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Addressing Gaps in Pediatric Mental Healthcare by Removing Barriers: A School-Based Integrated Model for Group Art Therapy

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Title: Addressing Gaps in Pediatric Mental Healthcare by Removing Barriers: A School-Based Integrated Model for Group Art Therapy
Language: English
Authors: Katie Hinson Sullivan, Erin Scherder, Laura Allen, Daniel L. Brinton (ORCID 0000-0002-7888-6708), Anne Crosswell, Elise Gruber, Janice Key (ORCID 0000-0001-9131-6489), Kathleen C. Head (ORCID 0000-0003-1130-6243)
Source: Psychology in the Schools. 2025 62(8):2362-2372.
Availability: Wiley. Available from: John Wiley & Sons, Inc. 111 River Street, Hoboken, NJ 07030. Tel: 800-835-6770; e-mail: cs-journals@wiley.com; Web site: https://www.wiley.com/en-us
Peer Reviewed: Y
Page Count: 11
Publication Date: 2025
Document Type: Journal Articles
Reports - Descriptive
Education Level: Elementary Education
Descriptors: Art Therapy, Mental Health, School Health Services, Elementary School Students, Multi Tiered Systems of Support, Group Therapy, Interpersonal Competence
Geographic Terms: South Carolina
Assessment and Survey Identifiers: Strengths and Difficulties Questionnaire
DOI: 10.1002/pits.23471
ISSN: 0033-3085
1520-6807
Abstract: In the fall of 2021, experts declared a national emergency in children's mental health, urging organizations to put in place school-based mental health care services to reduce barriers and increase access to care. This paper describes implementation and acceptability of an innovative school-based model to deliver group art therapy that is integrated into the school's Muti-Tiered System of Supports, and changes in student social-emotional competencies that occurred in association with participation. The 7-week pilot was implemented in three successive semesters, serving 280 elementary students. Guardians completed Strengths and Difficulties Questionnaires (SDQ) before and after the intervention to describe changes in student social-emotional competencies. SDQ data suggest improvement in internalizing symptoms amongst participants (n = 17, mean decrease in 1.7 points [95% CI: 0.2-3.2]; p = 0.0314). Guardians surveyed (n = 12) strongly agreed that art therapy programs should be continued in the school and that the art therapy process gave their child an alternative form of safe expression [4.88 and 4.75 out of 5 (SD = 0.14 and 0.29), respectively]. All students completed the program. Cost was $170.00 per child. This school-based group art therapy model was found feasible and acceptable, and if scaled, can impact a large population of children with barriers to mental healthcare access.
Abstractor: As Provided
Entry Date: 2025
Accession Number: EJ1477308
Database: ERIC
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  Value: <anid>AN0186727888;pis01aug.25;2025Jul21.06:39;v2.2.500</anid> <title id="AN0186727888-1">Addressing Gaps in Pediatric Mental Healthcare by Removing Barriers: A School‐Based Integrated Model for Group Art Therapy </title> <p>In the fall of 2021, experts declared a national emergency in children's mental health, urging organizations to put in place school‐based mental health care services to reduce barriers and increase access to care. This paper describes implementation and acceptability of an innovative school‐based model to deliver group art therapy that is integrated into the school's Muti‐Tiered System of Supports, and changes in student social‐emotional competencies that occurred in association with participation. The 7‐week pilot was implemented in three successive semesters, serving 280 elementary students. Guardians completed Strengths and Difficulties Questionnaires (SDQ) before and after the intervention to describe changes in student social‐emotional competencies. SDQ data suggest improvement in internalizing symptoms amongst participants (n = 17, mean decrease in 1.7 points [95% CI: 0.2–3.2]; p = 0.0314). Guardians surveyed (n = 12) strongly agreed that art therapy programs should be continued in the school and that the art therapy process gave their child an alternative form of safe expression [4.88 and 4.75 out of 5 (SD = 0.14 and 0.29), respectively]. All students completed the program. Cost was $170.00 per child. This school‐based group art therapy model was found feasible and acceptable, and if scaled, can impact a large population of children with barriers to mental healthcare access.</p> <p>Summary: School‐based art therapy can be an effective and feasible intervention for positively impacting students' social, emotional, and behavioral skills.Group‐based art therapy is easily integrated into a school's Multi‐Tiered System of Support (MTSS) framework.Art therapy is an acceptable small‐group mental health intervention as expressed by school teachers and guardians.</p> <p>Keywords: art therapy; children; implementation; mental health; model; school‐based</p> <p>There is a mental health crisis facing our children and youth in the United States that requires immediate action from educators, health professionals, and policymakers (U.S. Department of Education [<reflink idref="bib39" id="ref1">39</reflink>]). One in five children in the US suffer from a mental, behavioral, or emotional health disorder (Centers for Disease Control and Prevention [<reflink idref="bib6" id="ref2">6</reflink>]). The percentage of U.S. high school students who have experienced persistent feelings of sadness or hopelessness within the last year increased from 28% in 2007 (Eaton et al. [<reflink idref="bib9" id="ref3">9</reflink>]) to 42% in 2021 (Centers for Disease Control and Prevention [<reflink idref="bib7" id="ref4">7</reflink>]). This rising number of children in need of mental health care has placed strain on our health system, and is exhausting outpatient, emergency, community, and school‐based mental health resources (Leeb et al. [<reflink idref="bib23" id="ref5">23</reflink>]; McBain et al. [<reflink idref="bib25" id="ref6">25</reflink>]; Steinman et al. [<reflink idref="bib37" id="ref7">37</reflink>]; Torio et al. [<reflink idref="bib38" id="ref8">38</reflink>]).</p> <p>Before the COVID‐19 pandemic, it was estimated that only 20% of children with mental, behavioral, or emotional health disorders received care from a qualified mental health professional (Martini et al. [<reflink idref="bib24" id="ref9">24</reflink>]). During the COVID‐19 pandemic, children were subject to additional feelings of isolation, anxiety, and depression as they encountered periods of social and economic unrest and school interruptions (Krause et al. [<reflink idref="bib21" id="ref10">21</reflink>]; Patrick et al. [<reflink idref="bib32" id="ref11">32</reflink>]). Seventy percent of public schools experienced an increase in the number of students accessing mental health support during the pandemic (National Center for Education Statistics [<reflink idref="bib31" id="ref12">31</reflink>]), further exhausting the system. In the fall of 2021, experts in pediatric medicine and psychiatry declared a national emergency in children's mental health, urging organizations to put in place community‐based systems of care, connecting families to school‐based mental health care that could address disparate needs and inequitable access to care in communities (American Academy of Child and Adolescent Psychiatry [<reflink idref="bib1" id="ref13">1</reflink>]).</p> <p>The US Surgeon General issued a similar statement in December 2021 and provided action points on how corporations, healthcare organizations, and the community could support the school as a critical hub for mental health resiliency through implementation of prevention and treatment interventions (Murthy [<reflink idref="bib30" id="ref14">30</reflink>]). School behavioral health and education experts recommend responding to this crisis by expanding effective school mental health supports, which are a critical and necessary part of providing education (U.S. Department of Education [<reflink idref="bib39" id="ref15">39</reflink>]). Research suggests effective mental health supports for students are integrated into the school's framework (Walter et al. [<reflink idref="bib41" id="ref16">41</reflink>]) and engage guardians and teachers effectively (Garbacz et al. [<reflink idref="bib13" id="ref17">13</reflink>]) to meet needs of the school community and address barriers to care.</p> <hd id="AN0186727888-2">Art Therapy as an Effective Mental Health Intervention for Children</hd> <p>Art therapy is an evidence‐based field that provides therapeutic value and insight not available in verbal therapy sessions. It is grounded in the knowledge of human development, psychological theories, and counseling techniques. The practice is led by a certified art therapist who is trained to employ the creative, artistic process as a means of storytelling, providing patients with the tools and encouragement to express their feelings and experiences using visual media (Eaton et al. [<reflink idref="bib10" id="ref18">10</reflink>]). There is no emphasis on product quality or a creative goal, which promotes a safe space for free association and self‐exploration (Furman [<reflink idref="bib12" id="ref19">12</reflink>]).</p> <p>Art created within the therapeutic setting can inform a therapist on internal conflict experienced by the patient and, as the therapist‐patient partnership develops, creates opportunity for healthy integration of newly identified feelings back into the patient's psyche (Kramer and Gerity [<reflink idref="bib20" id="ref20">20</reflink>]). Furthermore, art therapy provides an opportunity for self‐awareness and exploration without relying solely on verbal communication, making it an excellent tool for patients with limited vocabulary, such as children (Piper and Lazar [<reflink idref="bib35" id="ref21">35</reflink>]).</p> <p>Children process conflict and emotional trauma differently than adults, thus therapeutic interventions often require unique and creative approaches to identify, express, and reconcile complex feelings. Data from a 2021 meta‐analysis of art therapy interventions for children with mental health disorders supports the use of art therapy interventions for children who have experienced trauma (Braito et al. [<reflink idref="bib5" id="ref22">5</reflink>]). The COVID‐19 pandemic was a universal traumatic event that all children in all communities experienced (Miller et al. [<reflink idref="bib28" id="ref23">28</reflink>]), and the public school system is an established organization that is critical in the response to help address resiliency and mental health needs of children (Watson et al. [<reflink idref="bib42" id="ref24">42</reflink>]).</p> <p>A 2020 systematic review of school‐based art therapy interventions including 247 children ages 5–12 concluded that school‐based participation in a series of 7–25 art therapy sessions ranging from 40 to 60 min each is beneficial to improve elements of children's emotional and behavioral health including anxiety, attitude toward school, problem‐solving, and self‐concept (Moula [<reflink idref="bib29" id="ref25">29</reflink>]). Teachers report positive changes in students' overall stress, conduct, hyperactivity, and pro‐social behavior following participation in school‐based art therapy services (McDonald et al. [<reflink idref="bib26" id="ref26">26</reflink>]).</p> <p>The purpose of this paper is to describe implementation and acceptability of a school‐based group art therapy model that engages guardians and teachers and addresses common barriers to mental healthcare access. In addition, describe changes in student social‐emotional competencies that occurred in association with participation. This pilot was formed in 2021 as a direct response to the mental health crisis, and uniquely fulfilled the Surgeon General's call‐to‐action for educators, donors, and healthcare professionals to engage families and build evidence‐based mental health programs within the schools to meet specific needs for students at higher risk for developing mental and/or behavioral health disorders (Murthy [<reflink idref="bib30" id="ref27">30</reflink>]). We hypothesized that this model would be feasible, well accepted, and correlated with positive social and emotional outcomes for students in the school‐based setting.</p> <hd id="AN0186727888-3">Methods</hd> <p>This is an implementation study of a school‐based group art therapy pilot in South Carolina. The study was approved by the Institutional Review Board at the Medical University of South Carolina as Quality Improvement and was drafted according to the Standards for Reporting Implementation Studies (StaRi) Statement (Pinnock et al. [<reflink idref="bib34" id="ref28">34</reflink>]).</p> <hd id="AN0186727888-4">Key Programmatic Partners to Support Implementation</hd> <p>During the COVID‐19 pandemic, a South Carolina school district experienced a rise in mental health needs similar to national trends. A state audit confirmed that while families appreciated school‐based mental health services (greater than 80% satisfaction among clients who had received services), service gaps existed due to increased number of referrals during the pandemic (South Carolina Department of Health and Human Services [<reflink idref="bib36" id="ref29">36</reflink>]). School district leaders requested assistance from the Medical University of South Carolina Boeing Center for Children's Wellness (MUSC BCCW) to fill service gaps through an innovative approach such as art therapy.</p> <p>Since 2010, the BCCW has supported schools in this district in the implementation of evidence‐based policy, systems, and environmental change strategies which improve nutrition, physical activity, and social‐emotional wellness (mental health) for students and staff (Key et al. [<reflink idref="bib19" id="ref30">19</reflink>]). In response to the rising mental health needs, this school‐based wellness initiative was expanded to include coordinated implementation of mental health supports in 2021. The BCCW partnered with MUSC Arts in Healing (Arts in Healing [<reflink idref="bib2" id="ref31">2</reflink>]), a department that provides comprehensive creative arts therapy services to patients and families, and formed a shared goal of expanding clinical services into schools. Together, they were awarded a grant from a philanthropic donor to support this group art therapy pilot.</p> <hd id="AN0186727888-5">Model for Delivering Group Art Therapy in Schools</hd> <p>This group art therapy pilot was launched in a South Carolina school district consisting of 82 schools, 3586 teachers, and 48,330 students. Implementation of this pilot was planned for the spring semester of the 2021–2022 school year, summer school of 2022, and the fall semester of the 2022–2023 school year, with quality improvement to be conducted between each cycle. Implementation strategy included efforts focused on gaining art therapy adoption at the school district and individual school level, coordinating and referring students to art therapy within the Multi‐tiered System of Supports (MTSS) framework, conducting art therapy, and conducting quality improvement (Figure 1).</p> <p> <img src="https://imageserver.ebscohost.com/img/embimages/rdk/PIS/01aug25/pits23471-fig-0001.jpg?ephost1=dGJyMNXb4kSepq84yOvqOLCmsE6epq5Srqa4SK6WxWXS" alt="pits23471-fig-0001.jpg" title="1 Workflow for Clinical Art Therapy Initiative Pilot Study." /> </p> <p></p> <p>Selection of schools to be served each semester under the "Clinical Art Therapy Initiative" (CATI) was determined by the school district. Schools to offer art therapy services were selected based on need, geographic location, and presence of school administrative leadership support. District leadership's goal in offering art therapy was to fill mental health service gaps across the district, offering access in each geographic area. The students invited to participate were reflective of the demographics of the overall district: 48.8% White, 34.3% Black, 1.5% Asian or Asian/Pacific Islander, 11.4% Hispanic/Latino, 0.1% American Indian or Alaska Native, and 0.2% Native Hawaiian or other Pacific Islander, with 51% of students living in poverty.</p> <hd id="AN0186727888-7">Integration of Art Therapy into Schools' Multi‐tiered Systems of Support Framework</hd> <p>Once participating schools were identified, art therapy services were coordinated through the schools' MTSS team to anchor the mental health intervention in the schools' framework. MTSS is a framework utilized by schools to guide data‐based problem‐solving practices and integrate intervention, instruction, and supports that are delivered to students across a tiered continuum (Barrett et al. [<reflink idref="bib3" id="ref32">3</reflink>]; McIntosh and Goodman [<reflink idref="bib27" id="ref33">27</reflink>]). Art therapy was offered as a targeted, small‐group intervention, at the Tier 2 level within the MTSS framework (Figure 2).</p> <p> <img src="https://imageserver.ebscohost.com/img/embimages/rdk/PIS/01aug25/pits23471-fig-0002.jpg?ephost1=dGJyMNXb4kSepq84yOvqOLCmsE6epq5Srqa4SK6WxWXS" alt="pits23471-fig-0002.jpg" title="2 Art Therapy Integration into MTSS Framework." /> </p> <p></p> <p>Through ongoing collaboration with BCCW and Arts in Healing, the MTSS teams were guided through the process of identifying students in need of therapeutic services. Referrals were made via the MTSS team's review of universal screening data focused on social, emotional, and behavioral risks as well as educators' observations. Students identified as having internalized behaviors, externalized behaviors, other mental health diagnoses, the loss of a loved one, chronic illness, limited social connections, and/or low self‐esteem were referred.</p> <p>To further support students and reinforce goals and themes introduced in art therapy, MTSS teams were asked to identify a school liaison to be in the room during the art therapy sessions. This liaison, typically a school counselor or social worker, acted as a direct point of contact for guardians of students referred to the program. Process and implementation measures for the pilot were reviewed with the school district and individual schools before services were implemented. Roles and responsibilities for workflow of the MTSS team, school liaison, art therapist, and teachers were outlined and reviewed with the entire school leadership team to ensure clear bidirectional communication and understanding of expectations (Figure 1).</p> <hd id="AN0186727888-9">Participant Enrollment</hd> <p>Once student referrals were made, enrollment packets were sent to guardians and the students' teachers to describe services and obtain consent. The packet contained programmatic material describing art therapy and intervention logistics, a Strengths and Difficulties Questionnaire, and a parent consent form including consent for release of artwork. The school liaison was encouraged to call guardians directly before the packets were delivered to answer any questions about the referral and participation in the study. They were also encouraged to speak directly to the student about their participation before the first session. Referred children were welcome to participate in art therapy group without consenting to participate in research. While all participating students and their guardians did agree to take part in the study, survey completion was optional and not required to begin participation in the art therapy group. Packet materials and consent were returned to the art therapist on or before the first day of the program.</p> <hd id="AN0186727888-10">Art Therapy Group Format</hd> <p>During the spring and fall semesters, five elementary schools piloted art therapy with two groups at each school, serving a total of 200 students across both semesters. During the summer semester, four schools piloted art therapy, with two groups in each school for a total of 80 participating students. Ultimately, 280 students were provided art therapy services across three semesters. All students enrolled completed the art therapy pilot program. Age of participating students ranged from 5 to 10 years of age, with an average age of 7.5 years old.</p> <p>Art therapy groups were facilitated by a board‐certified and registered art therapist (ATR‐BC) once weekly for 60 min within a 6‐week or 7‐week cycle. The 6‐week cycle length for semester 1 was due to holidays and other schedule‐based time‐constraints. Semesters 2 and 3 were conducted weekly for 7 weeks. A maximum of 10 students within a span of two grade levels (i.e., 1st and 2nd graders to support developmental stage) were invited to join each closed art therapy group. The sessions were facilitated during the school day to ensure all students had access and were able to participate no matter their transportation schedule, afterschool requirements, and other external barriers. School administrators reserved a private space with a door to encourage a safe and supportive environment for students to share. The art therapy group was supported by the identified school liaison who attended sessions. Art therapy interventions were specific to social or emotional goals and tailored to the participants developmental age and group development. The art therapist took the liberty to employ clinical judgment each week to adapt to the therapeutic needs of the students. These adaptations were documented for fidelity purposes. During the first week of art therapy groups, the art therapist spent time establishing rapport and setting "group rules" that aligned with the school‐wide behavior expectations (Table 1). Week 2 to Week 5, the art therapist facilitated directives that specifically focused on developing a sense of self‐awareness, building new coping skills, and building social connections with peers. During Week 6, the art therapist asked students to process themes around gratitude. The artwork was collected each week by the art therapist to support a collective review on Week 7 related to their individual and shared experiences throughout the cycle. All artwork was given back to each student during the final week of therapy. Examples of consented artwork produced, the art therapy directive, and student process are noted in Figure 3.</p> <p>1 Table Examples of art therapy integrated into school‐wide positive behavior expectations.</p> <p> <ephtml> <table><thead valign="bottom"><tr valign="bottom"><th align="left">STAR In Art Therapy</th></tr></thead><tbody valign="top"><tr><td>Stay Safe</td><td>We will use kind words.We will raise our hands to speak and share.</td></tr><tr><td>Take Responsibility</td><td>We will be respectful when others are sharing by listening to each other and respecting their artwork.</td></tr><tr><td>Act Respectfully</td><td>We will all be supportive of each other and artwork.</td></tr><tr><td>Reach for the Stars</td><td>We will make art therapy a safe place for everyone to share their feelings and their artwork.</td></tr></tbody></table> </ephtml> </p> <p> <img src="https://imageserver.ebscohost.com/img/embimages/rdk/PIS/01aug25/pits23471-fig-0003.jpg?ephost1=dGJyMNXb4kSepq84yOvqOLCmsE6epq5Srqa4SK6WxWXS" alt="pits23471-fig-0003.jpg" title="3 Art Therapy Case Studies‐ Art Therapy Directive, Goal, Process, and Artwork Produced." /> </p> <p></p> <p>During the CATI sessions, the art therapist supported each student's individual creative process within the group dynamic. The art therapist prioritized the needs of each student by offering varying levels of support to enable student's ability to communicate feelings and experiences. The art therapist encouraged discussion of the student's experience, their emotions, what feelings may have arisen, and if any insights were gained for the final 15–30 min of each group. Progress notes for each group were documented by the art therapist.</p> <hd id="AN0186727888-12">Family and Teacher Engagement</hd> <p>The BCCW and Arts in Healing teams contributed to the overall care of each student by communicating with school officials and their guardians throughout the cycle. Before beginning the art therapy pilot, district officials selected schools and solicited school administrator buy‐in. Once the schools committed to integrating art therapy into their framework, BCCW and Arts in Healing staff joined faculty and staff meetings to present the components of art therapy, referral process, data collection, and ways school officials could incorporate strategies in their schools and classrooms.</p> <p>Each week, paper communication slips were sent home to guardians to communicate art therapy goals and ways in which they could reinforce coping skills learned. Teachers received the slip when students re‐entered the classroom and slips were placed in homework folders to go home at the end of the day. Use of this slip was intended to integrate the art therapy concepts learned during sessions across environments.</p> <hd id="AN0186727888-13">Data Collection and Analysis</hd> <p>Quality improvement was conducted based on survey data received from a convenience sample of teachers, guardians, and students following each cycle of art therapy. Quality improvement surveys included questions regarding opinions on the art therapy as an intervention and changes desired. Data was analyzed using a conventional approach to identify common themes which guided quality improvement changes for the next cycle.</p> <p>A Likert‐style survey for guardians of participating students was additionally developed to help quantify observed changes to students' social and emotional behaviors in the home after participating in the art therapy pilot as well as programmatic acceptability. Questionnaire was developed with responses listed on a scale of strongly disagree (<reflink idref="bib1" id="ref34">1</reflink>) to strongly agree (<reflink idref="bib5" id="ref35">5</reflink>). Questions and content of the survey can be found in Table 2. At the end of the first cycle, stratified sampling (by school, student age, and school resource level) was used to select guardians of sixteen participating students to complete this survey by phone interview. During the third cycle, guardians and teachers were also provided the Strengths and Difficulties Questionnaire (SDQ) before and after the intervention.</p> <p>Participants, guardians, and teachers were asked to complete pre and post intervention SDQ's to monitor for changes in social‐emotional competencies of students participating in this pilot. The SDQ is a validated mental health screener that was developed with the goal of identifying and scoring emotional problems, conduct problems, hyperactivity, peer problems, and prosocial tendencies (Goodman [<reflink idref="bib16" id="ref36">16</reflink>]). It has been shown to be reliable and have internal consistency to screen for psychiatric pathologies in children (Goodman [<reflink idref="bib17" id="ref37">17</reflink>]).</p> <p>As an exploratory examination of changes in SDQ scores, SAS version 9.4 was used to perform paired Student's t‐test to compare changes in pre and post student SDQ scores. Spaghetti plots for both parent and teacher SDQ's were created showing the individual and mean changes in pre‐ and post‐scores for each of the three composite SDQ scores (internalizing, externalizing, and total difficulties) (Goodman and Goodman [<reflink idref="bib15" id="ref38">15</reflink>]). Internalizing score is the sum of emotional problems score and peer problems score. Externalizing score is the sum of conduct score plus hyperactivity score. Total difficulties score is the sum of internalizing and externalizing scores.</p> <hd id="AN0186727888-14">Results</hd> <p></p> <hd id="AN0186727888-15">Quality Improvement and Program Acceptability</hd> <p>Themes identified from the quality improvement survey administered after each cycle to teacher, student, and guardian were used to improve the pilot across the three semesters (Figure 1). Themes included:</p> <p></p> <ulist> <item> Teacher: decrease art prep‐time, increase number of sessions, start program at beginning of school year</item> <p></p> <item> Student: don't offer sessions during electives, group participants close in age</item> <p></p> <item> Guardian: increase guardian communication, increase number of sessions</item> </ulist> <p>Twelve of 16 (75%) guardian interviews regarding programmatic acceptability and perceived student social‐emotional benefits were obtained and completed. Nonresponse was secondary to the inability to contact the guardian by phone. Post‐intervention survey content and results are listed in Table 2. Nearly all guardians strongly agreed that art therapy programs should be continued in the school (4.88, SD 0.14). Most guardians strongly agreed that the art therapy process gave their child an alternative form of safe expression (4.75, SD 0.29). Guardians on average agreed that after participation in the art therapy pilot, their child demonstrated improved relationship‐building skills (3.5, SD 0.14) socialization skills (3.88, SD 0.31), and coping skills (3.88, SD 0.14) at home. In addition, guardians agreed that the utilization of art therapy in the school was beneficial for their child's emotional growth and overall well‐being (4.21, SD 0.41).</p> <p>2 Table Acceptability and perceived student social‐emotional benefits from a pediatric school‐based group art therapy intervention according to guardians.</p> <p> <ephtml> <table><thead valign="bottom"><tr valign="bottom"><th><italic>n</italic> = 12 Mean (SD)</th><th>Prompt</th></tr></thead><tbody valign="top"><tr><td>3.50 (0.14)</td><td>My child developed positive relationship building skills at home</td></tr><tr><td>3.88 (0.31)</td><td>My child demonstrates improved socialization skills at home</td></tr><tr><td>3.88 (0.14)</td><td>My child demonstrates improved coping skills at home</td></tr><tr><td>4.21 (0.41)</td><td>The utilization of art therapy in the schools was beneficial for my child's emotional growth and overall well‐being</td></tr><tr><td>4.75 (0.29)</td><td>The art therapy process gave my child an alternative form of safe expression</td></tr><tr><td>4.88 (0.14)</td><td>I would like for art therapy programs to continue in the school</td></tr></tbody></table> </ephtml> </p> <p>1 5=Strongly Agree, 4=Agree, 3=Neutral, 2=Disagree, 1=Strongly Disagree</p> <hd id="AN0186727888-16">Strengths and Difficulties Questionnaire</hd> <p>Guardians and teachers filled out 63 and 54 pre intervention SDQ's, and 19 and 26 post intervention SDQ's, respectively. Amongst this data set there were 17 paired guardian and 14 paired teacher pre‐post SDQ surveys to analyze. A description of the student sample from completed pre‐post guardian surveys is listed in Table 3. In this sample, the average student age was 8.6 (SD 3), slightly higher than the average age for all children enrolled in the pilot (7.5 years). Ten of the sample students (58%) were female, and 76.5% were white.</p> <p>3 Table Demographics & characteristics of children enrolled in art therapy who have complete pre‐/post‐SDQ questionnaires, completed by guardian.</p> <p> <ephtml> <table><thead valign="bottom"><tr valign="bottom"><th>Characteristic</th><th>Statistic<ext-link href="a" /></th></tr></thead><tbody valign="top"><tr><td>Age (years)</td><td>8.6 ± 1.3</td></tr><tr><td align="left">Sex</td></tr><tr><td>Male</td><td>7 (41.2)</td></tr><tr><td>Female</td><td>10 (58.8)</td></tr><tr><td align="left">Race</td></tr><tr><td>Black</td><td>3 (17.6)</td></tr><tr><td>White</td><td>13 (76.5)</td></tr><tr><td>Other/Unknown</td><td>1 (5.9)</td></tr><tr><td>WIC/TANF/SNAP/Medicaid</td><td>7 (41.2)</td></tr><tr><td>504 Plan</td><td>2 (11.8)</td></tr><tr><td>IEP Plan</td><td>3 (17.6)</td></tr><tr><td align="left">Comorbidities</td></tr><tr><td>Learning disability</td><td>2 (13.3)</td></tr><tr><td>Mood disorder</td><td>4 (23.5)</td></tr><tr><td>ADHD/ADD</td><td>5 (29.4)</td></tr><tr><td>Under care of mental health provider</td><td>5 (29.4)</td></tr></tbody></table> </ephtml> </p> <p>2 a All values expressed as mean ± SD, or frequency (%)</p> <p>Figure 4 depicts spaghetti plots showing the changes in pre‐ and post‐scores for each of the three composite SDQ scores (internalizing, externalizing, and total difficulties) for guardian and teacher. For these, we found only the parent survey for internalizing score to show a significant change (mean decrease in 1.7 points [95% CI: 0.2–3.2]; <emph>p</emph> = 0.0314). There was no significant change in externalizing (<emph>p</emph> = 0.2663) or total difficulties (<emph>p</emph> = 0.0734) when guardian SDQ's were examined using a paired Student's t‐test. Teacher SDQ data also showed no significant changes in externalizing (<emph>p</emph> = 0.0919), internalizing (<emph>p</emph> = 0.3644), nor total difficulties scores (<emph>p</emph> = 0.1412) when examined using a paired Student's t‐test.</p> <p> <img src="https://imageserver.ebscohost.com/img/embimages/rdk/PIS/01aug25/pits23471-fig-0004.jpg?ephost1=dGJyMNXb4kSepq84yOvqOLCmsE6epq5Srqa4SK6WxWXS" alt="pits23471-fig-0004.jpg" title="4 Individual and mean changes in student strength and difficulties questionnaire scores." /> </p> <p></p> <hd id="AN0186727888-18">Discussion</hd> <p>In light of steadily rising rates of mental health disorders in children (Kyu et al. [<reflink idref="bib22" id="ref39">22</reflink>]) that have outpaced our conventional medical system's abilities to provide care (Cummings et al. [<reflink idref="bib8" id="ref40">8</reflink>]) there is a unique opportunity to develop models for effective and integrated school‐based behavioral health programming. This school‐based art therapy initiative, anchored in and coordinated by the MTSS framework, was a feasible and acceptable model to deliver expanded mental healthcare support to children in need of services. Guardians of students enrolled in CATI indicated a high degree of acceptability (strongly agreed "art therapy programs should be continued in the school") and reported several forms of social‐emotional benefit for their children (overall wellbeing, emotional growth) following participation. Social‐emotional learning goals and skills emphasized during art therapy sessions transferred across environments from the therapy session to home, as guardians agreed that their children "demonstrated improved relationship building, coping, and socialization skills" at home. Integration of skills across multiple environments indicates mastery of skills learned. This integration of skills across environments is supported by the subset of participants in CATI which demonstrated statistically significant improvement in internalizing symptoms according to guardians. Improvement in internalizing behavior, which are often related to depression or anxiety, has been shown to increase academic engagement and improve interpersonal skills across school and settings (Pedersen et al. [<reflink idref="bib33" id="ref41">33</reflink>]). Internalizing behavior may have significantly improved more than externalizing behavior due to the nature of art therapy, as the process of art therapy encourages introspection. Participants with externalizing behavior problems possibly had more difficulty engaging in the art therapy sessions, and may not have received the full benefits of the intervention. The sample size of guardians completing both pre and post SDQ's may not have been large enough to detect a significant difference in student's total difficulties; however, total difficulties did trend downward to approach significance.</p> <p>This art therapy pilot was completed with no attrition, as barriers to obtaining traditional mental health services in the community were removed by this unique approach. Art therapy was delivered in the school setting, which research states is the best setting (compared to community‐based supports) to enhance routine student access to quality mental health care (Hoover and Bostic [<reflink idref="bib18" id="ref42">18</reflink>]). The stigma associated with mental health is often a barrier to students receiving help (Weist and Murray [<reflink idref="bib43" id="ref43">43</reflink>]). Art therapy delivered through the CATI Initiative was potentially viewed by guardians and students as a less stigmatized intervention than other forms of therapy, and therefore a more acceptable approach to addressing student mental health needs. Specifically, this pilot engaged guardians with tailored materials in a pre‐intervention packet to explain the personal and group goals of the program. This packet helped to reduce stigma and change the social norm surrounding the term "therapy," likely increasing engagement (Beers and Joshi [<reflink idref="bib4" id="ref44">4</reflink>]). Additionally, this model also supports previously published theories and recommendations that mental health supports are effective and more accessible when integrated into the academic setting (Murthy [<reflink idref="bib30" id="ref45">30</reflink>]; Walter et al. [<reflink idref="bib41" id="ref46">41</reflink>]). It allowed for decreased common barriers to mental health service access (including transportation and scheduling conflicts) and increased access to care in an equitable manner by making interventions a part of the students' day (Barrett et al. [<reflink idref="bib3" id="ref47">3</reflink>]; Ghuman et al. [<reflink idref="bib14" id="ref48">14</reflink>]; Weist and Murray [<reflink idref="bib43" id="ref49">43</reflink>]).</p> <p>Creating a framework for family and teacher engagement was critical for the success of this pilot. It is well known that increasing family and teacher engagement in mental health interventions has been shown to increase the effectiveness of such interventions (Barrett et al. [<reflink idref="bib3" id="ref50">3</reflink>]). Teachers were an active part of CATI and were engaged throughout the process, ultimately creating and supporting "School‐Wide Positive Behavior Expectations" (Table 1), a tangible way to integrate the weekly goals learned in art therapy into the classroom to reinforce social‐emotional strategies. The weekly communication slips and data collection process allowed guardians to give and receive feedback at all stages of the cycle and be a member of the team. In almost all schools, the school liaison, students, and guardians personally requested indefinite group art therapy sessions to be delivered at their school.</p> <p>Several additional lessons were learned during this pilot. Offering referral information in electronic and multi‐lingual formats (rather than English only/paper only format) helped to increase access, improved guardian communication, and time to consent return. Providing family and school staff written and visual resources in the pre‐intervention packet helped to better differentiate the goals of "art therapy" from "art class," and increase guardian understanding of the intervention. Increasing the number of sessions from 6 to 7 after the first cycle based on student and guardian feedback allowed for the art therapist more time to build rapport in the beginning and debrief with shared experiences at the end.</p> <p>There were several limitations in this pilot. This was a small pilot implemented in one school district with a well‐organized MTSS team and pre‐existing universal mental health screening. These resources are not currently present in some school districts but may be organized with support at the district or state level if replication of this model is desired. Screening and referral of students was conducted by the school district based on the student's need for the service and perceived "fit" of intervention for the student. This likely introduced selection bias (recruiting children or families who may be more likely to accept or complete the intervention), but the referral process as established mirrored mental health referral patterns in the standard clinical setting (Foy et al. [<reflink idref="bib11" id="ref51">11</reflink>]). One additional limitation that introduced response bias was the low response rate on the post‐intervention SDQ which decreased the number of paired surveys that were able to be analyzed.</p> <p>As a result of this pilot, local school districts and school officials are advocating for the integration of art therapy as a long‐term fixture in their schools. Incorporating art therapy into the district alleviated some of the strain placed on the school's mental health system. After the first two semesters of observed impact, the school district secured ongoing funding via federal Education Stabilization Fund for the Elementary and Secondary School Emergency Relief (ESSER) allotment to continue art therapy services. There is data to support cost‐effectiveness of art therapy as a mental health treatment in adults (Uttley et al. [<reflink idref="bib40" id="ref52">40</reflink>]), but similar data has yet to be analyzed in the pediatric population. The school district decided to provide ongoing funding as they determined art therapy to be cost‐effective, with the cost of the intervention being approximately $170 per student for the 7‐week‐long intervention. This cost estimate was based on salary support for the licensed clinical art therapist, supplies, and full programmatic support for every participant as provided by the philanthropic donor; no insurance was billed during this pilot. This model has expanded to 5 additional school districts following the pilot with plans to continue expansion to provide effective school‐based therapeutic services. Future research will aim to increase sample size and determine association of participation of this group art therapy model on multiple aspects of student social emotional health.</p> <hd id="AN0186727888-19">Implications for School Mental Health Policy and Practice</hd> <p>Coordination of school‐based art therapy programs through the school MTSS framework is a structured and evidenced‐based way to identify students who may benefit from participation, communicate progress with school leadership, and continue coordinated care of services with family and teachers. Social‐emotional strategies encouraged in art therapy can be reinforced across environments by engaging teachers, school staff, and guardians with tangible ways to practice weekly goals.</p> <p>School‐based group art therapy programs can reduce barriers to mental healthcare access for children including transportation, cost, scheduling conflicts, and stigma. To further reduce barriers, art therapy in schools should be universally supported by health insurance coverage. Currently, partnerships between schools, healthcare organizations, and donors are needed to increase evidence‐based, accessible school‐based mental health interventions.</p> <hd id="AN0186727888-20">Conclusions</hd> <p>The Clinical Art Therapy Initiative model integrated group art therapy services into a previously existing MTSS framework within the school system to provide a mental health intervention for at‐risk children. This pilot was received with a high degree of acceptability by guardians who reported benefit to their child's emotional growth and overall well‐being. Art therapy can be offered in several settings; however, school‐based art therapy has the ability to impact a large population of children that may otherwise not have access. By expanding services to include the field of art therapy as an option of care, specifically within our schools, we can address the increased challenges for children now and into the future.</p> <hd id="AN0186727888-21">Acknowledgments</hd> <p>This pilot was funded by generous support from the Samuel Freeman Charitable Trust and The Boeing Company.</p> <hd id="AN0186727888-22">Conflicts of Interest</hd> <p>The authors declare no conflict of interest.</p> <hd id="AN0186727888-23">Human Subjects Approval Statement</hd> <p>The pilot was approved by the Institutional Review Board at the Medical University of South Carolina as Quality Improvement.</p> <hd id="AN0186727888-24">Data Availability Statement</hd> <p>Please contact MUSC Arts in Healing at artsinhealing@musc. edu for more information about this pilot.</p> <ref id="AN0186727888-25"> <title> References </title> <blist> <bibl id="bib1" idref="ref13" type="bt">1</bibl> <bibtext> American Academy of Child and Adolescent Psychiatry. 2021. 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Items – Name: Title
  Label: Title
  Group: Ti
  Data: Addressing Gaps in Pediatric Mental Healthcare by Removing Barriers: A School-Based Integrated Model for Group Art Therapy
– Name: Language
  Label: Language
  Group: Lang
  Data: English
– Name: Author
  Label: Authors
  Group: Au
  Data: <searchLink fieldCode="AR" term="%22Katie+Hinson+Sullivan%22">Katie Hinson Sullivan</searchLink><br /><searchLink fieldCode="AR" term="%22Erin+Scherder%22">Erin Scherder</searchLink><br /><searchLink fieldCode="AR" term="%22Laura+Allen%22">Laura Allen</searchLink><br /><searchLink fieldCode="AR" term="%22Daniel+L%2E+Brinton%22">Daniel L. Brinton</searchLink> (ORCID <externalLink term="http://orcid.org/0000-0002-7888-6708">0000-0002-7888-6708</externalLink>)<br /><searchLink fieldCode="AR" term="%22Anne+Crosswell%22">Anne Crosswell</searchLink><br /><searchLink fieldCode="AR" term="%22Elise+Gruber%22">Elise Gruber</searchLink><br /><searchLink fieldCode="AR" term="%22Janice+Key%22">Janice Key</searchLink> (ORCID <externalLink term="http://orcid.org/0000-0001-9131-6489">0000-0001-9131-6489</externalLink>)<br /><searchLink fieldCode="AR" term="%22Kathleen+C%2E+Head%22">Kathleen C. Head</searchLink> (ORCID <externalLink term="http://orcid.org/0000-0003-1130-6243">0000-0003-1130-6243</externalLink>)
– Name: TitleSource
  Label: Source
  Group: Src
  Data: <searchLink fieldCode="SO" term="%22Psychology+in+the+Schools%22"><i>Psychology in the Schools</i></searchLink>. 2025 62(8):2362-2372.
– Name: Avail
  Label: Availability
  Group: Avail
  Data: Wiley. Available from: John Wiley & Sons, Inc. 111 River Street, Hoboken, NJ 07030. Tel: 800-835-6770; e-mail: cs-journals@wiley.com; Web site: https://www.wiley.com/en-us
– Name: PeerReviewed
  Label: Peer Reviewed
  Group: SrcInfo
  Data: Y
– Name: Pages
  Label: Page Count
  Group: Src
  Data: 11
– Name: DatePubCY
  Label: Publication Date
  Group: Date
  Data: 2025
– Name: TypeDocument
  Label: Document Type
  Group: TypDoc
  Data: Journal Articles<br />Reports - Descriptive
– Name: Audience
  Label: Education Level
  Group: Audnce
  Data: <searchLink fieldCode="EL" term="%22Elementary+Education%22">Elementary Education</searchLink>
– Name: Subject
  Label: Descriptors
  Group: Su
  Data: <searchLink fieldCode="DE" term="%22Art+Therapy%22">Art Therapy</searchLink><br /><searchLink fieldCode="DE" term="%22Mental+Health%22">Mental Health</searchLink><br /><searchLink fieldCode="DE" term="%22School+Health+Services%22">School Health Services</searchLink><br /><searchLink fieldCode="DE" term="%22Elementary+School+Students%22">Elementary School Students</searchLink><br /><searchLink fieldCode="DE" term="%22Multi+Tiered+Systems+of+Support%22">Multi Tiered Systems of Support</searchLink><br /><searchLink fieldCode="DE" term="%22Group+Therapy%22">Group Therapy</searchLink><br /><searchLink fieldCode="DE" term="%22Interpersonal+Competence%22">Interpersonal Competence</searchLink>
– Name: Subject
  Label: Geographic Terms
  Group: Su
  Data: <searchLink fieldCode="DE" term="%22South+Carolina%22">South Carolina</searchLink>
– Name: SubjectThesaurus
  Label: Assessment and Survey Identifiers
  Group: Su
  Data: <searchLink fieldCode="SU" term="%22Strengths+and+Difficulties+Questionnaire%22">Strengths and Difficulties Questionnaire</searchLink>
– Name: DOI
  Label: DOI
  Group: ID
  Data: 10.1002/pits.23471
– Name: ISSN
  Label: ISSN
  Group: ISSN
  Data: 0033-3085<br />1520-6807
– Name: Abstract
  Label: Abstract
  Group: Ab
  Data: In the fall of 2021, experts declared a national emergency in children's mental health, urging organizations to put in place school-based mental health care services to reduce barriers and increase access to care. This paper describes implementation and acceptability of an innovative school-based model to deliver group art therapy that is integrated into the school's Muti-Tiered System of Supports, and changes in student social-emotional competencies that occurred in association with participation. The 7-week pilot was implemented in three successive semesters, serving 280 elementary students. Guardians completed Strengths and Difficulties Questionnaires (SDQ) before and after the intervention to describe changes in student social-emotional competencies. SDQ data suggest improvement in internalizing symptoms amongst participants (n = 17, mean decrease in 1.7 points [95% CI: 0.2-3.2]; p = 0.0314). Guardians surveyed (n = 12) strongly agreed that art therapy programs should be continued in the school and that the art therapy process gave their child an alternative form of safe expression [4.88 and 4.75 out of 5 (SD = 0.14 and 0.29), respectively]. All students completed the program. Cost was $170.00 per child. This school-based group art therapy model was found feasible and acceptable, and if scaled, can impact a large population of children with barriers to mental healthcare access.
– Name: AbstractInfo
  Label: Abstractor
  Group: Ab
  Data: As Provided
– Name: DateEntry
  Label: Entry Date
  Group: Date
  Data: 2025
– Name: AN
  Label: Accession Number
  Group: ID
  Data: EJ1477308
PLink https://search.ebscohost.com/login.aspx?direct=true&site=eds-live&db=eric&AN=EJ1477308
RecordInfo BibRecord:
  BibEntity:
    Identifiers:
      – Type: doi
        Value: 10.1002/pits.23471
    Languages:
      – Text: English
    PhysicalDescription:
      Pagination:
        PageCount: 11
        StartPage: 2362
    Subjects:
      – SubjectFull: Art Therapy
        Type: general
      – SubjectFull: Mental Health
        Type: general
      – SubjectFull: School Health Services
        Type: general
      – SubjectFull: Elementary School Students
        Type: general
      – SubjectFull: Multi Tiered Systems of Support
        Type: general
      – SubjectFull: Group Therapy
        Type: general
      – SubjectFull: Interpersonal Competence
        Type: general
      – SubjectFull: South Carolina
        Type: general
      – SubjectFull: Strengths and Difficulties Questionnaire
        Type: general
    Titles:
      – TitleFull: Addressing Gaps in Pediatric Mental Healthcare by Removing Barriers: A School-Based Integrated Model for Group Art Therapy
        Type: main
  BibRelationships:
    HasContributorRelationships:
      – PersonEntity:
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            NameFull: Katie Hinson Sullivan
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            NameFull: Erin Scherder
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            NameFull: Janice Key
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            NameFull: Kathleen C. Head
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            – D: 01
              M: 08
              Type: published
              Y: 2025
          Identifiers:
            – Type: issn-print
              Value: 0033-3085
            – Type: issn-electronic
              Value: 1520-6807
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              Value: 62
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            – TitleFull: Psychology in the Schools
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