Online art therapy in elementary schools during COVID-19: results from a randomized cluster pilot and feasibility study and impact on mental health

May combine two claims.

Feedback from teachers and students indicated that both interventions were well accepted and appreciated, especially by teachers.

“Feedback collected from teachers and students alike shows that both interventions were well accepted and appreciated, especially by teachers”

May combine two claims.

Paired t-test sensitivity analyses found no significant pre-to-post change in inattention scores within either the emotion-based group (p=0.43) or the mandala group (p=0.35).

“However, sensitivity analyses using paired t-tests did not show significant pre-to-post changes in inattention scores in participants from each group (pemotion-based = 0.43; pmandala = 0.35).”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Informal discussions with teachers indicated they were highly motivated to help the online research project run smoothly and were eager to assist the research team.

“informal discussions (anecdotal information) with teachers indicated they were highly motivated in ensuring that this online research project could run smoothly and were keen to assist the research team”

May combine two claims.

The findings cannot establish whether either condition helps anxiety or depression, nor which condition is better for those symptoms.

“Results from this study do not enable us to conclude whether both interventions are effective or not in alleviating anxiety or depressive symptoms and whether one intervention is more effective than the other in this regard.”

May combine two claims.

The intervention group had no detectable effect on anxiety, depression, hyperactivity, or mindfulness levels.

“We found no impact of type intervention group on levels of anxiety, depression, hyperactivity or mindfulness (please refer to Tables 3, 4 and Figs. 1, 2, 3, 4, 5).”

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Early evidence suggests that both the emotion-focused drawing condition and the mandala condition may lessen signs of distress in elementary school children.

“Nonetheless, results offer preliminary evidence that both an emotion-based directed drawing intervention and a mandala drawing intervention can be helpful to decrease manifestations of psychological distress in elementary school children.”

• AssumptionRests on an assumption: The two randomized clusters (classrooms) were comparable at baseline on mental health and other relevant characteristics, so post-test differences can be attributed to intervention type.
• AssumptionRests on an assumption: The two intervention groups differed only in the intended intervention characteristics and not in other factors that could affect mental health outcomes.

Classified as probably not a substantial claim.

Students were randomly assigned to either the mandala drawing group or the emotion-based directed drawing group.

“were randomly allocated to either the mandala drawing group (1 classroom of 5th grade students; N = 8) or the emotion-based directed drawing group (1 multi-age classroom of 4th and 5th grade students; N = 14”

• Also stated in: § Methods · plain

  “Randomization occurred immediately after completion of pre-intervention measures.”

Probably not a substantial claim: may not pass S3 (load-bearing).

Low power and uneven group sizes might have hidden meaningful differences between groups in hyperactivity.

“It is quite possible that the lack of statistical power and unequal groups prevented us from seeing significant between-group differences on hyperactivity symptoms”

May combine two claims.

The two drawing programs are simple to deliver with little training and could serve as ways to support children emotionally at school.

“these preliminary findings indicate that both drawing-based interventions, which can be implemented easily and with minimal training involved, may be interesting options to provide emotional support to children in school settings.”

• AssumptionRests on an assumption: Informal teacher and student feedback adequately reflects the acceptability and feasibility of the interventions.
• AssumptionRests on an assumption: The online delivery and remote data collection did not introduce systematic bias into the outcome measures.

May combine two claims.

The internal consistency of the BASC subscales in this sample ranged from poor to good, with alphas for anxiety 0.77/0.79, depression 0.65/0.76, inattention 0.93/0.66, and hyperactivity 0.74/0.72 at pre/post.

“Internal consistency was variable, ranging from poor to good, across subscales (α anxietypre/post = 0.77/0.79; α depressionpre/post = 0.65/0.76; α inattentionpre/post = 0.93/0.66; α hyperactivitypre/post = 0.74/0.72) in this sample.”

May combine two claims.

In this sample, both interventions were associated with mental health gains, particularly in inattention.

“As such, results from this study indicate that both interventions were associated with mental health gains, namely with regards to inattention, in this sample.”

• AssumptionRests on an assumption: The two randomized clusters (classrooms) were comparable at baseline on mental health and other relevant characteristics, so post-test differences can be attributed to intervention type.
• AssumptionRests on an assumption: The two intervention groups differed only in the intended intervention characteristics and not in other factors that could affect mental health outcomes.

Probably not a substantial claim: may not pass S3 (load-bearing).

The Mindful Attention Awareness Scale for Children had good internal consistency in this sample, with alphas of 0.83 at pre-test and 0.85 at post-test.

“Internal consistency was good (αpre/post = 0.83/0.85) in this sample.”

May combine two claims.

Using few items probably lowered measurement sensitivity and may have harmed internal validity.

“Indeed, the small number of items that were administered most likely reduced the sensitivity of our measures, which may also have impacted our internal validity.”

May combine two claims.

Both the emotion-focused directed drawing condition and the mandala condition may improve mental health, specifically inattention and hyperactivity, among elementary school children during the COVID-19 pandemic.

“Overall, results from this pilot and feasibility study showed that both an emotion-based directed drawing intervention and a mandala drawing intervention may be beneficial to improve mental health, namely inattention and hyperactivity, in elementary school children, in the context of the current COVID-19 pandemic.”

• AssumptionRests on an assumption: The two randomized clusters (classrooms) were comparable at baseline on mental health and other relevant characteristics, so post-test differences can be attributed to intervention type.
• AssumptionRests on an assumption: The two intervention groups differed only in the intended intervention characteristics and not in other factors that could affect mental health outcomes.

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

A licensed child clinician provided weekly online clinical supervision to the research assistants, and these sessions were also used to check implementation fidelity of both interventions.

“Structured clinical supervision was offered to research assistants online and weekly by a licensed child clinician (CMH, first author of this study) throughout this project”

• Also stated in: § Procedure · plain

  “supervision sessions were also used to monitor both interventions’ implementation fidelity.”

Probably not a substantial claim: may not pass S3 (load-bearing).

The research assistants who led the sessions were unaware of the study hypotheses.

“They were blinded to the research hypotheses.”

May combine two claims.

Earlier child clinical work suggests that social-emotional learning programs might boost well-being, lower distress, and support persistence and school success.

“Results from previous child clinical research indicate that interventions based on social-emotional learning could potentially increase children’s well-being and reduce psychological distress, while encouraging perseverance and academic achievement in school [17].”

• cites [17] Jiao WY, Wang LN, Liu J, Fang SF, Jiao FY, Pettoello-Mantovani M, Somekh E. Behavioral and emotional disorders in children during the COVID-19 epidemic. J Pediatr. 2020;221:264. sourceNot checked yet

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Fewer social contacts, boredom, and family strain might all play a role in these difficulties.

“A lack of social interactions, boredom and family tensions may all contribute to the emergence of these problems [21].”

• cites [21] Liu JJ, Bao Y, Huang X, Shi J, Lu L. Mental health considerations for children quarantined because of COVID-19. Lancet Child Adolesc Health. 2020;4(5):347–9. sourceNot checked yet

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Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Art therapy first took its theory from psychoanalysis, but newer work draws on cognitive-behavioral and social-emotional approaches.

“Although art-based interventions and art therapy initially drew their theoretical framework in psychoanalytic perspectives, recent work has shown influence by a variety of theoretical paradigms, such as cognitive-behavioral therapy and social-emotional learning [5, 28].”

• cites [5] Coholic DA. Exploring the feasibility and benefits of arts-based mindfulness-based practices with young people in need: aiming to improve aspects of self-awareness and resilience. In: Child & Youth Care Forum. New York: Springer; 2011.Not checked yet

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• cites [28] Waller D. Art therapy for children: how it leads to change. Clin Child Psychol Psychiatry. 2006;11(2):271–82. sourceNot checked yet

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Child-adapted mindfulness programs have helped lower distress and improve general mental health in elementary classrooms, especially for anxiety, depression, and attention problems.

“Mindfulness-based interventions tailored to children have shown benefits for reducing psychological distress and improving overall mental health when implemented in elementary school classrooms, specifically with regards to anxiety, depression and inattention [4, 30].”

• cites [4] Carsley D, Khoury B, Heath NL. Effectiveness of mindfulness interventions for mental health in schools: a comprehensive meta-analysis. Mindfulness. 2018;9(3):693–707. sourceNot checked yet

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• cites [30] Zenner C, Herrnleben-Kurz S, Walach H. Mindfulness-based interventions in schools—a systematic review and meta-analysis. Front Psychol. 2014;5:603. sourceNot checked yet

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In face-to-face clinical work with young people, art has been found to support expression, conversation, and emotional awareness as another form of communication.

“The use of art in in-person clinical contexts with youth has been shown to facilitate and encourage self-expression, discussion and awareness of emotions, through an alternative means of communication [28].”

• cites [28] Waller D. Art therapy for children: how it leads to change. Clin Child Psychol Psychiatry. 2006;11(2):271–82. sourceNot checked yet

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Probably not a substantial claim: may not pass S2 (checkable), S3 (load-bearing).

Mindful art making combines the bodily and creative sides of art with a deliberate focus on the present as it unfolds.

“As such, mindful art making is defined as a practice in which both the physical and creative processes of art are included, along with a specific intent to concentrate on the unfolding of the present moment [3].”

• cites [3] Carsley D, Heath NL, Fajnerova S. Effectiveness of a classroom mindfulness coloring activity for test anxiety in children. J Appl Sch Psychol. 2015;31(3):239–55. sourceNot checked yet

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Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Parents and teachers gave informed consent, and the children gave assent.

“Informed consent was obtained from parents of participants and teachers, and assent was obtained from participating children.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Earlier school-based face-to-face art programs have been reported to build awareness and self-understanding in children with learning disabilities, improving their emotional and social adjustment.

“Previous research on the impacts of in-person art-based interventions conducted in school settings indicate that they promote awareness and self-understanding in children with learning disabilities, which in turn fosters better emotional and social adjustment [12].”

• cites [12] Freilich R, Shechtman Z. The contribution of art therapy to the social, emotional, and academic adjustment of children with learning disabilities. Arts Psychother. 2010;37(2):97–105. sourceNot checked yet

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May combine two claims.

Such difficulties could harm learning and staying in school, with effects lasting after the pandemic.

“It has been suggested that these problems may impede academic achievement and school perseverance [29] which may have long-lasting impacts extending well beyond the current pandemic.”

• cites [29] Wang G, Zhang Y, Zhao J, Zhang J, Jiang F. Mitigate the effects of home confinement on children during the COVID-19 outbreak. Lancet. 2020;395(10228):945–7. sourceNot checked yet

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Probably not a substantial claim: may not pass S3 (load-bearing).

The study's emotion-focused drawing program was not classified as mindfulness-based art therapy since it had no mindfulness element.

“The emotion-based drawing intervention used in this study was not considered as a subtype of mindfulness-based art therapy, namely because it lacked a mindfulness component.”

Probably not a substantial claim: may not pass S2 (checkable).

For a practice to count as mindful, it needs a structured element that directs attention.

“In order for a practice to be considered mindful, it must include a structured component that encourages the focus of attention [15].”

• cites [15] Greenberg MT, Harris AR. Nurturing mindfulness in children and youth: current state of research. Child Dev Perspect. 2012;6(2):161–6. sourceNot checked yet

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May combine two claims.

Art therapies, such as mindfulness-based art therapy, appear promising for children's well-being and distress, yet they have usually been provided face-to-face, not online.

“Art-based therapies, including mindfulness-based art therapy, have shown promise in this regard, although to date they have been mostly delivered in-person and not online [6, 12].”

• cites [6] Coholic DA, Eys M. Benefits of an arts-based mindfulness group intervention for vulnerable children. Child Adolesc Soc Work J. 2016;33(1):1–13. sourceNot checked yet

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• cites [12] Freilich R, Shechtman Z. The contribution of art therapy to the social, emotional, and academic adjustment of children with learning disabilities. Arts Psychother. 2010;37(2):97–105. sourceNot checked yet

  Not checked in the free run.

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Among children with autism, group art therapy was linked to less hyperactivity and internalizing behavior and better social skills.

“Furthermore, in a group setting, art therapy was associated to decreases in hyperactivity and internalizing behaviors, while improving social skills, in a sample of children with autism [10].”

• cites [10] Epp KM. Outcome-based evaluation of a social skills program using art therapy and group therapy for children on the autism spectrum. Child Sch. 2008;30(1):27–36. sourceNot checked yet

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That, in turn, may make it easier to put feelings into words and share hard emotions.

“This, in turn, encourages verbal expression of emotions and allows for easier communication of difficult emotions [9].”

• cites [9] Eaton LG, Doherty KL, Widrick RM. A review of research and methods used to establish art therapy as an effective treatment method for traumatized children. Arts Psychother. 2007;34(3):256–62. sourceNot checked yet

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