THE EFFECT OF
ART THERAPY ON A CHILD WITH A
DISRUPTIVE BEHAVIOR DISORDER DIAGNOSIS: A CASE STUDY
______
A Research Project
Presented to
the Faculty of Springfield College
______
In Partial Fulfillment
of the Requirements for the Degree
Master of Science
______
by
Heather S. Weinberg
April 2008
ii
Dedication
To my vinyl toys, you have stood by me through thick and thin . . . mainly because you cannot move on your own. iii
Acknowledgments
I would like to express a ridiculous amount of gratitude to my family - Mom, Dad, and Kevin. Without their support, love, encouragement, and laughter, I would probably be living in a van down by the river. You guys rock. I am also deeply indebted to Pat Davidson, Samantha
Penny, and Laura Woods who have helped me not only survive this journey, but have some fun along the way. Special thanks to my fellow residents in the Grad Annex, I have heard everything you have done for the past two years.
In addition, I would like state my appreciation to Ken
Duffy for his assistance in my data collection, for being there when I needed him, and agreeing to go to a hardcore/metal show even though he does not like that kind of music and it gave him a two-day headache. Words do a bad job of expressing it, but I could not have done this without you.
I would like to thank the Graduate Art Therapy program faculty for sharing their knowledge and time with me. Dr.
Leslie Abrams has been a valuable source of support, guidance, and wisdom. I do not think I would have made it through in two years if not for your help. I would also iv like to extend my gratitude to Dr. Simone Alter-Muri for her assistance in the research process.
Finally, I have to mention Alex Pardee, Chuck
Palahniuk, Touma, Venom, Kathie Olivas, Optimus Prime,
Evergreen Terrace, skulls, Usugrow, Denis Johnson, Dunnys,
Every Time I Die, Bloopy and Binkerstaff, Poison the Well,
Geek Love, headphones, The Devil’s Rejects, Brian Morris,
Grey’s Anatomy, things that go bump in the night, David
Lynch, ToDieFor, Kenzo, From Autumn to Ashes, Brad Pitt’s abs in Fight Club, Greg Simkins, Converge, Derek Hess, the tree I can see from my window, Thundercats, fresh air, Luke
Chueh, The Hills, Edgar Allan Poe, Sam Flores, Refused,
Pinkytoast, Coolvader, Juxtapoz, ParkeHarrison, hooded sweatshirts, and birds for inspiring and motivating me.
May 2008 H.S.W.
v
Table of Contents
Page
List of Tables ...... viii
Abstract ...... 2
Introduction ...... 3
Method ...... 9
Participant ...... 8
Measures...... 10
Procedures...... 14
Data Analysis ...... 20
Results...... 20
Participant Artwork and Session Summaries . . . . 21
CAFAS Results ...... 37
Behavioral Level System Results ...... 40
Discussion ...... 45
References ...... 55
Appendix A. RESEARCH DESIGN...... 61
Statement of the Problem...... 62
Definition of Terms ...... 63
Delimitations ...... 66
Limitations ...... 67
Research Questions...... 67
Appendix B. REVIEW OF LITERATURE ...... 69 vi
Appendix B. REVIEW OF LITERATURE (Continued)
Art Therapy with Children...... 72
Disruptive Behavior Disorders, Behavior Problems, and
Art Therapy...... 77
Disruptive Behavior Disorders and Behavior
Problems ...... 78
Art Therapy with Children with Disruptive
Behavior Disorders and Behavior Problems . . 89
Art Therapy with Aggressive Children ...... 97
Summary...... 106
Appendix C. CHILD AND ADOLESCENT FUNCTIONAL ASSESSMENT
SCALE...... 108
Appendix D. ART THERAPY SESSION NOTES...... 124
Appendix E. AGENCY CONSENT LETTER...... 125
Appendix F. PARENTAL CONSENT LETTER...... 127
Appendix G. SESSION DIRECTIVES ...... 129
Appendix H. PARTICIPANT ARTWORK...... 130
Session #1...... 130
Session #2...... 132
Session #3...... 134
Session #4...... 135
Session #5...... 136
Session #6...... 138 vii
Appendix H. PARTICIPANT ARTWORK (Continued)
Session #7...... 140
Session #8...... 142
BIBLIOGRAPHY ...... 143
viii
List of Tables
Table Page 1. Child and Adolescent Functional Assessment Scores ...... 58
2. Pre-Intervention and Post-Intervention Behavior Level Drops ...... 59
3. Behavior Level and Notes Pertaining to Art Therapy Session Dates...... 60
Effect of Art Therapy 1
Running head: ART THERAPY AND DISRUPTIVE BEHAVIOR
DISORDERS
The Effect of
Art Therapy on a Child with a
Disruptive Behavior Disorder Diagnosis: A Case Study
Heather S. Weinberg
Springfield College
Effect of Art Therapy 2
Abstract
This case study examined the effect of art therapy on a child with a disruptive behavior diagnosis. Level of functioning was assessed prior to commencement of an art therapy intervention and again at the conclusion of the intervention utilizing the Child & Adolescent Functional
Assessment Scale (CAFAS; Hodges, 2000). An improvement in rating on the behavior towards others subscale as well as in overall level of functioning was observed. Additionally, change was tracked through session notes and artwork produced. Participant artwork demonstrated a marked difference in scribbling technique, the release of aggression and anxious energy, and current issues. The behavioral level system employed by the residential treatment facility highlighted participant conduct improvement following each art therapy session.
Effect of Art Therapy 3
The Effect of
Art Therapy on a Child with a
Disruptive Behavior Disorder Diagnosis: A Case Study
According to the Surgeon General’s report on mental health, approximately 10.3% of children in the United
States, roughly 6 million individuals, have a disruptive behavior disorder (DBD) diagnosis (U.S. Department of
Health and Human Services, 1999). Behavior disorders, behavior problems, and aggression are the most common reasons for which children are referred to mental health services (Keenan & Wakschlag, 2002). The prevalence of behavior problems in this population necessitates new treatments and modalities as the needs of children diagnosed with DBDs are not being met utilizing current methods.
Residential treatment facilities, schools, and other therapeutic services rely heavily on verbal therapy.
Children with disruptive behavior disorders and the related behavior problems, however, struggle to get involved in verbal therapy (Pergjini, 1999). Talking about complex issues and behaviors is difficult for children, particularly those with psychological disorders. Moriya
(2000) pointed out that because people most often Effect of Art Therapy 4
communicate verbally, a variety of defenses have developed
on that level of communication. Thus, children with DBD
diagnoses are often resistant to speaking with a therapist.
Those children with DBDs are characterized in the
Diagnostic and Statistical Manual of Mental Disorders,
Fourth Edition, Text Revision (2000) as argumentative, angry, hostile, and openly defiant toward authority figures and adults. The features of these disorders create another treatment challenge that goes beyond verbal resistance and prevents traditional therapeutic methods from being effective.
Art therapy is a modality with the capacity to be beneficial to children diagnosed with DBDs. Creating artwork allows for the exploration of feelings and emotions, without solely emphasizing verbal communication
(Bush, 1997). Art therapy can help to combat verbal defenses by not only providing a nonverbal task, but also allowing the children to distance themselves from the emotion or issue and work within the metaphor of the art
(Moriya, 2000). The art product created combined with the artistic process form the basis for art therapy and provide a structure within which this form of therapy can be effective with the DBD population. Effect of Art Therapy 5
More than just a means to an end, the creative process in art therapy has an “inherent healing power” (Malchiodi,
2007, p. 6). The process taps into the unconscious and channels that material into a tangible form through creativity (McMurray & Schwartz-Mirman, 2001). Once a product is created, the issue can be examined from a position external to the individual. Through creating and processing the image, control and a sense of understanding can be gained. Children can easily take advantage of the creative process because art is instinctual for them, a natural drive (Rubin, 1984).
Regarding children diagnosed with DBDs, the artistic process can work to calm these individuals or direct their hostility into an alternate venue (Neibauer, 1988). Kramer
(1993) found that unconscious primal drives, such as aggression, can be altered into constructive energy during the artistic process. Venting these powerful emotions during art making redirects impulses and relieves children who struggle in maintaining control. The process is crucial to those with behavioral problems as they often experience outbursts.
Art therapy can also provide an outlet for those who are hesitant to show emotions, a characteristic of children Effect of Art Therapy 6 with DBDs (Broecher, 2000). Often, these children associate feelings with exposing weakness. Art therapy helps break down some of the obstacles connected with psychiatric help by working through symbols. Children are apt to become more open if they are speaking about the artwork rather than directly discussing their issues. Additionally, presenting children with a creative task can aid in overcoming refusal to participate in the therapeutic process (Dunn-Snow,
1994).
For children with DBDs, art making allows them a means of communication, expression, and therapy. Specifically, art therapy operates as a calming influence and a venue in which resistance is lowered. The challenges that working with the DBD population provide are directly addressed by the attributes associated with art therapy. Working with art therapeutically permits children with DBD diagnoses to more easily express their emotions, diminishing acting out behavior and detrimental cognitive processes (Saunders &
Saunders, 2000).
Although art therapy is therapeutically effective with children diagnosed with DBDs and behavior problems, it is not widely utilized with the population. While some research regarding the use of art therapy with children Effect of Art Therapy 7 with DBDs does exist, the amount is disproportionately less than that concerning art therapy and other populations. As the number of children with DBD diagnoses continues to rise, schools, residential facilities, and treatment centers must address the growing need. More research is needed regarding the use of art therapy with the DBD population. The intent of the current case study was to observe behavior, emotional, and functional change in a child as the result of an art therapy intervention.
Method
This case study examined the effect of art therapy on a child with a disruptive behavior disorder diagnosis in a residential treatment program and school. An 8-week art therapy intervention focused on aggression and behavior problems. Any changes in the participant over time were monitored through artwork and session notes and the behavioral level system employed by the residential treatment facility. Additionally, level of functioning was assessed prior to the commencement of the art therapy intervention and again at the conclusion of the intervention utilizing the Child & Adolescent Functional
Assessment Scale (CAFAS; Hodges, 2000).
Effect of Art Therapy 8
Participant
The participant in this case study was an 8-year old
Caucasian male who lives in a residential treatment program in Springfield, Massachusetts. He is currently diagnosed with oppositional defiant disorder and has frequent aggressive outbursts. Oppositional defiant disorder is a disorder which falls within the disruptive behavior disorder category. The pseudonym Sean was given in order to protect the identity of the participant.
Sean was removed from the custody of his biological parents at 3 months old and placed into foster care as the result of substantiated claims of both neglect and physical abuse. At the time of his removal, he had bruises all over his body and records indicate that he had been left alone in his crib for extended periods of time. His biological parents both have histories of mental illness, substance abuse, and cognitive delays. In addition, at the time of
Sean’s removal, the family was living with a registered sex offender. Sean had supervised contact with his biological parents until 2004 when his adoption was finalized.
The foster care family that Sean was placed with at 3- months of age would later become his adoptive family. In his adoptive family, Sean has a 10-year old sister, and two Effect of Art Therapy 9 brothers, ages 16 and 23. Prior to his adoptive parents’ separation and eventual divorce, Sean witnessed the physical and verbal abuse of his adoptive mother by his adoptive father. Problems began to surface for Sean around the age of 2 when sexualized behavior emerged (i.e. humping the family dog, inappropriate touching of female family members). By the age of 4, Sean was exhibiting encopretic and enuretic behavior. Additionally, he began having angry outbursts that culminated in the killing of several family pets (i.e. flushing mouse down the toilet, breaking the necks of 2 parakeets).
Sean was first hospitalized in April 2005 (until
September 2005) for assaultive behavior, the killing of family pets, and sexualized behavior toward his mother and sister. While in the hospital, he began smearing his feces and inducing vomiting. Over the next two years, Sean was hospitalized 3 more times for behaviors including running away from home, hiding under cars, violence, and verbal aggression.
Presently Sean has been struggling with hyperarousal and anxiety which lead to psychomotor agitation. Because of this, he is unable to sit still for even a few minutes and is very fidgety. Sean is also extremely impulsive, Effect of Art Therapy 10 especially when angry, causing him to have a complete disregard for his own safety and the safety of others (i.e. running into the road, throwing objects). He also has a lot of difficulty following direction, and he often becomes aggressive, hitting and threatening staff. Sean has poor personal boundaries and a poor understanding of social nuances and consequences.
Sean presents as pleasant and likeable. He is friendly and likes to joke around. He seems to respond to the one- on-one time that therapy offers him. Sean is talkative and able to maintain conversation. Though intelligence testing places him in the borderline range, he seems bright and sharp. At times, Sean can exhibit behavior that is not age appropriate, causing him to appear younger than he is.
Measures
Level of functioning was measured utilizing the CAFAS
(Hodges, 2000). A copy of this scale can be found in
Appendix C. The measure is intended for use with children and adolescents ages 7 to 17. The CAFAS has eight subscales relating to emotional and psychological functioning.
Subscales include: three role performance subscales
(school, home, and community), behavior toward others, moods/emotion, self-harmful behavior, substance use, and Effect of Art Therapy 11 thinking. Within each subscale, a child is rated as having no impairment, mild, moderate, or severe impairment.
The CAFAS can be rated reliably by an individual who is knowledgeable and informed regarding the child (Hodges,
2005). The overall score is determined by the behavioral descriptor items in each subscale that are identified as applying to the youth’s behavior and performance. The CAFAS is indicated for use as an outcome measure utilized to evaluate clinical change in an individual in order to determine program efficacy.
Reliability and validity information has been established for the CAFAS through the use of data gathered from two large evaluation studies (Hodges, 2005). The Fort
Bragg Evaluation Project (Breda, 1996) utilized the children of army personnel who had been referred for mental health services. The national evaluation of the demonstration service grants which was funded by The Center for Mental Health Services (CMHS; Holden, Friedman, &
Santiago, 2001; Manteuffel, Stephens, & Santiago, 2002) used a sample of youth diagnosed as having a severe emotional disturbance. The children in this sample came from families with low socio-economic status and were Effect of Art Therapy 12 receiving mental health services through a variety of different agencies.
In regards to reliability, coefficients were calculated to determine the internal consistency of the
CAFAS (Hodges, 2005). Moderate values were expected here since the CAFAS measures different facets of impairment.
The reliability coefficient values for the Fort Bragg
Evaluation Project were as follows: at intake r = .63, at 6 months r = .68, at 12 months r = .67, and at 18 months r =
.67. In the CMHS funded study, the coefficient values were r = .73 at intake and r = .78 at 6 months.
Content validity was established for the CAFAS through the selection of items for each category that would reflect impairment in that specific domain (Hodges, 2005).
Additionally, many of the selected items were shown to be
“psychometrically robust” based on a previous measure created by Hodges, the Child Assessment Scale (CAS; Hodges,
1978). Because CAFAS scores can be converted into identifiable delinquent behaviors, the measure has also established face validity. The items in each category coincide with observable behaviors, making change or improvement over time apparent. Effect of Art Therapy 13
The results from the Fort Bragg Evaluation Project and the CMHS funded study have provided evidence regarding the
CAFAS concurrent validity (Hodges, 2005). In both samples, children with more severe diagnoses and problems scored significantly higher on the CAFAS than those with less serious disorders. This was the expected outcome as it is assumed that children with more critical psychological problems would have higher levels of impairment then those with less severe issues.
Behavior change in the participant was assessed with the behavior level system employed by the residential treatment facility (Residential Treatment Program, 2006).
The system involves three levels: red, yellow, and green.
The concept behind this system is that children should be on the green or “getting along” level most of the time and that not all misbehaviors affect behavior level. When on green, children are expected to maintain appropriate behavior as determined by the facilities rules and their individualized behavior plans.
Children are dropped to the yellow level (a “yellow drop”) when they exhibit behaviors that are mildly to moderately severe (Residential Treatment Program, 2006).
Examples of this behavior include: verbal threats or abuse, Effect of Art Therapy 14 property destruction, aggression that is not intended to harm, stealing, and sexualized gestures/talk. A “red drop” is earned for behaviors that more severe than those in the yellow category. Assault, self-abuse, sexual misbehavior, and running away are examples of red level behaviors.
Children are eligible for level increases when they have completed the repair work assigned to them based upon the nature of the behavioral transgression. Records are maintained by the residential staff members regarding level drops.
Participant progress was further tracked through artwork and session notes produced during the art therapy intervention. The researcher made observations regarding the manner in which the artwork was made, the materials utilized, and symbols and themes in the final art product.
Additionally, detailed session notes provided record of verbal discussions between researcher and participant as well as participant behaviors during each session. An example of the session note form can be found in Appendix
D.
Procedures
The researcher obtained permission to conduct this case study from the Internal Review Board (IRB) at Effect of Art Therapy 15
Springfield College, Springfield, Massachusetts. In addition, consent to the research design was acquired from the residential treatment facility and school. An example of the agency consent form can be found in Appendix E. Once permission was gained from the agency, a parental consent form was sent to the participant’s adoptive parents. An example of the parental consent form can be found in
Appendix F.
Prior to the commencement of the art therapy intervention, the CAFAS was used to rate the participant and evaluate his current level of emotional and psychological functioning. Since the CAFAS requires that the rater be well informed regarding the child in all of the eight subscales, the assessment was completed by a residential facility staff member. The staff member was selected based on the amount of time spent with the participant and the member’s knowledge concerning the child.
The participant then took part in an 8-week art therapy program designed to redirect aggression and reduce the behavior problems associated with a disruptive behavior disorder diagnosis. The goal of this program was to provide an outlet or venue for the participant to expel anxiety and Effect of Art Therapy 16 hostile energy in order to avoid behavioral issues and aggressive outbursts. Each week, the participant met with the researcher for 1 hr and take part in the predetermined art therapy directive. Allowance was made in the intervention for the participant to create an art piece of his own choosing (a nondirective session). The 8-session plan was as follows: scribble pictures, scratch art, nondirective session, clay work, large scale painting, nondirective session, clay work, and scribble pictures. A list of sequential session directives can be found in
Appendix G.
Scribble pictures, functioning as both the first and final art activity, were utilized as a relaxing and kinesthetically pleasing activity. Children, like Sean, who have experienced trauma, often times regress in their artwork to earlier developmental stages (Malchiodi, 1998).
By regressing, children revert to that which is more comfortable to them, rather than attempting to create developmentally appropriate artwork. Additionally, Sean was able to release energy through the arm movement involved in making scribbles.
Including the scribble picture directive at the commencement of the art therapy intervention and at the Effect of Art Therapy 17 close of the program served as a means of comparison for
Sean’s progress over time. The directive for these two sessions was as follows: Scribble in any way that you chose using any of the materials provided. The materials offered were 11” x 14” and 8½” x 11” white paper, 9” x 12” black paper, crayons, colored pencils, markers, and graphite pencils.
The scratch art directive was aimed at reducing the anxiety level of the participant through the release of related energies in a manageable way. Again, the kinesthetic movement involved in scratching aids in venting energy tied to impulses and drives (Kramer, 1993). The specific nature of scratch materials, however, allows for controlled expression. In addition, the process of uncovering the colored area beneath the black film offers an engaging purpose for the participant. The directive for the session was: Create an image of your choosing using the materials provided. The materials were 9” x 12” scratch art paper and a pointed wooden scratching tool.
Sessions 4 and 7 focused on working with clay.
Regarding children dealing with aggression, there is satisfaction involved in manipulating clay (Riley, 1999).
Since clay is such a tactile material, two sessions were Effect of Art Therapy 18 devoted to its use. Simply by touching the clay and forming it with his hands, the participant can release and express emotions (Malchiodi, 2007). The directive for this session was: Work with the clay to create a product. The materials were Model Magic, a synthetic, air-dry clay.
Large scale painting was used in session 5 to address aggressive energy and anxiety using the distinctive properties of paint and the bodily movements necessary to create large artwork. Paint lends itself to very expressive creation (Steinhardt, 1993). In addition the material’s regressive qualities create a direct connection to aggression as a primitive drive. The emphasis in this session will be on spontaneous creation in order to free the participant from the expectation of creating a specific product. A piece of 5’ x 4’ paper was affixed to the wall and a foot stool provided to make all areas of the paper accessible. The directive was: Use the paints provided to create an image. The materials were tempura paints, paint brushes, and a 5’ x 4’ white piece of paper.
The two nondirective sessions (sessions 3 and 6) functioned as times when the participant exercised control in deciding what he would like to create with the art materials. Children with behavior disorder diagnoses tend Effect of Art Therapy 19 to be resistant and oppositional when faced with tasks to complete (Neibauer, 1988). By allowing for the participant to choose his own activity, not only is resistance counteracted, but his needs at the moment are more directly served.
Detailed session notes were completed following each session, with careful attention paid toward the participant’s interaction with the art materials and his general behavior and mood. The art product from each session was also documented and examined for content. At the end of the program, the session notes and artwork were used to investigate change in the participant over time.
When the participant completed the 8-week art therapy intervention, the CAFAS was again administered by the selected residential staff member for the purposes of comparing this score to his pre-intervention functioning.
Additionally, the participant’s behavior level drops
(according to the system used by the residential treatment facility) during the art therapy program were compared with his behavior levels in the 1 week prior to the start of the treatment and in the 1 week directly after it ended.
Particular attention was paid to his behavior level following each 1 hr session. Effect of Art Therapy 20
Data Analysis
Once each level of change had been assessed (the artwork and session note, the behavioral level system, and the CAFAS), the three levels were explored on an individual and collective basis. In other words, change was observed on each level and then compared with the change occurring on the other levels. The manner in which they related to each other provided additional information regarding the effect of art therapy on a child with a disruptive behavior disorder diagnosis.
Results
This case study examined the effect of art therapy on a child with a disruptive behavior disorder diagnosis. An
8-week art therapy intervention was designed to focus on aggression and behavior problems. Any change in the participant over time was monitored through artwork and session notes, the behavioral level system employed by the residential treatment facility, and utilizing the CAFAS.
Subsequently the results of the study were divided into the following subsections: participant artwork analysis and session summaries, CAFAS results, and behavioral level system results.
Effect of Art Therapy 21
Participant Artwork and Session Summaries
The participant took part in an art therapy intervention that was 8 weeks in length, with each session being 1 hr duration. The intervention was designed to target both aggression and behavior problems. The art therapy treatment sessions were laid out in the following manner: scribble pictures, scratch art, nondirective session, clay work, large scale painting, nondirective session, clay work, and scribble pictures. Photographs of all participant artwork can be found in chronological order in Appendix H. While Sean did participate in the directive for each session, he also took part in additional art activities within the time allotted. Due to his high energy level, Sean tended to move rapidly through projects and from one activity to the next.
Session #1 – Scribble Pictures
Directive: Scribble in any way that you chose using
any of the materials provided. The materials offered
were 11” x 14” and 8½” x 11” white paper, 9” x 12”
black paper, crayons, colored pencils, markers, and
graphite pencils.
Sean was given the directive to create a scribble picture utilizing any of the drawing media and paper Effect of Art Therapy 22 provided for him. He decided that he wanted to save this activity until the end of the art therapy session and chose to begin by working with model magic. After struggling to get the clump of yellow clay out of the bag, Sean began cutting into the clay with scissors. As he did this, little pieces of clay would fling off of the main piece, landing all over the table and floor. After working for a few minutes, he asked that the researcher get scissors and cut along with him. The activity turned into a game, with Sean setting up goals and keeping score.
Approximately 15 minutes after starting the game, Sean began picking up the loose pieces of yellow clay and putting them back into the bag. Next, he spotted a bird he had made out of model magic during an art therapy session a few months ago and asked if he could paint it. Using watercolor paints, he carefully painted blue onto the blue sections, yellow on top of yellow, and so forth. After observing the way in which the yellow and blue ran, mixed together, and became green, Sean began to mix all of the watercolors together. He alternated mixing colors and painting lines onto a piece of white 11” x 14” paper. He incorporated his freshly painted model magic bird into this piece by placing it on the paper and encapsulating it with Effect of Art Therapy 23 a line. Similarly, he painted a heart on the paper and created a circle around it as well.
Sean continued mixing paint, repeatedly going back to the cabinet to get out more watercolor sets. Each time, he would verbalize that he had “messed up.” Finally, he mixed a color that satisfied him, calling it “violet brown” and painting a splotch of it onto the paper. At this point,
Sean was ready to complete the scribble picture activity, gathering together some crayons and an 8½” x 11” piece of white paper. Utilizing three colors, he quickly covered the entire sheet in scribbles, going off the edge of the paper at multiple points.
During this session, Sean seemed to utilize the art media in order to explore boundaries: first, by reinforcing the outer edges of his model magic bird by painting over the different sections using the pre-existing color, then encapsulating the bird and heart inside circles in his watercolor piece, and finally by ignoring the borders of his paper while scribbling. These art activities
(particularly the clay game) also served the purpose of allowing him to expel and vent energy, anxiety and aggression. The researcher focused on reflective narration throughout the session since Sean was not talkative while Effect of Art Therapy 24 working nor was he responsive to questions. Reflecting back to the participant his own actions not only allows him to be more consciously aware of his process but also functions to strengthen his core and ego structure.
Session #2 – Scratch Art
Directive: Create an image of your choosing using the
materials provided. The materials were 9” x 12”
scratch art paper and a pointed wooden scratching
tool.
Sean began working immediately on his scratch art project, pressing hard with the wooden tool and scratching away larger areas of black to reveal bright colors. Though he seemed to enjoy scratching, he did not work for very long on his picture. When he was finished, he had created a variety of scribbles and images. The images included a heart, a flower with a large stem and leaves, and a wolf
(which was labeled as such).
He then decided to use watercolor paints to create a picture. Unlike last session, Sean used each color carefully and separately, making sure not to mix them in the paint set. He began painting with the black, creating a line just above the halfway point on the paper. He accented this line with black scribble marks at either end. Sean Effect of Art Therapy 25 proceeded to paint the red house, brown stick figure and green rectangle. Once he completed these images, he added a stick figure inside the green rectangle only to scribble the figure out with red and add a long red object to the brown figure’s hand. He explained that the brown stick figure was a robber who had killed the boy who was sleeping in bed (the green rectangle). The red lines crisscrossing the house represented the lasers that were a part of the home’s security system.
Sean would not discuss the image any further and, instead, got out a clump of blue model magic and started up the scissor game that we had played last session. As we played, Sean would help the researcher to score goals when he felt that the researcher did not have enough pieces in the goal. This behavior was reflective of how we worked together throughout the session, as a team of sorts with the researcher assisting and Sean directing. He seemed to use this game as a way to express and release some of his anxious energy. Following the game, he was able to transition well to the next part of his day.
Session #3 – Nondirective Session
Since Sean tended to be self-directed in our art therapy sessions, he was comfortable not receiving a Effect of Art Therapy 26 directive. He got out the model magic and used a cookie cutter in the shape of a “J” to create a form of the letter. He expressed wanting to paint the clay letter, but once the paint was set up, he opted to squish the “J” he made back into the bag of model magic and paint the cookie cutter with black paint.
Once he had done that, Sean painted around the cookie cutter onto a piece of black paper using black paint. He used red, blue, and white to paint what he relayed to be
“you got me” on the paper. I believe that this was a reference to a joke he had played on me at the start of the session to which I had replied, “You got me.” Sean then became concerned with the color the water had become from rinsing his paint brush in it. From there he began to mix all the paint colors together on the palette. This behavior connected to that of previous sessions where Sean had shown interest in mixing colors. It seems to benefit him therapeutically to combine colors and discover what new colors can be made.
At the end of our session, Sean made a comment regarding a horse project that had been made by another child. He said that the horse had guts in his head instead of a brain. When the researcher asked Sean whether or not Effect of Art Therapy 27 he ever felt like he had guts in his head, he replied that he did feel like that a lot. It meant that there was too much going on inside his head, and he couldn’t think straight. He added that at the present moment, he did not have very many guts in his head and he was able to think clearly.
Session #4 – Clay Work
Directive: Work with the clay to create a product. The
materials were Model Magic, a synthetic, air-dry clay.
Though Sean had used model magic many times in earlier
sessions, the researcher provided him with new colors that
had not previously been available (black, blue with
sparkles, and glow-in-the-dark). He was curious as to
whether the glow-in-the-dark clay really glowed and spent
quite a few minutes putting it in one of the cabinets to
observe how it reacted to the dark. During this session,
Sean got more into the reflective statements used by the
researcher, replying back to them. For example, the
researcher stated “Your using the plastic tool to poke a
hole in the clay,” and Sean would reply, “Yeah, I’m poking
the clay.”
Sean asked for the researcher’s help in taking all of
the model magic colors out of their containers. Once this Effect of Art Therapy 28 was done, he got out all of the plastic tools, and stabbed them into the sparkly blue clay so that they stood straight up. He bashed the tools together until all had fallen out except one. Sean used that one tool to pick up the clump of clay and twirl it in the air. Next, he asked that the researcher join him in a game where a plastic tool was placed onto the edge of the table and hit so that it would fling into the air. Sean was very animated during this game, laughing and singing songs.
When he had enough of the tool game, he began to roll out a long snake of glow-in-the-dark model magic. Sean added a snake of red and created pink. He then asked the researcher to help him to roll out snakes of other colors.
Once that was complete, he mixed them all together with his eyes closed, asking the researcher to tell him when to stop mixing. His mixing process became a routine that he repeated many times over. He would roll out a snake, twirl the ends with his fingers until they became quite thin, loop each end back to the middle of the snake, squish it all together, and start again. After awhile, Sean had formed a real rhythm with this procedure. The repetitive nature of his actions appeared to calm him. Effect of Art Therapy 29
During this session, Sean exercised his feelings of control through his work with the media as well as in directing the session. The kinesthetic activity provided by the clay allowed for the release of his anxiety. The manner in which he stabbed tools into the clay and the game he created served as venues for aggressive energy. His creation of a rhythmic method for mixing the model magic became an effective relaxation technique.
Session #5 – Large Scale Painting
Directive: Use the paints provided to create an image.
The materials were tempura paints, paint brushes, and
a 5’ x 4’ piece of white paper.
Upon walking into the art room and seeing the paints and large piece of paper on the wall, Sean grabbed a paint shirt and paint brush before the directive had even been given. He began by painting a large red arc, after which he turned to the researcher and asked, “What are you waiting for?” The researcher was careful to paint only in the area specified (upper right corner) and create an image as defined by the participant (tree branch). Sean continued to make a rainbow, asking after finishing each stripe which color came next. Similarly to last session, he created a Effect of Art Therapy 30 rhythm in a song about the colors of the rainbow. He repeated the song with the researcher multiple times.
After completing the rainbow, Sean began painting vertical lines to the right. He became frustrated when his brush was not clean of the previously used color, creating a mixture on the paper. Next, he started to use the black paint, painting what he called a “black tree branch,” continuing the branch up until it was touching the researcher’s image. Quickly, Sean completely obscured the black tree branch with more black paint. He made green marks directly on top of the researcher’s tree branch, but then attempted to repair the damage with blue paint. At this point, Sean began to fixate on the brown paint, going over and over the same area with his brush creating a thick vertical shape to the extreme right of the paper. While he was working, the researcher narrated his process to him as had been done in the previous sessions. This time, however, he asked that the researcher not do that anymore.
Once Sean deemed the painting complete, he wanted to use the clay from last session. He made a flat round shape out of glow-in-the-dark model magic and put bits of red clay on top. At first, he called the product a “pizza,” but it was quickly rolled together and referred to as “a snake Effect of Art Therapy 31 that pooped.” After that, the clay was rolled into a pink ball that he was excited to take back with him.
The kinesthetic motion required to complete the large scale painting allowed Sean to contend with his anxious energy. This activity in particular produced a product that he was very proud of, reinforcing his self-esteem and feelings of mastery. It was interesting that he asked the researcher to stop narrating for him as he had previously responded to it well. He seems to have moved beyond needing that reflective feedback, providing support to the notion that his core has been strengthened.
Session #6 – Nondirective Session
Sean was preoccupied by an incident involving him and a staff member that had happened earlier in the day. While, he went right for the box with the model magic in it, he had a lot of trouble deciding what he wanted to make. In sessions past, he would simply start working with the clay without focusing on a specific, predetermined product.
After approximately five minutes of indecision, he said he would like to make a monster. As he began to construct the creature, he decided that it was a bear and gave him giant red claws. Effect of Art Therapy 32
Sean then chose to use the scratch art paper, making an incomplete figure of a man with a large head and heavily shaded nose area. Next, he started to make what he called
“bubble tic-tac-toe boards,” and asked that the researcher play with him. Sean was animated and laughing during each of the games.
Sean’s immediate needs were addressed through the nondirective approach, allowing him to control the content of the session. His media selection illustrated his gravitation toward the tactile and kinesthetic release offered by the media’s specific properties. The creation of the bear seemed to have self-identifying significance for
Sean as it relates to his own aggression (large red claws).
As usually occurs, Sean left his art products in the art room. This lack of attachment to product could be representative of Sean’s working through complicated issues during the process and a desire to leave that behind. It is notable that the participant chose not to take his art projects with him because it is atypical behavior as compared to the other children at the residential facility.
Work is generally brought back, proudly shown off to peers and staff, and kept in the bedroom of the individual where it is safe from harm. Effect of Art Therapy 33
Session #7 – Clay Work
Directive: Work with the clay to create a product. The
materials were Model Magic, a synthetic, air-dry clay.
To start the session, Sean attempted to get the model magic out of the plastic containers by turning them over and banging on them as hard as he could. This was effective for a few of the containers, but for the others he had to flip them over and use his hands. He immediately began working the clay using his plastic tools, cutting, poking, and mashing. After that, Sean started to rip off small pieces of the colors and “hide” them in the larger clumps of other colors (example: hiding black clay inside the glow-in-the-dark clay). Then he would roll the color out into a snake and “discover” the hidden color by cutting the snake into sections.
Sean spotted the bear that he had made last session on the counter and went over to get it, becoming very animated with it (having it talk, burp, and sleep). He then started to roll out snakes of red and glow-in-the-dark, cutting them into sections and calling those sections “pillows.”
The bear scratched up the first few pillows because they were too small; so Sean asked the researcher to help him to make larger pillows. Finally three acceptable pillows were Effect of Art Therapy 34 made: one for the bear’s head, one for his feet, and one for his back. It seemed important to Sean that the bear be comfortable and nurtured.
Sean gave the bear a name (Mr. Bear) and decided that the bear was also hungry. After the bear rejected strawberries and bananas made from model magic, Sean revealed that Mr. Bear’s favorite food was grilled cheese sandwiches. He made the bear a grilled cheese sandwich using an overturned plastic container as a grill. Mr. Bear ate the sandwich hungrily, and Sean asked the researcher if she was hungry because he was. He offered to grill some food for us to eat and ended up making many different kinds of cheese (“with holes” and “without”) and vegetables. As he was making the food, he realized that he could put the pieces of cheese underneath the overturned plastic containers and create a guessing game for the researcher to play. Since the containers were clear, Sean asked the researcher to help his cover them with paper towels. Once the game was set up, he would ask the researcher to guess which piece of cheese was under each of the containers.
Sean decided to take Mr. Bear with him as the close of the session. As mentioned previously, attachment to product is unusual for him. His desire to take Mr. Bear furthers Effect of Art Therapy 35 the notion that he felt a personal connection to the character. Throughout the session, Sean was concerned with
Mr. Bear, wanting to nurture, nourish, and comfort him.
Again, working with the clay (and banging it out of the containers) provided Sean with an energy and drive release.
Session #8 – Scribble Pictures
Directive: Scribble in any way that you chose using
any of the materials provided. The materials offered
were 11” x 14” and 8½” x 11” white paper, 9” x 12”
black paper, crayons, colored pencils, markers, and
graphite pencils.
The final session of the art therapy intervention began with a discussion about Mr. Bear. Sean relayed that the bear had gotten so hungry that it scratched him on the knee. Because of this, Sean decided to starve Mr. Bear until he almost died. He then used model magic to illustrate how Mr. Bear’s heart had been crushed by not being able to eat. Following this conversation, Sean wanted to make his scribble pictures. He made two, one using blue colored pencil and the other using red crayon. Each of the scribbles was done in a controlled fashion and contained in one small spot on the paper. Effect of Art Therapy 36
When he said he was finished with the scribbles, Sean chose to work with model magic and spent a lot of time stabbing and cutting the red clay. He then made a series of mazes out of the clay for the researcher to complete with a time limit of 12 seconds. After making three mazes, Sean asked the researcher what she would like to eat, and got right to work making pancakes. While cooking, the researcher acted as Sean’s assistant as he directed what tools and clay he needed.
During his time working with the clay, Sean stated that he had “burp on” and “burp off” buttons that could control his burping. Then he stated that he also had “brain off” buttons that allowed him to shut his brain down so that he would not have to think about any bad memories. He was unresponsive to questions regarding what an example of a bad memory might be.
The scribble pictures created in this session differed vastly from the picture created in the first session. Here,
Sean’s scribble was controlled and contained well within the boundaries of the paper. The nurturance and nourishment theme continued in this session with Sean’s desire to make food out of clay. While working with the clay, Sean felt comfortable enough to verbalize about his “brain off” Effect of Art Therapy 37 buttons. This exhibits not only the strength of the therapeutic bond, but also the material’s ability to enhance communication.
It is important to note that termination of art therapy treatment was not initiated with the participant because the researcher continued to see Sean as his art therapist beyond the 8-week art therapy intervention. As a result, the therapeutic relationship remained intact with only the research aspect coming to a close. Sean was informed that his “special planned program” where we had set directives to follow was over, but his art therapy would continue.
CAFAS Results
The CAFAS was utilized to rate the participant and evaluate his level of emotional and psychological functioning prior to the commencement of the art therapy intervention as well as following the treatment. The use of the CAFAS in this case study was as an outcome measure, with change in the participant determined by comparing the pre-intervention and post-intervention scores. The assessment was completed by a residential facility staff member who was knowledgeable regarding the participant in all of the eight subscales: school/work role performance, Effect of Art Therapy 38 home role performance, community role performance, behavior towards others, moods/emotions, self-harmful behavior, substance use, and thinking.
Within each subscale, the participant was rated on his level of impairment: severe, moderate, mild, or minimal/no impairment. Each of the levels is assigned a numeric value,
30, 20, 10, and 0 respectively. It is pertinent to note that the participant was rated based on his most severe behavior, meaning that if the participant exhibited behavior in both the moderate and severe categories, a score of 30 was given. The scores from the eight subscales were then totaled to yield the overall level of functioning.
In the first evaluation (prior to the start of the art therapy intervention), Sean scored 30’s in school/work role performance, home role performance, and behavior towards others. The scores indicate a severe level of impairment within those subscales. A score of 20 was rated for the community role performance subscale, specifying a moderate level of impairment. In the moods/emotions section, Sean was rated as 10, meaning that he exhibited a mild amount of dysfunction. Sean’s scores in the self-harmful behavior, substance use, and thinking subscales suggest that he had Effect of Art Therapy 39 minimal or no impairment of functioning in these areas.
Based on the eight subscale ratings, the total score for the participant was 120. According the CAFAS assessment, a score of 120 is consistent with the level of impairment and dysfunction associated with a youth who requires intensive care and support. The results of the first evaluation can be found in Table 1.
At the time of the second evaluation (following the art therapy intervention), Sean scored 30’s (severe level of impairment) within the school/work role performance and the home role performance subscales. The participant was rated as 20 (moderate level of impairment) in both the community role performance and behavior towards others sections. A mild level of impairment, a score of 10, was rated in the moods/emotions subscale. Again, the participant received a score of 0 in the self-harmful behavior, substance abuse, and thinking subscales, indicating minimal or no impairment of functioning. Based on the eight subscales, a total score of 110 was determined. The results of the second evaluation can be found in Table 1.
Effect of Art Therapy 40
Behavioral Level System Results
Behavior change in the participant was assessed with the behavior level system employed by the residential treatment facility. The system involves three levels: red, yellow, and green. Detailed explanation regarding the meaning of the color levels is contained in the Measures
Section. It should be noted that Sean does not generally receive yellow drops for his behavior. He tends to either be on green or red level. Behavior level was examined during the week prior to the commencement of the art therapy intervention and in the week following the intervention. The results regarding the two weeks of behavioral examination can be found in Table 2.
During the week prior to beginning treatment, Sean received one red drop early in the week for assaulting a staff member. In addition, noticeable hyperactivity was reported. During the latter half of the week, the participant was on sick protocol. As a result, he did not go to school, participate in his regular activities, or interact as frequently with peers or staff. In the week following the treatment, Sean received two red drops early in the week, for assaulting staff and for attempting to run away. There was no other significant behavior reported. Effect of Art Therapy 41
In addition to assessing the participant’s behavior level before and after the art therapy intervention, the researcher also examined behavior level on the days coinciding with art therapy sessions. Results pertaining to the individual sessions can be found in Table 3. The dates for sessions 2, 5, and 8, had reports of minimal or no behavior problems for the length of the day. Trouble following directions, needing constant redirection, and issues involving peers were reported for the hours prior to art therapy for sessions 1, 3, and 4. Reports for the remainder of the day following the art therapy sessions contained no behavioral problems and marked change in conduct was noted. The dates for sessions 6 and 7 had red drops reported in the hours prior to art therapy for assaultive behavior and running out of the sight of staff.
Reports for the remainder of the day following art therapy sessions contained no behavioral problems and marked change in conduct was noted.
Since change was noted based upon three separate levels (artwork and session notes, CAFAS, and behavioral level system), it is also necessary to compare each of the variables to determine how each interacts. The researcher focused on the connection between the artwork and the Effect of Art Therapy 42 behavior before and after sessions 1, 3, 4, 6, and 7. These sessions were chosen because of the similar behavior patterns exhibited by the participant both before and after art therapy. Prior to each session, Sean was experiencing some behavior problems. Following the sessions, however, there was a pronounced change in his conduct.
As stated previously, the artwork made by the participant in Session #1 was related to boundaries. His inability to follow directions earlier in the day was also, in essence, a testing of his boundaries. Sean’s painting of the model magic bird and its encapsulation allowed him to work through his inner struggle with limits. It is possible that he was creating an expression associated with needing to contain himself and his behavior as well as feelings of being restricted or enclosed by the rules that are set for him. By scribbling wildly all over and off the edges of his paper, Sean was able fulfill to his need to be out of control and release the related energy.
By mixing paint colors in Session #3, Sean was able to exercise control over the things in his environment. Before his art therapy session, he had to be redirected numerous times by staff. In other words, he was not being allowed to do what he wanted to do. The art therapy session fulfilled Effect of Art Therapy 43 this need for him causing him to verbalize at the close of the session that he barely had any “guts” in his head and was able to think clearly.
In the hours preceding Session #4, the participant acted aggressively towards a peer. Working with clay, gave him the opportunity to vent that aggression in an appropriate manner. He spent a lot of time stabbing the clay and utilizing the plastic tools to cut and squish the media. Following that portion of the session, Sean self- soothed and calmed himself through the rhythmic mixing of the model magic. The process allowed for him to finish the rest of his day with improved behavior.
Sean’s creation of Mr. Bear in Session #6 and his self-identification with the character has a direct connection to his previous behavioral incident. Before coming to art therapy, the participant had assaulted a staff member. With this information, his creation of a bear with giant red claws becomes more poignant. At that point,
Sean chose to leave Mr. Bear in the art room, suggesting that the piece represented something that was difficult for him to deal with. By processing the incident through art,
Sean was able to modify his behavior for the remainder of the day. Effect of Art Therapy 44
Before attending Session #7, the participant had twice run from staff members. The art therapy session focused on taking care of Mr. Bear. By nurturing Mr. Bear, Sean was reflecting his own needs, most likely the cause behind his attention-seeking behavior. Being able to take care of Mr.
Bear, feeding him and making him comfortable pillows expressed and satiated Sean’s unmet desires. Sean also spent some time in the session working kinesthetically with clay and banging on the containers. This process again allowed for drive and energy release. Sean’s decision at the end of the session to take Mr. Bear with him reinforced the connection he felt with the character.
When Sean was reported to have consistently good days where his behavior remained stable and positive (sessions
2, 5, and 8), it was reflected in his behavior and in the artwork produced in the art therapy sessions. Although the participant created violent imagery in Session #2 (the watercolor painting showing a robber who had killed someone in bed), the piece acted as a venue for sublimination of
Sean’s aggressive impulses. Because he was able to experience a release through his art product, he utilized his energy in an alternate fashion. Effect of Art Therapy 45
In Session #5, Sean made a large-scale painting of a rainbow, an outward symbol of happiness and fantasy. He also exhibited his positive feelings toward the researcher by painting a tree branch up to meet the branch painted by the researcher, and then repairing damage he made to the researcher’s branch unintentionally. Similarly in Session
#8, the participant made food out of model magic for the researcher. Additionally, Sean made mazes out of model magic to be played with collaboratively. Because he was in a positive frame of mind and his current needs were being met, the participant was comfortable enough to speak about his “brain off buttons” and how he can exercise control over them. His scribble picture also exhibited more control, with his marks remaining contained to small section of the paper.
Discussion
This case study examined the effect of art therapy on a child with a disruptive behavior disorder in a residential treatment program and school. Change in the participant over time was assessed on three levels: artwork and session notes, level of function as rated by the CAFAS, and utilizing the behavior level system employed by the residential treatment facility. Each of these three Effect of Art Therapy 46 measures were analyzed and compared to determine the change and the overall effect.
The artwork and session notes provided literal and figurative illustration of the participant’s progress. The detailed session observations highlighted important themes that emerged from Sean’s process and product. The artwork and the creative process actively reflected his current struggles and issues, allowing him to grow and develop.
Sean’s personal growth was marked by improved behavior and functioning through aggression and anxiety reduction.
Throughout the art therapy intervention, Sean actively used the art materials to work out his aggression and energy. The researcher’s intention when designing the sessions was to provide Sean with media that would force him to react kinesthetically and that would appeal to him on a tactile level. Notably, the participant’s self- directed work with clay expressed his need to put his excess drive energy into something. By working the model magic with his hands, stabbing it with tools, cutting it with scissors, Sean transformed aggressive impulses.
Results of this nature coincide with Sean’s own verbalizations regarding his feelings following sessions as Effect of Art Therapy 47 well as with the behavioral improvement reported by the residential facility following each art therapy session.
The behavioral level improvement is also supported by the self-soothing that Sean did while working with model magic. He was drawn to mixing different colors of clay together, integrating two or three colors to see what color they would make. Whenever he began to mix, Sean would quickly set up a pattern, getting into a rhythm that he would then repeat over and over again. This was something that was completely self-directed exhibiting its relationship to what the participant needed at the moment.
He worked out his energy and left the sessions calmer with fewer “guts” in his head.
Allowing Sean to have control during the sessions
(after completing directives and during the two nondirective sessions) served to empower him. Being in residential care does not afford a child many choices in his/her daily life. Everything is done on schedule with little room for individual decision, and deviation is met with punishment. As the sessions progressed, Sean felt comfortable to take on a director role to the researcher’s assistant role. As he worked with the art materials, he would politely ask the researcher to help him get something Effect of Art Therapy 48 or to participate with him. Having a venue in which he was allowed to exercise some control is another factor leading to an improvement in Sean’s behavior and overall functioning.
Often Sean would come up with games for himself and the researcher to play, reflecting another aspect of his life in which there may be a void. When this need was met through art therapy, it contributed to his total well- being, as did working through his personal need for nurturance and nourishment. Because Sean’s family is not emotionally available, it is likely he feels starved in that area. The art therapy sessions gave him a place where he could process that need.
There was also a progression in the therapeutic relationship between the participant and the researcher. At the start of the intervention, Sean responded to the researcher reflectively narrating his process aloud. Once reaching Session #5 (a little past the halfway point of the treatment), Sean requested that the researcher not reflect anymore while he was working. It seemed that Sean’s core had been strengthened enough at that point, that he no longer required the reassurance. This is corroborated by the increase in his verbalizations in the latter part of Effect of Art Therapy 49 the intervention, finally feeling comfortable enough to express his idea of “brain off buttons.”
When looking directly at the artwork produced, Sean’s work demonstrates some interesting concepts. The sublimation of his aggressive impulses through his watercolor robbery painting and stabbing of tools into clay, his need for nurturance in the making of pillows and food for Mr. Bear, his identification with Mr. Bear (a harmless character except for his giant red claws), and the expression of positivism reflected in his large rainbow painting all show the power of Sean’s artwork as a therapeutic tool and accurate manifestation of his current frame of mind. The artwork closely tied into the behavioral level reports that corresponded with each session.
A most important result came from the scribble picture measure. The scribble picture that Sean completed at the start of the art therapy intervention was frenetic in appearance. He used three colors to make large marks that moved up and off of the piece of paper as though it could not contain them. Heavy pressure was used on the crayons, leaving them flat and unsharpened. This scribble picture coincided with the boundary work Sean did concerning his model magic bird. The scribble pictures that he made in the Effect of Art Therapy 50 final session, however, were of a completely different style. Each utilized only one color and was contained in one area of the paper. The scribble appears much more controlled, and a lighter instrument pressure was used.
This finding suggests that through the art therapy treatment, Sean gained a sense of control and released some amount of energy.
The first evaluation of the CAFAS showed that Sean had a severe level of impairment in the school/work role performance, home role performance, and behavior toward others subscales. He was rated as having a moderate level of impairment in the community role performance subscale.
Being a child in residential care with a disruptive behavior disorder diagnosis, these were the expected results regarding level of functioning. In the other four subscales, Sean was rated as having mild or no impairment.
The second evaluation, which was completed at the end of the art therapy intervention, showed a drop in the behavior towards others subscale. This moved Sean from the severe level to the moderate level. His school/work, home, and community role performance scores remained stable at the severe level. This result indicates the participant’s continued need to be in residential care. Effect of Art Therapy 51
The CAFAS scores displayed a change in Sean’s level of functioning. Over the course of the 8-week art therapy intervention, the behavior of the participant improved.
This finding is especially pertinent as the case study was designed to work on behavior as it relates to a disruptive behavior disorder diagnosis. Because of the drop in the behavior towards others subscale, Sean’s overall score on the assessment also went down, from 120 to 110. This indicates a general improvement in his level of psychological and emotional functioning. Findings of this nature further substantiate the results obtained from the artwork and session notes.
The results from the behavioral level system analysis of the week prior and the week following the art therapy intervention were less useful than originally anticipated because the participant was on sick protocol for most of the week before starting the treatment. Because of this, he did not go to school, participate in his regular schedule or activities, and did not interact as frequently with staff and peers. However, the behavioral level system results regarding the dates of each individual art therapy session were useful to the study. Effect of Art Therapy 52
When the behavioral levels and notes were compared to the artwork and session notes, another dimension of change and growth was observed. The artwork and session observations were shown to directly relate to Sean’s behavior that day. In each case of behavioral difficulties prior to art therapy, his conduct vastly improved following the session. In addition, the artwork tended to reflect whatever difficulty Sean was having that day, and his process with the media determined what he needed to do to work through that issue. On days when Sean exhibited no behavior problems and consistent, affirmative mood prior to art therapy, his artwork either mirrored his more positive stance or the art process was used in order to sublimate any aggression he may have been feeling.
Although favorable results were obtained, the current study does have some limitations. Due to the case study design, the results cannot apply to anyone other than the participant. The small sample size allowed for an in depth look through multiple measures, but did not allow for the use of any statistical measures to determine significance.
In addition, the study was limited by the inability to control for other therapies that the participant was receiving. The study was also limited by the number of art Effect of Art Therapy 53 therapy sessions, the participant being on sick protocol during the first week of behavioral observation, and the inability of the researcher to control for the effects of other therapies and outside influences.
This case study provides preliminary support for utilizing art therapy with children who have a disruptive behavior disorder diagnosis. By using multiple measures, change in the participant was witnessed on a variety of levels, substantiating art therapy’s effectiveness in this study. Sean’s improvement serves as one illustration of how potentially beneficial art therapy can be with this population. Because art therapy utilizes different therapeutic means than traditional methods and talk therapy, the researcher was able to more directly address
Sean’s specific needs. Because his needs were better serviced, he was able to show some improvement in over a short period of time.
While these findings do corroborate the results of other studies, more research needs to be done concerning the use of art therapy with those diagnosed with disruptive behavior disorders. In light of the large number of behavior problems and behavior disorder diagnoses amongst children in recent years, there is a large population whose Effect of Art Therapy 54 needs have to be met in the best way possible. Perhaps future research can help to guide the therapeutic direction taken with the population.
Effect of Art Therapy 55
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Effect of Art Therapy 58
Table 1
Child and Adolescent Functional Assessment Scores
CAFAS Subscale 1st Evaluation 2nd Evaluation
School/Work
Role Performance 30 30
Home Role
Performance 30 30
Community Role
Performance 20 20
Behavior Towards
Others 30 20
Moods/Emotions 10 10
Self-Harmful
Behavior 0 0
Substance Use 0 0
Thinking 0 0
Total Score 120 110
Effect of Art Therapy 59
Table 2
Pre-Intervention and Post-Intervention Behavior Level Drops
Week One Week Two
Red Drop for assaulting Red Drop for assaulting
staff staff and running
noticeable hyperactivity Red Drop for assaulting
reported staff
no other noticeable
behavior reported
Effect of Art Therapy 60
Table 3
Behavioral Level and Notes Pertaining to Art Therapy
Session Dates
Session Noted Behavior or Level Drops
1 Trouble following directions, displayed
improvement after art therapy
2 No problems reported
3 Required constant redirection, no behavior
problems following art therapy
4 Conflict with a peer, was in more positive
space after art therapy
5 No problems reported
6 Assaulted staff, improved conduct after art
therapy
7 Ran out of staff sight twice, no behavior
problems following art therapy
8 No problems reported
Effect of Art Therapy 61
Appendix A
RESEARCH DESIGN
Behavior disorders, behavior problems, and aggression are the most common reasons for which children are referred to mental health services (Keenan & Wakschlag, 2002). The frequency of behavior problems and difficulties has necessitated alternate methodologies and modalities regarding treatment, among them, art therapy. Art is accessible to children as they have an innate desire to express themselves creatively. Art therapy can employ that desire in order to tap into the subconscious (Barber,
2006). Children with disruptive behavior disorders and who exhibit the behavioral correlates associated with those disorders can benefit from therapeutic processes and ideologies inherent to art therapy. The artistic process can work to calm these individuals or direct their hostility into an alternate venue (Neibauer, 1988). Art therapy is a modality which can address resistance while allowing for children to work through painful emotions, leading to behavior change. While some research exists regarding the effectiveness of art therapy with children with behavior disorders, behavior problems, and/or aggression, art therapy is still not widely used with this Effect of Art Therapy 62 population. In addition, there is considerably less existing research compared to the amount of research involving art therapy and other populations.
Statement of the Problem
The researcher conducted a case study to examine the effect of art therapy on a child with a disruptive behavior disorder diagnosis who is in a residential treatment program and school. An 8-week art therapy intervention was designed to address both aggression and behavioral problems. The participant took part in weekly 1 hr art therapy sessions. Change in the participant over time was evaluated through the use of a variety of measures. Level of functioning was assessed prior to the commencement of the art therapy intervention and again at the conclusion of the intervention utilizing the Child & Adolescent
Functional Assessment Scale (CAFAS; Hodges, 2000).
Additionally, any changes were tracked by session notes and observations, the artwork produced, and the behavioral level system employed by the residential treatment facility. Each of the assessment measures was considered independently of one another as well as collectively.
Effect of Art Therapy 63
Definition of Terms
The following definitions were used within the context of this study:
Art Therapy
Art therapy has been defined according to Malchiodi
(2007):
Art therapy is a modality that uses the nonverbal
language of art for personal growth, insight, and
transformation and is a means of connecting what is
inside us – our thoughts, feelings and perceptions –
with outer realities and life experiences. It is
based on the belief that images can help us understand
who we are and enhance life through self-expression.
(p. ix)
Art Therapy Intervention
Art therapy intervention was defined as an art therapy program designed to specifically address the needs of the participant. In reference to this study, the art therapy intervention was 8-weeks in length and based on art directives meant to deal directly with the participant’s aggression and behavior problems.
Effect of Art Therapy 64
Behavior Problems
For the purposes of this study, the behavior problems term was characterized utilizing the following definition established by Broecher (2000): “Conspicuous behavior among youths (meaning quarrels, fights, disregarding the rules, etc.) . . . can be understood to be an indication of the distortion of the relationship between an individual and society” (p. 490).
Behavior Level
Behavior level was defined as the participant’s actions and conduct relative to the rules of the residential treatment program. The level was determined with the behavioral scale utilized by the residential treatment program (Residential Treatment Program, 2006).
The behavioral system involves three levels, listed with descending severity: red, yellow, and green.
Behavior level was operationally defined as the participant’s position within the residential program’s behavior scale at various points in time (red, yellow, or green).
Disruptive Behavior Disorders
According to the Diagnostic and Statistical Manual of
Mental Disorders, Fourth Edition, Text Revision (2000), Effect of Art Therapy 65 disruptive behavior disorders include oppositional defiant disorder and conduct disorder.
Oppositional Defiant Disorder
Oppositional defiant disorder is identified in the
DSM-IV-TR (2000) as “a recurrent pattern of negativistic, defiant, disobedient, and hostile behavior toward authority figures” (p. 100). This pattern of behavior goes beyond normative and causes impairment in functioning within the individual’s environments.
Conduct Disorder
Conduct disorder is identified in the DSM-IV-TR (2000)
as “the persistent pattern of the more serious forms of
behavior in which either the basic rights of others or age-
appropriate societal norms or rules are violated” (p. 98).
Aggression
Following a Freudian perspective, aggression has been
defined as a primary drive characterized by destruction and
rage. As with all instinctual drives, aggression seeks
outlet through various expressions. The behavioral
manifestations of aggression include, “acting out behavior
. . . hurting others, or destroying property” (Neibauer,
1988, p. 6).
Effect of Art Therapy 66
Level of Functioning
According to Hodges (2005), level of functioning was defined as the child’s performance during his everyday routines and in his daily environments.
Level of functioning was operationally defined as the total score as assessed by the rater on the Child &
Adolescent Functional Assessment Scale (CAFAS; Hodges,
2000). The CAFAS rates the child’s level of impairment as it relates to emotional, behavioral, and psychological problems.
Delimitations
This study was delimited by the following factors:
1. The participants were limited to one Caucasian male child in a residential treatment facility and school in
Springfield, Massachusetts.
2. Level of functioning was measured with the CAFAS
(Hodges, 2000).
3. Behavior level was assessed utilizing the existing behavior level system of the residential treatment facility.
4. Artwork and session notes were examined by the researcher. Effect of Art Therapy 67
5. Art therapy session directives were determined by the researcher.
Limitations
The following limitations should be considered when interpreting the results of this research study:
1. The results of this study were not generalizable as it is a case study.
2. No attempt was made to control for the effects of other therapies in which the participant was involved in during the course of this study.
3. No attempt was made to control for the outside influences that occurred in the participant’s school and home environments.
4. The researcher assumed that the participant would comply with treatment protocol to the best of his ability.
5. The researcher assumed that the participant would respond to the psychological scale openly and honestly.
6. This study was limited by the reliability and validity of the measurement instrument.
Research Questions
The following question was examined within the context of this research study: What is the effect of art therapy on a child with a disruptive behavior diagnosis? In order Effect of Art Therapy 68 to address this question, the following facets were examined:
1. The type of change in the child’s artwork
2. The type of behavioral change in his school and residential environments
3. The change in the child’s level of functioning
4. The concurrence of change among these various levels of change Effect of Art Therapy 69
Appendix B
REVIEW OF LITERATURE
Though art therapy is considered an emerging therapeutic modality, art is a form of therapy utilized since ancient times (Malchiodi, 2007). Art has been and continues to be unique in its ability to convey a vast array of human emotions. Malchiodi stated that everyone has creativity inside themselves that can be communicated through art. Creating artwork allows for the exploration of feelings and emotions, combining nonverbal and verbal communication (Bush, 1997).
Rubin (1984) asserted that the art product can say many things at once. The creative process taps into the unconscious and channels that material into a tangible external form (McMurray & Schwartz-Mirman, 2001). Once a product is created, the issue can be examined, outside of the individual. Through the image, control and a sense of understanding can be gained. Lowenfeld (1970) summarized the therapeutic importance of the artistic product:
However, the organizations of the elements in the
picture or in the construction is only one segment of
the experience, because the expression is a concrete
configuration of the emotion and perceptual Effect of Art Therapy 70
experiences that an individual has had in his
interaction with the environment. (p. 344)
Beyond the product or artwork that is created, the artistic process itself is therapeutically valid. More than just a means to an end, the creative process has an
“inherent healing power” (Malchiodi, 2007, p. 6). The process allows for the individual to work through emotions and experiences while releasing or transforming primitive energy. Kramer (1993), regarding sublimation, asserted that the actual making of art redirects impulses, relieving the individual. The manner in which the art materials are used is representative of life and problems. Individuals can express themselves through the medium and rework their images (Bush, 1997). This artistic process together with the product creates the foundation for the effectiveness of art therapy as a modality.
The art making process is particularly effective when used with children (Ulman, Kramer, & Kwiatkowska, 1977).
Art is a valuable therapeutic tool as children are instinctively creative. Rubin (1984) agreed that art takes advantage of a natural drive that exists during childhood:
“The impulse to touch, to make contact, to manipulate, and to make marks is evident in the sand play of a toddler” (p. Effect of Art Therapy 71
267). Art is an intrinsic means of expression for children
(Mooney, 2000). Art therapy allows for the creation of an image that can speak for the client (Barber, 2006). Having an alternative mode of communication can be especially important when dealing with children, particularly those with psychological disorders and problems.
Behavior disorders, behavior problems, and aggression are the most common reasons that children are referred to mental health services (Keenan & Wakschlag, 2002). Art therapy is a form of treatment which can be utilized for those children. While some research exists regarding the effectiveness of art therapy with children with behavior disorders, behavior problems, and/or aggression, art therapy is still not widely used with this population. In addition, there is significantly less existing research compared to the amount of research involving art therapy and other populations. Presenting art therapy’s benefits to many populations is pertinent to substantiating its use.
This review of literature will provide foundation and support for further research and the use of art therapy with the above-mentioned population. It has been divided into the following sections: art therapy with children; disruptive behavior disorders, behavior problems, and art Effect of Art Therapy 72 therapy; art therapy with aggressive children; and a summary.
Art Therapy with Children
Lowenfeld (1970) contended that the artistic creativity of children is unique to their life stage: “Art is not the same for a child as it is for an adult” (p. 6).
Art is not only a representation of the child’s world, but also an expression that has yet to be touched by maturity allowing for exposure without trepidation. Art therapy provides children with a safe environment in which art work can be made. The subsequent issues can then be dealt with, making it a good venue for the appropriate expression of feelings (Essex, Frostig, & Hertz, 1996).
Art is accessible to children as they have an innate desire to express themselves creatively. Art therapy can employ that desire in order to tap into the subconscious
(Barber, 2006). Art is a “natural medium of expression”
(Mooney, 2000, p. 34) for children because they tend to establish meaning through art.
Ulman, et al. (1977) suggested that art therapy with children can bring repressed issues, which are not easily articulated, to the surface symbolically. Children are likely to create artwork that contains a manifestation of Effect of Art Therapy 73 their problems. Art reveals the inner world and creates a concrete product. Children can then look at their conflict or problem from the outside, enabling them to come to terms with it (Mooney, 2000).
Being able to examine an issue as separate from the self is especially useful when children cannot use words to convey their feelings and emotions (Barber, 2006; Mooney,
2000; Ulman et al., 1977). When dealing with children, particularly those with psychological disorders, talking about complex problems can be a difficult task. Children may lack verbalization skills, not yet have the language to express complicated issues (much less recognize their presence), or be resistant to speaking with the therapist.
Art therapy allows children to let an image speak for them
(Barber, 2006). Through that image, the internalized process can be transformed into something which is now visually external (Rubin, 1984). That transformation permits the child to deal with emotions, feelings, and conflicts in a suitable way. If children are able to express these elements, they are then able to address and cope with the issues (Pergjini, 1999).
Malchiodi (1998) emphasized the therapeutic bond that needs to exist in conjunction with the art work: “While Effect of Art Therapy 74 children’s drawings convey information about their feelings, thoughts and fantasies, it is the process of drawing and the active presence of the therapist interacting with the child that encourages reparation and recovery through creative activity” (p. 63). The relationship between art therapist and client is especially important when working with children. The therapeutic bond in art therapy utilizes language that goes beyond words, which is both a challenge and an advantage to the approach
(Goodman, Williams, Agell, & Gantt, 1998). The therapist must be supportive and aware of those issues which are unique to working with children.
In her experience as an art therapist working with children, Mooney (2000) has found art therapy to be very effective with the population. She contended that its success comes from the fact that it operates on three levels pertinent to effective therapy and child development: mastery, sublimination, and awareness. Being able to use art materials to create something gives children a sense of power and control, contributing to their feelings of mastery. The process of sublimation allows for primitive energies (anger, aggression, etc.) to be released and employed in the creative practice, and Effect of Art Therapy 75 thereby diverted. Finally, making art leads to a better self and environmental knowledge. This awareness leads to a higher self-esteem and confidence in one’s ability to change. Through the creation of art products and the utilization of art materials, competency is gained which extends beyond the art therapy session (Moriya, 2000).
An additional benefit of art therapy is that the product created can be displayed. Lowenfeld (1970) stated that children experience a feeling of success when given the opportunity to have others view their work. Through their efforts with the Open Studio Project (OSP) for at- risk youth, Block, Harris, and Laing (2005) found that exhibitions and shows allow for children to be seen as artists. Being recognized for that role made the children who took part in the OSP feel like they were more than just their problems.
Much of the research pertaining to art therapy and children consists of case studies which document individual change exhibited in the children who have undergone art therapy. Waller (2006) attributed her success with a young girl referred to as Amanda to the art therapy process.
Amanda was not very verbal upon commencing her therapy sessions and seemed unwilling to address her current Effect of Art Therapy 76 issues. Waller immediately noticed that she seemed to be transferring her destructive energy into her artwork. Since
Amanda was willing to make art, the therapist used this as a means of communication, and was therefore able to make progress with her without a solid verbal component.
Likewise, a boy identified as Sam, was not very verbal in his therapy sessions (Mooney, 2000). He was able, however, to draw his emotions and then articulate his feelings to the therapist. Following the completion of his art therapy sessions, Sam’s mother reported that he appeared far less angry and was no longer getting in fights. Additionally, his teacher reported that his grades had improved along with his social skills in the classroom.
Based on her extensive art therapy work and success with children, Mooney was surprised that art therapy has not been more widely utilized.
Pine (1974), while working as an art teacher, noticed that the manner in which children worked with the art materials revealed elements of their personalities as well as personal issues. The art allowed for expression that may have otherwise not occurred. The benefits available to children through art therapy are numerable. The art product, process, and related advantages of art therapy are Effect of Art Therapy 77 unique to this modality, making it a constructive and practical choice for working with the child population.
Art therapy has been shown to be associated with better self-awareness, confidence, self-esteem, and social skills (Barber, 2006). The aforementioned factors are pertinent developmentally to children, particularly those children with behavioral problems. The aggressive nature, emotional disturbances, and behavioral deviations that are characteristic of these children are the issues with which art therapy can be the most beneficial.
Disruptive Behavior Disorders, Behavior
Problems, and Art Therapy
As was previously mentioned, disruptive behavior disorders and their behavioral correlates are the most common reasons children are referred to mental health services (Keenan & Wakschlag, 2002). The frequency of behavior problems and difficulties has necessitated new methodologies and modalities regarding treatment. Children who exhibit behavior problems have difficulty participating in verbal therapy (Pergjini, 1999). Art therapy provides a means by which to communicate with these children and aid them in expressing their emotions. In order to understand how art therapy works with the population, it is pertinent Effect of Art Therapy 78 to present identifying features and current information regarding disruptive behavior disorders and behavior problems.
Disruptive Behavior Disorders and Behavior Problems
According to the Diagnostic and Statistical Manual of
Mental Disorders, Fourth Edition, Text Revision (2000), disruptive behavior disorders include oppositional defiant disorder and conduct disorder. For the purpose of this literature review, the focus will be on the relevant research regarding oppositional defiant disorder (ODD) rather than conduct disorder (CD). Though the disruptive behavior disorders (DBDs) are closely related, this distinction is made because ODD tends to be a precursor to a diagnosis of CD (Essau, 2003). Based on the status of ODD as a precursory diagnosis, it is the DBD that is primarily identified in children, the pertinent population to this review. Due to the age factor, most children are not yet old enough to have moved to a CD diagnosis.
Oppositional defiant disorder is identified in the
DSM-IV-TR (2000) as “a recurrent pattern of negativistic, defiant, disobedient, and hostile behavior toward authority figures” (p. 100). This pattern of behavior goes beyond normative and causes impairment in function. The DSM-IV-TR Effect of Art Therapy 79 diagnostic criteria mandate that four or more of the following eight criteria be met for diagnosis:
1. often loses temper
2. often argues with adults
3. often actively defies or refuses to comply with
adults’ requests or rules
4. often deliberately annoys people
5. often blames others for his or her mistakes or
misbehavior
6. is often touchy or easily annoyed by others
7. is often angry and resentful
8. is often spiteful and vindictive (p. 102)
The signs and symptoms of ODD tend to be recurring and long lasting. ODD is not diagnosed if the criteria for CD are met as there is an overlap of signs and symptoms.
A variety of risk factors are associated with ODD.
Alvarez and Ollendick (2003) identified categories into which these risk factors fit: “dispositional factors, sociodemographic characteristics, behavioral patterns, and interpersonal influences” (p. 99). The first category contains issues related to one’s personality, character, and balance of mood. Individuals with DBDs are likely to change mood quickly, become distressed easily, and have a Effect of Art Therapy 80 short attention span. In regards to sociodemographic characteristics, those diagnosed with ODD are predominately male and tend to be of lower socioeconomic status (Alvarez
& Ollendick, 2003). Also commonly linked to DBDs are behavioral difficulties such as aggression and interpersonal factors including peer rejection. Slutske,
Cronk, and Nabors-Oberg (2003) stressed the importance of the family risk factors that are related to this disorder including, parental conflict, separation, and divorce.
Additionally, DBDs are apt to occur in combination with other psychiatric disorders, most notably with attention deficit hyperactivity disorder (ADHD), depression, anxiety, and substance abuse disorders (Essau,
2003). AS a result, clinical samples comprised of children singly diagnosed with ODD are atypical.
In addition to the above-mentioned risk factors, there are other patterns and trends that emerge with ODD.
Maughan, Rowe, Messer, Goodman, and Meltzer (2004) have examined the age, gender, and comorbidity characteristics associated with the disorder. The researchers used data collected from 10,438 children aged 5-15 years. The sample was gathered from the 1999 British Child Mental Health
Survey (B-CAMHS99; Meltzer, Gatwood, Goodman, & Ford, Effect of Art Therapy 81
2000). Along with demographic data, psychiatric disorder symptoms and impairments were assessed using the
Development and Well-Being Assessment (DAWBA; Goodman,
Ford, Richards, Gatward, & Meltzer, 2000), parent and child interviews, teacher questionnaires, and computer-assisted interviews.
The researchers found that 5 years was the average age at which the criteria for ODD were met and the disorder diagnosed (Maughan et al., 2004). The rate then held steady until approximately 10 years of age when the rate began to drop off. The decrease can most likely be attributed to symptom progression from ODD to CD. The rates of comorbidity were shown to be higher for ODD than CD in regards to ADHD, depressive disorders, and anxiety.
Further, ODD was found to be a predictor of anxiety in this sample.
Much of the research done regarding ODD has made use of clinically referred samples of children and adolescents causing researchers to question the generalizability of these studies (Rowe, Maughan, Pickles, Costello, & Angold,
2002). Rowe et al. sought to compare the established clinical data with that found in the general population.
They examined the Great Smokey Mountains Study (GSMS; Effect of Art Therapy 82
Schaie, 1965) community sample which included children aged
9-16 years. The researchers took annual assessments over the course of 4 years using the criteria in the DSM-IV
(1994) to judge psychiatric status.
Their investigation yielded results which confirmed
earlier findings (Rowe et al., 2002). As expected, ODD was
found to correlate with social and family adversity.
Parental criminality, care taker depression, and harsh
discipline had particularly strong positive correlations.
Some findings, however, diverged from what had been
previously reported. ODD was found in nearly equal numbers
amongst boys and girls, in contrast to the high male
prevalence usually reported. In addition, none of the girls
in the study were found to later develop CD. ODD is many
times considered to be a precursor to CD, an idea supported
by the male results in this study.
Due to the nature of both ODD and CD, developing
distinct criteria for the two has been problematic. Rowe,
Maughan, Costello, and Angold (2005) questioned whether ODD
was simply a minor form of CD and the implications of
different diagnostic tools on the diagnosis of the
disorder. Unlike the DSM-IV (1994), the International
Classification of Diseases (ICD-10; World Health Effect of Art Therapy 83
Organization, 1993) combines ODD and CD while making the distinction of more or less severe. The issue identified in this study was that those who meet the ICD-10 criteria may not be diagnosed under the DSM-IV criteria. Rowe et al. referred to these individuals as the “gap group.” Again utilizing the GSMS (Schaie, 1965), the researchers gathered information via child and parent reports and the Child and
Adolescent Psychiatric Assessment (CAPA; Angold & Costello,
2000).
Data collected regarding the psychological dysfunction of the “gap group” illustrated a high similarity to the ODD group diagnosed using DSM-IV criteria (Rowe et al., 2005).
The researchers could then conclude that the DSM-IV was excluding a group of the ODD population due to restrictive criteria. If the DSM-IV reduced the number of symptoms necessary for a diagnosis of ODD or allowed for symptoms to come from the combined ODD/CD list, the majority of those in the “gap group” would be diagnosed as having ODD.
In response to the difficulties involving the diagnosis of ODD, research was done regarding the development of a supplemental ODD diagnosis scale (Harada et al., 2004). ODD is generally assessed through the input of those around the individual in question. The scale, the Effect of Art Therapy 84
Oppositional Defiant Behavior Inventory (ODBI), was developed as a self-answer questionnaire. The items contained in the ODBI were meant to be easier to understand, thus wording was taken from answers given by parents regarding ODD. Researchers used a sample of 98 children with ODD (unrelated to the parents whose information was used to create the scale) between the ages of 6 and 15 years along with a control group to test the scale.
The ODBI was found to be an accurate tool for assessing ODD in this study (Harada et al., 2004). In order to test reliability and validity, the scale was compared to the Child Behavior Checklist (CBCL; Archenbach, 1991) and the Disruptive Behavior Disorders Ratings Scale (DBD-RS;
Barkley & Murphy, 1998). Though more extensive testing needs to be done, the researchers expect the ODBI to increase the accuracy of ODD diagnoses.
Improved accuracy in the diagnosis of ODD is especially pertinent when attempting to diagnose very young children. Keenan and Wakschlag (2001, 2004) have contributed much research on the topic of disruptive behavior disorders in preschool children. They examined whether the DSM-IV (1994) criteria is valid when applied to Effect of Art Therapy 85 preschool children. The researchers compared the rates of symptoms in clinically referred and nonreferred preschoolers. The sample included 79 referred subjects and
50 nonreferred between the ages of 2.5 and 5.5 years. The
DSM-IV symptoms were assessed using the Schedule for
Affective Disorders and Schizophrenia for School-Age
Children-Epidemiologic Version (K-SADS-E; Orvaschel, 1994).
The rates of ODD were found to be significantly higher in the referred group (Keenan & Wakschlag, 2004). Rates of
ODD were rare among the nonreferred children, providing evidence for DSM-IV validity with preschool children.
In another study, Keenan and Wakschlag (2001) examined whether or not these disorders can be validly measured in preschoolers considering the normative behavior of that age group. Additionally, they studied at-risk preschoolers in order to evaluate correlates. The researchers gathered a sample of 79 preschool age children from low-income environments who were referrals to a behavioral problems clinic. A matched group of 52 nonreferred children with no history of behavior problems was also used.
The participants were evaluated through testing, interviews, and observations (Keenan & Wakschlag, 2001).
The CBCL, the Diagnostic Interview Schedule for Children Effect of Art Therapy 86
(DISC; Speltz, McMellan, DeKlyen, & Jones, 1999), the
Schedules for Affective Disorders for School-Age Children
(K-SADS; Orvaschel & Puig-Antich, 1995), and the Child-
Global Assessment Scale (C-GAS; Setterberg, Bird, Gould,
Shaffer, & Fisher, 1992) were employed to assess psychological and developmental functioning. The Puzzle
Task (Matas, Arend, & Sroufe, 1978) was used to judge factors within the parent-child context. The correlates that were assessed fell into the following categories: child factors, sociodemographic factors, family environment, parental psychopathology, and parenting.
Tabulating each child’s symptoms as they related to both CD and ODD, the researchers discovered that the symptoms were closely linked to impairment (Wakschlag &
Keenan, 2001). It is this impairment of function that sets these symptoms apart from the disruptive behavior normally associated with the age group. Based on the results, it can be suggested that disruptive behavior disorder symptoms can be accurately measured in preschool children. Low soothability, prenatal exposure to cigarettes, high parental stress, and observation of low levels of maternal behavioral responses emerged as child-factor and parental correlates. These correlates coincided with those that have Effect of Art Therapy 87 been previously established for older children and adolescents.
The environmental correlates for ODD have been well- documented; however, little research has been done regarding biological factors (van Bokhoven, Matthys, van
Goozen, & van Engeland, 2005). In order to assess the biological aspects of ODD, van Bokhoven et al. collected a sample which consisted of 5 girls and 42 boys who met the
ODD criteria. The researchers additionally used this sample to test adolescent outcome.
At the first stage of evaluation, the age range of the sample was 2.8 to 7.0 years (van Bokhoven et al., 2005).
When the children were between 7 and 12 years old, they received either in-patient or day treatment in a hospital program. At both of these stages, intelligence was evaluated using the Wechsler Intelligence Scale for
Children–Revised (WISC-R; Wechsler, 1974). In addition, skin conductance level (SCL), which refers to the activity of the autonomous nervous system was measured while exposing the subjects to stress. The researchers hypothesized that low activity in the autonomous nervous system would lead to a poor adolescent outcome. Effect of Art Therapy 88
At the final stage, the age range of the sample was
15.7 to 18.7 years (van Bokhoven et al., 2005). In order to measure the outcome, the participants were administered the
CBCL and Youth Self Report (YSR; Achenbach, 1991). The researchers found that SCL was connected to ODD, providing evidence for the fearlessness theory. This theory postulates that low SCL is related to the effectiveness of socializing punishment, which can contribute to oppositional behavior. In addition, low SCL was found to be a good predictor of adolescent outcome. The lower the SCL, the more problems the individual had in adolescence.
In addition to the many children currently diagnosed with ODD, there are those children who exhibit behavior problems which do not reach the extent of diagnosis. The disruptive behavior of these children is having a huge impact on the classroom and home environments (Broecher,
2000). Broecher attributes this behavior to a variety of factors: family problems, lack of identity, and poor social interaction skills. The behavioral manifestation of these factors involves not following instructions, acting out, being explosive, and displaying a lack of respect for peers and authority figures. Effect of Art Therapy 89
Disruptive behavior disorders and behavior problems provide a specific set of challenges to a therapist. Known for their resistance and anger, these children often do not respond to traditional therapeutic methods.
Art Therapy with Children with Disruptive Behavior
Disorders and Behavior Problems
The hostile nature, emotional disturbances, and behavioral deviations that are characteristic of children with behavioral problems and those diagnosed with ODD are the areas in which art therapy is most beneficial. The artistic process can work to calm these individuals or direct their hostility into an alternate venue (Neibauer,
1988). Art therapy is a modality which can address resistance while allowing for children to work through painful emotions. Once issues have been addressed, children with behavior problems and DBD diagnoses can make strides towards altering their behavior.
Providing a creative task instead of verbal techniques can help to break down refusal to participate in therapy
(Dunn-Snow, 1994). The use of stimulus cards to provide focus for drawing and can help to alleviate anxiety that children may feel over beginning an art assignment.
Children with ODD or behavior problems have trouble with Effect of Art Therapy 90 the thought organization and order required to complete work. Thus, it is important to present art making to them in a way that encourages participation.
In connection with the resistance generally exhibited by children with behavioral problems, Moriya (2000) pointed out that because people most often communicate verbally, they have developed a variety of defenses on that level of communication. Art therapy can help to combat those defenses by not only providing a nonverbal task, but also allowing the children to distance themselves from the emotion or issue. Since children can then see themselves as separate from it, the therapist is able to work with them using metaphor. This can create an environment where children are more willing to talk.
Art therapy can also provide an outlet for those who are hesitant to show emotions, a characteristic of children with behavioral problems (Broecher, 2000). Often, these children associate feelings with exposing weakness. Art therapy helps break down some of the obstacles connected with psychiatric help by working through symbols. Children are apt to become more open if they are speaking about the artwork rather than directly discussing their issues. Effect of Art Therapy 91
Steinhardt (1993) focused on paint as an art therapy medium that promotes participation in children. The researcher placed an emphasis on abstract painting as it is not as intimidating as realistic art work. Paint is distinctive in its physical properties, and therefore, lends itself to very expressive creation. This is beneficial to children who can use it in lieu of words, as an escape from their current reality, or as a means of conveying troubling emotions. Children with ODD or behavioral problems benefit from the communication with primitive drives that this type of art therapy can provide.
Kramer (1993) also believed that unconscious primal drives can be altered into constructive energy during the artistic process. She describes it as a venting process which offers relief to the individual. The process is crucial to those with behavioral problems as they often experience outbursts. Shennum (1987) sought to determine the effectiveness of art therapy with a group of individuals prone to behavioral outbursts in a residential treatment facility. When pre-experimental functioning was compared to post-experimental functioning, it was determined that the children who received 2 hours a week of Effect of Art Therapy 92 art therapy had significantly reduced their behavioral outbursts.
In his work with children diagnosed with ADHD, Henley
(1998) found that children also became more open regarding their bad behaviors and issues when art therapy techniques were utilized. Through the use of drawings meant to address instances of negative behavior, the children were less resistant to discussing the incidents. In addition, they actively participated in generating possible solutions or areas for improvement. Henley referred to Edith Kramer’s ideas regarding the redirection of destructive impulses as further support for his findings regarding behavior.
Although DBDs are not specifically mentioned by Henley, the
DSM-IV-TR (2000) places ADHD in the same diagnostic category as DBDs.
Weston (1988) conducted a study of children with behavior disorders in a hospital setting. Art therapy projects were presented to these children that involved the core issues associated with their behavior problems. By creating an art piece involving an animal that they identified with, they gained a sense of self and individuality. Utilizing self-tracings, the children were able to discuss and understand the idea of personal Effect of Art Therapy 93 boundaries. Weston found that the art therapy was associated with improved behavior among his group of children.
Thyagarajan and Kapur (2000) examined the use of art therapy with emotionally disturbed children. A group of these children who had received twice-a-week art therapy sessions was compared with a group that did not. The researchers found that the treatment group benefited considerably. The treatment group showed improved academic performance as well as a reduction in their psychological symptoms. Interestingly, over the course of the treatment, the children began to draw themselves differently. At the onset of the art therapy sessions, nearly all of the participants drew themselves as small figures and made use of dull colors. By the end of the study, the children were drawing themselves much larger while employing drastically brighter coloring. The researchers attributed this to an increase in self-esteem and personal growth.
The therapeutic effectiveness of art therapy was further supported by Rosal (1993) in a study of children diagnosed with behavior disorders. A sample of children with moderate to severe behavior disorders was used to compare art therapy with more traditional verbal methods. Effect of Art Therapy 94
The art therapy groups experienced a change that was not reflected in the verbal therapy groups. A significant modification in the children’s negative behaviors was observed. In addition, after psychological testing and assessment, many of the children no longer registered as severe a diagnosis as was present at the beginning of treatment.
Stanley and Miller (1993) also focused on behavior change facilitated through art therapy. The researchers presented the case study of an adolescent male with severe behavior problems. The male was in a residential treatment facility and exhibited frequent outbursts, destruction of property, and uncooperative behaviors. The Coopersmith
Self-Esteem Inventory (CSEI; Coppersmith, 1990) was administered both before the art therapy sessions commenced and after their completion.
Following the 8 weeks of art therapy sessions, the participant’s self esteem score on the CSEI reflected a change from the low level of the scale to the moderately high level (Stanley & Miller, 1993). Additionally, the participant’s verbalizations regarding his view of himself exhibited a better self concept and a more positive outlook. Teacher reports and interviews with staff members Effect of Art Therapy 95 at the facility supported the CSEI results and cited a marked decrease in the participant’s verbal and physical aggression.
Saunders and Saunders (2000) sought to further support existing research on art therapy and behavior problems utilizing quantitative methods. The researchers asserted that most of the research regarding the effectiveness of art therapy has been done utilizing case studies and other qualitative methods. Data was collected over a 3-year time period from a human service agency in Iowa. A total of 94 participants were employed in the study with ages ranging from 2 to 16. Upon intake to the agency, participants exhibited defiant behavior, poor communication, fighting, and aggression. The children took part in art therapy for an average of 16.8 sessions.
Saunders and Saunders (2000) wanted to test whether art therapy would bring about a decrease in behavior issues, aid in the development of a strong therapeutic relationship between client and therapist, and whether the program-defined therapeutic goals would be met. Utilizing a pretest/posttest design, the researchers gathered information in order to determine statistical significance.
The participants were rated on 24 behaviors, and it Effect of Art Therapy 96 was found that there was a statistically significant decrease in both the frequency of problem behaviors and their severity (Saunders & Saunders, 2000). In addition, there was a statistically significant positive change regarding the strength of the therapeutic relationship with the length of treatment being strongly related to the relationship strength. Finally, the majority of the participants were shown to complete their primary, secondary, and tertiary therapeutic goals.
The process of making art holds special power with children with DBDs and behavioral problems as a means of communication, expression, and therapy. As a modality used with this population, art therapy is not only a calming influence but also a means through which one can lower resistance. Saunders and Saunders (2000) concurred that art therapy is uniquely effective with the population: “One of the central features of art therapy is its ability to help children become more communicative about their feelings and less likely to either internalize them in unhealthy ways or to act them out in destructive ways” (p. 105). The therapeutic effectiveness of art therapy with children and with DBDs and behavior problems provides a basis for Effect of Art Therapy 97 utilizing the modality to impart the specific help that this population needs.
Art Therapy with Aggressive Children
Aggression and the associated violent and hostile behaviors are characteristic of children with ODD and behavior problems, making the features important variables in therapeutic treatment (Kruesi et al., 1994). An increase in children with aggressive behavioral problems was mentioned by Broecher (2000). Research points to a variety of influencing factors: poor social skills and interactions, lack of a strong identity, family problems, and recurrent changes of environment. These children tend to act out in social situations, not follow instructions, display a lack of respect toward peers and authority figures, and become explosive when frustrated. Due to the latter, aggressive individuals may require restrictive environments in conjunction with their own safety and the safety of others (Danforth & Drabman, 1989).
Pepler and Rubin (1991) suggested that aggressive children suffer from “social cognitive deficits” that cause them to have difficulty interpreting their social interactions. They lack the skills necessary to reflect on the actions of others, leading to rejection by their peers. Effect of Art Therapy 98
Over time, this serves to reinforce their aggressive behavior. For example, if children act out aggressively, they become isolated socially. Social isolation causes individuals to feel that the outer world is against them, creating emotions which trigger more aggressive behavior.
Thus, a pattern of misinterpretation and overreaction is formed.
Aggression in childhood has been shown to strongly correlate with problems later in life, making it a solid predictor of future delinquent behavior (Kruesi et al.,
1994). Childhood aggression can lead to criminal behavior, adult psychopathology, academic problems, and social issues. Additionally, aggressiveness remains stable overtime, from childhood through adolescence (Rubin, Bream,
& Rose-Krasnor, 1991). In other words, aggression is resistant to change, and therefore, not easily treated.
Farrington (1991) found support for this idea in a longitudinal study. The researcher’s findings matched teacher reported aggression in 8-year olds with self reported violence at 18 years of age. The conclusion was made that aggression at age 8 predicted violent behavior at age 18. Effect of Art Therapy 99
In order to attempt to treat aggression, it is necessary to thoroughly understand this complex issue. In a study of children diagnosed with disruptive behavior disorders, Kruesi et al. (1994) sought to find a more apt definition for aggression in hopes that the clarification would allow for more accurate measurement. The researchers found that most current measurements fail to account for the complexity of aggression, not considering the reactive and proactive types. Dodge (1991) explained the former type to be individuals who are disturbed by others, while the latter type refers to those who are disturbing to others.
Children who are reactively aggressive use it as a response to the circumstances and individuals around them. On the other hand, proactive aggressive children use their aggressive behavior to achieve a desired end.
In addition, children and adolescents can be either overtly or covertly aggressive (Earwood, Fedorko, Holzman,
Montanari, & Silver, 2004). Individuals tend to utilize the type of aggression that is either role modeled for them or that has been successful for them in the past. Younger children and males are often times more overt in their aggression, being physical and fighting. Females, older children, and adolescents are more covert, expressing Effect of Art Therapy 100 aggression verbally (i.e. rumor spreading) in attempts to maintain their self esteem.
What is not clear through research is what the root causes of aggression are and from where it originates. It is an on-going topic of debate as to whether aggression is an innate instinct and natural reaction or if it is induced by environmental factors. Additionally, there is the possibility that the two categories each contribute to aggression.
Kramer (1993) found aggression to be primal in nature.
Looking back at human evolution, one can see that aggression has been necessary (i.e. to protect family or territory), and, over time, humans have learned to control or harness this energy. Environmental factors such as frustration and stress may bring out aggression, but they are not the cause for it. Kramer saw aggression as a portion of our creative energy, transformed into a source for artwork.
Art therapy can enable an individual to vent some of their aggression (Kramer, 1993). Allowing for the escape of aggression can lead to a “healthy explosion” (p. 160) after which a client feels a relief of pressure. A process of this nature can produce very strong artwork laden with Effect of Art Therapy 101 emotion. Kramer, however, cautioned that children might not have the capacity to deal with their emotions, and the art may lose its meaning, becoming an uncontrolled mess.
Additionally, children might feel threatened by this sort of release, and it could upset them in an unhealthy way.
In the art of aggressive children, it is common to see signs that an individual is trying to control aggression, identifying with aggression, or attempting to hide the aggression (Kramer, 1993). Art therapy, however, operates based on “the power of art to relieve pressures or to contain what is unbearable” (p. 208). Utilizing the art therapy modality, aggression can be changed into more constructive energy. Art therapy can also provide a venue for the temporary relief from behavior and emotional symptoms. Over time, these factors can contribute to a reduction in aggression and positive change within the individual. The artwork will serve as documentation of this journey.
Working within a series with aggressive children can help both therapist and client to observe change (Broecher,
2000). Since talking about these issues can prove challenging, art provides a different way to communicate and let emotions out. Broecher found that children with Effect of Art Therapy 102 aggression have particular difficulty sharing feelings, perceiving it as a weakness and preventing them from dealing with anything on an emotional level. Art allows them to work symbolically through metaphor, revealing important issues.
Some aggressive children are excited to engage in art activities while others seem afraid to produce anything
(Neibauer, 1988). Neibauer suggested that aggressive children “suffer from intense internal conflict resulting from injuries to self. Internal conflict and self-doubt are reflected in their attempts to define themselves through offensive interactions with the environment” (p. 6). Art forces these children to be introspective while allowing them freedom to explore without worrying about making mistakes. Neibauer categorized aggressive children according to their artistic style: aesthetic rigidity, aesthetic chaos, violent representation, and aesthetic discovery.
The first category, aesthetic rigidity, is defined by a controlled, neat, and organized approach (Neibauer,
1988). The child may appear hesitant or even oppositional, not willing to invest emotionally in the art process. Art from these children tends to contain stereotypical imagery Effect of Art Therapy 103 because defenses are up. Safe images such as hearts, suns, and flowers are utilized in the artwork as an avoidance mechanism. Children with aggression control any output of emotion during the art therapy session, thereby manipulating their expressivity.
Aesthetic chaos is marked by a children who are lost in their impulses in such a way that their needs are not suited (Neibauer, 1988). Children of this type work readily with regressive materials, but are unable to verbalize any accompanying emotions. Neibauer mentioned that these children were unable to organize both their internal and external worlds, needing a very structured experience to calm them.
The category that Neibauer (1988) referred to as violent imagery also featured identification with the aggressor. Artwork of this nature includes destructive themes and hostile imagery. Neibauer asserted that this is not the sublimation of the aggression drive; representing aggression in drawings is not the equivalent of releasing this emotion. Children in this category are not dealing with themselves. Instead, they identify with the aggressor in order to avoid their real fear and anxiety. The art therapy here needs to emphasize safety and security. Effect of Art Therapy 104
Aggressive children in the aesthetic discovery subgroup find themselves able to comfortably explore and experience the visual nature of their art (Neibauer, 1988).
The therapist should notice a sense of self emerging from the client and a genuine discovery of aspects about oneself through the art. It is important to remember that this process takes a great deal of valor on the part of the aggressive individual. Neibauer stated, “when an aggressive child faces a white piece of paper, the first image he sees is his own emptiness” (p. 13).
Art therapy can also be useful in groups of aggressive individuals, forcing them to work on important social and coping skills. Dunn-Snow (1994) highlighted group work with a case example which involved three fifth grade boys completing the Draw A Story Assessment (DAS; Silver, 1988).
As the boys chose their respective images, they began to fight, escalating until punches were exchanged. In talking about the drawing that they had produced and making up a story, however, they were able to apologize to one another and resolve the issue on their own. The process enabled them to learn and develop skills that would translate beyond the session. Effect of Art Therapy 105
In another study utilizing the DAS, the assessment was used to determine whether it could effectively screen for aggression (Earwood et al., 2004). The researchers found that aggressiveness was related to scores for emotional content and self image. Aggressive children scored significantly lower in the former and significantly higher in the latter, displaying a negative perception of the world and a positive perception of themselves.
When working with children in an art therapy session, it is important that they feel that their artwork is accepted. In the case of aggressive children, however, it may be difficult for the therapist to accept images with aggressive or violent content. Malchiodi (1998) asserted that a therapist should let the child know that their artwork is acknowledged, but that violent behavior is not.
While the content of the art can be shocking, it can also be more revealing than other types of work. Malchiodi found it imperative for children to be able to communicate in this way as it is necessary for change to occur.
Aggression is a difficult factor to deal with for both therapist and child: “Aggressive behavior demands tremendous energy and produces debilitating anxiety, as it often creates the very condition which it is designed to Effect of Art Therapy 106 avoid – isolation” (Neibauer, 1988, p. 12). Art therapy provides not only a constructive outlet for this energy, but also a way to learn about the self. Once an aggressive child is able to take that journey, real change can occur.
Whether all aggression is a primary drive or whether it is induced by environmental factors, art therapy seems to have the ability to commune with even the most aggressive and defensive child.
Summary
As a treatment modality, research has shown that art therapy can be effectively used with children. Children have the innate desire to be creative (Barber, 2006)
Creativity provides a link to the unconscious, and art therapy takes advantage of that connection in order to help children deal with emotions and issues. Because the emphasis is not on verbal communication, art therapy breaks down defenses. Making a concrete piece of artwork externalizes the issue and makes dealing with it much easier for children (Barber, 2006; Mooney, 2000; Ulman et al., 1977).
Beyond being a successful therapeutic tool with the young population, art therapy provides means of interaction between therapist and child which are essential to the Effect of Art Therapy 107 therapy of children diagnosed with ODD and those with behavioral problems. The research studies mentioned in the above sections concluded that art therapy connects with these children. The calming effects of making art combined with venting that can occur during the artistic process help children with DBDs and behavior problems to come to grips with their issues (Kramer, 1993; Neibauer, 1988).
Similarly, art therapy has been shown to be effective with children prone to aggression. As one of the trademark features of ODD and behavior problems, aggression is a pertinent facet to be considered in a therapeutic program.
Dodge (1991), Earwood et al. (2004), and Kramer (1993) have contributed to the literature regarding defining aggression. Through that definition, a better understanding of the concept is gained. Art therapy gives children with aggression issues the opportunity to engage in an activity that allows for the release of emotions. Once these feelings are let out, individual change can occur
(Broecher, 2000). Effect of Art Therapy 108
Appendix C
CHILD AND ADOLESCENT FUNCTIONAL ASSESSMENT SCALE
Effect of Art Therapy 109
Effect of Art Therapy 110
Effect of Art Therapy 111
Effect of Art Therapy 112
Effect of Art Therapy 113
Effect of Art Therapy 114
Effect of Art Therapy 115
Effect of Art Therapy 116
Effect of Art Therapy 117
Effect of Art Therapy 118
Effect of Art Therapy 119
Effect of Art Therapy 120
Effect of Art Therapy 121
Effect of Art Therapy 122
Effect of Art Therapy 123
Effect of Art Therapy 124
Appendix D
ART THERAPY SESSION NOTES
Client: DOB: Session Date: Clinician:
Directive/Materials Used:
Initial and General Observations of Client (mood, affect, activity, relatedness):
Observations during Session:
Description of Artwork and Client’s Verbal Associations:
Assessment of Progress and Advancement toward Goals:
Summary and Closure:
Effect of Art Therapy 125
Appendix E
Agency Consent Letter
Dear Sir or Madam:
This letter is a request to obtain consent to conduct a research case study at your agency.
The purpose of this case study is to examine the effect of art therapy on a child with a disruptive behavior disorder diagnosis. An 8-week art therapy intervention will be designed to address both aggression and behavioral problems, with the participant taking part in weekly 1-hr art therapy sessions. The art therapy program will include the use of paints, clay, drawing media (i.e. crayons, colored pencils, markers), and scratch art paper.
Any changes in the participant over time will be evaluated through the use of a variety of measures. Level of functioning will be assessed prior to the commencement of the art therapy intervention and again at the conclusion of the intervention utilizing the Child & Adolescent Functional Assessment Scale (CAFAS). As the CAFAS requires a rater who is well informed regarding the participant, the scale will be administered by a member of the residential staff at your agency. Additionally, possible changes will be tracked by session notes and observations, the artwork produced, and the behavioral level system employed by the residential treatment facility. Each of the assessment measures will be considered independently of one another as well as collectively.
All personal information and data collected regarding the participant will be handled in a manner which accounts for the confidentiality of the individual.
I thank you for your time and consideration.
Heather Weinberg Principal Investigator I CERTIFY THAT I HAVE READ AND FULLY UNDERSTAND THE PROJECT MENTIONED ABOVE. I HEREBY GIVE CONSENT TO THE PRINCIPAL Effect of Art Therapy 126
INVESTIGATOR TO CONDUCT THE ABOVE MENTIONED RESEARCH PROJECT.
______Signature Date
______Agency Title Effect of Art Therapy 127
Appendix F
PARENTAL CONSENT FORM
CONSENT TO PARTICIPATE VOLUNTARILY
IN A RESEARCH INVSTIGATION
School of Arts, Sciences, and Professional Studies Springfield College Springfield, MA 01109
Dr. Simone Alter-Muri _ Heather Weinberg___ Responsible Faculty Member Investigator
______Participant Date
PROJECT TITLE: The Effect of Art Therapy on a Child with a Disruptive Behavior Diagnosis: A Case Study
Your child is being asked to participate in a research investigation as described in this form below. All such investigational projects carried out within this department are governed by the regulations of both the Federal Government and Springfield College. These regulations require that the investigator obtain from you a signed agreement (consent) for your child to participate in this project.
The purpose of this case study is to examine the effect of art therapy on a child with a disruptive behavior disorder diagnosis. An 8-week art therapy intervention will be designed to address both aggression and behavioral problems, with the participant taking part in weekly 1-hr art therapy sessions. The art therapy program will include the use of paints, clay, drawing media (i.e. crayons, colored pencils, markers), and scratch art paper.
Change in the participant over time will be evaluated through the use of a variety of measures. Level of functioning will be assessed prior to the commencement of the art therapy intervention and again at the conclusion of Effect of Art Therapy 128 the intervention utilizing the Child & Adolescent Functional Assessment Scale (CAFAS). The CAFAS will be administered by a member of the residential staff at the treatment facility. Additionally, change will be tracked by session notes and observations, the artwork produced, and the behavioral level system employed by the residential treatment facility. Each of the assessment measures will be considered independently of one another as well as collectively.
The data received regarding the participant will be kept confidential. At any point during the 8-week session the participant and/or parent/guardian can choose to terminate the participant’s involvement with the study. Further information can be obtained from the School of Graduate Studies of Springfield College (413-748-3125) concerning pertinent questions about the research and an explanation of your child’s rights as a research participant.
I CERTIFY THAT I HAVE READ AND FULLY UNDERSTAND THE ABOVE PROJECT. I WILLINGLY CONSENT TO PARTICIPATE.
______Signature of Parent/ Date Guardian
Effect of Art Therapy 129
Appendix G
SESSION DIRECTIVES
Week 1 – Scribble Pictures
Week 2 – Scratch Art
Week 3 – Nondirective Session
Week 4 – Clay Work
Week 5 – Large Scale Painting
Week 6 – Nondirective Session
Week 7 – Clay Work
Week 8 – Scribble Pictures
Effect of Art Therapy 130
Appendix H
SESSION #1
Effect of Art Therapy 131
Effect of Art Therapy 132
SESSION #2
Effect of Art Therapy 133
Effect of Art Therapy 134
SESSION #3
Effect of Art Therapy 135
SESSION #4
Effect of Art Therapy 136
SESSION #5
Effect of Art Therapy 137
Effect of Art Therapy 138
SESSION #6
Effect of Art Therapy 139
Effect of Art Therapy 140
SESSION #7
Effect of Art Therapy 141
Effect of Art Therapy 142
SESSION #8
Effect of Art Therapy 143
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