**1. Introduction**

Over the past 30 years, a large increase in the number of children and adolescents suffering from anxiety and major depressive disorders or behavioural and conduct disorders has been described. Worldwide, 8.8% of the paediatric population has been diagnosed with several mental illnesses, accounting for a heavy disease burden [1]. Currently, it has become a real psychiatric emergency, exacerbated by the pandemic period, that leads many children to go through moments of sadness and emotional distress. The effects of the three years of the COVID-19 pandemic and its health security measures have had a

**Citation:** Gagliano, A.; Costanza, C.; Bazzoni, M.; Falcioni, L.; Rizzi, M.; Scaffidi Abbate, C.; Vetri, L.; Roccella, M.; Guglielmi, M.; Livio, F.; et al. Effectiveness of an Educational Filmmaking Project in Promoting the Psychological Well-Being of Adolescents with Emotive/ Behavioural Problems. *Healthcare* **2023**, *11*, 1695. https://doi.org/ 10.3390/healthcare11121695

Academic Editors: Athanassios Tselebis and Argyro Pachi

Received: 3 April 2023 Revised: 7 June 2023 Accepted: 7 June 2023 Published: 9 June 2023

**Copyright:** © 2023 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https:// creativecommons.org/licenses/by/ 4.0/).

strong emotional impact on people's lives worldwide [2]. Among the most important effects are the psychological and social ones, which are insidious, as they condition the mental health of children and adolescents, with the risk of continuing into their future. Many of them have experienced episodes or states of depression and anxiety due, for example, to school closures and the consequent social isolation and physical restrictions [3]. Currently, between 30 and 40 per cent of the school-age population suffer from a psychiatric condition [4,5].

This represents a challenge for the mental health care system, with a growing need for new therapeutic and preventive interventions, such as those based on music, theatre, and film therapy. It is urgent to focus not only on diagnostic and therapeutic procedures but also on creating opportunities for personal growth and empowering positive experiences with people dealing with the same obstacles. Evidence suggests that adolescents respond positively to early interventions, including psychosocial support and educational interventions, when offered in non-clinical settings [6].

Psychosocial interventions include art and creative therapies. A small body of literature supports using art therapy to empower youth [6]. Regarding young people, participation in the arts is thought to increase confidence and self-esteem [7]. It has also been argued extensively in the literature that models of youth participation benefit mental health over the longer term [8]. As reported by previous studies [9], the inclusion of arts in mental health programs can assist people in developing and maintaining a positive identity and creating a sense of meaning and purpose in their lives. As a matter of fact, an improvement in self-esteem and social awareness was detected in our work.

Although video-based intervention and filmmaking have been previously studied in adult psychotherapy [10], their efficacy with children and adolescents still needs to be explored. In fact, in the current literature, very few studies on the recovery of social skills for children with autism spectrum disorder or intellectual disabilities are available [11,12]. Studies documenting the usefulness of filmmaking programs specifically designed for children and adolescents with neurodevelopmental and emotional disorders are very rare. Some film-based interventions have been proposed to adolescents as educational tools, but their efficacy in mental health education remains largely under-explored [13].

Differently from other figurative arts, cinema allows for different psychological benefits, such as the identification with the character's feelings and emotions, the cathartic effect (learning through the character's experiences), and the improvement in social abilities through sharing emotions and experiences with other participants. There is clinical evidence that through the use of movies and follow-up sessions, pre-adolescent children whose parents were going through a divorce improved their capacity to identify and express their feelings and developed coping skills [14,15]. A monthly cinema therapy group session, proposed to a group of girls, allowed them to identify and work through anger and conflicts and to mark their feelings about their families and social relationships. Starting from this evidence, we argue that the cooperative work required for making a film is a collective experience which may have a stronger impact on both emotions and thoughts than the vision of a film made from other people.

Creativity should be an essential element of the education process of people with disabilities and mental disorders [12]. Indeed, working on a film project could be an opportunity to create stories and characters and identify with them while maintaining distance. In this way, individuals are exposed to their psycho-physical difficulties through the stories of the characters on the screen who are coping with the same issues as the patients [16]. Such an approach is also a strong stimulus to consider their problems from a different perspective. Consequently, this can help people to ponder their own life, promoting self-exploration and improving their ability to externalize problems [17].

This study shows how a film-based intervention, with typical structural and practical phases of the filmmaking process, can actively involve children and adolescents with mental health problems. This study has several objectives.

The first objective was therapeutic and psycho-educational. It intended to represent an educational and growth experience for children and adolescents with neurodevelopmental/psychiatric disorders to make them capable of putting their skills to the test by experimenting with the various roles that cinema caters to (screenplay, direction, set design, costumes, acting, video shooting, editing). At the same time, it wanted to stimulate them to live out highly creative and cooperative work experiences. In this way, the higher-order cognitive functions (executive functions) and the energetic, motivational, and empathic aspects (warm executive functions) have been strongly stimulated and trained. The constant presence of child neuropsychiatrists and psychologists, who supported the film director, ensured the achievement of these objectives.

The second objective was to offer a theoretical and practical introduction to the key principles of filmmaking. The participants attended a series of structured lessons on the skills necessary to use the cinematographic language (from brainstorming and storyboarding to camera use or video editing) with the purpose of creating a professional audiovisual product. All participants and professionals were members of the technical and artistic cast, working under the guidance of a qualified movie director and cinema teacher. The students also received a training certificate.

Finally, the current study explores whether, and to what extent, involvement in a filmmaking program could promote the psychological well-being of children and adolescents with emotive/behavioural problems. The hypothesis is that this highly creative and cooperative group experience could both enhance participants' self-esteem and reduce the severity of their emotional/behavioural problems.

Therefore, the research project included a quantitative assessment through standardized measures of the participants' emotional, social, and behavioural profiles. In addition, the benefits of the filmmaking course have been estimated on the extent of changes in the study measures (self-esteem and emotional/behavioural problems) through a before–after comparison. Furthermore, to support the outcomes of the filmmaking intervention, the evaluation of improvements observed by the caregivers was implemented.

#### **2. Materials and Methods**

#### *2.1. Participants*

The study involved 52 participants aged between 9 and 17 years: 24 girls (mean age 114 Mgirls = 16, SDgirls = 2.4) and 28 boys (age Mboys = 14.8, SDboys = 2.6), all with a diagnosis of neurodevelopmental/psychiatric conditions. The project was developed in two consecutive courses of 6 weeks each. A first group of participants (N = 18) was selected among patients from an outpatient service at the Child and Adolescent Neuropsychiatry Unit, "A. Cao" Hospital—"G. Brotzu" Hospital Trust, Cagliari. A second group (n = 34) was chosen at Rehabilitation and Education Center "Dismed Onlus-Centro Studi per Le Disabilita' del Mediterraneo", Messina, Italy.

Inclusion criteria were: (i) clinical diagnosis of neurodevelopmental/psychiatric conditions, (ii) aged under 17 years old.

Information regarding personal data (i.e., gender and date of birth), personal history (i.e., previous diagnosis), and family history (psychiatric conditions) was collected.

The several diagnoses in the total sample were, in descending order: anxiety disorder (n = 19), ADHD (n = 15), depressive disorder (n = 14), dyslexia (n = 13), adjustment disorder or PTSD (n = 12), autism spectrum disorder (n = 11), OCD (n = 7), bipolar disorder (n = 6), psychotic disorder (n = 5), Tourette syndrome (n = 5). Most of the enrolled adolescents received more than one diagnosis. The exclusion criteria were Total IQ (TIQ) < 70, assessed using the Wechsler scale (WISC-IV).

#### *2.2. Aims of the Study*

This study explores if a therapeutic approach based on a six-week filmmaking course would help adolescents with emotional/behavioural problems and neurodevelopmental disorders. We hypothesized that an intensive training course aimed to actualize an artistic

and creative product, such as a film, could lead to improving emotional and social abilities of a group of adolescents. We questioned if the peer interaction and the cooperative work on a film set could represent an effective tool for promoting adolescents' psychological well-being, as reported in most of the scientific literature [13,18].

#### *2.3. Procedure and Phases*

Different professionals (psychologists, child psychiatrists, educators) supervised all the project phases to provide appropriate support during the entire project.

An experienced movie director [19] coordinated the whole process, with the help of a professional actor who supported the participants as an acting coach [20].

First, the invitation to participate in the project was proposed to parents through the two clinical/rehabilitation centres. The interested parents were invited for a meeting during which they obtained all details and scope of the project and provided written consent for their child's participation. Subsequently, children participated in a meeting to receive information about the filmmaking project and to obtain their assent for voluntary involvement.

Then, participants started a daily course of 5–6 h per day, lasting in total three weeks. During the first two days, all project members attended theory-based lessons in filmmaking history and techniques. This phase also focused on building trust relationships among the participants.

From the third day onward, the three main stages of the film production process were structured. First of all, a pre-production workshop took place. In this phase, the participants, divided into groups, ideated and wrote many screenplays. Participants were assigned different filmmaking roles according to their interests and attitudes: scriptwriting, direction, photography, sound, costume design, make-up artistry, production organization, and digital editing. Some subjects also held more than one role. During the pre-production workshop, the participants were also engaged in storyboarding, spaces were selected, and equipment for sets was provided. A day-by-day film production timeline was also created. Additionally, following the creative (i.e., choice of the topic, narratives, roles, etc.) and technical phases (i.e., training on camera functioning), the filmmaking process took place in natural locations or public areas (sports ground, squares, etc.) that were chosen by the participants. Participants were expected to produce a few short films (lasting about 15 min), but they outperformed expectations and ultimately produced 13 short films in total (6 in the first edition and 7 in the second edition of the course). The script themes were largely inspired by the main adolescents' issues and concerns, such as unintentional injuries, violence, mental health, suicide, self-cutting, alcohol and drug use, gender dysphoria, sense of unease, etc. In addition, some scripts were inspired by social and political issues, such as the Russia–Ukraine war and the fear of the apocalypse. Only a few themes contain hopeful messages that aim to promote the power of friendship and love. However, every script and film told a good story with an exciting plot that promoted reflection on sensitive topics.

Finally, during the last two days of the programme, the video-editing crew worked with the movie director for the post-production phase: firstly, they drafted a rough cut of the film; then, they began to review and edit the footage making additions such as visual effects, background music, and sound design.

#### *2.4. Questionnaires*

Both the participants and their caregivers were asked to complete the following self-administered questionnaires at the beginning (T0) and at the end (T1) of the course (Supplementary Materials):

Rosenberg Self Esteem Scale (RSE [21,22]); Youth Self-Report scale (YSR; [23,24], Italian adaption by Frigerio A. et al., 2004 [25]); Social Responsiveness Scale (SRS; [26], Italian adaption Zuddas et al., 2010 [27]); and Revised Conners' Parent Rating Scale (CPRS-R; Conners, 1997, [28] Italian adaption Nobile, Alberti & Zuddas, 2007 [29]).

Firstly, children and adolescents completed the Rosenberg Self Esteem Scale, which is a 10-item questionnaire that assesses global self-esteem. All items have a 4-point Likert scale (ranging from "strongly disagree" to "strongly agree", half reversed). Higher scores indicate a higher sense of self-esteem and scores below 15 suggest low self-esteem. The Italian questionnaire has shown good internal validity (Cronbach's α = 0.84) and test–retest reliability (r = 0.76; Prezza et al., 1994 [22]).

Secondly, they filled out the Youth Self-Report Scale, which measures the severity of emotional and behavioural problems based on a sense of self-estimated evaluation. The YSR is recognized as having good psychometric characteristics, with α values ranging from 0.71 to 0.95. The questionnaire (112 items) is an instrument of the ASEBA (Achenbach System of Empirically Based Assessment; Achenbach, 1993 [23]) and includes 8 sub-scales or syndromes: anxious/depressed, withdrawn/depressed, somatic complaints, social problems, thought problems, attention problems, rule-breaking behaviour, and aggressive behaviour. Patients select responses (not true/somewhat or sometimes true/very true or often true), and syndrome scores are then calculated by summing the response of each problem item (e.g., "I am too shy or timid" and "I threaten to hurt people"). Higher scores indicate more severe levels of the measured syndromes.

Finally, all primary family caregivers were asked to complete Social Responsiveness Scale (SRS) and the Revised Conners' Parent Rating Scale (CPRS-R) at points T0 and T1.

The Social Responsiveness Scale (SRS) measures the severity of social impairments in children affected by autism spectrum disorder or children from the general population. This questionnaire has excellent psychometric characteristics, and it has also been proven to be a useful tool for verifying changes in the severity of social impairment following intervention [30].

The 65-item questionnaire includes five subscales: social awareness, social cognition, social communication, social motivation, and autistic mannerisms. Caregivers respond by estimating to what extent the item describes a child's observed behaviour on a 4-point Likert scale (from "not true" to "almost always true", "Seems much more nervous in social situations than when alone"). Higher scores indicate higher severity of social deficits in that area.

The Revised Conners' Parent Rating Scale (CPRS-R; Conners, 1997, [28] Italian adaption Nobile, Alberti & Zuddas, 2007 [29]) is a questionnaire measuring parental perception of a child's behavioural problems. The short form (27 items) comprises four subscales: oppositional behaviour, cognitive problems, hyperactivity, and ADHD index. The respondent rates on a 4-point scale how often the child engages in the described behaviour (from "not true at all/never, seldom" to "very much true/very often, very frequent"; for example, "Inattentive, easily distracted"). Higher scores indicate more severe behavioural problems than lower ones. This short form of the CPRS-R proved to be a valid tool and sensitive as a treatment outcome measure [31].

#### **3. Results**

Statistical procedures were performed using IBM SPSS 19.0 data analysis software. All participants recruited at T0 completed the filmmaking course with no dropouts, so the measurements (n = 52) at the two assessment points (T0 vs. T1) from both children and caregivers were available for the statistical analysis.

Firstly, descriptive statistics for dependent variables were calculated (see Table 1). The assumption of normality for all measures was verified by the Kolmogorov–Smirnov, with Lilliefors correction and Shapiro–Wilk tests: all *p <* 0.05. Therefore, Wilcoxon signed-rank tests were performed to estimate pairwise differences between the measures. These tests were employed as a non-parametric alternative to the paired *t*-test, as it does not rely on the assumption of normality. Specifically, they were utilized to identify significant differences (*p* < 0.05) between the YSR, SRS, and CPRS-R measures (T scores) at two different time points (T0 vs. T1). Results are reported in Table 2.

Primarily, an increase in self-esteem scores (RSE) can be observed (see Table 1), even though the differences between phases do not reach statistical significance. Nevertheless, the number of participants at T0 with low vs. normal/high self-esteem was 16 (30.8%)

and 36 (69.2%), respectively; at T1, the percentage of participants with low self-esteem was halved (8 participants, 15.4%), and 44 participants (84.6%) reported normal/high self-esteem levels. Then, the number/percentages of participants with high vs. low RSE were tested for the independence of distributions at T0 and T1 using the chi-square test (χ2). However, the test showed no significant association between self-esteem levels and phases: χ<sup>2</sup> (1) = 1.56, *p* = 0.21.

Moreover, all the subscales measured by the Youth Self-Report scale were decreased from T0 to T1. A significant decrease in YSR scores from T0 to T1 resulted in four sub-scales: withdrawn/depressed (*p* = 0.005), social problems (*p* = 0.007), thought problems (*p* < 0.001), and rule-breaking behaviour (*p* = 0.04) (see Table 2).

Moreover, in the Social Responsiveness Scale (see Table 2), all parameters decreased significantly between T0 and T1, with the only exception being autistic mannerisms. Most importantly, the parameters that reached the widest statistically significant improvement were the social awareness subscale (*p* = 0.001) and social motivation subscale (*p* = 0.03). Social awareness increased in all patients.

Finally, while a decrease in CPRS-R scores was observed (subscales and ADHD index), the differences (T0 vs. T1) did not reach statistical significance. This finding was highly predictable since the programme was too short to change core aspects of a disorder, such as hyperactivity or oppositional behaviour.

**Table 1.** Descriptive statistics of scores at single items for every scale used. Youth Self-Report scale (YSR), Rosenberg Self Esteem Scale (RSE), Social Responsiveness Scale (SRS), and Revised Conners' Parent Rating Scale (CPRS-R). T0 = scores before treatment; T1 = scores after treatment; M = Means values; DS = Standard Deviation; M = Mean; DS = Standard Deviation; Mdn = Median; Min = lowest score; Max = Highest score.



**Table 2.** Differences (*p* < 0.05) between the YSR, SRS, and CPRS-R measures (T scores) at two different time points (T0 vs. T1). Youth Self-Report scale (YSR), Rosenberg Self Esteem Scale (RSE), Social Responsiveness Scale (SRS), and Revised Conners' Parent Rating Scale (CPRS-R). T0 = scores before treatment; T1 = scores after treatment.

<sup>a</sup> Based on positive ratings. <sup>b</sup> Based on negative ratings.

#### **4. Narrative and Qualitative Reports**

In addition to the numerical data that we have collected and analysed via statistical methods, we included a qualitative research approach, collecting descriptions of thoughts and emotions from participants through observation and interviews.

The focus is on exploring subjective experiences, with the aim to better clarify the impact of the intervention on the participants and to uncover insights and meanings of the experience.

The filmmaking programme represented a growth opportunity not only for the young participants, but also for all the professionals that contributed to the realization of the project. The power of this experience and the impact it can have on individuals is evident in the following reports. All of them shared a common experience of learning new skills, feeling like professionals, and becoming part of a group.

#### *4.1. The Point of View of the Filmmaking Master*

The filmmaking master was highly enthusiastic about the experience of mentoring the students in this pilot study. He commented positively on such issues as the changes he saw in the students, the positive impact on the participants, and how impressed he was with their participation. Figure 1 shows a behind-the-scenes photo shot on the film set.

As the filmmaker noted:

"For many years I have been carrying out intensive filmmaking courses, including academic ones, in various parts of the world. I have had students of all kinds, preparation, culture, age, language, and professions, but this has genuinely been

my most surprising, gratifying and pleasant experience. Implementing a cinema project with such young kids was a challenge. Knowing then that these students had a difficult background and had psychiatric disorders left me uncertain about the possibility of helping them in my role as a director. But, surprisingly, I could see them following the first lessons with interest, travelling together on the bus for site inspections, casting, auditions and becoming more and more passionate. Then I saw them write their stories enthusiastically, get in front of and behind the cameras, stand at the microphones, and take the clapperboard. I saw them smile, communicate, and participate as a real team in an often tiring job full of responsibility and moments of stress. They came out stronger, aware of their abilities and proud to participate in something unique and unrepeatable. This was the real result that gratified me and made me proud. But even the strictly cinematographic results have been beyond all expectations. The stories of these short films, so intense and derived from an authentic and painful experience, have impressive communicative power. I called these young boys and girl "little giants" because of what they were capable of doing. But I would also call them little "seismographs" due to their incredible sensitivity in recording even the slightest painful movements of the world around them".

**Figure 1.** A behind-the-scenes photo shot on the film set.
