionnaires in one study (5.8%) as shown in Table 3.
Children 2024, 11, 706 7 of 17
Table 3. Quantitative instruments used in the analyzed interventions.
Instruments Authors
Abdulá et al. [26]; Mössler et al. [27]; Amel et al. [28]; Yum et
Social Responsiveness Scale-2 (SRS-2)
al. [29]
Conners children s behavior questionnaire Chen et al. [30]; Zhu [31]
OAT (Art Therapy Observation) and EAT-A (Therapist Evaluation) Schweizer et al. [32]; Schweizer et al. [22]
OAT-A (Child Observation) Schweizer et al. [22]
Ramirez-Melendez et al. [33]; Lagasse et al. [23];
Electroencephalography (EEG)
Kostilainen et al. [34]; Yum et al. [29]
Combined Raven s test Zhu [31]; Rabeyron et al. [35]
Childhood Autism Rating Scale (CARS) Yum et al. [29]; Al-Ayadhi et al. [36]; Koo and Thomas [37]
5-HT Park et al. [38]
ADOS and Assessment of the Quality of Relationship (AQR) Mössler et al. [27]
AMMT (auditory-motor mapping training) Chenausky et al. [39]
Laban Movement Analysis (LMA) Moo and Ho [40]
Autism Behavior Checklist (ABC) Yurteri and Akdemir [41]
Autism Diagnostic Observation Schedule (ADOS-2) and Bayley
Zaro et al. [42]
Scales of Infant and Toddler Development (BSID)
BRIEF, CSBQ, and Repetitive Behavior Scale-Revised (RBS-R) Schweizer et al. [22]
Social Communication Questionnaire (SCQ) and the Strengths and
Aithal et al. [43]
Difficulties Questionnaire (SDQ)
DUACS (Voices Together) Schmid et al. [44]
Conners Scale and the Wisconsin Card Sorting Test (WCST) Liu et al. [45]
Vineland Social Maturity Scale (VSMS) Minaabad and Lomar [46]
Parent-Child Movement Scale (PCMS) Moo and Ho [40]
Functional Near-Infrared Spectroscopy (fNIRS) Shi et al. [47]
FEATS (Formal Elements Art Therapy Scale) y PPAT (Person Picking
Rajabpour et al. [48]
an Apple from a Tree Test)
Impresión Clínica Global (CGI) Rabeyron et al. [35]
Korean ADHD Rating Scale (K-ADHDDS) and House-Tree-Person
Lee and Hyang [49]
Drawing Test (HTP)
Heart Rate Variability (HRV) measurements Madjar et al. [50]
Pediatric Quality of Life Inventory (PedsQL) Yurteri and Akdemir [41]
Repetitive Behavior Scale-Revised (RBS-R) and Physical Activity En-
Lakes et al. [51]
joyment Scale (PACES)
Sing and Speak 4 Kids” (SS4Kids) Lim et al. [52]
Electrodermal Activity (EDA) Akinloye et al. [13]
Social Skills Improvement System (SSIS) Lee [53]
Vineland Social Maturity Scale (VSMS) and the Test of Language
Minaabad and Lomar [46]
Development (TOLD)
Test of Everyday Attention for Children (TEA-Ch) Lagasse et al. [23]
VISK (Vocabulary Intensive Support Kit) and SBQ (Suicidal Behav-
Pater et al. [52]
iors Questionnaire)
Wechsler intelligence scale for children (WISC) and Wisconsin card
Zhu [31]
sorting test (WCST)
App MAP (versión beta) Williams et al. [54]
DLP LENA Laubová et al. [55]
The intervention contexts examined in the studies analyzed include school, clinical,
and home settings. Most studies were conducted in clinical settings (n = 55), representing
68.75% of the total analyzed. Additionally, school settings play a notable role, with 24
studies included in the analysis, representing 30% of the total. In contrast, home-based
interventions are less frequent with only one documented instance representing 1.25% of
the total.
Children 2024, 11, 706 8 of 17
3.3. Pathologies and Impacts

In the present systematic review, the distribution of pathologies in research in the
field of art therapy and music therapy was also analyzed. A total of 80 records were ana-
lyzed, and autism spectrum disorder (ASD) was the most prevalent, representing 72.50%
of the studies reviewed. The next most prevalent pathology was attention deficit hyperac-
tivity disorder (ADHD), which constituted 22.50% of the cases, followed by language de-
velopment disorders, which appeared in 2.50% of the cases.
The effects of art therapy and music therapy on the development and well-being of
individuals with any of the pathologies are under investigation. The data analysis re-
vealed that improvements in cognitive, emotional, and social skills were the most preva-
lent with a frequency of 29.85%. The data indicated that 20.90% of the participants re-
ported improvements in symptomatology, while 18.66% reported improvements in com-
munication and social skills. Furthermore, specific combinations of improvements
demonstrated notable variations. Improvements in symptomatology and behaviors
reached 14.18%, while those combining all the aforementioned areas reached 2.24%. Im-
provements in symptomatology, behaviors, and communication and social skills regis-
tered 2.99%, and improvements in symptomatology and communication and social skills
reached 3.73%. Other combinations included improvements in symptomatology and com-
munication and social skills (3.73%), improvements in symptomatology and cognitive,
emotional, and social skills (4.48%), and improvements in communication as well as cog-
nitive, emotional, and social skills (5.22%). Meanwhile, 1.49% of the cases reported that no
improvements were detected, all this can be seen in Figure 3.
Communication and Social Skills and Cognitive,

Emotional, and Social Skills
Symptomatology and Cognitive, Emotional, and
Social Skills
Symptomatology and Communication and Social
Skills
Symptomatology, Behaviors and Cognitive,
Emotional, and Social Skills
Symptomatology, Behaviors, Communication and
Social Skills, and Cognitive, Emotional, and Social…
Symptomatology, Behaviors, and Communication
and Social Skills
Symptomatology and Behaviors
No improvements detected
Cognitive, Emotional, and Social Skills
Communication and Social Skills
Symptomatology
0 5 10 15 20 25 30 35
Figure 3. Analysis of the impacts of art therapy and music therapy.
3.4. Results of the Interventions

In the present study, a systematic review of the participants perceptions of the art
therapy and music therapy interventions revealed that 55.56% of the participants per-
ceived the intervention as offering “High Value”. This indicates that the benefits received
were deemed to be amply justified by the effort invested. In contrast, 37.78% of the partic-
ipants evaluated the intervention as “Adequate Value”, indicating that the benefits were
Children 2024, 11, 706 9 of 17
commensurate with the resources utilized. Conversely, 6.67% of the participants per-
ceived that the benefits obtained did not justify the resources and time invested, catego-
rizing the intervention as “Low Value”.
4. Discussion
The objective of this study is to evaluate and synthesize the existing evidence on the
efficacy and applicability of art therapy and music therapy in the treatment of children
with autism spectrum disorder (ASD), hyperactivity disorder (HSDD), developmental
language disorders, and language learning difficulties. This will involve the identification
of best practices and key areas for future research. The variety of countries represented in
the systematic review indicates a global interest in the areas of art therapy and music ther-
apy applied to childhood disorders. The prevalence of research in this field in Asia sug-
gests a potential concentration of specialized studies in these countries. In the case of
South Korea, the combination of strong government support, a proactive approach to in-
novation in child welfare and education, and a culture that deeply values the arts and
music has contributed to this country s prominence in the research and application of art
therapy and music therapy to treat disorders in children.
The prevalence and awareness of disorders such as autism spectrum disorder (ASD)
and attention deficit hyperactivity disorder (ADHD) have increased significantly in recent
years. This may have led to an increase in research focused on innovative and non-tradi-
tional therapies such as art therapy and music therapy, which are considered promising
alternatives or complementary to conventional treatments. A bibliometric study on music
therapy revealed a significant increase in the number of publications in recent years, indi-
cating a growing interest in this field. This increase may be related to the increased ac-
ceptance and recognition of music therapy as an effective intervention for various condi-
tions, including pediatric conditions. The year 2020, which represents the peak in the num-
ber of publications, coincides with the onset of the global COVID-19 pandemic. The pan-
demic may have significantly affected the care and treatment of children with special
needs, driving renewed interest in finding treatment modalities that could accommodate
constraints such as confinement and social distancing or offer less invasive and more flex-
ible therapeutic approaches. Furthermore, the years 2020–2022 were distinguished by an
expansion in the availability of specific funding to investigate the impact of the pandemic
on the mental health and education of children, including those with conditions such as
ASD and ADHD. This may be reflected in the increase in studies seeking effective and
applicable alternatives in contexts where traditional methods may have been disruptive.
A plethora of journals are devoted to the publication of research on these topics,
which indicates the existence of an interdisciplinary field with a growing interest. The
notable presence of specific journals such as the Nordic Journal of Music Therapy at the fore-
front of this type of studies suggests the existence of an active and specialized academic
community in this field. Conversely, the recurrence of contributions by specific authors in
certain countries indicates the existence of centers of excellence or research groups at the
vanguard of this field of study.
With respect to methodological aspects, the prevalence of quantitative studies over
qualitative and mixed studies suggests a preference for methods that allow statistical gen-
eralizations and measurable results. Nevertheless, thanks to the substantial representation
of qualitative studies [24,25,48,55–60] and mixed methods [61], the literature indicates that
a deep understanding of individual experiences and specific contexts is also valued for its
ability to deepen understanding of individual experiences, which is crucial for tailoring
interventions to the specific needs of individual children [62]. This is of paramount im-
portance to address the inherent complexities of therapeutic interventions involving ar-
tistic and musical expressions, which are often subjective and multifaceted [36,63].
Regarding the instruments utilized in qualitative studies to assess the impact of a
given intervention, the following instruments stand out as particularly noteworthy:
Children 2024, 11, 706 10 of 17
systematic observation through the verbalization rating scale [56], the PLP LENA scales
[48], or the FEATS of art therapy [25], as well as in-depth interviews [55].
In quantitative studies, a variety of assessment instruments have been employed to
systematically analyze the efficacy and applicability of art therapy and music therapy in
the treatment of children with autism spectrum disorder (ASD), attention deficit hyperac-
tivity disorder (ADHD), developmental language disorders, and learning disabilities. To
study the impacts on autism spectrum disorder, the following instruments have been pref-
erentially employed: the Childhood Autism Rating Scale (CARS), which is used to assess
the severity of autism in children [43]; the Social Communication Questionnaire (SCQ),
which is used to measure social communication in children with ASD [26]; and the Autism
Spectrum Inventory (ASI), which is used in the assessment of autistic symptoms in several
studies [28].
With regard to attention deficit hyperactivity disorder (ADHD), the instruments most
frequently employed by researchers are the Behavioral Assessment System for Children
(BASC), which allows for the assessment of behavior in children with ADHD [64]; the
ADHD Diagnostic Questionnaire (ADHD-RS), which is used to measure the severity of
ADHD symptoms [51]; and the Conners Scale, which assesses ADHD through parent and
teacher reports [12–22,24–26,28,36,43,48,51,55–66].
The results indicate a significant concentration among schoolchildren, which may re-
flect the importance of intervention during the school-age period, which is a crucial stage
for social and cognitive development. This underscores the potential value of utilizing this
approach as a therapeutic tool during primary education, which is a time when children
are developing essential social skills [67].
The efficacy of music therapy in enhancing social responsiveness and communication
skills in children with autism spectrum disorder (ASD), attention deficit hyperactivity dis-
order (ADHD), and language disorders has been demonstrated in multiple studies
[39,44,47,68]. Additionally, music therapy has been shown to alleviate the symptoms of
these disorders in children [26,43,53,69–71], particularly in behaviors [39,44,47,53,66–72]
and cognitive skills [23,29,73–76].
Art therapy has also been demonstrated to be efficacious in a variety of contexts. For
instance, improvements have been observed in symptomatology and behavior [51], com-
munication, and cognitive and emotional skills [26,30,37,58,64,77,78].
Upon examination of the aggregate results, it becomes evident that most of the ob-
served improvements in the interventions pertained to cognitive, emotional, and social
skills. These findings indicate that both music therapy and art therapy are effective in
multiple dimensions of child development. This underscores the utility of these therapies
not only as treatments for specific symptoms but also as holistic approaches to overall
child development. The combination of improvements indicates that interventions can
have a multifaceted impact, addressing multiple symptoms and developmental domains
simultaneously [13,28,79].
Of the articles reviewed, only two indicated that they did not detect improvements
or worsening in any symptom or area of ASD. These two articles were both focused on
music therapy and art therapy applied to children with ASD. The first of these articles was
published in 2021 by Guénoun et al. [79], and the second was published in 2022 by
Harvánek et al. [80]
Regarding the modalities of intervention, it can be stated that music therapy is more
prevalent than art therapy. Of the 80 studies analyzed, 54 were classified as belonging to
the former category. This can be attributed to the perceived effectiveness of music therapy,
which has been demonstrated in numerous studies conducted in a variety of clinical con-
texts. A total of 39 studies employed music therapy, while 16 studies employed art ther-
apy. This perception of greater effectiveness is also due to the participation of a larger
number of subjects in the studies, as demonstrated by the research of El-Tellawy et al. [71],
which involved 146 children with ASD. Moreover, the accessibility of music, which can
be utilized with simple tools such as percussion or voice, renders it more readily available
Children 2024, 11, 706 11 of 17
than art therapy, which often necessitates specific and sometimes more expensive re-
sources [62].
About the context of intervention, it is notable that most studies (68.75% or 55) were
conducted in clinical settings. This may reflect the need for a controlled environment to
effectively evaluate the therapeutic intervention [72]. Nevertheless, studies also indicate
the potential for further research in diverse settings, including the school setting, which
accounts for 30% (24) of the total. The school setting provides a convenient avenue for
accessing therapeutic interventions during school hours, thereby minimizing the disrup-
tion to family routines [81]. Finally, a single intervention (1.25%) conducted in the home
of a child with ASD who was not in school was identified [13]. Outside the clinical context,
interventions can be implemented that are closely aligned with the child s educational
needs. This integration of academic and emotional support in the same setting allows for
the implementation of therapies that are tailored to the child s specific needs [45].
Regarding the diversity of sample sizes, it can be observed that most studies analyze
samples of fewer than 100 participants. Conversely, there are instances where the sample
size is significantly larger, which could indicate a greater degree of generalizability
[53,81,82]. An adequate sample size is crucial to ensure the statistical power needed to
detect significant differences, thus avoiding erroneous or insufficient conclusions. A total
of 13 single-participant studies (16.25%) were identified, including those by Akinloye et
al. [13], Charoenphol et al. [82], Durrani [56], and Harvánek et al. [80]. The following stud-
ies were conducted in 2022: Joo [76], Kim and Ho [83], Laubová et al. [55], Lee and Hyang
[49], Nielsen and Holck [84], Park [38], Hong [85], and Zaro et al [42]. The 2020 article
highlights the usefulness of case studies for the in-depth exploration of specific therapeu-
tic effects. Despite the limitations of generalization, case studies and small samples are
valuable for the exploration of specific phenomena in depth.
A review of the central themes of the studies revealed that autism spectrum disorder
(ASD) was the most prevalent, indicating a strong concentration of research on this disor-
der. In fact, ASD accounted for 73.75% of the studies reviewed. This may reflect the com-
plexity and variety of ASD symptoms, which make creative therapies such as art therapy
and music therapy particularly relevant and potentially effective. These therapeutic meth-
ods offer an expressive and nonverbal medium that may be more accessible to children
with ASD, facilitating improvements in communication and social skills.
Regarding the modality of intervention and the central theme of the papers, a curious
aspect is observed. Of the 26 art therapy studies, 50% (13) focus on ADHD, while the re-
maining 50% (13) focus on children with ASD. The studies on ADHD include
[26,28,36,43,61–64] Chen and Li [30], Cho et al. [64], Kim and Rhee [58], Kim and Ho [83],
and Rajabpour Azizi et al. [48]. The studies on children with ASD include Abdulá et al.
[26]. The following references were consulted in the preparation of this study: Durrani
[56], Fernández-Herrero [77], Guénoun et al. [79], Koo and Thomas [37], Moo and Ho [40],
Park [38], Saladino et al. [25], Schweizer et al. [22,32], Thayer and Bloomfield [86], and
Wypyszyńska [87].
In contrast, of the 54 music therapy studies, 85% (46) focus on children with ASD
[13,23,26,27,29,33–35,39–44,46–48,52–54,58,60,66,68–76,79,83–85,88–94], 11.3% (6) focus on
children with ADHD [22,41,42,52,72,82,94], and 3.7% (2) focus on children with language
disorders [14–95].
These prevalences suggest a possible perceived efficacy bias: art therapy might be
seen as more effective for ADHD, whereas music therapy might be considered more ef-
fective for children with ASD and language disorders.
In the studies, more than half of the participants (80%, or 64 individuals) perceived
the interventions to be of high value, suggesting that the perceived benefits were signifi-
cant compared to the effort and resources invested. Of these, 79.6% (43) were dedicated to
children with ASD, while 18.51% (10) were dedicated to children with ADHD. This find-
ing provides compelling evidence of the perceived effectiveness of the interventions. The
high rating of the interventions by the participants serves to reinforce the relevance of
Children 2024, 11, 706 12 of 17
continuing and expanding the use of music therapy and art therapy. The perceived bene-
fits underscore the significance of considering participants experiences as a pivotal indi-
cator of the efficacy of the interventions (45). Moreover, most participants (80%) indicated
that the interventions were adaptable to different contexts, which suggests potential for
the implementation of these therapies in diverse educational, clinical, or home settings
[64]. Nevertheless, the remaining 20% of participants identified limitations in adaptability,
underscoring the necessity for adjustments and customization in the application of these
therapies to optimize their efficacy and applicability.
5. Conclusions
The results demonstrate the efficacy and favorable perception of art therapy and mu-
sic therapy in the treatment of children with autism spectrum disorder (ASD), attention-
deficit hyperactivity disorder (ADHD), language development disorders, and learning
difficulties. The review revealed that autism spectrum disorder (ASD) was the most prev-
alent, indicating a strong concentration of research on this disorder. The evidence of im-
provements in multiple areas of development indicates that these therapies offer signifi-
cant benefits. However, the variability in the perceived value and adaptability of interven-
tions indicates that it is crucial to consider individual and contextual factors when imple-
menting these therapies to maximize their effectiveness and accessibility. The prevalence
of clinical settings in therapeutic intervention suggests a preference for controlled settings
for the effective evaluation of interventions. The concentration of studies in school-aged
children reflects the relevance of these therapies during a vital period for interpersonal
and cognitive development. This justifies the integration of music therapy and art therapy
in educational and therapeutic programs for children with ASD and related disorders.
Nevertheless, we conclude that there are significant advantages to expanding these inter-
ventions to settings such as the home and school, which also present unique challenges
and opportunities for research and therapeutic practice. Despite the advantages, diversi-
fying intervention settings beyond clinics presents challenges. One such challenge is the
need to adapt interventions to less controlled settings, ensuring treatment fidelity in home
and school settings.
This review provides a comprehensive overview of current art therapy and music
therapy research for children with disorders such as ASD, ADHD, developmental lan-
guage disorders, and learning disabilities. It indicates both current trends and potential
areas for future research.
Limitations of the Study and Lines of Action

It should be noted that this study has several limitations that require comment. Per-
haps the most significant of these is the possibility of expanding the number of studies
analyzed. Nevertheless, upon completion of this review, it becomes evident that there has
been a notable increase in interest in this subject, as evidenced by the growing number of
articles published in scientific journals in recent years. This suggests that music therapy
and art therapy, and their relationship with this type of disorder, are becoming increas-
ingly incorporated into the field of music education research. The limited number of stud-
ies on ADHD and developmental language disorders indicates a need for further investi-
gation into the potential for adapting or enhancing music therapy and art therapy for these
disorders. Research in these areas could benefit a broader and more diverse population,
potentially uncovering new therapeutic applications for these techniques.
One of the limitations to consider is that this systematic review is only descriptive,
and therefore, we do not obtain a sufficiently critical assessment. It would be advisable to
carry out a meta-analysis in the future that would allow us to obtain precise data and carry
out a less descriptive analysis.
It is of great interest to systematize these therapies in different contexts and to de-
velop training curricula for therapists that incorporate music and art as tools for the im-
provement of these types of disorders in the pediatric age group.
Children 2024, 11, 706 13 of 17
Author Contributions: S.D.-L., V.M.-V. and P.G.-R. conceived and reviewed all the studies, per-
formed the analysis and wrote the article. All authors have read and agreed to the published version
of the manuscript.
Institutional Review Board Statement: The study was conducted in accordance with the Code of
Good Scientific Practice developed by the Spanish National Research Council (CSIC Ethics Commit-
tee).
Conflicts of Interest: The authors declare no conflict of interest.
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Outcome-Based Evaluation of a Social Skills

Program Using Art Therapy and Group

KEY WORDS: art therapy; autism spectrum disorder;group therapy;

CCC Code: 1532-8759/08 $3.00 ©2008 National Association of 5ocial Workers 27

Psychological Theories that Present Intervention Practice Models

28 Children &Schools VOLUME 30, NUMBER I JANUARY 2008

acceptable means of discharging aggression PROGRAM DESCRIPTION

30 Children &Schoots VOLUME 30, NUMBER I JANUARY 2008

32 Children &Schoob VOLUME 30, NUMBER I JANUARY 2008

Pretest 41.09 10.20

34 Children S-Schools VOLUME 30, NUMBER i JANUARY 2008

36 Children drSchools VOLUME 30, NUMBER I JANUARY 2008

Contents lists available at ScienceDirect

The Arts in Psychotherapy

The contribution of art therapy to the social, emotional, and academic

Introduction difficulties than do children without LD (Auerbach, Gross-Tsur,

Therapy Teaching Pre–post group × time

Range: AA – 4–10; Achenbach – 0–2.

Art therapy Academic assistance

Pre Post Pre Post

Art therapy Academic assistance

Pre Post Pre Post

Child (N = 63) Therapist (N = 73) Group Evaluator Group × Evaluator

*p < .05, **p < .01, ***p < .001.

Therapy (N = 33) Teaching (N = 40) Group

Simple response .11 (.15) .10 (.14) .09

*p < .05, **p < .01, ***p < .001.

Fig. 1. Change process.

Using Visual Arts to Encourage Children with

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