Abstract
There is a lack of evidence-based practice to support the development of children with learning differences via art group interventions. Consequently, this mixed-methods systematic review synthesized existing international research on the outcomes and feasibility of art group interventions for children (≤18 years old) with learning differences, such as autism spectrum disorder and attention-deficit/hyperactivity disorder, and generated a framework to guide occupational therapists using art group interventions. Primary studies with a visual art group intervention, children with a neurodevelopmental disorder(s), and feasibility and/or effectiveness outcomes were included with no limiters being applied. Eight electronic databases were screened and two independent reviewers were involved in article selection. Data heterogeneity prevented the meta-analysis of effectiveness outcomes. Analysis showed art group interventions can reduce “problem behaviors” and improve social interaction, self-expression, well-being, general development, and caregiver attachment for children with learning differences. Guidelines: The AR3T Principles.
Plain Language Summary
Little is known about the extent to which art group treatment is beneficial for children with learning differences such as autism spectrum disorder and attention-deficit/hyperactivity disorder. Therefore, there is a need to summarize the international research regarding the effectiveness of art group treatments and the feasibility of implementing them so that guidelines for future art group interventions can be created. These guidelines will serve to inform occupational therapists interested in treating children with academic, social and emotional challenges as to the best available practice for this population. The research showed that art group interventions can have a positive effect on children with learning differences’ ability to interact with others, express themselves more assertively, bond with their caregivers, develop their fine motor and thinking skills, improve in their emotional well-being, and control their behavior for better task completion. Future art group interventions should include nurturing facilitators, opportunities for self-calming and alerting, structured routine, practical methods that are economical and easy to use, as well as techniques and activities that cater specifically for each child’s level of ability, needs, and cultural context.
Introduction
Arts and crafts have long been used by occupational therapists to influence participation and health, leading Perrin to argue that “the healing potential of occupation and creativity is a force to be reckoned with, an extraordinary dynamic that we as occupational therapists hold in the palm of our hands” (Perrin, 2001). Nearly 25 years later, we still do not fully understand this healing potential. Learning differences is a term that can take on a variety of meanings within different disciplines; however, for the purpose of clearly conceptualizing its meaning in this research, learning differences refers to a variety of early-onset and chronic neurodevelopmental conditions that hinder children’s socio-emotional, communication, academic, cognitive, and life skills development, according to the neurodevelopmental disorders listed in the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5; American Psychiatric Association, 2013). Without early intervention, children with learning differences are at risk of poor academic achievement, economic dependency, unconstructive leisure/criminal activities (such as substance abuse), corporal punishment, stigmatization, noncommunicable diseases, and poor social integration (Burger et al., 2020; Daelmans et al., 2015; Klasen & Crombag, 2013). To use participation in arts and crafts to its full healing potential for these children, we need to understand the outcomes, feasibility, and characteristics that support the success of facilitating art group interventions with children with learning differences, so that the therapeutic factors of art group interventions can be optimized.
Art group interventions offer a therapeutic medium that can be effectively adapted to different clients and environments (Fletcher & Lawrence, 2018; Schleien et al., 1995). Art groups differ from art classes, as they focus on the therapeutic power of participation in artmaking, rather than the end product being created (Winter et al., 2012). Thus, structured art group activities can offer occupational therapists a means to achieve therapeutic goals for children with learning differences in a way that is sensitive to community needs and cultural expectations (Alrazain, 2016). Moreover, the cathartic and constructive process of artmaking has the potential to promote health and well-being, thus enhancing children’s biopsychosocial development (Moula, 2020; Tam, 2016; Wypyszyńska et al., 2021). There is compelling evidence to support the use of recreational, activity-based programs to improve the social interaction of children with intellectual disabilities or developmental delays (Arbesman et al., 2013), as artmaking can provide an alternative means for autonomy, self-expression, and achievement (Macpherson et al., 2016; Moula, 2020; Tam, 2016), and can reduce anxiety when facilitating a just-right challenge that allows for enjoyment and relaxation (Fletcher & Lawrence, 2018).
Artmaking in occupational therapy can be informed by practice from other disciplines. One systematic review investigated the effectiveness of art therapy delivered in school settings for children between the ages of 5 and 12 years (Moula, 2020). This review synthesized eight studies, involving a total of 247 participants, and found that art therapy can be effective in reducing anxiety and emotional and behavioral challenges, and improving children’s problem-solving skills, quality of life, and attitudes toward school (Moula, 2020). This review highlighted the need for better intervention reporting, art therapy-specific outcome measures, and the need to determine the cost-effectiveness of treatments of different durations (Moula, 2020). Another systematic review of randomized controlled studies of art therapy conducted with adults found seven out of eight studies to report on the beneficial effects of art therapy interventions, indicating the usefulness of art therapy across a range of populations (Maujean et al., 2014). However, most of these studies lacked an active control group, thus raising the question of whether art therapy or simply group-based activities lead to beneficial outcomes such as improved social interaction, self-image, language comprehension, and mental health (Maujean et al., 2014). Although some guidelines exist to help govern visual arts group practice (Winter et al., 2012), there is little consensus about what specific methods and procedures yield a feasible and effective art group intervention for children with learning differences.
To date, there has not been a review that synthesizes the evidence on the outcomes and feasibility of art group interventions for children with learning differences. Given that art is used across such a broad range of disciplines, there is a need to synthesize the literature on the therapeutic potential and feasibility of visual arts activities more broadly, and create an intervention framework that can help occupational therapists to structure their art group interventions for children with learning differences according to evidence-based practice.
Research Objectives and Design
This review is structured according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement (Moher et al., 2015) and addresses the following objectives.
Objective 1
Evaluate the current, international evidence on the outcomes and feasibility of art group interventions for children (up to the age of 18 years) with learning differences.
Objective 2
Develop a framework that identifies the key components of a feasible and efficacious art group intervention, based on the available evidence.
Method
An electronic database search was completed between June 14 and 22, 2022. Medical Subject Heading (MESH) terms and synonymous terms related to the population and intervention were selected and constructed according to the Boolean method with the assistance of an experienced librarian at Stellenbosch University to create search strings. In addition, the online Systematic Review Accelerator made available through Bond University was used to adapt search strings to suit the different databases included in the study (Bond University, 2022). The following electronic databases were used in the literature search: Cochrane Library, EBSCOhost (including Academic Search, Africa-Wide, Art & Architecture Complete, CINAHL, and ERIC), OT Seeker, PubMed, Sabinet African Journals, Scopus, and Web of Science. The following search string was used for databases that recognized MESH terms: (“Neurodevelopmental Disorders/diagnosis” [Mesh] OR “Neurodevelopmental Disorders/education” [Mesh] OR “Neurodevelopmental Disorders/psychology” [Mesh] OR “attention deficit” OR hyperactivity OR ADHD OR ADD autism OR ASD OR Asperger OR “communication disorder” OR “language disorder” OR “speech sound disorder” OR “childhood onset fluency disorder” OR “intellectual disabilit*” OR “learning difference” OR “learning disabilit*” OR “learning disorder” OR dyscalculia OR dyslexia OR “motor disorder” OR “developmental coordination disorder” OR “stereotypic movement disorder” OR “tic disorder” OR Tourette’s OR neurodevelopmental) AND (child* OR adolescen* OR youth OR juvenile OR school OR young* OR pupil OR student OR learner) AND group AND (Creativity[Mesh] OR art OR “creative activit*”) NOT “antiretroviral therapy” NOT “assisted reproductive technology”
A formal search with ProQuest was completed by the primary reviewer to identify the relevant gray literature, including theses and dissertations. Research Gate was also used to look for any outstanding and relevant articles. There were no restrictions on the date of publication or language, and the eligibility criteria for articles are listed in Table 1.
Eligibility Criteria According to PICO.
In addition, citation tracking was done by the primary reviewer with all the systematic and scoping reviews identified in the search, along with the primary articles included, to search for other relevant reports not identified in the primary literature search.
All articles were uploaded to Rayyan and screened by two independent reviewers. The reviewers were blinded to each other’s article selection decisions using Rayyan’s “BLIND ON” setting (Rayyan, 2022). Conflicts in article selection choices were discussed between the reviewers to reach a consensus about whether certain articles should be included in the review. Upon further screening of these articles, all discrepancies were resolved via mutual agreement. Duplicates of records were removed and reasons for the exclusion of certain articles are detailed in the systematic review PRISMA flow diagram (Figure 1). In the case of incomplete records or missing essential information, the primary reviewer contacted the relevant study author where possible to gather the required information. Articles that were in a language other than English were screened using a free, online translation service (Google Translate, 2023).
PRISMA Flow Diagram.
Articles yielded in the literature search were uploaded in RIS text/PubMed format to the systematic review software, Rayyan. Then, the title and abstract of each article were screened to determine eligibility. The final articles selected were exported from Rayyan using a customizable file to maintain a data trail. The PDF files of relevant articles were downloaded for full-text screening and uploaded to the reference management software, Mendeley. Data were extracted using a Microsoft form data extraction template created by the primary researcher according to the data items in Table 2, thereby generating an Excel spreadsheet with the synthesized data post-extraction. A free, online translation service (Google Translate) was used for articles that were written in a language other than English and a translator was consulted for one article that required further clarity (Nguyen-Viet et al., 2022).
Data Extraction Items.
Study designs were evaluated according to the National Health and Medical Research Council (NHMRC) Levels of Evidence (Australian Government, 2009). Demographic and health equity data about participants, such as personal characteristics linked to discrimination (e.g., age and diagnosis), were extracted according to the Cochrane PROGRESS-Plus guidelines (Cochrane, 2014). The Cochrane Template for Intervention Description and Replication (TIDieR) checklist (Hoffmann et al., 2014) was used to evaluate the quality of intervention reporting for all the included studies. Finally, the Joanna Briggs Institute (JBI, 2020) Critical Appraisal Checklists were used for risk of bias assessment, according to the study design used in each article. These assessments were done by the primary author and checked for accuracy by the second reviewer.
Areas of feasibility were extracted according to Bowen et al.’s (2009) headings for feasibility, which are listed in Table 2. For the effect (cause-and-effect relationship between two or more variables), efficacy (the effect in ideal, clinical conditions), and effectiveness (effect in the real, non-ideal context) studies (Bowen et al., 2009), all clinician, child, or caregiver-rated outcomes relating to a child’s social interaction, academic performance, and/or participation in daily activities were included.
Feasibility data were extracted via content analysis, searching for feasibility reporting within each article, whereas effectiveness outcomes were extracted according to inductive analysis. For the latter, this meant identifying the dependent variable(s) outlined in the objectives and extracting data related to changes in these variables post-intervention. For qualitative research, this involved analyzing the conclusions and explanations drawn about researchers’ observations of art group interventions. Outcomes were collated thematically based on the most commonly reported outcomes.
The heterogeneity of the data prevented a meta-analysis of the effectiveness of the included interventions. Consequently, a convergent integrated approach was used (Stern et al., 2020). Data items for each study have been summarized in tables, evaluated according to measures of central tendency, and where possible, the magnitude of effect and statistical value of the outcomes have been reported. The key themes of feasible and effective art group interventions were inductively generated post-data extraction via the thematic analysis of the methods, practice, and findings of each article (specific observation of the various elements that yielded effective outcomes via the TIDieR checklists, Bowen et al.’s feasibility criteria, and critical reflection of the authors) to recognize patterns that generated beneficial outcomes. These themes can be regarded as the therapeutic factors that predispose art group interventions to the greatest chance of success, and are outlined in a recommended practice framework called the AR3T principles.
Results
In total, 3,968 articles were identified, of which 896 duplicate records were removed by the primary author with the assistance of Rayyan software. Thereafter, 3,041 articles were excluded as per the abstract and title screening, and 31 articles were assessed for eligibility via full-text review. All screening was completed by two independent reviewers. The reasons for article exclusion are detailed in the PRISMA Flow Diagram below. Citation tracking/pearling with the 11 reviews that met the eligibility criteria and the 31 articles downloaded for full-text review yielded another two articles to be included in the review (Schleien et al., 1995; Venn et al., 1993). This resulted in 20 articles being included in the final review. Study characteristics, intervention type, and results are listed in Table 3. The outcomes of risk of bias, quality of intervention reporting, and NHMRC levels of evidence evaluations are listed in Table 4.
Data Summary Table.
Synthesis of Reporting Bias and Level of Evidence.
High Risk of Bias: below 50%. Medium Risk of Bias: 51%–74%. Low Risk of Bias: above 75%.
The results confirmed the healing potential of art group interventions for children with learning differences. Although the heterogeneity of the data prevented a meta-analysis for effectiveness, and there were gaps in the intervention reporting quality for several articles, trends in the results and methods highlight some key findings and themes that can be useful when planning future art group interventions. On average, art group interventions were facilitated over 4 months with sessions being between 30 and 40 min and the average number of sessions being 22. However, the frequency and duration of treatment varied significantly, and programs that were of a longer duration did not necessarily improve treatment outcomes. The intervention structure, procedures, and materials used had a larger effect on treatment outcomes than the duration of treatment. For example, a 4-week art as relaxation program with weekly 45-min sessions had a statistically significant effect on the tic severity and physiological and psychological stress of children with Tic Disorder (TD) (Choi et al., 2021). In contrast, an evaluation of the Daily Life Therapy program that offered an art group intervention for children with ASD throughout a school year found that the program was not effective in improving its targeted outcomes (Talusan-Dunn, 2012). These results reflect the findings of two systematic reviews that analyzed the effectiveness of art therapy for a variety of clients and found that a longer intervention duration does not necessarily render a therapeutic program more effective (Maujean et al., 2014; Moula, 2020).
Bibliometric Information
Of these 20 articles, most were written in English, with the exception of three articles which were written in French, Spanish, or Hebrew. Eighteen of the included articles were published in the last two decades, with two having been published in the early-mid 1990s. Nine articles came from Asia, eight from the United States, and the remaining three from Europe, highlighting a lack of art group intervention reporting in low-to-middle income countries.
Outcomes
Seven common outcomes for art group interventions for children with learning differences were identified across the 20 studies.
Social Interaction
Autism Spectrum Disorder
Eight studies assessed the influence of art group interventions on the social skills of children with ASD. All reported beneficial outcomes related to this domain of functioning, yet few studies yielded results that met statistical and clinical significance. Moreover, the varying levels of evidence, quality of intervention reporting, risk of bias, and lack of active control groups should be considered when evaluating these results. Nguyen-Viet et al. (2022) commented that weekly art workshops over 3 months had a potential effect in promoting social inclusion and increased symbolization among children with ASD and their neurotypical peers. In another study which offered art activities modified to encourage cooperation within small groups for children with ASD and their neurotypical peers, as well as a training session for neurotypical peers on how to initiate social interactions pre-intervention, Schleien et al. (1995) found that there was a significant increase in interactions directed by the peers toward students with ASD; however, these efforts were not significantly reciprocated by students with ASD. In another study conducted with 82 caregivers of Polish children/adolescents with ASD, Wypyszynska et al. (2021) found that art therapy had a positive effect on social relations, such as creating friendships with peers; however, there was poor intervention reporting quality in this article as the exact procedures and methods that yielded these results were not included.
Furthermore, Epp (2008) found that social skills showed a trend of improvement post-intervention for participants with ASD, yet these scores did not reach statistical significance. Similarly, D’Amico and Lalonde (2017) showed that after weekly 75-min art therapy group sessions over 21 weeks, there were no statistically significant improvements in social skills, although communication and cooperation scores showed trends of improvement. Chou et al. (2016) also concluded that a behavioral art program improved the social skills of two children with ASD according to the perception of the participants’ parents and teachers. Liu et al. (2021) reported that parent-child painting and creative crafting therapy were not effective in reducing the core symptoms of ASD relating to social difficulties, yet the study’s control group, which received an Applied Behavior Analysis (ABA) intervention, improved in their social interaction skills post-intervention (Liu et al., 2021). Finally, in a case report by Vaisvaser (2019), three minimally verbal children with ASD showed increased social engagement and social initiation behaviors after 30 weekly sessions of a dynamic expressive creative therapy group that incorporated movement, creative play, and drawing. This intervention used mirroring, a structured opening and closing phase, props as means of expression, and background instrumental music to generate rhythm (Vaisvaser, 2019). These treatment factors may have contributed toward the reported increase in social interaction.
Therefore, it appears that visual art group interventions are more likely to promote social inclusion and positive peer experiences than to improve the core social challenges associated with autism spectrum disorder, unless certain play-based and behavioral modification methods are included in the art groups’ interventions.
Attention-Deficit/Hyperactivity Disorder
Art group interventions also have promising results for improving the social interaction skills of children with ADHD. G. Saavedra et al.’s (2010) study had inconclusive results (given its small sample size) yet provided evidence of significant short-term improvement in behavioral outcomes for children with ADD post-6 months of art therapy group intervention. Al-Hariri and Faisal also reported that art group interventions resulted in a trend of improvement in the average behavioral skills of children with ADHD, but no significant changes were discovered (Al-Hariri & Faisal, 2013). In contrast, Alrazain (2016) found that after 8 weeks of three art therapy sessions per week, there was a high effect on the improvement in the social skills of participants with ADHD. This program incorporated mirroring movements, rhythmic clicking and clapping to accommodate religious restrictions, had a standardized beginning and end phase, and incorporated self-awareness and regulation techniques (body awareness games and deep breathing; Alrazain, 2016). When using parent–child art therapy with children who had a variety of neurodevelopmental difficulties (including ASD, ADHD, and other behavioral and social challenges), Shlomit and Dafna (2015) discovered that participants’ social behaviors showed a trend of improvement post-intervention without statistically significant change.
In conclusion, visual art group interventions may contribute to the improvement of social interaction skills for children with learning differences; however, the methods and procedures used in the intervention play an important role in fostering appropriate social behaviors and may need to be thoughtfully structured to include other therapeutic techniques (such as regulatory inputs) to optimize social interaction outcomes.
Self-Expression
Shlomit et al. reported a significant improvement in self-perception in cognitive skills for children with learning differences after 16 sessions of parent–child art therapy (Shlomit & Dafna, 2015). Moreover, D’Amico and Lalonde (2017) and Epp (2008) both found statistically significant improvements in assertion skills for children with ASD from pre- to post-art group intervention in two separate studies. This may be because, as Kotowski (2013) and MacLean (2009) suggest, children with learning differences who participate in art group interventions have more opportunity to develop a stronger sense of self that can improve self-expression. Therefore, although art group interventions may not significantly improve social communication and interaction skills, they appear to effectively enhance self-expression and assertion skills, which are prerequisites for participation in age-appropriate occupations such as collaborating with others in school or play-oriented activities.
“Problem Behaviors”
Several studies provided robust evidence to suggest that art group interventions can help reduce what was often described as “problem behaviors” such as hyperactivity and inattention. Alrazain (2016) showed that participating in a culturally sensitive art therapy program had a high effect in reducing inattention, hyperactivity, and impulsivity for children with ADHD. These results are reflected in Habib and Ali’s (2015) study where there was a significant reduction of impulsive behaviors among children with ADHD post-art group intervention. Similarly, D’Amico and Lalonde’s (2017) study showed a statistically significant improvement in hyperactivity and inattention scores for children with ASD while Epp (2008) calculated a significant decrease in internalizing behaviors, hyperactivity, and “problem behaviors” for participants with ASD from pre- to post-art group intervention. Beh-Pajooh et al. (2018) also found that engaging in art group interventions was effective in reducing externalizing behaviors for children with ID; however, the study’s increased risk of bias should be considered when interpreting these results. This speaks to the cathartic and constructive process of art making noticed by previous researchers which can enhance children’s well-being and overall development (Moula, 2020; Tam, 2016; Wypyszyńska et al., 2021).
Emotional Well-Being
Three studies reported on the effect of art group interventions on the outcome of emotional well-being. Alrazain (2016) reported that participating in an art therapy program has a high effect on the emotional well-being and emotional regulation of participants with ADHD. Choi et al. (2021) also showed that a 4-week art as relaxation program resulted in a statistically significant improvement in the physiological and psychological stress of children with TD. This art program significantly reduced the interference of tic symptoms on the children’s participation in daily activities (Choi et al., 2021). Another study, with a lower level of evidence, reported that art therapy has a positive effect on well-being and relaxation according to the parents of children with ASD (Wypyszyńska et al., 2021).
Cognitive Skills
Two studies conducted with children with ADHD found that participating in an art group intervention had a statistically significant improvement in average thinking skills (Al-Hariri & Faisal, 2013; G. G. Saavedra et al., 2010), such as attention and observation (Al-Hariri & Faisal, 2013).
Caregiver Attachment
Shlomit and Dafna (2015) found a statistically significant change in the emotional closeness and communication between parent and child after 16 sessions of parent-child art therapy for children with a variety of learning differences. Similarly, Liu et al. (2021) showed that 40 sessions of parent–child painting and creative crafting therapy over 20 weeks significantly reduced parental distress and parent–child dysfunctional interaction for caregivers of children with ASD.
General Development
Two studies suggest that engaging in art activities is beneficial for the development of motor skills; however, both articles include low-level evidence studies (Erim & Caferoğlu, 2017; Venn et al., 1993). Venn et al. discovered that using a progressive time delay technique in daily 15-min art activities with three children (presenting with ASD, language, and developmental delays) and their neurotypical peers was effective in teaching participants how to imitate their peers’ fine motor actions. This skill attainment was generalized to other classroom activities (Venn et al., 1993). Erim and Caferoğlu (2017) also reported that, according to 85 special education teachers in Turkey, children with ID’s engagement in art activities, especially drawing tasks, play an influential role in developing their motor skills. These skills include eye–hand coordination and bilateral integration, as well as the development of pro-social skills such as eye contact, helping, and sharing (Erim & Caferoğlu, 2017).
Feasibility
Only four aspects of feasibility were considered in the 20 studies.
Practicality
The content analysis of one article showed that art group interventions are practical when easily found materials are used (Erim & Caferoğlu, 2017). Intervention providers tend to prefer activities that are easy to practice and do not require additional research and expenses for activities such as stained glass works (Erim & Caferoğlu, 2017). Beh-Pajooh et al. (2018) also commented that their painting therapy program was easy for participants to use given the facilitators’ simple choice of mediums.
Adaptation
Other studies suggest that art programs can be effectively adapted to different clients, cultures, and environments. This can be done by modifying elements of standardized art programs to cater to the religious and cultural expectations relevant to participants (Alrazain, 2016), restructuring art activities to allow for more cooperative participation (Schleien et al., 1995), or following the same intervention procedures in a home, school, or community setting (Habib & Ali, 2015; Schleien et al., 1995).
Demand
A survey completed with parents of children with ASD highlights that the demand for art interventions is growing as awareness of these methods spreads (Wypyszyńska et al., 2021). In this study, which was conducted in Poland in 2021, 59.5% of parents had not heard about the therapeutic effect of art (Wypyszyńska et al., 2021). The growing prevalence of children with ASD in Poland has increased the demand for effective interventions that support the psychosocial development of these children (Wypyszyńska et al., 2021).
Implementation
One study evaluated whether the Daily Life Therapy program was being successfully implemented in a school setting, as per the program’s objectives (Talusan-Dunn, 2012). The quantitative data from this mixed-methods analysis showed that the program did not achieve its planned goals, partly due to inconsistent data collection (Talusan-Dunn, 2012).
AR3T Principles to Achieve Healing Potential
Five general principles to guide future art group interventions for successful and effective implementation for children with learning differences were identified and are outlined in Figure 2. These follow the AR3T acronym: representing an Attentive facilitator, emotional and sensory Regulation, Realistic for the context, following a Routine, and Tailored to the setting and participant.
The AR3T Principles.
Attentive Facilitator
Six studies that included nurturing and accepting facilitators (neurotypical peers, caregivers, or therapists) proved to promote social interactions directed toward peers with ASD (Schleien et al., 1995), caregiver–child attachment (Liu et al., 2021; Shlomit & Dafna, 2015), social engagement (Nguyen-Viet et al., 2022; Vaisvaser, 2019), emotional well-being, and decreased “problem behaviors” (Alrazain, 2016). Moreover, increased teacher prompts or interactions to promote participation and task completion helped to improve the performance of learners with ASD (Talusan-Dunn, 2012). Therefore, an attentive facilitator or more knowledgeable other is recommended to model social interaction and foster social inclusion for children with learning differences engaging in art group interventions.
Regulation
Several authors acknowledged the need for autonomy to promote regulation, as free play can allow for participation without feelings of performance anxiety (Alrazain, 2016; Beh-Pajooh et al., 2018; Talusan-Dunn, 2012). However, various authors observed that unstructured interventions are not beneficial for children with learning differences, as they do not develop the task concept and structure the sensory and social experience offered in a way that supports the executive functioning and social-emotional needs of this population (Alrazain, 2016; Nguyen-Viet et al., 2022; Talusan-Dunn, 2012; Vaisvaser, 2019). Therefore, space for regulation within a structured intervention procedure and environment (that meets some children’s need for predictability) is recommended as best practice (Vaisvaser, 2019).
Realistic
To ensure that an art group intervention is feasible, it needs to include accessible materials and methods for the participants’ cultural and physical context (Alrazain, 2016; Beh-Pajooh et al., 2018; Erim & Caferoğlu, 2017).
Routine
Studies that included a behavioral therapy component (Chou et al., 2016; Liu et al., 2021) and a more structured routine in art group interventions (Alrazain, 2016; Talusan-Dunn, 2012; Vaisvaser, 2019) helped to promote social interaction and provide a framework in which children felt safe (Alrazain, 2016).
Tailored
Taking the evidence-based principles for art group interventions and adapting them to be acceptable to the occupations and culture of the participants’ population is necessary to ensure quality service delivery that fosters participation and constructive identity formation (Alrazain, 2016). Moreover, interventions should be tailored to the level of ability of each participant (Talusan-Dunn, 2012) and adapted according to the goals of the group, for example, grading activities to allow for more cooperative participation between participants instead of solitary engagement (Schleien et al., 1995).
Discussion
All 20 articles commented on effectiveness-related outcomes, with few to no studies commenting on the clinical significance or magnitude of effect obtained from pre- to post-intervention. The strongest evidence exists to show that art group interventions are effective in reducing “problem behaviors,” such as hyperactivity, impulsivity, inattention, and internalizing and externalizing behaviors in children with ASD, ADHD, and/or ID (Alrazain, 2016; Beh-Pajooh et al., 2018; D’Amico & Lalonde, 2017; Epp, 2008; Habib & Ali, 2015). The bulk of the evidence synthesized in this review examined the effectiveness of art group interventions in enhancing behavioral or social interaction outcomes for children with learning differences; however, most of these findings originated from studies that included lower levels of evidence. These data suggest that art group interventions can improve behavioral and social skills; however, for many of these studies, these outcomes did not achieve a statistically significant change post-intervention. It should be acknowledged that the majority of articles reporting on these outcomes did not consider neurodiversity-affirming terminology or care, casting differences in perceiving, relating, and being as “problem behaviors.” This does not reflect the personal views of the authors, who value the unique strengths and abilities of children with learning differences.
Art group interventions appear to have a greater chance of improving the social interaction and behavioral skills of children with ASD if a behavioral therapy component is included (Liu et al., 2021). Moreover, including neurotypical peers or caregivers and children with learning differences in the same art group interventions has the potential to promote positive social inclusion/a sense of belonging (Liu et al., 2021; Schleien et al., 1995; Shlomit & Dafna, 2015). There is also preliminary evidence to suggest that art group interventions are more effective in promoting social interaction for children with learning differences when a movement and play-based component is included, along with a structured beginning and closing phase utilizing regulatory techniques (Alrazain, 2016; Vaisvaser, 2019).
The findings of this research align with the work of Macpherson et al. (2016), Moula (2020) and Tam (2016) whose research emphasized that art group interventions offer an alternative, nonverbal means for self-expression and autonomy that can bolster identity formation and self-confidence. Other studies showed that art group interventions can improve cognitive skills for children with ADHD (Al-Hariri & Faisal, 2013; G. G. Saavedra et al., 2010), foster relaxation and emotional well-being (Alrazain, 2016; Choi et al., 2021; Wypyszyńska et al., 2021), promote a stronger caregiver–child relationship (Liu et al., 2021; Shlomit & Dafna, 2015), and even improve areas of general development, just as fine motor skills (Erim & Caferoğlu, 2017; Venn et al., 1993; Wypyszyńska et al., 2021).
Only seven studies reported on feasibility-related content (Alrazain, 2016; Beh-Pajooh et al., 2018; Erim & Caferoğlu, 2017; Schleien et al., 1995; Talusan-Dunn, 2012; Wypyszyńska et al., 2021), with two studies setting out to evaluate feasibility in their initial objectives (Alrazain, 2016; Talusan-Dunn, 2012). These studies highlight the growing demand for culturally sensitive and effective methods to support the psychosocial development of children with learning differences. Moreover, there is evidence to show that there is a need for practical and accessible methods and materials to be used in art group interventions. Consistent data collection procedures should be implemented in art group programs to ensure that interventions can be successfully evaluated against the program’s objectives.
The above evaluation of factors that predispose art group interventions to the greatest chance for success for this population led to the development of the AR3T principles. These principles serve as a framework to guide occupational therapists when conducting future visual arts-based interventions for children with learning differences, ensuring an evidence-based and feasible practice.
Strengths and Limitations of This Review
This review utilized a comprehensive literature search strategy, the process of study selection and data extraction was performed in duplicate, and reasons for excluded studies were provided. Moreover, risk of bias and quality of intervention reporting analysis was completed for the included studies and was considered when interpreting the results. However, this review lacks a meta-analysis, given the heterogeneity of the data, thus preventing further commentary on the effectiveness of art group interventions for children with learning differences. This may stem from the use of a broad Population-Intervention-Comparison-Outcome (PICO) question that did not specify certain comparators and outcomes to be included in the literature search. A larger search string including terms related to other visual art mediums may have also yielded more relevant art group intervention research.
Conclusion
This systematic review provides a summary of the existing evidence about the outcomes and feasibility of art group interventions for children with learning differences worldwide. The articles included indicate several trends in intervention outcomes that suggest that art group interventions have the healing potential to improve the social interaction, “problem behaviors,” cognitive functioning, caregiver attachment, development, self-expression, and emotional well-being of children with learning differences when reinforced with behavioral and play-based therapy methods. The research highlights a significant gap in feasibility criteria reporting, emphasizing the need for more feasibility studies to be conducted in this field before further effectiveness testing is undertaken. However, from the existing evidence, it can be concluded that art group interventions offer a versatile intervention that can be used with a variety of clients in different settings and tailored in such a way that it challenges participants to realize the next attainable level of their development. Art group interventions should therefore be considered as a viable therapeutic method to improve the functioning and development of children with learning differences.
Footnotes
Registration
The review is registered with PROSPERO (ID: CRD42022340991). The review protocol can be accessed via this platform.
Data Availability
The data included in this article are available within this review.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The Neurodiversity Foundation, specifically Mr. Ben Truter, is acknowledged for their financial assistance during this research.