Background: Arts-based programs have re-emerged as a focus of population mental health policy, with the World Health Organisation Healing Arts initiative and social prescribing programs across the UK, Australia, USA, and Canada signaling growing interest in scalable, accessible approaches to mental health prevention. With this growing trend there is an opportunity for seeking complementary scalable approaches implemented during childhood to prevent mental-ill health. Objective: The aim of this study was to provide a broad overview of the nature of the relationships between participation in arts programs and mental health and wellbeing outcomes during middle childhood, with a specific emphasis on the mechanisms that may underlie this relationship. This review also aimed to identify program characteristics and the context in which this relationship exists. Methods: This systematic review was performed according to PRISMA guidelines with a focus on studies examining the relationships between arts participation and mental health and wellbeing outcomes among children in the general population during the middle childhood years (6 to 12 years). Results: A total of 34 studies were included, made up of primarily quantitative studies. The evidence base reviewed suggests therapeutic approaches in non-clinical settings led by specialists over shorter periods of implementation (typically 4-10 weeks) shows preliminary signs of promise. Recreational programs showed inconsistent effects across outcome domains: some studies reported benefits to wellbeing and stress, while others reported no effect on internalising or externalising symptoms, with no consistent pattern across program features. Psychological and biological constructs were the most commonly identified mechanisms of change. The certainty of evidence across all mental health outcomes was rated as low or very low. Conclusion: This first systematic review of arts-inclusive programs in middle childhood points to preliminary signs of promise, particularly for therapeutic approaches in non-clinical settings, although the certainty of evidence is low. Future research should focus on conducting high quality studies in school contexts with a focus on pedagogical design and facilitator expertise. This would address cost effectiveness for scaling at the general population level for prevention. Systematic Review Registration: https://www.crd.york.ac.uk/PROSPERO/view/CRD42024581364.
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