A Strength-Based Arts and Play Support Program for Young Survivors in Post-Quake China: Effects on Self-Efficacy,Peer Support,and Anxiety

Abstract

A year after the earthquake in Sichuan, China, a strength-based arts and play support program was launched to promote the well-being of young survivors, and this study was designed to examine its effectiveness. It was hypothesized that participation in the program would have direct positive effects on general self-efficacy and peer support, and that these would mediate the effect of the program on anxiety. One hundred twelve Grade 4 students joined the study, the measures of which included the General Self-Efficacy Scale, the Classmate Support Scale, and the Generalized Anxiety subscale in the Spence Children’s Anxiety Scale. The results showed that participation in the program was associated with increased general self-efficacy and peer support, which lowered anxiety, although the relationship was not statistically significant. This study has provided insights for the development of a culturally sound arts and play program for young disaster victims in China.

Keywords

intervention/prevention school context at-risk/high-risk populations self-efficacy peer relationships mental health

Introduction

Nearly a quarter (23%) of the children who survived experienced high levels of anxiety following the 2008 Sichuan earthquake in China (K. Liu et al., 2010). The onset was found to be associated with the children’s exposure to death, bereavement, and intense fear as a result of the disaster (M. Liu et al., 2011). In addition, the experience of being relocated to temporary housing and the stress of having inadequate basic necessities also adversely affected the psychological health of these young survivors (Uscher-Pines, 2009). Understanding the anxiety felt by these young people is important, because the occurrence of high levels of anxiety at a young age is correlated with a high risk of anxiety disorders in adulthood (Pine, Cohen, Gurley, Brook, & Ma, 1998). In view of the developmental challenges faced by the children of Sichuan, a group of therapists specializing in dance, play, and creative art therapy launched a strength-based arts and play support program in post-quake Sichuan. This article discusses the theoretical foundation and empirical evidence on which this program was established and presents the findings on its effectiveness for earthquake survivors who were grade-school children in Sichuan.

Theoretical Foundation: Strength-Based Approach to Decrease Anxiety

The term strength-based approach refers to the use of interventions to increase the resilience of subjects to negative events, which may in turn prevent them from developing undesirable psychological outcomes (Chan, Chan, & Ng, 2006). The term promotion of resilience indicates the increase in positive psychological resources and capacities of a subject, which is expected to protect the individual against the negative effects of unfortunate events (Chan et al., 2006). For children who have undergone trauma, resilience also holds a similar connotation, emphasizing positive, adaptive transformation (Masten & Obradović, 2008). Resilience in children calls for flexibility and the ability to adapt to changes. The strength orientation of resilience for children goes beyond the resumption of functioning at their developmental level.

Because the Chinese traditional culture encourages individuals to “go with the flow” of nature, strategies that focus on helping people to accept reality and distracting them from negative feelings may be more culturally appropriate than interventions that advocate mental control and the alteration of emotions (Tang, 2007), such as cognitive behavioral therapies. In supporting children after Hurricane Katrina, trauma-focused cognitive behavioral therapy (TF-CBT) and the cognitive behavioral intervention for trauma in schools (CBITS) effectively lowered the symptoms of post-traumatic stress (Jaycox et al., 2010). Conversely, a strength-based approach tends to focus on the promotion of positive resources and does not require the subjects to directly address their negative feelings at the outset; such an approach should thus be more suitable for Sichuan quake survivors. Even when children are supported through the emotional aftermath of the earthquake, the psychological impact of trauma has epigenetic effects on the body, which could be manifested in children through poor immunity or compromised school functioning (Zomeran-Dohm et al., 2013). Often, such psychophysiological effects require more than directly talking about and processing the event, which could also be more difficult for young children given their limited vocabulary. Thus, non-verbal therapies that preclude the need to directly confront their traumatic experiences, such as dance movement-based approaches, may offer yet another medium for young survivors to process these experiences. In the light of these considerations, the current program adopted a strength-based approach to decrease the negative psychological outcomes of the young quake victims in Sichuan.

To implement strength-based interventions for children in Sichuan, understanding the key psychological factors that could prevent these young people from having high levels of anxiety was first necessary. Self-efficacy is one of the positive psychological components associated with low levels of anxiety in disaster management (Bandura, 1997, 2001; Benight & Bandura, 2004). This psychological quality enables individuals to have a better sense of their capacity to deal with undesirable events, which can be regarded as a protective factor against the development of anxiety (Benight, Swift, Sanger, Smith, & Zeppelin, 1999; Karademas, 2006). A high sense of self-efficacy has been found to be associated with lower levels of anxiety among youngsters (Cryder, Kilmer, Tedeschi, & Calhoun, 2006). Alternatively, having low self-efficacy increases vulnerability to intrusive thoughts stemming from traumatic experiences and may lead to elevated levels of anxious feelings (Benight & Bandura, 2004).

Although the relationship between self-efficacy and anxiety is less apparent immediately after the occurrence of disasters, the association appears to become stronger over time (Yang et al., 2010). Three years after the eruption of the volcano Mount St. Helens, self-efficacy accounted for a larger variance in the decrease in anxiety levels among victims than it did at the onset of the disaster (Murphy, 1987). Such findings suggest that a possible strategy to tackle post-disaster anxiety in young disaster survivors is to enhance their self-efficacy, which is considered to be one of the central tenets of the resilience of children through adversity (Masten & Obradović, 2008). Successfully overcoming adversity raises self-worth, confidence, motivation to overcome future difficulties, and feelings of pleasure in young people. Such feelings of agency and positive feelings may be associated with lower levels of anxiety in young earthquake survivors. Strength-based interventions, which can be used to enhance the self-efficacy of individuals, are regarded as a strategy for achieving this specific purpose.

Another possible means to help relieve anxiety among young disaster victims is to promote their positive peer relationships (Cohen & Wills, 1995). The stress buffering hypothesis suggested by Cohen and Wills (1995) denoted that emotional support can decrease the stress of individuals through companionship, sharing, caring, and trust. A study on adolescents affected by the September 11 attack in the United States showed that peer support helped relieve the symptoms associated with post-traumatic stress disorders (Dorinson, 2011). Peer support is thus believed to be another protective factor against the development of anxiety in young disaster victims.

Medium for Intervention: Arts and Play Activities

The use of arts and play activities to treat post-traumatic stress disorders in young people has been well documented (Goodman, Chapman, & Gantt, 2009), notably the studies by Malchiodi (2008, 2011) with traumatized children and those with experience of sexual abuse. Arts and play activities rely on non-verbal strategies to help individuals develop healthy attitudes (Lieberman, Berlin, Palen, & Ashley, 2012) and establish positive resources within themselves (Zeng & Bordeaux Silverstein, 2011). Interventions using arts and play activities, such as photography, map-making games, movies, and memorial marches, implemented after disasters can promote the positive psychological development of young disaster survivors (Zeng & Bordeaux Silverstein, 2011), which may in turn decrease their anxiety (Benight & Bandura, 2004; Cohen & Wills, 1995). Engagement in arts and play activities allows children to develop and test new coping behaviors in safe environments and recognize their personal strengths, such as self-efficacy (Bandura, 1997; Kim, Kirchhoff, & Whitsett, 2011; Orr, 2007). In addition, interventions using arts activities have been demonstrated to be effective in promoting the self-reliance and self-concept of young people, which are also psychological constructs related to self-efficacy (Eaton, Doherty, & Widrick, 2007).

Arts and play activities can also encourage interpersonal interactions and mutual support, which can foster social relationships in young people (Bratton, Ray, Rhine, & Jones, 2005; Wallace-DiGarbo, Lancaster, & Hill, 2006). Bratton et al. (2005) found that play therapy could enhance the social adjustment of children, and a study that used painting murals and writing journals as interventions demonstrated enhanced positive peer relationships among participating youth (Wallace-DiGarbo et al., 2006).

When professionals have deliberated on the medium for interventions for young Chinese earthquake survivors, the non-verbal nature of arts and play activities has shown a tendency to align with the cultural and developmental needs of the affected children (Ho, 2005; Tang, 2007). Chinese people are accustomed to expressing emotion through their bodies and, in some circumstances, suppressed emotions have been manifested as somatic symptoms (Ho, 2005). Moreover, individuals brought up within the Chinese culture may encounter difficulties in expressing their inner feelings verbally (Tang, 2007). Chinese people are taught to be reserved about their emotions and to maintain harmonious social relationships, based on the Confucian doctrines of discipline (Ho, 2005). In addition to cultural teachings, traditional sit-and-talk interventions require disaster survivors to coherently narrate their traumatic experiences and are perceived to be beyond the cognitive capacity of grade-school children (Piaget, 1977). Non-verbal strategies, such as arts and play activities, may thus be more appropriate for young Chinese earthquake survivors.

A Post-Disaster Arts and Play Support Program Using a Strength-Based Approach

A school-based arts and play intervention that entails the promotion of self-efficacy and peer support was launched in post-quake Sichuan with the aim of lowering the anxiety levels of affected students. After consideration of the existing literature on the implementation of arts and play interventions, this program was designed to be carried out in school settings, to be delivered by local school teachers, and to be conducted in a group format.

Masten and Obradović (2008) drew parallels with ecological resilience to illustrate that, rather than being individually focused, resilience emerges from interactions within a system, particularly at schools. School is one of the most appropriate milieus in which to deliver post-disaster support programs thanks to the availability of peers and teacher-support networks in such settings (Harper, Harper, & Stills, 2003; Margolin, Ramos, & Guran, 2010; Yu et al., 2010; Y. Zhang et al., 2010). School-based trauma interventions have been shown to be effective in lowering post-traumatic stress disorders, depression, and trauma-related symptoms while instilling hope and improving overall functioning among students (Bratton et al., 2005; Rolfsnes & Idsoe, 2011; Wolmer, Laor, Dedeoglu, Siev, & Yazgan, 2005). Meta-analyses by Bratton et al. (2005) and Rolfsnes and Idsoe (2011) found conclusive evidence that school-based play therapy can help improve the behavior, personality, and coping skills of children. Concomitantly, the peer support rendered as a result of school-based interventions has been found to help young victims to process their trauma, from which they can draw a positive meaning (Yu et al., 2010; Y. Zhang et al., 2010).

In addition, the familiarity between teachers and their students renders the former suitable candidates to deliver the interventions (Baggerly & Exum, 2008; Harper et al., 2003; Margolin et al., 2010). Teachers who experienced the trauma themselves and who are more familiar with the local culture and taboos are in a good position to understand the needs of their students. In addition, with suitable assistance and guidance, teachers who receive training may also benefit by learning new skills and perspectives during the process.

Because the consequences of a disaster are usually massive and community based, group-based interventions are more cost effective than individual interventions. First, the large number of children affected in a disaster such as that in Sichuan in 2008 may lengthen the waiting times for services considerably. Also, group-based work can also offer opportunities for students to establish mutual support, which may help them rebuild the sense of community that was lost in the post-disaster setting (Kim et al., 2011). Thus, arts and play activities delivered in group format were perceived as appropriate in post-quake Sichuan.

Aim of the Study

Although the existing literature suggests that strength-based arts and play interventions implemented in school settings and in group format can be effective, few studies have provided evidence that such programs are effective for Chinese youngsters. Furthermore, because traditional Westernized therapy may not be the most appropriate for Chinese quake survivors (Chan et al., 2006; Tang, 2007), the testing of alternative interventions was necessary; professionals would then know how to proceed if an area were hit by another disaster in the future. As such, the present study examined the effectiveness of a strength-based arts and play support program launched in post-quake Sichuan. It was hypothesized that participation in this program would lead to improvements in self-efficacy and peer support among the affected students, which would in turn lower anxiety levels (Figure 1).

Figure 1.

Sample size and attrition of the experimental and control groups of the intervention.

Method

Study Design

This project was designed as a quasi-experimental study in which data were collected in two waves. Baseline measures were taken during the beginning of the fall semester of 2009, and the program was delivered between September 2009 and January 2010. The same set of post-test measures was again taken at the beginning of the spring semester of 2010.

The selection of the schools was limited by the location, which should be within the area affected by the earthquake. Three elementary schools were invited to join the study because the principals agreed to support the intervention. The schools were similar in size and served similar populations. Two schools were assigned to be the experimental group and one was assigned to be the control. The assignment was compromised among school principals and teachers. All participants (n = 112) were in Grade 4 (girls, 61.8%), were deemed to be old enough to understand the ramifications of the earthquake, and had sufficient literacy to complete the questionnaires.

All three schools were supplied with a tool box of art materials and toys for their support programs. Teachers from the two experimental schools were asked to deliver arts and play support programs for their students, while no arts and play support program was conducted in the control school during the study. To compensate, the students from the control school received one session of art and play activities delivered by a creative arts therapist after the research was completed.

This research was approved by the Human Research Ethics Committee for Non-Clinical Faculties at the University of Hong Kong. Because the participants lived at school and only traveled back home during the holidays, the collection of signed consent forms from their parents was not feasible. Informed consents were thus obtained from the principals of the participating schools and all the students prior to the study. A notice was given to parents informing them of their rights to withdraw their children from participation in the study at any time.

Intervention

The arts and play support programs provided for this study were designed and delivered by teachers in the experimental schools to elicit three main outcomes: (a) enhancing self-efficacy, emotional expression, and self-understanding; (b) promoting interpersonal relationships, cooperation, and teamwork; and (c) positive thinking and problem solving. The programs were delivered once every 4 to 6 weeks throughout one semester, and each lasted for approximately 60 to 90 minutes. Each support program was carried out in group format with a group of approximately 30 students. The teachers were trained by a team of qualified creative arts and play therapists from the University of Hong Kong. Before delivering the programs at their school, teachers were required to join a 3-day intensive training workshop on the use of expressive arts and play activities in school settings. The details of the training program and its efficacy on teachers have been published by the team (Ho et al., 2012). The teachers also received continuous supervision and support from the team of therapists (Ho et al., 2012). Intervention proposals designed by the teachers in this study were reviewed prior to their administration, and teachers were provided with on-site supervision by therapists to provide support and to ensure the correct use of strategies. The presence of the supervising therapists also ensured that students who had special emotional needs during the intervention could be provided with immediate individual support. Although the intervention programs between the two schools differed in some of the activities that were selected by the teachers, the structure, framework, format, and purposes of each session in two programs remained the same. Teachers could choose from a range of expressive arts activities depending on the appropriateness to their school environment and children. For example, in one school, children were asked to think of an animal to represent themselves and present it in drawing or sound, while in another school, children were asked to think of an animal to represent themselves and present it through body movement or voice. Table 1 gives a summary of the support programs implemented in the experimental schools.

Table 1.

The Flow and Activities of the Intervention Implemented by Teachers.

	Purposes	Activities
Warm up	Warm up the students physically and psychologically through arts and play activities	Movement imitation games, dancing to traditional Sichuan folk songs, naming of animals that best represented themselves, and naming of objects that matched the season
Key activity	Promote self-efficacy, emotional expression, and self-understanding through art making	Painting, sock puppet making, movement games, and representational art
	Promoting mutual support, interpersonal relationships, cooperation, and teamwork skills	Movement imitation, games in pairs, and group movement improvisations
	Promoting positive thinking and problem solving	Encouraging children to think about hope, care, love, and positive things about the present situation
Discussion and wrap-up	Consolidating mutual support, discussion of what could be learnt from the activity in relation to the earthquake and the future, relaxation, and farewell	Appreciation and sharing of arts work, discussing implications and learning from the key activity, singing, breathing, dancing for relaxation, and saying goodbye

Measurements

Self-report questionnaires to assessing their levels of general self-efficacy, peer support, and generalized anxiety were administered to the students in the classroom by two research assistants. Their gender and grade levels were collected at the baseline measurement. Standardized measures in simplified Chinese to assess the changes in the students’ levels of general self-efficacy, peer support, and generalized anxiety were taken at both the baseline and post-test. All scales were written in simplified Chinese as this is the official written language in Mainland China. A research assistant was present during data collection, although the majority of students had little trouble completing the assessments on their own.

The Chinese-validated version of the General Self-Efficacy Scale (Zhang & Schwarzer 1995), which is a 10-item Likert-type scale pertaining to the students’ self-beliefs regarding their ability to cope with difficulties (1 = not at all true, 2 = hardly true, 3 = moderately true, 4 = exactly true), was used. A total score was obtained by summing the scores of the 10 items, and higher scores indicated higher levels of general self-efficacy. The internal consistency of the scale was satisfactory in this study (pre-test Cronbach’s α = .73, post-test Cronbach’s α = .70). The range of the pre-test of this scale was between 16 and 40, and the post-test range fell between 15 and 41. The translated simplified Chinese version of the Classmate Support Scale (Torsheim, Wold, & Samdal, 2000) was used to assess the children’s perception of their levels of peer support. The scale was first translated into Chinese by a bilingual research assistant experienced in the use of psychological measures and then back-translated into English by a second translator with similar qualifications. The original and the back-translated English versions were then compared to check for consistency. The scale has four items, with a 5-point Likert-type scale ranging from strongly agree to strongly disagree (5 = strongly agree, 1 = strongly disagree). A total score was generated by summing the responses, and a higher score indicated a higher level of perceived peer support. The internal consistency of the scale was acceptable in this study (pre-test Cronbach’s α = .67, post-test Cronbach’s α = .79). Pre-test range fell between 7 and 20, while post-test range fell between 4 and 20.

The Chinese-validated version of the Generalized Anxiety subscale in the Spence Children’s Anxiety Scale (Spence, Barrett, & Turner, 2003), which contains six items with a Likert-type scale ranging from 1 to 4 (1 = never, 2 = sometimes, 3 = often, 4 = always), was used. The total score was obtained by adding the score of the six items, and a higher score was associated with a higher level of generalized anxiety. The scale had acceptable internal consistency with the current sample size (pre-test Cronbach’s α = .72; post-test Cronbach’s α = .66). Both pre-test and post-test ranges fell between 6 and 21. Boys who scored below 8 in this subscale were considered falling into the normal ranges, while girls who scored below 9 were regarded as normal (Spence, 2015).

Statistical Analysis

Path analysis was used to estimate the hypothesized model to examine the direct and indirect effects of arts and play support programs on general self-efficacy, peer support, and anxiety using Mplus 6.0. A path model was established to test for the direct effect of participation in the program on general self-efficacy and peer support, controlling for pre-measurement effects (i.e., pre-test general self-efficacy and pre-test peer support) and demographics. The indirect effect of participation in the program on anxiety, mediated by general self-efficacy and peer support, was also examined. Bootstrapping analysis was used to obtain the bootstrap standard errors for the parameters and indirect effects. In this analysis, the bootstrap standard errors were computed using 1,000 draws (Muthen & Muthen, 2010). Regarding power analysis in the assessment of fit of the path model (MacCallum, Browne, & Sugawara, 1996), we set the alpha level = .05, degrees of freedom = 18, sample size = 112, null hypothesized root mean square error of approximation (RMSEA) = 0.00, alternative hypothesized RMSEA = 0.08. This resulted in a statistical power of 54.6% for the current analysis.

The full information maximum likelihood (FIML) method that is the default in Mplus was used to handle missing data. This method, which is conceptually similar to imputation, estimates parameters based on the available data and the implied values of the missing data given the observed data (Schlomer, Bauman, & Card, 2010). FIML estimation was preferred over the traditional imputation method because it produces accurate standard errors by maintaining the sample size (Schlomer et al., 2010).

Results

Table 2 summarizes the means and standard deviations of the pre-test and post-test measures. Approximately, 25% of the students dropped out of the study and did not complete the post-test measurements (Figure 1).

Table 2.

Descriptive Statistics of All Variables.

Variables	Experimental group (n = 60)	Control group (n = 52)
Grade	4	4
Gender
Male	21	21
Female	38	30
Missing	1	1
	$\bar{X}$ SD	$\bar{X}$ (SD)
Pre-test measurements
Pre-test general self-efficacy	27.75 (4.74)	28.54 (5.32)
Pre-test peer support	15.15 (2.82)	14.03 (3.30)
Pre-test generalized anxiety	10.20 (2.71)	12.48 (3.80)
Post-test measurements
Post-test general self-efficacy	29.85 (5.56)	25.75 (5.12)
Post-test peer support	16.00 (3.22)	13.19 (3.18)
Post-test generalized anxiety	9.27 (2.46)	11.04 (3.34)

Attrition Analysis

There were 16 missing patterns in the data. Considering the 25% attrition rate, regression analysis was conducted to explore whether or not attrition was associated with the levels of self-efficacy, peer support, anxiety, and gender of the participants at baseline. The results suggested that attrition from the program was not related to personal factors, such as baseline general self-efficacy (b = .01, z = 0.15, p > .05), generalized anxiety (b = .12, z = 1.18, p > .5), peer support (b = .21, z = 0.84, p > .05), or gender (b = −.33, z = −0.52, p > .05). In addition, teachers from the experimental schools explained that dropouts were related to school arrangements (e.g., class schedules or examinations) rather than individual preferences. Further analyses were thus conducted under the assumption that attrition was not associated with baseline differences among participants.

Path Analysis

The results of the path analysis showed satisfactory model statistics (χ² = 4.02, df = 6, p = .67, CFI/TFI = 1.00, RMSEA = 0.00, and SRMR = 0.035) and are shown in Figure 2 and Table 3. Program participation had a direct positive effect on post-test general self-efficacy, after controlling for pre-test general self-efficacy and gender, and was also positively correlated with post-test peer support, after controlling for pre-test peer support and gender. Students in the experimental group scored an average of 4.15 points higher on post-test general self-efficacy and 2.03 higher on post-test peer support than children in the control group. Post-test general self-efficacy was also positively correlated with post-test peer support but tended to be negatively related to post-test generalized anxiety, although the result was not statistically significant. Similarly, post-test peer support did not affect post-test anxiety. Thus, the indirect effects of program participation on generalized anxiety through general self-efficacy and peer support were not statistically significant. Values of the residual variances and r²s suggested that approximately 24% of the variances in general self-efficacy was explained by the model; 42% and 23% of the variances in peer support and generalized anxiety were similarly explained, respectively.

Figure 2.

The effect of program participation on GSE, PS, and anxiety (GA): standardized output of analysis.

Table 3.

Path Analysis on the Effectiveness of Program Participation on GSE, PS, and GA.

	Unstandardized parameters	SE (unstandardized)	Standardized parameters
Direct effects of program participation
Program participation →Post-test GSE	4.15	1.23	0.36*
Program participation → Post-test PS	2.03	0.67	0.28*
Program participation → Post-test GA	−0.99	0.73	−0.17
Direct effects of post-test GSE and post-test PS
Post-test GSE → Post-test GA	−0.05	0.08	−0.10
Post-test PS → Post-test GA	−0.15	0.11	−0.17
Covariance between post-test GSE and post-test PS
Post-test GSE ↔ Post-test PS	6.63	1.84	0.49*
Direct effects of gender
Gender → Post-test GSE	−0.04	1.25	−0.00
Gender → Post-test PS	1.08	0.67	0.15
Gender → Post-test GA	−0.32	0.64	−0.05
Direct effects of pre-test measures
Pre-test GSE → Post-test GSE	0.36	0.11	0.31*
Pre-test PS → Post-test PS	0.59	0.10	0.51*
Pre-test GA → Post-test GA	0.19	0.10	0.23
IND effects
Post-test GA IND Post-test GSE	−0.21	0.32	−0.04
Post-test GA IND Post-test PS	−0.29	0.25	−0.05
	Residual variances (standardized)		R² (standardized)
Post-test GSE	0.76*		.24*
Post-test PS	0.58*		.42*
Post-test GA	0.77*		.23*

Note. GSE = general self-efficacy; PS = peer support; GA = general anxiety; IND = indirect.

p < .01.

Discussion

This study examined the effectiveness of a strength-based arts and play support program on improving self-efficacy and peer support and on lowering anxiety in students affected by an earthquake. The results showed that participation in the program was associated with increased general self-efficacy and peer support after controlling for the baseline levels of both parameters. Although the results indicated that participation in the program tended to produce lower anxiety, this relationship was not statistically significant. One possible explanation is that time is needed for self-efficacy and peer support to have an effect on anxiety (Murphy, 1987). Because all the post-test measurements were carried out at the same time, such a temporal factor may be the cause of the absence of relationships between general self-efficacy, peer support, and general anxiety. Students may also need further support to practice with the strategies or use their newly found resources in their own personal anxiety-provoking contexts. Nevertheless, the score of the generalized anxiety did drop from the elated range to normal for the experimental group before and after the intervention, while the score of the control group remained in the elated range, suggesting that the change in the experimental group could be clinically meaningful.

The findings supported previous reviews on the positive effects of arts and play on young people. As one of the first intervention studies to use arts and play activities to help children affected by natural disasters in Mainland China, the results will be useful for directing future applications of such a program in post-disaster settings in China.

One merit of this study is the solid theoretical foundations and empirical evidence upon which the conceptual model was established. Thus, the findings provide a theoretical framework that can guide future interventions that use a similar program design. Moreover, the program was delivered by teachers with whom the students were familiar and who were aware of the trauma-related information of the recipients. The results from this study further also lend support for the training of local individuals to enable them to offer psychosocial support to their counterparts in post-disaster areas.

A related study conducted on 330 students who were approximately the same age as the current sample (Grades 3-5) about a year after the earthquake (M. Liu et al., 2011) revealed that some 10% to 30% of students suffering from anxiety, depression, or post-traumatic stress disorders had experienced one or more of the following: being trapped, injured, or bereaved, witnessing death, or having extreme fear. Although the collection of information on trauma in children was not permitted, the traumatic experiences and repercussions experienced by the current sample cannot be undermined. Interventions that could help children to improve their resources to cope with adversity and trauma should strongly be encouraged. Self-efficacy and peer support, which could be enhanced by the arts and play support program, should be considered as the important inner and external resources for children to cope with the challenges.

Nevertheless, this study had a few limitations. First, the convenience sampling of participating schools in this study might decrease the generalizability of the findings, although this is inevitable given the practical limitations of safety and resources. Similarly, the examination of outcomes at the individual level while assignment to conditions occurred at the school level is also a limitation. Future studies with random sampling may increase the validity of the research. For path analysis, a sample size of smaller than 100 is considered small, which may pose threat to Type II error. A larger sample would also have increased the power of the study. Second, the quasi-experimental design may limit our ability to draw causal conclusion between program participation and the improved general self-efficacy and perceived peer support of the young people. Third, the study was carried out in naturalistic settings where the control of extraneous effects, such as exposure to trauma and family demographics, was limited. Personal and trauma-related information could not be obtained because both the local government and the school preferred not to include questions that would intrude on the privacy of the students or remind them of the earthquake. The possible differences in students in exposure to trauma and family background might produce diverse outcomes, which might affect the real efficacy of the program. Fourth, although most of the measurements used in this study showed acceptable internal consistency, the Cronbach’s values of the pre-test of Classmate Support Scale and the post-test of Generalized Anxiety subscale were relatively low. Further examination of the psychometric properties and factor structures of these measurements is thus warranted. One final limitation was that the time frame of this research was relatively short, which may have affected our understanding of the findings. Longer follow-up periods should be included in future studies.

Implications

The current findings provided empirical evidence on the efficacy of strength-based group expressive arts and play interventions in a post-disaster setting. In view of the non-intrusive elements that are intrinsic to arts and play activities, this study offered insights for the development of culturally sound arts and play programs for young disaster victims from countries that value the acceptance of fate and nature. Future research with a more rigorous design, such as randomization on a larger sample, longer follow-up, and the inclusion of additional demographic information, may also present additional evidence. Last, this study provided indications for the possibility of incorporating arts and play support programs as part of school activities to enhance the self-efficacy and peer support of children. Future research could focus on understanding the best implementation strategies for strength-based arts and play support programs in school settings.

Footnotes

Acknowledgements

The authors would like to extend their thanks to Professor Fumin Fan and her team from Tsinghua University as well as the Beichuan Psychological Service Stations for their help in this study. Gratitude should also go to all the traniners and helpers in this project, in particular, Dr. Jordan Potash and Ms. Debra Kalmanowitz for their great help in this project in different stages.

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) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The Training project mentioned in the article received funding support from the Robert H.N.Ho Family Foundation.

Author Biographies

Rainbow T. H. Ho is an associate professor at the Department of Social Work and Social Administration, The University of Hong Kong, as well as the director of the Centre on Behavioral Health, The University of Hong Kong. Her research interests focus on creative and expressive arts therapy. mind-body medicine, and psychophysiology in diverse populations.

Angel H. Y. Lai was the project coordinator at the Centre on Behavioral Health, The University of Hong Kong. She received her PhD from the George Warren Brown School of Social Work, Washington University in St Louis. She is currently a senior researcher at Our Hong Kong Foundation, overseeing healthcare policy and youth policy research in Hong Kong.

Phyllis H. Y. Lo was a counselor and senior research coordinator at the Centre on Behavioral Health, The University of Hong Kong. She is currently studying in the clincial psychology program.

Joshua K. M. Nan is an assistant professor at the Department of Social Work and Social Administration, The University of Hong Kong. His research interests focus on clay art therapy, expressive arts therapy, and psychosocial interventions for diverse populations with health and mental health related issues.

Alicia K. L. Pon is an honorary assistant professor and research fellow at the Department of Social Work and Social Administration, The University of Hong Kong. Her research for her dissertation was on play therapy with terminally ill adults and she works with children, adolescents, and family with diverse issues and needs.

References

Baggerly

Exum

H. A.

(2008). Counseling children after natural disasters: Guidance for family therapists. The American Journal of Family Therapy, 36, 79-93. doi:10.1080/01926180601057598

Bandura

(1997). Self-efficacy: The exercise of control. New York, NY: W.H. Freeman.

Bandura

(2001). Social cognitive theory: An agentic perspective. Annual Review of Psychology, 52, 1-26.

Benight

C. C.

Bandura

(2004). Social cognitive theory of posttraumatic recovery: The role of perceived self-efficacy. Behaviour Research and Therapy, 42, 1129-1148. doi:10.1016/j.brat.2003.08.008

Benight

C. C.

Swift

Sanger

Smith

Zeppelin

(1999). Coping self-efficacy as a mediator of distress following a natural disaster. Journal of Applied Social Psychology, 29, 2443-2464.

Bratton

S. C.

Ray

Rhine

Jones

(2005). The efficacy of play therapy with children: A meta-analytic review of treatment outcomes. Professional Psychology: Research and Practice, 36, 376-390. doi:10.1037/0735-7028.36.4.376

Chan

C. L. W.

Chan

T. H. Y.

S. M.

(2006). The strength-focused and meaning-oriented approach to resilience and transformation (SMART): A body-mind spirit approach to trauma management. Social Work in Health Care, 43(2-3), 9-36.

Cohen

Wills

T. A.

(1985). Stress, social support, and the buffering hypothesis. Psychological Bulletin, 98, 310-357. doi:10.1037/0033-2909.98.2.310

Cryder

C. H.

Kilmer

R. P.

Tedeschi

R. G.

Calhoun

L. G.

(2006). An exploratory study of posttraumatic growth in children following a natural disaster. American Journal of Orthopsychiatry, 76, 65-69. doi:10.1037/0002-9432.76.1.65

10.

Dorinson

P. M.

(2011). The role of social support on the mental health status of adolescents exposed to traumatic events on September 11 (Fordham University, New York). Available from ProQuest Dissertations & Theses A&I database. (PhD 3465663). Retrieved from http://search.proquest.com/docview/883391954?accountid=14548.

11.

Eaton

L. G.

Doherty

K. L.

Widrick

R. M.

(2007). A review of research and methods used to establish art therapy as an effective treatment method for traumatized children. The Arts in Psychotherapy, 34, 256-262. doi:10.1016/j.aip.2007.03.001

12.

Goodman

R. F.

Chapman

L. M.

Gantt

(2009). Creative arts therapies for children. In Foa

Keane

Friedman

Cohen

(Eds.), Effective treatment for PTSD: Practice guidelines from the International Society for Trauma Stress Studies (pp. 491-507). New York, NY: Guilford Press.

13.

Harper

F. D.

Harper

J. A.

Stills

A. B.

(2003). Counseling children in crisis based on Maslow’s hierarchy of basic needs. International Journal for the Advancement of Counseling, 25, 10-25.

14.

R. T. H.

(2005). Regaining balance within: Dance movement therapy with Chinese cancer patients in Hong Kong. American Journal of Dance Therapy, 27, 87-99.

15.

R. T. H.

Fan

Lai

A. H. Y.

P. H. Y.

Potash

J. S.

Kalamanowitz

D. L.

. . . Chan

C. L. W.

(2012). An expressive arts-based and strength-focused experiential training program for enhancing the efficacy of teachers affected by earthquake in China. Creative Education, 3, 67-74. doi:10.4236/ce.2012.31011

16.

Jaycox

L. H.

Cohen

J. A.

Mannarino

A. P.

Walker

D. W.

Langley

A. K.

Gegenheimer

K. L.

. . . Schonlau

(2010). Children’s mental health care following hurricane Katrina: A field trial of trauma-focused psychotherapies. Journal of Traumatic Stress, 23, 223-231. doi:10.1002/its.20518

17.

Karademas

E. C.

(2006). Self-efficacy, social support and well-being: The mediating role of optimism. Personality and Individual Differences, 40, 1281-1290. doi:10.1016/j.paid.2005.10.019

18.

Kim

J. B.

Kirchhoff

Whitsett

(2011). Expressive arts group therapy with middle-school aged children from military families. The Arts in Psychotherapy, 38, 356-362. doi:10.1016/j.aip.2011.08.003

19.

Lieberman

L. D.

Berlin

Palen

Ashley

O. S.

(2012). A theater-based approach to primary prevention of sexual behavior for early adolescents. The Journal of Early Adolescence, 32, 730-753. doi:10.1177/0272431611424726

20.

Liu

Liang

Guo

Xin

. . . Li

(2010). Acute stress disorder in the paediatric surgical children and adolescents injured during the Wenchuan earthquake in China. Stress & Health, 26, 262-268. doi:10.1002/smi.1288

21.

Liu

Wang

Shi

Zhang

Shen

(2011). Mental health problems among children one-year after Sichuan earthquake in China: A follow-up study. PLoS ONE, 6(2), e14706. doi:10.1371/journal.pone.0014706

22.

MacCallum

R. C.

Browne

M. W.

Sugawara

H. M.

(1996). Power analysis and determination of sample size for covariance structure modeling. Psychological Methods, 1, 130-149.

23.

Malchiodi

(2008). Creative interventions with traumatized children. New York, NY: Guilford Press.

24.

Malchiodi

(2011). Trauma informed art therapy with sexually abused children. In Goodyear-Brown

(Ed.), Handbook of child sexual abuse: Prevention, assessment, and treatment (pp.341-354). New York, NY: Wiley.

25.

Margolin

Ramos

M. C.

Guran

E. L.

(2010). Earthquakes and children: The role of psychologists with families and communities. Professional Psychology: Research and Practice, 41, 1-9. doi:10.1037/a0018103

26.

Masten

A. S.

Obradović

(2008). Disaster preparation and recovery: Lessons from research on resilience in human development. Ecology & Society, 13(1), 9.

27.

Murphy

S. A.

(1987). Self-efficacy and social support: Mediators of stress on mental health following a natural disaster. Western Journal of Nursing Research, 9, 58-86.

28.

Muthen

L. K.

Muthen

B. O.

(2010). Mplus users’ guide: Statistical analysis with latent variables. Retrieved from https://www.statmodel.com/download/usersguide/Mplus%20Users%20Guide%20v6.pdf

29.

Orr

P. P.

(2007). Art therapy with children after a disaster: A content analysis. The Arts in Psychotherapy, 34, 350-361. doi:10.1016/j.aip.2007.07.002

30.

Piaget

(1977). The development of thought: Equilibration of cognitive structures. New York: Viking Press.

31.

Pine

D. S.

Cohen

Gurley

Brook

(1998). The risk for early-adulthood anxiety and depressive disorders in adolescents with anxiety and depressive disorders. Archives of General Psychiatry, 55, 56-64. doi:10.1001/archpsyc.55.1.56

32.

Rolfsnes

E. S.

Idsoe

(2011). School-based intervention programs for PTSD symptoms: A review and meta-analysis. Journal of Traumatic Stress, 24, 155-165. doi:10.1002/jts.20622

33.

Schlomer

Bauman

Card

(2010). Best practices for missing data management in counseling psychology. Journal of Counseling Psychology, 57, 1-10.

34.

Spence

S. H.

(2015). Spence Children’s Anxiety Scale website. Retrieved from http://www.scaswebsite.com/index.php?p=1_9

35.

Spence

S. H.

Barrett

P. M.

Turner

C. M.

(2003). Psychometric properties of the Spence Children’s Anxiety Scale with young adolescents. Journal of Anxiety Disorders, 17, 605-625. doi:10.1016/S0887-6185(02)00236-0

36.

Tang

C. S.

(2007). Assessment of PTSD and psychiatric comorbidity in contemporary Chinese societies. In Tang

C. S.

(Ed.), Cross-cultural assessment of psychological trauma and PTSD (pp. 135-168). New York, NY: Springer Science + Business Media. doi:10.1007/978-0-387-70990-1_7

37.

Torsheim

Wold

Samdal

(2000). The Teacher and Classmate Support Scale: Factor structure, test-retest reliability and validity in samples of 13- and 15-year-old adolescents. School Psychology International, 21, 195-212.

38.

Uscher-Pines

(2009). Health effects of relocation following disaster: A systematic review of the literature. Disasters, 33, 1-22. doi:10.1111/j.1467-7717.2008.01059.x

39.

Wallace-DiGarbo

Lancaster

P. A.

Hill

D. C.

(2006). Art as agency: Exploring empowerment of at-risk youth. Art Therapy: Journal of the American Art Therapy Association, 23, 119-125.

40.

Wolmer

Laor

Dedeoglu

Siev

Yazgan

(2005). Teacher-mediated intervention after disaster: A controlled three-year follow-up of children’s functioning. Journal of Child Psychology and Psychiatry, 46, 1161-1168.

41.

Yang

Liu

Tian

Zhu

Miao

(2010). Self-efficacy, social support, and coping strategies of adolescent earthquake survivors in China. Social Behavior and Personality, 38, 1219-1228. doi:10.2224/sbp.2010.38.9.1219

42.

X.-N.

Lau

J. T. F.

Zhang

Mak

W. W. S.

Choi

K. C.

Lui

W. W. S.

. . . Chan

E. Y. Y.

(2010). Posttraumatic growth and reduced suicidal ideation among adolescents at month 1 after the Sichuan earthquake. Journal of Affective Disorders, 123, 327-331. doi:10.1016/j.jad.2009.09.019

43.

Zeng

E. J.

Bordeaux Silverstein

(2011). China earthquake relief: Participatory action work with children. School Psychology International, 32, 498-511. doi:10.1177/0143034311402921

44.

Zhang

J. X.

Schwarzer

(1995). Measuring optimistic self-beliefs: A Chinese adaptation of the General Self-Efficacy Scale. Psychologia, 38, 174-181.

45.

Zhang

Konga

Wang

Chena

Gaoa

Tan

. . . Liu

(2010). Mental health and coping styles of children and adolescent survivors one year after the 2008 Chinese earthquake. Children and Youth Services Review, 32, 1403-1409. doi:10.1016/j.childyouth.2010.06.009

46.

Zomeran-Dohm

Howard

Kenney

Ritchmeier

Gourneau

(2013). How trauma gets under the skin: Biological and cognitive processes of child maltreatment (Children’s Mental Health eReview). Retrieved from http://www.extension.umn.edu/family/cyfc