Barbara Kariz

ART THERAPY AND AD/HD

Ongoing Art Therapy Groups with Children.
Researching the Process and Outcomes of Therapeutic and Educational Art Interventions
for Children with Special Needs.

SUMMARY
Art Therapy is a useful therapeutic and educational intervention with AD/HD children.
Terapi seni adalah pengobatan yang bermanfaat dan intervensi yang berupa edukasi
untuk anak yang ADHD. It provides a way of helping the child encounter and correct
attention and hyperactivity issues and offers the opportunity to socialise and practice the
social skills. Terapi seni memberikan sebuah cara untuk membatu anak menghadapi dan
meperbaiki masalah perhatian dan hiperaktif dan menawarkan kesempatan untuk
bersosialisasi dan melatih keterampilan berinteraksi. It provides visual imagery and
graphomotor experiences, that enhance learning and allows practice of different skills. Selain
itu, memberikan gambaran visual dan pengalaman graphomotor, yang menambah
pengetahuan dan memungkinkan melatih keterampilan yang berbeda.

INTRODUCTION
The diagnosis of attention deficit disorder, with or without hyperactivity is a recent
one. Diagnosis gangguan defisit perhatian, dengan atau tanpa hiperaktif adalah yang terbaru.
It is seen as a neurologically based disorder that impacts both learning and behaviour. It often
impacts school performance and beyond (Mikuš, 1995).
Hal ini dilihat sebagai gangguan berbasis neurologis yang berdampak pada pembelajaran dan
perilaku. Seringkali berdampak pada prestasi sekolah dan seterusnya Art is a good medium
for working with AD/HD children because it is an activity that uses visual learning skills to
give structure and offers a way to express feelings in therapy. Seni adalah media yang baik
untuk anak dengan ADHD karena merupakan kegiatan yang menggunakan keterampilan
pembelajaran visual yang memberikan struktur dan memberikan cara untuk mengekspresikan
perasaan dalam terapi. Art activity also helps redirect energy and hyperactivity. Kegiatan seni
juga mengarahkan energi dan hiperaktif. The art product provides a child with visual record
and becomes the way to record and re-encounter certain feelings, thoughts and learnt skills.
Hasil dari seni memberikan anak sebuah rekaman visual dan menjadi sebuah cara untuk dapat
merekan dan menghadapiThe art therapy drawings reinforce learning adding another
dimension to a multisensory approach to learning (Safran, 2002)..

AD/HD (ATTENTION DEFICIT HYPERACTIVITY times they do not do well

DISORDER) academically and socially
Basic characteristics of AD/HD are inattention or in the school
distractibility, impulsivity, hyperactivity, frequent environment and
disturbance, sudden changes in temper, inability to focus, consequently they are at
inability to be or stay still in a certain place for a longer high risk to have low
period of time, hyper-sensitivity. Children with AD/HD have self-esteem and low self-
problems with listening to others, being patient, making worth. At school, which
arrangements, planning, organising, co-operating, being is supposed to be their
aware of others, sharing space and materials, estimating the primary occupation, they
situation, paying regard to structure and boundaries. constantly feel
Many children with AD/HD have specific learning incompetent and
disabilities which often derive from the disorder itself. Many unhappy. Because of this

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they can become defensive and start avoiding school. Being
in an art therapy group they have the opportunity to
experience they are not alone and that it is not their fault
they cannot succeed at school or please their parents. They
learn that their problems derive from the disorder and that
they have the possibility to do something about it by learning
the strategies to cope.

ART THERAPY AND AD/HD

Non verbal communication

Art is an activity that uses strong visual learning skills to lend structure and give those
who tend not to be contemplative a way to express their feelings in therapy. The product of art

therapy, the art itself, provides a child with a visual record of those feelings or ideas that have

come up (Safran, 2002). Drawings can help children organise themselves. As they draw, their
relationship is only with paper in front of them. They are able to be open, honest and
revealing because the drawing is impersonal; it does not question, challenge or criticise
(Thomson, 1998). The drawing serves as a form of self expression where verbal
communication is not always possible. A child who for example cannot talk about school may
find it easier to first draw a picture. With drawing in front of him it becomes easier to talk
about the situation.

Expression of feelings
Many of AD/HD

children are not able to

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express themselves verbally especially when it comes to and how it effects their
talking about their emotions. It is true that many of them talk life. Frequent their
a lot, but it is usually around feelings not about them, drawings express pain,
because often they are not really aware of their feelings. social isolation and great
Art making is a great opportunity for children to unhappiness.
communicate their feelings which have been many times
repressed. During the art therapy process they reveal deep
feelings of negativity they experience about having AD/HD

Group art therapy - learning social skills and managing behaviour

The art therapy group provides a safe and controlled environment where children can
achieve a successful social, therapeutic and educational experience. It is a place where they
can observe and interact with their peers who have the same problems and where the therapist
can observe them. It offers a fresh start and a new opportunity for social success with peers.

The AD/HD children often have poor, weak and underdeveloped social skills. Many
have no close friends although they are desperate for friendship. Some children may not have
problems making friends because they are very outgoing but may have difficulty keeping
them. They often exaggerate, interrupt, are over-enthusiastic, do not respect personal space or
boundaries, hurt other children’s feelings, are talkative, highly defensive, self involved,
forgetful and often miss or misunderstand social clues. Most of the children do not have
insight into their inappropriate behaviour. With art making and discussion they can
understand that their problems in making and keeping friends derive from their disorder.
Working together on art projects they find opportunities to experience different social
situations, to observe themselves in social contacts, to practice social communication in a safe
environment and to make some improvements if necessary. Group projects and working in
pairs are especially good for resolving these kind of problems.

ART THERAPY GROUPS AT THE COUNSELLING CENTRE IN LJUBLJANA

Over the last five years I have been working with AD/HD children aged 7-12 at the
Counselling Centre for Children, Adolescents and Parents in Ljubljana, Slovenija. The
children are referred by psychiatrists, psychologists and special needs educators. Each group
consists of 5 to 7 children. Limiting group size is necessary, because the AD/HD children
perform better in smaller, less distractible and more predictable environments. We meet once
a week for an hour and a half. Art therapy sessions begin in October and terminate in June. I
meet with the referring specialist every two months or by request if there are any special
developments. I have two presentations for the entire staff – at the beginning of October when
I present the methods of my work and inform the staff about terms and availability of places.

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The second presentation is at the end of June when I present the results of my work. Once a
year I organise a practical workshop for the members of staff interested in art therapy.
Parents must commit to bringing their children to group every session. Attendance at
every session is important because allows children to have the full experience and teaches
them about living up to a commitment. It is important for the parents to understand what are
the goals of AT so that they do not expect miraculous changes. I meet with parents after each
session when we discuss child’s participation and behaviour. I also give them instructions on
how to practice certain skills at home. Every two months the parents have the opportunity to
see their child’s art work, to assess their progress and to discuss appropriate individual goals.
These meetings are also very important for me to hear how the child is functioning at home
and to learn if the child can generalise any of the strategies taught in the group.

Goals of AT
Before starting art therapy groups I set some basic goals which I wanted to achieve:
1. Using art therapy methods children will become more aware of their emotions and
behaviour. This will help them cope with their every day (school) situation and improve
their life quality.
2. Special creativity based exercises will help them improve and develop their motor skills,
attention, orientation and concentration, which will consequently influence their writing
skills and body awareness.
3. Relaxation exercises will help them enter and exit functional requirements and cope with
emotional distress.
4. Being in a group will give them the possibility of simulating school/family situation which
will improve their communication skills.
5. Therapists and other professionals will benefit from art therapy methods. They will be able
to incorporate art based activities into their professional treatment of children.
6. Parents will also benefit from art therapy - they will find new ways of communicating with
their children and coping with their problems which will have positive influence on parent-
parent and parent-child relationship.

The main end of AT is to take beginning steps toward reaching the child’s long-term goal
of improving his skills and actualising his potential. Collaboration with parents and
professionals working at the Counselling Centre is necessary.
Based on the above mentioned goals I developed certain methods and wrote an AT
programme defining the contents and structure for every session. Using the action research
method I planned each session, set the short term goals, applied certain measures, observed
the effects, evaluated the results which were the foundation for planning a new action. For the
purpose of my research I used questionnaires for children, parents and referring specialists,
had various interviews with all three groups, collected various documents and materials and
kept a research diary.

The modes of AT
The modes of AT were as follows: educating children regarding AD/HD; establishing
the environment of trust where children can express and explore their feelings; using
educational social-skills art therapy approach for practising social appropriate skills; using
structured drawing to contain the anxiety by offering a structured and predictable reality that
was controllable by children; using free drawing to allow children to externalise their
feelings; influencing the AD/HD core components: inattentiveness, impulsivity, hyperactivity;
developing strategies to cope; using strategies of empowerment to improve self esteem;
enhancing creativity throughout the process.

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AT programme
The programme is based on four deficit areas of AD/HD:
 FUNCTIONAL (fine/gross motor skills, space orientation, visual perception,
distractibility, concentration, organising ability and other).
 EMOTIONAL (self-esteem and self worth, expression and exploration of feelings,
empathy).
 BEHAVIOURAL (impulsivity and hyperactivity issues, changes of temper, conflicts,
aggressiveness, structure and boundaries etc.).
 SOCIAL (making and keeping contacts, active participation, understanding social clues
etc.).

Session structure

Each session consists of three parts:

1. Introduction (20 min),
2. Main art activity and discussion (60 min),
3. Conclusion (10 min).

The introductory part includes different warm-up activities, the purpose of which is to start
communication among children and to prepare them for the main art activity. The
introduction is followed by the main art activity which is divided into three parts: (a) the
review of the previous session, (b) art making, (c) discussion. In the conclusion we do the
cleaning up and make plans for the next session. Art based exercises can be successfully
combined with music, writing, movement and play.

Art activity
According to the needs of the group members the art activity can focus on improving
functional skills, it can open certain emotional issues or the majority of time can be spent on
practising social skills and appropriate behaviour. I developed specific art based exercises for
each of the four deficit areas of AD/HD.
For improving the graphomotor skills, visual perception, memory skills, space
orientation, prolonging concentration, directing attention and improving organising ability I
apply different art based exercises such as geometry, pattern drawing, fine collage technique,
sampling, frames, seals, puzzle, mosaic, stencils, textures and other.
I mentioned at the beginning that many of AD/HD drawing and make up a
children have specific learning disabilities, meaning they story which they then
have problems with writing and reading. We try to practice write and read to other
these skills on every possible occasion: for example when children.
we draw and colour patterns I ask children to look at the
To express and explore one’s emotions we use certain exercises regarding self-
perception, self-esteem, family relationships, peer relationships and other. Children are
offered different general topics such as: my feelings (about having AD/HD, about friends,
family members etc.), my wishes, friendship, self-portrait, personal symbol, my life line,
masks and other.
Regarding social and behavioural area different group paintings and games as well as
work in pairs has proven to be very successful allowing children to develop positive social
interaction, to learn about listening, sharing, organising, helping others, respecting diversity,
improving self-control, developing feelings of happiness, optimism and content.

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 We also use different relaxation (art) techniques such as mobilisation, exploring art
materials, using different body parts to paint, painting while listening to music and other.
It is important that we always repeat what we learnt in the previous session(s), because
repetition is essential for children with AD/HD. It helps them internalise the information. The
drawings, being visual reminder, are used for review and reinforcement of each session.

The first session is important for establishing the trust so the children can commit to
the group process. We should always begin by making sure everyone is introduced. After
brief introductions the therapist presents the rules and concept of art therapy and explains
what it offers. The rules should be written down and reviewed from time to time. They are
very important, because they provide structure and boundaries. We should also discuss
confidentiality and ask children for permission to share their drawing with parents and
professionals who work with them.
We can then ask the children to do the first drawing introducing themselves (different
possibilities). On this occasion we can explain that the art making part of the session is always
time limited so there is adequate time left to discuss their work, which is an important part of
the exercise. When children do the art work the therapist should not only observe what they
draw but also how they have used space and materials, how they communicate with each
other, how they manage time, how they plan and organise themselves, how they behave. The
advantage of group therapy is that therapist can observe a child in a social setting. The
observations should be recorded so that they can be addressed in later sessions.
In the second session each member of the group is asked to introduce the other
members, using their names and mentioning what they have learned about the person.
As the group members in the following sessions learn more about each other, they
develop a relationship of trust and can start addressing problems and learning managing skills.
The final session includes evaluating the achievements and making plans for the
future.

Discussion
At the end of each session children look at each other’s drawings (art objects) and
discuss their feelings. The discussion helps develop verbal communication skills. Presenting
one’s drawing is very important because many times children with AD/HD are not able to
present information in a clear manner. Discussion also solidifies the group and initiates the
development of trust. It helps the children make a verbal connection with the emotions
presented in art media.

RESULTS

The most significant improvements were seen in the area of social interaction: children
learnt and used certain social skills to better communicate with peers and their parents.
Furthermore the children attending AT became less defensive and more open to suggestions
which positively influenced their school performance. By exploring and expressing their
feelings their self-esteem grew, as they felt more confident and competent. Certain

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improvements were seen also in the functional area: they improved their motor skills and
learnt strategies to help them focus better, remember more and be less distracted. The parents
reported that the children acted less impulsively and performed better at school.
Other interventions were planned and used simultaneously with the same children
from the other specialists’, teachers’ and parents’ side so we can conclude that the
improvements resulted from the common efforts.
The art therapy group has been successful in helping children identify their feelings
about having AD/HD and has presented them with certain strategies which can help them
perform better at school, establish good social contacts and control their behaviour. They have
learnt new ways to handle problems and achieve better results.

CONCLUSION

All the art therapy sessions focus on learning strategies to empower children and improve
their self-esteem. Of course there is always a big step from what the children learn at AT
sessions to actually incorporate helpful strategies into their daily life. This is difficult to
achieve and children and their parents should be aware of this.
AD/HD is a chronic and complex disorder that cannot be easily fixed. Art therapy
program can achieve certain level of success, but children need much practice and visible
results can be achieved only if the children, parents, teachers and other professionals are
willing to participate and accept the responsibility to continue using the learnt skills.

REFERENCES
(1) Case, C.; Dalley, T.: Working with Children in Art Therapy. Routledge, London 1990.
(2) Goldstein S., Goldstein M.: Hyperactivity: Why won't my Child Pay Attention?, John Wiley & Sons,
Inc, New York, 1992.
(3) Hickson, A.: Creative Action Methods in Groupwork, Winslow Press Ltd., Oxon, 1997.
(4) Kramer, E.: Art as Therapy with Cildren, Magnolia Street Publishers, Chicago, 1993.
(5) Liebmann, M.: Art Therapy for Groups - A Handbook of Themes, Games and Exercises. Routledge,
London 1994.
(6) Magajna, L. Koncentracija za učenje, Svetovalni center za otroke, mladostnike in starše, Ljubljana, 1991.
(7) Mikuš Kos A., Žerdin T., Strojin M.: Nemirni otroci, Svetovalni center za otroke, mladostnike in starše,
Ljubljana, 1995.
(8) Safran D.S. Art Therapy and AD/HD, Diagnostic and Therapeutic Approaches, Jessica Kingsley
Publishers, London, 2002.
(9) Thomson, M.: On Art and Therapy: An Exploration, Free Association Books, London, 1998.

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