Introduction - Toronto Art Therapy Institute€¦ · Web viewAttention Deficit Hyperactivity...

Running head: HOW DO ADULTS WITH ADHD EXPERIENCE THE CREATIVE PROCESS IN ART THERAPY? 1

Thesis Proposal:

How do Adults with ADHD

Experience the Creative Process in

Art Therapy?"

Andrea Charendoff

380 Spadina Road

Toronto, Ontario

M5P2V9

Home: 416-480-1235

Cell: 416-564-9998

[email protected]

HOW DO ADULTS WITH ADHD EXPERIENCE THE CREATIVE PROCESS IN ART THERAPY? 2

Introduction

Attention Deficit Hyperactivity Disorder (ADHD) is a chronic, debilitating,

neurodevelopmental disorder that is characterized by inattention, hyperactivity, and impulsivity

(Kalbag & Levin, 2005; Ramirez et al., 1997). It is one of the most frequently diagnosed

psychiatric disorders of childhood across the globe, accounting for 5% of the world’s population

(Polancyzk & Rhode, 2007). ADHD has one of the highest rates of genetic transmission of all

psychiatric disorders. In-depth twin studies have shown that for approximately 80% of identical

twins with a diagnosis of ADHD, their identical siblings also have the disorder (Teplin, 2012).

The symptoms of ADHD arise from a deficiency in areas of the brain responsible for

executive functioning. Executive brain functions are cognitive processes, such as working

memory, planning, time management, organization, problem solving, attention/focus, behaviour

regulation, control over emotions, and impulse control (Centre for ADHD Awareness Canada,

2012). There are three subtypes of this disorder: predominantly hyperactive-impulsive (no

significant problems with inattention), predominantly inattentive (no significant hyperactive-

impulsive behaviour), and combined hyperactive-impulsive and inattentive (National Institute of

Mental Health, 2008).

ADHD is often diagnosed in elementary school-aged children. While behavioural

challenges may be experienced in the home, it is often within the school setting that

characteristics of ADHD are underscored, since it noticeably interferes with the ability to

function in the classroom and the playground (Safran, 2003). ADHD affects 3% to 5% of

school-aged children, accounting for at least one child in every classroom (National Institute of

Mental Health, 2008). The Centre for ADHD Awareness Canada estimates that rate as being


higher, noting that 5% to 12% of school-aged children will be diagnosed with ADHD,

accounting for approximately one to three children per classroom (2012).

Problem

In the past it was believed that ADHD was usually outgrown by adolescence; however,

over the last two decades, follow-up studies have shown that this is often not the case.

According to The National Institute of Mental Health (NIMH), approximately 30% to 70% of

children diagnosed with ADHD will continue to have symptoms in adulthood (1996).

Biederman and associates conducted a 10-year follow-up study of boys with ADHD (6-17 years

of age), and found that 78% of subjects continued to have symptoms and functional impairments

into early adulthood (Biederman, Petty, Evans, Small, & Faraone, 2010).

The true prevalence of ADHD in adults may be underestimated by the current statistics,

due to improper or complete lack of diagnosis. There is concern that the wording of the current

diagnostic manual (DSM-IV) may not be directly applicable to adults, because the diagnostic

criteria were established for children. Adults with ADHD, who are more advanced in brain

maturity and psychosocial functioning, may exhibit symptoms that are not included in the

diagnostic manual (Davidson, 2008; Johnston, Mash, Miller, & Ninowski, 2012). In addition,

ADHD in adults often presents differently than in children. Some symptoms, such as

hyperactivity, tend to fade in adulthood, and others, such as restlessness and impulsivity, persist

(Barkley, 2010; Teplin, 2012).

Some adults with ADHD have eluded a childhood diagnosis. This is particularly

disturbing, because they often grow into adulthood with low self-esteem and poor self-concept,

due to the accumulation of negative, diminishing experiences in all areas of psychosocial

functioning (Davidson, 2008; Newark & Stieglitz, 2010). Once diagnosed, many adults have


difficulty finding a qualified physician who is willing to take on an ADHD patient. Some

physicians are unwilling to treat them pharmacologically, and/or are unwilling to take on patients

with comorbid diagnoses (Teplin, 2012; Waite & Ramsay, 2010).

Research Question

This study will seek to answer the following: How do adults with ADHD experience the

creative process in art therapy?

Rationale

Extensive studies have shown that art therapy is an effective treatment modality for

children who have ADHD. The art making process involves using visual skills, which are often

stronger than verbal skills for these children (i.e., it is easier for them to draw their problems than

to use words), and it provides a structured activity, which helps them to maintain focus and

attention (Henley, 1998; Kearns, 2004). Art therapy also offers children with ADHD an

opportunity to express their feelings in a safe, contained, therapeutic environment. The art

making process often reduces anxiety and aggression and increases self-esteem (Henley, 1998).

The art product is an externalized visual record of their emotions and experiences, which can be

reflected upon to enhance self-awareness and learning (Safran, 2002) . Group art therapy also

helps children with ADHD to practice and develop social skills, such as listening, regulating

behaviour, and problem solving (Hanson, Meissler & Ovens, 2000; Henley, 1998; Safran, 2002).

Many of the issues for children with ADHD continue into adulthood. In addition, adults

experience compounding factors, such as stressful jobs, family responsibilities, and, in many

cases, comorbid psychological disorders. It seems reasonable to assume that art therapy would

be as effective for adults with ADHD, as it is for children. Unfortunately, no studies have been

found that support or suggest that Art therapy might be beneficial for adults who have ADHD.


This study will attempt to fill gaps in the literature, by examining the use of art therapy

with a sample of this population. It will seek to understand the participant’s subjective

experience of the art making process in art therapy. It is hoped that this study will open the door

to more research on the effects of art therapy on adults with ADHD.

Definition of Terms

Adult ADHD

For the purposes of this study, adult ADHD will be defined as a chronic, debilitating,

neurodevelopmental disorder that is mainly characterized by symptoms of inattentiveness, or

inattentiveness plus impulsivity (Kalbag & Levin, 2005; Ramirez et al., 1997; Teplin, 2012).

Literature Review

Symptoms of Adult ADHD

According to Barkley (2010), an internationally recognized authority on ADHD in

children and adults, ADHD is a frontal lobe disorder that affects executive brain functions.

Adults may not recognize lifelong problems as symptoms, but may consider them to be

personality defects or character flaws. The following symptoms are tell-tale signs of ADHD:

trouble concentrating, trouble thinking clearly, being easily distracted, exhibiting impulsive

behaviour, problems with organization and time management, difficulty finishing tasks, talking

loudly, feeling restless, and forgetting urgent tasks (Barkley, 2010). Additional symptoms of

adult ADHD include: difficulty regulating attention (inability to pay attention to details, hyper-

focusing on one aspect of an issue or activity and being unable to refocus to the whole),

difficulty regulating behaviour (talking at inappropriate times, talking loudly, interrupting,

temper outbursts), being easily bored, impatience, mood swings, anger issues, difficulty with

relationships and social interactions, job loss and frequent job changes, difficulty managing


money and paying bills, and substance abuse (Barkley, 2012; Centre for ADHD Awareness,

Canada, 2012).

Many adults don’t believe they have ADHD because they are not hyperactive. As

children grow in to adulthood hyperactivity tends to wane, and is replaced by inner restlessness

or fidgety behaviour (Barkley, 2010; Barton, 2011; Schneider, 2012). “Often the only thing

that’s left of hyperactivity in adults with ADHD is that feeling of restlessness and the need to

keep busy…” (Barkley, 2010, p. 7).

Some adults don’t recognize the symptoms of ADHD in adulthood, because they were

not diagnosed in childhood. They may have been mislabelled as lazy or uninterested by parents

and school teachers. They may have undergone assessments by pediatricians who did not

believe that ADHD is a legitimate disorder, which was often the case even twenty years ago.

They may have had parents who did not believe that hyperactive behaviour and social difficulties

were appropriate reasons to take the child to see a doctor (Barkley, 2010). With regard to

ADHD primarily inattentive type, research shows that the symptoms tend to be less obvious and

less disruptive, and children with this type of ADHD are less likely to be diagnosed (Barkley,

2011). This is the most common form of ADHD in girls and women, according to Sari Solden, a

private practice psychotherapist, and author of the book, Women with Attention Deficit Disorder

(Solden, 2005). Primary features of this type of ADHD include: daydreaming, mental fogginess,

passivity, lack of focus, and inactivity. There is less research about the effects of this type of

ADHD on the child as he/she grows into adolescence and adulthood (Barkley, 2011).

Impact of Adult ADHD: Psychosocial Effects

Adults with ADHD suffer significant repercussions in several areas of everyday life.

Barkley (2011) found that approximately 10% to 25% of people with ADHD developed


substance abuse problems (legal or illegal), with the highest risk for substance abuse being

among those who also had conduct disorder or delinquent behaviour in adolescence. In a

longitudinal study by Biederman and associates (1993), it was determined that lifetime

prevalence rates for substance use disorders for adults with ADHD was 52% compared with 27%

in adults without ADHD.

In a study which examined psychosocial functioning in eighty-four adults with a

diagnosis of childhood-onset ADHD, Biederman and associates found that separation and

divorce rates were higher for adults with ADHD than for adults who did not have ADHD. In

addition, their sample of adults with ADHD had lower socioeconomic status, and poorer

academic performance than the control group (Biederman, et al., 1993).

Parenting is a complicated task for adults with ADHD. Undiagnosed adult ADHD is

particularly detrimental; it increases the risk for “negative and chaotic parenting” (Waite &

Ramsay, 2010, p. 672). In a review of the literature on ADHD and parenting, Weiss, Hechtman,

& Weiss (2000) highlighted several tasks that are challenging for parents with ADHD:

managing child behaviour and sustaining attention while supervising children, being consistent

with discipline, controlling anger and hostility in response to child behaviour, demonstrating

patience, managing daily routines (e.g., consistent meal-times, getting child to and from school,

performing household tasks, attending to child’s homework), managing appointments and

extracurricular activities, and handling finances (as cited in Waite & Ramsay, 2010).

Chronis-Tuscano et al. (2008) conducted a study on maternal parenting and ADHD, and

found that mothers with ADHD had lower levels of self-esteem, higher levels of depression, self-

blame and social isolation than mothers without ADHD (as cited in Waite & Ramsay, 2010).

This result may be attributable to the fact that women tend to have multiple role-conflicts and


distractions — they are usually responsible for structuring the daily lives of their families,

especially the activities of their children (Solden, 2005).

All tasks of parenting prove to be even more difficult when the children also have

ADHD. Children with ADHD require more stringent monitoring, more structure, and more

patience, which is a tall order for parents who have ADHD. This is a very significant issue,

since, as mentioned above, ADHD is an inheritable disorder—a fact which is supported by Weiss

et al. (2000), who found that more than half of parents with ADHD had a child with the disorder

(as cited in Waite & Ramsay, 2010). Biederman et al. (1993) conducted studies on families with

children who had ADHD, and found that approximately 20% of mothers, 30% of fathers, and

37% of siblings also had ADHD (as cited in Waite & Ramsay, 2010). In a longitudinal study

that began in 1995, Chronis et al. (2008) examined 98 children with ADHD, age three to seven,

and 116 non-ADHD comparison children. They discovered that parents of children with ADHD

were 24 times more likely to have ADHD than parents of children who did not have ADHD.

Difficulty regulating emotions is a symptom of ADHD that begins in childhood and

continues into adulthood. Ramirez et al. (1997) conducted a study on anger and anger

expression in college students with non-medicated ADHD, as compared with non-ADHD college

students. Participants from both groups ranged in age from 18-50. The participants filled in self-

report questionnaires about ADHD symptoms and behaviours, and then were asked to listen to

“anger-induction” tapes while engaging in a visualization exercise related to being humiliated in

front of peers. Once the tape was finished, they immediately filled in self-report questionnaires

designed to measure levels of anger. The researchers reported that adults with symptoms of

ADHD were more easily angered than adults without ADHD, and were more likely to react to

negative situations in dysfunctional, socially inappropriate ways (Ramirez, et al., 1997).


Over the past two decades, several studies have been conducted on the effects of adult

ADHD on self-esteem. Isolation, low self-esteem, and poor self-concept are all by-products of a

lifetime of negative experiences due to the symptoms of ADHD (Davidson, 2008). According to

Susan Young, from the department of psychology at the Institute of Psychiatry in London, UK,

the debilitating effects of these negative experiences are deep-seated. She writes, “Failure has

been repeatedly reinforced by more failure. Successes are often minimized, if recognized at all.

In other words, they no longer believe in themselves” (2002, p. 150).

Studies that focused on levels of self-esteem in college students found that students with

ADHD had lower levels of self-esteem, as compared to a matched group of students (Dooling-

Litfin & Rosen, 1997; Shaw-Zirt, Popali-Lehane, Chaplin, & Bergman, 2005). Levels of self-

esteem were closely tied to social skills, in that those with higher social skills had higher levels

of self-esteem.

Co-existing Disorders

Comorbidity is another factor associated with ADHD in children and in adults. Common

comorbid disorders in children include oppositional defiant disorder (ODD), conduct disorders

(CD), learning disabilities, and anxiety disorder (Davidson, 2008). In adults, co-existing

psychiatric disorders include mood disorders (bipolar disorder, depression, and dysthymia),

anxiety disorders, personality disorders, and substance abuse disorders. Comorbid disorders tend

to develop in adolescence or adulthood, unlike ADHD which is usually experienced in early

childhood (Wilens, Prince, Biederman, Spencer, & Frances, 1995). In a large study conducted in

the United States, psychiatric comorbidity was assessed in adults with ADHD and was compared

to adults who did not have the disorder. Both groups of adults were parents of children

diagnosed with ADHD. The parents with ADHD had significantly higher rates of comorbid


psychopathology; 87% had one co-existing psychiatric disorder and 56% had at least two other

psychiatric disorders. This result was much higher than the non-ADHD group of parents in

which 64% had one existing disorder, and 27% had at least two comorbid disorders (McGough,

et al., 2005).

In a study that examined the prevalence of ADHD in adults, Kessler (2006) found that

18.6% of adults with ADHD also had major depressive disorders, 12.8% also had dysthymia,

19.4% also had bipolar disorder, 47.1% also had anxiety disorders, 15.2% also had substance

abuse disorders, and 19.6% also had intermittent explosive disorder (as cited in Schneider, 2012,

p.6).

Diagnosis and Treatment

A diagnosis is often made by specialized physicians, through the use of self-report scales

(e.g., the Adult Self-Report Scale Symptom Checklist, or the Conner’s Adult ADHD Rating

Scales), a functional history of the presenting complaints, a developmental history including a

review of functional impairments in childhood, a detailed history of co-existing psychiatric

disorders, a family history, short cognitive tests (e.g., the Montreal Cognitive Assessment), and if

possible, confirming histories from other family members (Davidson, 2008; Farrone & Antshel,

2008; Schneider, 2012). In addition, and largely in part to the work of Dr. D. G. Amen, brain

imaging via a process called “single photon computed emission tomography” (SPECT), which

takes functional images of the brain that are affected by ADHD, is sometimes used to support the

diagnosis. Brain SPECT images of adults who have ADHD typically show less cortical activity

in the prefrontal poles, orbits, and parietal lobes than the brains of normal adults (Amen, 2008,

p.p. 143-145).


Treatment of adult ADHD generally consists of psychoeducation and psychotherapy,

cognitive behavioural therapy, self-management skills training, family therapy, and

psychopharmacology (stimulant medication) (Davidson, 2008). Prescriptions for medication

may be supplied by psychiatrists or general practitioners.

Unfortunately, many adults have difficulty finding a qualified physician who is willing to

take on an ADHD patient. Reasons for this include the following:

Lack awareness about the existence of ADHD in adults by general practitioners

who treat ADHD in children (Waite & Ramsay, 2010).

Lack of willingness on the part of physicians, to treat adults with ADHD

pharmacologically (i.e. with stimulants); they are concerned about prescribing this

type of medication for adults, since stimulants are controlled substances and are

often abused by drug-seeking individuals (Teplin, 2012).

Doctors who do accept a diagnosis of ADHD in adult patients may still be

reluctant to treat them if a comorbid illness exists (Waite & Ramsay, 2010)

Art Therapy

Diane Stein Safran (2002) is one of the few art therapists who has written about her

professional experiences with adults diagnosed with ADHD. She is the co-founder of the

Attention Deficit Disorders Institute in Connecticut, and has over twenty-five years of

experience as an art therapist working with children, adolescents, adults, and families. Safran

asserts that for adults with ADHD who frequently have difficulty maintaining selective focus and

avoiding distraction, the artwork serves as a visual reminder of their experiences, emotions, and

thoughts, and can be reviewed over and over again to enhance learning. The finished art piece

can also provide a baseline level of functioning, against which to measure progress over time.


Preferring groups to individual art therapy sessions, Safran believes that the shared

experience is extremely helpful. She conducts art therapy groups for adults, couples and

families, as well as a men’s group and a women’s group. Some of the issues for men centre

upon the ways in which ADHD, and the associated problems of impulsivity (e.g., gambling,

drinking, fast driving, poor financial management, and so on), impact their roles as employers,

employees, fathers, and husbands (Safran, 2002). The focus for the women’s group is similar to

the men’s group, and includes a discussion of women’s hormonal cycles and how they affect or

exacerbate the symptoms of ADHD (e.g., during puberty, pregnancy, and menopause), as well as

the difficulties of managing children (some of whom may also have ADHD) and households

(Safran, 2002). For couples, the non-verbal method of communication and interaction that art

therapy offers is very important. Many individuals with ADHD act and speak loudly and/or

impulsively, and more often than not this makes deep meaningful communication difficult for

both parties. Art media, such as drawings, sculptures, and collages, allow couples to express

their thoughts, concerns, and feelings without the influence of words that can be misspoken or

misunderstood (Safran, 2002).

David Henley, professor and director of art therapy programs at Long Island University

in New York, and clinical director of a psychiatric group serving children with ADHD, has

written extensively about his experience running art therapy groups for children with ADHD.

He discovered that creating artwork had several benefits for these children: it was easier and

more effective for the children to draw about behaviour problems than to use words, since

defenses and oppositional behaviours were often tied to the language use; drawing about

behaviours served to externalize them making them more concrete and easier to understand; art

making often lead to sublimation of anxiety, depression and aggression; and artistic activities


sometimes helped to overcome visual perception difficulties, enabling children to “organize

perceptions into meaningful gestalts” (Henley, 1998, para. 31).

In a single-case study of a child with sensory integration difficulties (such as those often

seen in children with ADHD), Kearns (2004) reported that the use of clay sculpture,

fingerpainting and easel painting in art therapy, helped the child to regulate his behaviour and

allowed him to interact more successfully in the classroom and with peers.

In a study of the use of mandalas as a focusing device for older children (ages 10-13)

diagnosed with ADHD, it was discovered that the mandala drawing exercises used in art therapy,

increased attention abilities, and reduced the frequency of impulsive behaviours over time.

Additional results included improved decision-making skills, and increased likelihood of task

completion (Smitheman-Brown & Church, 1996).

Methodology

This qualitative study will use a phenomenological approach, in which the symbolic

imagery of the artwork, communication during the therapy process, and interviews immediately

following the sessions, will be described, recorded, and explained in detail. The data from all

participants will be analyzed for common themes and patterns.

Rationale

A phenomenological approach will allow an in-depth examination of the quality and

meaning of the creative process in art therapy as it is experienced and communicated by the

participants. Interpretations by other people (including this researcher), pre-conceived ideas

about the use of art therapy with this population, and/or outside viewpoints will not influence

the findings, because the participants themselves will be describing their unique experiences as

they occur.


This approach will provide valuable information about the impact of art therapy on this

population, and increase our understanding of the nature of adult ADHD. It will also act as a

starting point for future research about the use of art therapy with adults who have ADHD.

Recruitment

Participants for this study must be over 18 years of age and have received a diagnosis of

ADHD by a qualified health professional, such as a family physician, a psychologist, or a

psychiatrist. There will be a minimum of 2, but no more than 4, participants.

Potential participants will be solicited by providing information/recruitment letters (see

appendix A) to a private mental-health professional, Mary-Lynn Trotter, M.S.W., R.S.W., who

treats adults diagnosed with ADHD.

Recruitment will begin in January 2013. The study will hopefully commence by

February 2013 or March 2013 and be completed by the end or middle of April 2013.

Procedures

The art therapy sessions will be conducted on the premises of the referring social worker.

There will be a 60 minute initial intake interview to determine demographic information

and suitability for the study (see appendix B), and to answer any questions potential participant

may have.

The researcher will conduct a series of six art therapy sessions. Each session will last for

up to 2 hours, and will consist of an art activity, followed by an in-depth interview. Because

many adults with ADHD are impulsive and easily distracted, most art activities will be structured

to promote focus and provide direction (Safran, 2002).

During the interview participants will be asked to report on their experience of art

therapy. The following open-ended question will be asked at each interview. “Please describe,


in as much detail as possible, your experience of this session and the process of creating the

piece of artwork”.

The interviews will be recorded, and typed verbatim for future analysis.

Six Art Therapy Sessions

Art activities will be based on the expressive therapies continuum (ETC), developed by

Vija Lusebrink and Sandra Kagin Graves in 1978 (Lusebrink & Dzilna-Šilova, 2012). ETC is a

foundational theory in the field of art therapy, which refers to a hierarchy of levels of

information processing experienced during the creative process. There are three levels of

increasingly sophisticated processing in the ETC hierarchy. Each level contains two bipolar

components—kinesthetic/sensory, perceptual/affective, and cognitive/symbolic— and a creative

level that can be associated with any of them (Hinz, 2009). Emphasis on one polarity decreases

the involvement of the other; for example, an activity which is predominantly kinesthetic in

nature will have less sensory involvement, and so on (Lusebrink & Dzilna-Šilova, 2012). Lisa

Hinz has further developed the ETC in her book The Expressive Therapies Continuum: A

Framework for Using Art in Therapy, by incorporating information from the fields of

psychology and neurology to explain the different aspects of functioning elicited by various art

based activities (Hinz, 2009). The art activities for this study will follow this continuum, and

will include kinesthetic, sensory, perceptual, affective, cognitive, and symbolic elements to

provide the client with a wide variety of art therapy experiences.

Session One: The Kinesthetic Component of the ETC

The kinesthetic sense provides information about bodily movements. It involves a

feedback loop of neuromuscular information from the physical movement of muscles and joints

through space, to the brain. It is generally preverbal, and includes the concept of natural bodily


rhythms—an awareness of one’s own movement in relation to the rhythm of the nature that

surrounds it. The healing component of the kinesthetic sense is based on the release of energy

(tension) or the stimulation of bodily energy (arousal) through movement (Hinz, 2009).

Art Activity and Materials : A scribble drawing will be used as a warm-up for all

sessions. The participants will be asked to make large unstructured motions in the

air with their arm, while holding a marker (or other drawing utensil). They will

gradually lower the arm to make random squiggles on a piece of paper. This is a

non-threatening experience that can be used to ground and regulate behaviour.

Directive : Painting to classical music. This activity involves matching physical

movements of painting to the rhythm of the music.

Purpose : People with ADHD are often impulsive and have difficulty regulating

their behaviour. According to Hinz, activities that are action oriented, and focus

on the kinesthetic sense, can help to regulate behaviour by promoting an

awareness of the rhythms and movements of the body through space (Hinz, 2009).

Art Materials : Watercolour paints, artist quality brushes, watercolour paper,

classical music.

Session Two: The Sensory Component of the ETC

The sensory component of the ETC includes information from the five senses (visual,

auditory, olfactory, tactile, gustatory), and involves the stimulation of some or all of these senses

while interacting with art materials. Like kinesthetic information processing, sensory

information processing begins in infancy and early childhood, before the ability to use words

develops (Hinz, 2009). According to Klorer (2003) and Malchiodi (2003), many early preverbal

memories are stored on the right side of the brain, and can be accessed through nonverbal


expressive therapy experiences, such as those that isolate the senses (as cited in Hinz, 2009).

Using art activities that focus primarily on the senses allows the conscious mind to relax, so that

attention can be turned to internal experiences. At times, this can result in the release of

emotions that were previously suppressed, consciously or unconsciously. Stimulating the senses

encourages an attunement with the body, independent of the influence of thought (Hinz, 2009).

Directive: Immediate art response to aromas (spices, herbs, essential oils). The

participants will be offered an item to smell (with their eyes closed to increase the

focus on the olfactory senses), then asked to create a quick drawing, immediately

after each scent.

Purpose: Stimulation of olfactory senses to evoke personal memories and/or

emotions.

Art Materials: Scents: cinnamon, ginger, lavender, mint, orange peel. Art

materials for immediate art response: Paper and a variety of coloured pencil

crayons. Pencil crayons were chosen because they provide instant colour and

allow the artists to change line pressure and/or add shading for more intricate art

expression. Markers, on the other hand, provide only one line quality and

intensity of colour. Paints require brush cleaning, which may increase the

reaction time for the art response, and detract from the olfactory experience.

Session Three: The Perceptual Component of the ETC

The Perceptual component of the ETC focuses on form and structure. It is concerned

with how a piece of artwork is created and not what is created (Gantt & Tabone, 2012). It

involves distancing oneself from the affective content of artwork, and examining the formal

visual elements, such as line, colour, pattern, texture, shape, form, space, line pressure, character


and so on. Focusing on the perceptual components of the images has the effect of containing

emotions. When emotions are overwhelming, this type of activity can be calming (Hinz, 2009).

According to Lusebrink (1990), this component also promotes cognitive functioning by asking

the artist to examine the visual schema, allowing new perspectives to be realized (as cited in

Hinz, 2009).

Directive: Changing point of view aciticvity. Participants will be asked to draw

three pictures:

1. “How does ADHD impact your life?”

2. A close-up view of the same drawing.

3. A bird’s-eye view of the same drawing.

Purpose: To increase self-understanding and self-awareness, and to gain

perspective about the impact of psychosocial issues.

Art Materials: Drawing materials (markers, pencil crayons, pencils), and paper.

Session Four: The Affective Component of the ETC

The affective component of the ETC is concerned with accessing, processing, and

expressing emotions through manipulation of the art media. Art media that are fluid, such as

paints and pastels have the potential to elicit the direct expression of feelings (Hinz, 2009). In

addition to offering art materials that facilitate emotional release, a process known as reflective

distancing is used once the piece of artwork has been completed. For this process, the artist is

asked to physically step back from the piece of art. If the artwork is a painting or a drawing, it

can be posted on a wall. The emotional and symbolic content embodied in the finished art piece

is observed as a separate entity, apart from, and outside of, the individual (Hinz, 2009). While

examining the artwork, an introspective discussion is initiated by the art therapist who asks


questions that facilitate the identification of feelings aroused by the creative process and/or the

finished piece. This process can help the individual gain insight into underlying emotional

issues.

Directive: Use the art materials to depict a response to the following question:

“How does it make you feel when significant people in your life are angry or

frustrated with you?” After the artwork is completed, the researcher will use the

method of reflective distancing (mentioned above).

Purpose: To facilitate emotional expression. One aspect of ADHD involves

difficulty regulating emotions. According to Hinz (2009), offering people art

media and directives that facilitate emotional expression leads to an increased

awareness of affect, which in turn, may lead to the development of more

appropriate affective responses.

Art Materials: Fluid media (e.g., water colour paints, acrylic paints, finger paints,

and pastels) artist quality paint brushes, and paper.

Session Five: The Cognitive Component of the ETC

The cognitive component of the ETC requires the use of complex thought processes,

known as executive brain functions (Hinz, 2009). This component directly challenges people

with ADHD, who have deficiencies in areas of the brain responsible for these functions (Teplin,

2012). As mentioned previously, executive brain functions are cognitive processes that include:

working memory; action planning; time management; organization of thought, time, and action;

problem solving; attention/focus; behaviour regulation; emotion regulation; and impulse control

(Centre for ADHD Awareness Canada, 2012). Art therapy activities that are very structured, and

utilize many procedural steps require the use of these cognitive skills.


Directive: Create a lifeline from birth to the present signifying the salient ups and

downs of your life, and include magazine collage images as visual

representations.

Purpose: This activity requires active memory, problem-solving skills, impulse

control, mental and visual organization, planning and sorting, and reflective

cause-and effect thinking.

Art Materials: Pencils, pencil crayons, rulers, large sheets of paper, collage

materials from magazines, scissors, and glue.

Session Six: The Symbolic Component of the ETC

The symbolic component of the ETC involves the ability to form complex concepts that

are both imaginative and intuitive (Hinz, 2009). Symbols are words, phrases, objects, or images

that have associated meanings, and are also perceived to have inherent values that are separate

from their original structure. They often express what cannot be spoken (The archive for

research in archetypal symbolism, 2010). According to Meister Eckhart, “When the soul wants

to experience something she throws out an image in front of her and steps into it” (as cited in

The archive for research in archetypal symbolism, 2010, p.6). Symbolic content in the artwork

can reveal previously unknown psychological information, and lead to a new sense of self

(Hinz, 2009).

Directive: Create a self-symbol. This is a fairly open directive with room for

interpretation to give the participants freedom to represent any or all aspects of

themselves.

Purpose: To integrate aspects of the personality, and potentially discover new

facets of the self. To re-establish and solidify a positive self-image.


Art Materials: Coloured plasticene (as many colours as possible).

Human Subjects Policy Requirements

Participants will fill in a consent form in order to take part in this study (see appendix C).

The consent form is based on the sample form found in Introduction of Art Therapy Research, by

Lynn Kapitan (2010). The consent form will inform them about the potential risks and possible

benefits associated with participating in this study. There is no known harm associated with

these art activities; however, some imagery may remind individuals of bad memories, may evoke

strong or unpleasant feelings. Benefits that may be expected from taking part in this research

include: increased self-awareness and insight, processing of intense and/or unpleasant feelings,

relief from stress and anxiety, improved self-esteem, and improvement in mood (Dalebroux &

Goldstein, 2008, Safran, 2002). If additional psychological support is needed as a result of

participating in this study, the researcher will provide the appropriate referrals, with the help of

her on-site supervisor.

The rights and privacy of all participants will be respected, and confidentiality of

personal information will be strictly maintained. Names and specific identifying information

will not be used to ensure confidentiality.

The consent form will ask for participants will volunteer to be in the study. It will

include a notification that indicates that they can drop out of the study at any time with no

repercussions (appendix B). Participants will be required indicate that they have received an

official diagnosis of ADHD by a general practitioner, psychologist, or psychiatrist.


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Appendix A

BE PART OF AN IMPORTANT STUDY!

How Do Adults with ADHD Experience the Creative Process in Art Therapy?

This is a low-risk, short-term study involving the use of expressive arts (drawing,

painting, sculpting, collaging, writing etc.). No artistic ability is required. The creative process

is the focus of art therapy, not the quality of the art.

Purpose

The purpose of this study is to examine the experience of art therapy as a treatment

modality, for adults who have attention deficit hyperactivity disorder.

What is Art Therapy?

Art therapy is a form of psychotherapeutic treatment that uses the process of art-making

(using basic materials) to address psychological, emotional, and behavioural issues. Art

therapists have training in psychology and psychotherapeutic practices. The creation of art is a

non-verbal process, unlike traditional psychotherapy. Conscious and unconscious thoughts,

feelings, and ideas, are expressed symbolically through formal elements of design, such as the

use of lines, shapes, patterns, and colours.

About the Researcher

I am an art therapy student at the Toronto Art Therapy Institute, completing my diploma

in Art Therapy. I have a Bachelor of Arts degree in Psychology, and a Bachelor of Science

degree in Occupational Therapy. I am currently collecting data for my research, a qualitative

study entitled, “How do adults with ADHD experience the creative process in art therapy?” I

hope to learn more about adults with ADHD, and gain and understanding of the potential effects

of art therapy on these individuals.


What’s Involved?

Study participants will be asked to take part in an initial intake interview (up to one

hour), and six art therapy sessions (one session per week, for a duration of up to 2 hours).

Participants will be asked to sign a consent form, granting the researcher permission to record the

sessions and photograph their artwork for educational purposes. Full anonymity will be

guaranteed.

Participants must be over 18 years of age, and have received a medical diagnosis of

ADHD by a family physician, a psychologist, or a psychiatrist.

Please contact me, Andrea Charendoff, at (416) 564-9998 for more information.

I would be happy to answer any questions you may have. Thank you.


Appendix B

Intake Interview

Participant’s Name _______________________________________________________

D.O.B. ________________________________________________________________

Male Female

Married Single In a Relationship

Number of Children ___________ __________________________________________

Do any of your children have ADHD?________________________________________

Occupation _____________________________________________________________

Level of education _______________________________________________________

Were you diagnosed by a qualified physician? _________________________________

When were you diagnosed? ________________________________________________

Do you have any other psychological diagnoses or conditions? _____________________

Have you heard of art therapy before? _________________________________________

If yes, have you had art therapy before? _______________________________________

What are your expectations of this study (if any)? _______________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

Date ___________________________________________________________________

Participant’s Signature _____________________________________________________

Researcher’s Signature _____________________________________________________


Appendix C

Research with Human Subjects Consent Form

Date: (to be determined)

Dear Research Participant,

I am conducting a study of adult ADHD as part of my diploma in art therapy at the

Toronto Art Therapy Institute. The purpose of my research is to examine the experience of the

creative process in art therapy with adults who are diagnosed with ADHD. This research is

expected to contribute to our understanding of adult ADHD and art therapy as a treatment

modality.

During this study you will participate in an initial intake interview (up to 60 minutes in

length), followed by six art therapy sessions (one per week, for one hour). After each art therapy

session, there will be an in-depth discussion/interview (one hour in length). In the art therapy

sessions you will be asked to create a piece of artwork based on a specific directive given by the

researcher. All of this will be conducted at a mutually agreeable time at a specified location.

The sessions and interviews will be audiotaped and/or videotaped, and artwork that you create

will be photographed and used as part of the research outcomes. The results of the research may

be presented to others for their information. However, all responses will be kept confidential and

your name or any direct or indirect identifying characteristics will not be used in any report

regarding this research. You are free to decline to participate at any time. After the research is

completed I will forward to you by mail a summary of my findings. The following are possible

discomforts or risks that may be reasonably expected: Participants who are unaccustomed to

creating artwork may feel awkward or uncomfortable. Some imagery may remind individuals of

good and bad memories, and may evoke strong or unpleasant feelings. The benefits that may be


expected include: increased self-awareness and insight, processing and healing of intense and/or

unpleasant emotions, stress relief and anxiety reduction, improvement in mood, improved self-

esteem. In the event that further psychological support is required as a result of participating in

this study, the researcher, with the support of her on-site supervisor, will provide the appropriate

referrals.

In order to take part in this study participants must be older than 18 years of age, and

have received an official diagnosis of ADHD, by a family physician, a psychologist, or a

psychiatrist.

If you have any questions about this study, please feel free to contact me at 416-564-

9998. If I am not immediately available, I will return your call as soon as possible. Thank you

for your interest and willingness to participate in my study.

Sincerely,

Andrea Charendoff

I, ______________________________consent to participate in the study, conducted by

Andrea Charendoff from the Toronto Art Therapy Institute, entitled: “How do adults with

ADHD experience the creative process in art therapy?” I have reviewed and fully understand the

contents of this consent form. I understand that I may refuse to participate and/ or withdraw

from the study at any time. I understand that all my responses will be kept confidential. I have

been given a copy of this consent form.

Signed:____________________________________________________Date:________

Witness to participant’s signature:_______________________________Date:________

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