Ongoing Art Therapy Groups with Children

Barbara Kariz ART THERAPY AND AD/HD Ongoing Art Therapy Groups with Children. Researching the Process and Outcomes of Therapeutic and Educational Art Interventions for Children with Special Needs.

SUMMARY Art Therapy is a useful therapeutic and educational intervention with AD/HD children. It provides a way of helping the child encounter and correct attention and hyperactivity issues and offers the opportunity to socialise and practice the social skills. It provides visual imagery and graphomotor experiences, that enhance learning and allows practice of different skills.

INTRODUCTION The diagnosis of attention deficit disorder, with or without hyperactivity is a recent one. It is seen as a neurologically based disorder that impacts both learning and behaviour. It often impacts school performance and beyond (Mikuš, 1995). Art is a good medium for working with AD/HD children because it is an activity that uses visual learning skills to give structure and offers a way to express feelings in therapy. Art activity also helps redirect energy and hyperactivity. The art product provides a child with visual record and becomes the way to record and re-encounter certain feelings, thoughts and learnt skills. The art therapy drawings reinforce learning adding another dimension to a multisensory approach to learning (Safran, 2002)..

AD/HD (ATTENTION DEFICIT HYPERACTIVITY DISORDER) Basic characteristics of AD/HD are inattention or distractibility, impulsivity, hyperactivity, frequent disturbance, sudden changes in temper, inability to focus, inability to be or stay still in a certain place for a longer period of time, hyper-sensitivity. Children with AD/HD have problems with listening to others, being patient, making arrangements, planning, organising, co-operating, being aware of others, sharing space and materials, estimating the situation, paying regard to structure and boundaries. Many children with AD/HD have specific learning disabilities which often derive from the disorder itself. Many times they do not do well academically and socially in the school environment and consequently they are at high risk to have low self-esteem and low self-worth. At school, which is supposed to be their primary occupation, they constantly feel incompetent and unhappy. Because of this they can become defensive and start avoiding school. Being in an art therapy group they have the opportunity to experience they are not alone and that it is not their fault they cannot succeed at school or please their parents. They learn that their problems derive from the disorder and that they have the possibility to do something about it by learning the strategies to cope.

1 ART THERAPY AND AD/HD

Non verbal communication Art is an activity that uses strong visual learning skills to lend structure and give those who tend not to be contemplative a way to express their feelings in therapy. The product of art therapy, the art itself, provides a child with a visual record of those feelings or ideas that have come up (Safran, 2002). Drawings can help children organise themselves. As they draw, their relationship is only with paper in front of them. They are able to be open, honest and revealing because the drawing is impersonal; it does not question, challenge or criticise (Thomson, 1998). The drawing serves as a form of self expression where verbal communication is not always possible. A child who for example cannot talk about school may find it easier to first draw a picture. With drawing in front of him it becomes easier to talk about the situation.

Expression of feelings Many of AD/HD

children are not able to express themselves verbally especially when it comes to talking about their emotions. It is true that many of them talk a lot, but it is usually around feelings not about them, because often they are not really aware of their feelings. Art making is a great opportunity for children to communicate their feelings which have been many times repressed. During the art therapy process they reveal deep feelings of negativity they experience about having AD/HD and how it effects their life. Frequent their

2 drawings express pain, social isolation and great unhappiness.

Group art therapy - learning social skills and managing behaviour The art therapy group provides a safe and controlled environment where children can achieve a successful social, therapeutic and educational experience. It is a place where they can observe and interact with their peers who have the same problems and where the therapist can observe them. It offers a fresh start and a new opportunity for social success with peers.

The AD/HD children often have poor, weak and underdeveloped social skills. Many have no close friends although they are desperate for friendship. Some children may not have problems making friends because they are very outgoing but may have difficulty keeping them. They often exaggerate, interrupt, are over-enthusiastic, do not respect personal space or boundaries, hurt other children’s feelings, are talkative, highly defensive, self involved, forgetful and often miss or misunderstand social clues. Most of the children do not have insight into their inappropriate behaviour. With art making and discussion they can understand that their problems in making and keeping friends derive from their disorder. Working together on art projects they find opportunities to experience different social situations, to observe themselves in social contacts, to practice social communication in a safe environment and to make some improvements if necessary. Group projects and working in pairs are especially good for resolving these kind of problems.

ART THERAPY GROUPS AT THE COUNSELLING CENTRE IN LJUBLJANA

Over the last five years I have been working with AD/HD children aged 7-12 at the Counselling Centre for Children, Adolescents and Parents in Ljubljana, Slovenija. The children are referred by psychiatrists, psychologists and special needs educators. Each group consists of 5 to 7 children. Limiting group size is necessary, because the AD/HD children perform better in smaller, less distractible and more predictable environments. We meet once a week for an hour and a half. Art therapy sessions begin in October and terminate in June. I meet with the referring specialist every two months or by request if there are any special developments. I have two presentations for the entire staff – at the beginning of October when I present the methods of my work and inform the staff about terms and availability of places. The second presentation is at the end of June when I present the results of my work. Once a year I organise a practical workshop for the members of staff interested in art therapy. Parents must commit to bringing their children to group every session. Attendance at every session is important because allows children to have the full experience and teaches them about living up to a commitment. It is important for the parents to understand what are the goals of AT so that they do not expect miraculous changes. I meet with parents after each session when we discuss child’s participation and behaviour. I also give them instructions on

3 how to practice certain skills at home. Every two months the parents have the opportunity to see their child’s art work, to assess their progress and to discuss appropriate individual goals. These meetings are also very important for me to hear how the child is functioning at home and to learn if the child can generalise any of the strategies taught in the group.

Goals of AT Before starting art therapy groups I set some basic goals which I wanted to achieve: 1. Using art therapy methods children will become more aware of their emotions and behaviour. This will help them cope with their every day (school) situation and improve their life quality. 2. Special creativity based exercises will help them improve and develop their motor skills, attention, orientation and concentration, which will consequently influence their writing skills and body awareness. 3. Relaxation exercises will help them enter and exit functional requirements and cope with emotional distress. 4. Being in a group will give them the possibility of simulating school/family situation which will improve their communication skills. 5. Therapists and other professionals will benefit from art therapy methods. They will be able to incorporate art based activities into their professional treatment of children. 6. Parents will also benefit from art therapy - they will find new ways of communicating with their children and coping with their problems which will have positive influence on parent- parent and parent-child relationship.

The main end of AT is to take beginning steps toward reaching the child’s long-term goal of improving his skills and actualising his potential. Collaboration with parents and professionals working at the Counselling Centre is necessary. Based on the above mentioned goals I developed certain methods and wrote an AT programme defining the contents and structure for every session. Using the action research method I planned each session, set the short term goals, applied certain measures, observed the effects, evaluated the results which were the foundation for planning a new action. For the purpose of my research I used questionnaires for children, parents and referring specialists, had various interviews with all three groups, collected various documents and materials and kept a research diary.

The modes of AT The modes of AT were as follows: educating children regarding AD/HD; establishing the environment of trust where children can express and explore their feelings; using educational social-skills art therapy approach for practising social appropriate skills; using structured drawing to contain the anxiety by offering a structured and predictable reality that was controllable by children; using free drawing to allow children to externalise their feelings; influencing the AD/HD core components: inattentiveness, impulsivity, hyperactivity; developing strategies to cope; using strategies of empowerment to improve self esteem; enhancing creativity throughout the process.

AT programme The programme is based on four deficit areas of AD/HD:  FUNCTIONAL (fine/gross motor skills, space orientation, visual perception, distractibility, concentration, organising ability and other).

4  EMOTIONAL (self-esteem and self worth, expression and exploration of feelings, empathy).  BEHAVIOURAL (impulsivity and hyperactivity issues, changes of temper, conflicts, aggressiveness, structure and boundaries etc.).  SOCIAL (making and keeping contacts, active participation, understanding social clues etc.).

Session structure

Each session consists of three parts: 1. Introduction (20 min), 2. Main art activity and discussion (60 min), 3. Conclusion (10 min).

The introductory part includes different warm-up activities, the purpose of which is to start communication among children and to prepare them for the main art activity. The introduction is followed by the main art activity which is divided into three parts: (a) the review of the previous session, (b) art making, (c) discussion. In the conclusion we do the cleaning up and make plans for the next session. Art based exercises can be successfully combined with music, writing, movement and play.

Art activity According to the needs of the group members the art activity can focus on improving functional skills, it can open certain emotional issues or the majority of time can be spent on practising social skills and appropriate behaviour. I developed specific art based exercises for each of the four deficit areas of AD/HD. For improving the graphomotor skills, visual perception, memory skills, space orientation, prolonging concentration, directing attention and improving organising ability I apply different art based exercises such as geometry, pattern drawing, fine collage technique, sampling, frames, seals, puzzle, mosaic, stencils, textures and other. I mentioned at the beginning that many of AD/HD children have specific learning disabilities, meaning they have problems with writing and reading. We try to practice these skills on every possible occasion: for example when we draw and colour patterns I ask children to look at the drawing and make up a story which they then write and read to other children. To express and explore one’s emotions we use certain exercises regarding self- perception, self-esteem, family relationships, peer relationships and other. Children are offered different general topics such as: my feelings (about having AD/HD, about friends, family members etc.), my wishes, friendship, self-portrait, personal symbol, my life line, masks and other. Regarding social and behavioural area different group paintings and games as well as work in pairs has proven to be very successful allowing children to develop positive social interaction, to learn about listening, sharing, organising, helping others, respecting diversity, improving self-control, developing feelings of happiness, optimism and content. We also use different relaxation (art) techniques such as mobilisation, exploring art materials, using different body parts to paint, painting while listening to music and other.

5 It is important that we always repeat what we learnt in the previous session(s), because repetition is essential for children with AD/HD. It helps them internalise the information. The drawings, being visual reminder, are used for review and reinforcement of each session.

The first session is important for establishing the trust so the children can commit to the group process. We should always begin by making sure everyone is introduced. After brief introductions the therapist presents the rules and concept of art therapy and explains what it offers. The rules should be written down and reviewed from time to time. They are very important, because they provide structure and boundaries. We should also discuss confidentiality and ask children for permission to share their drawing with parents and professionals who work with them. We can then ask the children to do the first drawing introducing themselves (different possibilities). On this occasion we can explain that the art making part of the session is always time limited so there is adequate time left to discuss their work, which is an important part of the exercise. When children do the art work the therapist should not only observe what they draw but also how they have used space and materials, how they communicate with each other, how they manage time, how they plan and organise themselves, how they behave. The advantage of group therapy is that therapist can observe a child in a social setting. The observations should be recorded so that they can be addressed in later sessions. In the second session each member of the group is asked to introduce the other members, using their names and mentioning what they have learned about the person. As the group members in the following sessions learn more about each other, they develop a relationship of trust and can start addressing problems and learning managing skills. The final session includes evaluating the achievements and making plans for the future.

Discussion At the end of each session children look at each other’s drawings (art objects) and discuss their feelings. The discussion helps develop verbal communication skills. Presenting one’s drawing is very important because many times children with AD/HD are not able to present information in a clear manner. Discussion also solidifies the group and initiates the development of trust. It helps the children make a verbal connection with the emotions presented in art media.

RESULTS

The most significant improvements were seen in the area of social interaction: children learnt and used certain social skills to better communicate with peers and their parents. Furthermore the children attending AT became less defensive and more open to suggestions which positively influenced their school performance. By exploring and expressing their feelings their self-esteem grew, as they felt more confident and competent. Certain improvements were seen also in the functional area: they improved their motor skills and learnt strategies to help them focus better, remember more and be less distracted. The parents reported that the children acted less impulsively and performed better at school. Other interventions were planned and used simultaneously with the same children from the other specialists’, teachers’ and parents’ side so we can conclude that the improvements resulted from the common efforts. The art therapy group has been successful in helping children identify their feelings about having AD/HD and has presented them with certain strategies which can help them

6 perform better at school, establish good social contacts and control their behaviour. They have learnt new ways to handle problems and achieve better results.

CONCLUSION

All the art therapy sessions focus on learning strategies to empower children and improve their self-esteem. Of course there is always a big step from what the children learn at AT sessions to actually incorporate helpful strategies into their daily life. This is difficult to achieve and children and their parents should be aware of this. AD/HD is a chronic and complex disorder that cannot be easily fixed. Art therapy program can achieve certain level of success, but children need much practice and visible results can be achieved only if the children, parents, teachers and other professionals are willing to participate and accept the responsibility to continue using the learnt skills.

REFERENCES

(1) Case, C.; Dalley, T.: Working with Children in Art Therapy. Routledge, London 1990. (2) Goldstein S., Goldstein M.: Hyperactivity: Why won't my Child Pay Attention?, John Wiley & Sons, Inc, New York, 1992. (3) Hickson, A.: Creative Action Methods in Groupwork, Winslow Press Ltd., Oxon, 1997. (4) Kramer, E.: Art as Therapy with Cildren, Magnolia Street Publishers, Chicago, 1993. (5) Liebmann, M.: Art Therapy for Groups - A Handbook of Themes, Games and Exercises. Routledge, London 1994. (6) Magajna, L. Koncentracija za učenje, Svetovalni center za otroke, mladostnike in starše, Ljubljana, 1991. (7) Mikuš Kos A., Žerdin T., Strojin M.: Nemirni otroci, Svetovalni center za otroke, mladostnike in starše, Ljubljana, 1995. (8) Safran D.S. Art Therapy and AD/HD, Diagnostic and Therapeutic Approaches, Jessica Kingsley Publishers, London, 2002. (9) Thomson, M.: On Art and Therapy: An Exploration, Free Association Books, London, 1998.