Abstract
Aims:
The rising number of displaced children and youth underscores the urgent need for appropriate mental health support. Arts-based interventions (ABI) offer a promising approach to addressing this need. This scoping review aims to map key themes on the effects of the different types of ABI on the mental health of refugee and asylum-seeking children and youth (RASCY), identifying gaps and recommendations for future intervention and mental health policy.
Method:
Literature was searched across Web of Science, PubMed, ERIC, and Scopus (till March 2024) in the English language. A narrative analysis identified themes and mapped the intervention types to the themes.
Results:
Four main themes emerged from the eight included studies, indicating that ABI positively impacts RASCY’s emotional, psychological, and social wellbeing and behaviour, consistent with the WHO definition of mental health, with an additional outcome: behavioural change. Findings highlight the need for mixed-methods approaches and stand-alone dance, drama and poetry interventions. Future interventions should commit to longer interventions (⩾ 10 weeks), integrate ABI into schools and community settings, and provide training on ABI for both educational and health professionals.
Conclusions:
There is strong evidence that ABI can effectively improve RASCY’s mental health and prevent mental health difficulties by changing behaviour and promoting mental wellbeing. ABI can help these vulnerable populations thrive and contribute to healthier, more inclusive societies. The integration of ABI within mental health intervention and prevention strategies should be promoted and implemented, particularly for RASCY.
Plain Language Summary
Why was the study done? More children and young people are being forced to leave their home countries due to war, persecution, and other dangers. These refugee and asylum-seeking children often struggle with their mental health and need support that works for them. Creative programmes like art, music, dance, and drama might be helpful, but we need to better understand what research tells us about how well these programmes work. What did the researchers do? The researchers looked at studies published up to March 2024 that tested creative programmes with refugee and asylum-seeking children and young people. Research databases were searched to find studies that measured whether creative programmes helped improve these children and young people’s mental health. What did the researchers find? There were eight studies that showed creative programmes helped refugee and asylum-seeking children in four main ways: they felt better emotionally, psychologically, and socially. This matches what the World Health Organization says mental health should include, with a new finding: behaviour improved. The research showed that longer programmes (10 weeks or more) worked better, and programmes that happened in schools and community centres were most helpful. The studies also found that teachers and health workers can be provided with training to run these programmes. What do the findings mean? Creative programmes can help refugee and asylum-seeking children and young people improve their mental health and prevent future mental health problems. More research is needed to test specific types of creative activities like dance, drama, and poetry programmes on their own and to use better research methods to prove how well they work. These programmes should be included in schools and healthcare services that support these vulnerable children.
Keywords
Introduction
Displacement makes children and youth particularly vulnerable to mental health disorders. Neuroscience research shows that the brain in early developmental years is sensitive to toxic stress. 1 Refugee children often exhibit high posttraumatic stress disorder (PTSD) (19%–54% prevalence), 2 depression (3%–30% prevalence), 2 anxiety (8.7%–31.6% prevalence), 3 and behavioural or emotional problems (19.8%–35% prevalence). 3 With global displacement reaching its highest level since World War II, which includes a significant proportion of children and young people,4,5 addressing and creating solutions around its consequences on mental health has become more critical than ever.
Only recent literature has started to shed light on the issues of refugee healthcare 6 and highlights several challenges. First, although a large body of research on mental health interventions has emerged from Western understandings, traditional methods such as cognitive behavioural therapy (CBT) or eye movement desensitisation and reprocessing (EMDR) mainly focus on the reduction of specific psychological or emotional symptoms, such as PTSD or low life satisfaction. This provides an incomplete assessment of the mental health of refugee and asylum-seeking children and youth (RASCY). The other aspects of mental health, namely the social wellbeing component, which refers to having feelings of social acceptance and contribution, 7 are overlooked, 8 indicating a need for a more holistic approach.
Second, the UNHCR UK 9 explicitly states that migrants and refugees are distinct categories. However, despite having vastly different experiences, research often grouped refugees and asylum-seeking individuals under the inclusion criteria ‘migrants’, and across all age groups. Oepen and Gruber 10 found that refugee children, compared with other migrant groups, suffered emotional, behavioural, anxiety and depressive symptoms. The significantly different experiences of these groups need to be acknowledged, such as being forced to flee out of fear, and having limited access to healthcare and support postmigration.10,11
Third, many refugees and asylum-seeking individuals may feel interrogated during Western therapeutic sessions, compounded by the challenges of a language barrier.8,12 Psychologists have found that traumatic memories are not stored as explicit, or conscious memory, but as implicit, or unconscious memory.13,14 This means that the questions in therapy would not help individuals to verbally share their traumatic memories, as these emotions are encoded subconsciously. Therefore, traditional interventions may struggle to provide holistic mental health assessments even after mitigating the language and cultural barriers.
This is where arts-based interventions (ABI) could be effective in addressing the psychological,15,16 emotional, 15 and social dimensions of mental health.15,17,18 Cost-effective and accessible, ABI can support individuals across diverse socio-economic and cultural backgrounds. 15 In particular, ABI has been beneficial for groups who have gone through significant life transitions such as cancer, dementia, and pregnancy.17,19–23 For RASCY, ABI are especially appropriate, as art helps to move memories from implicit to explicit memory, allowing individuals with trauma to process their emotions and neurological patterns, thereby reducing stress and anxiety. 24 Despite recent recognitions, the understanding of ABI specifically for RASCY is still lacking. Therefore, this scoping review aims to examine the extent of ABI and the effects of ABI on RASCY’s mental health.
Methodology
The methodology for this scoping review was based on Arksey and O’Malley’s five-stage framework 25 and Levac et al.’s 26 recommendations. For this review, the optional element of involving consulting actors was not taken up. The research questions identified in Stage 1 are: What is the extent of ABI on mental health within RASCY in literature? What are some of the effects of ABI on RASCY’s mental health? How can these results be used to direct future research, interventions, and policy? In Stage 2, a literature search was conducted of papers published up to March 2024 in Web of Science, PubMed, ERIC, Scopus, using a modified PICO (Population, Intervention, Comparison, Outcome) framework 27 to identify relevant studies. This review did not take forward the element ‘Comparison’, as most ABI are not compared with non-ABI.
In Stage 3 study selection, the following papers were included: (1) the target population are children, youth, and adolescents (who are refugee and asylum-seeking)–to encompass as many people under 25 years old, according to the UN’s parameters of children and youth; 28 (2) applied ABI, which clarified as visual arts, music, drama, dance, and poetry; (3) the outcomes encompass the mental health and wellbeing; (4) quantitatively assessed the effects of interventions using validated and reliable measurements on mental health and wellbeing to evaluate the effectiveness of ABI; and only results from the quantitative analysis were included when mixed methods were applied, and (5) written in English. We excluded the following papers (1) only broadly focused on migrants and did not specify refugee and asylum-seekers, as sometimes they are used interchangeably, and this could cause inaccurate results; (2) did not explicitly state the type of ABI; (3) did not explicitly state the outcome relating to mental health; and (4) using purely qualitative methods.
The data were charted in Stage 4, using the Preferred Reporting Items for Systematic Reviews (PRISMA) guidelines 29 as shown in Figure 1, and the thematic analysis was conducted in Stage 5 and is reported in the results and discussion sections below.
PRISMA flow chart displaying the identification, selection, and inclusion of studies i
Results
A total of 127 articles identified from the search were imported into EndNote and then into Covidence. Duplicates were removed, then a title and abstract screening and full-text review were conducted. In total, 39 duplicates were removed, and 59 were excluded from the title and abstract screening, resulting in 8 papers after the full-text review. The flow of papers through identification to final inclusion is presented in Figure 1.
The general characteristics of the eight papers included in this scoping review are reported in Table 1, which includes the authors, publication dates, study type, location, aims, population, intervention, and outcome. The eight studies identified in this review were heterogeneous in population and study type, covering 453 participants ranging in age from 4 to 20 years old, representing RASCY from 11 countries, primarily Syria. Most studies were conducted in Global North countries, except for one in Turkey. 30 Gender balance was generally equal, except for Meyer et al.’s 31 study, which focused on unaccompanied boys. Despite this, none of the eight studies examined the effect of gender on the effect of the intervention. Four interventions were based on schools,32–35 and four were community-based.30,31,36,37 Five quantitative studies only,30,31–33,37 three were mixed methods,34,36,35 in which quantitative results were pulled in the analysis. Three studies included control groups.31,33,36
Description of included studies
The type of ABI (e.g.: visual arts, music, dance, drama, or poetry) is highlighted in bold.
A narrative synthesis was conducted to identify four themes, which aligned with WHO’s mental health framework: emotional wellbeing, psychological wellbeing, and social wellbeing, 7 with an added external theme of behavioural change. Various tools were used to assess mental health and wellbeing. Emotional wellbeing was associated with emotional symptoms and life satisfaction, measured through the VAS, SDQ, Life Satisfaction Questionnaire, Mood and Motivation State Questionnaire.31,35 Psychological wellbeing was linked to measurements of PTSD, anxiety, depression, and assessed using HTQ, UCLA Posttraumatic Stress Disorder Parent version, State-Trait Anxiety Scale, CDI, SCARED, and HSC or HSCL-25A.30,31,33,34,36,37 Social wellbeing was assessed through Socialisation Questionnaires, Special Education Classroom Climate Inventory, and retention rates.35–37 Common measurement tools for behaviour include the BASC, 32 the BSI, 32 and SDQ.33,34,37
Table 2 displays how the studies related to the themes and intervention types. Interventions fell into three categories: visual arts, music, and multi-interventions. ‘Visual arts’ grouped both ‘art therapy’ and ‘art workshops’ under one umbrella. All three multi-intervention studies consisted of visual art and music. No stand-alone drama and dance interventions were identified. None of the studies included poetry within any of the multi-interventions. The effect sizes were also reported and interpreted based on Cohen’s suggestion, 38 indicating small effect (d < 0.5), medium effect (0.5 < d < 0.8) and large effect (d > 0.8).
Categorising studies by themes and intervention type
The effect sizes are classified based on Cohen’s suggestion 38 and are interpreted as small effect (d < 0.5), medium effect (0.5 < d < 0.8) and large effect (d > 0.8). NA- NOT available.
Emotional wellbeing
Four studies demonstrated a positive impact with a medium effect size on emotional wellbeing. Lukito et al. 37 reported significant reductions in emotional symptoms and increased mood and motivation. Heynen et al. 35 observed a significant decrease in negative emotions over time after music intervention. Quinlan et al. 33 and Meyer et al. 31 found reduced emotional symptoms and increased life satisfaction post-intervention, respectively. Interestingly, Meyer et al. 31 found that life satisfaction continued to increase after the intervention, from 1 week to 25 months post-intervention.
Psychological wellbeing
Six studies revealed changes in psychological wellbeing, the most frequently referred to theme. The ABI are highly beneficial for improving psychological wellbeing, with larger effect sizes. For example, significant reductions in PTSD symptoms and significant increases in self-concept scale were noted.34,36,37 Decreased anxiety symptoms were reported which include decreases in measures of separation anxiety symptoms, social anxiety and a positive 15.4% increase in ‘free of anxiety’ (measured by HTQ).34,36 Similar findings showed decreased PTSD symptoms (using formal diagnostic criteria for PTSD) and significant reductions in trait anxiety (a consistent characteristic attribute) symptoms.30,33 However, some showed insignificant effects in PTSS (which measures the severity of trauma-related symptoms) and state anxiety (a temporary experience of anxiety).30,31 Conflicting results were reported on depression. Ugurlu et al. 30 reported a significant decrease in depressive symptoms, whereas Rowe et al. 34 reported an increase in depression, albeit insignificant. However, this increase in depression could be temporary as participants open up and explore their trauma via art therapy. 34
Social wellbeing
Three studies explored social wellbeing. Two studies36,37 applied visual arts and one 35 music intervention. There are no multi-intervention studies which measure social wellbeing. Results from Lukito et al.’s 37 socialisation question found that after five weekly art workshops, all participants (22 refugee children) enjoyed spending time with others, 87% found the intervention helped them make friends, 60% felt less lonely, and 67% felt more confident to talk to new people. Feen-Calligan et al.’s 36 visual art intervention had a high attendance rate of 83%, which leads to higher social wellbeing with a small effect size. A decrease in negative affect was detected during the time of the music intervention, which in turn strengthened a number of protective factors for refugee children and stimulated a sense of belonging. 35
Behaviour changes
Baker and Jones 32 found significant positive changes with a medium effect size in one aspect of behaviour–‘hyperactivity’ decreased at 10 weeks using music intervention, whereas the other behavioural measurements were deemed insignificant, such as ‘aggression’, ‘attention problems’, and ‘atypicality’. Improvements in behaviour were noted when applying visual arts interventions. Rowe et al.’s 34 measure of SDQ filled by teachers showed a 5.2% decrease in children with severe behavioural and emotional difficulties. Lukito et al.’s 37 study also reported decreases in disrupted sleep with a large effect size. In comparison, Quinlan et al. 33 found an insignificant decrease in behavioural difficulties measured with the SDQ when applying multi-interventions.
Discussion
Findings reveal improvements in emotional wellbeing, reflected in the increase in life satisfaction, and reduction of negative emotions, while psychological benefits were seen in reduced PTSD, anxiety and depressive symptoms.34,35 Behaviour is an externalisation of this inner state, evident in decreased ‘hyperactivity’ and ‘better sleep’. 32 Contrary to the focus on traditional therapies such as CBT and EMDR, ABI reveal their impact on social wellbeing and behaviour changes. Positive behavioural changes with medium to large effect sizes were found after ABI.32,34,37 This is in line with a previous meta-analysis, which found music therapy effective for improving behavioural and developmental outcomes among children and adolescents with psychopathology, 39 and a systematic review which concluded behavioural improvement among refugees (all ages) after music interventions. 40
The ABI observed broadly falls into three categories–visual arts, music, and multi-interventions (combining visual arts, music and drama). Visual arts interventions consistently addressed all themes, particularly psychological wellbeing. Current results suggest positive effects for visual arts interventions to support RASCY’s mental health needs. However, gaps and implications were found when these themes were broken down further into three intervention types (Table 2).
First, there is high heterogeneity in the type of ABI and considerable variation in the mental health outcomes in the studies included in this review. No stand-alone drama, dance or poetry interventions were reported, despite existing literature demonstrating positive impacts of drama, dance and poetry interventions on children’s mental health and wellbeing.41–43 Music interventions lacked a focus on psychological wellbeing, and there are no multi-interventions examining social wellbeing. Social wellbeing emerged as a critical but unexplored theme. Given that different types of ABI are related to specific mental health themes and outcomes (such as music interventions having a focus on behaviour, emotional and social wellbeing32,35), future investigations are needed to confirm this and determine which interventions are most effective for specific outcomes.
Second, longer intervention periods (>10 weeks) should be considered, as mental health and behavioural improvements often manifest later in the process. 32 In a shorter time frame, Keller et al. 44 found that depressive symptoms instead spiked at the beginning of the intervention. Even though these spikes were not associated with the outcome of the intervention, this was explained to be a natural reaction from bringing up the heavy memories, big emotions, grief and hurt RASCY are prone to. Sensitivity to displacement stages of children and youth is critical, with interventions proving most effective between the first 6 months to 3 years postdisplacement, at least for music therapy. 45
Third, the mixed methods could enrich quantitative approaches to capture holistic outcomes. The qualitative methods can complement quantitative tools by capturing participants’ emotional growth and strengths, 34 psychological wellbeing.46,47 For instance, Heynen et al. 35 found an increased ‘sense of belonging’ in semi-structured interviews, despite quantitative findings showing decreased ‘support’, although this decrease was later attributed to contextual factors such as holidays, resulting in less teacher interaction. The connection between the sense of belonging, life satisfaction and support aligns with prior literature emphasising the emotional and psychological benefits of ABI,31,37,48 and highlights the need for mixed-method approaches in researching the mental health of RASCY. 49
Furthermore, ABI, particularly visual arts and music, offer culturally adaptable and cost-effective approaches to supporting RASCY’s mental health. Programmes such as ‘Skills for Psychological Recovery’ 30 and the HEAL initiative 33 exemplify practical applications of such interventions. Given the cultural diversity of RASCY populations, ABI are promising and effective alternatives to traditional psychotherapy, 30 especially in areas of limited resources or in non-Western contexts. 50 ABI’s high attendance and retention rate are also encouraging.36,37 For example, a high ABI retention rate of 83% compared to 52% for exposure therapy was reported. 36 When RASCY individuals may not have the vocabulary to express or recollect their memories,13,14 ABI are not only accessible but also acceptable to participants. This is an important consideration for implementing interventions. Moreover, ABI should be implemented in various settings such as schools and communities to widen participation. Around 50% of included studies were conducted in school settings, addressing barriers to mental health access and supporting classroom dynamics,32–35 whereas community-based programmes may better serve RASCY with school anxiety or those outside formal education systems.30,36 ABI can be used to reduce healthcare burdens by educating the public, educational and health professionals. Meyer et al.’s 31 EXIT intervention has been integrated into stress management training for public health professionals and is mandatory in Norwegian and Swiss universities. Incorporating similar interventions and models could equip communities and professionals to support displaced populations, improving mental health support for RASCY.
While this review provides valuable insights, research in this emerging area is limited. There are limited studies on each type of intervention with high heterogeneity. Connected to this is the nature of researching a marginalised group, which raises logistical challenges, leading to a small sample size and/or lack of control groups.30,33,35,37 We recommend further work built from this review and expand research into underexplored interventions such as drama, dance, and poetry to deepen understanding of ABI in RASCY. 51
Conclusion
Many RASCY bear the weight of war trauma, family and community loss alone, risking long-term psychological and developmental impacts.1,52 This scoping review identified eight studies published in English to examine the effects of ABI for RASCY. As the first review to assess the nature, impact, and implications of the different types of ABI for RASCY, this review finds encouraging and strong results across emotional, psychological, and social wellbeing and behavioural outcomes. This review highlights the need to conduct more research around stand-alone drama, dance, and poetry interventions, incorporating measures of social wellbeing and behavioural change, and ideally lasting over 10 weeks, applying mixed methods to obtain a more holistic understanding of ABI on RASCY’s mental health and wellbeing.
ABI offer culturally adaptable and cost-effective approaches to supporting mental health. The adaptability of ABI allows the interventions to be effectively implemented in various community settings such as schools, community centres, museums, and so on 16 and to be incorporated into diverse cultural and low-resource settings. 15 In addition, the high attendance and retention rates, which are key feasibility indicators in public health contexts, suggest that ABI are both engaging and acceptable to participants. Examples such as the United Kingdom’s social prescribing programmes 18 and Australia’s endorsement of arts as part of its healthcare policy 17 highlight the feasibility of incorporating ABI into primary care and national health policies globally. These findings point to the potential of ABI to support RASCY’s mental health, which not only improves individual wellbeing but also fosters a healthier and more inclusive society. Therefore, there is a public health need to integrate ABI into mental health promotion and prevention strategies and programmes to better support marginalised and disadvantaged groups such as RASCY.
Footnotes
Acknowledgements
The authors would like to acknowledge the support of Theo Stickley, anonymous reviewers, Bonnie Shen, Mandy Meng, and Paul Verzosa, Hannah Walter for their valuable feedback on earlier drafts.
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) received no financial support for the research, authorship, and/or publication of this article.
Ethical Approval
Not applicable, as this study did not involve human participants, animals, or sensitive data requiring ethical approval.
Informed Consent
Not applicable, as this study did not involve human participants.
Data Availability Statement
No new data were generated or analysed in this study. Data sharing is not applicable to this article.
