<%D]DUJDQ63DNGDPDQ

Original Article

The Effectiveness of Art Therapy in Reducing Internalizing and

Externalizing Problems of Female Adolescents
Yasaman Bazargan MSc1, Shahla Pakdaman PhDƔ

Abstract
Objective: 7KHLQWHUQDOL]LQJDQGH[WHUQDOL]LQJSUREOHPVUHODWLQJWRFKLOGKRRGDQGDGROHVFHQWKDYHDOZD\VEHHQVLJQL¿FDQW%HFDXVHWKHUH
LVVSHFLDOFRQVLGHUDWLRQVLQHVWDEOLVKLQJFRPPXQLFDWLRQZLWKWKHPDQGKHQFHWKHWKHUDSHXWLFPHWKRGVIRUWKHVHSUREOHPVPXVWWDNHLQWR
DFFRXQWWKHVHFRQVLGHUDWLRQV$VHVWDEOLVKLQJDWKHUDSHXWLFUHODWLRQVKLSLVDQLPSRUWDQWFRPSRQHQWRIHIIHFWLYHFRXQVHOLQJLWVHHPVWKDWDUW
WKHUDS\PD\KHOSDOOHYLDWHWKHVHSUREOHPV7KHSXUSRVHRIWKLVVWXG\LVWRGHWHUPLQHWKHHIIHFWLYHQHVVRIDUWWKHUDS\LQUHGXFLQJLQWHUQDO-
L]LQJDQGH[WHUQDOL]LQJSUREOHPVRIDGROHVFHQWJLUOV±\HDUVROG
Method:7KLVLVDVHPLH[SHULPHQWDOVWXG\FDUULHGRXWLQWKHIRUPRIDSUHWHVWSRVWWHVWGHVLJQZLWKFRQWUROJURXS7KHSRSXODWLRQRIWKLV
VWXG\LQFOXGHVIHPDOHVWXGHQWVRI*ROH/DOHK6FKRRORI$UWLQGLVWULFWRI7HKUDQ,UDQRXWRIZKLFKVWXGHQWVZLWKLQWHUQDOL]LQJSUREOHPV
DQGLQGLYLGXDOVZLWKH[WHUQDOL]LQJSUREOHPVZHUHVHOHFWHGWKURXJKWDUJHWHGVDPSOLQJ6WXGHQWVZHUHUDQGRPO\DVVLJQHGWRFRQWURODQG
H[SHULPHQWDOJURXSV([SHULPHQWDOJURXSVSDUWLFLSDWHGLQSDLQWLQJVHVVLRQVGHVLJQHGEDVHGRQ$UWWKHUDS\WKHRULHVDQGSUHYLRXVVWXGLHV
7KHPDWHULDOXVHGIRUGLDJQRVLVRIWKHSUREOHPVLQSRVWWHVWDQGSUHWHVWZDVDQ$FKHQEDFKVHOIDVVHVVPHQWIRUP
Results:'DWDZHUHDQDO\]HGXVLQJDPL[HGDQDO\VLVRIYDULDQFH$129$2XUUHVXOWVVKRZHGWKDW$UWWKHUDS\VLJQL¿FDQWO\UHGXFHG
LQWHUQDOL]LQJSUREOHPV) PKRZHYHULWVHIIHFWLQUHGXFLQJH[WHUQDOL]LQJSUREOHPVZDVQRWVLJQL¿FDQW) P 
Conclusion:$UWWKHUDS\DVDSUDFWLFDOWKHUDSHXWLFPHWKRGFDQEHXVHGWRLPSURYHLQWHUQDOL]LQJSUREOHPV7RUHGXFHH[WHUQDOL]LQJSURE-
OHPVPRUHVHVVLRQVPD\EHQHHGHG7KXVIXWXUHVWXGLHVDUHUHTXLUHGWRLQVXUHWKHVH¿QGLQJV

Keywords:$UWWKHUDS\H[WHUQDOL]LQJLQWHUQDOL]LQJSDLQWLQJSV\FKRORJLFDOSUREOHPV

Cite this article as: Bazargan Y, Pakdaman S. The effectiveness of art therapy on reducing internalizing and externalizing problems of female adolescents. Arch Iran
Med. 2016; 19(1): 51 – 56.

Introduction The prevention programs are performed to prevent the emergence

and aggregation of internalizing and externalizing problems. Pre-
he psychological problems of children and adolescents are vention programs are mainly pursued in schools and child day-
T considered as ways to identify underlying reasons of many
disorders in adulthood. So, many researchers are interested
care centers.5 However, in more acute and advanced cases, drug
therapy can also be used for mitigation of severe and uncontrol-
in studying these problems. In some studies, the number of chil- lable symptoms of internalizing and externalizing problems of
dren and adolescents with severe problems requiring treatment is children and adolescents.5
estimated about 15% to 22%. Furthermore, a 20-year follow up Among various methods of psychotherapy, psychoanalytical ap-
study has shown that most children and adolescents suffering proaches have a special place in treatment of internalizing and
from psychological problems turn into adults with psychological externalizing psychological problems of children and adoles-
disorders in future.1 cents. Because these approaches provide the appropriate condi-
One of the frequently used dimensional categories for behav- WLRQVIRUPHQWDOUH¿QHPHQWDQGH[SUHVVLRQRIIHHOLQJVFRQFHUQV
ioral disorders of children and adolescents is classifying them in problems, and emotions. One of these psychoanalytical therapies
groups of internalizing and externalizing behavioral problems.2 is Art therapy; the treatment and healing of mental and psycho-
The internalizing problems include three symptoms scales of logical problems using art media in which the clients can reveal
anxiety/depression, withdrawal/depression and somatoform dis- what they have inside.6–8 Art therapy is the therapeutic use of art
orders. Reason behind this naming is that it includes internal prob- making, within a professional relationship. Art therapy combines
lems.3 On the other hand; the externalizing problems include two traditional psychotherapeutic theories with the nonverbal, creative
symptoms of rule-breaking and aggressive behaviors. The under- self-expression.9 Every art that can create a bridge between inner
lying reason behind the name of this syndrome is that it includes and outer experiences of the person have therapeutic basis. This
FRQÀLFWZLWKRWKHUV3 therapeutic approach leads the clients to perform new activities
The therapeutic interventions for internalizing and externalizing and enhances their experiences.10 Therefore, various art therapies
problems are mainly consisted of prevention programs, as well including theatre, music, dance, movement, and painting are in-
as different medicinal therapeutic and psychological treatments.4 creasingly used in therapeutic environments.11–16 Among different
$XWKRUV¶ DI¿OLDWLRQV Islamic Azad University- Qazvin Branch, Qazvin, Iran,
methods of Art therapy, painting techniques have been greatly
2
Shahid Beheshti University, Tehran, Iran. considered by researchers as a potential method to demonstrate
‡&RUUHVSRQGLQJDXWKRUDQGUHSULQWVShahla Pakdaman PhD, Assistant profes- an individual's inner feelings and emotions.17 Art therapy provides
sor at Shahid Beheshti University, Tehran, Iran. Tel: 021-29905348, Fax: 021-
29905301 , E-mail: S-pakdaman@gmail.com.
an individual with opportunities through which they can freely
Accepted for publication: 14 October 2015 express their feelings, affections, needs, and even knowledge.18

Archives of Iranian Medicine, Volume 19, Number 1, January 2016 51

 7KH(IIHFWLYHQHVVRI$UW7KHUDS\

Previous studies have shown that individuals with the experience dents (14 – 18 years old) who were attending an art schools in dis-
RIPHQWDOWUDXPDFDQEHQH¿WIURPSDLQWLQJE\DFKLHYLQJDIHHOLQJ trict 3 in Tehran, Iran between from 2013 to 2014. Using targeted
of security toward unpleasant memories of a traumatic event. The sampling, 30 students with internalizing problems were selected
HPRWLRQVDQGWKRXJKWVDUHLQÀXHQFHGE\FRQÀLFWVIHDUVDQGGH- and randomly assigned into experimental and control groups.
sires and painting allows clients to express them in a symbolic Similarly, 30 students with externalizing problems were chosen
way.19 Art making, within the context of the therapeutic relation- and randomly assigned to experimental and control groups. The
VKLSSURYLGHVDVDIHQRQYHUEDOPHDQVH[SUHVVLQJGLI¿FXOWHPR- selection process was based on students’ scores in the Achenbach
tions, allowing individuals to confront, work through, and even- System of Empirically Based Assessment (ASEBA) considering
tually integrate aspects of the illness experience that may have test cut points (+2 standard deviations from the mean for internal-
previously seemed unspeakable. Art therapy further offers indi- izing problems and +1.3 standard deviations from the mean for
viduals opportunities to regain a sense of personal agency, to ex- externalizing problems). To ensure adequacy of sample size, the
plore existential concerns, and to reconnect to the physical body.20 necessary number of subjects for this study was calculated using
Although painting has a long history in human life,21 in the G-Power software that is used frequently in medical and behav-
¿HOGRISV\FKRORJ\LWKDVEHHQQRWLFHGVLQFHWKHHDUO\WZHQWLHWK ioral studies. The input parameters entered into the software were
century. For example, an artistic book based on the paintings of HIIHFWVL]HRIĮHUURUSUREDELOLW\RIȕHUURUSUREDELO-
mental patients in an asylum22 was published in 1922. Moreover, ity of 0.95, as well as the correlation between repeated measures
psychoanalysts began to analyze the neurotic behaviors of adults of 0.75. Using these parameters, resulted in a total sample size
using free painting. This newly established branch rapidly found of 30 subjects that is similar to the sample size obtained based
its place as an essential parameter in the effort of psychologists on previous criteria. Randomization of subject assignment into
such that in 1958, Kramer used painting to treat the emotional experimental and control group accomplished by subjects names
disorders in children.23 DOSKDEHWLFDOVHTXHQFH7KHPDLQHQWU\FULWHULDWRWKH¿QDOVDPSOH
Recent studies have also demonstrated that Art therapy is a for internalizing groups (experimental and control) was gaining
practical technique for multiple purposes including testing, diag- a score equal or above +2 standard deviations in internalizing
nosis, and treatment.24–26 A local study, for instance, was carried problems while having a score below +1.3 standard deviations in
out with the aim of increasing the creativity of secondary school externalizing problems. The main entry criteria for externalizing
students and decreasing their anger intensity.27 He concluded that groups (experimental and control) was gaining a score equal or
Art therapy (painting techniques) has been effective in reducing above +1.3 standard deviations in externalizing problems while
internalizing and externalizing angers. In another study, Mohtash- having a score below +2 standard deviations in internalizing prob-
am investigated the effect of painting in reduction of emotional lems. Test scores of subjects who missed 3 or more session, had
problems of hearing-impaired children using an experimental re- health related problems, and provided incomplete pre and post
search design. Art therapy has been an ongoing facet of some edu- WHVWVZHUHH[FOXGHGIURPWKH¿QDODQDO\VHV
cational intervention programs for several decades.28 According
to Kim and recent documents,29 art therapy has been globalized Measures
as a topic of discussion at the American Art Therapy Association.
Overall, various art therapy methods, especially painting pro- The history of artistic interest and activities scale
YLGHD¿QHFRQWH[WIRUHPRWLRQDOUHOHDVHDQGKHOSZLWKLPSURYLQJ To control for the confounding effects of having a history of ar-
mental disorders. The emotional component is one of the main tistic activities and interest on Art therapy subjects were asked: a)
dimensions of different kinds of psychological problems of chil- How much have you been engaged in artistic activities? b) How
dren and adolescents (internalizing and externalizing). Children much are you interested in such activities? The subjects’ respons-
DQG DGROHVFHQWV PLJKW IDFH GLI¿FXOWLHV LQ FRPPXQLFDWLQJ ZLWK es were measured on a scale of 1 (very low) to 5 (very much).
therapists due to their age, as well as cognitive and emotional fea-
tures. Art therapy techniques can improve communication due Achenbach System of Empirically Based Assessment (ASEBA)
to its simple language without using unnecessary jargon. Thus, To evaluate internalizing and externalizing problems, Achen-
the main purpose of this research is whether Art therapy (painting bach System of Empirically Based Assessment (ASEBA) was
techniques) can be effective in reducing the internalizing and ex- used.3 This self assessment questionnaire for adolescents includes
ternalizing psychological problems of female adolescent students 112 items and is normalized for 11 to 18 year-old individuals. The
attending Art schools. questions have been designed to evaluate emotional behavioral
problems, social problems and desired social behaviors. The em-
Materials and Methods pirically based symptom scales include anxiety/depression, with-
drawal/depression, somatoform complaints, rule-breaking and
Procedure DJJUHVVLYHEHKDYLRUV7KH¿UVWWKUHHFDVHVFRQVWLWXWHLQWHUQDOL]LQJ
This study applies a semi-experimental research design using a problems and the last two constitute externalizing problems. The
pretest-posttest with the control group. The procedure consists of test scores range between 0 – 2. 0 = it does not apply to me; 1 = it
two separate tests performed in parallel, each having a control and is somehow and occasionally true for me; and 2 = it is completely
H[SHULPHQWDOJURXS7KH¿UVWWHVWZDVSHUIRUPHGRQLQGLYLGXDOV and often true for me. Minimum and maximum scores for inter-
with internalizing problems and the second one on individuals nalizing problems are 0 to 62, and for externalizing problems are
with externalizing problems. 0 to 64. These scores were turned into T scores using a T-table.
The clinical range for internalizing problems is T scores above
Population, Sample and Sampling method 69 and for externalizing problems is T scores above 63. The inter-
The population of this study includes all female adolescent stu- QDOFRQVLVWHQF\FRHI¿FLHQWIRUPRVWHPSLULFDOO\EDVHGV\PSWRP

52 Archives of Iranian Medicine, Volume 19, Number 1, January 2016

 <%D]DUJDQ63DNGDPDQ

Figure1. 7KHLQWHUDFWLYHHIIHFWRIJURXSDQGHYDOXDWLRQWLPHRQWKHLQWHUQDOL]LQJSUREOHPV

scales has been reported as satisfactory and desired such that their Results
Cronbach Alpha is above 0.6. The test- retest validity of Achen-
bach scales, including the Youth Self-Report (YSR) have been Due to the drop out of subjects through sessions and in the post-
assessed with time interval of 5 to 8 weeks and all correlation test phase, the number of valid data for analysis in the internal-
FRHI¿FLHQWVEHWZHHQ¿UVWDQGVHFRQGWHVWVZHUHVLJQL¿FDQWP < izing group included 14 subjects in the experimental group and 13
0.05). Furthermore, the study of construct validity has shown that subjects in the control group (one subject omitted from analysis
3HDUVRQFRUUHODWLRQFRHI¿FLHQWVEHWZHHQHPSLULFDOO\EDVHGVFDOHV because of disappearing in 3 art therapy sessions and two subjects
DUHDOOVWDWLVWLFDOO\VLJQL¿FDQWP < 0.01).30 were exited from analysis because their questionnaires in post-
test were imperfect). The age means of control and experimental
Intervention package of Art therapy groups in internalizing group were 16.35 and 16.23, respectively.
Art therapy intervention in the experimental group to reduce The independent tWHVWVKRZHGQRVLJQL¿FDQWGLIIHUHQFHVEHWZHHQ
psychological problems included six painting sessions. Mul- them (t(25)= -0.27, P = 0.78). The age of experimental and control
tiple resources were applied to organize this package.22–27,31 The groups for internalizing and externalizing problems was 16.46
required materials in all sessions include cardboard and acrylic DQGUHVSHFWLYHO\7KHLQGHSHQGHQWWWHVWVKRZHGQRVLJQL¿-
paint for drawing and painting. Using this package, which con- cant differences (t(23)= -0.01, P = 0.92).
sists of six 1.5-hour sessions, the therapist interacted with subjects In the internalizing group, the mean regarding the history of ar-
IRUWKH¿UVWPLQXWHVRIHDFKVHVVLRQDQGH[SODLQHGWKHVHVVLRQ tistic activities for the experimental and the control groups was
plan. According to the plan, subjects had 45 minutes to one hour  DQG  UHVSHFWLYHO\  ZKLFK ZHUH QRW VLJQL¿FDQW W(25)=
to draw. At the end, based on the session plan subjects had 15 0.34, P = 0.73). Also, the mean regarding the interest in artistic
minutes to talk with the therapist and other members about works, activities for the experimental and control groups was 3.92 and
feelings, interests and events.  UHVSHFWLYHO\ ZKLFK ZHUH QRW VLJQL¿FDQW W(25)= 0.55, P =
7KHWRSLFRIHDFKVHVVLRQZDVDVIROORZV¿UVWVHVVLRQZDUP 0.58). In the externalizing group, the mean for the history of artis-
up activities using painting and coloring; second session: learning tic activities for the experimental and the control groups was 2.84
DERXWDUWPHGLDWKLUGVHVVLRQJHQHUDOWRSLFVIRXUWKVHVVLRQ¿UVW DQG  UHVSHFWLYHO\ ZKLFK ZHUH QRW VLJQL¿FDQW W(23)= 1, P =
FKLOGKRRGPHPRU\IDPLO\UHODWLRQVDVZHOODV¿IWKVHVVLRQWKH 0.33). Also, the mean for the interest in artistic activities was 3.58
directed mental image, visualization, dream and meditation; sixth DQGUHVSHFWLYHO\ZKLFKZHUHQRWVLJQL¿FDQWW(25)= 0.55, P =
session: anger releasing. 0.58). Table 1 includes total subjects’ scores in pre-test and post-
test for internalizing and externalizing problems.
Procedures To answer the research question about internalizing and exter-
All subjects did not attend in one session and the number of in- nalizing problems, two separate analyses were performed. There
dividuals in different classes varied from 3 to 15. The sessions was a between group, independent variable (experimental and
were generally held in the volume and maquette or publishing control groups) and a within group, independent variable (evalu-
workroom where there was a better space for painters. The time DWLRQLQSUHWHVWDQGLQSRVWWHVWLQWKLVVWXG\ZKLFKKDGVWUDWL¿HG
of classes was set in tune with teachers from 8(when the school scales. The level of measurement of dependent variable (the rate
started) to 14 (when the school closed). At the end of Art therapy of internalizing problems- the rate of externalizing problems),
interventions of experimental groups, Achenbach System of Em- however, was interval. Therefore, mixed Anova was used for
pirically Based Assessment was re-implemented as posttest on the DQDO\]LQJGDWD7KHUHVXOWRIWKH¿UVWDQDO\VLVIRUWKHLQWHUQDOL]LQJ
subjects of control and experimental groups. problems is presented in Table 2. In addition, before performing
the analysis, the hypotheses of analysis (The Sphericity Assump-

Archives of Iranian Medicine, Volume 19, Number 1, January 2016 53

 7KH(IIHFWLYHQHVVRI$UW7KHUDS\

Table1. 7KHPHDQDQGVWDQGDUGGHYLDWLRQRIWKHVFRUHVRILQWHUQDOL]LQJDQGH[WHUQDOL]LQJSUREOHPVLQSUHWHVWDQGSRVWWHVWLQWHUPVRIFRQWURODQG
H[SHULPHQWDOJURXSV
Pretest Posttest Total
Group
Mean 6' Mean 6' Mean 6'
Internalizing
Experimental 33.57 4.65 27.57 3.75 30.57 3.6
Control 34.77 2.35 35.53 5.34 35.15 3.64
Total 34.14 3.7 31.4 6.05 32.77 4.24
Externalizing
Experimental 31 6.6 26.53 8.2 28.76 6.67
Control 29.41 4.85 30.25 8.9 29.83 6.31
Total 30.24 5.76 28.32 8.57 29.28 6.4

Table2. 7KHUHVXOWVRIPL[HG$129$IRULQYHVWLJDWLRQRIWKHHIIHFWRI$UWWKHUDS\RQWKHLQWHUQDOL]LQJSUREOHPV
Source SS df MS F Sig. (WDFRHI¿FLHQW
Between group
Group 283.1 1 283.1 10.8 0.005 0.3
Error 655.24 25 26.21
Within group
Evaluation time 92.21 1 92.21 10.52 0.005 0.29
Group* Evaluation time 154.44 1 154.44 17.61 0.001 0.41
Error 219.5 25 8.76

Table3. 7KHUHVXOWVRIPL[HG$129$WRHYDOXDWHWKHHIIHFWRI$UWWKHUDS\RQH[WHUQDOL]LQJSUREOHPV
Source SS df MS F Sig. (WDFRHI¿FLHQW
Between group
Group 14.13 1 14.13 0.16 0.68 0.007
Error 1946.95 23 84.65
Within group
Evaluation time 41.07 1 41.7 1.84 0.18 0.07
Evaluation time*group 87.47 1 87.47 3.93 0.06 0.14
Error 511.45 23 22.23

tion and Homogeneity of error variance) were controlled. Due to of Leven test also showed that the values of error variance be-
the fact that between group variable has two levels, the Sphericity tween groups were equal in pretest and posttest (for pretest: F(1,25)=
of the data is automatically met and there was no need to perform 3.28, P = 0.08 and for posttest: F(1,25)= 1.77, P = 0.19).
the Mauchly’s test. The results of Leven test also showed that er- The results of the analysis show that the interactive effect of
ror variance values between groups in pretest and posttest were group and evaluation time on externalizing problems is not sig-
equal (for pretest, F(1,25) = 3.28, P = 0.08 and for posttest, F(1,25)= QL¿FDQW KRZHYHU WKH PYDOXH LV YHU\ FORVH WR VLJQL¿FDQW OHYHO
1.77, P = 0.19). 7KHVLJQL¿FDQFHOHYHORIDQGHIIHFWVL]HRIGHWHUPLQHV
The results of mixed analysis of variance (ANOVA) show that WKDWODFNRIVLJQL¿FDQFHLVSUREDEO\GXHWRWKHORZSRZHURIWHVW
the interactive effect of group and evaluation time on internalizing or the issues related to using independent variable. Thus, it can be
SUREOHPVZDVVLJQL¿FDQWLQ7KLVPHDQVWKDWDOWKRXJKWKHUH concluded that there is not enough evidence for effectiveness of
ZDVQRVLJQL¿FDQWGLIIHUHQFHEHWZHHQSUHWHVWDQGSRVWWHVWLQLQ- Art therapy in the reduction of externalizing problems of female
ternalizing problems in control group, in the experimental group, adolescent students in Art schools.
WKHVFRUHVRISRVWWHVWZHUHVLJQL¿FDQWO\ORZHUWKDQWKHVFRUHVRI
pretest (Figure1). 'iscussion
Concerning the performed analyses, it can be concluded that Art
therapy can effectively reduce internalizing problems of female $FFRUGLQJWRRXUGDWDWKHUHZDVDVLJQL¿FDQWGHFUHDVHLQLQWHU-
adolescent students of Art schools. nalizing problems of the test group as a result of six Art therapy
The result of the second analysis for externalizing problems is sessions. However, the reduction of externalizing problems was
presented in Table 3. Before performing the analysis, the hypoth- QRWVLJQL¿FDQW
eses of analysis (The Sphericity Assumption and Homogeneity The review of previous studies in which the effect of Art therapy
of error variance) were controlled. Because of the within group on multiple problems has been investigated shows that the results
variable, which has 2 levels, the Sphericity Assumption was met of the present study are compatible with some studies and incom-
and there was no need to perform the Mauchly’s test. The results patible with others. For example, Huges-Brand studied a group of

54 Archives of Iranian Medicine, Volume 19, Number 1, January 2016

 <%D]DUJDQ63DNGDPDQ

14 to 18 year- old Juvenile offenders and concluded that the ado- themselves into the school and, if so, what should be their role
lescents who received Art therapy reported lower social-family with teachers and parents?35
issues,32 had lower symptoms of depression, anxiety and obses- In addition, it seems that the therapeutic package used in this
sive-compulsive behaviors, as well as a better relationship with study is more suitable for adolescents with internalizing problems
their parents. Similarly, in the present study, the depression and since its emphasis is mainly on the expression of emotions and
anxiety decreased as subgroups of internalizing problems. This impulses, which is the exact problem of these adolescents. But,
is also similar with the result of a new research on 222 children.25 the problem of adolescents with externalizing behavior is most-
Dabaq and Khajeh Pour also studied the effect of Art therapy in ly about managing these emotions rather than their expression.
reduction of depression, anger and anxiety in girls who were vic- Thus, future studies are recommended to improve this interven-
tims of sexual abuse. Their study had a semi-experimental pretest- tion based on regulation and control of the emotions and evalua-
posttest research design and concluded that this intervention is ef- tion of its effectiveness on externalizing problems.
fective in the reduction of depression, anger and anxiety in these Another important limitation of this study is that the sample was
individuals.27 Since anxiety and depression are the subgroups of limited to girls. Since the internalizing and externalizing problems
internalizing problems the results of the present study are consis- have different distribution in both genders, it is recommended that
tent with the above mentioned study on the reduction of internal- future studies consider this issue. Another limitation had to do
izing problems. However, since anger is the subgroup of external- with the study sample that was an artistically oriented one, which
izing problems, the results of present study are inconsistent with could yield exaggerated effects and limit generalization of our
that study in the reduction of externalizing problems. There is an ¿QGLQJV
important limitation to the present study, which can limit the gen-
HUDOL]DWLRQRILWV¿QGLQJ7KLVKDGWRGRZLWKRXUVWXG\ZKLFKZDV References
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56 Archives of Iranian Medicine, Volume 19, Number 1, January 2016