Introduction
Behavioral disorders are occurring more and more often in children. These problems often interfere with their daily functioning, increase the risk of poor results at school and have a major impact on their future personal and professional life. Conduct disorders cover a range of issues; emotional, behavioral and social, which, however, very often occur together (Jaspers et al., 2012). Emotional problems are also referred to as internalizing problems. They include e.g. anxiety, depressive feelings, tightness and psychosomatic complaints. Externalizing problems include hyperactivity, aggressive behavior, educational difficulties, etc. Social problems are problems related to a child's ability to initiate and maintain social contacts and interactions with others. The etiology of conduct disorders is complex and varies according to the particular individual's problems. The most common theory in Western psychology is the biopsychosocial theory, which assumes that a combination of genetic predisposition and environmental stressors trigger the onset of behavioral disorders (Lehman et al., 2017).
Currently, much attention is paid to relational attachment theory. These theories focus on the role of early caregiver-child relationships and hypothesize that a lack of secure attachment affects the child's self-regulatory abilities and thus their emotional, behavioral, and social competencies (Groh et al., 2016). A number of biological, psychological, and environmental factors have been identified that contribute to the development or progression of behavioral disorders (trauma, adverse childhood experiences, genetic predisposition, temperament, etc.) (Patrick et al., 2019). The results of many researches show that among the most important factors behind the manifestations of behavioral disorders are poor regulation of emotions and feelings (Gratz et al., 2012) or low self-esteem. Effective interventions for children with conduct disorders could prevent or reduce the likelihood of long-term mental health deterioration.
However, commonly used psychological, special pedagogic or socio-pedagogical techniques and intervention methods may not always suit everyone. Especially children and adolescents with behavioral disorders often have a problem verbally expressing and formulating their problems and feelings (Teel, 2007). For such situations, other forms of intervention and therapy are subsequently sought. It is precisely among these forms that we include expressive therapies, especially art therapy, in which children express themselves mainly through artistic expression. With the help of art therapy, it is possible to make positive changes in the form of cooperation between the therapist and the child using art materials in a playful and safe environment. The underlying principles are that the creation of visual images is an important aspect of the natural learning process. In the presence of an art therapist, children can come into contact with feelings that otherwise cannot be simply named with words (Waller, 2006). Being able to express yourself and practice skills can give a sense of control and self-efficacy and promotes self-knowledge. Art can be an effective system for communicating implicit information (Gerge, Pedersen, 2017).
Art therapy as an effective method of prevention, intervention and therapy of behavioral disorders
Art therapy is an experiential form of treatment and has a special position in the treatment of children and adolescents, as it is an easily accessible and non-threatening form of therapy. It has traditionally been used to improve self-esteem and self-awareness, cultivate emotional resilience, improve social skills, and reduce conflict (Fig. 1).
Fig. 1: Use of art therapy
According to L. Běhounková (2010), it represents an effective method of preventing behavioral problems and at the same time accompanying students with diagnosed behavioral disorders at school. B. Jankovská and J. Jankovský (2001) describe it as a treatment using creative means, which they include in medical rehabilitation (psychotherapy) and also in pedagogical rehabilitation. It is located on the border between health care and educational care. M. Lhotová (2010) understands art therapy as a space where the goals of activities in free time, education, upbringing, treatment, psychotherapy or social work meet and overlap. At the same time, it is a set of various artistic techniques and procedures that aim to change a person's self-evaluation, increase their self-confidence and overall integrate their personality. At the same time, knowledge from psychology, art education or various pedagogical disciplines is used, e.g. and special pedagogy (Šicková – Fabrici, 2002). The application of visual arts means is also an effort to change behavior, thinking and emotions in a socially acceptable direction (Müller, 2014) and change in the area of more positive expressions towards oneself and the environment, empathy, cooperation and improvement of expressive skills (Kučerová, 2013). Artistic expression is perceived here as a means of self-expression and a way of communication (Lhotová, 2010). Zicha (1981) defines art therapy as the intentional adjustment of the disturbed activity of the organism with psychological and educational elements that are immanent in artistic activity. In their study, the authors I. Ulrichová and Z. Sládečková (1992) describe the positive effects of artistic activities in facilities for children with behavioral disorders. According to them, drawing or painting are very engaging activities for children and teenagers, which in itself ensures good motivation for work. The child likes to talk about what he has created. This is beneficial both for diagnosis, but also for establishing a quality relationship, which is supportive in building positive patterns of behavior. During the art therapy process, the child relaxes and calms down, and then approaches the next work more easily. For children and adolescents with behavioral disorders, creative activity is a suitable means for training willpower, patience, concentration, and at the same time supports imagination and creativity. A significant advantage of art therapy is also the fact that children are led to a deeper interest, forced to suppress their destructive tendencies, learn to value their work as well as the works of others. Kožnár (1999) sees the potential of artistic expression especially where words are not enough. In addition to drawing, painting, modeling, or working with various plastic materials and the collage technique also play such a role. It is necessary to develop a discussion about individual creations, clarifying intrapsychic connections, relationships and interactions, even if the child does not want to talk about them very much. It is also possible to release negative emotions, adjust the emotional state, develop creativity, improve communication and ventilate various problems through creative activity. Every art therapy intervention must be targeted, while the therapeutic-creative process itself is more important than the resulting artefact, or created work.
When working with children with behavioral disorders, it should be borne in mind that all activities aimed at solving problem situations must be appropriately planned in advance in order to achieve a positive effect. Through creative activities, children can have a positive self-image and thereby create conditions for expressing their own emotions (Majzlanová, 2017). At the same time, M. Liebmann (2010) emphasizes the importance of the creative process as a means of personal expression and prefers it to an aesthetically satisfying final product. In addition to authenticity, it is important to support self-esteem in children with behavioral problems, which affects their relationship with themselves and other people. Drawing, painting or modeling are the most frequently used means that we offer to the child to express his own vision of the world, his own feelings and relationships in his surroundings. A. Beh-Pajooh, A. Abdollahi and S. Hosseinian (2018) in their research study investigated the effectiveness of art therapy in reducing externalizing behavior of children with intellectual disabilities. Their clinical research involved 60 children who were divided into intervention and control groups. Findings revealed that art therapy moderates children's externalizing behaviors. L. Bosgraaf, M. Spreen, K. Pattiselanno and S. Van Horeen, (2020) analyzed the results of 37 research papers focused on the application of art therapy methods when working with children and youth with behavioral disorders. The purpose of their systematic narrative review was to provide an overview of art therapy interventions that have been effective in reducing conduct disorders. The main results showed that the use of a wide range of artistic activities and materials in therapy can lead to the improvement of behavioral problems. The authors Cohen-Yatziv and Regev (2019) also confirm the positive effects of art therapy in children experiencing trauma or juvenile offenders. Ulrichová and Sládečková (1992) in their research study, in turn, monitored the impact of these methods on clients of the diagnostic center. She specifically focused on changes in emotional tuning, activities, attention, improvement of somatic state and subjective feeling of well-being. The results showed improvement in all monitored areas. In her study, S. Furneaux-Blick (2019) focused on the technique of joint painting (client and art therapist) with children with learning disabilities. As the author herself states, the joint activity reflects a dyadic meeting between a parent and a child. Working on a joint activity with a child with learning disabilities made it possible to create a strong relationship. Her case study documents how shared activity can enable a child with a learning disability to develop more confidence and create a stronger sense of self.
Description of the technique of art therapy templates
Art therapy templates are a projective technique with a wide range of uses: diagnostic, therapeutic, abreactive, playful, etc. Applying this projective material causes different reactions in a child with a behavioral disorder, thanks to which he can express his feelings, experiences, or reflection of his personal world and his own personality. The technique of art therapy templates can be used by art therapists, psychologists, special and social pedagogues, teachers, educators or parents. Their use depends on the art therapy goal and the specific problem that needs to be solved.
The technique consists of 25 cards with templates (fig. 2). From the cards, the child can choose a template at will, or draw lots. The series of cards is supplemented by 15 cards with themes (topics) containing specific instructions divided by age categories (Fig. 3):
- Instruction 5-7 years
- Instruction for 8-11 years
- Instruction for 12-15 years
Fig. 2: Sample art therapy templates
Fig. 3: Sample card with subject and instructions according to age categories
The use of the technique of art therapy templates is universal and does not depend on artistic talent. Kožnár (1999) even admits that the less artistically gifted a child is, the more authentic and spontaneous he is. The choice of topic is also related to the specific goal that we want to achieve with the child. The assumption is that the art therapist knows the basic problem with which the child enters the intervention. It is not the way of filling the topic that is important, but the truth of the content. However, having a theme is important for those who are unsure at the beginning and need a "kick". Then it is also advisable to use cards with topics and instructions. Topic or however, the topic must not be a command but a way of finding answers to questions, connecting with your self, discovering yourself and experiencing yourself. However, children often have trouble even starting to create something. It is a remnant of negative experiences from art education classes. They are mostly evaluated through the teacher's subjective perception of what is beautiful and tasteful. That is when it is appropriate to use art therapy templates that children can draw on paper and draw and color them themselves. Later they can work with their own theme. It often emerges from the gradual understanding of one's own symbols. The therapist notices how the child approaches the processing of the topic. How did you choose the process of creation, presentation and reflection. Free expression brings the opportunity to understand your inner self. Art therapy templates can be used when working individually with a child, but also in groups. In group art therapy, both the collective and the art therapist act as a strong motivational and stimulating component. During group meetings, children relax, get to know each other's relationships, and the therapist has an opportunity for irreplaceable knowledge. However, if the child is facing bigger problems, it is more appropriate to approach individual therapy. The charm of individual meetings is that it is not important how the work looks from an aesthetic point of view. Authenticity and the potential for free and truthful expression are important.
Structure of an individual art therapy session using art therapy templates
The first meeting of an art therapist with a child with behavioral disorders is very important. It provides a space for the child to get to know the person of the helping professional and the space where the art therapy will take place. The meeting should last one to two hours, depending on the age of the child. The choice of topic depends on the specific problem that we want to solve and on the formulated therapeutic goal. Although the topic may seem simple at the beginning, it is advisable to enter general topics at first and more personal ones during the next meetings. For older children, it is possible to leave the choice of topic to them (Šicková - Fabrici, 2006).
The art therapist should have a variety of art tools and materials at his disposal and give the child a choice of which tools he wants to manipulate. His task is to sensitively guide the child towards materials that compensate for his disorder or deficit. The choice of aids itself has a significant telling value. Anxious and depressed children usually do not like to work with colors and choose only black or an ordinary pencil. Aggressive or hyperactive children, on the other hand, prefer working with different modeling materials. An art therapist must create a pleasant environment for a child with behavioral disorders and provide him with his presence and involvement. At the same time, he should lead the child to use materials balancing his disorder, i.e. lead depressed children to work with colors and children with externalizing manifestations to calm down by manipulating a single-color medium (Šicková - Fabrici, 2006).
When assembling the structure of an individual art therapy meeting, we start from the model of A. Goren-Bara (1997, p. 413-414), which calls the art therapy process the Creative Axis Model and divides it into the following stages:
- Contact – the initial phase, during which the child gets to know the art therapy technique of stencils. The child can draw or choose a card from a set of art therapy templates. He looks at the material and tools he wants to use in his work.
- Organization - after the child becomes familiar with the selected template and tools, he organizes the elements to start work. The child can also draw a card with an instruction (topic) on how to complete the template, or decide to work spontaneously on their own topic.
- Improvisation – this is a continuation of the organizational phase, during which the child makes mistakes and gets to know the characteristics of the material. Art aids and materials can be changed or combined by the child in the process.
- Central topic – the moment when the child comes to an important topic, procedure and invests more energy in the individual parts of the artistic work. After tracing the template, the child gradually fills in the drawing with his own lines.
- Processing – in this phase, the central theme is formed and consolidated, when the child is immersed in the modification, improvement and completion of the artistic work. The child focuses on the details when processing the drawing, colors the lines and completes them in various ways.- Preservation – the final phase of the experience, which includes the presentation of the creation, preservation and subsequent distance and distance.
Individual art therapy meetings require a firmer structure and arrangement of the space, as well as the establishment of certain rules and greater activity of the art therapist. It is always advisable to adapt the work to the current needs of the child and to influence him through the experience. Adapting the therapist's materials, forms and behavior to the problems and needs of the participating children and adolescents is called responsiveness. The ability to respond consists in interacting in such a way that the other is understood, appreciated and supported in fulfilling personal needs and goals. Responsiveness supports and strengthens the relationship and its members (Reis, Clark, 2013).
The goal of individual interventions is to develop a symbolic language that allows access to deeply hidden feelings or memories. The use of art therapy templates can be very helpful when working with children with behavioral disorders, thanks to their ability to calm and regulate the nervous system. They provide the art therapist with a range of options and techniques that he can use with regard to the individual characteristics of a particular child. If the child focuses on creation, his attention will be transferred from negative feelings to a more positive experience. Any creative process allows him to process even complex mental processes, gives rest to thoughts, helps to detach himself from feelings and see the form of the experienced situation from a different perspective (Ťulák, Krčmáriková, 2017). Through artistic activities, the art therapist tries to help the child to develop positively. The art therapist chooses a topic from the offered cards (or leaves the choice up to the child), leads him to achieve insight, understanding of the problem. It helps develop knowledge and stimulates cognitive processes in creative activity. Ulrichová and Sládečková (1992) emphasize that during an art therapy session it is not important that the child completes the drawing or painting. More important is the very interpretation of the product by the child, during which he can also talk about what he did not have time to complete. Here, even anxious children, who would otherwise not get the chance to express themselves, get a chance. With the help of an art therapist, they can gradually gain self-confidence and experience the joy of work and a pleasant experience. Later, there is a space for a conversation about what happened in the creative process, as well as for a conversation about the result of this work.
Conclusion
Art therapy aims to restore the individual to a state of harmony and enable him to express his feelings and emotions in a positive way. In our article, we tried to approach the technique of art therapy templates when working with children with behavioral disorders. This technique serves to alleviate disorders and also to stabilize the psychological and emotional state of children. It can be used for diagnosis, self-discovery, or as a game in group art therapy. Artistic and creative activity offers great potential for relaxation, relaxation and strengthening of self-evaluation and inner experience, therefore we believe that the procedures described by us are useful for all helping professions when working with children and adolescents.
Author: Mgr. Barbora Sender, PhD.
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