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A Proposal on Effect of Visual Therapy on Expressive Art Performance of Autistic Children


Conceptual review


Autism is a complex developmental disorder that causes impairments in social interaction and developmental language and communication skills combined with rigid, repetitive behaviors. An autistic child who is very sensitive may be greatly troubled sometimes even pained by lights, sounds, touches, smells, or sights that seem normal to others. Many people with autism are cognitively impaired to some degree. In contrast to more typical cognitive impairment, which is characterized by relatively even delays in all areas of development, people with autism show uneven skill development. Autism is four times more common in boys than in girls. Autism typically appears during the first three years of life. It knows no racial, ethnic, or social boundaries. Family income, lifestyle, or educational levels do not affect a child’s chance of being autistic (Aadil, 2014).

Symptoms of autistic disorder fall under three domains: social relatedness, communication, and behaviors and interests, with delays or abnormal functioning in at least one of these areas prior to age 3 years. To meet criteria for autistic disorder, an individual must demonstrate at least 6 of 12 symptoms, with at least 2 coming from the social domain and 1 each from the communication and restricted behaviors/interests categories (Ozonoff, et al., 2005).

Visual Arts

Visual art are forms of art that with the aim of presenting diverse concept and complex emotion as documented by the artist. This in turn is communicated to the audience through representation media. These are any works of art that appeals to our sense of vision which include drawing, painting, sculpture, textile design, graphics design, industrial design and ceramics.  (Quadri, 2012)

Wangboje (1990) defines Art as a process as well as a product. He explains that art as a process is a means through which we give sensual and concrete expression to our ideas and feelings about the world around us. According to him art as a product includes pictures, images, buildings, clothes, furniture, utensils, music, dance, drama, food, etc.

Hornby (2001) defines Art as the use of imagination to express ideas or feelings particularly in painting, Drawing or Sculpture. While Elsen (1981) sees art as a skillful and imaginative process of expression that historically has led to the creation of objects capable of producing an aesthetic response.

Read (1966) his impression of what art is and what art cannot stand for depends on whether or not it is expressive. The man who makes, becomes potentially or partially an artist, the moment the things he makes express feelings and invite responses. Read (1972) also explains that Benedetto Croce defines art as an “expression”.

 Conceptual meaning of visual art therapy

Visual Art Therapy is an effective, versatile treatment modality that addresses a list of complex issues such as Abuse, Adolescence, Bullying, Death & Bereavement, Disasters, Homelessness, Illness, Lifestyle Choices, Sexual Abuse, Terrorism, and Violent Crime Psychologically, art therapy is the use of artistic methods to treat psychological disorders and enhance mental health. Art therapy integrates psychotherapeutic techniques with the creative process to improve mental health and well-being. (Martin, 2009). It is also referred to as “a mental health profession that uses the creative process of art making to improve and enhance the physical, mental and emotional well-being of individuals of all ages. It is based on the belief that the creative process involved in artistic self-expression helps people to resolve conflicts and problems, develop interpersonal skills, manage behavior, reduce stress, increase self-esteem and, foster self-awareness, manage behaviour and addictions, develop social skills, improve reality orientation, reduce anxiety, and increase self-esteem and achieve insight.” Art therapy practice requires knowledge of visual art (drawing, painting, sculpture, and other art forms) and the creative process, as well as of human development, psychological, and counseling theories and techniques. A goal in art therapy is to improve or restore a client’s functioning and his or her sense of personal well-being. (Betts, 2005).

Today Visual art therapy is widely practiced in diverse settings including hospitals, psychiatric and rehabilitation facilities, wellness centers, forensic institutions, schools, crisis centers, private practice, and other clinical and community settings. During individual and/or group sessions art therapists elicit their clients’ inherent capacity for art making.

Theories on Autism

Refrigerator Parenting Hypothesis (RPH)

Kanner (1943) had originally suggested that autism was partly the result of cold ‘, unemotional parenting, specifically by the mother. However, the prevailing current view is that parent ‘s behavior doesn ‘t initiate or in any way provoke autism (Powell, 1999). Indeed, any difference in parents ‘behavior towards their autistic child is more likely to be caused by the autism than vice versa (Powell, 1999). Also, autism seems to strike indiscriminately. It is not respecter of social class or family environment: it can affect a child with extremely warm and loving parents (Mitchell, 1997).

Genetic Theories (GT)

Kanner suggested that autism has a genetic component. According to (Rutter, Andersen‐ Wood, Beckett, Bredenkamp, Castle, Groothues, Kreppner, Keaveney, Lord, & O’Connor, 1999) finding from several independent studies provided compelling evidence for a strong genetic component underlying autism (Richard 2010). If one member of a twin pair is autistic, the probability that the other will also be autistic depends to a significant degree on whether they share all their genes or only half their genes (the same as ordinary siblings). Rutter et al (1999) autism is the most strongly genetically influenced of all multi factorial child psychiatric disorder.

Theories of Mind (TOM) and Mind-Blindness

The most influential theory of autism in recent years maintains that what all autistic people have in common (the core deficit) is mind- blindness (Boron-Coher, 1993). A sever impairment in their understanding of mental states and in their appreciation of how mental states govern behavior. Autistic individuals fail to develop the ability to attribute mental states to other people and this has fundamental implications for communication, where making sense of others ‘intentions enables the listener to understand what ‘s being said (Baron-Cohen, 1993). The strongest evidence for autistic children ‘s lack of a theory of mind (ToM) and mind-blindness is their consistent failure on false belief tasks by comparison; Down syndrome normal children reliably pass them. Autism individuals may become distressed by changes in their immediate ritualized behaviors: they don‘t plan to anticipate the consequence of their actions. Executive function deficit is not a sufficient explanation of the specific nature of autism (Lewis, 2003).

Empathizing Systemizing (E-S) Theory

The theory was developed by, Baron and Cohen (1993). According to the E-S theory, Female brain is hard-wired for empathy (E-type), while male brains are hard-wired for constricting system (S-type). These differences are reflected in male /female difference from birth until the adult skills and occupations, according to which the autistic individuals have an extreme male brain.

Empirical Review

Historical Development of Autism

Autism was first described by Leo Kanner in 1943 based on the case histories and observation of children who showed a similar pattern of behaviors including language delay, social remoteness, excellent rote memory, obsessive to sameness, oversensitivity to stimuli and delayed echolalia. At that time, the term autism was used to describe early infantile autism or infantile autism. In 1944, Hans Asperger independently described a syndrome which is now known as Asperger Syndrome (AS). The descriptions of Kanner and Asperger shared a similarity in some autistic characteristics such as poor eye contact, stereotyped language and physical movements, resistance to change and narrowed special interests. The important value of the identification of AS was the recognition that autistic-like syndromes can arise in individuals of normal language and cognitive development but who have often shown subtler abnormalities in communication patterns. With the development of research and clinical practice, more behavioral symptoms were described and categorized as autistic characteristics (Hens and Van Goidsenhoven 2017).

Prevalence of ASD

Recent reviews estimate a global median prevalence of 62/10 000, that is one child in 160 has an autism spectrum disorder and subsequent disability. In Europe, the median rate is 61.9/10,000 (range 30.0–116.1/10,000) and in America, the median rate is 65.5/10 000 (range 34–90/10 000). Autism spectrum disorders account for 0.3% of all disability adjusted life years. Autism spectrum disorders impose a huge emotional and economic burden on families (WHO, 2013).

Although most studies on ASD prevalence reflect the estimates for developed countries, little is known about the ASD /PDD prevalence in low income countries. However, the estimates suggest that it is less that or as high as in developed countries (Nyoni and Serpell, 2014).

Although prevalence studies reflect the prevalence of developed countries and the global rate is adopted for developing countries, chronic problems related to reproductive health, prevalence of diseases like malaria, poverty and food security are assumed to contribute for increased prevalence of ASD and PDD in Nigeria and other low income countries (Elizabeth et al., 2003).

Studies conducted by different researchers at different region revealed that, the prevalence of all forms of autism combined is estimated to be 1 in 162 individuals (Elsabbagh et al., 2012). Taking the global median estimate, Autism Spectrum Disorder ASD=17/10000 and Pervasive Developmental Disorders (PDD) 62/10000. 5000 and 18500 children and parents/care givers are estimated to suffer from having children with ASD and PDD (Elsabbagh et al., 2012).

If one in every 115 children is diagnosed with autism in the United States, we should fairly be able to say that with Nigeria‘s population of more than 80 million, we can estimate that there are at least 530,000 children suffering from autism and related developmental disorders in the country (Nyoni and Serpell, 2014).

Despite the above estimated number of children suffering from ASD and other PDD syndromes, the prevailing lack of prevalence study and diagnostic capacity/setup implies the pervasive lack of attention and awareness. There is lack of awareness among the community and parents about ASD. Usually when parents found out that their child has some kind of mental development problem, even without being diagnosed, they consider him/her as useless. Children with ASD are often denied any rights whatsoever, even the right to see daylight, enjoy sunshine, or the right to in some way participate in society. Such disorders are sometimes even seen as “punishment for some spiritual wrongdoing or a tragic incidence‖ (Autism in Nigeria, 2014).

Autism in Africa

Little is known about autism in Africa: the vast majority of autism research studies to date have been conducted in Western, high-income countries (Durkin et al. 2015), resulting in a research gap concerning studies from low-income countries like Nigeria. Due to a lack of epidemiological studies the prevalence of autism in Africa is unknown (Elsabbagh et al. 2012). The few autism studies conducted in Africa indicate a lack of knowledge and awareness about autism, inadequate mental healthcare facilities and a severe shortage of trained personnel (Bakare&Munir, 2011). No African country has published policies or good practice guidelines for autism assessment, treatment, education and support (De Vries, 2016). A recent report of an autism meeting attended by 47 delegates from 14 African countries highlighted the lack of available autism services throughout Africa and the need to raise awareness and develop autism screening, training and service strategies on the continent (Ruparelia et al. 2016).

Similar to other African countries, Nigeria has limited autism service provision. The detection of, and care for, children with autism in Nigeria is further impeded by stigma surrounding mental health (Shibre et al. 2006) and misconceptions about the causes of developmental disability and mental illness (Alem et al. 1999; Abera et al. 2015). We recently examined the experienced stigma, explanatory models and unmet needs of 102 help-seeking caregivers of children with autism and/or intellectual disability (ID) in Nigeria (Tilahun et al. 2016). Caregivers provided a mixture of biomedical (e.g. head injury or birth complications) and supernatural (e.g. spirit possession or sinful act) explanations for their child‘s condition.

Caregivers also reported high levels of stigma, with higher stigma associated with seeking help from traditional institutions, providing supernatural explanations and affiliation to Orthodox Christian faith. The majority (75%) of caregivers reported unmet needs regarding their child‘s educational provision and many (47%) also indicated an unmet need for support from health professionals. These findings illustrate the great challenges experienced by families with children with developmental disorders in Nigeria (De Vries, 2016).


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