Practitioner Review: Effectiveness and mechanisms of change in participatory arts-based programmes for promoting youth mental health and well-being – a systematic review

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Introduction
A recent report by the UK Education Policy Institute (Crenna-Jennings & Hutchinson, 2020) suggests that many children and young people (CYP) continue to experience serious difficulties in accessing highquality mental health services.There is a pressing need for accessible, cost-effective, and acceptable alternative provision for delivery in community settings.Participatory arts-based (PAB) programmes have been gaining recognition as a non-clinical, CYPfriendly approach that could contribute to the promotion, prevention, and early intervention agenda in UK Child and Adolescent Mental Health Services (CAMHS; O 'Donnell, Lohan, Oliffe, Grant, & Galway, 2022).
Participatory arts-based (PAB) activities are a form of art (including music, dance, theatre, visual arts, storytelling, poetry, and film) involving active engagement (e.g.creating and performing) and collaboration with those taking part during the creative process.They are usually facilitated by artists or arts practitioners in the form of group workshops (O 'Donnell et al., 2022) and delivered in community settings, such as schools, youth centres, and justice sites.PAB approaches contrast with arts therapies and interventions delivered by trained therapists in clinical settings, using clinical approaches alongside art and creativity to support emotional work (Kalmanowitz et al., 2019).They are also distinct from other community-led arts programmes, such as choral singing or life drawing, which often emphasise the use of artistic engagement as a resource for building social inclusion and supporting mental well-being, but are similarly delivered to receptive participants, rather than participatory involvement in creative processes, such as through composing, co-creation, or design.
There has been increasing recognition over the last decade of the importance of meaningful participation for promoting the well-being, social connection, and agency of CYP (Pavarini et al., 2021;van Bijleveld, Dedding, & Bunders-Aelen, 2015).Creating the space for youth voices to be heard and prioritised in decision-making related to social care and in mental health research has provided the opportunity for services, interventions, and research processes to be co-produced, helping make them more responsive to CYP's needs and expectations (Pavarini et al., 2021;van Bijleveld et al., 2015).Processes of co-creation in PAB programmes likewise make it possible to tailor engagement and therapeutic benefits for mental health to particular individuals and groups (Pavarini et al., 2021).Dialogic engagement enables artists and practitioners to draw on the experiences of the CYP involved, ensuring participation is meaningful for them (Lowe, 2012).
There are new opportunities to expand the delivery of PAB programmes in the United Kingdom, including the launch of social prescribing (https://www.england.nhs.uk/personalisedcare/social-prescribing/) and the devolved commissioning of services to meet local needs (Health and Social Care Act, 2012).Social prescribing, which includes 'Arts on Prescription' (AoP), links people receiving primary care services with sources of non-medical support in the community usually via the voluntary and third sector (Bungay & Clift, 2010).A recent systematic review (SR) evaluating UK social prescribing schemes in community settings identified several outcomes related to promoting good mental health and well-being from AoP projects including increased self-esteem, self-confidence, and positive mood, and reduced social isolation, anxiety, depression, and negative mood (Chatterjee, Camic, Lockyer, & Thomson, 2018).There are policy development calls for more research on how social prescribing can best involve CYP in PAB programmes to reduce mental health problems and increase wellbeing (Fancourt, Warran, & Aughterson, 2020).

The evidence landscape
Before considering the evidence landscape relating to PAB programmes, it is important to clarify what the term 'mental health' encompasses and how it relates to well-being.The notion of what it means to have 'good mental health' has come to have two distinct meanings.In the medical literature, it is usually defined as the absence of mental health problems (Granlund et al., 2021;Westerhof & Keyes, 2010), whilst the World Health Organization (WHO, 2005) explicitly aligns it to 'well-being'.The dual-continua model (Granlund et al., 2021;Westerhof & Keyes, 2010) integrates both meanings, conceptualising mental health as involving two distinct but related continua, modelled as two cross-cutting axes with one focussed on mental health problems (from less severe mental strain to more severe symptoms fulfilling criteria for mental illness) and the other on degree of well-being (from flourishing to languishing).Seeking to combine the hedonic ('feeling good') and eudaimonic ('doing well') aspects of well-being, Keyes, Shmotkin, and Ryff (2002) link flourishing to high scores in emotional, psychological, and social well-being and languishing to the opposite.Different PAB programmes for CYP have employed outcome measures that test for a reduction in mental health problems and for increases in well-being, or in closely related psychological states, such as self-esteem.
The positive impact that PAB programmes can have on mental health problems in CYP such as anxiety and depression and on well-being is widely reported (All-Party Parliamenatary Group on Arts, Health and Wellbeing, 2017;Fancourt & Finn, 2019;Fancourt et al., 2020;Tymoszuk, Perkins, Spiro, Williamon, & Fancourt, 2020).A rapid review (RR) of performing arts programmes (including music, drama, singing, and visual arts) for young people (11-18 years) found that the most commonly reported outcomes related to well-being were increased self-confidence and selfesteem, a sense of achievement and empowerment, improved social skills, and positive behavioural changes, which could be helpful for mental health (Bungay & Vella-Burrows, 2013).Similarly, Zarobe and Bungay's (2017) RR of PAB programmes for adolescents reported positive impacts on resilience, self-confidence, and self-esteem.Fancourt et al.'s (2020) government-commissioned report concluded that the evidence base for the use of PAB for CYP is strong enough to be used for policy development.Clift, Phillips, and Pritchard (2021), however, give a more negative assessment, criticising the two commissioned government scoping reviews cited above (Fancourt et al., 2020;Fancourt & Finn, 2019) for overclaiming on the effectiveness of PAB programmes, highlighting a number of methodological issues in included studies and the very diverse nature of studies included, which make drawing conclusions problematic.Bungay and Vella-Burrows (2013) and Zarobe and Bungay (2017) also note a number of methodological weaknesses in studies, including attrition, use of non-standardised measures, and poor questionnaire completion.

Practice-based evidence and mechanisms of change
In addition to methodological issues, Zarobe and Bungay (2017) and others (De Witte et al., 2021;Raw & Mantec on, 2013) highlight a knowledge gap in our understanding of key mechanisms of change in PAB programmes involving collaborative engagement.Better characterisation and conceptualisation of these, including in what ways they might be shaped by contextual factors, such as population and art form, would increase understanding of how mental health benefits for CYP come about, as well as helping guide future programme design.
Increasing demands in recent years for PAB studies to better evidence outcomes using robust quantitative evaluation methodologies to inform commissioning and scale-up decisions (Clift et al., 2021;Crossick & Kaszynska, 2016;Daykin, De Viggiani, Moriarty, & Pilkington, 2017) have perhaps overshadowed the potential of practice-based evidence to offer rich, contextualised, and robust insights in the early stages of mapping mechanism of change.Studies reporting on PAB programmes using qualitative approaches often provide detailed process-focussed analyses of interview, focus group, and observational data.Artists and arts practitioners are in a position to offer nuanced and reflexive accounts of their practice that recognise the complexities of their own and young people's involvement, the cultural context in which the arts activities take place and the artistic process (Clift et al., 2021).They can report on aspects of the arts practice that facilitate, or hinder, change and the role played by the art form itself in this.Analysis of the accounts of CYP can inform our understanding of what does, or does not, work for them and why, whilst cross-case analyses of individual experiences can tell us more about common and specific pathways of change.

Rationale for current systematic review
Whilst two previous reviews have examined the impact of PAB programmes for CYP on reducing mental health problems and increasing well-being (Bungay & Vella-Burrows, 2013;Zarobe & Bungay, 2017), both were conducted several years ago, employed rapid review methodologies, did not undertake a detailed formal critical appraisal of included literature, and focussed only on children aged 11-18.A RR is a form of knowledge synthesis that speeds up the process of conducting a traditional systematic review (SR) by simplifying or omitting some of the steps (Garritty et al., 2021).This can introduce bias, raising concerns about the reliability and validity of the findings.There is a need for a SR that provides a detailed formal critical appraisal of the literature, includes a wider age range of CYP, and integrates qualitative evidence relating to mechanisms of change in addition to considering effectiveness outcomes.Integrating findings relating to processes of change in PAB programmes from included studies will help address gaps in knowledge and increase impact, informing the development, deployment, and ongoing research evaluation of PAB studies.This SR addresses the following questions, the first in relation to the quantitative data and the second through a metasummary of the qualitative data:

Search strategy
The review protocol was registered on PROSPERO (No. CRD42022343497) and follows the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines (Moher et al., 2009).A systematic search was conducted of 11 electronic databases: MEDLINE, PsycINFO, CINAHL, Arts & Humanities Citation Index, Social Science Citation Index, Art and Architecture, ERIC, British Education Index (BEI), Scopus, Child and Adolescent Studies, and RILM.An initial search strategy was developed in consultation with a subject librarian and previous related systematic reviews (Bungay & Vella-Burrows, 2013;O'Donnell et al., 2022;Zarobe & Bungay, 2017).This search strategy, which used a combination of controlled vocabulary and free-text terms (see Appendix S1 for the search strategy as applied to the EBSCO MEDLINE database), was subsequently refined through an iterative process and adapted according to subject headings and keywords for each database.To supplement the electronic database search, we hand searched the reference lists of included studies and relevant systematic reviews for potentially eligible articles missed in the database search.
Eligibility criteria.The search was restricted to empirical articles published in English in peer-reviewed journals during the past 10 years (from 01 January 2012 to 01 November 2022) reporting on the use of PAB programmes across all art forms delivered by arts practitioners or artists to improve the mental health and/or mental well-being of CYP aged 4-25 years.Studies involving only CYP under 4 were excluded, as their ability to enter into processes of co-production is more limited and likely to be mediated by a parent or caregiver.The search was restricted to the previous 10 years due to escalation of PAB programmes in the previous decade and to keep the focus on current practice.Art forms included the following: (a) performing arts (music, dance, and theatre); (b) visual arts, design, and craft; (c) literature; and (d) online, digital, and electronic arts.Studies reporting on mental wellbeing or mental health outcomes that were not planned for at the outset, but which arose in the course of a PAB programme, were included.Studies including measures testing for psychological states (e.g.self-esteem and self-confidence) about which there is a lack of consensus regarding whether they are related or central to well-being (Martela & Sheldon, 2019) were also included.
Studies were restricted to participation that required 'active engagement' (e.g.creating and performing) where the practice described was collaborative.Articles reporting on arts activities involving 'passive engagement' (e.g.watching a play or where arts activities were used as a distraction) or where the focus was primarily on skill development, so involving more directed engagement towards a goal specified at the outset (e.g. the El Sistema music programme), were excluded.Studies delivered by arts therapists were excluded, as were those that primarily focussed on physical illnesses or serious mental conditions (e.g.personality, bipolar, cognitive, and/or psychotic disorders) and involved predominantly CYP with severe learning difficulties (over 50%), which would require different participatory processes.

Screening and selection of articles. All search results
were exported to an EndNote library, where duplicates were identified and removed.All remaining citations were uploaded to Covidence for article screening (www.covidence.org).Four authors were involved in the screening and selection of eligible studies (EW, SG, HN, and AK).The title and abstract of each article were independently screened by two authors to identify potentially relevant studies.Discrepancies were resolved through consultation with the lead author (EW).The full-text versions of all potentially relevant articles were then retrieved for eligibility assessment.Where it was unclear from the title and abstract screen whether an article met the inclusion criteria, the full-text article was reviewed.Two independent reviewers from the review team screened all full-text articles to evaluate whether they met the selection criteria.Any disagreements were resolved by consensus discussion with the first author.Where an agreement was not reached, a third member of the review team was consulted.Reasons for excluding studies were documented using the Covidence software.
Data extraction.Data from all included articles were extracted using a template created for this review (EW extracted data from all included articles; SG extracted data from six articles to quality assure the process).Extracted data for each included article were written up as a narrative summary of the study and sent to an additional author who was a specialist in the specific PAB activity in the study.They checked the extracted data to ensure accuracy and completeness.Disagreements were resolved via discussion.The predefined categories for extraction were as follows: (1) publication details: first author, year, and country; (2) aim(s) and/or research question(s); (3) theoretical/conceptual frameworks adopted; (4) population demographics and recruitment; (5) details of the PAB programme, including nature of arts activities, setting, duration, and timing of sessions; (6) study methodology; (7) study outcomes related to mental well-being and/or mental health; (8) acceptability indicators; and (9) reported mechanisms of change reported and contexts in which they occurred.
• Recruitment: Via social media and posters at a youth centre a year, whilst n = 2 studies lasted 2 days to one week.The arts-based activities included music (n = 9), visual arts (n = 6), theatre (n = 4, one of combined creative writing and theatre), and dance (n = 3).PAB programmes were conducted in various community settings, including schools (n = 10), community and youth centres (n = 2), an art studio (n = 1), justice sites (n = 1), an arts museum (n = 1), and a gym (n = 1).In a few cases (n = 4), the setting was not specified, and some took place across multiple community sites (n = 2).Table 2 presents additional information about acceptability indicators for PAB programmes.Acceptability relates to the extent to which people delivering/receiving an intervention consider it to be appropriate, based on anticipated or experienced cognitive and emotional responses (Sekhon, Cartwright, & Francis 2017).

Critical appraisal
Methodological quality appraisal was conducted independently by two reviewers for each paper using the Mixed Methods Appraisal Tool 2018 (MMAT) (Hong, Gonzalez-Reyes, & Pluye 2018).There were high levels of agreement (>80%) with a third reviewer helping resolve discrepancies.Methodological quality was categorised as follows: weakmeeting two criteria or less; moderatemeeting three or four criteria; or strongmeeting all five criteria (see Tables 1 and 2).
Quantitative Qualitative studies.Highly rated qualitative studies (n = 3) clearly specified the theoretical perspectives shaping data collection and analysis.
There was a clear link between data sources, data collection, analysis, and interpretation.They described methods of data collection and analysis clearly.Sufficient concrete examples of the original data were presented to both illustrate the analytic procedure(s) used and provide evidence that the findings were well-grounded in them.The data were appropriately (neither under-nor over-) analysed, with nuances and complexities clearly portrayed and diversity considered and explained.Lower rated (weak and moderate) qualitative studies (n = 10), and qualitative components of mixed-methods studies (n = 4), included one or more methodological flaws.The most common issues included insufficient detail about the PAB activities and steps taken to analyse the data.Confirmability and credibility were undermined by a lack of balance between the analytic commentary and original data.Either too little data were included to fully support the analytic claims made, or conversely, not enough analytic commentary was given to provide an adequate interpretation of the data.Both limited the number of findings that could be extracted from the study for the metasummary presented below.There was also a lack of attention to diversity in the data, with subtleties and complexities not addressed, and the data insufficiently contextualised and situated.

Effectiveness of PAB programmes
The 10 studies reporting quantitative data collectively used 15 different measures to evaluate outcomes relating to CYP's mental health and well-being (see Table 1 found an increase of 4 points, which is above the level for clinical significance (3 points).However, Efstathopoulou and Bungay (2021) found that this improvement was not sustained at the three-month follow-up.Likewise, Archambault et al. ( 2020), who used the WHO-5 to evaluate young people's mental well-being, found that post-programme gains were not maintained at the 3-month follow-up.In contrast to other studies, Cal o et al. ( 2020) found no significant increase in mental well-being, using the Life Satisfaction Measures of Personal Well-being (ONS National Wellbeing Programme) following young people's participation in a series of participatory music workshops.A RCT study (Philipsson et al., 2013) found a significant increase in quality of life (QoL) score (as measured by the Health Utility Index Mark 3 (HU3) in the treatment group at 4, 8, 12, and 20 months, suggesting it was being maintained over time.However, there are some methodological weaknesses in the study, including that the validity and reliability of the Swedish version of the QoL measure used have not been tested and there were also differences in baseline between the treatment and control groups.
Self-esteem.Two studies (Miao & Stewart, 2022;Wood et al., 2013) evaluated young people's selfesteem using Rosenberg's Self-Esteem Scale (RSES).One lasting 10 weeks identified a significant effect post-intervention (Wood et al., 2013) and the other (Miao & Stewart, 2022), very short intervention (1 week), did not.However, the wording of the items in the RSES used in the study by Wood et al. (2013) was altered after the pre-test to make it more understandable, invalidating the pre-to postcomparison.
In addition to the wording of items being changed to improve understanding mid-way through the study described above (Wood et al., 2013), Efstathopoulou and Bungay (2021) report that CYP had difficulty understanding some of the questions in the WEMWBS, for example asking the meaning of 'optimistic'.Daykin et al. (2017), who initially planned a mixed-methods study, abandoned the quantitative data on the basis that the participating young people in the justice settings were observed to engage 'in banter, conferring and joking' (p944) with each other, during completion.This suggests that there are issues with the measures themselves that need to be addressed.

Mechanisms
A qualitative metasummary was undertaken to integrate findings relating to mechanisms of change reported in the qualitative studies with a view to addressing our second research question.Qualitative metasummary integrates the manifest content of qualitative study findings organised into topics or themes, via statements of the findings, as opposed to producing interpretative syntheses represented by integrating concepts, models, or metaphors (Sandelowski, Barroso, & Voils, 2007;Thorne, Jensen, Kearney, Noblit, & Sandelowski, 2004).The metasummary process involves the following: (a) extracting relevant statements of findings from included studies and then (b) consolidating these statements into a smaller set of abstracted findings.
Extraction.A working definition of findings of relevance was established to guide data extraction: this was, 'any second-order findings relating to the mechanisms or processes of change impacting on well-being or mental health outcomes of CYP reported in the included qualitative papers.This includes specified pathways by which change is said to come about, any contextual factors affecting these, and any information specific to the wellbeing or mental health outcomes themselves'.
Second-order findings refer to analytic claims made by the author that are based on the original data.To be extracted, second-order findings had to be supported by first-order evidence, for example participant quotations, detailed case studies, or summary tables of specific topics showing frequency of mention by participants.Statements of findings from each paper were extracted independently by the first and second authors, leaving behind other elements of each paper such as original data (e.g.participant quotations), data and findings not consistent with the above working definition, findings from other studies and/or theories referred to by researchers, accounts of the analytic procedures used, and researchers' discussions about the theoretical or applied significance of their findings.Disagreements between researchers about the data to be extracted were discussed and resolved.In this way, 413 findings were extracted and edited into complete sentences understandable to a naive reader, whilst keeping close to the original words used by the authors of included papers and preserving any relevant contextual information (e.g.type of arts intervention, duration of programme, and key details about the CYP).
Abstraction.These 413 statements of findings were further consolidated by clustering them according to whether reported mechanisms of change or related contexts were similar or different.The consolidation of statements was conducted by the first two authors (EW and SG) until a smaller set of 42 statements was generated that captured the content of all 413 statements of findings.These 42 statements were further organised into two main sections and eight sub-sections (see Table 3).The proportion of papers

Relationship building
Creating a space separate from everyday life Practitioners sought to build an accepting and supportive environment in which young people felt free to explore, discover and create without fear of judgement .59 Practitioners sought to create a protected space separate from the stresses, rules, sociocultural norms, and structures young people associate with everyday life .47 Concept of freedom is central to function of the 'safe space': for example embodied freedom, freedom from school curriculum, freedom from critical judgements, and free to be self .47 Sense of enjoyment in activity led to deeper engagement that was linked to social connections.
In turn, social connections fostered enjoyment of sessions .18

• • •
Fostering relationships and team spirit between young people Engagement in participatory arts workshops/ sessions facilitated the making of social connections between young people .76contributing material relating to each abstracted finding statement is recorded in the table.Only findings included in three or more papers of the total of 17 included papers are presented in Table 3 (n = 33).These figures are provided as an indicator of having sufficient data to interpret rather than as a measure of salience or representativeness.Qualitative metasummary reflects a quantitative logic whereby higher frequency findings are taken to be evidence of the replication that is both foundational to validity in quantitative research and to the claim of having discovered a pattern or theme (Sandelowski, 2001) or 'preponderance of evidence' (Thorne et al., 2004(Thorne et al., , p. 1362) in qualitative research.
Figure 2 presents a logic model representing the structure of the identified mechanisms of change and is also a proposal for how these work synergistically.It suggests that practitioners' creation of a protected 'play' space based on mutual trust and respect, through various forms of relationship building, offers CYP a mechanism for freeing them (in a temporary and boundaried way) from everyday social rules and pressures.This opens up possibilities for creating a more positive self-narrative based on the discovery of new strengths, identities, and skills through deeper engagement in facilitative PAB activities and practices.This, in turn, gives rise to a number of outcomes linked to well-being through the development of an increased sense of accomplishment, agency, and community.Each mechanism is explained in more detail below, along with aspects of context reported to inform them, such as the art form, physical setting, implementation, and population.
Cluster 1: Relationship building, creating a space separate from everyday life Analysis of the final second-order finding statements suggests that most PAB programmes began with a period of relationship building, which is the first of two main organising clusters (see Table 3 and Figure 2).In some studies, this started with partnership organisations providing information about the history and interests of likely participants, and through recruiting and supporting CYP into the programme.Once the PAB sessions started, practitioners often worked to create a 'safe' social space, separate from the pressures and rules of everyday life, in which CYP felt free to be different and 'other' to their socially constructed normative roles.
Creating a protected space.The finding statements suggest that arts practitioners commonly sought to establish a space bracketed off from the external stresses, perceived sociocultural norms, rules, and social hierarchies that CYP are subject to in their everyday lives (Archambault et al., 2020;Atkinson & Robson, 2012;Cal o et al., 2020;Duberg et al., 2016;Hanrahan & Banerjee, 2017;MacPherson, Hart, & Heaver, 2016;Parker, Marturano, O'Connor, & Meek, 2018;Ritchie & Gaulter, 2020).This is foundational for all other mechanisms.The protected space was variously described as a 'safe' space (Archambault et al., 2020;Baker, Jeanneret, & Clarkson, 2018;Cal o et al., 2020;MacPherson et al., 2016;Ritchie & Gaulter, 2020), a 'liminal' space (Atkinson & Robson, 2012), an 'oasis' (Duberg et al., 2016), or as 'space-giving for the self' (Hanrahan & Banerjee, 2017).Practitioners aimed to create a nurturing, supportive, play-based environment in which CYP felt free to explore, discover, create, and make mistakes without fear of judgement (Baker et al., 2018;Brown & Jeanneret, 2015;Cal o et al., 2020;Daykin et al., 2017;Duberg et al., 2016;Ennis & Tonkin, 2018;Levstek & Banerjee, 2021;MacPherson et al., 2016;Parker et al., 2018;Stephenson & Dobson, 2020).The play-based or ludic qualities of this space resonate with Turner's concept of liminality (1967,1987).The concept of 'freedom' appeared central to included authors' understanding of the functions of this protected 'space'.This extended beyond its role in providing a temporary 'breathing space' or 'secure oasis' to more psychological and embodied freedoms.Duberg et al. (2016) described the undemanding and supportive nature of her dance programme as offering relief from critical self-judgements, as well as an escape from competitive diachronic structures of progression.Stephenson and Dobson (2020) suggested that their creative writing workshops release children's minds from the captive 'constraints of a neoliberal curriculum' enabling the agentic potential of 'imaginative freedom' to be harnessed.In dance programmes, freedom was conceptualised as embodied in the sense of enabling physiological relaxation and feeling physically comfortable in your own skin, as well as freedom from the 'controlled and sedentary movement' associated with everyday life (Duberg et al., 2016;Ritchie & Gaulter, 2020).
Several papers reported that CYP were given the freedom to express and explore their 'real' and authentic selves (Duberg et al., 2016;Hanrahan & Banerjee, 2017;Levstek & Banerjee, 2021;Mac-Pherson et al., 2016).Finally, attention to confidence building was said by some authors to confer the freedom, or agency, to young people to lead their own learning (Atkinson & Robson, 2012;Brown & Jeanneret, 2015).
A key issue foregrounded in the papers is that, whilst this protected space provides freedom (temporarily) from everyday social norms, structures, and relationships that often disempower young people and restrict preferred expression, it is boundaried both physically and psychologically.It is evident in the included articles that there are rules for safe 'play' so that risk taking can happen with limited possibility of causing harm (Atkinson & Robson, 2012;Daykin et al., 2017;Ennis & Tonkin, 2018;Hanrahan & Banerjee, 2017).Confidentiality is a contributory factor to the concept of a 'safe' space (Cal o et al., 2020;Duberg et al., 2016;MacPherson et al., 2016; see also Pavarini et al., 2021).A number of situational factors are identified as facilitating the establishment of this boundaried space, as well as movement into and out of it.These include the use of a dedicated room or place for PAB sessions (Atkinson & Robson, 2012;Brown & Jeanneret, 2015), mixing with different peers, and the use of starting/warm-up rituals at the beginning and end of sessions, as well as codes of practice (Atkinson & Robson, 2012).Conversely, the absence of these can threaten the integrity of the space, including not having a dedicated place, being moved at the last minute, sharing the space with someone else, mixing with the same peers as in school, and use of art materials to tease or bully other young people (Daykin et al., 2017).Several authors referred to having to manage power structures to ensure CYP continued to be comfortable enough to take social and emotional 'risks' (Atkinson & Robson, 2012;Daykin et al., 2017).This is supported in the literature by Mullen and Deane (2018), who having worked extensively with CYP in Pupil Referral Units (PRUs) posit that boundary setting by practitioners is essential to making change happen.
Building trust between practitioners and young people.Most authors highlighted the importance of establishing mutual trust and respect between arts practitioners and CYP to facilitate engagement in the PAB programme (Atkinson & Robson, 2012;Cal o et al., 2020;Clennon & Boehm, 2014;Daykin et al., 2017;Ennis & Tonkin, 2018;Hanrahan & Banerjee, 2017;Parker et al., 2018;Ritchie & Gaulter, 2020).Several described this as a fundamental contextual characteristic when vulnerable and marginalised young people are involved (Cal o et al., 2020;Clennon & Boehm, 2014;Daykin et al., 2017;Hanrahan & Banerjee, 2017), who are suspicious of adults and authority (Clennon & Boehm, 2014), or who have had many experiences of being 'let down' in the past (Hanrahan & Banerjee, 2017).Clennon and Boehm (2014) note that an extended period of relationship building is needed to counteract this.The relationship of mutual trust and respect is conceived of as an egalitarian one, with hierarchies between the CYP and practitioners being intentionally flattened to ensure a sense of collaboration and co-production (Cal o et al., 2020;Clennon & Boehm, 2014;Daykin et al., 2017;Ennis & Tonkin, 2018;Hanrahan & Banerjee, 2017;Levstek & Banerjee, 2021;Stephenson & Dobson, 2020).This ensures that CYP do not see themselves as being 'done to' as they often do in traditional interventions.
Finding statements indicate that building a relationship of trust between youth and arts practitioners is facilitated by practitioners making various points of social connection between them (Atkinson & Robson, 2012;Cal o et al., 2020;Clennon & Boehm, 2014;Daykin et al., 2017;Ennis & Tonkin, 2018;Parker et al., 2018).Daykin et al. (2017), Cal o et al. (2020), and Parker et al. (2018) all highlighted self-identification, via shared lived experiences (Cal o et al., 2020;Parker et al., 2018) and gender or sexual identity (Daykin et al., 2017), as helping establish trust and as a pathway to deeper engagement in the PAB programme.Selfidentification can be facilitated where the social identities and background of young people and practitioners are similar (Clennon & Boehm, 2014;Parker et al., 2018).Conversely, where these differ markedly this presented barriers to establishing mutual rapport and trust (Daykin et al., 2017).The creation of mutual trust and respect between arts practitioners and youth beneficiaries of PAB programmes was linked to CYP feeling 'safe ' and protected (Cal o et al., 2020;Clennon & Boehm, 2014;Daykin et al., 2017;Ennis & Tonkin, 2018;Hanrahan & Banerjee, 2017;Parker et al., 2018;Ritchie & Gaulter, 2020). Cal o et al. (2020), Hanrahan andBanerjee (2017), andParker et al. (2018) all reported that this, in turn, resulted in better connectedness with the programme, constituting another pathway to engagement.
Tailored and flexible approach.The tailored and flexible approach noted above requires arts practitioners to meet CYP where they are.This entailed establishing their needs, capacities, and interests and designing arts activities around these.Explicit attention to confidence building within such an approach was said to give CYP the freedom and agency to express and share their own ideas, as well as to initiate, request, and lead activities (Atkinson & Robson, 2012;Brown & Jeanneret, 2015;Levstek & Banerjee, 2021), subverting the rules and expectations typically associated with the classroom (Atkinson & Robson, 2012).Several authors (Brown & Jeanneret, 2015;Cal o et al., 2020;Daykin et al., 2017;Parker et al., 2018) highlighted that a one-to-one approach can be especially beneficial with less confident and harder-to-engage CYP.
Finding statements suggested the sense of freedom, or agency, encouraged by arts practitioners and experienced by CYP in the PAB programmes interlinked with their feelings of being protected or 'held' within its boundaries, enabling CYP to feel secure enough to push boundaries and take up the challenge of learning new ways of thinking, feeling, and doing (Ennis & Tonkin, 2018;Hanrahan & Banerjee, 2017;Ritchie & Gaulter, 2020).This, in turn, seemed to make possible the discovery of new strengths and capabilities, as well as exploration of alternative perspectives and identities (Ritchie & Gaulter, 2020;Stephenson & Dobson, 2020).
Fostering connection and team spirit between young people.Most papers suggested that the informal, relaxed, and non-hierarchical atmosphere created by the arts practitioners helped CYP connect to each other, fostering a sense of group cohesion (Atkinson & Robson, 2012;Baker et al., 2018;Brown & Jeanneret, 2015;Cal o et al., 2020;Daykin et al., 2017;Duberg et al., 2016;Ennis & Tonkin, 2018;Hanrahan & Banerjee, 2017;Lai, Chui, Deng, & Jordan, 2021;Levstek & Banerjee, 2021;MacPherson et al., 2016;Miao & Stewart, 2022;Ritchie & Gaulter, 2020).According to some authors, these developing social connections offered a pathway to deeper engagement in PAB programmes.Cal o et al. (2020) reported that they reinforced a sense of trust and feeling of safety which encouraged engagement.MacPherson et al. (2016) noted that some young people reported feeling a sense of responsibility to peers, which motivated them to return.Ritchie and Gaulter (2020) and Duberg et al. (2016) both linked the making of new friends during dance sessions to sustained engagement.
Social affordances of art stimuli and practices.-Finding statements relating to the affordances of specific art stimuli and the practice structures surrounding them suggested several ways in which these helped scaffold social connection between young people within the protected space, as well as between practitioners and youth.Several papers (Atkinson & Robson, 2012;Brown & Jeanneret, 2015;Daykin et al., 2017;Ennis & Tonkin, 2018;MacPherson et al., 2016) reported that engagement in shared PAB activities connected young people to each other.For example, youth learned about each other and exchanged personal stories (MacPherson et al., 2016) whilst working productively together.Atkinson and Robson (2012) reported the growth of a sense of 'communitas' (community solidarity) through collaboration on specific art outputs.Several authors (Atkinson & Robson, 2012;Brown & Jeanneret, 2015;Daykin et al., 2017;Miao & Stewart, 2022) focussed on the role art outputs played in facilitating reciprocal support between young people as they acknowledged and praised each other's efforts.Other papers (Clennon & Boehm, 2014;Lai et al., 2021;Levstek & Banerjee, 2021) highlighted that shared interests and passions in PAB activities can serve as a joint focus of interest which pulled youth in whilst helping lower barriers.activities draw on leisure-time pursuits (e.g.music, dance, and drama) that may already feature and have positive associations and meaning in young people's everyday lives.
Specific art stimuli and related practices themselves helped forge social connection (Clennon & Boehm, 2014;Daykin et al., 2017;Ennis & Tonkin, 2018;Hanrahan & Banerjee, 2017;Lai et al., 2021).Production in drama programmes is reported to shift the emphasis towards collaborative theatre making, rapidly creating a sense of community as a production team (Ennis & Tonkin, 2018;Hanrahan & Banerjee, 2017).Theatre practice also engenders inclusion with different opportunities and roles for young people, including backstage activities for those who do not want to perform.Duberg et al. (2016) and Ritchie and Gaulter (2020) referenced the shared embodied joy that adolescent girls experienced dancing together, connecting through a newly found acceptance of their bodies.Daykin et al. (2017) made the important point that these affordances are situated.A specific art stimulus, such as a particular sound or type of music, which functions as a tool of social connection between some young people, can disrupt interpersonal engagement for another who finds the sound aversive or lyrics offensive.Other authors highlighted that an art task that is too difficult can lead to disengagement (Baker et al., 2018;Miao & Stewart, 2022).
In summary, finding statements suggest that the development of a sense of being free, being protected, and socially connected, as well as a sense of selfidentification and enjoyment, may all support CYP's sustained and deep engagement with PAB programmes as protected spaces in which social rules can temporarily be subverted.Deeper engagement, in turn, appeared to open up possibilities for developing more positive or 'authentic' selfnarratives, with the PAB activities and practices described in the next section facilitating the discovery and exploration of new skills, strengths, and identities leading to an increased sense of agency, accomplishment, and belonging and a number of outcomes related to well-being (see Figure 2).
Cluster 2: Creating a more positive self-narrative Validation from performances and exhibitions of art outputs.Finding statements suggest that the immediate positive validation received from family, friends, practitioners, and other participants who view the performances and art exhibitions generated a sense of pride and accomplishment in young people (Atkinson & Robson, 2012;Brown & Jeanneret, 2015;Cal o et al., 2020;Daykin et al., 2017;Ennis & Tonkin, 2018;Miao & Stewart, 2022;Parker et al., 2018).Some authors linked this to increased self-confidence (Atkinson & Robson, 2012;Cal o et al., 2020;Daykin et al., 2017;Parker et al., 2018).From a psychological perspective, a sense of having succeeded, validation from other people, and witnessing similar peers succeed (vicarious performance) are all different ways in which sense of self-efficacy can be increased (Bandura, 1977(Bandura, , 1997)).Furthermore, the sense of group capability or collective self-efficacy derived from performances and exhibitions noted by some authors is also thought to positively influence selfefficacy (Bandura, 1997;Katz-Navon & Erez, 2005).(Ennis & Tonkin, 2018).These examples all involve a distancing or 'othering' of the self and are said to bring about a shift in young people's understanding of themselves resulting in deeper self-understanding.There is a progression here from the pleasure of creative play and freedom to be other to the normative sense of self, through to risk taking and an agentic awareness of the potential for changing identities and narratives.This represents another potential pathway to positive well-being in that displacement or transposition of the self gives rise to an increased sense of agency in young people, opening up a different sense of what is possible for them and their view of themselves.The identification of new possible future selves is linked to increased self-esteem, optimism, and hope about the future (Markus & Nurius, 1986).Duberg et al. (2016) also described a profound change in the self-perspective of participating adolescent girls as the dance programme progresses.They moved from being outwardly focussed on the critical judgements of others and of the self to an embodied focus on, and 'trust in', their own body.They shifted from a tendency to make upward social comparisons (Festinger, 1954)  In answer to the first question, the small number of quantitative studies identified, coupled with several methodological weaknesses, limits conclusions about the effectiveness of PAB programmes based on included studies.A key difficulty identified was the use of standardised measures in community (uncontrolled) settings with CYP.The completion of standardised measures for PAB studies can be burdensome, for both young people, whose primary interest is in making art rather than research, and for staff who may have low confidence in administering them.Young people often perceive standardised measures as tests and worry about giving the 'correct' response, or resent being used as 'guinea pigs', raising questions about the validity of their responses for evaluation purposes.Improvements are needed in the construction and implementation of mental health and well-being measures for CYP in the context of participatory arts-based programmes so that their use is acceptable, meaningful, and increased in PAB programme research, rather than presenting a barrier to engagement (see Table 4).Changes should be strongly informed by the perspectives of young people, in line with the 'no research about me without me' agenda.
The second focus of this review was on mechanisms of change in PAB approaches for CYP mental health and well-being.We offer a unique contribution to the field via a provisional model of mechanisms of change, capturing reported, potential processes and apparent active ingredients from our eligible studies.Many observations can be made about our model, but we draw attention here to the resonance between potential mechanisms in PAB programmes and those in both counselling and clinical approaches.For example, there are clear similarities in the claim that therapeutic work in both clinical and PAB programmes rests on a critical relational foundation and can progress only if trust and safety are established (see Pavarini et al., 2021).
We note particular similarities between PAB programme mechanisms and those in Person-Centred Approaches to Counselling (PCC; Rogers, 1957Rogers, , 1959)).For example, the PCC therapist has a responsibility to establish therapeutic conditions, in the form of understanding, acceptance, and unconditional positive regard, and second, to use these to help their client reconnect and consolidate living by their 'authentic' self (Motschnig & Nykl, 2003).In PAB programmes, arts practitioners aim to create a non-judgemental, accepting, 'safe' space for CYP to take social and emotional 'risks' through engagement with art stimuli and practices in order to help them reconnect to their thoughts, feelings, and bodies (see Table 4).A further similarity with PCC is that, in PAB programmes, CYP are supported to express themselves and create their own meanings (phenomenology) through engagement with the arts activities, restoring or building a sense of agency and self-direction (Bennett, 2022).Rogers ' (1961) hypothesised therapeutic mechanisms in PCC thus show several commonalities with those in PAB programmes.Rogers (1961) suggested that facilitative therapeutic conditions would help the client: . . .experience and understand aspects of himself which previously he has repressed, will find himself becoming better integrated, more able to function effectively, will become more similar to the person he would like to be, will be more self-directing and self-confident, will become more of a person, more unique and more self-expressive. . .(Rogers, 1961, p. 37-38) Our review suggests that, like many clinically therapeutic approaches, PAB programmes in turn open up possibilities for the development of a more positive or 'authentic' self-narrative.
However, our review identified distinctive mechanisms in PAB programmes compared to traditional clinical/therapeutic approaches.PAB programmes seem to be an alternative therapeutic social space particularly well-suited for CYP.These programmes also cultivate a sense of communitas (or community belonging) in organic ways that young people do not resent or perceive as coerced; working collaboratively as artists involves the pleasure of community engagement in composition, which often involved beneficial validation from practitioners and peers.Another distinctive element of PAB programmes identified in our review is that they offer a 'play space' that taps into CYP intrinsic motivation and de-pathologises the therapeutic space.This is a critical finding from our review, as the stigma that CYP associate with mental health problems, their tendency not to seek help for these types of difficulties, and a high level of disengagement with services once accessed (Colizzi, Lasalvia, & Ruggeri, 2020) point to reasons why traditional CAMH services may be unable to meet rising youth mental health need alone, even if resources were not so scarce.

Limitations
Transferability of findings.Given the predomi- nance of studies from the United Kingdom and Commonwealth countries, caution is needed regarding the transferability of the SR's findings beyond this cultural context.It is notable, for example, that the study conducted in Hong Kong by Lai et al. (2021) shared few metasummary finding statements with other included studies and was distinct in having a very strong prioritisation of group over individual self-expression.This suggests that evidence from a more diverse set of countries is needed to tell us how cultural context shapes mechanisms of change, highlighting a gap in the literature.The focus on PAB studies involving collaborative engagement means further work is needed to determine to what extent the key mechanisms identified are transferable to PAB studies involving more directed or passive approaches.Whilst focussing on a particular type of PAB approach can be described as a limitation, we contend that synthesising very diverse studies is likely to obscure key mechanisms, suggesting a need for separate SRs.
Quality of the evidence.A metasummary relies on the quality of findings from eligible studies.Whilst we found some very rich data, the potential value of some qualitative studies was limited by methodological issues (see Table 5).When analytic claims are made in reports about specific processes and the contexts in which they arise, these can only be extracted for the purpose of synthesis when they are clearly supported by the original data.Conversely, where original data are presented (e.g. in the form of quotes from CYP or practitioners) with limited analytic commentary to aid interpretation, then this also means that little can be extracted.PAB activities were sometimes intertwined with other elements such as CBT or tutoring.This made it impossible to disentangle what specific impacts are due to PAB activities and those relating to other elements.The participatory activities were sometimes poorly described, meaning it was difficult to determine the extent of co-creation between the CYP and arts practitioners.
Whilst the PAB programme setting in the included qualitative studies was often described in detail, any mechanisms of change relating to attributes of the art stimuli themselves often remained within the proverbial 'black box '. For example, Cal o et al. (2020) note that the establishment of trust became a 'fundamental characteristic' (p993) in their programme, but the potential role of music in this process was unexplored.Creating rhythmic predictability, a non-judgemental environment, and safe place to explore/improvise through musical structured interventions are all possible practitioner approaches that could be used to support this process.In the articles reporting on dance programmes, there was limited analysis of the physical tasks and qualities in bringing about feelings of freedom and social connection.In Lai et al. (2021), the notion of 'synchronisation' is referred to (p149) in relation to 'teamwork' but the physiological 'prosocial' effects of synchronised moving together are not considered.In Duberg et al. (2016), one of the participants referred to spinning and twirling when describing her sense of freedom.However, no reference was made to these movements being culturally and socially associated with notions of freedom, and the fact that movements themselves contribute to these feelings as well as being an expression of them in a reciprocal process.Findings from the metasummary indicate that practitioners are central to the processes of engagement and change and likely work with implicit assumptions about them.However, not all studies included their perspective.It would be helpful if they were interviewed and these data were analysed and triangulated with CYP data, or alternatively, their reflections or field notes were included in the analysis.More use could also be made of observational methods of data collection and analysis to provide an additional perspective on processes of change.

Conclusion
Evidence from our metasummary indicates that we can be confident that PAB programmes involve therapeutic processes.The model presented represents a first step to better understanding key mechanisms of change.A next step to build on and extend this work could be a search of the grey literature and to remove date restrictions, as this could be a rich resource for more qualitative data.Methodological development in this domain will help researchers generate better theories of change relating to their specific arts practices and generate guidance on what might work best and why in relation to certain youth populations with specific mental health issues.Richer and more robust reporting of qualitative analyses arising from practice-based evidence will increase the quality of any syntheses conducted.However, before entering into this there is a need for more discussion to explore tensions about what counts as evidence.Going forward, investigations of both processes and outcomes of PAB programmes with young people would be best conducted by transdisciplinary teams (Raw & Robson, 2017) to maximise the complementary strengths that the arts and science bring to the field.These must ensure sufficient space for sharing of perspectives if researchers are not to remain in their metaphorical bunkers, which risks limiting what we can understand about the effectiveness and processes of PAB programmes (Leigh & Brown, 2021).

Figure 1
Figure 1 PRISMA flow chart Ó 2023 The Authors.Journal of Child Psychology and Psychiatry published by John Wiley & Sons Ltd on behalf of Association for Child and Adolescent Mental Health.

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Art form: Visual arts • Duration: 12 weeks; once per week for 2 hr • Setting: Montreal Museum of Fine Arts (MMFA) • Facilitator: Arts educator • Delivery: Individual and group work • Arts activities: YP collaborate on artworks inspired by museum visit.Introduced to various artistic techniques, for example painting, printmaking, photography, and collage • Mixed methods • Data Collection: Individual semistructured interviews Art form: Visual arts • Duration: Group met regularly over at least a term for a am/pm session 91 per week • Facilitator: Arts practitioners • Arts activities: One school used drawing and modelling; other school used writing.Practitioners ran and facilitated range of different activities • Qualitative • Data collection: Practitioners acted as participant-researchers • Open format form prompting recording of session activities/ intentions and dynamics • Data Analysis: Thematic analysis (TA) • Perceived effectiveness: Self-expression, increased self-confidence, improved literacy skills Affective attitude: Enjoyment, fun • Self-efficacy: Sense of increased personal agency • Burden: Some YP excluded due to behaviour, other competing activities (e.g.schoolwork prioritised by teachers disrupting sessions for some YP).Not having same physical space for the arts activities was disruptive Strong Baker et al. (

•
Background: Many of the YP faced barriers to participating in mainstream educational settings • Recruitment: YP selected as identified by youth workers/ school staff as not fitting in at school or were home schooled • Art form: Music (songwriting) • Duration: 2 days • Setting: Community hall • Facilitator: Artists • Delivery: Large group • Details of arts activities: Songwriting activities comprised preparatory games and tasks, creating the lyrics, rehearsing, recording, and performing the song and accompanying dance, and planning/recording a video for the song • Qualitative • Data Collection: Video footage, ethnographic observations • Data Analysis: Video footage, ethnographic field notes, and artefacts thematically analysed and themes produced relating to contextual factors and well-Authors.Journal of Child Psychology and Psychiatry published by John Wiley & Sons Ltd on behalf of Association for Child and Adolescent Mental Health.
Metasummary statements generated by findings from three or more papers and which papers contributed to each statement Statements of findings (n = 33; classified into two main categories and eight sub-categories)

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space is boundaried.There are rules for 'safe' play to Aspects of context help maintain 'safe' space and ability to move into and out of it, including having the same room for the PAB programme, starting/ warm-up rituals, and codes of practice .18• • Building relationships between practitioners and young people Practitioners sought to establish successful relationships with young people based on mutual trust and support, which helped facilitate engagement in the PAB 2023 The Authors.Journal of Child Psychology and Psychiatry published by John Wiley & Sons Ltd on behalf of Association for Child and Adolescent Mental Health.The trust relationship developed between PAB intervention and participants contributed to young people feeling 'safe' leading to better connectedness and engagement with the arts programmeto-one approach is particularly beneficial for young people who are less confident and harder to engage in the PAB programme

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positive self-narrative Validation from performance and exhibition of art outputs Positive validation from other people in response to performances and exhibitions of artwork engenders a sense of pride and/The sense of pride/accomplishment derived from taking part in performances and exhibitions of artwork results is linked to increased selfperspectives Practitioners encouraged young people to explore alternative perspectives, including different aspects of self, self at different points in time and in different situations Expression and exploration of difficult emotions Participatory arts interventions/programmes give space for the 'safe' and cathartic expression of emotion, Authors.Journal of Child Psychology and Psychiatry published by John Wiley & Sons Ltd on behalf of Association for Child and Adolescent Mental Health.

Figure 2
Figure 2 Logic model mapping mechanisms of change ; the use of a tailored and flexible approach adaptive to individual needs and interests (Atkinson & Robson, 2012; Brown & Jeanneret, 2015; Cal o et al., Ó 2023 The Authors.Journal of Child Psychology and Psychiatry published by John Wiley & Sons Ltd on behalf of Association for Child and Adolescent Mental Health.

Ó
2023 The Authors.Journal of Child Psychology and Psychiatry published by John Wiley & Sons Ltd on behalf of Association for Child and Adolescent Mental Health.

Table 1
Summary of quantitative studies and quantitative elements of mixed-methods studies Journal of Child Psychology and Psychiatry published by John Wiley & Sons Ltd on behalf of Association for Child and Adolescent Mental Health.Journal of Child Psychology and Psychiatry published by John Wiley & Sons Ltd on behalf of Association for Child and Adolescent Mental Health.Journal of Child Psychology and Psychiatry published by John Wiley & Sons Ltd on behalf of Association for Child and Adolescent Mental Health.Journal of Child Psychology and Psychiatry published by John Wiley & Sons Ltd on behalf of Association for Child and Adolescent Mental Health.
Weak Ó 2023 The Authors.Journal of Child Psychology and Psychiatry published by John Wiley & Sons Ltd on behalf of Association for Child and Adolescent Mental Health.doi:10.1111/jcpp.13900Participatory arts-based programmes 9 14697610, 0, Downloaded from https://acamh.onlinelibrary.wiley.com/doi/10.1111/jcpp.13900 by Test, Wiley Online Library on [02/11/2023].See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions)on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License

Table 2
Summary of qualitative studies and qualitative elements of mixed-methods studies

Table 2
• Art form: Mixed visual arts • Duration: 8 weeks, twice a week for 5-hr sessions • Setting: Dedicated youth studio • Facilitator: Artist • Delivery: Small groups of up to 8 • Details of arts activities: YP explore diverse forms of visual art, design, film/video, animation, and photography.Exhibition held at end • Qualitative • Data Collection: Interviews with: artist; youth worker; artist and youth worker together; YP and parent/guardians • Researcher observations of representative sample of workshops • Data Analysis: Process of 'progressive focussing' (Stake, provided • Art form: Music • Duration: 16 sessions • Setting: 1 school, 2 community centres, and 1 charity • Facilitator: Music practitioners • Delivery: One-to-one and group work • Details of arts activities: Participatory musicmaking; use of music technology, music recording, songwriting, learning to play instruments.Focus on expressing emotions/ exploring problems • Qualitative • Data Collection: Interviews: YP (n = 23); COOL music leaders; stakeholders (educators, teacher, and social/support worker who worked with YP (n = 8) • Data Analysis: Thematic analysis (TA) • Perceived effectiveness: • Background: Disadvantaged • Recruitment: YP attending youth club and drop-in group could attend creative sessions • Art form: Music • Duration: More than a year; 91/week • Setting: Youth club and drop-in group • Facilitator: Workshop leaders with musical background/training • Delivery: Group activities.Older YP mentored younger ones • Details of arts activities: YP encouraged to develop own distinctive and creative engagement with local heritage, mediated through musical, media, and musictechnological activities.Series of weekly creative sessions music and music technol-Ó 2023 The Authors.Journal of Child Psychology and Psychiatry published by John Wiley & Sons Ltd on behalf of Association for Child and Adolescent Mental Health.doi:10.1111/jcpp.13900Participatory arts-based programmes 11 14697610, 0, Downloaded from https://acamh.onlinelibrary.wiley.com/doi/10.1111/jcpp.13900 by Test, Wiley Online Library on [02/11/2023].See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions)on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License

Table 2
Ó 2023 The Authors.Journal of Child Psychology and Psychiatry published by John Wiley & Sons Ltd on behalf of Association for Child and Adolescent Mental Health.Ó 2023 The Authors.Journal of Child Psychology and Psychiatry published by John Wiley & Sons Ltd on behalf of Association for Child and Adolescent Mental Health.doi:10.1111/jcpp.13900Participatory arts-based programmes 13 14697610, 0, Downloaded from https://acamh.onlinelibrary.wiley.com/doi/10.1111/jcpp.13900 by Test, Wiley Online Library on [02/11/2023].See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions)on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License

Table 3
Downloaded from https://acamh.onlinelibrary.wiley.com/doi/10.1111/jcpp.13900 by Test, Wiley Online Library on [02/11/2023].See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions)on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License The Authors.Journal of Child Psychology and Psychiatry published by John Wiley & Sons Ltd on behalf of Association for Child and Adolescent Mental Health.

Table 4
Key points• Youth-centred approach Tailor PAB activities to youth interests (considering individual and group) and follow youth lead.It is beneficial for practitioners and/or the creative team to offer a palette of skills and engagement strategies to meet different needs and interests • Create 'safe' space Trust, flattening of hierarchies, and non-judgemental and positive validation help create a space in which young people feel protected enough to engage more deeply in PAB programmes and take 'risks' • Practitioner background/social identity It is helpful if a young person can make a connection between a practitioner's background/social identity and their own; perceived social and cultural differences can present barriers to engagement • Managing power structures 'Walking the line' between providing a space in which young people feel free to be themselves and the need to set boundaries (especially behavioural) to ensure 'safe play' in sessions is difficult and needs careful reflection/management.A co-produced agreement on rules or codes of practice supports this process • Duration PAB programmes typically last around 10 weeks, but a longer period is often needed for programme delivery to build trust, deepen engagement, and support agency and positive change, especially with vulnerable populations • Barriers to engagement Barriers include the following: art tasks perceived as 'too difficult'; perception that not creative/good at art/dance/music, etc.; creative stimuli can have negative and positive effects; lack of interest in activities; self-consciousness/embarrassment/ inhibitions when engaging in activities that involve self-expression, particularly physical engagement; and use of standardised measures resulting in young people feeling 'objectified' Ó 2023 The Authors.Journal of Child Psychology and Psychiatry published by John Wiley & Sons Ltd on behalf of Association for Child and Adolescent Mental Health.

Table 5
Recommendations for reporting of PAB qualitative research PAB activities and contexts Sufficient information about the PAB activities is needed for it to be clear to another practitioner exactly what was done and who was involved (group information, settings, numbers, and age) Practitioner perspectives Practitioner reflections/field notes should be included in the analysis if they are not interviewed (and the interviews included in the analysis) Role of art stimuli and related practices More analysis and critical reflection are needed of the art tasks/methods/attribute themselves, particularly how these facilitate processes of engagement and change Role of art stimuli /practices in representing change More analysis is needed of the art outputs as a means of evaluating outcomes relating to mental well-being and mental health Balance between analytic commentary and supporting evidence There needs to be sufficient data presented to support analytic comments and sufficient analytic commentary to provide rich interpretations of the data to support future metasyntheses Ó 2023 The Authors.Journal of Child Psychology and Psychiatry published by John Wiley & Sons Ltd on behalf of Association for Child and Adolescent Mental Health.doi:10.1111/jcpp.13900Participatory arts-based programmes 27 14697610, 0, Downloaded from https://acamh.onlinelibrary.wiley.com/doi/10.1111/jcpp.13900 by Test, Wiley Online Library on [02/11/2023].See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions)on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License