Art therapy for children and adolescents with autism: a systematic review

Figures & data

Table 1. MeSH headings and keywords utilised in search strategy.

Element	Concept	Medical Subject Headings	Key words
Population	Children and adolescents. Autism spectrum disorder, including neurodevelopmental disorder, autistic disorder, Asperger's syndrome, pervasive developmental disorder.	- Child/ - Adolescent/ - Child developmental disorders, pervasive/ - Neurodevelopmental disorder/	- ASD - autis* - ‘autism spectrum disorder’ - ‘neurodevelopmental disorder’ - ‘asperger*’ - ‘pervasive developmental disorder’ - PDD - ‘mental disorder*’
Intervention	Art therapy, including painting, drawing, clay, colour therapy, sensory art therapies, art-based therapy.	- Art therapy/ - Sensory art therapies/ - Colour therapy/	- ‘Art therap*’ - ‘creative art therap*’ - ‘sensory art therap*’ - ‘paint* therap*’ - ‘draw* therap*’ - ‘clay therap*’ - ‘colo?r therap*’ - ‘art intervention’ - ‘art based therap*’ - ‘art-based therap*’

Figure 1. PRISMA flow chart.

Table 2. Study and participant characteristics.

Study Design Country	Sample size (n)	Age (years)	ASD diagnosis (n)	Outcome of interest
Chou et al., 2016 Quasi-experimental (multiple probe design) Taiwan	2 (2 M)	6 (m = 6)	Pediatrician in a medical centre	Social
D'Amico & Lalonde, 2017 Quasi-experimental Canada	6 (5 M, 1 F)	10–12 (m = 10.5)	NR	Social, behavioural
Epp, 2008 Pre-test–post-test United States of America	44 (31 M, 6 F, 5 NR)	NR	DSM-IV	Social, behavioural
Koo & Thomas, 2019 Pre-test–post-test India	18	4–12	NR; however, completed in an autism centre	Social, motor
Schleien et al., 1995 Quasi-experimental (multiple baseline design) United States of America	15 (13 M, 2 F)	4–11 (m = 7.5)	NR; severity determined by TARC	Social, behavioural
Schweizer et al., 2020 Mixed methods Netherlands	12 (7 M, 5 F)	6–12 (m = 10.5)	NR	Social, behavioural
Sabet & Abadi, 2021 Quasi-experimental Iran	30	6–12	GARS	Motor

m = mean; M = male; F = female; NR = not reported.

DSM-IV = Diagnostics and Statistical Manual of Mental Disorders, 4th edition; TARC = Topeka Association for Retarded Citizens; GARS = Gilliam Autism Rating Scale.

Table 3. Intervention characteristics.

Study	Intervention modality	Delivered by	Mode of delivery	Duration	Frequency	Intensity (min)
Chou et al., 2016	Creative arts using themed sessions – multi-modality	Researchers (×2)	Individual	NR	17 sessions	60
D'Amico & Lalonde, 2017	Multi-modality – drawing, mask making, mind-mapping, paper making, mirrors for facial expressions, tower building	Art therapist (×2)	Group	21 weeks	1× per week	75
Epp, 2008	Social skills art therapy – drawing	Art therapist	Group	9 months	1× per week	60
Koo & Thomas, 2019	Abstract art – drawing, painting, clay or Play-doh, craft or college	Art therapist (lead researcher)	Individual	10 weeks	8 sessions	30
Schleien et al., 1995	Manipulative art activities	Museum art therapist	Group	7 months	1× per month	120
Schweizer et al., 2020	Self-guided multi-modality	Art therapist	Individual	15 weeks + 1 follow-up	1× per week	45
Sabet & Abadi, 2021	Painting therapy	Lead researcher	Individual	6 weeks	3× per week	40

NR = not reported.

Table 4. Summary of results.

Study	Social	Behavioural	Motor
Chou et al., 2016	↑ (+) [observation, VABS]
D'Amico & Lalonde, 2017	↑ (+) [SSIS-RS student and parent form]	↓ (+) [SSIS-RS student and parent form]
Epp, 2008	↑ (+) [SSRS]	↓ (+) * [SSRS]
Koo & Thomas, 2019	↑ (+) * [CARS]		↑ (+) [CARS]
Schleien et al., 1995	↑ (+) [observation]	↑ (+) [observation]
Schweizer et al., 2020	↑ (+) [OAT-A, CSBQ]	↑ (+) [OAT-A, CSBQ, BRIEF]
Sabet & Abadi, 2021			↑ (+) * [Lincoln-Ozertsky Motor Skills Test]

Results key: ↑ = positive trend; ↓ = negative trend; (+) = positive change/improvement; * = statistically significant (p < 0.05).

Outcome measurement tool definition: Vineland Adaptive Behaviour Scale; SSIS-RS = Social Skills Improvement System Rating Scale; SSRS = Social Skills Rating System; CARS = Childhood Autism Rating Scale; OAT-A = Observation in Art Therapy of a child diagnosed with ASD; CSBQ = Children's Social Behavior Questionnaire; BRIEF = Behavior Rating Inventory of Executive Functioning.

Table 5. NHMRC FORM framework analysis.

Component	Grade	Comments
Evidence base	D Poor Level IV studies, or level I to III studies/SRs with a high risk of bias.	Quantity: 7 studies; Total participants: 127; Level III-2: 2; Level IV: 5; Quality: Low.
Consistency	C Satisfactory Some inconsistency reflecting genuine uncertainty around clinical question.	Varied study design; 4 studies reported statistical significance (p value); All participants in the intervention groups had a diagnosis of ASD; however, the diagnosis process was unclear; Wide variety of outcome measurements (assessment tools used); Heterogeneous intervention, with various modalities of delivery; Consistent reporting of data (within group).
Clinical impact	D Poor Slight or restricted.	No studies provided justification of the sample size; Minimal studies reported on clinical significance; Majority of studies identified a positive outcome measures; Some interventions were adequately described; Only 1 study reported a long-term follow-up; No adverse effects reported; Minimal drop out with majority of dropouts explained.
Generalisability	C Satisfactory Population/s studied in body of evidence differ to target population for guideline but it is clinically sensible to apply this evidence to target population.	Population studied represents the population of interest (children and adolescents with ASD); Age range: 4–12 years; Female population was under-represented in all studies (except 1 study); Small sample sizes; Majority of studies did not report if participants had comorbidities; Studies conducted in a variety of countries; Majority of studies did not report on co-interventions.
Grade of recommendation	D Poor Body of evidence is weak and recommendation must be applied with caution.	Overall, the studies measured different outcome subdomains and had varying interventions. However, all the included studies reported a positive effect for the applied intervention. The sample size represents the target population.

Chou, W.-C., Lee, G. T., & Feng, H. (2016). Use of a behavioral Art program to improve social skills of Two children with autism spectrum disorders. Education and Training in Autism and Developmental Disabilities, 51(2), 195–210. https://www.proquest.com/docview/1789770401?accountid = 14649&forcedol = true&pq-origsite = primo

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D'Amico, M., & Lalonde, C. (2017). The effectiveness of Art therapy for teaching social skills to children With autism spectrum disorder. Art Therapy, 34(4), 176–182. https://doi.org/10.1080/07421656.2017.1384678

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Epp, K. M. (2008). Outcome-Based evaluation of a social skills program using Art therapy and group therapy for children on the autism spectrum. Children & Schools, 30(1), 27–36. https://doi.org/10.1093/cs/30.1.27

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Koo, J., & Thomas, E. (2019). Art therapy for children With autism spectrum disorder in India. Art Therapy, 36(4), 209–214. https://doi.org/10.1080/07421656.2019.1644755

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Schleien, S. J., Mustonen, T., & Rynders, J. E. (1995). Participation of children with autism and nondisabled peers in a cooperatively structured community art program. Journal of Autism and Developmental Disorders, 25(4), 397–413. https://doi.org/10.1007/BF02179375

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

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Sabet, S., & Abadi, Z. C. H. (2021). The effect of art therapy on motor skills of children with autism. International Journal of Applied Behavioural Sciences, 8(4), 27–34. https://doi.org/10.22037/ijabs.v8i4.33684

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