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Transforming Social and Emotional Learning

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Transforming Social and Emotional Learning

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Teachers’ Interpersonal Behavior and Students’ Socio-Emotional Learning Skills in Social Sciences

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Teachers’ Interpersonal Behavior and Students’ Socio-Emotional Learning Skills in Social Sciences

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Animal-Assisted Therapy for Students with EBD

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Animal-Assisted Therapy for Students with EBD

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Login - CAS – Central Authentication Service

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Mindfulness and Emotional Behavioral Disorders

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Mindfulness and Emotional Behavioral Disorders

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Are Inclusive Education or Special Education Programs More Likely to Result in Inclusion Post-School?

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Are Inclusive Education or Special Education Programs More Likely to Result in Inclusion Post-School?

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A Collaborative Approach to Teaching Indigenous Literatures

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A Collaborative Approach to Teaching Indigenous Literatures

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What is Inclusive Didactics? Teachers’ Understanding of Inclusive Didactics for Students with EBD in Swedish Mainstream Schools

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What is Inclusive Didactics? Teachers’ Understanding of Inclusive Didactics for Students with EBD in Swedish Mainstream Schools

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https://files.eric.ed.gov/fulltext/EJ1142203.pdf

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Disabilities Inclusive Education Systems and Policies Guidefor Low- and Middle-Income Countries

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Disabilities Inclusive Education Systems and Policies Guidefor Low- and Middle-Income Countries

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https://files.eric.ed.gov/fulltext/ED581498.pdf

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Has Inclusion Gone Too Far? Weighing its effects on students with disabilities, their peers and their teachers

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Has Inclusion Gone Too Far? Weighing its effects on students with disabilities, their peers and their teachers

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The model of special education known as inclusion, or mainstreaming, has become more prevalent over the past 10 years, and today, more than 60 percent of all students with disabilities (SWDs) spend 80 percent or more of their school day in regular classrooms, alongside their non-disabled peers (see Figure 1). This is not the full inclusion favored by some disability advocates, wherein all SWDs would be educated in inclusive classrooms all day; however, many supporters celebrate the increasing acceptance of differently abled students in general education as an opportunity to improve the academic and long-term trajectories of these traditionally underserved learners. In theory, inclusion provides SWDs with access to the grade-level curriculum and the same educational opportunities as their peers.

Unfortunately, research has yielded only weak evidence that inclusion confers benefits on SWDs. Studies that report better academic and behavioral outcomes for SWDs who are taught in a general-education setting suffer from methodological flaws. Even less evidence suggests that general-education teachers are adequately prepared to meet the unique academic and behavioral needs of SWDs. Further, studies of inclusion seem to assume that SWDs are educated in a vacuum; that is, they fail to examine the experiences of non-disabled classmates.

In this article, I explore policies and existing research on inclusion to describe what we know, what we don't, and how current knowledge should inform decisions about where to educate SWDs. An underlying theme of this discussion is that inclusion influences not only SWDs but also their peers and teachers. The interplay between and among these three groups suggests areas of research that can inform future discussion about inclusion and how it can work well for all stakeholders.
The Least-Restrictive Environment
Inclusion did not become the widespread practice it is today because of a robust evidence base that supports its effectiveness. Rather, it is prevalent because of federal laws that establish special rights for SWDs and their parents. The Individuals with Disabilities Education Act (IDEA), first signed into law in 1975 as the Education for all Handicapped Children Act, mandates that SWDs receive a free appropriate public education (FAPE) in the least-restrictive environment (LRE) possible. A student's FAPE and LRE are established through a team process that produces an Individualized Education Program (IEP). After a school identifies a student with a disability, it convenes an IEP team meeting. This team typically consists of the student's parents or guardians; special- and general-education teachers with knowledge of the student; school staff members who can interpret the results of evaluations; other service providers; and, in many cases, the student. At this meeting, the team identifies annual goals for the student. These individualized goals determine what constitutes an "appropriate education" for that particular student.

Once the goals are in place, the IEP team discusses the instruction, related services, and accommodations the student requires to meet the goals. During this stage of the IEP process, the team decides where the student will receive services-for example, in a regular classroom; in a regular classroom with the support of a paraprofessional or special-education teacher, or perhaps with additional support in a resource room or pullout setting; or in a self-contained special-education classroom. IDEA requires that students be educated in regular classrooms unless their academic and behavioral needs cannot be met in that setting even with the use of supplemental aids and services.

Consider the following two examples. A 1st-grade student with a speech or language impairment might require one hour of speech therapy a week from a speech/language pathologist to improve his enunciation. His IEP team may also decide that he needs accommodations in the classroom, as his impairment influences his reading fluency. Apart from his weekly speech therapy, the student would attend a general-education class with the occasional accommodation for his reading skills. Removing this student from the regular classroom because of an enunciation problem would be inappropriate: the student can likely make progress there with the suitable supplemental services and accommodations.

Contrast this student with a 5th-grade student receiving special-education services for a specific learning disability who is struggling with sounding out words while his non-disabled peers are focused on reading comprehension. Because this student has such significant educational needs, the IEP team would likely decide that he should receive some of his reading instruction outside of the regular classroom.

These examples illustrate the individualized nature of placement decisions. The IEP team determines where a child will be educated based on the services the student needs and where those services can practicably be delivered. But IDEA explicitly states that most SWDs should be taught in the general-education classroom, and IEP team members may be unduly influenced by this requirement. For example, IDEA requires that states report to Congress each year the percentage of the school day that SWDs spend in general-education classrooms, in addition to other indicators such as dropout rates, SWDs' participation in assessments, their proficiency rates on these tests, and suspension and expulsion rates. The Department of Education compiles these data in an annual report to Congress and uses the information to determine if a state is in compliance with IDEA. In this publication, data related to the setting in which SWDs are educated are disaggregated by state, yet the data regarding student academic outcomes are not. The reports therefore appear to assess the extent to which students are receiving an appropriate education by the location in which they are served.

There is little federal guidance on whether schools can consider students' classmates and teachers in their decisions about where SWDs are educated, further complicating placement judgments. IDEA only briefly addresses the needs of non-disabled classmates: schools are required to consider the use of positive behavioral interventions when an SWD's behavior affects his classmates' learning. Beyond this mention of peers, federal policies pay scant attention to the interplay between SWDs, their classmates, and general-education teachers. Special-education case law includes conflicting opinions as to whether placement decisions can be based on how a student might influence their classmates. What is clear is that placement is to be an individualized decision determined by the needs of each student with a disability, but it seems unlikely that a student will derive appropriate benefit from the prescribed services if his placement causes disruption or detriment to his peers and teachers.
Access to the Curriculum
A key assumption of IDEA is that including SWDs in the regular classroom will expose them to grade-level, general-education curriculum. Yet exposure may not result in progress in that curriculum. Research suggests that many SWDs will not be able to advance along grade-level academic standards with the instruction typically provided in regular classrooms, even with accommodations and supports. For example, a recent study by Lynn Fuchs and colleagues compared the size of the math achievement gap between students with or at risk for learning disabilities and their non-disabled peers. SWDs were randomly assigned to two groups. In the first one, students with or at risk for disabilities received intensive fractions instruction, exemplifying special-education techniques, while those in the second group were exposed to fractions instruction in the regular classroom with accommodations based on the principles of Universal Design for Learning (that is, instruction that includes multiple means for students to express what they know). The math achievement gap between students with or at risk for disabilities and without disabilities in the regular classroom setting was twice as large as the gap in the first group (see Figure 2).

It is a mistake to equate the setting in which a student is educated (that is, the general-education classroom) with the actual progress a student is making. Such an assumption ignores the fact that students are found eligible for special-education services precisely because they are failing to progress in general education. Placement data may suggest that SWDs are being exposed to the general-education curriculum, but achievement data suggest that they are not actually learning the curriculum: SWDs placed in general-education classrooms continue to lag dramatically behind their peers. A recent meta-analysis that I conducted with my colleagues Doug Fuchs and Joe Wehby estimated that SWDs score about 1.2 standard deviations below their non-disabled peers in reading, a gap that translates to more than three years of academic growth. Achievement gaps between SWDs and their peers are similarly large in math. Though federal laws stress the importance of educating SWDs in the regular classroom, there is no good evidence that placement there improves the outcomes of these students.
Inclusion and Student Outcomes
That's not to say that researchers have not examined the issue. Many studies have compared SWDs who are educated in inclusive settings to those who are educated in special-education settings, generally finding that the former have better academic, social, and long-term outcomes. For example, data from the Special Education Elementary Longitudinal Study conducted from 2000 to 2006 show that SWDs who spent 75 percent or more of their school day in inclusive settings scored higher in reading comprehension and math than those who spent 25 percent or less of their day in such settings. These results fueled the push to move more SWDs into general-education classrooms.

More-recent work also finds that SWDs educated in general-education settings have better outcomes. Roddy Theobald and colleagues observed that high-school students with disabilities in Washington State who spent more time in general-education settings had higher reading scores than their peers who had less time in such settings, even after taking into account differences in prior achievement and a wide range of student characteristics. They were also more likely to graduate on time and enroll in college than students educated in more-restrictive settings. Laura Schifter has reported similar results regarding graduation for students in Massachusetts: SWDs educated in general-education classrooms have higher probabilities of graduating than their peers who were educated in more-isolated settings. These recent studies and others have led many to conclude that inclusion benefits SWDs.

Unfortunately, this determination ignores a major limitation of the current research base: the failure to account for selection bias. Students with higher academic abilities or fewer behavioral challenges are more likely to be placed in inclusive settings, while their peers who may have the same disability label but greater learning or behavioral needs are placed in special-education settings. The consistent finding that SWDs have better outcomes when educated in general-education settings likely reflects this bias. Even in studies that account for students' prior levels of academic achievement, the researchers may not capture all the aspects of a student, such as his behavior, that can influence both the setting in which he is placed and his future outcomes. A student's educational placement is an IEP team decision and may be based on a host of factors not included in the administrative data sets to which researchers typically have access. This makes estimating the true causal effect of inclusion on student outcomes nearly impossible.

One study does improve on these others in regard to selection bias. In 2002, Eric Hanushek and colleagues used Texas students whose special-education classification changed over time to examine the influence of special-education classification (as determined by a student having an IEP) and educational setting on students' math outcomes. The researchers first compared the students' progress in school years when they had an IEP to their progress when they did not have an IEP, allowing each student to serve as his or her own control. They found that students scored higher on state math assessments when they had an IEP than when they did not. This result suggests that special-education services may benefit the students who receive them. When the researchers examined SWDs' math achievement by the setting in which they were educated, however, they found that SWDs performed neither better nor worse in regular classrooms than in special-education settings. While this study design is stronger than that of the research discussed above, its results only extend to students who took the regular state assessment and whose special-education eligibility changed over time, thus excluding students with more-significant disabilities. The one clear takeaway is that accounting for unmeasured differences between students who are placed in different types of settings can influence estimates of the association between general-education placement and student outcomes.

In sum, ample correlational evidence confirms that SWDs have better academic and social outcomes when they spend more time in general-education classrooms. But our ability to draw conclusions from these studies is limited, because it is likely that SWDs who would be expected to have better academic and social outcomes are more often included in general-education classrooms than their peers with more-intensive needs.
Inclusion and Peer Outcomes
A key component of inclusion is that SWDs are educated with their peers who do not have disabilities, yet little research has examined whether and how SWDs' outcomes are influenced by their peers-and vice versa. The scarcity of research in this area is surprising, as research on peer effects in general education shows that students' classmates shape their educational experiences. Particularly concerning are findings that students' academic and behavioral outcomes are influenced by classmates who exhibit challenging behaviors. For example, Scott Carrell and Mark Hoekstra found that an increase in the percentage of students' classmates who had experienced domestic violence-a variable highly correlated with children's behavior-negatively affected students' academic outcomes and increased their behavioral problems (see " Domino Effect," research, Summer 2009). Further, exposure to a peer who was more likely to exhibit challenging behavior led students to complete less schooling and earn less as adults. These findings are relevant to the topic of inclusion because SWDs have a higher probability of exhibiting challenging behavior than their peers without disabilities.

Most students without disabilities have at least two SWDs in their classes, but few studies have examined whether SWDs affect their classmates. Early studies that addressed peer effects in inclusive classrooms using older data did not identify any negative academic consequences of inclusion for students without disabilities. However, more-recent research based on the U.S. Department of Education's Early Childhood Longitudinal Studies (ECLS) has identified some worrisome findings, particularly related to the inclusion of students with an emotional/behavioral disorder (EBD).

These recent studies have examined both academic and social outcomes of students without disabilities in inclusive classrooms. In a 2009 study, Jason Fletcher found that having a classmate with an EBD was associated with a 0.09 standard-deviation decrease in students' math scores and a 0.13 standard-deviation decrease in students' reading scores. In 2016, Michael Gottfried and colleagues reported that students without disabilities who had a classmate with an EBD were 1.42 times more likely to be chronically absent than those who did not have such a classmate. A 2014 study by Gottfried found that students without disabilities were rated by teachers as having more behavior problems, lower levels of self-control, and lower interpersonal skills when they were in classrooms with SWDs, not just students with an EBD.

These studies, like those relating inclusion to SWDs' outcomes, are correlational and must be interpreted with caution. Yet they improve on prior work by limiting comparisons to students attending the same school. This approach allows the researchers to rule out the possibility that their results reflect differences in the characteristics of schools that make greater use of the inclusion model. These studies do not account for the sorting of students within schools based on unobserved characteristics, such as if students who exhibit more problem behavior owing to a change in their home life in a specific school year are grouped in classes with more SWDs. However, this type of sorting seems less likely than the sorting of higher-achieving SWDs into inclusive classrooms, which is a natural byproduct of the IEP process. Though this body of work is small and just emerging, the findings underline the importance of examining whether and how the inclusion of SWDs in general-education classrooms may change the environment in ways that affect their peers.
Inclusion and Teachers
Teachers are likely a key element in the successful inclusion of SWDs, but again few studies have investigated how general-education teachers are influenced by the presence of SWDs. An older body of research examined the attitudes of general-education teachers toward having SWDs in their classrooms. These studies reported that general educators were accepting of SWDs in their classrooms under certain conditions-for example, if additional supports were provided to the teacher and if the SWDs did not exhibit disruptive behavior. Yet both surveys and qualitative studies found that general-education teachers often do not have training, or feel they have the proper skills, to meet the academic and behavioral needs of SWDs while also teaching their non-disabled peers.

Two recent studies have aimed to assess the experiences of general educators with SWDs in their classrooms. These works are, again, correlational and not causal. Using an administrative data set from North Carolina, I estimated the association between the percentage of SWDs in teachers' classes and the rate of teacher turnover, as defined by changing schools or leaving teaching in the state. I found that the probability of turnover increased as the percentage of SWDs in teachers' classes went up if the teacher was not certified in special education, after controlling for differences in student, teacher, and school characteristics. This increase was especially pronounced when teachers had students with an EBD in their classrooms (see Figure 3). All else being equal, teachers with classes in which 20 percent of students had an EBD were 2.15 percentage points more likely to leave their school or teaching than teachers who had students with disabilities in their classes, but none with an EBD. I also found that the teachers who, based on other characteristics, were most likely to change schools or leave teaching were actually the least likely to have SWDs. This suggests that schools are not assigning SWDs to teachers who are more likely to leave and attenuates concerns that the relationship between the presence of students with an EBD and turnover is an artifact of selection bias.

Teachers might also be changing their instruction in undesirable ways when they have SWDs in their classrooms. North Cooc recently examined the amount of time teachers of inclusive classrooms reported that they spent on instruction, using data from an international survey of teachers. He found that teachers reported that they spent less time on instruction and more time on classroom management when their classes contained more SWDs. The association between instructional time and having SWDs in the classroom nearly disappeared once Cooc accounted for the number of students in teachers' classes that exhibited disruptive behavior.

These studies provide preliminary evidence that the presence of SWDs affects teachers in ways that could negatively influence the teachers themselves with regard to turnover, the outcomes of SWDs, and their peers without disabilities. Clearly, more research is needed to understand how teachers address the needs of SWDs in their classrooms and how inclusion changes the demands placed on educators with potentially negative consequences for all students.

Research on general-education teachers and their role in educating students with and without disabilities is particularly important given that general-education teachers are the primary educators for both of these populations. Jim Dewey and colleagues reported in 2017 that the number of special-education teachers declined more than 17 percent between 2005 and 2012; the number of students with special needs also decreased, but by only 4 percent. The student-to-teacher ratio in special education is now greater than the overall student-to-teacher ratio, suggesting that SWDs spend more time with general educators than with special educators. Even SWDs with the most significant needs, such as students with intellectual disabilities or autism, are often instructed by teachers without special-education certification. Since general educators are largely responsible for teaching SWDs, it is critical that we understand their role in teaching all students if we hope to improve outcomes for all.
An Ecological Perspective
Overall, what is known about inclusion from research is quite limited in the context of such a widespread practice. SWDs appear to have better outcomes when educated in inclusive settings, yet studies of the association between setting and outcomes do not account for important differences between the SWDs placed in inclusive classrooms and those who are taught in special-education settings. Students without disabilities have lower academic and behavioral outcomes when they are taught in classrooms that include SWDs, particularly students with an EBD. General-education teachers may welcome SWDs into their classrooms, but they spend more time on classroom management and less on instruction and are more likely to leave teaching when SWDs are present. This limited body of correlational research may not provide many conclusions about inclusion, but it does suggest a framework for future research and policy decisions.

In particular, this research highlights the importance of evaluating inclusion from an ecological perspective. Instead of focusing narrowly on the effects of inclusion on outcomes for SWDs, an ecological perspective would acknowledge that inclusion influences SWDs, their peers without disabilities, and general-education teachers, and should focus on the interactions between and among these three groups. SWDs may influence their peers, but this relationship likely goes both ways. If peer behavior changes in response to the inclusion of SWDs in the classroom, these changes likely influence teacher behavior. Without understanding how inclusion influences all three groups and the complex interactions among them, inclusion is unlikely to be successful for all those involved. The small body of literature that currently exists tends to examine the experiences of SWDs, their peers, and their teachers separately. Moving forward, researchers should focus more holistically on the classroom ecosystem in order to identify the conditions and supports necessary for inclusion to improve outcomes for all students. The results of these studies could be used to develop interventions that support teachers who work with SWDs in inclusive settings, to determine effective service-delivery models that enable all students to access the general curriculum, and to investigate ways that students of different ability levels can benefit from each other.

But considering inclusion from an ecological perspective is problematic in the context of current policy guidance and special-education case law. IDEA emphasizes the importance of making placement decisions based on the needs of an individual student, not the implications of the decision for their classmates or teachers. In its 2017 decision in Endrew F. v. Douglas County School District, the Supreme Court established a higher standard for determining the "educational benefit" a student is entitled to receive under IDEA. The new standard emphasizes the "unique circumstances" of the individual student, and it is likely that these "circumstances" could include the available teachers and the student's classmates. For example, parents and school personnel deciding on where a student should receive individualized reading instruction may weigh the ability of the general-education teacher to provide this instruction in her classroom against the ability of a specially trained teacher to provide it in a pullout setting. IEP team deliberations might also include frank discussions of teachers' skills at meeting the needs of all students in a classroom. Considering such factors means acknowledging the unique circumstances and constraints within a school and the reality that the education of SWDs is not context-free. In fact, a study I conducted with Gary Henry suggests that schools may already be making decisions about how best to educate SWDs based on the available resources in a school. We find that students with autism and intellectual disabilities are more likely to be grouped with other students with similar disabilities in smaller classes taught by special education-certified teachers. The legality of taking this ecological approach to placement decisions is questionable under current federal policy and requires clarification when Congress next revises IDEA.

In the meantime, policymakers and school personnel should keep in mind the limited evidence base suggesting that placing an SWD in a general-education classroom will result in the student making progress in the general-education curriculum. Special education is an amalgam of services, not a place. IDEA requires that SWDs receive educational services based on their individual needs. This means that decisions about where a student is educated should not be dictated by school, district, or state bureaucratic goals related to the percentage of SWDs that "should" be included in the general-education classroom for a fixed amount of time each day. Instead, decisions regarding placement in a general-education classroom, special-education classroom, or a mixture of settings should be determined by students' individual needs. If a student is not making progress in an educational setting, the student is not accessing the curriculum. Oftentimes, students may need intensive and individualized instruction to make progress and gain access to the general-education curriculum. This level of instruction might not be possible if a student is taught exclusively in a general-education setting.

On a related note, policymakers should stop using location or setting as an indicator of access. Increasing the numbers of SWDs in regular classrooms does not necessarily result in improving their academic outcomes, and may unintentionally affect non-disabled peers and general-education teachers. When the numbers of SWDs in inclusive classrooms rises without a concomitant increase in their achievement, it could mean that schools are failing to make individualized decisions regarding placement. This conflicts with IDEA's mandate and will not result in better outcomes for students.

Special education in the United States has long focused on improving SWDs' access to neighborhood schools, general-education classrooms, and the general-education curriculum. Policies and practices have increasingly veered toward inclusion. However, these policies, and the research on their effects, have narrowly focused on SWDs' outcomes without considering the confluence of factors that can affect a classroom. With inclusion as the dominant model in special education, it is imperative that researchers also focus on whether and how these students influence the experiences of their peers and their teachers in order to make schools effective for all children.
Allison F. Gilmour is assistant professor of special education at Temple University.

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Weighing its effects on students with disabilities, their peers, and teachers

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Social Emotional Learning and Student Benefits 

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Social Emotional Learning and Student Benefits 

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Implications for the
Safe Schools/Healthy Students Core Elements

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Understanding Vocabulary Use by Native American Students and the Relationship with Special Education

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Understanding Vocabulary Use by Native American Students and the Relationship with Special Education

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Abstract
The Pueblo People of the Southwest face numerous challenges with reference to language issues. A substantial number of Native American students are placed into special education possibly due to different linguistic abilities. The over-identification of Native American students for special education programs may be due to the lack of knowledge as a product of a limited research base on linguistic differences in the English spoken by Native populations. This study examined one aspect of language, oral vocabulary, spoken by Tewa Pueblo children. The goal of this study was to determine whether there were similar patterns in the use of oral language among the Tewa children. The methodology utilized was qualitative narrative analyses based upon interviews, transcriptions, observations, and field notes. The results revealed that all of the participants used a noticeable amount of non-specific vocabulary and required probing to produce specific vocabulary. The implications indicate the need for more research on Tewa linguistic patterns as well as the need for educators to understand such linguistic patterns to better assess and teach Tewa students.

Public Interest Statement

In education there are still issues of prejudices toward students who are diverse. Although there has been a great emphasis on making education accessible and understandable for all students, there continues to be issues in the way some students, namely Native American students, are assessed and treated. Our research was aimed to understand how Native American students are placed into special education by first understanding how a certain group of Native American students use language. Because language is the basis of all subjects in school, interviews, and analyses were based on the common threads of how these students use language. The research also examined how these same linguistic commonalities could be misconstrued as being a disability rather than a difference.

1. Introduction

There is an overabundance of minority students in special education in the United States. Students from Native American backgrounds make up 19% of students in special education compared to 7% who are from other ethnic minorities (Volante, ). The U.S. Census Bureau reported that in 2010, students who are Native American were 96% more likely to be placed into special education as compared to Caucasian students (United States Census Bureau, ). Furthermore, 79% of the Native students who qualified to receive special education were classified as having speech and/or language disabilities (United States Department of the Interior, ). According to the 2009 New Mexico Annual Performance Report (NMAPR), the reported ethnicity of students who were considered to have a disability is as follows: Hispanic-1472/54.5%, Caucasian-858/31.7%, Native American-288/10.8%, Black-55/ 2%, Asian-7/1%, and Multi Racial 7/3% (New Mexico Public Education Department [NMPED], New Mexico Public Education Department (NMPED), ).

According to the United States Commission on Civil Rights (), the African-American, Hispanic, Native American, and Limited English Proficient (LEP) student populations are over-represented in special education. Artiles and Trent () stated that minorities represent a majority in special education. The authors further suggested that there is a need to examine the trend of minority student overrepresentation in special education in order to ensure fairness in assessment. According to Volante (), addressing issues of diversity in school systems, especially when it comes to diagnoses, is a challenge but also an opportunity to understand fundamental differences that impact student learning.

1.1. Education issues in the Pueblo community

1.2. The focus on vocabulary

1.3. Research questions

In order to examine what the linguistic patterns are among Tewa school-age children, this study focused on the use of vocabulary in conversational speech. This study sought to describe the use of vocabulary to understand linguistic patterns for the Tewa students.

The following were the guiding research questions for this study:

1.4. Population of the study

The Pueblo People of the Southwestern United States reside along the Rio Grande River in New Mexico and are descendants of the Anasazi people (Sims, ). The name for the Pueblo people came from Spanish conquistadors who saw adobe dwellings of various heights surrounding a plaza and described them as "pueblos" or villages in Spanish. The Pueblos include Taos, Picuris, San Juan, Santa Clara, Nambe, Pojoaque, Tesuque, San Ildefonso, Cochiti, Santo Domingo, Santa Ana, San Felipe, Sandia, Jemez, Laguna, Isleta, Zia, Zuni, and Acoma. Although each of the Pueblos has varying populations, they comprise a significant amount of New Mexico's overall demographics. Most of the Pueblos house their own school systems with preschool and elementary services provided by Bureau of Indian Education (BIE), or by the tribe.

2. Methodology

2.1. Participants

There were 20 participants in the study: four kindergartners, one first grader, three second graders, one third grader, three sixth graders, two seventh graders, five eighth graders, and one tenth grader. There were 8 males and 12 females. The mean age was 12 and the mean grade was 3rd. All of the participants were enrolled members of one Pueblo, whose traditional language is Tewa. All of the participants lived on a Tewa reservation at the time of the study, either with their parents or legal guardians, such as grandparents. All of the students considered English to be their primary preferred language used for speaking, but all reported being bilingual or trilingual. A Parent Questionnaire was used to obtain language information including language percentage uses (Table 1).

Understanding vocabulary use by Native American students and the relationship with special education

2.2. Measures

Language sampling is widely recognized by speech-language pathologists as a necessary element for describing children's language abilities correctly (Hadley, ). A language sample is usually a recording and analysis of a student's language ability based on either an interview or conversation. In the speech-language pathology arena, language sampling is commonly used to examine language in order to identify children who have a possible language disability that affects learning a language.

2.3. Procedures

Field notes were taken from observations during all interactions with each participant. The observations were done in both formal and informal environments, such as language sampling testing designations and community events. During the actual language sampling sessions, a digital audio-recorder was utilized to ensure that quality and entirety of the interactions were captured. An individual lapel microphone was placed on each participant to ensure quality recordings.

A pre-designated time was set up with the participants' parents or legal guardians for each of the language samples. Each participant was recorded on separate occasions. During the half-hour session, each participant answered some simple questions initially to build rapport and then each participant was shown a series of pictures. The pictures were color photographs of traditional Tewa dances or places. Each of the sessions included a minimum of 100 utterances for analyses, measured by the researcher's online tally marks. An utterance is a spoken word, statement or vocal sound (American-Speech-Language-Hearing Association, ). Each participant was asked if he or she felt comfortable expressing ideas about their dances with the researcher. All of the participants verbally accepted because the researcher was Tewa also.

2.4. Inter-rater reliability

The rater who performed the second analyses of the transcripts was a certified SLP who had been working in the public school system for over 20 years. The second rater was provided all of the twenty transcripts independently. Each of the two raters determined which pre-determined category each of the transcriptions fell into and then a percentage of the agreement between the raters was calculated. Results revealed an agreement rate of 90%.

2.5. Systematic analysis of language transcripts software

3. Results

3.1. Introduction

Narrative analyses were performed on 20 students, who were enrolled Tewa Pueblo members, in order to determine the semantic patterns among the students during spoken English. The participants' ages ranged from 5 to 16. The students were from the grades kindergarten through tenth grade. Every student was first asked if they felt comfortable talking about their Native dances and they all verbally agreed because the researcher was Tewa also. Each student was shown four pictures of Tewa dance ceremonies in various places and asked to describe the pictures. The results are discussed according to the major themes that emerged from the narrative analyses results. The SALT program was then utilized to analyze specific language constructs such as TTR, the use of non-specific vocabulary and the use of descriptions.

3.2. Participation in the research

The goal for the study was to have at least 30 participants including students ranging from 5 to 20 years old. For recruitment, the researcher asked over 60 parents and/or guardians to provide consent for their children. By the end, only 20 parents agreed. At least 10 parents/guardians communicated that they were interested and willing to have their children participate, but when it came to signing the consent form, they did not sign. Many of the families who were open to discussing why they were hesitant to participate made comments such as "my kid is fine and I don't want to scare him/her" or, "the university should study other people." Even after many attempts on the part of the researcher to try to clearly state the purpose of the study and to reiterate that the university was not the researcher, a Tewa woman was the researcher, a majority of the parents and guardians still declined. The lack of participation as a means of relating the researcher to the university relates to the notions of colonization and imperialism because the parents felt like they were being invaded in some way.

There was a situation where one of the parents told the researcher that she was worried about the research because she, "already felt like everyone was against her," but because she knew the researcher's true intentions, therefore, "she was willing to share her children's minds with others."

3.3. Findings

3.3.1. Use of non-specific vocabulary

During the recorded sessions, all of the student participants showed a willingness to answer questions and communicate ideas. Many of the students demonstrated an excited demeanor when talking about the pictures of Tewa dances. Also, many of the students utilized other means of communication when discussing the pictures. For example, all of the participants used pointing, gestures, and interacted with the photographs while discussing ideas. As a part of the use of these communication methods, 100% of the students used non-specific vocabulary for describing nouns or adjectives.

Non-specific vocabulary is defined as the use of vague terminology to describe an object (American-Speech-Language-Hearing Association, ). For example, some non-specific vocabulary includes words such as "thing," "stuff," "this," or "that." The reason non-specific vocabulary is a focus in many education curricula is because the use of non-specific words most often leads to a misunderstanding in meaning when speaking. For example, if a person says, "Look there are those things over there?" the interpretation could be whatever the listener assumes the speaker is talking about; however, if the same person says, "Look there are those birds over there?" the message is much more clear.

In fact, the Clinical Evaluation of Language Fundamentals-Fourth Edition (CELF-IV), which is the most widely used assessment for diagnosing language disorders, has one whole section dedicated to examining vocabulary use (American-Speech-Language-Hearing Association, ). Likewise, many state-mandated assessments also have a vocabulary component to examine student language ability (Volante, ). As such, all of the student language samples were analyzed for the use of non-specific vocabulary. The Tewa dance pictures were shown so that the images were familiar and relatable to the students' own Tewa world and culture; therefore, less likely to be unfamiliar and increase the likelihood that students would not know the vocabulary (Table 2).

When shown the first picture, a picture of the Tewa buffalo dance at the day school, the students all were able to describe what was happening without the use of any non-specific vocabulary. Most of the students responded to the picture by saying, "That is the buffalo dance," however, when probed further and asked to describe the clothing or background presented in the picture, they used non-specific vocabulary to describe the images. For example, when Student 1 was asked how she knew that the dancers were buffalo she stated, "Because they have those (pointing to head of dancers) on them." When asked, "What are 'those'"? She replied by saying, "Buffalo heads I guess." She was correct in the terminology she used to describe the dancers' headdress, but had the researcher not probed her use of non-specific vocabulary there would have been further confusion about the message being sent. Although the student did point to what she was talking about, on most standardized assessments, pointing is not a credible way to assess expressive vocabulary. Also, on most standardized assessments, probing or re-structuring the questions is not allowed.

Student 2 was similar in how she responded to the first picture of the buffalo dance at the day school. Her first response was, "They are dancing buffalo because I can see that they have these [pointing to picture] things." In response, the researcher stated, "Ok. Pretend I can't see you pointing. What word can you use to tell me what these 'things' are?" The student replied, "Oh um, these are like fluffy and come from buffalo. I think they are just called buffalo heads." Again, like Student 1, she was correct in that she knew what the object was, but used non-specific vocabulary to describe the picture at first.

For Student 3, the results again were similar. She stated, "They're dancing buffalo" when first asked to describe the picture and when asked, "how do you know that?" she stated, "Um because, [paused 10 s] they have those [pointed to picture\." When the researcher probed further, by asking, "what are those?" Student 3 said, "Um, those are buffalo, um [paused 5 s] heads." It appeared that even though the student knew the correct terminology for the buffalo head, she first used non-specific vocabulary by using the word "those."

This same pattern emerged at least three times each with every single student who participated in the study. The following are the direct quotes from students that showed how they used non-specific vocabulary during the sessions with the researcher (Table 3):

Student 1

Because they have those [pointing to head of dancers] on them.

Yeah [paused 7 s] ... The girls are wearing those dresses [pointing to picture] and the boys are wearing those skirts [pointing to picture].

Well [paused for 8 s], they have those things, I mean, they have um, [paused for 5 s] feathers too.

Student 2

They are dancing buffalo because I can see that they have these [pointing to picture] things.

Well like because you can see this thing here, um,[(paused 6 s], this portable is at the day school [pointing to picture] but it looks different now. And even because you can see these [pointing to picture] um, chairs and stuff. We don't have those anymore.

The buffalo dancers are dressed different because they have more stuff on.

[Paused 10 s] yeah, the girls have those [pointing to picture].

And um yeah [paused 5 s] the girls also have these things [ pointing to picture].

And they have [pointing to picture] these.

Student 3

Um because, [paused 10 s] they have those [pointed to picture].

Because, um, [paused 6 s], this thing is here..."

"He has those things [pointing to picture].

Because there are these [pointing to picture] and those.

Um, he, like um [paused 7 s] has these [ pointing] and um they like make noise.

Because um they like um have these fluffy things.

Um the dancers have different um these [pointing].

Student 4

Trees and um, other stuff.

and to pray to get stuff.

Oh cause this one [pointing] has feathers and this other stuff.

Because I can see these things [pointing].

They have those [pointing].

They have like those things ...[paused 10 s] sticks.

Well um like there is this stuff all over.

Student 5

That plants have to have water, and sun and other stuff to grow.

Because they have long hair [pointing] and they have the um feathers [paused 7 s] and they have those things that go around their head like that (motioning to circular motion around head).

Um because the um the deer have long horns and the buffalo have like a thing that goes down here [motioning to self on the back].

And um for the legs, [paused 6 s] they have those ones [pointing].

Because I knew more about the people and dances and stuff.

Student 6

Because they have those things [pointing].

Um [paused 17 s] um those are those um buffalo heads.

There are those people [pointing] who watch the dance and then there is more people who dance the dance.

Student 7

Um cause they have their dancing stuff on.

Um they have that on [pointing].

Cause they have these [ pointing]

I see these guys [pointing].

Cause they have bells on and they have these um things ...

But he likes boy things.

Student 8

Student 9

Student 10

And they have an um, an um [paused 5 s] those things on [pointing].

Oh and they have those things in their hands [pointing].

Oh and um they have on these things too [pointing].

Or they don't have the same head things on.

Just that they have those things right there [pointing]...

I can see these over here [pointing].

And they have these [pointing] um these ...um.

Student 11

Playing with this.

Cause um they have those things [pointing]!

There are those other ones too!

Um they have these things [pointing].

And um [paused 7 s] they have these different things!

Oh and these [pointing].

Oh and um they have these things on!

Yeah um you can see that part [pointing].

Um [paused 12 s] [picked up picture] oh um I see these things over here [pointing].

[Paused 6 s] oh um cause they have these [pointing] things!

Student 12

Student 13

Um these guys [pointing] are singing.

Um [paused 6 s] because they have this [pointing].

Cause um [paused 7 s] there are these[(pointing] and those.

Um ok well [paused 7 s] they have those and those and those....[pointing]

Oh um they have these [ pointing)]

Student 14

Student 15

Um [paused 7 s] we are learning how to inlay stones and um [paused 5 s] and how to use all of the things ...

Well [paused 6 s] because you can see these [pointing].

Well um [paused 6 s] the dancers have the head things ...

And these ones [pointing] are dressed different on top.

These ones [pointing]!

Um yeah these [pointing].

Um they have the same as deer except for that they wear these things ....(paused 8 s) that um go over their body.

Yeah. I like like learning about different things.

Student 16

Yeah, and is it a horn thing?

They have their things on [pointing].

Um you see this thing.

Student 17

Because the guys have a buffalo head and they girls have those on their heads [pointing].

They have mantas, and rattles and those [pointing] things and the deer have sticks and antlers and quilts.

They are wearing the feather of the stuff.

Student 18

Because of the stuff um I mean the clothing.

[Paused 8 s] Cause the plaza doesn't look like this [ pointing].

Well um because they have these things [pointing].

And the houses surround it [ pointing].

They are wearing those head things.

Student 19

Student 20

Um cause you can see their buffalo things.

Ok um [paused 7 s] they have these things and their dresses and moccasins and feathers.

There are these guys [pointing].

Um cause I can see these big windows and those things on the roof.

Oh and my Mom wanted me to give you this.

The results demonstrated that the students who participated in the study used non-specific vocabulary when speaking. All of the participants used non-specific vocabulary more than 20% of the time. The transcripts showed that the students consistently used non-specific vocabulary most often to replace adjectives and nouns. Also, the transcripts showed that the students utilized pointing and gestures consistently when describing the pictures. The students would either point or demonstrate behaviors when they used the non-specific vocabulary and the students used gestures in conjunction with the non-specific vocabulary as an aide to communication. As noted earlier, in most standardized assessments, pointing is not an acceptable demonstration of expressive vocabulary. Table 4 shows the number of times each student used non-specific vocabulary to replace nouns vs. adjectives in the 100-utterance sample.

It must be noted that Student 16 utilized the most Tewa words in his description of the pictures. His guardian is a Tewa teacher and reported that they use Tewa in the home. Because of his reported comfort level with Tewa, the researcher told him if he would rather use Tewa to talk about the picture that was acceptable. He had the fewest uses of non-specific vocabulary possibly because he would use Tewa words when he did not have a word to use in English.

At this time, there are no standardized assessments that consider the use of Tewa words to be an acceptable language to examine vocabulary repertoires. The reasons for the lack of knowledge about Tewa could be due to the lack of research surrounding Tewa, the lack of people who speak Tewa, and also because of the guarded nature of the Tewa communities.

Although the participants used non-specific vocabulary throughout the transcripts and some of the communications may have initially appeared to be confusing, when probed or cued, the students were able to provide the appropriate vocabulary in English for which they originally used non-specific vocabulary.(Table 5)

4. Conclusions

4.1. Summary of results

The following were the guiding research questions for this study:

Are there unique pattern(s) of English vocabulary spoken by members of one Tewa community? If so, what are the pattern(s)? The results that emerged from transcripts were as follows: All of the students utilized a noticeable amount of non-specific vocabulary when describing the pictures of Tewa dances in various places, and when asked to clarify, the same students were able to provide specific target vocabulary. The researcher probed the students by either asking further questions or by providing leading statements. The students also used descriptions more than 10% of the time in their language to describe vocabulary. A majority of the students reported using English as the primary means to communicate; however, several of the students used Tewa words in conjunction with English. All of the homes reported using at least two languages.

The impacts of the Tewa language on the spoken English of Tewa students are unclear but definitely present. Even though all of the students either self-reported or the parents reported that they spoke English primarily, all of the homes were either bilingual or trilingual in nature. Many assessments and even interview protocols ask parents and/or students about the presence of another language in the home for considerations in language ability, but many do not consider biculturalism or triculturalism a concern for language. In the Tewa community, because the Tewa language is ingrained into the culture and ceremonies, it is difficult to separate the language from culture; therefore, the term bicultural or tricultural in the Tewa community defines the use of different languages in many facets of life.

Although there are no standardized assessments that examine language ability that use Tewa words or cultural pictures, current assessments must be viewed as merely a tool for discovering patterns. Because Tewa words do not translate into English well and vice versa, there must be some exceptions to how Tewa students use vocabulary.

4.2. Possible reasons for results

There may be several reasons why Tewa students utilize non-specific vocabulary in spoken English. Furthermore, there may be several reasons why these same Tewa students were able to provide the specific terminology when asked for clarification by the researcher. Because Tewa is highly guided by non-verbal cues, many Tewa people, even if they are not fluent in Tewa, speak English using a noticeable amount of gestures. The results from the parent/guardian survey showed that all of the homes of the participants were bilingual and bicultural. Even though the parents/guardians may not consider themselves or their children bilingual, the entire Tewa culture is based upon the Tewa language. It is impossible to separate language and culture in for the Tewa people.

Tewa is descriptive in nature. Many Tewa words describe objects and do not name objects. For example, even Tewa names are descriptive of places or animals. Many Tewa words such as the word for car, which translated means "wind wagon," are based on the premise that the description of the item is far more communicative than a name. In 100% of the students' responses to the researcher, the students were able to describe the objects that they were discussing, and then were able to provide the specific vocabulary. The clarifying questions functioned as leading the student's thoughts from descriptions to actual vocabulary.

Many Tewa words do not translate well into English. For example, a word known as "wi sigi" would translate loosely to "love" in English. But in Tewa, "wi sigi" means much more than love. It involves aspects of respect, admiration, and connection. All of the homes in the study were bilingual or trilingual with all homes having Tewa usage. Because many of the Tewa students come from a foundation of Tewa speakers in the home, it is difficult for Tewa speakers to translate meanings. For example, much of the vocabulary used in English is simply not present in Tewa and vice versa. This lack of translation from English to Tewa then creates a type of barrier between the languages. How can a student be asked to name vocabulary that is present in their Tewa vocabulary but not in English or vice versa? This transference can only lead to non-specific vocabulary use as a first means of description until both linguistic foundations can merge. Most state and national mandated standardized assessments do not take this complicated linguistic interaction into consideration.

Many Tewa people speak a form of Native American English, which was described in detail early in the literature review. Although, prior to this study, there were no studies done about the specific way Tewa speak English; many Tewa people speak English in such a way that they can be identified as being Tewa people simply by the way they speak. It is possible that if the entire community speaks English with the use of non-specific vocabulary because of interactions between Tewa and English, the younger generations would also speak in a similar fashion. In this study, there were no differences depending on age or grade, which contributes to the ideas that all Tewa students are using a similar way to speak English. The foundations for learning English are probably introduced by Tewa speakers; therefore, the students most likely represent their home language influences (Sims, ; Suina-Lowery, ; Villa & Villa, ; Volante, ).

Because the students were able to connect a vocabulary word with the non-specific vocabulary word with probing, it is highly unlikely that they are disabled in language ability. If anything, the results of this study showed that Tewa students do know specific vocabulary when probed. Many assessments that are used to analyze language ability for diverse students do not take into account bilingualism and especially do not recognize biculturalism as a factor for communication results (Volante, ).

According to Labov and Waletzky (), Villa and Villa (), as well as Sims (), indicating unique linguistic features in a group of people involves finding unique linguistic cues among a diverse group of participants from the same cultural group. Although this study only focused on school-aged students, the same unique vocabulary use discovered in this study may be present in the whole community. Children often reflect the language use of their homes (McCarty, ). If this notion is discovered to be true, there is a high probability that these same unique patterns present in the participants are also present within the rest of the community.

4.3. Significance of research

Cultural imperialism has led to the over identification of Native students in special education because of the use of standardized approaches that are biased to Native students. The results indicate a need to test with other measures or in a variety of unstandardized ways such as dynamic assessment. The results of the research revealed the need for dynamic assessment when examining the language ability of Tewa students. According to American-Speech-Language-Hearing Association () dynamic assessment is "a method of conducting a language assessment which seeks to identify the skills that an individual child possesses as well as their learning potential. The dynamic assessment procedure emphasizes the learning process and accounts for the amount and nature of examiner investment. It is highly interactive and process-oriented" (p. 5). In dynamic assessment, the examiner conducts interviews, language samples, and other means of understanding language ability beyond a standardized assessment. In fact, the types of questions asked when the students were asked to clarify their responses could be viewed as dynamic assessment. As such, students were able to show their expressive vocabulary in a way that would not be possible with strict adherence to a standardized assessment.

The results of the study also demonstrated the need for an understanding of the relationship between language and culture. Even though all of the students felt comfortable speaking about the Tewa dance pictures, non-specific vocabulary was still present. Now, if these same students were provided pictures that were unfamiliar, the use of non-specific vocabulary may have increased because of the lack of knowledge or background about the pictures being shown. For example, there is a picture on CELF-IV assessment that shows a scene in a city where people are walking on the street and there are tall buildings and traffic lights. Considering that most Tewa communities do not have these features in their environments, asking a Tewa student about such a scene and expecting to gain knowledge about vocabulary and language use may guide poor results. In the student transcripts, all were able to describe the scene of dancing in the plaza with probes because they were familiar with the cultural and social expectations of the picture. These results of the study have several implications for educators.

There is a need for further work and research to establish the unique linguistic patterns among the Tewa people. Further research should be more extensive to examine various ages among the Tewa. Also, further research should examine a range of aspects of language such as morphology, syntax, and phonology. The need for the extensive research in the area of Tewa linguistic patterns is crucial to understanding whether the patterns in this study truly reveal patterns of a unique dialect.

4.4. Implications for educators

The following are issues for educators to consider when working with students from a Tewa background:
Community Considerations
Remember that although many Tewa communities are similar, they are still very unique. These considerations are merely a guide for interactions with Tewa communities in general. Because all Tewa communities share a common thread of language loss and the crucial demand of language on culture, educators must define the specific community need on a more individual basis.
Student Considerations
When working with Tewa students, there are some considerations that educators should be aware of:

4.5. Implications for future research

The implications for future research involve a further and deeper understanding of the patterns in language use among Tewa students. This study only examined the vocabulary patterns among the participants; however, there is a need to examine the other aspects of language patterns such as the syntactic, morphological, phonological, and especially pragmatic language patterns because of the effects of non-verbal cues on language in Tewa communities.

Because the Tewa language is being lost, many younger generations do not speak Tewa fluently even if their parents and guardians do speak Tewa fluently. This shift in language ability among the generations may be a clue as to how students are speaking English. This study examined school-age children only. Further research may extend the research to examine all ages of Tewa speakers so that comparisons can be made in terms of language ability in different generations as well as the importance of Tewa influences on English.

Currently, research is still an issue that needs to be understood as a means to develop and learn about Tewa communities. In order to not function as a mode of destruction, future research must carefully consider the needs and desires of the community itself. Only through the results of positive research studies will the barrier of research among the Tewa and other Native American communities diminish. One way to accomplish this goal is to help Native American students succeed through education so that they themselves can be the researchers who produce positive outcomes for their communities.

Because of the unfortunate history that Native people have endured, there may never be enough research to fully understand the complexities of language, culture, and special education. Cultural imperialism has impacted the interactions of Native people in today's society and in education. This study is only a piece of the research needs that impact Native people.

4.6. Limitations

The limitation of this study is that the research only examined one element of the language system for Tewa students. Vocabulary was the focus; therefore, other linguistic systems such as syntax, morphology, and phonology were not examined. Also, because the study focused only on vocabulary, the finds of pausing and other pragmatic language interactions were not fully explored. Also, there was a wide range of ages in the population of this study, and the influence of the student's age was not specifically examined.

The implications provided from this study were not all directly delineated from the results, but were a combination of implications obtained from literature research results, personal cultural experiences, and communication interactions. Further research needs to address more in depth the noticeable pausing phenomena among the Tewa students, the other linguistic systems such as pragmatic language as well as cultural language transference issues.

4.7. Final thoughts

Language is like a beaded medallion: full of complex weavings and beautiful colors and designs. In order to completely understand how language impacts Tewa people in education, educators must be willing to view the beauty and complicated detail. Just like a woven object, the overall product cannot be sustained without many different parts coming together to create a strong solid production. This study is only a small piece of the work that needs to be performed to understand the linguistic patterns of Tewa people. Just like beading, research aimed at understanding the language of Tewa people is worthy of artistry and skill.

Although research is still taboo for many Native American communities, positive outcomes from research, such as this study, will help to diminish the hesitancy of Native communities to be open to learning about how our people and culture interact with the world around us. The researcher comes from a history of people who loved to bead. Beading itself requires the ability to take different entities and connect those parts with a strong idea of an end product. And so goes the hopes for connecting education, research, and Native people to ensure a strong, beautiful future.

Code

Highest ed self (parent/guardian)

Highest ed spouse

Occupation self (parent/guardian)

Occupation spouse

Additional information

Funding

Funding. The authors received no direct funding for this research.

Notes on contributors

Leslie Costa-GuerraWe as scholars seek to generate inquiry and dialog around the issues of diversity and education. We have researched assessment, technology, language, and communication issues surrounding students who are diverse in the school system. It is our hope that we can reduce biases and unjust practices in education toward students who are diverse.

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# data[].attributes.attachment_link.title
Understanding vocabulary use by Native American students and the relationship with special education

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Abstract The Pueblo People of the Southwest face numerous challenges with reference to language issues. A substantial number of Native American students are placed into special education possibly due to different linguistic abilities.

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Experiencing higher education in Louisiana through a Native American lens

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Experiencing higher education in Louisiana through a Native American lens

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Colonial contexts continue to shape the experiences of Indigenous students, especially in special education, even as educators work to respond to Indigenous perspectives. In this article we first apply a decolonizing critique to consider how colonialism affects special education programming, then survey Indigenous and decolonizing scholarship to (re) imagine how educators may start to address these concerns.

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Introduction: Justifying SEL in Primary Schools in Aotearoa New Zealand

Social and Emotional Learning (SEL) is a burgeoning area of educational research and its presence within the online or offline classroom is all the more important when considering student wellbeing in the face of COVID-19. Marsay states we need SEL interventions "more than ever" to "learn strategies to deal with adversity" ( 2020, p. 4). This article explores the key reasons or requirements for SEL within schools in Aotearoa New Zealand, establishing both a need within schools, a call from teachers and a gap in research relating to our unique cultural and emotional context. From there the article draws on Māori, Indigenous, Pasifika, international psychology and decolonialisation authors to begin to conceptualise an appropriate approach for Aotearoa New Zealand primary schools and the directions research could take to aid this.

Researchers suggest that, due to the COVID-19 pandemic, there has never been a time when there was such a need for SEL (Gehlbach & Chuter, 2020; Hadar et al., 2020; Katzman & Stanton, 2020; Marsay, 2020). Although teachers have taught forms of SEL for years (albeit with neither a focused curriculum nor the catchy acronym), it is now increasingly recognised as an essential new part of international educational curriculum development and research. Gehlbach and Chuter's ( 2020) overview of this area of education suggests the need for "conceptualising the core of Social Emotional Learning" (p. 24). An increasing number of models are promoted, including "The Collaborative for Academic, Social and Emotional Learning (CASEL), Transforming Education, The Aspen Institute, European Commission Network of Experts on Social Aspects of Education (NESET), and many others" (Gehlbach & Chuter, 2020, p. 25). CASEL and the predominantly North American authors influencing this field have produced a plethora of empirical research reporting the many benefits of SEL, such as improving classroom environments, academic success, social and emotional skills, as well as reducing disruptive and harmful behaviours (Brackett et al., 2012; Durlak et al., 2011; Hagelskamp et al., 2013; Rivers et al., 2013a, b).

Wellbeing is not just a warm, fuzzy recommendation for schools. It is explicitly included within our curriculum documents and required by ERO ( 2015, 2016a, b) and NZCER (Boyd et al., 2017). Te Whāriki, the Early Childhood Curriculum (MOE, 1996) is renowned for its intentional focus on adopting a more holistic, relational, culturally responsive pedagogy (Arndt, 2012; Jenkins, 2016, 2017; Ritchie, 2012). It incorporates wellbeing/mana atua as a strand of the woven mat (whāriki), stating the goal that "their emotional wellbeing is nurtured" (MOE, 1996, p. 15). In comparison, the primary and secondary curricula (MOE, 2007) includes "wellbeing, conceptualised as hauora" (O'Toole et al., 2019, p. 91). (Hauora is a Māori term encompassing a holistic wellbeing concept that is discussed in the next paragraph.) Soutter et al. ( 2012) report that this document (MOE, 2007) has a much more narrow, individualistic emphasis than that of the early childhood document (MOE, 1996).

The New Zealand Curriculum for English- medium teaching and learning for years 1- 13 (MOE, 2007) also identifies five Key Competencies to be included within school programmes: thinking; relating to others; using language, symbols, and texts; managing self; and, participating and contributing. While these all have some relationship to SEL, it is hard to conceive managing self and relating to others without learning something about emotions and social interaction. Both competencies align with CASEL's model of SEL, which summarises 20 years of SEL research into five competencies: Self Management, Self Awareness, Relationship Skills, Social Awareness, and Responsible Decision-making (CASEL, 2019). With social and emotional competencies to support wellbeing already integrated across the school curriculum, the framework is set to enable teachers to incorporate these areas of learning into their classroom practices. However, wellbeing and hauora are wide-ranging terms: how might researchers and practitioners conceive translating these broad concepts into pedagogy?

In Whaiora, Durie ( 1998) begins this process of elaborating and exploring the broad terms or directions. His concept of Te Whare Tapa Whā is renowned and well utilised throughout the health sector. Within the section headed "Health and wellbeing," Durie introduces the Whare (Māori house) with four pillars holding up the roof: Taha Wairua (Spiritual Wellbeing), Taha Hinengaro (the holistic capacity for thinking, feeling and communicating that Durie terms "Mental" Wellbeing), Taha Tinana (Physical Wellbeing) and Taha Whanau (Relational wellbeing) (Durie, 1998, p. 69). As noted above, this model is referenced as underpinning the conception of "Hauora" within the New Zealand Curriculum (ERO, 2016a, b; MOE, 2007). While this is a positive step, isolating the model from the more profound understanding of history, place, culture and context, can create tokenism and hinder progress, as Durie's entire volume illuminates ( 1998). He specifically highlights the contradiction of promoting health and wellbeing while denying aspects of culture and identity (Durie, 1998, p. vii). This issue was elucidated 27 years ago in the first edition of Whaiora and then in its many subsequent editions. Although seated within a long reaching history of colonising violence, it remains a current issue, generally, and one which must be considered in conceptualising SEL. In the remainder of this article, "Whaiora" the title of Durie's ( 1998) book will be used to not only represent Te Whare Tapa Whā and Hauora but the links to environment, history, equity/power issues and land, holistically. Whaiora means "who has wellbeing" and relates directly to a holistic view of health, according to the Royal Australian and New Zealand College of Psychiatrists ( 2000, vii), having consulted with Te Taura Whiri i te Reo Māori.

Malatest International ( 2016) through the New Zealand Ministry of Health, produced a report evaluating the national Youth Health Service. It notes the need for Tikanga Māori, ('ways of doing' in keeping with Māori values and worldviews), stating, "evidence suggests that for some Māori service users it is important to be able to access a service provider who shares their Māori understanding of health and wellbeing" (Malatest, 2016, p. 37). Taking this evidence from the health sector into education, a need is highlighted for researchers, schools and teachers to better understand Whaiora and the cultural aspects underlying SEL.

However foundational, Durie's ( 1998) Whaiora remains a broad concept, and further research and development are needed to embrace all that it offers. SEL grounded on Whaiora acknowledges the historical, political and cultural structures within the Aotearoa New Zealand context. It becomes a potential vehicle to create culturally safer spaces and move on an uncharted road towards decolonisation of the curriculum. The Prime Minister's Youth Mental Health Project, launched in 2012 (cited in ERO, 2016a, b), and the subsequent ERO Wellbeing for success: A resource for schools ( 2016a, b) link to culture, wellbeing and academic success with SEL, including references to CASEL. In conjunction with the use of the North American organisations, ERO ( 2016a, b) chooses to draw heavily on prominent New Zealand Indigenous researchers to inform implementation, paving the way for SEL research in New Zealand to do the same.

While literature indicates the unequivocal integration of wellbeing and bicultural practices in early childhood education (Arndt, 2012; Jenkins, 2016, 2017; Ritchie, 2012), these are not as apparent within primary or secondary education research and practices (Soutter et al., 2012). This glaring gap integrating holistic wellbeing practices into primary schools was reinforced in Wellbeing for success: A resource for primary schools (ERO, 2015):

This report identifies that Years 7 and 8 were particularly important years in terms of wellbeing, due to the greater risks faced as children get older and the cumulative effect of how well their wellbeing needs had been met in previous years (p. 3).

Current Teacher Practice of SEL in Primary Schools in Aotearoa New Zealand

Exploring Different Ways of Viewing SEL

Any approach to SEL in Aotearoa New Zealand will need to be premised on our bicultural Treaty of Waitangi foundation. Research into a response that incorporates many different cultural ways of knowing, being and doing to support emotional wellbeing may be appropriate. Similarly, this article and any research conceptualising this topic benefit from the intersection of multiple viewpoints and disciplines.

An International View of SEL

I am concerned that SEL could become another method that determines not only which epistemology is important but reinforces westernised, hierarchal, homogenising power structures, defining which ontological values are 'correct'. Our emotions are linked by some emotional appraisal theorists to culture, to what we prioritise, what we value, to our very being (Goodman, 2019).

While O'Toole et al. ( 2019) focus on overviewing SEL in New Zealand, they discuss international recommendations such as North American Carol Ryff's ( 1989) Personal Well-Being model. (Refer also Ryff, 2014). The relevance of American research is debatable in the unique bi-cultural setting of New Zealand, but Tayor et al.'s ( 2017) meta-analysis of 82 schools with school-wide SEL interventions in place ("38 of which were outside of the USA") is useful in validating the push for SEL (O'Toole et al., 2019, p. 96). The study found fostering SEL skills and positive attitudes provides students with markedly long-term (up to 18 years) improved outcomes in wellbeing and protection against adverse effects (Taylor et al., 2017). O'Toole et al. recommend "experimental research" into the content and processes of SEL in Aotearoa New Zealand as a result ( 2019, p. 99).

SEL in a Treaty of Waitangi and Bi-cultural Context

The inclusive and respectful way in which the MOE and ERO prioritise wellbeing inspires an opportunity to research SEL free from universalising views to incorporate Māori's position as Tāngata Whenua (Indigenous people of Aotearoa New Zealand). The Teaching Council of New Zealand's Standards for the teaching profession require that educators:

Understand and recognise of the unique status of tangata whenua in Aotearoa New Zealand;

Understand and acknowledge the histories, heritages, languages and cultures of partners to Te Tiriti o Waitangi;

Practise and develop the use of te reo and tikanga Māori (n.d., p .1).

Therefore, all education in Aotearoa New Zealand needs to include Kaupapa Māori (values, principles and goals) and te ao Māori perspectives (the broad holistic Māori worldview), as well as Tikanga Māori (Andreotti, 2009; Macfarlane et al., 2017). This article proposes that SEL presents a unique, pedagogical opportunity and an ethical responsibility to create culturally safe spaces aligned to tikanga, kaupapa and te ao Māori.

In line with the holistic Māori ontology described earlier, student wellbeing suffers when the academic focus is compartmentalised from emotions. For Māori, thoughts and feelings come from the same place (Durie, 1998). For a classroom to be socially, emotionally and culturally safe for Māori students, a more open, connected environment is essential. Consequently, it is not only about incorporating a holistic, cultural viewpoint but also emotive, empathetic care and understanding into the classroom that is crucial to Māori student wellbeing.

O'Toole et al. ( 2019) determined that "imbuing SEL approaches with te ao Māori perspectives, inclusive of mātauranga Māori (Māori knowledges), experiences and spirituality, should enhance the authenticity of any SEL intervention programme for both teachers and children/students and their whānau, hapū, iwi and community" ( 2019, p. 97). Māori authors caution that programmes must not be prescriptive, but deeply collaborative (Kohtahitanga or Taha Tangata), not only between teachers and students but within each whānau, hapū and community (Bishop & Berryman, 2009; Habib et al., 2013; Macfarlane et al., 2007; Macfarlane et al., 2017). Otherwise, the theoretical and conceptual basis would do the opposite of enhancing authenticity.

Even the very term SEL does not appear to align with Māori or Pacifika epistemology and ontology. It is effectively compartmentalising Taha Hinengaro, contrary to Durie's holistic view of Hauora. For Māori the metaphorical "heart" or ngākau is where both emotions and thoughts come from, and many Māori emotions' words are linked to parts of the physical body (Durie, 1998; Jones, 2017; Macfarlane et al., 2017). Emotional wellbeing and the teaching and learning regarding it not only relate to thoughts and physical occurrences, but to space, time, relationship to the land, whakapapa (heritage), to values, spiritual beliefs and ways of knowing, being and doing. Durie ( 1998) states "Understanding occurs less by division ... than by synthesis into wider contextual systems" (p. 70) and that wellbeing is "viewed as an interrelated phenomenon rather than an intra-personal one" (p. 71). There are many reasons SEL does not fit with a holistic view of wellbeing. Therefore, I will refer to Cultural, Social and Emotional Learning (CSEL) for the remainder of this article, to describe a way of beginning to reconceptualise this interrelated, holistic, culturally embedded view of moving toward greater hauora and wellbeing.

A Multicultural View of the CSEL 'Space'

Along with incorporating a Māori world view, any CSEL approach appropriate for Aotearoa New Zealand primary schools must take into account the increasingly multicultural, multi-lingual context of this country. Intentionally planning educational strategies that encompass cultural difference to produce positive student outcomes is emphasised by Habib et al. ( 2013). The mono-linguistic and potentially homogenising approaches used in other countries will not meet this brief. Since emotions link to the epistemological and ontological core of who students are, ignoring this could be all the more damaging for students of minority cultural groups. Educational research in Aotearoa New Zealand has an opportunity to utilise an innovative, interdisciplinary approach to operationalise CSEL for our diverse context.

Savaii explores wellbeing from a 'Pacific youth' perspective and proposes that "the literature on New Zealand youth wellbeing pays little attention to the Pacific holistic understanding of wellbeing, which reflects a harmony in people's spiritual, social and physical relations" ( 2017, p. 5). She critiques the deficit-theorising behind current models and highlights that Pacific youth "fared better than their New Zealand European counterparts on the spiritual faith dimension" ( 2017, p. 6). Savaii concludes that this dimension is "often dismissed as unimportant to policy decisions, with youth status on the economic indicators highlighted and prioritised instead" ( 2017, p. 6). Taleni et al. ( 2018) identify the need to explicitly incorporate Pasifika "Cultural values, principles and languages" as a foundation to the learning environment for student success. The Fale Model for the Pasifika success Talanoa project framework incorporates "respect, love, service, relationship, spirituality, reciprocity, family, leadership, integrity, belonging and inclusion" as its crucial foundation (Taleni et al., 2018, p. 184). Similarly, the Ministry of Social Development (MOSD) ( 2012) identified respect, belonging, reciprocity, spiritual centrality and acknowledgement and identity with Pasifika heritage and languages as key concepts underpinning Pasifika wellbeing. This research demonstrates some of the many concepts linking to Pasifika ways of knowing, being and doing to be included in a reconceptualised, cross-cultural CSEL space that is inclusive and assists in the wellbeing of the Pasifika students of Aotearoa New Zealand.

For the educational space to be appropriate for Māori, Pasifika and the many other cultures, New Zealand classrooms require CSEL to be framed as cross-cultural communication. Authors outline the many misunderstandings and damage that can occur if this cross-cultural context and differing world views are not acknowledged (Hall, 2002; Metge & Kinloch, 1993; Ting-Toomey & Chung, 2005). Devine et al. ( 2012) challenge the metaphorical bicultural education mat of Te Whāriki, suggesting that in multicultural reality of New Zealand, different fala (woven mats) could represent a new connecting, relational education space.

Literature indicating different viewpoints explored thus far combine to illustrate a pressing need within CSEL research to focus on creating a space that allows the ngākau to be heard and culturally diverse voices to speak about emotions, values and ways of knowing and being in an empathetic way.

What Might Research and Practices Within This CSEL Space Focus on in the Future?

Listening and Dialogical Practices

This multicultural space of empathy would need to include listening and dialogue that acknowledge the social, emotional and cultural realities of students. Many culturalists are calling for a move within classrooms to 'listen to culture' (Bishop & Glynn, 1999; Clark, Smith & Pomare, 1996; Hohepa, 1993; Macfarlane, 2000; Penitito, 1996; cited in Habib et al., 2013, p. 172). Sharon Todd's Toward Imperfect Education ( 2009) inspires towards the messy, yet healthy, starting place for such a CSEL space, along with many other relevant authors (Andreotti, 2009; Berryman & Eley, 2017; Davies, 1994; de Sousa Santos, 2016; Devine et al., 2012; Jones, 2017; May, 2009).

Considering listening and dialogue in such a space links to Freire's Pedagogy of the oppressed (1970, 2001). He connects social interaction with the ontological and epistemological, noting it is starkly different from the everyday conversation (Freire, 2001, p. 170). This is a dialogical space that teacher and students will step into acknowledging the taonga (precious treasures) each brings to it. Freire's ( 2001) dialogue is linked to the historical past and power-differentials and is about entering that conversation and space knowingly and intentionally. The way in which this concept ties into this reconceptualisation of CSEL is summed up by Freire and Macedo in "A dialogue: Culture, language and race":

In order to understand the meaning of dialogical practice we have to put aside the simplistic understanding of dialogue as a mere technique ... dialogue characterises an epistemological relationship. Thus, in a sense, dialogue is a way of knowing and should never be viewed as a mere tactic ... I engage in dialogue because I recognise the social and not merely the individualistic character of the process of knowing. In this sense, dialogue presents itself as an indispensable component of the process of both learning and knowing ( 1995, p. 379).

Care, Empathy and Manaakitanga

Authors from many different backgrounds and disciplines point to care, empathy, understanding and manaakitanga as being the way to nurture emotional wellbeing; yet, there is very little clarity on the means teachers might use to achieve this. Davies ( 2014) explores the knowledge needed to move the primary school students she studied to "look at each other with compassion not driven by social exclusion anxiety, but by a shared sense of social justice" (p. 59). She goes on to ask what teachers could do to help students towards this.

Conclusion

Rather than choosing one lens to study SEL, this article seeks to open a theoretical discussion at the intersection of differing viewpoints. It does not seek compromise, or even common ground necessarily, because some work does not stand up to critique when viewed through a different lens, but to seek signs (key research and theories) that direct us to new ways of seeing SEL. The convergence of the various disciplines or fields of knowledge provides different lenses through which to look at the same thing. It is to be hoped, therefore, that the theory emerges more holistic, more balanced and equitable from this point of intersection.

This article concludes that research is needed to reconceptualise SEL into CSEL for Aotearoa New Zealand. It will need not only to acknowledge holistic Māori ways of knowing and being but create a safe cross-cultural space for many different emotions and world views to be heard. While this article acknowledges the international research into SEL, te ao Māori viewpoints have also been championed, much in the way that our educational spaces need to respond to the call of the Treaty and decolonisation. Listening to culture within the SEL space is crucial, more specifically dialogical practices and manaakitanga, which connect to the diverse ways of knowing and being under emotions. Research reconceptualising SEL will also need to acknowledge the effects of the colonial past of Aotearoa and its current effects on the space. The CSEL that has begun to be conceptualised would need to be collaborative, with the teacher, student, whānau, iwi, hapū, multi-lingual and multicultural resources and communities all being a part of the extended classroom. Within the multicultural context of Aotearoa New Zealand, influenced by Te Tiriti o Waitangi, it is essential to ensure that the CSEL model is flexibly co-constructed to celebrate different ways of knowing, being and doing. If research can theorise and conceptualise CSEL on this basis, we may move towards supporting diverse students' emotional needs in revolutionary new ways.

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K. A. Goodman

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Goodman, K.A. Conceptualising SEL in the Cross-Cultural Spaces of Primary Schools in Aotearoa New Zealand. NZ J Educ Stud 56, 285-299 (2021). https://doi.org/10.1007/s40841-021-00213-4
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DOI: https://doi.org/10.1007/s40841-021-00213-4

Keywords

Social and emotional learning

Wellbeing

Bicultural spaces

Empathy (4-6 words)

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Conceptualising SEL in the Cross-Cultural Spaces of Primary Schools in Aotearoa New Zealand - New Zealand Journal of Educational Studies

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Social and emotional learning (SEL) to support students' wellbeing is even more critical within schools dealing with the COVID-19 pandemic. This article establishes why New Zealand primary schools need strategies to support the emotional wellbeing of students and why a prescriptive approach is not appropriate for the bicultural and multicultural classroom context.

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Effects of a Targeted Art Program On Social Emotional Learning - EBD Students 

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Effects of a Targeted Art Program On Social Emotional Learning - EBD Students 

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Effects of a Targeted Art Program On Social Emotional Learning in Students with Emotional Behavioral Disorders

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Art Therapy for Psychosocial Problems in Children and Adolescents

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Art Therapy for Psychosocial Problems in Children and Adolescents

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Art Therapy for Psychosocial Problems in Children and Adolescents: A Systematic Narrative Review on Art Therapeutic Means and Forms of Expression, Therapist Behavior, and Supposed Mechanisms of Change

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Faculty of Healthcare and Social Work, NHL Stenden University of Applied Sciences, Leeuwarden, Netherlands

Alliade, Care Group, Heerenveen, Netherlands

KenVaK, Research Center for Arts Therapies, Heerlen, Netherlands

Faculty of Psychology, Open University, Heerlen, Netherlands

Faculty of Healthcare, Zuyd University of Applied Sciences, Heerlen, Netherlands

Background: Art therapy (AT) is frequently offered to children and adolescents with psychosocial problems. AT is an experiential form of treatment in which the use of art materials, the process of creation in the presence and guidance of an art therapist, and the resulting artwork are assumed to contribute to the reduction of psychosocial problems. Although previous research reports positive effects, there is a lack of knowledge on which (combination of) art therapeutic components contribute to the reduction of psychosocial problems in children and adolescents.

Method: A systematic narrative review was conducted to give an overview of AT interventions for children and adolescents with psychosocial problems. Fourteen databases and four electronic journals up to January 2020 were systematically searched. The applied means and forms of expression, therapist behavior, supposed mechanisms of change, and effects were extracted and coded.

Results: Thirty-seven studies out of 1,299 studies met the inclusion criteria. This concerned 16 randomized controlled trials, eight controlled trials, and 13 single-group pre-post design studies. AT interventions for children and adolescents are characterized by a variety of materials/techniques, forms of structure such as giving topics or assignments, and the use of language. Three forms of therapist behavior were seen: non-directive, directive, and eclectic. All three forms of therapist behavior, in combination with a variety of means and forms of expression, showed significant effects on psychosocial problems.

Conclusions: The results showed that the use of means and forms of expression and therapist behavior is applied flexibly. This suggests the responsiveness of AT, in which means and forms of expression and therapist behavior are applied to respond to the client's needs and circumstances, thereby giving positive results for psychosocial outcomes. For future studies, presenting detailed information on the potential beneficial effects of used therapeutic perspectives, means, art techniques, and therapist behavior is recommended to get a better insight into (un)successful art therapeutic elements.

Introduction

Psychosocial problems are highly prevalent among children and adolescents with an estimated prevalence of 10%−20% worldwide ( Kieling et al., 2011; World Health Organization, 2018). These problems can severely interfere with everyday functioning ( Bhosale et al., 2015; Veldman et al., 2015) and increase the risk of poorer performance at school ( Veldman et al., 2015). The term psychosocial problems is used to emphasize the close connection between psychological aspects of the human experience and the wider social experience ( Soliman et al., 2020) and cover a wide range of problems, namely, emotional, behavioral, and social. Emotional problems are often referred to as internalizing problems, such as anxiety, depressive feelings, withdrawn behavior, and psychosomatic complaints. Behavioral problems are often considered as externalizing problems, such as hyperactivity, aggressive behavior, and conduct problems. Social problems are problems related to the ability of the child to initiate and maintain social contacts and interactions with others. Often, emotional, behavioral, and social problems occur jointly ( Vogels, 2008; Jaspers et al., 2012; Ogundele, 2018). The etiology of psychosocial problems is complex and varies with regard to the problem(s) and/or the specific individual. A number of theories seek to explain the etiology of psychosocial problems. The most common theory in Western psychology and psychiatry is the biopsychosocial theory, which assumes that a combination of genetic predisposition and environmental stressors triggers the onset of psychosocial problems ( Lehman et al., 2017). But also, attachment theories get renewed attention ( Duschinsky et al., 2015). These theories focus on the role of the early caregiver-child relationships and assume that (a lack of) security of attachment affects the child's self-(emotion)regulatory capacity and therefore his or her emotional, behavioral, and social competence ( Veríssimo et al., 2014; Brumariu, 2015; Groh et al., 2016). Research has identified a number of biological, psychological, and environmental factors that contribute to the development or progression of psychosocial problems ( Arango et al., 2018), namely, trauma, adverse childhood experiences, genetic predisposition, and temperament ( Boursnell, 2011; Sellers et al., 2013; Wright and Simms, 2015; Patrick et al., 2019).

Psychosocial problems in children and adolescents are a considerable expense to society and an important reason for using health care. But, most of all, psychosocial problems can have a major impact on the future of the child's life ( Smith and Smith, 2010). Effective interventions for children and adolescents, aiming at psychosocial problems, could prevent or reduce the likelihood of long-term impairment and, therefore, the burden of mental health disorders on individuals and their families and the costs to health systems and communities ( Cho and Shin, 2013).

The most common treatments of psychosocial problems in children and adolescents include combinations of child- and family-focused psychological strategies, including cognitive behavioral therapy (CBT) and social communication enhancement techniques and parenting skills training ( Ogundele, 2018). These interventions are designed with the idea that cognitions affect the way that children and adolescents feel and behave ( Fenn and Byrne, 2013). However, this starting point is considered not suitable for all youngsters, in particular, for children and adolescents who may find it difficult to formulate or express their experiences and feelings ( Scheeringa et al., 2007; Teel, 2007). For such situations in clinical practice, additional therapies are often offered. Art therapy (AT) is such a form of therapy.

AT is an experiential form of treatment and has a special position in the treatment of children and adolescents because it is an easily accessible and non-threatening form of treatment. Traditionally, AT is (among others) used to improve self-esteem and self-awareness, cultivate emotional resilience, enhance social skills, and reduce distress ( American Art Therapy Association, 2017), and research has increasingly identified factors, such as emotion regulation ( Gratz et al., 2012) and self-esteem ( Baumeister et al., 2003) as mechanisms underlying multiple forms of psychosocial problems.

Art therapists work from different orientations and theories, such as psychodynamic; humanistic (phenomenological, gestalt, person-centered); psychoeducational (behavioral, cognitive-behavioral, developmental); systemic (family and group therapy); as well as integrative and eclectic approaches. But also, there are various variations in individual preference and orientation by art therapists ( Van Lith, 2016). In AT, the art therapist may facilitate positive change in psychosocial problems through both engagement with the therapist and art materials in a playful and safe environment. Fundamental principles in AT for children and adolescents are that visual image-making is an important aspect of the natural learning process and that the children and adolescents, in the presence of the art therapist, can get in touch with feelings that otherwise cannot easily be expressed in words ( Waller, 2006). The ability to express themselves and practice skills can give a sense of control and self-efficacy and promotes self-discovery. It, therefore, may provide a way for children and clinicians to address psychosocial problems in another way than other types of therapy ( Dye, 2018).

Substantial clinical research concerning the mechanisms of change in AT is lacking ( Gerge et al., 2019), although it is an emerging field ( Carolan and Backos, 2017). AT supposed mechanisms of change can be divided into working mechanisms specific for AT and overall psychotherapeutic mechanisms of change, such as the therapeutic relationship between client and therapist or the expectations or hope ( Cuijpers et al., 2019). Specific mechanisms of change for AT include, for instance, the assumption that art can be an effective system for the communication of implicit information ( Gerge, and Pedersen, 2017) or that art-making consists of creation, observation, reflecting, and meaning-making, which leads to change and insight ( Malchiodi, 2007).

Recently, it has been shown that AT results in beneficial outcomes for children and adolescents. Cohen-Yatziv and Regev (2019) published a review on AT for children and adolescents and found positive effects in children with trauma or medical conditions, in juvenile offenders, and in children in special education and with disabilities. While increasing insight into the effects of AT for different problem areas among children is collected, it remains unclear whether specific elements of AT interventions and mechanisms of change may be responsible for these effects. In clinical practice, art therapists base their therapy on rich experiential and intuitive knowledge. This knowledge is often implicit and difficult to verbalize, also known as tacit knowledge ( Petri et al., 2020). Often, it is based on beliefs or common sense approaches, without a sound basis in empirical results ( Haeyen et al., 2017). This intuitive knowledge and beliefs consist of (theoretical) principles, art therapeutic means and forms of expression, and therapist behavior [including interactions with the client(s) and handling of materials] that art therapists judge necessary to produce desired outcomes ( Schweizer et al., 2014). Identifying the elements that support positive outcomes improves the interpretation and understanding of outcomes, provides clues which elements to use in clinical practice, and will give a sound base for initiating more empirical research on AT ( Fixsen et al., 2005). The aim of this review is to provide an overview of the specific elements of art therapeutic interventions that were shown to be effective in reducing psychosocial problems in children and adolescents. In this review, we will focus on applied means and forms, therapist behavior, supposed mechanisms of change of art therapeutic interventions. As the research question was stated, i.e., which art therapeutic elements support positive outcomes in psychosocial problems of children and adolescents (4-20)?

Methods

Study Design

A systematic narrative review is performed according to the guidelines of the Cochrane Collaboration for study identification, selection, data extraction, and quality appraisal. Data analysis was performed, conforming narrative syntheses.

Eligibility Criteria

In this review, we included peer-reviewed published randomized controlled trials (RCTs), non-randomized clinical controlled trials (CCTs), and studies with group pre-posttest designs for AT of psychosocial problems in children and adolescents (4-20 years). Studies were included regardless of whether AT was present within the experimental or control condition. Qualitative data were included when data analysis methods specific for this kind of data were used. Only publications in English, Dutch, or German were included. Furthermore, only studies in which AT was provided by a certified art therapist to individuals or groups, without limitations on duration and number of sessions, were inserted. Excluded were studies in which AT was structurally combined with another non-verbal therapy, for instance, music therapy. Studies on (sand)play therapy were also excluded. Concerning the outcome, studies needed to evaluate AT interventions on psychosocial problems. Psychosocial problems were broadly defined as emotional, behavioral, and social problems. Considered emotional (internalizing) problems were, for instance, anxiety, withdrawal, depressive feelings, psychosomatic complaints, and posttraumatic stress problems/disorder. Externalizing problems were, for instance, aggressiveness, restlessness, delinquency, and attention/hyperactivity problems. Social problems were problems that the child has in making and maintaining contact with others. Also included were studies that evaluated AT interventions targeted at children/adolescents with psychosocial problems and showed results on supposed underlying mechanisms such as, for instance, self-esteem and emotion regulation.

Searches

Fourteen databases and four electronic journals were searched: PUBMED, Embase (Ovid), PsycINFO (EBSCO), The Cochrane Library (Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials), Web of Science, Cinahl, Embase, Eric, Academic Search Premier, Google Scholar, Merkurstab, ArtheData, Relief, and Tijdschrift Voor Vaktherapie (Journal of Arts Therapies in the Netherlands). A search strategy was developed using keywords (art therapy in combination with a variety of terms regarding psychosocial problems) for the electronic databases according to their specific subject headings or structure. For each database, search terms were adapted according to the search capabilities of that database ( Appendix 1). The search period had no limitation until the actual first search date: October 5, 2018. The search was repeated on January 30, 2020. If online versions of articles could not be traced, the authors were contacted with a request to send the article to the first author. The reference lists of systematic reviews, found in the search, were hand searched for supplementing titles to ensure that all possible eligible studies would be detected.

Study Selection

A single RefWorks file of all identified references was produced. Duplicates were removed. The following selection procedure was independent of each other carried out by four researchers (LB, SvH, MS, and KP). Titles and abstracts were screened for eligibility by three researchers (LB, SvH, and KP). The full texts were subsequently assessed by three researchers (LB, MS, and KP) according to the eligibility criteria. Any disagreement in study selection between a pair of reviewers was resolved through discussion or by consultation of the fourth reviewer (SvH).

Quality of the Studies

The quality of the studies was assessed by two researchers (LB and KP) applying the EPHPP "Quality Assessment Tool for Quantitative Studies" ( Thomas et al., 2004). Independent of each other, they came to an opinion, after which consultation took place to reach an agreement. To assess the quality, the Quality Assessment Tool was used, which has eight categories: selection bias, study design, confounders, blinding, data collection methods, withdrawal and dropouts, intervention integrity, and analysis. Once the assessment was completed, each examined study received a mark ranging between "strong," "moderate," and "weak." The EPHPP tool has a solid methodological rating ( Thomas et al., 2004).

Data Collection and Analysis

The following data were collected from the included studies: continent/country, type of publication of study, year of publication, language, impact factor of the journal published, study design, the primary outcome, measures, setting, type of clients, comorbidity, physical problems, total N, experimental N, control N, proportion male, mean age, age range, the content of the intervention, content control, co-intervention, theoretical framework AT, other theoretical frameworks, number of sessions, frequency sessions, length sessions, outcome domains and outcome measures, time points, outcomes, and statistics. An inductive content analysis ( Erlingsson and Brysiewicz, 2017) was conducted on the characteristics of the employed ATs concerning the means and forms of expression, the associated therapist behavior, the described mechanisms of change, and whether there were significant effects of the AT interventions. A narrative analysis was performed.

Results

Study Selection

The first search (October 2018) yielded 1,285 unique studies. In January 2020, the search was repeated, resulting in 14 additional unique studies, making a total of 1,299. Four additional studies identified from manually searching the reference lists from 30 reviews were added, making a total of 1,303 studies screened on title and abstract. In the first search, 1,085 studies, and in the second search, nine studies were excluded, making a total of 1,094 studies being excluded on title and abstract. This resulted in 209 full-text articles to assess eligibility. In the full-text selection phase, from the first search, another 167 studies were excluded; in the second search, five studies were excluded. This makes a total of 172 studies being excluded in the full-text phase. Twenty-three studies were excluded because a full text was unavailable; five studies because the language was not English, Dutch, or German; 99 studies did not meet the AT definition; 16 studies had a wrong design; 10 studies did not treat psychosocial problems; and 19 studies concerned a wrong population. In total, 37 studies were included (see Figure 1 for an overview of the complete selection process).

Figure 1. PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) flow chart.

Study Design

The final review included 16 RCTs, eight CCTs, and 13 single-group pre-post designs (total n = 37). Of the RCTs, a mixed-method design, involving both quantitative and qualitative data, was used in two studies. In one RCT, the control group received AT meeting our criteria, while the experimental group did not receive such a therapy (11). In another RCT, the experimental and the control group both received AT meeting our criteria (13). Also, two CCT studies used a mixed-method design, but these qualitative results were not included due to inappropriate analysis. Of the single-group pre-posttest designs, two studies had a mixed-method (quantitative and qualitative) design ( Table 1).

Table 1. Study characteristics/outcome.

Quality of the Studies

Of the 16 RCTs, two studies were evaluated as weak, 11 studies received a moderate score, and three studies were labeled as strong. Concerning the CCTs, five studies were evaluated as weak, one study as moderate, and two studies as strong. Of the 13 pre-posttest designs, five studies were assessed as weak and eight studies as moderate ( Table 1).

Study Population

The studies in this review included children and adolescents (ages 2-20) with a wide range of psychosocial problems and diagnoses. Most of the studies included children from the age of 6 years onward, with children's groups ranging from 6 to 15, adolescent groups ranging from 11 to 20, and mixed groups with an age range of 6-20 years. In 13 studies, both boys and girls were included, three studies only included boys, three studies only included girls, and 18 studies did not report the gender of the participants. Psychiatric diagnoses were reported, such as depression, autism spectrum disorder (ASD), conduct disorder (CD), post-traumatic stress disorder (PTSD), and mild intellectual disability (MID). However, also more specific problems were reported, such as children with suicidal thoughts and behavior, children having a brother/sister with a life-threatening disease, boys and girls in an educational welfare program needing emotional and psychological help, and orphans with a low self-esteem. Another group of children that were reported had medical concerns, such as persistent asthma, traumatic injuries, or serious medical diagnoses such as cancer, often combined with anxiety problems and/or trauma-related problems ( Table 1).

Number of Participants

The sample sizes of the RCTs ranged from 16 to 109. The total number of children of all RCTs was 707, of which 317 were allocated to an experimental condition and 390 to a control condition ( Table 1). The sample sizes of the CCTs ranged from 15 to 780, and the total number of participants was 1,115. The total number of participants who received an AT treatment was 186; the total number of the control groups was 929. Notice that the sample size for the CCTs was influenced by one study in which a control sample database of 780 was used. The sample size of the included pre-posttest designs ranged from 8 to 94 participants, with a total number of 411 participants ( Table 1).

Type of Intervention, Frequency, and Treatment Duration

In the 37 studies, a total of 39 AT interventions were studied. In two studies, two AT interventions were studied. Of the 39 interventions, 30 studies evaluated group interventions, seven studies evaluated an individually offered intervention, one study evaluated an individual approach within a group setting, and in one study, the intervention was alternately offered as a group intervention or as an individual intervention. The number of sessions of the AT interventions varied from once to 25 times. The frequency of the AT interventions varied from once a week ( n = 14) or twice a week ( n = 5) and variations such as four times a week in 2 weeks ( n = 1); six sessions were varying from one to three times a week ( n = 1), 10 sessions during 12 weeks ( n = 1), and eight sessions in 2 weeks ( n = 1). The frequency of sessions has not been reported in nine studies. In five studies, the intervention was offered once ( Table 1).

Control Interventions

In six RCTs, care, as usual, was given to the control groups. In study four, this also concerned AT, but it was offered in a program that consisted of different forms of treatment as child life services, social work, and psychiatric consults and therefore did not meet our criteria for inclusion. The control groups receiving "care as usual" received routine education and activities of their programs in school (6); counseling/medications and group activities as art, music, sports, computer games, and dance (8); standard arts- and craft-making activities in a group (9); and standard hospital services (14). One study did not specify what happened as care as usual (2). In five RCTs, a specific intervention of activity was offered in the control condition. These control interventions involved 3 h of teaching (5), a discussion group (7), offering play material (magneatos) (12), and a range of games (11), and one study offered weekly socialization sessions, these sessions were offered by the same professionals as the experimental group, and activities were playing board games, talking about weekend activities, and taking walks on the school grounds (16). Two RCT studies did not mention the condition in the control group (1, 10). Two studies mentioned that the control group did not receive any intervention program (3, 11). One study mentioned that the control group had the same assessments as the treatment group but did not receive therapy until all of the assessments were collected (15).

Regarding the eight CCTs, two studies described the control condition in more detail, consisting of academic work (21) or 3 h of informal recreational activities (24). No intervention was offered to the control group in four studies (19, 20, 22, 23). The control intervention was not described within two studies (17, 18) ( Table 1).

Applied Means and Forms of Expression

The applied means and forms of expression in the AT interventions could be classified into three categories: art materials/techniques, topics/assignments given, and language as a form of verbal expression accompanying the use of art materials. Results will be shown for 39 AT interventions in total, coming from 37 studies ( Table 2). Two studies applied two different types of AT interventions. These two types of AT will be referred to as 13 a/b and 29 a/b.

Table 2. Characteristics AT interventions.

Materials/Techniques

Regarding the category art materials/techniques, three subcategories were found. In the first subcategory, only two-dimensional art media/techniques were used, such as drawing, painting, or printing (the art product possessed length and width, but not depth). Used as materials were for instance, (acrylic) paint, markers, color pencil, crayons, gouache and water, white pieces of paper, cardboard, construction paper with pencils and colored markers, a "sketch" coloring, pencils, markers, and oil pastels (1, 3, 6, 7, 10, 14, 18, 21, 23). No specific art techniques concerning the way the materials were applied were mentioned in this subcategory. In the second subcategory, both two-dimensional and three-dimensional art media and techniques (art that can be defined in three dimensions: height, width, and depth) were offered: clay, papier-mâché masks, paint, paper decoration forms and markers, pictures and journals, paper, cardboard, construction materials, hospital socks, buttons and threads, sewing materials, magic beans, sand, fiberfill, photos, wood, stone, plaster, felt and other textiles, and yarn. In this subcategory, specific art techniques were mentioned, such as paper cutting and paper folding, collage technique, bookmaking, building a face, basket-making, clay techniques, guided fantasy, group painting, story-making through a doll, placing feelings in boxes, drawing/sculpting feelings, making clay shapes, creating self-portraits, and molding clay (2, 5, 8, 11, 13a, 19, 20, 22, 26, 27, 28, 29a, 29b, 30, 31, 32, 33, 36, 37). In the third category, both two-dimensional and three-dimensional art materials/techniques were applied, which matched the specific assignment or topic given (4, 9, 12, 13b, 14, 15, 17, 24, 25). For instance, drawings were made, and the collage technique was used to make a book (9). Four sets of facial features (eyes, noses, mouths, and brows), as well as a mannequin head, were offered for representing facial emotions (12), and in one study, patients used buttons, threads, and sewing materials with which they constructed their Healing Sock Creature, which the children filled with magic beans, sand, or fiberfill (15).

Topics/Assignments

Three subcategories were found concerning the category topics/assignments. The first subcategory, free working with the materials without topics/assignments given, was applied in five AT interventions (3, 5, 11, 13a, 16). In the second subcategory, 26 AT interventions used assignment(s) or gave topics (1, 2, 4, 7, 8, 9, 10, 12, 13b, 14, 15, 17, 19, 20, 21, 22, 23, 24, 25, 27, 29 a/b, 32, 33, 36, 37). The third subcategory concerned combinations of these two. Two studies mixed free working and giving topics/assignments (28, 30), and seven studies did not describe the intervention explicit enough to classify them (6, 18, 26, 31, 34, 35, 36). A wide range of activities based on topics and/or assignments were reported. Eleven categories could be detected; (1) getting familiar with the art material (1, 17) like "learning about art media" (1) and "warm-up clay activities and introduction to theme-related clay techniques" (17); (2) focusing on family perspective, like for instance, "draw first childhood memory/family relations"(1, 23), drawing family as animal (19); (3) working with visualization, fantasy, and meditation (1, 10, 20, 21), such as guided fantasy with clay, and story-making through a doll (20); (4) expressing emotions (1, 14, 19, 20, 23, 32) like "the participant was asked to create four different faces, representing happiness, sadness, anger, and fear" (14) or "make an anger collage" (19); (5) focusing on specific problems such as chronic disease or stress-related events (2, 4, 8, 9, 14, 15, 19, 37) such as "the experience associated with stress is drawn on small white paper and the future solution contents will be drawn on colorful, larger paper" (8) and "drawing feelings, drawing perpetrators, placing of these in boxes" (19); (6) applying group activities (10, 19, 20, 32), for instance, "make a group painting"(20) and "all the children were asked to work on a group project to bring closure by drawing a ceremony on a large paper together with comments" (10); (7) working on an exhibition of artwork (10, 32), for instance, "at the end, a small exhibition of artwork was made" (10); (8) focusing on the material/technique (17, 21, 27, 37) such as "making shapes using clay" (17) and "mold clay into a pleasing form, which could be an animal, a person, an object, or an abstract form" (21); (9) focusing on specific art techniques (19, 21, 29) such as "arrange a variety of objects in a pleasing orientation and draft the still life with a pencil" (21) or "make a photo collage"(19); (10) working with a product/object as a result (24, 25, 27, 32) such as, for instance, "making a bracelet" (32), "making paper bags" (27), or creating therapeutic art books (25); (11) applying general activities (1, 7, 19, 22, 27, 32) like drawing of a picture (7) and "the given theme was heroes"(22). Two studies (13b, 33) gave assignments/topics but did not specify these.

The Role of Language

Three subcategories were found concerning the role of language as a form of verbal expression accompanying the use of art materials and techniques: the produced artwork was mainly discussed afterward in a group meeting or on an individual basis (1, 2, 3, 4, 9, 10, 11, 13b, 14, 17, 29, 36) or feelings and concerns were mainly discussed and reflected on while working (5, 12, 13a, 15, 18, 22, 25, 26, 28) and other varieties such as: the work was (verbally) presented (4) and/or patients also retold the narrative created (5). In one study (7), the originator gave a title, offered associations to it, and said how he/she felt before and after drawing other members gave their associations. In one study (8), all artworks were gathered as a collection and reviewed at the end of the intervention (last session) together with the parents.

Therapist Behavior

Regarding therapist behavior, the information is structured in two categories: the therapist behavior, including social interactions with the client(s), and the handling of materials by the therapist, including material interactions with the client(s).

Therapist Behavior, Including Social Interactions With Their Client(s)

The information revealed three broad behaviors: non-directive behavior, directive behavior, and behavior that can be considered eclectic. Non-directive behavior refers to AT interventions in which the therapists showed mainly a following and facilitating attitude toward the children/adolescents. Thirteen AT interventions applied this kind of therapist behavior (13a, 15, 16, 17, 18, 20, 21, 22, 23, 25, 29a, 30, 36). Interactions with clients were for example, "the therapist was non-interpretive, with the participants creating their direct statements and finding their meanings in the individual artwork they created" (21) and "the therapist facilitates the creation of the artistic product and is supportive" (13a). Directive behavior refers to AT interventions in which the therapist showed an active and leading role toward the children/adolescents. Ten AT interventions (4, 8, 10, 11, 12, 13b, 24, 26, 28, 29b) used this kind of therapist behavior. Interactions with the clients were, for example, "the therapist asks exception/difference questions" (8) or "the participant was directed to choose a mouth, nose, eyes, and brows that represented the correct emotion" (12). A mix of these two types of therapist behaviors (eclectic) was applied in nine AT interventions (2, 5, 7, 9, 14, 32, 33, 34, 35), for instance: "each adolescent was asked at the beginning of the session to do a 'feelings check-in' describing how he or she was feeling in the moment and a 'feelings check-out' at the end of the session. In the art-making period, a minimal discussion took place" (9) or "art therapists worked with their clients to form therapeutic goals during initial sessions, followed by both structured and unstructured weekly AT sessions" (34). In seven AT interventions (1, 3, 6, 19, 27, 31, 37), insufficient information was given to classify the therapist's behavior.

The Handling of Materials by the Therapist, Including Material Interactions With the Client(s)

Information was provided by seven studies: "the therapist assists and supports the youngster in carrying out the activity" (5), "the therapist embeds solution-focused questions and skills in the art-making process" (8), "during working with materials, there was minimal discussion" (9), "the child was directed to choose features/materials that represented the correct emotion" (12), "the therapist gave delineated verbal instructions and directions for art media" (13a), "the therapist-assisted the child having difficulty with a specific medium" (13b), "the therapist became the co-creator" (15), and "the therapist avoided giving art instructions" (25).

Supposed Mechanisms of Change

In the introduction and discussion sections of the articles, a range of supposed mechanisms of change as substantiation of the intervention and outcomes were described ( Table 2). The supposed mechanisms of change could be categorized into two categories: art therapy specific and general psychotherapeutic mechanisms of change.

Specific Mechanisms of Change

Eight subcategories of a specific mechanism of change were detected. The first category was Art therapy as a form of expression to reveal what is inside. This large subcategory, could be divided into three forms: art as a form of visualizing and communication in general (1, 13, 15, 19, 20, 26, 28, 33, 35, 36), such as, "it enables the child to visualize" (15); art as a manageable expression and/or regulation of emotions (1, 2, 3, 7, 8, 10, 19, 20, 23, 27, 28, 31, 33, 35, 37), e.g., "through art emotions can be processed" (2); and art as a way of expression through specific processes (1, 4, 5, 9, 10, 11, 14, 15, 17, 19, 22, 25, 28, 29, 31, 32), for instance, "reduces threat inherent in sharing experiences of trauma by permitting a constructive use of displacement via the production of imagistic representations" (9). The second category was Art therapy as a way of becoming aware of oneself, mentioned by 10 studies (1, 2, 11, 13, 16, 23, 24, 25, 35, 36), for instance, "to regain a sense of personal agency" (1). The third category was defined as art therapy as a way to form a narrative of life, like "facilitation of the integration of the experience into one's larger, autobiographical life narrative" (4), while the fourth category dealt with art therapy as integrative activation of the brain through experience, which was mentioned in six studies (4, 12, 14, 16, 34, 26), for instance, "utilizing the integrative capacity of the brain by accessing the traumatic sensations and memories in a manner that is consistent with the current understanding of the transmission of experience to language"(4). The fifth category art therapy as a form of exploration and/or reflection was mentioned in seven studies (1, 9, 15, 18, 30, 5, 8), for instance, "to explore existential concerns" (1), and the sixth category the specifics of the art materials/techniques offered in art therapy was mentioned in three studies (13, 17, 30), for instance, "because they could change the shape as they wished, which contributed to a positive evaluation of their own performance"(17). The seventh category art therapy as a form to practice and/or learn skills was mentioned in four studies (10, 19, 28, 33), for example, "in art therapy interventions, children can learn coping responses, new skills, or problem-solving techniques" (10). Finally, the eighth category art therapy, as an easily accessible, positive and safe intervention by the use of art materials was mentioned by 15 studies (1, 2, 6, 8, 10, 16, 19, 23, 24, 25, 28, 29, 30, 32, 37), for instance, "non-verbal expression that is possible in art therapy is a safe way"(10).

General Mechanisms of Change

Two subcategories of general mechanisms of change could be defined. The first subcategory was defined as art therapy as a form of group process, mentioned by eight studies (7, 9, 13, 18, 20, 29, 30, 36), for instance, "present thoughts and feelings in a non-verbal way within the structure of the group"(7). The second, the therapeutic alliance in art therapy, was mentioned by six studies (5, 8, 16, 18, 26, 29), for instance, "the primary role of the therapist as listening, accepting, and validating" (16).

Synthesized Findings

Means and Forms of Expression and Therapist Behavior

Concerning the search for similarities and differences, the three found forms of therapist behavior were used to distribute the means and forms, which gave the following results.

The Therapist Behavior Was Non-directive

The therapist showed mainly a following and facilitating attitude toward the children/adolescents; in this category ( n = 13), the use of means and forms of expression was variable, but most often, children and adolescents worked on base of topics and assignments with both two- and three-dimensional materials and techniques, while during working, process and product were discussed. Specifically, four AT interventions used only two-dimensional materials/techniques (15, 18, 21, 23), six AT interventions offered both two- and three-dimensional materials/techniques (13a, 20, 22, 29a, 30, 36), and three AT interventions offered materials/techniques fitting the topic/assignment (15, 17, 25), which included a combination of two- and three-dimensional materials/techniques. Three AT interventions let the clients work freely without topics and assignments given (13a, 18, 30), eight AT interventions were based on topics/assignments (15, 20, 21, 22, 23, 25, 29a, 36), and two AT interventions combined both ways (17, 30). Concerning the use of language, in three AT interventions, there was a discussion on process/product afterward (17, 29a, 36), in five AT interventions, there was a verbal exchange while working (13a, 15, 18, 22, 25), and five studies (16, 20, 21, 23, 30) in this category did not make their use of language explicit as an additional form of expression. The most mentioned subcategories of supposed mechanisms of change for this category were "art therapy as a form of expression to reveal what is inside," "art therapy as a form of exploration," and "art therapy as a way of experiencing the self."

The Therapist Behavior Was Directive

The therapist showed mainly an active and leading role toward the children/adolescents; the use of means and forms of expression was again variable in this category ( n = 10), but most often, children and adolescents worked on base of topics and assignments with both two- and three-dimensional materials/techniques, whereby the process and work were reflected upon afterward in different forms. Specifically, one intervention used only two-dimensional materials/techniques (10), five AT interventions offered both two- and three-dimensional materials/techniques (8, 11, 26, 28, 29b), and four AT interventions offered materials/techniques fitting the topic/assignment (4, 12, 13b, 24), which included two- and three-dimensional materials/techniques. Two AT interventions let the clients work without topics and assignments given (11, 28), and seven AT interventions were based on topics/assignments (4, 8, 10, 12, 13b, 24, 29b), one AT intervention combined both ways (28), and one study did not provide information on this topic (26). Concerning the use of language, in five AT interventions, there was a discussion on process/product afterward (4, 10, 11, 13b, 29b), in three AT interventions, there was a verbal exchange while working (12, 26, 28), and one study used language in a specific form (reviewing the collection with children and parents) (8). One AT intervention discussed the work afterward in a different form (a narrative retold) (4). One intervention did not make the use of language explicit as an additional form of expression (24). The most-reported subcategories of supposed mechanisms of change were the same as for the non-directive therapist behavior.

The Therapist Both Performed Directive and Non-directive Behavior (Eclectic) Toward Clients

Also, the use of means and forms of expression was variable in this category ( n = 9). All kinds of materials/techniques were used but most often were worked on base of topics/assignments. The use of language was not often mentioned, but if it was used, it was used as a discussion afterward. Specifically: two AT interventions used only two-dimensional materials/techniques (7, 14), four AT interventions offered both two- and three-dimensional materials/techniques (2, 5, 32, 33), and two AT interventions offered materials/techniques fitting the topic/assignment (9, 14), which included both two- and three-dimensional materials/techniques. One study did not provide information on this topic (34). In one AT intervention, the clients worked freely without topics and assignments given (14), and six AT interventions were based on topics/assignments (2, 5, 7, 9, 32, 33). Concerning the use of language, in three AT interventions, there was a discussion on process/product afterward (2, 9, 14), no AT interventions mentioned a verbal exchange while working, and four studies (32, 33, 34, 35) in this category did not make their use of language explicit as an additional form of expression. The most-reported subcategories of supposed mechanisms of change for this category were "art therapy as a form of expression to reveal what is inside"; "art therapy as a form of exploration," and "art therapy as an easily/safe accessible intervention."

In seven studies (1, 3, 6, 19, 27, 31, 37), the AT interventions were not enough explicated to make combinations.

Outcomes

Therapist Behaviors in Relation to Psychosocial Outcomes

The division into three categories of non-directive, directive, and eclectic therapist behavior gave the opportunity to show outcomes in accordance with these. To structure the outcome, these are reported by categorizing psychosocial problems into internalizing problems, externalizing problems, and social problems and in outcomes that can be considered underlying mechanisms of psychosocial problems. These underlying mechanism outcomes were divided into the domains self-concept/self-esteem and emotion regulation.

Non-directive Therapist Behavior

Eight studies (15, 16, 18, 20, 21, 23, 25, 36), which applied the non-directive therapist behavior, focused on Internalizing Problems as an outcome. These results showed significant improvement in post-traumatic stress symptoms (23); emotional functioning (36, 16), depression, rejection, and anxiety (16), reduction of symptoms of Separation Anxiety Disorder (18), and symptoms of anxiety and depression (20). The quality of two studies (16, 23) was strong, and the other three studies were assessed as being of weak quality. Also, four times no significant improvement was reported for negative mood states (15), negative mood and distress (25), feelings of anxiety (23), and anxiety, depression, internalizing problems, and emotional symptoms (21). The quality of these studies was strong (23) or weak (15, 21, 25).

Five studies (13a, 16, 21, 29, 36) showed results for Externalizing Problems. The results showed significant improvement in inattention/hyperactivity problems for the Honors track group (21) (weak), behavioral conduct (29) (moderate), attention span (16) (strong), and problem behavior (13a) (moderate). However, also, no significant improvement was reported on behavioral problems (36, 16) and inattention/hyperactivity for the Average track group (21).

Four studies (16, 21, 29a, 36) reported results for Social Problems. A significant effect was found on social functioning and resilience (36) (weak), social acceptance (29a) (moderate), personal adjustment (21), and degree of perceived support available from others and reliance upon others (16) (strong). No significant improvement was found for personal adjustment (21). The qualitative data revealed improvement in behavioral and peer interaction (36, 21).

Some studies evaluating interventions with non-directive therapist behavior showed results on outcomes that can be considered underlying mechanisms of psychosocial problems. For the domain Self-concept/Self-esteem, nine studies (13a, 16, 20, 21, 23, 25, 29a, 30, 36) showed results on this domain. They reported significant improvement in self-esteem (21, 30); feelings around body image (30) (weak); self-approval (29a); sense of identity, overall personality, positive feelings about themselves (16); and resilience (36). Also, no significant improvement was shown on this domain, e.g., self-esteem (10, 21, 25, 29a), self-concept (23) (strong), and Locus of Control (13a) (refers to how strongly people believe they have control over the situations and experiences), which was a study of moderate quality. Qualitative results showed improvement in this domain on resilience (13, 36). Two studies reported results on Emotion Regulation. In one study, a significant improvement was seen in emotion regulation and maladaptive strategies (22) (moderate), while in another study, no improvement was found. This study was assessed as being a weak study (17). Qualitative results showed that participants reported that "ventilation of uncomfortable feelings occurred, and an outlet for alleviating stress was provided" (21), and there were improvements in emotional expression and cognition (36).

Directive Therapist Behavior

Four studies that applied the directive therapist behavior (4, 8, 24, 28) showed results for Internalizing Problems. In these studies, there was a significant improvement in internalizing behaviors (28), PTSD, and sleep-related problems (8). The quality of these studies was moderate (28) and strong (8). No significant improvement was reported for mood, depression (24), PTSD, and acute stress (4). The quality of these two studies was strong and moderate.

Four studies (10, 13b, 26, 28) reported results for Externalizing Problems, and significant improvement was found on anger (10), problem behavior (13b), hyperactivity/inattention (26), hyperactivity scores, and problem behavior (28). Also, no significant improvement was reported, specifically on problem behaviors (26). The qualitative results of these AT interventions described improved classroom behavior (13). The quality of these studies was moderate (10, 13, 28) and weak (26).

Four studies (11, 26, 28, 29) reported results for Social Problems. These studies reported significant improvement for close friendship (29) and assertion (28). But in other studies, no significant improvement was reported for social skills (26), socially lonely (11), and responsibility (28). The quality of the studies was assessed as being moderate (11, 29) and weak (26, 28). Qualitative results revealed that "the clients appeared to initiate social exchanges more independently and were improved on sharing feelings, thoughts, and ideas" (26).

Some studies applying directive therapist behavior showed results on (supposed) underlying mechanisms. Five studies (10, 11, 13, 24, 29) showed results on Self-esteem/Self-concept. Significant improvement was found on self-esteem (10) and self-approval (29). Also, no significant improvement was found on self-esteem (29, 24, 11), a sense of empowerment (11), responsibility for success/failure at school (11), Locus of Control (13), and educational self-esteem (10). The quality of the studies was strong (24) and moderate (10, 11, 13, 29). Also, positive qualitative results were reported in this domain, i.e., "a shift in self-image, were more confident and assured of their skills, and were more capable of expressing their ideas, thoughts, and feelings and in sharing these. They also showed an increased capacity to reflect on their behaviors and display self-awareness" (26) and improved Locus of Control (13). One study reported no significant improvement in Emotion Regulation (12). This study was of moderate quality.

Eclectic Therapist Behavior

Seven studies (2, 5, 9, 14, 32, 33, 34) in which interventions with eclectic therapist behavior was applied showed results on Internalizing Problems. Significant improvement was reported on internalizing problems (5), anxiety (2, 32, 33), and parent & child worry (2), depression, dissociation, sexual concerns, sexual preoccupation, and sexual distress (33), dissociative symptomatology (32), and post-traumatic stress (9, 32, 33). However, no significant results were reported on anxiety (34), depression (2, 32), dissociation (fantasy) (33), sexual concerns (32), and PTSD symptoms (14). The quality was assessed as being weak (2, 9) and moderate (14, 32, 33, 34).

Five studies (2, 5, 32, 33, 35) reported on Externalizing Problems, and they reported significant improvement on externalizing problems (5), problematic behaviors (35), and anger (33). No significant improvement was reported for disruptive behavior (2), hyper-response (33), and anger (2, 32). The study quality was weak (2, 35) and moderate (5, 32, 33).

Two studies (2, 7) reported on Social Problems, and significant improvement was found for parent and child communication (2) (weak). No significant improvement was reported on sociability, responsibility, and assertiveness (7).

Within the category eclectic therapist behavior, one study showed results on underlying mechanisms, specifically no significant improvement on Self-concept (34). This study was being assessed with moderate quality.

Overall Results

As is shown in Table 3, more than 50% of the studies on the effects of AT interventions using non-directive therapist behavior showed significant effects on the outcome domains, with high impact on externalizing (80%), social problems (75%), and internalizing problems (62,5%). Self-esteem/self-concept and emotion regulation showed lower figures, with 55.6 and 50%, respectively. AT interventions in which directive therapist behavior was used showed a different picture. The number for treating externalizing problems stood out, with 100% of the studied AT interventions being significantly effective in this domain. However, percentages of significant interventions for internalizing problems, social problems, self-esteem/self-concept were equal to or <50%. AT interventions using eclectic therapist behavior showed best results on internalizing and externalizing problems with, respectively 71.4 and 60% of the AT interventions that were evaluated on these outcome domains.

Table 3. Number and percentage of interventions per type of therapist behavior showing significant effects on outcomes.

Discussion

The purpose of this systematic narrative review was to provide an overview of AT interventions that were effective in reducing psychosocial problems in children and adolescents. The emphasis was on the applied means and forms of expression during AT, the therapeutic behavior applied, and the supposed mechanisms of change to substantiate the use of the intervention. The main results showed that a broad spectrum of art materials and techniques are used in AT treatments for psychosocial problems in children and adolescents. No specific art materials or techniques stood out. Also, forms of structure such as working on the basis of topics or assignments and the way language is applied during or after the sessions vary widely and do not seem to relate to a specific category of therapist behavior. From this point of view, it seems less important which (combination of) materials/techniques and forms of structure art therapists use in treatments of psychosocial problems. The wide variety of materials, techniques, and assignments that are used in AT shows that AT is very responsive to individual cases in their treatments. This is in line with the concept that art therapists can attune to the client's possibilities and needs with art materials/techniques ( Franklin, 2010).

Therapist behavior appeared to be the only distinctive component in the interventions. Three broad forms were found: non-directive, directive, and eclectic. In practice, art therapists often define their practice with orientations such as psychodynamic, gestalt, person-centered, etc. or choose an approach according to their individual preferences ( Van Lith, 2016). For instance, a stance in which the therapist sees its role as being a witness to the experience of the inherent process of knowing the self ( Allen, 2008) is often related to a non-directive therapist behavior or a stance in which they elicit meaning-making by engendering a new perspective ( Karkou and Sanderson, 2006) is often related to a form of directive therapist behavior. Also, many art therapists work from the point of view that the art therapist should adapt to the client needs, which can be considered an eclectic approach ( Van Lith, 2016) and which incorporates both forms of therapist behavior. Next to individual preferences, many psychotherapeutic approaches are being used in art therapeutic treatments of children and adolescents ( Graves-Alcorn and Green, 2014; Frey, 2015; Gardner, 2015; Van Lith, 2016). However, in the end, they all range on a continuum from non-directive to directive therapist behavior ( Yasenik and Gardner, 2012).

The results of this review show that AT for children and adolescents with psychosocial problems can lead to improvement in all domains for all three forms of therapist behavior in combination with a variety of means and forms. And, although the focus of this review was less on therapy outcomes, the results confirm the conclusion of Cohen-Yatziv and Regev (2019) that AT for children and adolescents with psychosocial problems can be effective. Non-directive therapist behavior, whereby the therapist is following and facilitating, shows the most significant effects in this study for psychosocial problems, next to eclectic therapist behavior for internalizing and externalizing problems. Also, it was striking that directive therapist behavior was effective for externalizing problems in all studies evaluating interventions with this type of therapist behavior, while this was not the case for the other outcome domains. Children and adolescents with externalizing problems may thus profit from directive, non-directive, and eclectic art therapist behavior. In addition, the findings suggest that we need to carefully consider using directive behavior in children with internalizing or social problems.

To substantiate the use of the AT interventions and the results, a variety of supposed mechanisms of change were described. Both specific and more general mechanisms of change were reported to substantiate AT interventions. The majority concerned specific AT mechanisms of change. Often, AT is considered a form of expression to reveal what is inside or its effects are explained by an exploration of feelings, emotions, and thoughts. These mechanisms of change were seen in AT interventions with non-directive, directive, and eclectic therapist behavior. The simultaneous occurrence of supposed mechanisms of change in all these categories of therapist behavior that differ substantially from one another can be explained by the central use of art materials, which distinguishes AT from the other ATs and from other psychotherapeutic approaches ( Malchiodi, 2012). It can be considered as an additional and specific value of AT and, therefore, frequently used as substantiation for the used AT interventions and their effects.

Corresponding between the studies that showed positive results was the adaptation of the materials/techniques, forms of structure, and therapist behavior to the problems and needs of the children and adolescents involved. This process is called responsiveness. Responsiveness consists of interacting in a way such that the other is understood, valued, and supported in fulfilling important personal needs and goals. It can be seen as a moment-by-moment process of the therapeutic alliance between therapist and client ( Sousa et al., 2011). Responsiveness supports and strengthens both the relationship and its members ( Reis and Clark, 2013). In AT, therapist behavior and the use of materials and techniques can both be adapted to these needs and may be considered an important element in explaining the positive effects of AT. Processes such as responsiveness and therapeutic alliance relate partially to attachment theories. In AT, a therapeutic alliance includes, next to the client and art therapist, a third "object," the art medium, comprised of art materials, art-making, and artworks ( Bat Or, and Zilcha-Mano, 2018). From the perspective of attachment theory, the encounter between client and art material in AT may reflect attachment-related dynamics ( Snir et al., 2017). Therefore, art therapists recapitulate positive relational aspects through purposeful creative experiences that offer sensory opportunities to reinforce a secure attachment ( Malchiodi and Crenshaw, 2015). In this way, materials and techniques can offer the child and adolescent a "safe bridge" to bond with the therapist and explore and grow in developmental areas that are treated.

Given the results, relational, experiential (combined with art) knowledge to connect to the children's and adolescent's problems and needs seems indispensable for art therapists. This study included AT interventions performed by certified art therapists. Art therapists get a thorough education in relational and experiential (art) skills and obtain tacit knowledge through practice. By having more insight into the importance of the role of therapist behavior and the use of materials/techniques in AT interventions for children and adolescents, art therapists can improve results. Choices for therapist behavior and the use of materials/techniques should not depend that much on context or individual preference but on the client's problems and needs and which therapist behavior fits the client best. The results of this study provide clues on which and how to use AT elements in clinical practice, but above all, it gives a sound base for initiating more empirical research on AT. For practice and research purposes, a thorough elaboration and description of the therapist behavior in manuals are then of importance.

Strengths and Limitations of This Review

In this study, a narrative synthesis was performed because of the focus on substantive aspects and the heterogeneity of the studies. A common criticism of narrative synthesis is that it is difficult to maintain transparency in the interpretation of the data and the development of conclusions. It threatens the value of the synthesis and the extent to which the conclusions are reliable. For instance, in this study, we searched for similarities and differences in two core elements of AT ( Schweizer et al., 2014). Sometimes, forced choices had to be made in the division of the defined components into group categories and, eventually, to divide them into categories of therapist behavior. Separating and distinguishing components of an intervention are not straightforward.

From the literature, it is known that studies with positive results are overrepresented in the literature ( Mlinarić et al., 2017). Probably also in this study, therefore, publication bias must be taken into account when interpreting the results.

Also, regarding showing significant results, some studies showed significant and no significant results in the same domain. This can cause bias, for example, considering a study to be significantly effective in internalizing problems, but in reality, the study shows significant results in anxiety, but for instance, not in depression. It should be taken into account that, in this study, only a broad overarching view is given.

In this study, we included RCTs, CCTs, and group pre-posttest designs because these three designs (in this order) can be considered to provide the most reliable evidence ( Bondemark and Ruf, 2015). Questionable is whether these types of designs are the most appropriate designs for (a part of) the research question posed in this study. For detailed, more qualitative information on interventions, case studies seem very suitable. Potential advantages of a single case study are seen in the detailed description and analysis to gain a better understanding of "how" and "why" things happen ( Ridder, 2017).

Recommendations

Remarkably, seven studies did not describe their AT interventions sufficiently explicitly concerning the use of means and forms of expression and therapist behavior. This, while art materials/techniques and therapist behavior constitute the basis for AT interventions ( Moon, 2012). Insight into the core elements of interventions helps us better understand why and how certain interventions work. By understanding these components of an intervention, we can compare interventions and improve the effectiveness of interventions ( Blase and Fixsen, 2013). Therefore, for future AT studies, it is recommended to present more information on used therapeutic perspectives, means, art materials and techniques, and therapist behavior.

The results of this study show that AT interventions for children and adolescents are characterized by a variety of materials/techniques, forms of structure such as giving topics or assignments, the use of language, and therapist behavior. These results point out to more specific aspects of the dual relationship of material-therapist, which contributes to the effects, such as, for instance, responsiveness. More (qualitative) research into these specific aspects of the therapeutic relationship and the role of the relational aspects of the material could provide more insight and be of great value regarding AT for children and adolescents.

The results of the AT interventions show that AT leads to positive results for psychosocial problems, although, in some studies, both significant and not significant results were seen within a domain. A more personalized research approach, which is linked to individual treatment goals, can possibly give more clarity on the effects. Goal Attainment Scales (GAS) can be considered useful for this purpose.

Conclusions

This study shows that the use of means and forms of expression and therapist behavior is applied flexibly. This suggests a responsiveness of AT, in which means and forms of expression and therapist behavior are applied to respond to the client's needs and circumstances, thereby giving positive (significant) results for psychosocial problems. Searching for specific elements in the use of materials and the three defined forms of therapist behavior that influence the result is therefore recommended.

Data Availability Statement

The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.

Author Contributions

All authors listed have made a substantial, direct and intellectual contribution to the work, and approved it for publication.

Funding

This research was funded by NHL/Stenden, University of Applied Science in Leeuwarden and Care-group Alliade in Heerenveen, Netherlands.

Conflict of Interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Acknowledgments

We would like to thank Mrs. T. van Ittersum of the Research Institute SHARE/Research office UMCG in Groningen for her help with search strategy and data collection.

Supplementary Material

The Supplementary Material for this article can be found online at: https://www.frontiersin.org/articles/10.3389/fpsyg.2020.584685/full#supplementary-material

References

Duschinsky, R., Greco, M., and Solomon, J. (2015). The politics of attachment: lines of flight with bowlby, deleuze and guattari. Theory. Cult. Soc. 32, 173-195. doi: 10.1177/0263276415605577

Fixsen, D. L., Naoom, S. F., Blase, K. A., Friedman, R. M., and Wallace, F. (2005). Implementation research: a synthesis of the literature. Tampa, FL: University of South Florida, Louis de la Parte Florida Mental Health Institute, National Implementation Research Network. FMHI Publication No. 231.

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Art Therapy for Psychosocial Problems in Children and Adolescents: A Systematic Narrative Review on Art Therapeutic Means and Forms of Expression, Therapist Behavior, and Supposed Mechanisms of Change

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Background: Art therapy (AT) is frequently offered to children and adolescents with psychosocial problems. AT is an experiential form of treatment in which the use of art materials, the process of creation in the presence and guidance of an art therapist, and the resulting artwork are assumed to contribute to