Drama Therapy for Children and Adolescents with Psychosocial Problems: A Systemic Review on Effects, Means, Therapeutic Attitude, and Supposed Mechanisms of Change
Abstract
:1. Introduction
2. Methods
2.1. Study Design
2.2. Search
2.3. In- and Exclusion Criteria
2.4. Selection of Studies
2.5. Quality Assessment of Individual Studies
2.6. Data Collection Process and Analysis
3. Results
3.1. Study Selection
3.2. Quality of the Studies
3.3. General Study Characteristics
3.4. Clients Characteristics
3.5. Drama Therapy Characteristics
3.6. Outcomes
3.7. Outcome Psychosocial Problems
3.7.1. Overall Psychosocial Problems
3.7.2. Internalizing Problems
3.7.3. Externalizing Problems
3.7.4. Social Functioning
3.7.5. Coping and Regulation Processes
3.7.6. Social Identity
3.7.7. Cognitive Development
3.8. Outcome Drama Therapy Characteristics
3.8.1. Drama Therapeutic Means
3.8.2. Drama Therapeutic Attitude
3.8.3. Supposed Mechanisms of Change
Specific Mechanisms of Change
General Mechanisms of Change
4. Discussion
5. Conclusions
Author Contributions
Funding
Institutional Review Board Statement
Informed Consent Statement
Data Availability Statement
Acknowledgments
Conflicts of Interest
References
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First Author/Year | Design/Time Points | Quality Assessment Rate | Study Population | n = (Treated/Control) | Type (Group or Individual or Both), Frequency, Duration | Control Intervention/Care as Usual |
---|---|---|---|---|---|---|
Anari, 2009 [75] | CCT | Moderate | Age 10–11 | 14 (7/7) | Group | No intervention |
Follow-up: 3 months | Social anxiety disorder | 12 times | ||||
Elementary school | 120 min per session | |||||
Twice per week | ||||||
D’Amico, 2010 [76] | Pre- and post-test design | Moderate | Age 1–12 | 6 | Group | - |
Asperger’s syndrome or High-Functioning Autism and Pervasive Developmental Disorder Not Otherwise | 21 sessions | |||||
Specified Social service center | 75 min per session | |||||
Once per week | ||||||
Ghiaci 1980 [77] | CCT | Weak | Age 3–5 | 12 (6/6) | Individually in a group setting | No intervention |
Follow-up: 1 month | Young children | Follow up: 8 (4/4) | 6 sessions | |||
Day nursery | 60 min per session | |||||
Six successive weekdays | ||||||
Hoogsteder, 2014 [78] | CCT | Weak | Age 16–19 | 91 (63/28) | Individual and group | Care as usual |
Delinquents (combination of conduct disorder n = 30, oppositional disorder n = 24, Attention Deficit Hyperactivity Disorder n = 11, mental disability n = 15) | Average duration in weeks 46.86 | |||||
Secure juvenile justice institution | Average hour of treatment per week 1.72 | |||||
Individual: 60 min, once per week Group: 12–14 sessions 90 min | ||||||
Hylton, 2019 [79] | Pre- and post-test design | Moderate | Age 14.71 (mean) | 11 | Group | - |
Students affected by the February 14th shooting at MSD High School in Parkland Florida | Four days per week over two weeks | |||||
Summer arts trainings camp | 3.5 h for a total of eight sessions (28 h) | |||||
The two-week camp was held three times, four, five and 5.5 months after the date of the shooting. | ||||||
Irwin, 1972 [80] | RCT | Weak | Age 7–8 | 12 (4/4/4) | Group | Group II: activity psychotherapy group in which regular group social work principles were applied Group III: recreation group in which the workers assumed the role of recreation leaders |
Emotionally disturbed children | 20 sessions | |||||
Outpatient treatment center | 60 min per session | |||||
Once per week | ||||||
Lowenstein, 1982 [81] | RCT | Weak | Age 9–16 | 5 | Individual and group | No intervention |
Extreme shyness in maladjusted children | 6 months | |||||
School psychological service | ||||||
Mackay, 1987 [82] | Pre- and post-test design | Weak | Age 12–18 | 5 | Group | - |
Girls who have been sexually abused, | 8 sessions | |||||
Special organized location: drama studios at Concordia University in Montreal | 4–5 h per session | |||||
Once per week | ||||||
Rousseau, 2007 [83] | RCT | Strong | Age 12–18 | 123 (66/57) | Group | No intervention |
Newly arrived immigrant and refugee adolescents | 9 sessions | |||||
Integration classes in a multiethnic high school | 75 min per session | |||||
Once per week | ||||||
Rousseau, 2012 [84] | RCT | Strong | Age 12–18 | 55 (27/28) | Group | No intervention |
Immigrant and Refugee | 12 sessions | |||||
High school serving an underprivileged neighborhood of immigrants | 90 min per session | |||||
Once per week |
First Author/Year | Psychosocial Outcome Domain/Measure | Results | Effect Sizes |
---|---|---|---|
Anari, 2009 [75] | Self-report Leibowitz social anxiety scale for children and adolescents (LSAS-CA) [85] Performance anxiety subscale Performance avoidance Social anxiety subscale Avoidance subscale | The experimental group showed significant decline in symptoms of social anxiety (all subscales) compared to the control group (p < 0.05). The therapeutic changes lasted after three months, and these scores of three months differ from the scores of the control group | No information given |
D’Amico, 2010 [76] | Social skills improvement system-rating scales (SSIS-RS) [86] - Social skills (SK) - communication, cooperation, assertion, responsibility, empathy, engagement, self-control Problem behaviors (PB) - externalizing, bulling, hyperactivity/ inattention, internalizing. On the parent form as well as autism spectrum problem behavior | Student Form: The overall mean score on SK and PB did not change significantly after the intervention. There was a significant decrease in the symptoms on the mean score on the subscale hyperactivity/inattention (p < 0.05) after the intervention. All other subscales did not change after the intervention Parent Form: There was a significant decrease in the symptoms on the mean score on the overall the SK and PB score (p < 0.05) after the intervention. Regarding the subscales, there was a significant decrease after the intervention for externalizing problem behavior, engagement, hyperactivity/inattention, autism spectrum problem behavior (p < 0.05). Other subscales did not change after the intervention | No information given |
Ghiaci 1980 [77] | Repertory grids * were employed to depict the systems of personal constructs, since these permit a description of an individual’s cognitive structure to be given in his own terms | Compared to the control group, the experimental group showed a larger increase from pretest to posttests on both the original constructs (p < 0.025) as well as the focused constructs (p < 0.01) | No information given |
Hoogsteder, 2014 [78] | Structured assessment of violence risk in youth (SAVRY) [87,88] Three risk domains
Self-control, assertiveness and dealing with anger assessed by juvenile- and mentor report * Self-report Utrecht coping list (UCL) [89,90] Cope with stressful situations:
Measure cognitive distortions on aggression (externalizing) and sub-assertive (internalizing) HIT [92] Self-report on physical aggression and opposition-defiance | All analyses were controlled for pre-test score, gender, length of stay, and participation in EQUIP, a CBT based module Risk of recidivism and aggressive behavior The experimental group had a significant lower violent recidivism risk (p < 0.001), higher score on assertiveness (p < 0.05 reported by the mentors and p < 0.001 reported by the juveniles), lower scores on self-control skills (p < 0.001 reported by the mentors and by the juveniles), and on dealing with anger (p < 0.001) after the intervention compared to the control group. Fewer incidents were registered in the experimental group, but there was no significant difference Coping skills The experimental group scored significantly better on coping skills problem solving (p < 0.001), palliative coping (p < 0.001), social support (p < 0.001), reassuring thought (p < 0.001), and lower scores on stress and poor coping (p < 0.001) after the intervention compared to the control group Cognitive distortions Compared to the control group, the experimental group showed significantly lower on aggression/justification (p < 0.001), physical aggression (p < 0.001), opposite behavior scales (p < 0.001), and sub-assertive (p < 0.001) after the intervention. There was no significant difference after the intervention on negative attitude Responsiveness The experimental group scored compared to the control group significantly better for motivation for treatment (p < 0.05), attention deficits (p < 0.05), and scored significantly lower on medium to large for distrust (p < 0.001), and impulsivity (p < 0.001) after the intervention | SAVRY Recidivism Risk 1.01 Dealing with anger 0.84 AR-list Juv. Self-Control 2.36 Assertiveness 1.99 AR-list mentor Self-Control 1.38 Assertiveness 0.35 UCL Problem Solving 1.37 Palliative Coping 1.73 Social Support 1.05 Reassuring Thought 0.92 SAVRY Stress—Poor Coping 0.49 BITI Aggression/justification 1.38 Sub assertiveness 0.55 HIT Oppositional behavior 0.95 Physical Aggression 1.45 SAVRY Negative Attitude 0.30 SAVRY Motivation for treatment 0.42 Distrust 0.73 Attention deficit 0.45 Impulsivity 0.73 |
Hylton, 2019 [79] | Depression was measured by self-report Patient Health Questionnaire (PHQ-8) [93] Anxiety was measured by the self-report Generalized anxiety disorder (GAD-7) [94] Posttraumatic stress was assessed using the self-report child’s reaction to traumatic events scale (CRTES) [95] Positive and negative affect were assessed using self-report positive and negative affect schedule (PANAS) [96] Satisfaction of the treatment was assessed using an evaluation questions * especially developed for the camp | The drama treatment program resulted in significant decreases in symptoms of posttraumatic stress (p < 0.023), anxiety (p < 0.007), depression (p < 0.034), and in increases in positive affect (p < 0.009). There was no effect on the negative affect after the intervention in the drama group. Participants of the creative arts therapies camp, including visual arts (n = 15) music (n = 8) and drama (n = 11), evaluated: 93.3% agreed or strongly agreed and 6.1% indicating neutrality and 0% disagreed or strongly disagreed on having fun at the camp; 79.8% agreed or strongly agreed and 15.2% indicating neutrality and 6.1% disagreed or strongly disagreed that they learned something new about myself; 84.4% agreed or strongly agreed and 12.5% indicating neutrality and 3.1% disagreed or strongly disagreed that they felt safe at the camp; 87.9% agreed or strongly agreed and 6.1% indicating neutrality and 6.3% disagreed or strongly disagreed that engaging the creative arts gives me a deeper understanding of myself and others | No information given |
Irwin, 1972 [80] | Rorschah Index of Repressive Style (RIRS) [97] indicate the extent to which images, emotions and past experiences are verbally labeled and thus available in consciousness in communicable terms Verbal Fluency (VF)—assessing each child’s response to a set of thematic pictures which was designed to elicit projective material through a verbal modality Semantic Differential (SD) * – specifically designed to measure attitude changes: three dimensions: evaluative, potency, activity. Each had six concepts (me, grown-ups, feelings, sharing, imagination, other kids) Parent Competence Scale (PCS) *—to measure mastery of major areas of functioning both at home and with peers and consisted of concrete descriptions of child behavior: Factor I perception degree of interest and participation in activities vs. degree withdrawal and associated depression. Factor II perception of relative degree cooperation and compliance compared to child’s anger and defiance in daily interpersonal relationships | Comparing the change scores, the intervention group showed more positive changes from pre- to posttest in RIRS score (p < 0.05) and verbal fluency (p < 0.01) compared to the control groups. In addition, change scores between pre- to post were significantly higher in the intervention group compared to the control groups on two of the three semantic dimensions of the SDC, namely “evaluating” (Me and Other kids; p < 0.05), and “potency” (Me, Other kids and Grown-up; p < 0.05). There were no significant differences in either the activity or recreation group after the intervention. From the parent competence scale: Factor I and of factor II rating score differences yielded no significant results for all groups after the interventions | No information given |
Lowenstein, 1982 [81] | Maudsley Personality Inventory self-report scale [98] Timidity scale on a 1–5 rating scale, 1 = very timidity, 5 = moderately outgoing Assessed in reading, spelling, and mathematics. | The experimental group had a significantly less severe timidity score (p < 0.01) after the intervention compared to the control group. In addition, there was a significant difference changed in intelligence (p < 0.05) ** between the groups after the intervention. No differences between groups were seen in attainments in reading, spelling and mathematics after the intervention | Severity of timidity: 2.075 MPI extraversion: 0.998 |
Mackay, 1987 [82] | Beck depression Inventory (BDI) [99] self-report scale to assess depression level SCL-90 self-report [100] depression, anxiety, somatization, interpersonal sensitivity, obsessive-compulsiveness, hostility, phobic anxiety, paranoid ideation and psychoticism Texas social behavior inventory-self-report short form (TSBI) [101] to assess self-esteem Attributional Style Questionnaire (ASQ) self-report [102] attributions were assessed along three dimensions: internal-external, stable-unstable, global-specific Social support questionnaire (SSQ) self-report [103] assess number of social supports and satisfaction with level of social support The Marlowe–Crowne Social Desirability Scale (MCSDS) self-report [104] employed to assess the tendency of the participants to seek social approval by responding in a culturally appropriate manner. | The experimental group showed significant reductions on the levels of hostility (p < 0.01), depression (p < 0.10), and psychotic thinking (p < 0.10) after the intervention. No significant changes between pre- and posttest were found on self-esteem level (TSBI), attribution style (ASQ), number of social supports or reported satisfaction with social supports (SSQ), or social desirability score (MCSDS) | SCL90 Overall intensity of symptoms 1.042 Hostility 0.642 Depression 1.813 Psychoticism 0.561 Anxiety 0.492 Interpersonal sensitivity 0.795 Paranoid ideation 0.345 Obsessive compulsive 0.562 Phobic anxiety0.688 Somatization 0.574 Beck Depression Inventory 1.022 Self-esteem (TSBI) 0.603 Attributional style questionnaire Internal, stable. Global Attributions: bad events 0.309 good events 0.308 Social support questionnaire Number of social supports 0.374 Satisfaction with social supports 0.135 Marlowe-Crowne Social Desirability Scale 0.037 |
Rousseau, 2007 [83] | Strengths and Difficulties Questionnaire (SDQ) [105]: Emotional and behavioral symptoms Impairment perception: Self-report: Difficulties distress me Interfere with home life Interfere with friendships Interfere with classroom learning Interfere with leisure activities Teacher’s report: Difficulties Distress adolescent Interfere with friendships Interfere with classroom learning Self-Esteem Scale (SES) [106] School performance was assessed on the basis of the first and the last report cards of the school year * | There were no significant differences on emotional and behavioral symptoms at post between both groups, controlling for group differences at baseline The participants in the experimental group reported less impact in all categories except learning at posttest, whereas those in the control group reported more impact on distress (p < 0.022) impairment of friendships (p < 0.033), and a higher total impact score (p < 0.035). No significant group differences were found in the teachers’ reports of the impact scores. Girls in the experimental group showed a significant decrease in the total impact score (p < 0.001), whereas boys in the control group showed a significant increase in the total impact score (p < 0.028). No age effect was observed School performance comparing the first and last report cards of the school year showed a significant difference in oral expression (p < 0.000) for the experimental group and (p < 0.001) for the control group and a significant improvement in mathematics (p < 0.005) for the experimental group. Controlling for group differences at baseline, results showed posttest differences between both groups in mathematics. No significant improvement was reported between the first and the last report cards with regard to overall French results of both groups. With regard to self-esteem, the analysis did not show significant differences within groups between pre and post assessment | No information given |
Rousseau, 2012 [84] | Strength and difficulty questionnaire (SDQ) self-report [103] | Total SDQ symptom score did not change after the intervention on both, experimental and control, groups. The students of experimental group showed significant decrease in the impact on the impairment (p < 0.021) after the intervention. The symptom score of the subgroup of youth who did not report difficulties in school in the countries of origin also decreased following the intervention but not significance (p < 0.053) | No information given |
First Author/Year | Goal of the Study | Intervention | Therapist Attitude | Drama Therapeutic Means and Supposed Mechanisms of Change of the Intervention |
---|---|---|---|---|
Anari, 2009 [75] | This study examines the effectiveness of drama therapy in reducing symptoms of social anxiety disorder in children | Emunah’s Integrative Five-phase Model [107]: Focusing on group play and direct teaching of social interactions | No information given | Participation in a drama activity such as storytelling, movement, voice, role play, pantomime Experience positive human relations Experience and recreate life situations and actualities |
D’Amico, 2010 [76] | To determine the efficacy of drama therapy in addressing the children’s performance or acquisition deficits across the social skill domains targeted over the course of the project (determined by the results obtains on the SSIS-RS forms) | The weekly sessions using each skill from the SSIS as a theme for the two subsequent weeks. Therapeutic modality based on the child’s social and behavioral needs The drama therapy techniques centered on making connections among the group members, while discovering commonalities and shared interests, and encouraged self-expression. Used components of drama therapy: dramatic projection; dramatic reality; role-playing; and storytelling | Adaptive approach | Dramatic projection through improvisational scenes Express their own ideas Emotional expression Dramatic reality within a playspace using improvisational scenes with both conflict and cooperative activities where children act out different social issues. Creativity Experiencing (social connection) Explore their vulnerabilities and psychological issues and reflection on experiences, feelings, and emotions of oneself and others Role-playing Explore new identities Embody the personas Share experiences and feelings Observing (non-verbal) behavior and interpreting behavior of others Storytelling Expression of experiences, feelings, emotions, and thoughts Reflection on experiences, feelings, and emotions of oneself and others Self-control, participants become active participants in their own treatment General Fun and playfulness Use imagination |
Ghiaci 1980 [77] | Cognitive change |
Each session comprised five stages:
| No information given | No information given |
Hoogsteder, 2014 [78] | Decrease severe aggressive behavior | Re-ART: a cognitive behavioral approach combined with drama therapeutic techniques, role-playing games in order to practice perspective taking and problem solving skills. All arts therapists targeted self-image, emotions, and social interaction (especially situations that elicit aggressive behavior), but they did not use any form of established manualized treatment | No information given | Role-playing games Perspective taking |
Hylton, 2019 [79] | Improving mental health status by decreasing symptoms of PTSD, depression levels, anxiety levels and lower levels of negative affect and by increasing positive affect. Drama therapy Role theory and method: participants explore life roles in order to gain insight into group dynamics and internalize new roles that help expand individual resilience and strengths | Improvisation exercises: Participants activate imagination, try new roles, and explore spontaneity. Participants share and enact a personal story with group members in order to promote empathy, insight, and interpersonal connection. Projective technique: each participant chooses and object that he/she feels connected to and verbalizes how he/she feels through the use of this projective | The therapist gave the participants the freedom to share the traumatic memory however they felt comfortable | Improvisation exercises to imaginal exposure, explore life roles and acting out stories through bodily and verbal processing Explore life roles Reflection on experiences, feelings, and emotions of oneself and others Embodied emotional experience Share experiences, feelings, and emotions of oneself and others Activate imagination Explore spontaneity Internalize new roles Projective technique Emotional expression Verbal expression Reflection on experiences, feelings, and emotions of oneself |
Irwin, 1972 [80] | Exploring the feasibility of using drama therapy as a form of treatment with emotionally disturbed children. Prepare inarticulate non-communicative children emotionally for more traditional forms of verbal psychotherapy by learning a progressive sequence of communication skills through dramatic play | Improvisational dramatic play to express and play out wishes, conflicts and fantasies | No information given | Repeated experiences in improvisational dramatic play Share feelings Making emotional discrimination Play out Share feelings Witnessing Immediate feedback and reflection on experiences, feelings, and emotions of oneself and others Express internal states in verbal terms Playing a role Expression in a role: - Verbal expression - Nonverbal expression |
Lowenstein, 1982 [81] | Treat the problem of timidity by reducing anxiety, increasing assertiveness, promoting the ability to communicate effectively with other people, treating feelings of inadequate, influencing parental background and decreasing over-sensitivity | Drama therapy, in which timid children were given especially extroverted and assertive parts in contrast to their normal introverted or non-assertive demeanor. | No information given | No information given |
Mackay, 1987 [82] | A primary goal of the program, structured drama therapy, was to help establish feelings of power and control to combat the feelings of worthlessness and loss of integrity and power often associated with rape and incest | Improvisation, roleplaying and storytelling | The views of Carl Rogers where expression of self is best fostered in an atmosphere of psychological safety | Symbolic role playing (as a projective technique) Improvisation Storytelling Expression of feelings, thoughts, and their identity Creativity Share thoughts or experiences Experience: - Fun and playfulness - of acceptance and being heard - of getting close to each other - acting out ideas and feelings - control in their role play |
Rousseau, 2007 [83] | The goal of the drama therapy program was to give young immigrants and refugees a chance to reappropriate and share group stories, in order to support the construction of meaning and identity in their personal stories and establish a bridge between the past and present | The program is based in Augusto Boal’s forum [108] and Jonathan Fox’s playback theater [109] | No information given | Pairs technique Reflect on a person’s contradictory feelings Reflect different points of view of the same situation or experience Storytelling, acting Exploration of ideas and feelings associated with key experiences Sharing strong emotions and subsequent relief Feeling of agency Symbolic play Expression Witnessing others |
Rousseau, 2012 [84] | The goal is to alleviate problems associated with distress, behaviors stemming from the losses of migration and the tensions of belonging to a minority in the host society, as well as to improve social adjustment, academic performance, and to provide schools and teachers with tools for adapting their teaching methods to suit the emotional and social needs | Each session includes a warm-up period composed of theatrical exercises and of a language awareness activity which also uses dramatization | No information given | Theatrical exercises, dramatization, play out stories Sharing of stories Creation of links among participants |
First Author/Year | A. Selection Bias | B. Study Design | C. Confounders | D. Blinding | E. Data Selection Methods | F. Withdrawals and Dropouts | Overall |
---|---|---|---|---|---|---|---|
Anari, 2009 [75] | Moderate | Strong | Weak | Moderate | Strong | Strong | Moderate |
D’Amico, 2010 [76] | Moderate | Moderate | Weak | Weak | Strong | Strong | Moderate |
Ghiaci 1980 [77] | Weak | Moderate | Weak | Weak | Weak | Weak | Weak |
Hoogsteder, 2014 [78] | Moderate | Moderate | Weak | Weak | Moderate | Moderate | Weak |
Hylton, 2019 [79] | Moderate | Moderate | Strong | Moderate | Weak | Moderate | Moderate |
Irwin, 1972 [80] | Weak | Moderate | Weak | Moderate | Weak | Weak | Weak |
Lowenstein, 1982 [81] | Moderate | Strong | Weak | Weak | Strong | Strong | Weak |
Mackay, 1987 [82] | Moderate | Moderate | Weak | Weak | Strong | Strong | Weak |
Rousseau, 2007 [83] | Moderate | Moderate | Strong | Moderate | Strong | Strong | Strong |
Rousseau, 2012 [84] | Moderate | Strong | Moderate | Moderate | Strong | Strong | Strong |
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Berghs, M.; Prick, A.-E.J.C.; Vissers, C.; van Hooren, S. Drama Therapy for Children and Adolescents with Psychosocial Problems: A Systemic Review on Effects, Means, Therapeutic Attitude, and Supposed Mechanisms of Change. Children 2022, 9, 1358. https://doi.org/10.3390/children9091358
Berghs M, Prick A-EJC, Vissers C, van Hooren S. Drama Therapy for Children and Adolescents with Psychosocial Problems: A Systemic Review on Effects, Means, Therapeutic Attitude, and Supposed Mechanisms of Change. Children. 2022; 9(9):1358. https://doi.org/10.3390/children9091358
Chicago/Turabian StyleBerghs, Marij, Anna-Eva J. C. Prick, Constance Vissers, and Susan van Hooren. 2022. "Drama Therapy for Children and Adolescents with Psychosocial Problems: A Systemic Review on Effects, Means, Therapeutic Attitude, and Supposed Mechanisms of Change" Children 9, no. 9: 1358. https://doi.org/10.3390/children9091358