‘Keeping my mind strong’: enabling children to discuss and explore issues relating to their perceptions of positive mental health through the arts

Abstract

Background

The ramifications of mental ill health are enduring and potentially disabling. This research study focuses on using art to explore children’s understanding and awareness of mental health issues.

Aims

To explore the medium of ‘drawing’ as a method of communication by young people for expressing feelings and thoughts about what keeps their minds strong and what makes them happy as children.

Method

Arts-based research was used as a primary mode of inquiry to collect data and conduct analysis.

Sample

A total of 16 schools participated, with 10 from the primary school sector (children aged 5–11 years) and six from the post-primary sector (11 + to 18 years). A total of 358 posters were submitted.

Findings

Emergent themes suggested the existence of the awareness of stigma, which accompanied mental health issues and social isolation. In addition, perceptions of what makes children happy were also apparent, for example, family and friends. Similarities existed in the relationship between genders of a similar age group, and some differentiations presented between primary and post-primary educational sectors.

Implications

Arts-based research offers children an opportunity to recognise and express their feelings. Early identification of a child’s mental health problems may enable mental health nurses to engage in early intervention strategies to promote positive health functioning.

Keywords

arts-based research children health promotion mental health stigma

Introduction and background

On a global level, it is estimated that approximately 20% of youth experience a mental health condition each year (United Nations Children’s Fund, 2012). Furthermore, according to the Healthy Young Minds Report (Layard and Hagell, 2015), around 10% of the world’s children are currently suffering from diagnosable mental health problems; mainly anxiety, depression, and stress. It is further projected that one in every four to five youth in the general population meet criteria for a lifetime mental health disorder that is associated with severe role impairment and/or distress (Merikangas et al., 2010).

Additional estimations indicate that over half of all mental ill health starts before the age of 14 years, and 75% has developed by the age of 18 years (Murphy and Fonagy, 2012). Moreover, mental health conditions adversely impact youth development, quality of life and the ability to participate fully in their communities (Fisher and Cabral de Mello, 2011). The World Happiness Report (Helliwell et al., 2015) cites research that has determined that over half of children who have a mental health problem will experience mental ill health as adults. Furthermore, it explains that mental health problems such as depression can be more disabling than physical problems such as arthritis or asthma.

In Northern Ireland approximately 25% of the population are children and young people (Northern Ireland Statistical Research Agency, 2011). In addition, it has been determined that Northern Ireland appears to have higher-than-average rates of attempted and completed suicide among young people (Largey et al., 2009). Furthermore, it is recognised that socioeconomic disadvantage places children at increased risk of exposure to poor parental health, including mental ill health, and that such children are themselves at increased risk of developing chronic health patterns (Emerson and Hatton 2007; Rees et al., 2013).

Psychological and mental health is paramount to a person’s overall health and functioning. Mental health problems significantly compromise a person’s coping abilities, leading to low self-esteem, poor body image, social isolation/exclusion and dysfunctional relationships (Department of Health, 2009; Parry-Langdon et al., (2008)). Moreover, mental health conditions affect young people's self-esteem, social interaction and even their chances of personal injury and harming themselves and others (Bradshaw et al., 2012). Unmistakeably, youth may face a number of stressors in the course of their development, and it is often more the accumulation of these risks that signifies greatest risk, rather than any one particular experience (Bradshaw et al., 2012; Young Minds, 2014).

The foundations for good mental health functioning are laid down in childhood, ensuring that children have the potential to lead positive lives, develop resilience and have the ability to cope with the challenges that life may bring (Cooper et al., 2005; Killen and Coplan, 2011). Good social, emotional and psychological health helps protect young people against emotional and behavioural problems, violence and crime, teenage pregnancy and the misuse of drugs and alcohol (Adi et al., 2007; Colman et al., 2007). Good mental health also facilitates young people in achieving developmental milestones that occur during adolescence (Gibb, 2010; Kapphahn et al., 2006). Research has shown that age, family support, the absence of psychological problems, social support and a positive school experience are potent protective factors to self-harm (McMahon et al., 2010; Moran et al., 2012).

The advantages of using expressive arts as a means of communication are well documented within the literature (Hubley and Copeman, 2010; Malchiodi, 2005; Wikström, 2005). In addition, the role of arts education in forming the competences for young people for life in the twenty-first century has been widely recognised at European level (European Commission, 2009). Children need opportunities to consider ideas and topics that are meaningful to them and Barone and Eisner (2012) stated that arts-based research (ABR) is about enticing people to think more about important social issues. Leavy (2009) suggested that ABR is about completing the arch from ‘word to image’.

Furthermore, using ABR as a means of promoting mental health awareness among middle school children in the USA has also been reported (Reisz, 2012). With respect to people who experience mental health issues, Stickley and Hui (2012) proposed that utilising an arts in-reach programme enabled mental health clients to think about their futures restoring a sense of hope linked to their concept of recovery. Coad (2007) identified the significance of using research methods that were considered ‘enabling’ while engaging children and young people in the area of health care consultations. The author suggested that while much progress had been achieved in this area, particularly with respect to narrative techniques, there was less critical work in the utilisation of ABR. Earlier researchers (Pink, 2001; Prosser, 1998) have clearly indicated the significance and importance of arts-based techniques and their intrinsic link to the process of child development and early learning. Correspondingly, Hopperstad (2010) proposed that children’s drawings convey meaning and help them to articulate ideas and perceptions in different ways to that of verbal language and in ways that they may not be able to verbalise. This implies that children can use drawing to express their thoughts more clearly than using expressive language. Coad (2007) thus suggested that ABR enabled children to express their views across a wide range of the development continuum, and pointed out that such activities were rarely used in isolation but were operationalised with a combination of other research techniques, such as interviewing, quite effectively.

Recognition therefore of the myriad of issues that children and adolescents may face can enable mental health nurses to provide responsive and meaningful nursing and caring interventions that maximise on the young person’s capacity for recovery. Development of knowledge and expertise in this important area of health and social care can ensure that nursing and health care delivery can be strategically planned to address the uniqueness of the needs identified for children and young people experiencing mental health problems or distress. This takes due cognisance of the research for better health and social care aspirations and objectives (Department of Health and Social Services and Public Safety, 2016).

Methodology

The aim and objectives of the research

The overall aim of the research study was to involve young people and their teachers in utilising ABR within their schools. ABR is an effective way to translate word into image in an expressive manner that promotes individualistic artistry, thus widening the concept and depth of communication in areas where the spoken word is perhaps difficult. Art teachers will thus facilitate the young people drawing a poster as a method of communicating and expressing their feelings and thoughts about what helps to keep their minds mentally strong and happy and moreover what they feel makes them sad or challenged as young people. Young people will be directed to provide a narrative interpretation of their own poster on the rear of it and this will be analysed for thematic content. Furthermore, a poster analysis worksheet will be operationalised more objectively to provide further interpretation and analysis.

The objectives were:

To facilitate and coordinate with the teachers for the young people to complete the art posters at school level.

To gather teacher facilitated open and freely expressed narrative from children using three open-ended questions (see Table 1).

To enable exploration of the child’s own personal constructs concerning positive mental health and mental health issues within a wider context.

To determine the personal experiences of teachers in facilitating both the drawing activity and the children’s experience of engaging with the teachers in the process.

Table 1.

Open ended questions.

Q1. What is the title of your poster?
Q2. What is your poster about?
Q3. What message are you communicating within your poster?

Ethical approval and procedures

All procedural, ethical and key considerations (Cohen et al., 2011; International Council for Nurses, 2006) for ethical approval for the study were obtained from the relevant educational authority, school of nursing ethics committee, Ulster University ethics committee and the respective school principals within both the primary and secondary school sectors. Three discrete participant information sheets (PISs) and consent forms were compiled for all participants and approved by Ulster University ethics committee. For all young people under 16 years research information was sent to their parents and consent and approval for participation was provided by the parents. For those over 16 this was provided by the participant themselves. In advance of the semi-structured interviews, the teachers were also sent the PIS and a consent form. This ensured that all participants were fully informed of the research study in advance of providing consent to participate (Punch, 2006). Moreover, the opportunity was also provided to discuss any queries or concerns fully with the researchers within a month and prior to participation. This time period was built in to allow for any active queries from parents or participants. Thus fully informed consent was gained in advance and the teachers were specifically also asked to provide additional consent to audio recordings on a digital recorder.

Data collection

Data were collected from both the primary and secondary schools sector with a 50% (n = 16) participation rate from the total school population. Young people were asked to draw a poster that they felt communicated and expressed their feelings and thoughts about what helps to keep their minds mentally strong and happy and moreover what they felt made them sad or challenged as young people. Data were thus collected as follows from both sectors:

The submitted art posters (n = 358).

Narrative responses provided by the participant in response to three open-ended questions (see Table 1) at the rear of their poster submissions (n = 1074).

Semi-structured interviews following the interview topic guide (see Table 3), which were recorded with a convenient sample of the participating teachers, 36% (n = 8).

Rationale

The submitted art posters (n = 358), were further analysed using a critiquing framework afforded by the National Archives (2012), which was modified and adapted (with the National Archives' permission) for the purposes of poster analysis within this research study (see Table 2). Furthermore, the application of such a framework enabled the researchers to reduce subjectivity and potential bias and, as Coad (2007) suggests, researchers should ensure that using art-based activities are planned and well thought out and thus not chaotic.

Table 2.

Poster analysis worksheet.

1. What are the main colours used in the poster?
2. What symbols (if any) are used in the poster?
3. If a symbol is used, is it:
a. Clear (easy to interpret)?	YES/NO
b. Memorable?	YES/NO
c. Dramatic?	YES/NO
3. Are the messages in the poster primarily visual, verbal, or both?
4. Who do you think is the intended audience for the poster?
5. What message or purpose/s is served by the poster?
6. The most effective posters use symbols that are unusual, simple, and direct. Is this an effective poster? YES/NO
Adaptation of a poster analysis worksheet, designed and developed by the Education Staff, National Archives and Records Administration, Washington, DC 20408

Table 3.

Semi-structured interview topic guide used with teachers.

Q1. Introduction and reaffirm title: ‘Keeping my mind strong’: enabling children to discuss and explore issues relating to their perceptions of positive mental health through the arts	(a) Outline researchers’ background
	(b) Confirm verbal consent for study
	(c) Reaffirm consent for recording field notes
	(d) Assure participants of confidentiality
Q2. What are your general thoughts and feelings around facilitating the art project?	(a) Effective/ineffective medium
	(b) Has the pupil demonstrated an understanding of mental health issues?
	(c) What messages are being communicated by the pupils?
Q3. What are your thoughts and feelings about the actual posters being painted?	(a) Is this poster effective with use of colours and symbols?
	(b) Does the pupil express an intended audience/group for their poster?
	(c) What messages do you feel are communicated within the poster, colours, sense of drama etc.?

Moreover, collecting qualitative narrative comments from the young people on the rear of their own posters in response to three open-ended questions (see Table 1) was viewed as an enabling way to facilitate their own specific translation of their art into another mode of communication, the spoken word, which could be further analysed by the researchers for thematic content analysis, using a framework as provided by Newell and Burnard (2006) (see Table 4).

Table 4.

Overview of thematic content analysis, guided by Newell and Burnard (2006).

Stage one	Notes were made after each interview regarding the topics talked about during the interview. Notes were also made following reading through the children’s narrative in response to the three open-ended questions. These notes constituted memos similar to field notes of an idea, theory, thought or feeling that occurred to the researchers.
Stage two	These notes were read searching for general themes. The aim was to focus and become more familiar with the data. General notes were written up at this stage, for example: there were discussions about the meanings and interpretations of colours and symbols and messages within the art work.
Stage three	The researchers read through these notes and the notes from the children’s responses to open-ended questions several times and thematic headings were written down to describe different aspects of the content. In this stage the researchers used words and phrases, recorded in the margins of the interview notes and posters, to assist with categories and summarisation. This required the researchers to make judgements on such interpretations.
Stage four	A number of themes clearly overlapped and were thus grouped and placed together, such as stigma and mental health issues. Sub-themes were evident within major themes that supported the major theme. For example, material possessions was indicative of protective and positive mental health functioning.
Stage five	In this stage, the researchers returned again to the interview notes and children’s narratives with the major and sub-themes identified. Thereafter, these major themes were separated into the different thematic sections.
Stage six	This process and organisation of the datasets have enabled the researchers to formulate the material from which this ABR study reports on.

Finally, as the school art teachers facilitated the young people drawing the posters the researchers included this group as it was felt that this would enhance reliability, validity and credibility of the research process. Moreover, it was felt that they could add further rich qualitative narrative to the research study. Semi-structured interviews were thus completed by the researchers (ranging from 45 to 60 minutes’ duration), using a brief semi-structured topic guide (see Table 3). These interviews were recorded verbatim and also subjected to a thematic content analysis framework as provided by Newell and Burnard (2006) (see Table 4).

Sample

The target population of each participating school category within the educational catchment area consisted of 23 primary schools and nine secondary schools. In total, 16 schools participated, with 10 from the primary school sector (children aged 5–11 years) and six from the secondary sector (children 11 + to 18 years). A total of 358 posters were submitted. A total of 22 teachers (n = 16 primary and n = 6 secondary) took part in the art work submission. Within this sample a convenience sample of eight teachers participated in semi-structured interviews (see Table 5).

Table 5.

Analysis of school and teacher participation.

Type of school	Total school population sample	Total schools participated	Total posters submitted	Total participating teachers	Teachers interviewed
Primary Aged 5–11 years	(n = 23)	43% (n = 10)	(n = 244)	(n = 16)	25% (n = 4)
Secondary Aged 11 + –18 years	(n = 9)	66.6% (n = 6)	(n = 114)	(n = 6)	66.6% (n = 4)
Totals	100% (n = 32)	50% (n = 16)	(n = 358)	(n = 22)	36% (n = 8)

Data analysis

ABR is an attempt to extend beyond the limiting constraints of discursive communication in order to provide interpretations and meanings that would otherwise be inexpressible (Barone and Eisner, 2012), and thus using the posters and a poster analysis worksheet as an approach within data collection enhanced the credibility and transparency for this ABR approach. Furthermore, using the other combined data collection methods within this ABR study provided an integrative and innovative approach to data analysis procedures.

The poster analysis worksheets, young people’s narrative and the transcripts from the audio interviews with the teachers provide for descriptive non-interpretative accounts that lack explanations or analysis, thus requiring the researchers to interpret and make sense of these data. An interpretive art analysis approach in keeping with ABR was thus facilitated by the poster analysis worksheet. This enabled a detailed and critical examination of these data that provided meaningful understandings while concurrently enhancing empirical knowledge. This approach combined with thematic documentary analysis of the young people’s narrative in response to the three questions and the transcripts from the teacher interviews enabled a much more critical, interpretive and cross-comparative exploration of all aspects of the data.

Document analysis is a social research method that involves extensive appraisal and interpretation of patterns within data. It classifies patterns and generalises results that are useful when looking at actions, events or occurrences (Bowen, 2009; Silverman, 2001). Cohen et al. (2011) point out that in the examination of documents it is important to note that they do not speak for themselves but require careful analysis and interpretation. Summaries were thus created for each group of primary or secondary school posters and these were progressively refined and analysed to create an overall composite summary within emergent themes. This allowed the researchers to evaluate and explore complex and diverse details within the data (Miles and Huberman, 1994).

The transcripts from the semi-structured interviews with the teachers were also analysed for emergent themes and sub-themes using the framework of Newell and Burnard (2006). These were subsequently further categorised and grouped within an overall thematic analytical approach to all of the existing data collection procedures. This facilitated cross-comparisons of all datasets with the identification of shared and common themes, constructions, similarities and differences, providing synthesis and validation. These processes facilitated a comprehensive determination and understanding of all of the datasets collected.

Results

The results from the poster analysis worksheets for both sectors are tabulated in Table 6. The key themes that were determined from the combined data synthesis of primary/secondary narratives and teachers’ semi-structured interviews were: stigma, mental health issues, social isolation, supportive and protective mechanisms and positive mental health functioning. These are presented and discussed in more detail within two discrete sections, the primary and secondary school sectors.

Table 6.

Poster analysis worksheet composite results.

Details					Primary school sector				Secondary school sector
Total posters presented					68.15% (n = 244)				31.84% (n = 114)
What are the main colours used in the poster?					Multiple colours of the rainbow are used frequently such as red, pink, yellow, orange, green and blue.				All colours of the rainbow are evident such as red, pink, yellow, orange, green, blue, black and purple. Black was the only colour used in evident in approx. 33.3% (n = 38) of all posters.
What are the main colours used in the poster?					Purple and black are used in a small number of posters only, approx. 10.24% (n = 25).
What symbols (if any) are used in the poster?					Symbols are used to represent material items such as a mobile phone/IPad/laptops/clothing/family pets/friends in approx. 63.9% of posters (n = 156)				Complex symbols and cyphers are used alongside other complex codes/signs on approx. 71.9% of posters (n = 82)
If a symbol is used, is it:					Yes (n = 148)	Yes (n = 148)		Yes (n = 23)	Yes (n = 102)	Yes (n = 102)		Yes (n = 102)
Clear	Memorable			Dramatic	No (n = 96)	No (n = 96)		No (n = 221)	No (n = 12)	No (n = 12)		No (n = 12)
Are the messages in the poster primarily:					Visual	Verbal		Both	Visual	Verbal		Both
Are the messages in the poster primarily:					(n = 210)	(n = 160)		(n = 180)	(n = 114)	(n = 80)		(n = 94)
Visual		Verbal	Or both
Who do you think is the intended audience for the poster?					Friends and family (n = 124)				Myself (n = 76)
					The teacher (n = 35)				Others: including teacher, close friends and university lecturer (n = 38)
					The university (n = 45)
What message or purpose/s is served by the poster?					Messages suggest things that contribute to feeling happy, especially family, friends, pets, teachers and some television programmes. Things that make me sad are evident with messages about calling names, bullying and not having certain things such as the most up to date phone.				Messages point to positivity and feeling involved and connected to family and relationships as promoting mental health, with similar messages indicating a reverse relationship was also evident. Cyber bullying, intimidation, not having a voice with stigma and depression are cited as clear messages within posters that cause poor mental health functioning.
The most effective posters use symbols that are unusual, simple, and direct. Is this an effective poster?					Yes		No		Yes		No
					(n = 138)		(n = 106)		(n = 110)		(n = 4)

Section 1: Primary school sector

Children’s narratives

Stigma

Attitudes are formed at a young age, and it is important to prevent young people developing negative attitudes towards people with mental health problems and that it is okay to talk about mental health. There was strong evidence of cultural, peer and societal influences within the portrayal of children’s art, clearly articulating both positive and negative influences for mental health functioning. Children highlighted the difficulty telling their friends, family and teachers when experiencing mental health problems. They recognised the importance of creating an open culture around mental illness and challenging discrimination.

Sometimes words hurt more than actions, like bullets.

There is a person under the insults.

Mental health issues

Bullying affects young people’s mental health, emotional wellbeing and identity. Moreover, the relationship between bullying and mental health is complicated by the nature of these issues: some young people are bullied as a result of their mental health issues; and some young people develop mental health issues as a consequence of being bullied.

My friend got bullied by two of the p.7s, the teacher had to sort that out and he had to leave his last school because of that.

People have many problems but no one knows. So those weird times when someone in your class starts to cry, ask if they are OK?

Social isolation

Social isolation and mental health problems co-occur in childhood, and children may struggle to cope with the social challenges that accompany their progression through the early school years. Children identified the importance of ‘not being alone’ and getting support from their parents, relatives, teachers, other adults and their friends.

I hated school, I was on my own. I never wanted to go back but my teacher helped me.

Supportive and protective mechanisms

As children get older they appear to demonstrate more awareness of physical, psychological, social, financial and cultural issues. Young children, particularly 5–7 year olds, portrayed vibrant colours and representations of things in their art work that made them feel happy or sad, that is, mum and dad, siblings, home, best friends, teachers and family pets (see Figure 1).

There was an emergence of other core things such as relationships and trusting friendships (best friends and buddies). Other issues relating to things that made them unhappy were examinations (transfer test) and perceived lack of material possessions. Exemplars from children’s narrative indicated an understanding of the importance of supportive networks that were directly influential in promoting positive mental health functioning.

Forget about the past, think about the future. Be grateful for what you have.

Sit down and have a family meeting.

Being with my family.

When you are worried watch your favourite TV programme. Like if I was worried I would watch my favourite programme ‘Good luck Charlie’.

My friends and playing with my sister, mummy and daddy makes me happy.

Positive mental health functioning

Children’s posters demonstrated how children endeavoured to find methods of coping and adaption with respect to stressful life experiences, which in turn produced adaptive coping strategies that helped them to foster resilience. Children identified the importance of relationships, belonging and personal achievement as key drivers in promoting their positive social and emotional wellbeing including a sense of purpose, connectedness and meaning (see Figure 2).

Sharing with friends and playing together.

Looking forward to my birthday party.

Doing my best work.

Being with my family.

Teachers’ narratives

Stigma

Teachers reported that a significant number of students have experienced, or currently live with, a mental health problem. However, the school environment can negatively impact on students’ mental health due to the pressure of academic achievement. Teachers reported that even though mental health issues exist, mental health awareness is still not talked about routinely and welcomed the opportunity to instigate discussions on mental health issues.

We discussed how common this type of ill health is and how less a stigma there is attached to it now. (T1)

Mental health issues

Mental health problems can range from the worries we all experience as part of everyday life to serious long-term conditions. The early years of a child’s life are critically important and positive early experiences provide a broad range of skills and learning capacities. It is imperative that all gatekeepers of children’s welfare are concerned in promoting positive mental health functioning and wellbeing of children of all ages. In so doing, this will help to prevent or limit the severe and enduring effects of mental illness.

Even with small children anxiety and worry are really big issues, many people are just too afraid to talk about them, in recent years we have introduced a counsellor who is talking to children as young as seven. Everything from family break ups to bullying. (T3)

Social isolation

It is within the school environment that children obtain many of their early social experiences and develop peer relationships. This process can be hindered in various ways, for example, children may experience rejection by classmates, or they may themselves withdraw from social activities, which may have an impact on mental health.

The school environment is not only a place of learning, it also creates opportunities to develop friendships and social networks, and provides access to support structures, all of which have a significant influence on the development of young people. (T5)

Supportive and protective mechanisms

Teachers perceived that by undertaking the art project and through a discussion of mental health issues, students displayed an increased interest in learning about mental health and were perceptive of the importance of positive mental health promotion.

I feel it is so important for them to have friends who support them in school and for them to thrive at school and home. (T1)

Positive mental health functioning

An important means to promoting children’s mental health is an understanding of the protective factors that enable children to be resilient when they encounter problems and challenges.

It served to dissolve any ideas the children had that mental ill health is for the ‘mad’ and not for very ordinary, healthy people. (T6)

I feel it is so important for them to be educated in recognising symptoms in themselves and in others and to develop their empathy towards others. (T7)

Section 2: Secondary school sector

Young people's narratives

Stigma

Students developed proposals to promote positive messages of mental health through the media, and local authorities, that is, education, health services and police. Moreover, young people demonstrated a mindfulness of complex mental health issues, that is, living with stigma as indicated in the following statements (see Figure 3).

Mental disorders are not adjectives like … you look so anorexic, I was feeling so depressed yesterday, my mum yelled at me last night she is so bipolar … mental health should be taken more seriously by everyone.

Some people think that just because you have a mental illness that you should be treated differently from everyone else and that is not right.

Everyone has issues. Movies tell us that people with mental health problems are dangerous or scary or even stupid but that’s what life is.

Some people with problems may not show it due to paranoia or embarrassment.

Mental health issues

It is evident that young people have varied levels of understanding about mental health, and that children and young people associate mental health issues with the ramifications of bullying (see Figure 4).

Mental health can damage your confidence in life and make you want to kill yourself.

Depression is not something to laugh about or belittle.

Bullying, drugs, alcohol, and anxiety affect young people this leads to feeling down.

Bullying can push you towards suicide and bullying can lead to depression.

Furthermore, these young people identified that bullying and the use of social media negatively caused them severe annoyance and distress. Consequently, some young people identified that these factors were attributed to increased levels of anxiety, stress and poor mental health.

‘The Dark Truth’ – Mental health to me is an important issue as it is normally hidden beneath the surface causing pain and suffering! It’s difficult to live with mental health issues, overthinking and depression makes you self-doubt and harm, feeling stuck in your own head with no escape! It’s a deep and dark life!

Social isolation

Having mental health problems and experiencing discrimination has a detrimental influence on an individual’s self-esteem and confidence. This can result in increased isolation from society and reinforce feelings of exclusion and social withdrawal (see Figure 5).

‘Words can hurt more than actions’ – The person is surrounded in black to resemble how when you’re in depression you feel like you are alone in the dark while everything going on around you is great and happy and bright.

‘Drowning’ – This artwork represents the sadness and loneliness that people who suffer with bad mental health experience every day. I used pastels to create a smudged effect, which represents the feeling of drowning. I went with the colour purple as to me the colour purple symbolises sadness and depression.

Supportive and protective mechanisms

In the over 11 age category there was an increased awareness of a myriad of factors that either contributed to increased happiness or detracted from their perceived sense of life satisfaction. Core antagonists for poor self-esteem issues were directly influenced by school and peer pressure, lack of privacy and space. Significantly, the issue of relationships, sexuality and gender identification appeared to cause conflict with respect to self-esteem and self-awareness. Conversely, relationships with a partner, teacher or parent were perceived as meaningful; this appeared to contribute to positive mental health functioning.

‘Express your Emojis’ – Talk to someone and express your feelings. Even a supportive text message could be the start of someone’s mental recovery.

Recognise the signs! Talk to someone! Get Help! Don’t suffer in silence!

Positive mental health functioning

Exemplars from young people’s narrative indicated an understanding of the importance of social connectedness and supportive networks that were directly influential in promoting positive mental health.

Without a positive mind, you won’t have a positive face, life or mind-set or health functioning.

Your mind controls your body. Why should you neglect your most important attribute?

Teachers’ narratives

Stigma

Teachers conveyed that when they introduced the context of undertaking the art work project this resulted in diverse reactions from the young people on the subject of mental health. All teachers concurred that there had been a positive change in attitudes towards mental health/illness evidenced through discussions on how to challenge prejudice associated with mental illness.

We discussed how certain things like depression or alcohol/drug abuse can be stigmatised and how this inhibits someone looking for help. (T8)

It served to dissolve any ideas that young people had that mental ill health is for crazy people not for ‘ordinary’ people like you and me. (T4)

Mental health issues

Teachers outlined an understanding of the myriad of contextual influences that result in the prevalence of mental health problems in young people. Teachers perceived a higher prevalence of mental health issues as experienced by their students.

I know there are children too scared or too shy to talk about how they are feeling. We have to change that, and make it OK especially for boys. I know that they find it really hard to talk and then of course they are ridiculed by their friends and end up worrying and fretting on their own. (T8)

Furthermore, the everyday actions of effective teachers and their positive relationships with the children were found to promote actively the positive mental health of their students.

As a result of undertaking the whole mental health discussion I had to consult with a child’s parents and introduce a counsellor … things were just not right at home … a divorce. (T6)

Social isolation

Teachers indicated the need for collaborative and collegiate processes between the home, the school and the local community. Furthermore, they perceived that this collaboration with the university in areas relating to mental health was innovative and supportive and a positive step in the right direction of promoting health with children and young people.

We all need to be singing from the one hymn sheet when it comes to mental health and not working in isolation. (T2)

Supportive and protective mechanisms

Teachers also reported that their involvement in the art project resulted in enhanced relationships with their students, which were sustained beyond the project's life. In addition, teachers have attended key presentations and workshops at annual mental health conferences, pertaining to adolescent self-harm, suicide awareness, depression and emotional resilience. Other themes that related to the importance of supportive and protective mechanisms utilised were: the child’s family, friends, school teachers and material possessions.

I think discussions regarding mental health are important, whether we’re talking about stigma, or whether we’re talking about people not necessarily knowing what mental health really is about. (T5)

Positive mental health functioning

Teachers have a key role to play in the implementation of emotional wellbeing and mental health knowledge in young people. Their access to young people places them in a prime position to interact with those with less obvious mental health problems such as depression or anxiety, who may otherwise be missed by mental health services. They also have the ability to address interrelated academic, emotional, behavioural and developmental needs.

I found the main benefit of undertaking this project was that it gave the teacher the opportunity to discuss in depth the need to look after your mental health as well as your physical health. (T4)

Together we discussed a range of ways of preserving our mental health as well as the steps to be taken if unwell. (T6)

Discussion

Within this study ABR provided opportunities and challenges for the participants that included the deeply personal and sometimes intimate nature of artistic enquiry (Barone and Eisner, 2012; Bresler, 2011; Leavy, 2009; McNiff, 2013). Moreover, ABR provided children and young people with the opportunity to communicate their feelings through visual illustrations, to portray a sense of their meaningful affective experiences throughout their lifespan. Bresler (2011) suggested that ABR is based on the notion that the processes and products of art can contribute to research, as is evident within this study. Furthermore, Coad (2007) has articulated its importance in engaging children and young people in health and social care consultations. Bishop and Picard (2007), in their review of Coad’s work, have also advocated its utilisation and state that art in its broadest form offers the researcher unparalleled opportunities for investigations. Furthermore, that study has reinforced the views that ABR demonstrates positivity in promoting mental health awareness and in finding unique ways for effective communication other than verbalisations (Hopperstad, 2010; Reisz, 2012; Stickley and Hui, 2012).

It is known that significant importance has been placed on primary and secondary schools to become effective agencies for promoting the social and emotional wellbeing of young people (Morrison and Kirby, 2010; Rees et al., 2013; The World Happiness Report; Helliwell et al., (2015); Stewart-Brown, 2006). The key signiﬁcance of this ABR study lies in its evaluation of an inclusive approach to raising young people's awareness of mental health and wellbeing. Moreover, this study highlighted that the teachers felt their active participation within this study enabled discussions on mental health issues, which helped to promote mental health awareness and break down social isolation barriers. Emotional wellbeing is critical in developing a healthy successful school community including developing a pupil’s social, emotional and behavioural skills (The Pursuit of Happiness: A New Ambition for our Mental Health (2014); Hooper et al., 2012). This ABR study offered children and young people an opportunity to recognise and express their feelings in an open, honest and, quite often, in a very thought provoking manner. This supports the view that ABR thus becomes an enabling component for young people who have difficulties in articulating or verbalising their needs, and consequently provides insightful and meaningful interpretations for mental health nurses working in this area of health care (Hopperstad, 2010; Reisz, 2012).

Drawing can invigorate a young person’s ability to interrogate and relate better with the world around them, and the supportive and collegiate nature of this was very evident within this study. This can enable them to cultivate positive hopes or dreams, increase their confidence and the aptitude for independent analytical thought. It can also help them to develop the life skills and resilience to manage their life’s journey. Within this research study emergent themes of supportive and protective mechanisms and positive mental health functioning were clearly evidenced.

Children and young people can experience a range of mental health problems throughout their life continuum, and can respond or cope with this in a variety of positive or often negative ways (Rees et al., 2013). This ABR study reinforces this view and demonstrated the participants’ individualistic interpretations and coping abilities to mental health issues throughout their lifespan. Childhood and teenage years are a time when coping with many different situations and unfamiliar challenges like examinations, relationships and many other endogenous and exogenous pressures of growing up occur. Within this ABR study participants highlighted examples of being bullied, either physically, psychologically or via media as precursors to seriously affecting their physical and mental health resulting in sadness and loneliness, lack of confidence, poor self-esteem and becoming anxious and/or depressed. Similar findings are also reported upon within Family Lives (2016).

Maladaptive coping responses may result in school avoidance as a means of coping even long after the bullying has stopped. The effects of bullying are direct, pleiotropic and long-lasting, with the worst effects for those who are both victims and bullies (Copeland et al., 2013). This ABR study also highlighted the important role teachers had to play in managing issues of bullying more proactively.

Within this study similarities were evident in the relationship between boys and girls of a comparable age group, across different schools. This was particularly evident with respect to their perception of events that depicted happiness or sadness in their lives. Notably, differences existed between the primary and the secondary sectors with respect to how colours were operationalised within the posters and in their representation of factors perceived to make them happy or sad. In particular, older children appeared to focus more on the significance of trusting relationships including teachers, friends and family, material possessions and the influence of peer pressure. When these were problematic in their lives there was a greater tendency to use darker colours such as black and purple within the posters. In contrast, younger children appeared to focus more on family, friends and pets, and brighter colours were also more evident primarily.

This ABR study highlighted that the individualistic nature and context of personal relationships were core issues for many young people. Both children and young people outlined how relationship difficulties/disharmonies or breakdowns, even within their own families, could be devastating for them. Some young people focussed more on how relationship difficulties influenced their sense of self, their self-confidence, self-esteem and their mood, particularly when these were same sex relationships. Young people also depicted that there was a parental or teacher expectation for them to cope with life’s demands no matter what was happening in their personal lives; even if they had family problems, personal problems or mental health difficulties. Moreover, in some cases poor academic results were considered detrimental to their pursuit of happiness and positive health functioning.

It is recognised that stigmatising attitudes including media images do not respect people with mental health problems, and living within such a culture often leads to self-stigmatisation also. Nearly nine out of 10 people (87%) with mental health problems have been affected by stigma and discrimination (Time to Change, 2008). The findings of this study show that young people are acutely aware of the effects of stigma associated with mental ill health. Positive mental health is important to all of us especially during the transition and inherent challenges to becoming a young adult within a modern and evolving technocratic society. It is at this point in our lives that many of the personal choices, personal errors and personal opportunities occur that may determine the nature of our adult life.

Young people, especially in the older age categories also identified and recognised the impact of mental health difficulties on individuals, families and communities, and demonstrated an acute awareness of the effects of stigma, discrimination and bullying within not just school but also society as a whole. Some expressed a reluctance to seek help when feeling stressed or depressed.

It is recognised that adult mental health services are often not designed or delivered in ways that young people wish to engage with, and the fear of being stigmatised for having a mental health problem is also a major factor in young people’s decisions not to access help from mainstream, traditional mental health services.

Barone and Eisner (2012, p. 1) state:

ABR represents an effort to explore the potentialities of an approach to representation that is rated in aesthetic considerations and that when it is at its best culminates in the creation of something close to a work of art.

Therefore utilising ABR as a facilitative medium for children and young people is clearly an enabling process in exploring issues related to mental health, which can effectively promote psychological wellbeing and mental health awareness. This active participation of children and young people in ABR research must be harnessed (Bishop and Picard, 2007; Coad, 2007) by mental health services to enhance professional understanding of the uniqueness of children and young people’s experiences and meanings attached to their lives as they grow and develop.

Limitations

This study only collected data using ABR from one large educational authority and therefore caution should be exercised in generalising the findings to all young people. Applying the principles of ABR data collection with a larger population sample might increase the cost and time for such data collection, but could yield useful comparative data, particularly in comparing urban and rural educational institutions. Some young people might have more worries about participating in the ABR study if they were less confident for fear of being unable to accomplish the artistic/creative task. Moreover, the employment of ABR can present data analysis problems if researchers move beyond the poster analysis worksheet and attempt to enter the world of analytical art therapy, which is not what ABR is about. A further limitation of this research study is evident in collecting and analysing narrative responses to three open-ended questions from the posters. Much richer qualitative enquiry using focus groups may have enabled young people to describe their artworks or provide more details to facilitate more critical and analytical interpretation.

Conclusions

This research paper demonstrates an approach using ABR as a method of data generation with children and young people, and illustrates the intrinsic value of such an innovative approach to understanding these groups as they interact with health and social services provision. It provides meaningful and invaluable insight into catalysts for keeping children’s minds strong. It also enables young people to discuss and explore complex and interconnected issues relating to their perceptions of factors that promote positive mental health. Conversely, it enables discussion on those factors that may result in health deterioration, particularly stigma in mental health.

ABR as an approach to educational research presents many challenges, but similarly it creates essential and important professional understandings in core areas of mental health care for nurses working with children and young people. Mental health nurses must be proactive and strategic in the delivery of responsive and compassionate services to children and young people that takes due cognisance of their lived experiences and their interpretations throughout their life continuum to becoming adults. Relying solely on the client to use traditional methods for communicating within health and social care may not provide the holism that is aspired to; rather it may be minimalistic in its approach to young people who may wish to choose art as a means of verbalising.

The topic of children’s mental health is of current international concern and this paper adds to the existing body of knowledge about resilience and coping for children and young people. It is crucial that ABR exploration studies like this promote and demonstrate the efficacy of using ABR in promoting positive mental health and wellbeing of children and young people. Moreover, active participation of children and young people in research is critical to ensure that such service provision addresses the unique needs for those who need to access it. The authors suggest that ABR techniques not only facilitate such active participation, but enhance the understanding for nurses working in these areas, which in turn helps to promote more effective caring and compassionate strategies to promote positive mental health in young people.

Key points for policy, practice and/or research

The understanding of mental health issues affecting children and young people nationally and internationally presents challenges for the provision of effective and responsive mental health nursing. This paper presents an understanding of using art as a means of gathering data with primary and secondary school children from a large educational authority in the UK.

Little is understood about how children view the world around them in terms of positive mental health functioning, or how they express themselves using art as a medium. Ensuring an understanding of this myriad of issues facing children can be an enabling influence to develop mental health practice and education standards for all practitioners working within health and social care.

It illustrates how the use of ABR is an enabling influence for children to explore issues relating to positive mental health functioning and factors related to ‘keeping their minds strong’. This empowers them to develop further their coping strategies and mental health resilience.

Early identification of potential mental health problems and positive intervention strategies are paramount to ensuring children’s emotional health and wellbeing as they continue to grow and develop. This paper adds to the existing body of knowledge in child and adolescent mental health.

Footnotes

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Marie Therese O’Neill is a lecturer in nursing at Ulster University. She commenced her nursing career as a registered general nurse before undertaking her registered mental health nurse training. She has worked in a managerial capacity in a number of hospital and community nursing positions in adult, mental health and learning disability services in England, Ireland and Northern Ireland before entering nurse education in 2003. She is a graduate of the Ulster University and successfully completed her specialist nurse practitioner course in psychosocial interventions in 2005 and MSc in advanced nursing in 2006. As a prelude to undertaking her PhD in 2014, Marie undertook a mental health fellowship from 2012 to 2013 exploring the prevalence of mental health disorders in care homes. She has particular research interests in the health needs of older people, individuals with severe and enduring mental illness and in enabling children to discuss perceptions of positive mental health through the arts.

Kevin David Moore is the academic lead for continuing professional development at Ulster University, School of Nursing. Kevin completed his primary degree in 1991 and took a post as senior charge nurse for community psychiatric nursing in the UK. He returned to the University of Ulster in 1995 and completed his advanced diploma in education and took up a post as a nurse tutor. He has worked at Queen’s University Belfast for 6 years in post-registration nurse education and began as a lecturer in nursing at the University of Ulster in 2001. He completed his MSc in 2005. He completed his PhD in 2013. His current research interests are in the area of older people and mental health. He is currently a post-doctoral fellow at Ulster University and Nursing Homes Ireland investigating the ‘lived experiences of nursing home residents in the context of the nursing home as their own home’. He has published in academic circles and has a book chapter with Cambridge Scholars published earlier this year.

References

Adi Y, Killoran A, Janmohamed K (2007) Systematic review of the effectiveness of interventions to promote mental wellbeing in children in primary education. Report 1: universal approaches (non-violence related outcomes). London: National Institute for Health and Clinical Excellence.

Barone

Eisner

(2012) Arts Based Research, London and LA: SAGE.

Bishop

Picard

(2007) Review: Using art-based techniques in engaging children and young people in health care consultations and/or research. Journal of Research in Nursing 12: 499.

Bowen

(2009) Document analysis as a qualitative research method. Qualitative Research Journal 9(2): 27–40.

Bradshaw CP, Rebok G, Zablotsky B, et al. (2012) Models of stress and adapting to risk. In: Eaton W (ed) Public Mental Health. New York: Oxford, pp. 269–302.

Bresler L (2011) Arts-based research and drama education. Key Concepts in Theatre/Drama Education 321–326.

Coad

(2007) Using art-based techniques in engaging children and young people in health care consultations and/or research. Journal of Research in Nursing 12: 487–497.

Cohen

Manion

Morrison

(2011) Research Methods in Education, 7th ed. London: Routledge Taylor and Francis Group.

Colman

Ploubidis

Wadsworth

(2007) A longitudinal typology of symptoms of depression and anxiety over the life course. Biological Psychiatry 62: 1265–1271.

10.

Cooper

Hooper

Thompson

(2005) Child and Adolescent Mental Health Theory and Practice, Oxford: Edward Arnold Ltd.

11.

Copeland

Wolke

Angold

(2013) Adult psychiatric outcomes of bullying and being bullied by peers in childhood and adolescence. JAMA Psychiatry 70(4): 419–426. doi: 10.1001/jamapsychiatry.2013.504.

12.

Department of Health (2009) New horizons: Towards a shared vision for mental health, Consultation. London: Department of Health.

13.

Department of Health and Social Services and Public Safety (2016) Research for Better Health and Social Care: A Strategy for Health and Social Care Research and Development in Northern Ireland (2016–2025). Available at: www.dhsspsni.gov.uk.

14.

Emerson

Hatton

(2007) The Mental Health of Children and Adolescents with Learning Disabilities in Britain, Lancaster: Institute for Health Research, Lancaster University.

15.

European Commission (2009) Arts and Cultural Education at School in Europe, Brussels: EACEA/Eurydice.

16.

Family Lives (2016) Bullying UK. Listening, supportive and non-judgmental. Available at: http://www.bullying.co.uk/cyberbullying/effects-of-cyberbullying/ (accessed January 2016).

17.

Fisher

de Mello

(2011) Using the World Health Organization's 4S-Framework to Strengthen National Strategies, Policies and Services to Address Mental Health Problems in Adolescents in Resource-Constrained Settings. International Journal of Mental Health Systems 5(1): 1.

18.

Gibb

(2010) Burden of psychiatric disorder in young adulthood and life outcomes at age 30. British Journal of Psychiatry 197: 122–127.

19.

Helliwell

Layard

Sachs

(2015) World Happiness Report 2015, New York: United Nations Sustainable Development Solutions Network.

20.

Hopperstad MH (2010) Studying meaning in children’s drawings. Journal of Early Childhood Literacy 10(4): 430–452. Available at: http://ecl.sagepub.com/content/10/4/430.full.pdf+html (accessed 24 February 2016).

21.

Hubley

Copeman

(2010) Practical Health Promotion, Cambridge: Polity Press.

22.

International Council for Nurses (2006) Code of Ethics For Nurses. Available at: http://www.icn.ch/about-icn/code-of-ethics-for-nurses/ (accessed December 2015).

23.

Kapphahn

Morreale

Rickert

(2006) Financing mental health services for adolescents: A background paper. Journal of Adolescent Health 39: 318–327.

24.

Killen

Coplan

(2011) Social Development in Childhood and Adolescence. A Contemporary Reader, Chichester: John Wiley & Sons Ltd.

25.

Largey

Kelly

Stevenson

(2009) A study of suicide rates in Northern Ireland 1984–2002. Ulster Medical Journal 78(1): 16–20.

26.

Layard

Hagell

(2015) Healthy young minds: Transforming the mental health of children. In: Helliwell

Layard

Sachs

(eds) World Happiness Report 2015, New York: United Nations Sustainable Development Solutions Network.

27.

Leavy

(2009) Method Meets Art: Arts-based Research Practice, New York: The Guilford Press.

28.

McMahon

Reulbach

Keeley

(2010) Bullying, victimisation, self-harm and associated factors in Irish adolescent boys. Social Science and Medicine 71(7): 1300–1307.

29.

McNiff S (2013) Art as Research: Opportunities and Challenges. UK: Intellect Books; Chicago: University of Chicago Press.

30.

Malchiodi

(2005) Expressive Therapies, New York: The Guilford Press.

31.

Merikangas

Burstein

(2010) Lifetime prevalence of mental disorders in US adolescents: Results from the National Comorbidity Study–Adolescent Supplement (NCS-A). Journal of the American Academy of Child and Adolescent Psychiatry 49(10): 980–989.

32.

Miles

Huberman

(1994) Qualitative Data Analysis: An Expanded Sourcebook, 2nd ed. Thousand Oaks, CA: SAGE.

33.

Moran

Coffey

Romaniuk

(2012) The natural history of self-harm from adolescence to young adulthood: A population based cohort study. Lancet 379(9812): 236–243.

34.

Morrison W and Kirby P (2010) Schools as a setting for promoting positive mental health: Better practices and perspectives. Joint Consortium for School Health.

35.

Murphy

Fonagy

(2012) Mental health problems in children and young people. In: Annual Report of the Chief Medical Officer, London: Department of Health.

36.

National Archives (2012) Education Staff, National Archives and Records Administration. Washington, DC 20408. Available at: http://www.archives.gov/education/lessons/worksheets/poster.html (accessed 15 December 2015).

37.

Newell

Burnard

(2006) Vital Notes for Nursing Research: Research for Evidence-based Practice, Oxford: Blackwell.

38.

Northern Ireland Statistical Research Agency (2011) Population Statistics. NISRA. Available at: http://www.nisra.gov.uk/demography/default.asp136.htm (accessed 4 August 2014).

39.

Parry-Langdon N, Clements A, Fletcher D and Goodman R (2008) Three years on: Survey of the emotional development and well-being of children and young people. Office for National Statistics.

40.

Pink

(2001) Doing Visual Ethnography, London: SAGE.

41.

Prosser

(1998) Image Based Research, London: Falmer Press.

42.

The Pursuit of Happiness: A New Ambition for our Mental Health (2014) A CENTREFORUM Commission. Available at: http://www.bing.com/search?q=Pursuit+of+Happiness%3A+A+New+Ambition+for+our+Mental+Health+(2014)&src=IE-SearchBox&FORM=IENTTR&conversationid=&pc=EUPP_ (accessed June 2016).

43.

Punch

(2006) Developing Effective Research Proposals, 2nd ed. London: SAGE.

44.

Rees

Goswami

Pople

(2013) The Good Childhood Report, London: The Children’s Society.

45.

Reisz E (2012) Using visual arts to promote awareness of mental health among middle school students. Community-Campus Partnerships for Health (CCPH) Conference, Houston, 21 April 2012.

46.

Silverman

(2001) Interpreting Qualitative Data: Methods for Analyzing Talk, Text and Interaction, 2nd ed. London: SAGE.

47.

Stewart-Brown

(2006) What is the evidence on school health promotion in improving health or preventing disease and, specifically what is the effectiveness of the health promoting schools approach, Copenhagen: WHO Regional Office for Europe’s Health Evidence Network (HEN).

48.

Stickley

Hui

(2012) [Arts In-Reach: Taking ‘bricks off shoulders’ in adult mental health inpatient care]. Journal of Psychiatric and Mental Health Nursing 19(5): 402–409.

49.

Hooper C, Thompson M, Laver-Bradbury C and Gale C (2012) Child and adolescent mental health: Theory and practice. (2nd Edition) CRC Press. Hodder Education An Hachette UK Company.

50.

Time to Change (2008) Stigma shout: Service user and carer experiences of stigma and discrimination, London: Time to Change.

51.

United Nations Children’s Fund (2012) Progress for Children: A Report Card on Adolescents (No. 10). UNICEF. Available at: http://www.unicef.org/publications/index_62280.html (accessed 24 February 2016).

52.

Wikström

(2005) Communication via expressive arts: The natural medium of self-expression for hospitalized children. Paediatric Nursing 31(6): 480–485.

53.

Young Minds (2014) What’s the Problem? Available at: http://www.youngminds.org.uk/about/whats_the_problem.