A Review of the Effectiveness, Feasibility, and Acceptability of Art Therapy for Children and Adolescents during the COVID-19 Pandemic

Art therapy has been widely offered to reduce symptoms of psychological disturbance. Pooled evidence about its effectiveness in epidemic contexts, particularly during the COVID-19 pandemic, has not been yet established. This study reviewed the effectiveness, feasibility, and acceptability of art therapy on children and adolescents during the COVID-19 pandemic and past epidemics. We searched PubMed/Medline, PsycINFO, CENTRAL (Cochrane Library), and CINAHL for articles on art therapy during COVID-19. Included studies reported improvements in measures of mental health, sleep quality, and psychological well-being in children with or without disabilities in the epidemic context. Results also showed that art therapy was highly feasible and accepted by children and adolescents as well as their families during epidemics in reviewed studies. Art therapy can be effective at improving various aspects of mental health, sleep quality, and psychological well-being. More empirical evidence is needed with larger sample sizes and longer duration of interventions.


Introduction
The COVID-19 pandemic is recognized as a global public health crisis as well as a mental health crisis [1]. Children and adolescents are especially vulnerable to social disruptions caused by COVID-19 control measures [2]. Not only did the COVID-19 pandemic exert negative impacts on the well-being and mental health of children directly but also indirectly via the implementation of public health interventions for COVID-19 such as school closure and lockdown. Along with the socio-economic burden, the lack of social interactions and appropriate support systems during COVID-19 has further amplified mental health risks, especially among the younger population [3].
Extant literature has demonstrated that children and adolescents experienced mental health problems related to the COVID-19 pandemic. A number of mental conditions were documented during the time of the pandemic: increased measures of fear, anxiety, depression, suicidality, sleep disturbance, post-traumatic stress disorder (PTSD)-related symptoms, as well as drug and alcohol misuse coinciding with school closures [4][5][6]. Other reported psychological conditions caused by COVID-19 included clinging, inattention and irritability, decreased appetite, fatigue, and discomfort [7]. Furthermore, increased stress related to family life had also been reported among both children and parents and this further dampened the parent-children worsening relationship during the COVID-19 pandemic; examples of stressors include parents' pressure from home childcare during social lockdowns, family members' admission to quarantine and/or hospitalization or even deaths resulted from COVID-19 infection, children's lack of access to resources of mental health care such as telepsychiatry [3,8]. Increased risk of exposure to domestic violence, abuse, and neglect during COVID-19 was also noted; lack of contact with people, who would normally notice the mental consequences of such maltreatment, posed further challenges in improving the mental state of children and adolescents [8]. Besides immediate effects on mental health, the aftermath of COVID-19 poses tremendous impacts on the longterm development of children and adolescents. For instance, Liu et al. discussed that stable companionship is among the core of a child's healthy psychological development, and thus separation from parents, both short-term and long-term, due to COVID-19 presents adverse changes in their mental health [9]. Salient issues encountered by parental loss and isolation from parents in previous settings include heightened risk of mood disorders and psychosis as well as latent depression and anxiety in adulthood [10].
Art therapy is defined as a form of psychotherapy that includes the use of art as its main mode of expression and communication [11]. A wealth of studies have strived to identify the root of art therapy and its development trajectory. By origin, art therapy was utilized for treating impairment in symbolic systems or trauma-induced troubles in behavioral development [12,13]. It is distinguished from other forms of therapy in the unique benefits of soothing mental issues through methodological use of lightweight yet influential art means such as music, drawing, painting or sculpting with an aim to induce changes, progress and acceptance in the mental state of the receiver [14]. Therefore, although the event of a pandemic or disaster rarely results in such extreme disability, art therapy is still considered a potential intervention to improve the mental well-being of children and adolescents [15,16]. During COVID-19, most common art therapies include music-, visual art-, movement-, and expressive-writing-based therapies [17].This approach allows children to use art as a form of emotional expression, and at the same time enhances psychosocial care for children during medical treatment and recovery [18]. Art therapy as mental health treatment has been widely used and successfully applied in different healthcare and non-healthcare settings [19]. An example of art therapy used to improve mental health is art therapy telehealth, which has been reported to promote emotional stabilization, a sense of connection, and self-worthiness and foster engagement, integration, and participation of family and community members [20,21].
Previous reviews of the effectiveness of art therapy in different populations of children suggest that art therapy is effective in improving their physical and psychological health as well as their quality of life [22][23][24]. During COVID-19, the use of art therapy underwent major changes in its implementation, specifically through online platforms and on a larger scale instead of private in-person therapy sessions. This characteristic is a prime advantage during the context of a public health crisis, as services can be provided online, and thus can be available wide-scale to reach a larger number of children. Therefore, the objective of this study is to assess the effectiveness, feasibility and acceptability of art therapy among children during COVID-19 as well as identify knowledge gaps to be fulfilled for future settings. This rapid review aims to inform therapists and care providers with a comprehensive picture of art therapy globally to develop best-fit art therapy services and art-based rehabilitation programs for their community, especially after COVID-19.

Example Implementations of Art Therapy
During COVID-19, art therapy was delivered in several forms, most common of which were drawing, music listening and playing, narrative interactions [25]. Although all were generally effective, their impacts ranged from mild mood enhancement to major improvement of sleep quality or reduction of hyperactivity. In this review, we investigated three main art therapy interventions to assess their effectiveness, feasibility and acceptability among children and parents. Table 1 summarized selected interventions of art therapy during COVID-19 including their settings, delivery, measures and outcomes.

Effectiveness of Art Therapy
Malboeuf-Hurtubise et al. conducted a randomized cluster trial in Quebec, Canada during the COVID-19 lockdown period [28]. The authors employed two groups comprising 14 school children who received emotion-based directed drawing intervention in the first group and 8 children who received mandala drawing intervention in the second group. Both groups underwent five weekly 45-min sessions during which children were asked to make drawings and discuss their works. Contents of the drawings in the first group were child participants' feelings and COVID-19-related mental issues (e.g., fear, worry, irritation, etc.); meanwhile, the second group drew mandala only for each session, with no COVID-19-related exercise being given. While the authors could not identify any post-intervention differences regarding inattention, anxiety, depression, hyperactivity, and mindfulness between groups 1 and 2, they observed that across the entire sample, after the post-hoc sensitivity analysis, hyperactivity scores among children showed a significant reduction, suggesting that drawing-based interventions could provide mental health improvement [28].
Bombard et al. and Cho et al. explored how using music therapy could stimulate positive feelings among children during the COVID-19 pandemic [26]. One study provided specifically curated music playlists to 19 mothers and instructed them to play the music to children during the week, especially when their children were in a negative mood and in need of improvement, or when in a positive mood but in need of prolonging such a state. The study reported that 81.2% of mothers reported that children reported themselves as happier and experienced less psychological distress after listening to the music, while 13.7% of mothers did not find any effects of the intervention on children's mood [26]. Another study [27] used home-based music therapy aiming to improve sleep quality, and created personalized visual soundtracks for children with developmental disorders, whose rehabilitation therapies were disrupted by COVID-19. Among 12 children who participated, the authors observed that sleep breathing disorders, sleep-wake transition disorders, and overall sleep disturbance improved after the intervention (p < 0.05) [27].

Feasibility and Acceptability of Art Therapy
Regarding the feasibility, of offline interventions, the material preparation seemed to be the most complicated stage. For example, Sarah Bompard et al. (2021) emphasized that for children with developmental disorders, visual soundtrack preparation required the involvement of a music specialist who completed clinical training in music therapy and held a degree in Education; persons with such combined backgrounds might be hard to find for similar studies [27] (Table 2). For online interventions, Malboeuf-Hurtubise et al.
(2021) noted that the intervention was highly feasible with few technical complications, such as a secured video call platform. Requirements for instructors who had experience in mindfulness-based intervention and art-therapy knowledge to organize drawing were mentioned [28]. Cho & Ilari (2021) found that they were unable to control participants' engagement through virtual intervention; and they suggested that increased social presence during the study (e.g., via visual representation of researchers) might help improve and sustain the motivation of participants [26].
In terms of acceptability, all trials found that children and facilitators engaged in the intervention and, to a certain extent, accepted to continue performing intervention-related activities even after the intervention ended, suggesting that there is a high acceptance level of art therapy for children in the epidemic context [16,[26][27][28].  All families agreed to continue participating in the therapy.

Not available
The development of the soundtrack should have the involvement of the mother. Facilitators' required experience: Parents should have basic experience in using these files. Children's ability: No requirement.

Changes in COVID-19 Art Therapy Delivery
A key difference in delivering art therapy interventions during the COVID-19 pandemic when compared to the normal context or the previous Ebola epidemic is the use of virtual video conference tools due to local social distancing requirements since two out of three interventions were implemented via this platform. The core advantages of this approach in the context of epidemic are that art therapy is easily accessible and there are several types of art-based interventions available that are inexpensive and capable of large-scale implementation with high level of acceptability by children and their families. When children and adolescents stay at home due to infectious epidemics can participate in virtual art therapy sessions via the Internet, art therapists can provide their therapy services to a greater percentage of the healthcare-seeking population and address an important gap in the healthcare system [28]. Videoconferencing technology enables art therapists to have timely access to a larger number of children and adolescents who experience disruptions in mental healthcare and allow children to interact in a group during highly collective activities. The use of technology to deliver online art therapy sessions has also been shared in two case studies in the United Kingdom and the United States, to healthy children and those with anorexia nervosa during the COVID-19 pandemic [29,30].
As the stress induced by COVID-19 shares many similarities with previous pandemics, implications can also be drawn from discussed settings. However, practitioners need to make suitable adaptations due to unique characteristics of COVID-19. Firstly, to successfully implement an art therapy intervention during the COVID-19 pandemic and future epidemics, the content should consider children's culture and abilities. Secondly, further virtual art therapy interventions should be warranted and tested among children in quarantine areas who were particularly vulnerable to mental disorders [6], or children whose parents were frontline health workers since none of the interventions were performed for this population. Several knowledge gaps in art-based interventions need to be addressed, for instance, evidence from wide-ranging art therapies or responses from diverse-background populations to art-based interventions.

Quality Assessment and Ethical Considerations
The methodological quality of the studies was assessed by using the Mixed Methods Appraisal Tool, which examines the methodological quality of qualitative research, randomized controlled trials, nonrandomized studies, quantitative descriptive studies, and mixed-methods studies [31]. As this review used published and secondary data, no ethical review was thought of.

Limitations
This review has several limitations. Firstly, although we included major types of art therapy in the inclusion criteria, we only found four studies for analysis. Therefore, it is possible that some relevant articles might not be retrieved during our search process despite using search strategies and iterative stages to minimize omissions. Secondly, we restricted our search to the English language and scientific articles; thus, studies published in other languages or other document forms (e.g., grey literature, reports, etc.) could be missed. Moreover, due to the relatively nascent area, there is insufficient data to characterize aspects of the setting, training requirements, outcome measures, and how best to personalize art therapy treatment approaches.

Conclusions
Art therapy is feasible a complementary therapy and can help individuals to overcome the psychological conditions during COVID-19 should it be integrated into schools, community-based activities and family supports.