The Effectiveness of Art Therapy Based on the Coping Cat Program on Sleep Disorders in Syrian Children with Secondary Traumatic Stress

Abstract

The prolonged exposure to the Syrian war has profoundly affected the mental health of children, leading to disruptions in cognitive development and long-term well-being. This study examined the efficacy of an expressive art therapy intervention based on the Coping Cat Program in alleviating sleep disorders among Syrian war-affected children with secondary traumatic stress (STS). Twenty children residing in war-exposed areas and scoring high on the Secondary Traumatic Stress Scale were included; 10 children were randomly assigned to the expressive art therapy intervention. The Pittsburgh Sleep Quality Index and semi-structured interviews were conducted at three time points: pre-treatment, post-treatment (8 weeks), and follow-up (12 weeks). Repeated measures analyses of variance demonstrated significant improvements in sleep disorder symptoms for the experimental group compared to the control group at post-treatment, with sustained effects observed at the 3-month follow-up. These findings demonstrate the potential of expressive art therapy as an intervention for addressing sleep disorders in war-affected children.

Introduction

For over a decade, Syrian children have faced immense hardship due to bombings, starvation, and the loss of loved ones. The destruction of their homes and the absence of functioning schools and hospitals have further exacerbated their suffering. Unfortunately, there is a severe shortage of mental health and psychosocial support in Syria, leaving parents and caregivers struggling to cope. As a result, the majority of children in Syria exhibit signs of severe emotional distress, as highlighted in a study by Hijazi and Weissbecker (2015). Moreover, 71% of Syrian children experience bedwetting and involuntary urination (Save the Children, 2017). In addition, approximately one-third of Syrian children display indicators of mental health issues, including anxiety, sadness, fatigue, and sleep disorders, as reported by UNICEF (2022).

Secondary traumatic stress (STS) occurs when an individual experiences the effects of a traumatic incident indirectly. For instance, children may be more affected by their parents' emotional states and behaviors than by the dangers present. When a parent with post-traumatic stress disorder (PTSD) exhibits violent or aggressive behavior, emotional withdrawal, or avoidance, it can affect the development of their children (Dekel & Goldblatt, 2008). Indicators of STS encompass fatigue or illness, cynicism, irritability, decreased productivity, feelings of hopelessness, anger, despair, sadness, re-experiencing of the event, nightmares, anxiety, avoidance of people or activities, persistent anger, and lingering sadness (Siegfried, 2008).

Research suggests a strong link between trauma and sleep disturbances, with various types of sleep difficulties observed in children exposed to trauma (Keeshin et al., 2019). Specifically, children who have experienced trauma may display sleep-related problems such as distressing or anxiety-provoking dreams, re-living the traumatic event during sleep, fear of darkness, resistance to sleep, or reluctance to sleep alone (APA, 2013). Inadequate sleep quality can have adverse effects on physical health, leading to a higher likelihood of obesity, diabetes, and cardiovascular disease. Furthermore, disrupted sleep can negatively influence cognitive development, academic achievement, and social-emotional well-being (Keeshin et al., 2019). Additionally, it is worth noting that there is a suggested reciprocal connection between sleep difficulties and anxiety, where disrupted sleep can increase a child's susceptibility to developing anxiety, while anxiety, in turn, disrupts sleep (Weiner et al., 2015).

Cognitive-behavioral therapy (CBT) has demonstrated positive outcomes in treating various mental health conditions, including anxiety disorders, depression, and post-traumatic stress disorder (PTSD) (Bentham & Eaves, 2022; Deblinger et al., 2020; Sammehr et al., 2022). It has also been found effective in addressing secondary traumatic stress (STS). CBT's cognitive approach involves identifying and modifying negative thoughts and beliefs related to sleep, which can contribute to insomnia and sleep disturbances (Bentham & Eaves, 2022). In the short term, CBTs are at least as effective as medication in treating sleep disorders, and their benefits tend to be more enduring (Schoenfeld et al., 2012). One of the therapeutic interventions that is based on CBT is the Coping Cat Program (Kendall & Hedtke, 2006). This program integrates cognitive restructuring to promote an understanding of alternative strategies for managing anxiety (Hudson & Kendall, 2002). Additionally, it should be noted that engaging in art activities can have cognitive benefits for children. Children are able to solve problems, think critically, and have spatial awareness through the creation of art (Zabelina et al., 2020). Art can also help children develop their working memory, attention, and focus (Kountouras & Zannos, 2018).

The first author of this study is a Syrian artist who developed an expressive art therapy intervention using a qualitative and quantitative approach. This was done through drawing analysis, practical observations, and interviews with Syrian children over an extended period of work in Syria as an art teacher for children. Moreover, he participated in various activities aimed at providing psychological support to children displaced from cities directly affected by armed conflict. After participating in a doctoral program in art research at the Art University of Isfahan, he developed an intervention program for war-affected children by integrating expressive art therapy activities with the Coping Cat program (Kalthom et al., 2023).

Several academic studies have investigated the effects of cognitive-behavioral therapy (CBT) on addressing sleep disturbances associated with post-traumatic stress disorder (PTSD). Notable studies by Galovski et al. (2009), Germain et al. (2007), and Kanady et al. (2018) have contributed to this area of research. Additionally, research by Liu (2017) and Coffee (2016) suggests that combining art therapy with CBT enhances the well-being of children experiencing sleep disturbances and reduces insomnia symptoms. However, to the best of the researchers' knowledge, there is a gap in the literature regarding the integration of expressive art therapy with CBT, especially for children affected by war. Furthermore, this is the first time expressive art therapy has been integrated with the Coping Cat program. Therefore, the objective of this study is to evaluate the impact of this therapeutic intervention on sleep disorders among internally displaced Syrian children who have exhibited symptoms of secondary traumatic stress (STS). By investigating this novel intervention, the study aims to contribute to the existing knowledge on effective therapeutic interventions for sleep disorders in war-affected children.

Method

This was a controlled trial in which participants were randomized into either a control group, which received no therapy, or an experimental group, which received an expressive art therapy intervention.

Participants and Measures

The study involved Syrian children aged 10–12 who had lived in cities directly impacted by war, such as the Damascus countryside and Aleppo, before relocating to the city of Salamiyah. The assessment tool used was the Secondary Traumatic Stress Scale, developed by Bride et al. (2004), and assessments were conducted et al.-Fatimiyya School and Qutaiba School, institutions specifically designated for children displaced from other cities.

The sample consisted of 84 girls (54%) and 69 boys (46%), totaling 153 children. Among these participants, 44 children (27.7%) exhibited symptoms indicative of secondary traumatic stress. From this group, a subset of 20 children was randomly selected and divided into two equal groups: 10 children were assigned to receive an expressive art therapy intervention, while the other 10 served as the control group.

The Pittsburgh Sleep Quality Index (PSQI), developed by Buysse et al. (1989), was administered at the start, midpoint, and end of treatment, as well as at a 3-month follow-up. The PSQI measures sleep quality across seven component scores, each ranging from 0 (no difficulty) to 3 (severe difficulty), which are then summed to produce a global score between 0 and 21. Higher PSQI scores indicate poorer sleep quality.

Expressive Art Therapy Protocol

This therapeutic approach was carefully designed through a comprehensive study involving both quantitative and qualitative methods. It is based on the Coping Cat program, which comprises 16 sessions divided into two main parts. The first part provides psychoeducation on anxiety, while the second part involves gradually confronting anxiety triggers. The original therapy sessions were adapted into art-based exercises to enhance engagement and cultural relevance. Modifications were made to accommodate cultural differences, optimize time and resources, make activities more enjoyable, simplify certain art tasks, and align with cognitive behavioral principles (Kalthom et al., 2023).

This intervention, consisting of sixteen 60-min sessions, was specifically tailored for children who have experienced war-related trauma. The program is divided into two sections: the first section uses various art techniques to teach children about anxiety, while the second section focuses on using expressive arts to imaginatively confront anxiety triggers. This approach provides a safe space for children to express their distress and develop new coping skills, thereby reducing harmful behaviors. Children are guided through visualization exercises to help them address anxiety triggers (see Tables 1 and 2).

Table 1.

The expressive art-therapy 16-session intervention protocol based on coping cat program

N		Title	Expressive art therapy assignments	Homework
1	Psychoeducation	Building rapport and getting familiar with art materials	Guess what? Using air drawing to inspire the imagination Squiggle game: creating a scribble, with eyes open or closed, on a sizable shared sheet	Name decoration: embellishing the initial letter of the child's name, adding decorations, and applying paint to enhance its appearance
2		Identifying different feelings	Animation movie (Inside Out): depicts the emotions and thoughts flowing within the human mind (love, fear, anger, etc.) The game of emoji masks involves selecting multiple masks, switching between them, and connecting facial expressions with body language	Taking a sheet of paper that contains a series of blank faces and painting various moods for each face according to their own choice
3		What’s That Your Body Is Saying	Crossing the River: creating a paper boat and a river, imagining themselves in the boat, and drawing themselves crossing the river Body Tracing On the wall: tracing the outline around the child's body to create a simple representation, placing stress-related emotions on the body outline Introducing the first Concept of FEAR (the Yellow Card)	Painting a nightmare: Using a pencil and paint, every child draws something they are afraid of Completing the yellow card
4		Learning How to Relax	Role-playing (Robot—Puppet): stiffening the muscles like a cartoon robot, a puppet playing without any joints Untangle a colored wool Music Relaxation: drawing what you hear with curvy lines	Make a mandala by drawing outlines during the session and completing it at home Completing the yellow card
5		Identify stress and fear and learn to challenge thoughts	Drawing what scares you: Draw a large oval and imagine you are inside a cave Introduce the second concept of fear (the red card)	Magic Egg Painting: drawing a magic egg and illustrating what comes out of it Completing red and yellow cards
6		Attitudes and Actions I Can Take to Help Myself Feel Better!	Creating a magazine photo mashup puppet show: narrating and performing a short story with puppets Introducing the third concept of FEAR (the blue card)	Painting yourself as a superhero Completing blue, red, and yellow cards
7		Rewarding oneself for effort	Olympic Medal Craft Blessing Card: creating a blessing card using a child's name and various colored papers and paints Introduce the fourth concept of FEAR (the green card)	Paper Ribbon Prize: making a paper ribbon prize and writing their name on it Completing yellow, red, blue, and green cards
8		Art exhibition in the presence of the parents	Inviting parents to the session and children to hang their paintings on the wall like an art gallery Buying these artworks from parents and putting Olympic medals around children's necks	––––
9	Imaginal Exposure	Facing Your FEAR: Low anxiety-inducing situations	Military equipment and weapons: creating tools and weapons used in the war using painting and collage techniques Exposure through music: presenting an abstract piece of war music and the children interpreting that music in an expressive way through abstract straight lines	completing the FEAR plan for Low anxiety-inducing situations with colored cards
10		Facing Your FEAR: Low anxiety-inducing situations	Displaying various paintings related to the war, children explain their feelings about these paintings Each child expresses their emotions through painting	completing the FEAR plan for Low anxiety-inducing situations with colored cards
11		Facing Your FEAR: Moderate anxiety-inducing situations	Displaying different real photographs of the war, children explain their feelings about these photos Each child expresses their emotions through painting	completing the FEAR plan for moderate anxiety-inducing situations with colored cards
12		Facing Your FEAR: Moderate anxiety-inducing situations	War-related equipment show with flashcards: It includes weapons, along with reading war poems and analyzing them Drawing and painting a member of ISIS as the child imagines them and expressing their feelings	completing the FEAR plan for moderate anxiety-inducing situations with colored cards
13		Facing Your FEAR: High anxiety-inducing situations	Drawing destroyed city or village or child’s home before and after the war	completing the FEAR plan for high anxiety-inducing situations with colored cards
14		Facing Your FEAR: High anxiety-inducing situations	Portrait drawing: drawing a portrait of a dear person (from the child’s family or friends) who has gone missing in the war Writing their emotions about that person in a letter on the margins of the drawings	completing the FEAR plan for high anxiety-inducing situations with colored cards
15		Primetime	Installation Art: Depicting the impact of war and children's emotions through installation and conceptual art Paper Cup trophy: Giving the child a pre-made paper cup and letting them decorate it however, they like	completing the FEAR plan for high anxiety-inducing situations with colored cards
16		installation exhibition with the presence of the parents	showcasing the prepared installation art from the previous session, in the presence of parents Presenting the paper cup trophy made in the previous session to each child	–––––

Table 2.

Comparison of the mean and standard deviation of sleep disorder scores in Syrian children with symptoms of secondary traumatic stress at the pretest, posttest, and follow-up stages

Statistical indices	Scale	Art-therapy program		Control group
		Mean	Standard deviation	Mean	Standard deviation
Sleep disorders	Pretest	14/40	0/96	15	1/05
	Posttest	13/40	1/34	15/10	1/10
	Follow-up	13/40	1/42	15	1/05

Procedures

Children who consented to participate in the study were randomized to receive sixteen 60-min expressive art therapy intervention sessions. The sessions were conducted in an apartment located near the children's schools to ensure easy access for the children and maintain the continuity of the sessions. One child refused to attend after the first session, resulting in the involvement of a substitute child. In general, the commitment to therapy sessions and the engagement in artistic activities were good (Fig. 1), except for some parents who did not attend the sessions designated for parental involvement. In the psychoeducation part of the sessions, the focus was on teaching children to identify bodily reactions to anxiety and talking about their nightmares (Figs. 2 and 3).

Fig. 1.

This image shows a group of Syrian children participating in expressive art therapy sessions

Fig. 2.

This drawing was created by a young girl who expressed that it represents her recurring nightmare of migrating from Syria and drowning in the sea after one of her relatives drowned while trying to reach Europe illegally

Fig. 3.

This drawing was created by a boy who explains that it depicts the night when a car was detonated in their neighborhood. He still experiences frightening dreams about that night

Moreover, relaxation exercises and coping techniques utilizing the colored cards mentioned in the therapeutic program were conducted. These cards were systematically used in the second part of the sessions, which were dedicated to imaginal exposure therapy, allowing the children to address and process war-related events they witnessed or heard about, which were deeply imprinted in their memories. This involved drawing specific places (Fig. 4) or people they have lost (Fig. 5). Finally, the sessions concluded with the parents' presence, where the children's artworks were showcased, and symbolic rewards were given.

Fig. 4.

This drawing represents the school of one of the children, which was destroyed during the war and has remained non-operational since then

Fig. 5.

A portrait drawing of the mother of one of the children who passed away during the war

Data Analysis

An analysis of variance (ANOVA) with repeated measures was used to analyze the results of quantitative rating scales for sleep disorder symptoms. The dependent variable was the Pittsburgh Sleep Quality Index (PSQI). The independent variable was the expressive art therapy intervention. The statistical results were analyzed using SPSS.

Upon evaluating the normality of sleep disorder scores in Syrian children, the Kolmogorov–Smirnov test (Lilliefors, 1967) and Mauchly’s test (Box, 1954) were conducted. The results indicated that using covariance is appropriate for examining sleep disorders in Syrian children with symptoms of secondary traumatic stress. Consequently, parametric tests can be employed for the pretest, posttest, and follow-up stages.

As observed in Table 3, the results based on Greenhouse–Geisser (Greenhouse & Geisser, 1959) indicate significant differences (p < 0.01) in sleep disorders between the pre-test, post-test, and follow-up stages. The eta-squared for the test factor is 0.411, indicating that 41.1% of the variance in sleep disorders is attributed to the independent variable (expressive art therapy intervention), which is confirmed.

Table 3.

The results of repeated measures analysis of variance (ANOVA) for within-group factor, within-group factor interaction, and between-group factor were obtained for the sleep disorders variable

Effect	Analysis type	Sum of squares	Degrees of freedom	Mean squares	F ratio	Significance	Eta-squared	Test power
Within-group	Assuming Sphericity	17.489	2	8.744	18.838	0.001	0.411	1
	Greenhouse–Geisser	17.489	1.650	10.601	18.838	0.001	0.411	0.999
	Huynh–Feldt	17.489	1.873	9.335	18.838	0.001	0.411	1
	Lower-bound	17.489	1	17.489	18.838	0.001	0.411	0.987
Interaction	Test*Group (Sphericity)	12.111	4	3.28	6.325	0.001	0.623	0.689
	Greenhouse–Geisser	12.111	3.003	3.176	6.325	0.001	0.623	0.699
	Huynh–Feldt	12.111	3.747	3.232	6.325	0.001	0.623	0.189
	Lower-bound	12.111	2	6.056	6.523	0.005	0.326	0.873

Additionally, in sleep disorders, the test-group interaction based on Greenhouse–Geisser is significant. This implies that there are significant differences between the pre-test, post-test, and follow-up stages in both the experimental group (expressive art therapy intervention) and the control group. The eta-squared for the interaction effect between test and group membership is 0.326, with a test power of 0.969. This suggests that 32.6% of the differences between the experimental group and the control group in sleep disorders can be attributed to the independent variable, which is confirmed with 100% power.

Discussion

The findings of this study support the effectiveness of the expressive art therapy intervention, based on the Coping Cat program, for war-affected children. The children reported recovering blocked memories and gaining insights into their nightmares, indicating that sensory methods of accessing traumatic memories facilitated memory integration. These results align with prior hypotheses suggesting the existence of a nonverbal component of traumatic memory, as suggested by Langer (2011). Throughout the therapy sessions, the importance of artistic activities for children became evident. As the sessions progressed, the children’s engagement and willingness to share their drawings and discuss their meanings increased. Some children even requested to take their drawings home, which was significant for those experiencing symptoms of secondary traumatic stress. These observations highlight the therapeutic value of art therapy in fostering expression and communication among war-affected children. The creative interventions also contributed to enhancing self-acceptance and coping mechanisms, promoting deeper self-understanding and hope for the future. Furthermore, the use of FEAR drawing cards as a therapeutic technique proved valuable in addressing anxiety-related issues and building resilience. Reward sessions, which included paper medals and cups, positively impacted the children’s motivation and self-esteem throughout the intervention.

The study demonstrated a reduction in sleep disorder symptoms among Syrian children with secondary traumatic stress (STS) who received the expressive art therapy intervention. Comparing these results to a matched control group without treatment suggests that these changes were not merely due to the passage of time but were attributable to the intervention program itself. However, the study faced limitations due to the small sample size and limited logistical support in Syria, which affected the availability of art materials and may have impacted the results. Future research should replicate this program with larger sample sizes across different war-affected regions and compare its outcomes with those of the current study. Additionally, this intervention could be adapted for adolescent groups and examined in a comparative analysis with the present study. Researchers are encouraged to design future studies investigating the impact of the expressive art therapy intervention based on the Coping Cat program for children, with additional variables such as post-traumatic stress disorder (PTSD), self-criticism, academic challenges, and more.

In conclusion, this study demonstrates the potential of the expressive art therapy intervention as a valuable treatment option for war-affected children and provides insights into the role of artistic activities in fostering expression and communication. While the results are promising, future studies should address the limitations and further explore the mechanisms underlying the benefits of expressive art therapy for war-related symptoms.

Authors' Contributions

Mohammad Kalthom, PhD: Dr Kalthom is a Syrian art therapist: as the primary author, Mohammad Kalthom conducted the research, designed the art therapy intervention and the study methodology, collected and analysed the data, and made necessary adjustments. Parisa Darouei, PhD: Dr. Darouei is an art therapist with extensive research experience in the field. She provided the necessary advice to support the integration of artistic activities in accordance with the duration of the sessions and the specified age of the children, In addition to the general supervision of the design and analysis stages of the therapeutic package. Amir Ghamarani, PhD: Dr. Ghamarani, a child psychologist, offered his clinical perspective on the article's topic. Shared his experiences in facilitating art therapy sessions with children struggling with STS in accordance with the cognitive-behavioural approach.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Data Availability

The datasets generated and/or analyzed during the current study are available from the corresponding author on reasonable request.

Declarations

Ethical Approval

This study was conducted following the ethical guidelines outlined by the World Medical Association Declaration of Helsinki. Informed consent to participate was obtained from the parents or legal guardians of the children involved in the study. Additionally, consent to publish the findings was also obtained from the parents or guardians. The study ensured confidentiality and the protection of the participants' rights throughout the research process.

Competing Interests

The authors declare that they have no competing interests.

Conflict of Interest

There are neither financial nor personal relationships with people or organizations that could inappropriately influence the authors’ work.