Stacha C. Leslie, MEd, BCBA, LBA, Breanna Roberts, MA, BCBA, LBA, and Thomas Zane, PhD, BCBA-D
Department of Applied Behavioral Science, University of Kansas

Is there science behind thatDeficits in social-emotional development, motor skills, and sensory regulation are highlighted as potential challenges faced by individuals with autism (American Psychiatric Association, 2013). Several alternative treatments and therapies have been developed to address these challenges. Some of these are aimed at improving autistic individuals’ understanding of themselves and their environment. One alternative therapy, often used in conjunction with related professional services (i.e., occupational therapy, speech therapy, etc.), is art therapy.

What is Art Therapy?

Art therapy is defined as “an integrative mental health and human services intervention that enriches the lives of individuals, families, and communities through active art-making, creative process, applied psychological theory, and human experience within a psychotherapeutic relationship” (American Art Therapy Association, 2017). It differs from art classes in that art therapy does not emphasize technique or aesthetics but builds on the strengths, behaviors, and psychological attributes of the individual being served (Alter-Muri, 2017). With this individualized approach, art therapy aims to increase self-awareness, develop coping skills, structure behavior, reduce stress, and develop interpersonal skills (American Art Therapy Association, 2014 cited in Schweizer et al., 2014). Furthermore, individuals are encouraged to focus on their own perceptions and feelings (rather than attempting to mimic others) and “to express their inner world more than…expressing their outer world” (Cherry, 2022, p. 4).

Art therapy can be implemented and expressed through various mediums, including music, drawing and painting, drama, dance, and movement (Thayer & Bloomfield, 2021). It is typically administered in a small group or in a 1:1 setting in conjunction with other therapies like talk therapy (American Art Therapy Association, 2017). When administered in a small group setting, activities are typically broad enough to encompass a wide range of adaptive functioning levels and allow for individualized engagement. When administered in a 1:1 setting, activities are tailored to the individual and likely embed the individual’s personal treatment goals that may also be shared with a multidisciplinary team (Chapman & Evans, 2020).

How is Art Therapy Implemented with Children with Autism?

For most individuals with autism receiving art therapy, sessions are typically implemented in a 1:1 setting. This may include gradual exposure to group settings as adaptive functioning levels improve. Sessions are implemented to improve functioning across three domains that support the development of “foundational skills” (Gabriels, 2003): social & emotional learning (including communication and emotional regulation), fine and gross motor development, and sensory regulation (Emery, 2004; Martin, 2009; Schweizer et al., 2014; Thayer & Bloomfield, 2021). Often, the goals targeted for intervention during art therapy are implemented in conjunction with other related disciplines (i.e., music therapy, occupational therapy, ABA therapy; Dalien, 2022). That is, art therapy potentially offers another avenue in which an individual’s goals are shared across relevant stakeholders and targeted to improve overall adaptive functioning.

With respect to social & emotional learning, the visual aspects of art therapy materials (i.e., clay, Play-Doh, precut paper samples, etc.) can be used to encourage individuals with autism to associate words with pictures, with the ultimate goal of producing communicative responses. For example, an art therapist may use pre cut drawings of body parts and provide instructions to match the precut drawings to a picture while simultaneously labeling the body parts (Gabriels, 2003). With respect to fine and gross motor development, art therapy has been used to practice motor coordination and imitation skills through activities such as cutting, pasting, drawing, and painting (Gabriels, 2003). Additionally, Alter-Muri (2017) suggests that providing art materials and activities like weaving, printmaking, and stenciling may offer “control and containment” of repetitive behaviors and other motor movements. That is, the “discharge of gross motor movement” through art activities can help individuals “manage pent-up emotions” (Alter-Muri, 2017). Finally, given the overall aims of this approach (i.e., self-awareness and self-expression; Schweizer, 2014), art therapy may improve sensory regulation (i.e., tactile awareness, auditory and olfactory sensitivities, and emotional issues; Gabriels, 2003) by providing a “safe space” for individuals to express themselves. That is, the art therapist can “invite the individual” to express themselves and provide visual and tactile experiences that may facilitate spatial insight (e.g., awareness of themselves, others, and objects around them; Schweizer et al., 2014).

Art Therapy seems to take an individualized, person-led approach to treatment. In fact, some of the techniques administered by art therapists (i.e., identifying objects, modeling, pairing, etc.) are similar to techniques embedded within evidence-based practices like ABA therapy. At first glance, art therapy may seem like a unique alternative to other treatments that address some core deficits associated with the autism spectrum. But is there science behind it?

Does Science Support Art Therapy?

Research to date supporting the use of art therapy as a treatment for autism has mainly been expressed through case studies and articles reviewing its potential effectiveness. Durrani (2014) evaluated an art therapy intervention for a 12-year-old boy with autism with severe sensory dysfunction and self-regulatory issues, who frequently engaged in stereotypy (i.e., flapping hands and jumping), self-injurious behavior (i.e., banging head to floor), and anxiety (i.e., fleeting eye contact and minimal engagement with their therapist). Weekly, individual 30-min sessions were implemented across one year, during which art materials were provided, and therapists mirrored the client’s movements and followed their lead. For example, if the client picked up paint to pour, the therapist imitated his movement by picking up paint to pour. Reported outcomes of this case study suggested increased durations of tolerating sitting at a desk, an increased ability to make choices between preferred art materials, and increased engagement in a preferred activity. There are some limitations of this case study worth mentioning. First, pre-intervention levels of engagement with the art activities are unknown. Second, steps detailing the systematic implementation of therapy sessions were not provided. Additionally, behaviors targeted for increase and reduction were not defined. Given this, the readers are unable to determine the effectiveness or generality of outcomes.

Similar outcomes were observed by Emery (2004), who evaluated the use of art therapy for a 6-year-old boy with autism who engaged in rigid leisure skills (i.e., only played with letters), repetitive speech (i.e., high-pitched vocalizations), and had limited vocal-verbal skills. Various stages of treatment were implemented across a period of 7 months (the frequency and duration of sessions were not provided), including an initial stage of modeling shapes with Play-Doh and prompting tracing, a middle stage of using puppets to facilitate interaction (i.e., modeling normal voice pitch), and a final stage of identifying objects in the pictures they drew. Reported outcomes suggested increased eye contact, variability in drawings, and vocal communication (i.e., 1-word to 3-word phrases). Additionally, Emery (2004) reported that caregivers were consistently engaged in sessions and frequently implemented similar procedures with their child at home, which enhanced their success over time. However, similar to Durrani (2014), no objective measures were reported to evaluate the effects of the art therapy sessions. Furthermore, procedures reported to improve behaviors were unclear and difficult to interpret, such that they could not be replicated with similar individuals.

In addition to these two case studies, two additional studies evaluated the effectiveness of art therapy in conjunction with other interventions. Chapman & Evans (2020) evaluated art therapy and Acceptance and Commitment Therapy (ACT) to improve a 15-year-old’s social anxiety (i.e., interaction with novel people and places) and communication skills (i.e., improving rate and volume of speech). Experimenters implemented an 8-week ACT art protocol which included one, 1-hr session per week. Additionally, following each weekly session, a 1-hr follow-up session was completed to generalize and apply skills learned during initial training. Reported outcomes suggested improved levels of overall “well-being,” relationships, and independence. However, neither baseline data nor objective measurement were included to evaluate the efficacy of art therapy as the intervention responsible for the qualitative outcomes. Thayer & Bloomfield (2021) evaluated art therapy and Developmental, Individual-differences Relationship-Based (DIR®; see ASAT column on DIR® FloorTime). Twenty-one students participated in individual and group-based DIR® and art therapy programs consisting of weekly dance, music, and art therapy sessions across six months. Overall, the program aimed to improve sensory regulation, engagement, and communication. Reported outcomes suggested some increases in communication and engagement in the dance and music activities. However, several limitations with respect to data collection and an inadequate number of parent surveys to draw conclusions were also reported.

Other studies have provided parent-reported outcomes suggesting satisfaction with art therapy treatment (Schweizer et al., 2020), evaluation of measurement systems to analyze the effectiveness of art therapy treatment (Schweizer et al., 2019), and suggestions for its potential use (Bernier, 2002; Martin, 2009; Gabriels, 2003). However, although some anecdotal, positive outcomes were reported, evidence promoting the effectiveness of art therapy as a treatment for autism is preliminary at best and suggests that traditional art therapy alone is not enough to produce successful outcomes for individuals with autism (Martin, 2009).

What Else Should We Consider?

Although we do not recommend art therapy as an evidence-based treatment for autism, we encourage the reader to consider art materials and art classes as preferred activities or reinforcers for engaging in appropriate, adaptive behaviors as well as antecedent interventions to prevent the occurrence of problem behavior. For example, once identified as preferred stimuli, art materials may be included as an antecedent intervention, similar to environmental enrichment (EE; Gover et al., 2019), for problem behavior maintained by automatic reinforcement (i.e., stereotypy and repetitive movement). Additionally, with clinical oversight, some aspects of art therapy could be integrated into evidence-based procedures like natural environment teaching, fluency-based instruction, and discrete trial training (Lerman, et al., 2016; Weiss, 2001). For example, our earlier mention of using art materials to teach body part identification (Gabriels, 2003) may facilitate learning by using highly preferred stimuli (i.e., art materials) to teach labeling and listener responding skills. Although art therapy on its own is not enough to address potential deficits in individuals with autism (Martin, 2009), the above examples suggest that some techniques may be integrated into an individual’s programming across multidisciplinary teams.

What should I take away from this?

Limited research has been conducted on the effectiveness of art therapy as a treatment for autism. Although case studies and potential-for-use columns suggest positive outcomes with respect to social-emotional learning, fine and gross motor development, and sensory regulation, results are preliminary at best. Comprehensive and well designed, rigorous research is needed on both the implementation of art therapy and the generality of its potential outcomes. Research must first outline how art therapy procedures are developed and provide recommendations on implementing such procedures with high integrity to ensure best outcomes and to allow for replication by future researchers. Researchers must operationally define their measures (e.g., social, cognitive, and academic goals targeted for change) and ensure they are measured validly and with agreement. They must then evaluate its effects across diverse populations, such that more conclusive suggestions can be made for its use. Although art materials and activities may be highly preferred by some individuals with autism and may even be integrated with other techniques, there is not enough evidence to suggest that art therapy alone is an effective treatment for autism. Therefore, we do not recommend the use of art therapy as a scientific treatment for autism at this time.

References

American Art Therapy Association. (2017). About art therapy. https://arttherapy.org/about-art-therapy/

Alter-Muri, S. B. (2017). Art education and art therapy strategies for autism spectrum disorder students, Art Education, 70(5), 20-25. https://doi.org/10.1080/00043125.2017.1335536

Bernier, Ratcliff, K., Hilton, C., Fingerhut, P., & Li, C.-Y. (2022). Art interventions for children with autism spectrum disorder: A scoping review. The American Journal of Occupational Therapy, 76(5). https://doi.org/10.5014/ajot.2022.049320

Chapman, & Evans, B. (2020). Using art-based acceptance and commitment therapy (ACT) for an adolescent with anxiety and autism. Clinical Case Studies, 19(6), 438-455. https://doi.org/10.1177/1534650120950527

Cherry, K. (2022). What is Art Therapy? Verywell Mind. https://www.verywellmind.com/what-is-art-therapy-2795755

Dalien, S. (2022). What exactly is art therapy and how can it possibly help? Special Ed Resource. https://specialedresource.com/art-therapy-children-special-needs

Durrani, H. (2014). Facilitating attachment in children with autism through art therapy: A case study. Journal of Psychotherapy Integration, 24(2), 99-108. https://doi.org/10.1037/a0036974

Emery, M. J. (2004). Art therapy as an intervention for autism. Journal of the American Art Therapy Association, 21(3), 143-147. https://doi.org/10.1080/07421656.2004.10129500

Gabriels, R. L. (2003). Art therapy with children who have autism and their families. In C. A. Malchiodi (Ed.), Handbook of Art Therapy (pp. 193-206). The Guilford Press.

Gover, H.C., Fahmie, T.A. & McKeown, C.A. (2019), A review of environmental enrichment as treatment for problem behavior maintained by automatic reinforcement. Journal of Applied Behavior Analysis, 52(1), 299-314. https://doi.org/10.1002/jaba.508

Lerman, D. C., Valentino, A. L., & LeBlanc, L. A. (2016). Discrete Trial Training. In R. Lang, T. B. Hancock, & N. N. Singh (Eds.), Early intervention for young children with autism spectrum disorder (pp. 47-83).

Martin, N. (2009). Art therapy and autism: Overview and recommendations. Art Therapy, 26(4), 187-190. https://doi.org/10.1080/07421656.2009.10129616

Schweizer, C., Knorth, E. J., & Spreen, M. (2014). Art therapy with children with autism spectrum disorders: A review of clinical case descriptions on ‘what works.’ The Arts in Psychotherapy, 41(5), 577-593. https://doi.org/10.1016/j.aip.2014.10.009

Schweizer, C., Knorth, E. J., van Yperen, T. A., & Spreen, M. (2019). Evaluating art therapy processes with children diagnosed with autism spectrum disorders: Development and testing of two observation instruments for evaluating children’s and therapists’ behaviour. The Arts in Psychotherapy, 66, 101578. https://doi.org/10.1016/j.aip.2019.101578

Schweizer, C., Knorth, E. J., van Yperen, T. A., & Spreen, M. (2020). Evaluation of ‘Images of Self,’ an art therapy program for children diagnosed with autism spectrum disorders (ASD). Children and Youth Services Review, 116, 105207. https://doi.org/10.1016/j.childyouth.2020.105207

Thayer, F. & Bloomfield, B. S. (2021). An evaluation of a developmental individual differences relationship-based (DIR®)- creative arts therapies program for children with autism. The Arts in Psychotherapy, 73, 101752. https://doi.org/10.1016/j.aip.2020.101752

Weiss, M. J. (2001). Expanding ABA intervention in intensive programs for children with autism: The inclusion of natural environment training and fluency based instruction. The Behavior Analyst Today, 2(3), 182-186. https://doi.org/10.1037/h0099946

Citation for this article:

Leslie, S. C., Roberts, B., & Zane, T. (2023). Art Therapy: Is there science behind that? Science in Autism Treatment, 20(10).

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