Although children with SLCD are more at risk of developing various mental health problems (13), very few interventions specifically target mental health symptoms like anxiety or depression. To date, research including students with various learning disabilities and SLCD has focused on supporting children's basic psychological needs for autonomy, competence and affiliation to foster well-being in many different life domains (14–17). Self-determination theory, a macro theory of human motivation, posits that supporting these universal psychological needs is essential for a flourishing life (18). The need for autonomy can be defined as the desire to experience a sense of volition and choice. It involves feeling that one's own behavior and action is self-directed and congruent with personal values and interests. The need for competence consists of seeking to be effective and capable in handling challenges and achieving desired outcomes. This includes mastering skills and accomplishing meaningful tasks. Finally, the need for relatedness refers to the desire to connect with others, experience meaningful social relationships, and feel a sense of belonging within a social context. Creating spaces that support these three psychological needs can foster children's creativity, motivation, and school engagement (18). Children with SLCD could particularly benefit from interventions that support their autonomy, competence, and relatedness, as they face additional challenges in these domains (19). Indeed, autonomy, supportive experiences, feeling connected to peers, and tasks that enable a sense of competence can all contribute to emotion expression through introspection and self-understanding (20). Art-based interventions may be particularly beneficial for introspection and emotional expression in youth who may not possess the vocabulary to thoroughly describe their emotions (21). As such, these interventions can facilitate communication for children who experience trouble verbally communicating their thoughts and feelings, which could, in turn, foster feelings of competence (21, 22). Furthermore, the focus on subjective experiences and the creative process, rather than the finished piece of art, makes such interventions particularly suitable for children with SLCD. However, to date, no research has evaluated whether art-based interventions can effectively promote emotional expression and self-determination in children, namely those with SLCD.

Art-based approaches may be particularly beneficial for children and adolescents. Traditional therapeutic methods like individual psychotherapy have become increasingly inaccessible, and wait-lists times are at an all-time high (23, 24). Hence, art-based approaches could serve as an effective alternative for youth, particularly as they provide a sense of empowerment and prompt participants to share their work, thoughts, and feelings with their peers (25, 26). In youth populations, art-based interventions have namely served to overcome resistance to therapy (21). Furthermore, the arts (e.g., painting, sculpture, dance, etc.) allow psychologists to adapt their interventions according to the demographic they are working with. This capacity to adjust an approach is crucial to create interventions that align with the context of their participants, such as offering age and culturally appropriate activities (27, 28). Hence, art-based interventions have a promising potential to allow for introspection and emotional expression in children, supporting their mental health.

School settings may be particularly suitable for implementing art-based interventions. Indeed, in a review of eight studies involving school-based arts interventions among children aged 5–12 years old, Moula (29) found that integrating creative arts into the classroom had significant positive effects in improving children's quality of life, anxiety, self-concept, problem-solving skills, attitudes towards school, as well as emotional and behavioral difficulties. Another review of the literature on school-based art therapy found that creativity, expression of emotions through art, and finding meaning within the artwork could lead to better classroom behavior, improved self-concept, and help with separation anxiety disorder in children (30). However, only four experimental studies met the inclusion criteria for the review and the authors highlight that further evidence is needed to support these findings. Although few studies have examined the potential mental health outcomes of school-based art interventions, initial evidence from the present research team supports that art therapy can improve children's well-being and reduce psychological distress (31). Moreover, school-based drama therapy for children with autism and/or various developmental disorders has been linked to improved confidence in expressing emotional needs, increased use of creativity and imagination, and improved working memory (32). Other effective art-based interventions in schools include storytelling, drawing, puppetry, songwriting, and activities based on empowerment, such as creating characters based on children's superpowers (33). Noted benefits from these creative activities include children's increased sense of personal strength, confidence, identity, and positive emotions (33). Art-based interventions can also extend therapeutic relationships when conducted in a group setting, particularly when creative and interpretive processes are combined (25). Indeed, group settings can provide additional value to art-based interventions through peer support, self-regulation, and cooperation (34). School-based art interventions, when conducted in group settings, can also improve children's self-acceptance and acceptance of others. A qualitative systematic review of the mechanisms of change of school-based art therapies posits that the school context, the process of art-making and reflecting on the artwork were important components of positive change (35). Authors recommend art-based approaches for children who struggle to verbalize their challenges, difficulties, and emotions. However, to our knowledge, there is no evidence regarding the integration of art-based workshops to improve the emotional expression of children with SLCD. Noteworthy are some studies that explored music therapy to enhance motor skills of children with SLCD. While these approaches may be beneficial in promoting various components of language (36, 37), there is a lack of evidence on its potential benefits for this populations’ mental health.

Qualitative research has a unique potential for studying arts’ creative, embodied and artistic dimensions, with more emphasis on the individual's experience, while embracing complexity rather than reductionism (38, 39). In fact, there has been an increased call for the inclusion of participants’ voices in research on the use of creative arts in therapy (29, 38). Within the context of school-based art interventions specifically, the students’ and teachers’ perspectives on the art interventions have generally been excluded from the published research to date. Including these perspectives early on in the development of art-based interventions would arguably enhance the participants’ experience and researchers’ understanding of results (29).

The objectives of this qualitative study were to explore (1) the acceptability and feasibility of an art-based intervention for elementary school students with SLCD, (2) the perceived benefits of the intervention on children's mental health from the perspective of the students and the educational staff, as well as through observational data.

The initial stages of program development should rely on various forms of qualitative data to document if the intervention should be further refined to better reflect the needs of the population (40). As such, early research evaluating interventions does not need to include large samples both for feasibility and ethical reasons. Instead, it is recommended to include fewer participants and gain insight into their experiences of the intervention, as well as obtain their recommendations (40). Once an intervention is refined and initial testing done, its efficacy can be documented with larger samples and quantitative methods. However, at the time of study, the present intervention was still at its early development stages. The development of the program had been ongoing within the research team and previously piloted with smaller groups. As such, the present study allowed for the beginning of the next stage of documenting the acceptability and feasibility of the intervention with the population directly.

A descriptive qualitative design was used in this study. Data were obtained through individual semi-structured interviews with the students, the teachers and specialized education technicians, as well as through focus groups and observational data collected during the workshops. This design was implemented to examine the participants’ perceptions of the art-based intervention, acknowledging the subjective nature of their experience. This approach was guided by a pragmatic paradigm, focusing on what “works,” deriving context-dependent meaning through human experience (41). Our team chose a qualitative design based on the general recommendation that preliminary studies need to focus on the acceptability and feasibility of a new intervention rather than on its efficacy. This allows for changes to be done to the intervention's components before they are evaluated for their efficacy on specific mental health variables (42). This is not to say that the intervention's perceived effects (benefits/drawbacks) are not to be investigated, as the participants’ perception is central to evaluating its acceptability and feasibility. Hence, acceptability and feasibility studies aim first to explore whether an intervention can be done, how it should be done optimally, and if we should carry out further testing (43).

There is no consensus on the definition of acceptability within intervention research (44). The present paper follows the theoretical framework of acceptability (TFA) proposed by Sekhon et al. (45), whereby acceptability is “a multi-faceted construct that reflects the extent to which people delivering or receiving a healthcare intervention consider it to be appropriate, based on anticipated or experienced cognitive and emotional responses to the intervention” (p. 1). As such, acceptability integrates the attitudes, satisfaction, and perceived feasibility of a study by the participants who directly experience the intervention, stakeholders, and those who deliver the intervention (44). The TFA includes seven components of affective attitude towards the intervention: perceived burden, ethicality, intervention coherence, opportunity costs, perceived effectiveness, and self-efficacy (45) (p. 7). The feasibility of the intervention can be understood as its usability (46). In the present study, this included the perception that the intervention was doable, easy to implement/use, that the materials were appropriate, and that the time constraints were well adapted to the context (45). In short, feasibility answers questions regarding whether the intervention can be done and can be differentiated from a pilot study that evaluates aspects of a study design and procedures for implementing a future larger-scale trial (43).

Study participants included two groups: (1) children with SLCD and (2) school personnel. Twenty children with SLCD aged 8–12 years old from two classrooms participated in the activities, the focus groups, and individual interviews. Two teachers and two specialized education technicians participated in this study. To be placed in these classrooms, communication difficulties experienced by the children had to be identified as moderate to severe (based on the level of impairment and need of support) by the school psychologist and/or a speech pathologist. Most children from these classrooms also experienced comorbidity with either mild intellectual disability, ASD, ADHD, or oppositional defiant disorder; however, the list of comorbidities and severity was not disclosed to the researchers, and this information was shared verbally by the teachers, and thus we could not include detailed information on this. Special needs presented by the children included repeating many times in different words the instructions, wearing a remote microphone for students with hearing aids, and speaking clearly. Observations did not indicate severe speech impairments, as all of the children were able to share their thoughts and experiences.

The two classrooms were recruited from an ongoing partnership between the corresponding author and principal investigator of this study (CMH) and an elementary school in the province of Quebec, Canada. Both classrooms were adapted for the needs of children with SLCD (e.g., a full-time specialized education technician in class, smaller class size, etc.). The inclusion criteria for the school were to be a francophone or anglophone elementary school in the province of Quebec, Canada with specialized classes for children with SLCD. There were no additional exclusion criteria. Parents consented to their child participating in the art-based activities, focus groups, and individual interviews. Verbal assent was also obtained from the children for the focus groups and the interviews. Teachers and specialized education technicians who agreed to participate in the intervention conveyed their full informed consent to host the workshops and participate in a brief post-project interview. The present study obtained the approval of Bishop's University ethics board (102682).

The arts-based intervention used in this project was developed by a child psychologist (CMH) and a Ph.D. student in clinical psychology (TLG), in collaboration with a researcher with extensive training in dance and movement therapy (AM). Themes were first chosen based on prior research projects led by the research team using art-based approaches to improve elementary school-aged children's mental health [see (21, 39)]. The choice of various art mediums was done in collaboration with both teachers taking part in the project. The 8-week intervention included different art mediums to address each weekly theme. Many complementary mediums were chosen to appeal to the different preferences of children, as well as promote various domains of creativity. As such, mediums included drawing with coloring pencils and crayons on white pieces of paper, as these mediums are easily accessible to children, and non-threatening. Crayons also allow for the exploration of perceptual components and symbolism within art (47). Play-Doh and Lego were chosen to encourage the kinesthetic components of art, which promote body awareness and release of tension (47). Further, these mediums are also familiar to children and easily accessible to allow a feeling of comfort and encourage creativity within cognitive development. Dance was also chosen to further bring consciousness to internal emotional experiences, promote emotional awareness and expression, as well as to release stress and tension (48). While music therapy could be beneficial for exploring emotions while promoting motor skills, it is recommended that these be led by a licensed music therapist with extensive training (36, 37). Further, with the limited time constraint, we wanted to repeat each art medium at least once to promote feelings of competence, so we limited the number of mediums included. The breakdown of the intervention mediums and themes can be found in Table 1. Drawing, sculpting (including the use of Lego and Play-Doh), and dance were selected to introduce a variety of accessible means of creation and expression for the students. Workshops were led by a clinical psychology Ph.D. student (TLG), who was assisted by an undergraduate psychology student, and both were supervised by a child clinical psychologist (CMH). Each weekly 50 min workshop around one theme was divided as follows: instructions, artistic creation with one medium, group discussion, sharing and presenting the creations to the group. The art-based activities were selected to encourage introspection, emotional awareness, and expression in children. The Canadian school curriculum for elementary schools already includes visual art classes. These classes aim to teach various art techniques and mediums and “To learn to create, interpret and appreciate artistic productions as a means of integrating an artistic dimension into their daily lives” (49). In this context, the children's visual art is evaluated for its content (coherence, organization, complexity of artistic elements). In contrast, the aim of art-based therapeutic approaches is to focus on the process of creation and less on the finished art piece (50). Children are rather encouraged to express themselves, focusing on various internal experiences (thoughts, emotions, physical sensations) related to art-making. As such, special care was taken during the intervention to differentiate these different creative spaces, emphasizing that the finished piece would not be evaluated, and children were never obliged to share them.

In line with a pragmatic approach, data were obtained from four sources to triangulate the findings: focus groups after each workshop, observations during each activity, individual semi-structured interviews with the children and individual semi-structured interviews with teachers and specialized education technicians at the end of the intervention.

After each activity, the weekly focus groups were led by the first author of this paper and included questions about what the children had created, if there was something they wished to share with the group, how they appreciated the activity, if the activity was challenging in any way, and how the activity related to their everyday life. These discussions were recorded and transcribed (mean duration of group discussions = 8.15 min).

An undergraduate student in psychology, who acted as a research assistant, took observational notes during each activity based on an observation grid (see Supplementary Table 1). Questions from this grid included: What are the reactions to the activity? What roles (leadership, listening, oppositional, etc.) did the children take? What were the interactions during the workshop? What did the children do or say? The first author, who led the group discussions, also added any additional observations after the workshops.

After the eight-week intervention, each student participated in a brief individual semi-structured interview. These were recorded and transcribed (mean duration of interviews = 11.92 min). The interview guide included questions about children's perception of the activities, and if there were things they had not understood or would have been done differently (see Supplementary Table 2). The first author and a research assistant led these interviews in separate rooms in the school. Special care was taken when developing the interview guide to use words that were easy to understand and questions that were also easily comprehended. Further, children were told that questions could be repeated, that they could take all the time they needed to answer and find their words. The last drawing made (summary of the activities from the child's perspective) also guided the interviews, as children could point to elements on their drawing to describe their answers. Interviewers also took care to summarize what they understood from the children’s answers and ask them if it reflects what they experienced.

Finally, the teachers and the specialized education technicians from each classroom participated in semi-structured interviews in pairs (teacher with the class specialized education technician; mean interview time = 43.83 min). These interviews were conducted online on the Microsoft Teams platform (version 1.5.00.31168), housed on a secured server. Semi-structured interviews aimed to obtain the teachers’ and technicians’ perceptions of the intervention to find out what they thought had worked best and could be improved, as well as the perceived benefits of participating in these activities (see Supplementary Table 3). All interviews were recorded and transcribed for analysis.

Given the clear criteria related to the acceptability and feasibility TFA framework of Sekhon et al. (45), content analysis was used to analyze data. This deductive approach to qualitative coding allowed for the application of a theory to the data (51). The transcriptions were analyzed using MaxQDA Plus 2022 (Release 22.7.0). Codes were first defined. Two researchers (MB and JP) then immersed themselves in the data, by reading and re-reading the transcripts, getting a sense of it as a whole (preparation phase); open coding of the codes was then applied. Interviews were then independently coded by a third researcher (TLG). A flexible approach was also used to allow any additional codes to emerge inductively. Next, all codes were grouped into meaningful categories through extensive discussions between researchers.

Following the deductive analysis, an inductive thematic analysis with a description-focused coding strategy was used to closely represent the participants’ specific behaviors, experiences and perceptions (52) to answer research questions regarding mental health. The method proposed by Braun and Clarke (53) guided the analysis. After the transcription and familiarization phase, one researcher (TLG) generated the initial codes, guided by the research questions. These initial codes were discussed with and reviewed by a second research team member (CMH). Three independent coders (TLG, MB, JP) then analyzed the transcripts using the same coding tree. Next, the codes were grouped into overarching categories representing themes within the data to ensure that they closely represented the voices of participants. The validity, coherence and consistency of these categories were discussed with the research team. Finally, overarching themes were named and defined. Data from the observation of the activities and the reflective journal were combined and used to add to the emerging themes from the interviews and focus group data. Hence, results present these themes that are rooted in the transcripts and closely represent what participants experienced and shared within this study.

Six constructs of the TFA were coded through the interviews with the children and the teacher-specialized education technician pairs, as well as the focus groups and observation notes. Results are summarized in Table 2 with quotes supporting the acceptability of the art-based intervention from both perspectives. The construct of opportunity costs of participating in the intervention was not identified in the interviews nor the observational data and thus is not presented. Furthermore, the perceived effectiveness construct is integrated within the theme of the perceived mental health implications of the intervention (Section 4.3).

Content analysis of the interviews, focus groups and observational data revealed the four categories from the TFA. Each is presented below and in Table 3 with the supporting quotes from the interviews.

Thematic analysis yielded the overarching theme of the mental health implications of the intervention. The sub-theme of creative exploration emerged as being related to these perceived benefits. Creative exploration was defined as using art and creativity to explore emotions, thoughts, themes, and ideas about the world. This led to perceived changes in children in the domains of the self and with others in the classroom setting. Both these sub-themes are discussed below and supporting quotes can be found in Table 4.

Overall, the findings suggest that the school-based creative art intervention was acceptable and feasible for children experiencing SLCD. Notably, components of the interventions that reinforce previous findings regarding school-based interventions include using age-appropriate approaches (54), reiterating that the goal of art-making is not the final art piece but the process itself (55), allowing enough time for discussions through the art (56), and choosing a variety of accessible mediums to discuss emotions (57). The results also indicate that the intervention was not perceived as a burden in the classroom. To this point, it is essential that interventions integrated into the classroom avoid teacher burnout (58). Further, one of the main goals of an acceptability and feasibility study is to determine if further testing should be conducted (43). These findings indicate high levels of these two constructs. Paired with support for the intervention from the students, the teachers and specialized education technicians, this suggests that the present intervention should be further evaluated using experimental methods. Finally, the results also indicated that more time should be given to discuss the art creations after the workshop. This element is essential to the process of change during art-making (56) and should be better integrated into future studies using art-based approaches.

Although this study did not quantitatively measure the impact of the art-based intervention on the well-being of children with SLCD, perceptions gathered from students themselves, their teachers and specialized education technicians, as well as from the observation grids, tend to support the fact that the intervention facilitated self-expression, fostering self-confidence and creativity. As discussed previously, students initially felt challenged to express their emotions. However, the intervention—and the safe space created in its implementation—encouraged them to share their emotional and internal worlds through their artwork. This approach enabled them to feel more capable of expressing themselves, particularly because there was no concept of a “right” or “wrong” way to participate, which helped develop their perceived confidence, competence, and pride in themselves. These findings align with previous research highlighting the benefits of art-based interventions for individuals who have difficulty expressing themselves verbally (21, 22). Indeed, a study with preschool children with communication difficulties reported similar results, where movement, visual art-making, and theatre provided a space to communicate emotions in these younger children (12). These art-based activities in turn, reduced anxiety in children and increased their empathy (12). It thus seems that art-making could foster the emotional expression of children with SLCD within the classroom. To this end, parents of children with SLCD have expressed the need for mental health interventions that do not rely on verbal communication (59). It appears that art-based interventions could potentially serve this purpose.

While some students initially expressed frustration at letting go of perfectionist ideals, this challenge represented an opportunity to step out of their comfort zones and relinquish the notion of an aesthetic final piece of art. Since the focus of the activity was more on the creative process than the final creation, children with SLCD were freed from these expectations. They could concentrate on self-expression and enjoying the activity. This ultimately made them more comfortable expressing themselves and gaining confidence in their artistic abilities, as emphasized by various other studies (21, 22). Introspection and self-expression are fundamental to the therapeutic process of art-making, as this is believed to be a mechanism of change by which art-making can support mental health (60). However, this process of introspection and self-expression through art might not be accessible to children in all contexts. An approach that may be beneficial when young people are hesitant to open up to the creative process is philosophy for children (P4C), which could be useful to encourage young people's questioning about the work they are asked to create, thus enriching the creative process itself (61). Within the creation of art, combinations with P4C would make it possible to explore reluctance linked to performance anxiety (e.g., discussing what beauty is) and the fear of the gaze or judgment of others (61). It could therefore offer children a space to explore their doubts related to the creative process. In doing so, adding a P4C component would act as a catalyst to carry out artistic activities. Our own research suggests that combining P4C and other approaches may increase its benefits, as it helps children create meaning from their experiences while supporting their self-determination (62).

One of the most salient results from this study lies within perceived changes in satisfaction of the basic psychological need for autonomy in students, which can be linked to increased self-expression. Indeed, children reported that the freedom to express themselves authentically through their artwork, along with the absence of pressure to produce something aesthetically pleasing, contributed to building a stronger sense of self and to their feelings of acting volitionally, in accordance with their true self and thus in a more self-determined manner. While the need for autonomy is often referred to as an internalized and relatively hard-to-observe need (63), the fact that teachers and facilitators observed these changes could indicate that this was an essential aspect of the intervention. Interestingly, this diverges from other studies suggesting that teachers may not be the best proxy to identify changes in their students’ autonomy (64). Future research should investigate in what situations teachers or parents could provide valid evaluations or observations of changes in the satisfaction of autonomy in children. Furthermore, offering a variety of materials with which to create and sufficient time to do so allowed students to select what resonated with their thoughts and their envisioned creation, thus encouraging their autonomy.

Although a distinct concept from autonomy, self-confidence can contribute to feeling more autonomous and competent (65). Noteworthy, previous research evaluating the impacts of art-based interventions on mental health has also shown that artistic creation can enhance self-confidence in children (66). Other initiatives, such as the YouCreate program, have highlighted the essential role of the creative process in the journey towards self-discovery, self-expression, and acting in coherence with one's values (67). Further, children with emotional and behavioral difficulties who participated in school-based dance and movement psychotherapy reported that it encouraged self-expression, emotional regulation, mastery and acceptance of emotions, improved self-confidence and self-esteem, reduced stress, and helped develop positive relationships; all of which are essential in feeling self-determined, competent and affiliated (68).

Moreover, art-making promoted a sense of trust between students, their peers, and their teachers, thus contributing actively to the satisfaction of their need for relatedness. This echoes other research that found that an art-based intervention could increase empathy and connection between preschool students (12). Indeed, fostering a safe space for students to share their emotions with their teachers can positively impact their relationships. Many studies highlight the benefits of positive student/teacher relationships in students’ academic, behavioral, and social-emotional spheres (69–71) and consequently on the satisfaction of their basic psychological needs (72). Moreover, because the art intervention occurred within a group setting, it facilitated active participation and the development of social skills. Some participants mentioned how the activities also mitigated the language barrier challenge across students, facilitating the affiliation process. As a result, children felt more at ease expressing their emotions and being themselves in the company of others. These outcomes align with previous work based on self-determination theory, which emphasizes the role of relatedness in promoting psychological well-being (63). In this study, the sense of community and trust established through the activities nurtured a sense of security, authenticity, and belonging among the students, their teachers and specialized education technicians. This also resonates with literature on the importance of autonomy support in the classroom, which indicates that warm, supportive relationships could reduce students’ anxiety and depression levels (73, 74), while also promoting better adjustment (75). As such, feeling connected to other students and their teachers through the art-making process, while feeling supported in their autonomy in doing so, could be mechanisms of change in art-based interventions (76).

Finally, students felt that art-making and emotional expression led to increased feelings of competence. Indeed, it has been shown that engaging in accessible, yet challenging activities can contribute to feelings of competence in children, as they can observe their skills improve. With appropriate support, children can learn skills that are just out of their comfort zone, a concept that has been named scaffolding in the zone of proximal development (77). Introducing activities that are “optimally challenging” allows students to test and broaden their abilities (78). Art-making specifically can be a way of offering this means of support to scaffold children's introspection and emotional expression (79). In the context of this study, children who typically had a hard time expressing their emotions were provided with a new way to articulate their feelings with the support of both the mediums used and the facilitators. Hence, art-making perhaps contributed to enhanced feelings of competence, not only in creating art but also in the overall emotional expression. Art-based activities are flexible approaches that can be well-suited to meet children at their unique developmental stage through the variety of mediums and themes (80) allowing for feelings of competence to emerge.

Overall, feedback from students, teachers, and specialized education technicians alike all highlighted how the intervention allowed the creation of a safe space for individual introspection and emotional expression in the classroom. This, in turn, facilitated creativity and authenticity in children. Further, concepts pertaining to familiarity and comfort were considered significant factors supporting the acceptability and feasibility of the intervention, as indicated in the TFA's intervention coherence and ethicality components. For instance, students mentioned that they had already engaged in similar activities at home, which made them feel more at ease (thus more familiar) when participating and expressing themselves emotionally in school. These findings align with previous research highlighting the need for educators to include non-academic elements, like emotional expression, within the curriculum (81). Taking part in the intervention reinforced teachers’ conviction that it is important to consider their students’ emotional well-being in their teaching while providing a resource to do so. Children have been found to thrive in environments where their social-emotional skills are nurtured, and they feel self-assured, relaxed, and secure (82). Thus, it appears that results from this study support the premise that art-based interventions could support the satisfaction of the three basic psychological needs for autonomy, competence, and affiliation, contributing to overall mental well-being in children.

Both students and teachers provided favorable feedback in terms of ease of implementation, time efficiency, and practicality. Teachers also expressed appreciation for the help of an external host overseeing the activities, allowing them to actively participate and engage in the process. They even reported indirect perceived benefits of participating in the activities on their own mental health. Although we did not plan the intervention with any benefits for teacher mental health, these results may hold promise. Indeed, it is well known that teachers often face multiple layers of stress that make them more vulnerable to burnout, mental, and physical health issues, as well as strain their relationships with students (83). Results from this study lead us to believe that developing art-based interventions, whether in individual or group settings, could be a valuable resource for teachers themselves and have trickle-down effects on their students. However, further research on this topic specifically is warranted.

One recommendation of interest raised by teachers was to enable the sharing of the created art with the children's families at home, to facilitate parent-child communication about school activities. Indeed, the research linking parental involvement and communication in their child's activities has established a clear causality with children's development, academic success, and emotional well-being (84, 85). Although many studies have explored the benefits of family-based art therapy, there exist no indications to our knowledge on the question of sending pictures of the students’ creations to their parents/guardians. Ethical considerations raised by the research team on this topic involve obtaining children's consent before sending these pictures and the limited emotional support that could be extended at home. Indeed, the variety of family dynamics and realities may bring about unexpected challenges. Nonetheless, the benefits of using the created pieces to continue discussions, emotional expression at home, and their inherent ethical and practical issues, should be further explored. In the meantime, organizing an exhibition of the students’ artwork after the intervention could serve to present creations to families and the community, drawing inspiration from photovoice research (86).

This study counts notable strengths. It presents and integrates the rich perspectives of children and teachers on the effects of an art-based intervention on acceptability, feasibility, and mental health, through semi-structured interviews, focus groups and observational data. The qualitative design selected for this study allowed participants to voice their reflections on the process and the perceived benefits of the intervention and directly share their experience in their own words. Children's perspectives are often not directly taken into account in published research, while they provide valuable information about their lived experience (29). This is especially true in the context of art making. As such, a considerable strength of this study resides in giving them a voice about the perceived benefits of the intervention, while triangulating their experiences with other sources of data. However, like all studies that rely on participant self-reports, potential desirability biases may have been at play. Observational data and other strategies were used to reduce this bias (87), but it is possible that the children and teachers were biased in reporting their perceptions about the intervention. This may also have been brought about by the dual roles of facilitators and researchers, which could have hindered the expression of negative perceptions of the intervention. This was partly overcome by presenting an open attitude with a genuine desire to improve the intervention to benefit other classes and children.

Another limitation lies in the identification of the children with SLCD included in this study. Indeed, the diagnosis was given by the school psychologist, who would determine if the child was eligible to be in the special needs classroom. However, the researchers did not have access to these diagnoses and did not know the severity of the SLCD of the children nor the exact prevalence of comorbidities. Hence, the transferability of the results may also be compromised by this limited information about the participants. Furthermore, in the researcher's observation, the children had a relatively high level of verbal expression, and communicated with a wide range of vocabulary, as can be seen in the chosen quotes. These were representative of the language level of the participants. Most challenges resided in receptive functions and only required speaking loudly, articulating clearly, and repeating at times. Nonetheless, obtaining verbal information from the population of children with SLCD remained a challenge for this study and constitutes a limitation, as children were perhaps not able to express everything that they desired during the interviews. Body language and general reactions were noted in the observational data to allow for further understanding of the children's experience beyond what they expressed verbally. Several children asked questions during the interviews, asked for certain words to be defined or repeated, and expressed themselves when they did not understand questions. These problems were addressed by using different wording, allowing the children a certain amount of time to express their thoughts, and using reflection to ensure comprehension. Upon reflection, diverse strategies that go beyond verbal expression in the interviews could be used, such as drawing and miming techniques (88). Member-checking involves checking with the participants whether the results reflect their experience and seem valid or accurate. This approach could also be used with children in future studies to ensure accuracy of results, and whether these resonate with the participants’ experiences to ensure the credibility of the results (89).

Furthermore, it is strongly recommended to continue evaluating factors associated with acceptability and feasibility over time, as some longer-lasting perceptions may be relevant (90). Implementing a longitudinal design would be recommended. Finally, the transferability or social validity of the present results remains limited to the specific population (children with SLCD) in a relatively small sample within a particular setting (elementary school in Quebec, Canada). The present school-based research had limited access to some information that could have given a better portrait of the samples (e.g., socioeconomic data). It is recommended to find ways to access and present this data without compromising the confidentiality of participants to gain a better portrait of participants. Future experimental studies, employing both qualitative and quantitative designs, are needed to better understand the extent of the impacts of art-based interventions on student mental health in elementary schools, specifically those with SLCD or in special education classrooms across various age groups, socioeconomic groups and for children with various comorbidities. Positive findings in the present work indicate that the intervention effectively addressed the needs of participants. However, the same intervention themes and mediums may not be relevant to all youth populations. Indeed, the adaptability of art therapy enables researchers to cater their approach to meet the unique needs of participants (28, 91). To ensure an intervention is culturally appropriate, it is strongly recommended to include community partners in the research process, particularly in the creation of an intervention (92).