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Children with autism spectrum disorders (ASD) are often referred to art therapy. To investigate what works in art therapy with children with ASD, the tacit knowledge of 8 experienced art therapists was explored through interviews. Promising components were arranged into the Context and Outcomes of Art Therapy (COAT) model. According to the respondents, art therapy with children with ASD contributes to becoming more flexible and expressive, more relaxed, and more able to talk about their problems in the therapeutic setting as well as in their home situation. Considering the evidence in this study, further empirical research into the process and outcomes of art therapy with children with ASD is strongly recommended.

The art therapy (AT) program for children diagnosed with Autism Spectrum Disorders (ASD), 'Images of Self', has been evaluated with repeated single case studies (n = 12) in a mixed-methods design. The program focuses on children's difficulties with their 'sense of self', 'emotion regulation', 'flexibility' and 'social behavior'. Parents, teachers and art therapists scored the BRIEF and CSBQ, instruments for rating child behavior. Children filled out the SPPC, a self-image scale. To evaluate the quality of the program, therapists used a child observation scale (OAT-A) and a therapists' self-evaluation scale (EAT-A). All instruments were applied three to five times per case, depending on the corresponding measurement objectives: one week before the start of the program (T0), during session 3 (T1), session 8 (T2), session 15 (T3), and 15 weeks after termination of the treatment (T4). Parents and teachers were invited to complete a form for qualitative comments which was structured around the four problem areas. Therapists video-recorded three sessions and evaluated these with parents and -during training sessions -with the principal investigator. At the end of the treatment parents, teachers and art therapists gave a rating for their overall satisfaction with the treatment. Main improvements after treatment were seen in children's flexible and social behavior. Overall satisfaction regarding the program showed averages between 7.1 and 7.7. Implications of our study for the AT-practice and future research are discussed.

Two instruments were developed and examined to enable treatment evaluation for art therapy (AT) with children diagnosed with Autism Spectrum Disorders (ASD). One instrument is the OAT-A (Observation in Art Therapy with a child diagnosed ASD), the other the EAT-A (Evaluation of actions of the Art Therapist during treatment of a child diagnosed ASD). Both scales were refined in a three round procedure. In each round raters (art therapists and students) observed and coded four videos of different AT sessions. For each round interrater reliability was tested and when necessary items were revised. In each round the first video was used for training purposes only. Both instruments showed in the third round an acceptable level of intercoder agreement. Using the OAT-A and EAT-A in clinical research requires extensive training of raters who preferably work in pairs, thereby enabling comparison of their assessments. It is concluded that important steps have been taken to enable systematic evaluation of art therapy with children diagnosed ASD including the actions of the art therapist.

Art therapy (AT) offers a specific treatment for developmental, social and behavioural problems of children with autism spectrum disorders (ASD). In this study typical elements of AT with ASD diagnosed children are specified and validated in a two-round Delphi study with 19 art therapists and 10 referrers. In the first round, relevance and applicability of the elements were rated. The degree of consensus per element was computed using the Gower coefficient. Results were subsequently, to the extent necessary, clarified by a focus group discussion involving seven professionals (five art therapists; one psychologist-ASD specialist; one social worker with an ASD diagnosis who is also a parent of an ASD diagnosed child). Consensus was achieved on 46 elements which relate to goals, means, and outcomes of AT, including therapists' appropriate attitude and behaviour. The findings are helpful to clarify the role of AT in treatments for children with ASD. Plain-language summaryChildren with autism are often referred to AT for a range of problems. Their self-image and selfesteem is often low. A lack of flexibility often appears in daily life and at school. Also these children often have difficulties in expressing themselves. These problems have consequences for their social behaviour.

12 the third circle. The outer circle frames the treatment Outcomes. The COAT-model and the descriptive results were used as building blocks in further studies. Research sub-question 2. Based on the literature, which typical elements in art therapy for children diagnosed with ASD can be identified that contribute to positive treatment outcomes? Children diagnosed with ASD are often referred to AT. The therapy seems promising for helping them with problems in the areas of social behavior, learning skills, and focusing attention (Schweizer, 2014; Teeuw, 2011). Also, there are some indications that improvements are generalized at home and in the classroom (Pioch, 2010). In this second study we systematically explored what evidence could be found in the research literature for 'working' elements of AT for children diagnosed with ASD. A search for intervention studies published between 1995-2012 was executed with relevant keywords (art, art therapy, Autism Spectrum Disorder, child, effect, outcome) using well-known databases: Cochrane, ERIC, MEDLINE, PubMED, psychINFO, ERIC, and Google. Assessment studies were excluded. The search did not find any intervention study that matched the criteria, also meaning that no systematic reviews, meta-analyses or RCTs could be identified. What we did find was a number of well-documented publications concerning art therapy for individual children diagnosed with ASD in the form of case descriptions that enabled a thorough content analysis. This analysis was structured according to the four categories of the COAT-model and resulted in a second description of promising elements of art therapy with children diagnosed with ASD. As a result of study 1 and 2 a substantial number of typical elements was identified. Our next aim was to compute the degree of consensus in a sample of art therapists and referrers regarding the relevance and applicability of these elements in daily practice. From the resulting list of consensus-based items two measuring instruments were developed for respectively observing the child's and the therapist's behavior during AT. This was because there was no instrument that could be used to monitor the behaviors of the main people involved in AT: the child and the therapist. Research sub-question 3. To what extent is there consensus among art therapists and referrers regarding the relevance and applicability in daily practice of typical elements of art therapy with children diagnosed ASD, identified in studies 1 and 2? 17 13 The scope of the third study was to determine the degree of consensus among experienced art therapists and referrers about the relevance and applicability of typical elements of art therapy with children diagnosed ASD. The input was the 'longlist' of elements (items) obtained from studies 1 and 2. For this third study the Delphi methodology was applied using a mixed-methods design. Additionally, a Focus group session was conducted to clarify some contradictory results from the Delphi study. The result was a 'shortlist' of elements with face valid...

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