Copyright B 2016 Wolters Kluwer Health, Inc. All rights reserved.

Yael E. Derman, BSN, RN

Janet A. Deatrick, PhD, RN, FAAN
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Promotion of Well-being During

Treatment for Childhood Cancer
A Literature Review of Art Interventions as a Coping Strategy

K E Y W O R D S Background: Scientific literature suggests that art interventions can assist

Art making children with cancer cope with physical and psychosocial difficulties associated with
Art therapy cancer treatment. Little is known about how the making of tangible visual art can
Childhood cancer be helpful and which proposed therapeutic mechanisms are clinically important.
Coping Objective: The purpose of this literature review is to assess and synthesize
Creative arts the research evidence regarding the role of art therapy/art-making interventions
Literature review for promoting the well-being of children with cancer undergoing treatment.
Pediatric oncology Methods: A search of electronic databases (MEDLINE [PubMed], CINAHL,
Well-being PsycINFO) and EBM Reviews including Cochrane Database of Systematic Reviews
(OVID) and manual review of references in articles accessed were undertaken.
Inclusion criteria were as follows: research studies of any design; children with
cancer undergoing treatment (2Y21 years old), and art therapy/art-making
intervention. Data extraction and quality appraisal were undertaken. Data were
analyzed with an author-developed review sheet and synthesized into a table.
Results: Six articles reporting 6 studies met the inclusion criteria. Studies
were based on qualitative (n = 3) and mixed quantitative/qualitative (n = 3)
methodologies. Three outcome categories emerged that outline potential therapeutic
roles of art interventions. Conclusions: Though sparse and developmental in
nature, the existing evidence suggests that art interventions may potentially promote
the well-being of children undergoing cancer treatment by reducing anxiety,
fear, and pain and promoting collaborative behaviors; enhancing communication
with the treatment team; and counteracting the disruption of selfhood that cancer

Author Affiliations: School of Nursing, University of Pennsylvania, Philadelphia. Correspondence: Yael E. Derman, BSN, RN, 1213 Crofton Avenue N.
The authors have no funding or conflicts of interest to disclose. Highland Park, IL 60035 (yaelderman@gmail.com).
Accepted for publication September 29, 2015.
DOI: 10.1097/NCC.0000000000000318

Well-being During Treatment for Childhood Cancer Cancer NursingTM, Vol. 39, No. 6, 2016 n E1

Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.

 treatment evokes. Implications for Practice: Further and higher-quality research
is warranted before routinely integrating standardized art interventions into the
treatment protocols for children with cancer.
E
ach year, approximately 16 000 children in the United
States receive a diagnosis of cancer.1 Advances in cancer
treatment have dramatically improved survival rates. De-
spite these advances, treatments include those that are potentially
traumatic. Children, however, may not have developed adequate
coping mechanisms for dealing with those traumas.2Y4 Thus, sig-
nificant patient suffering can ensue, and issues related to can-
cer treatment remain a dominant influence on their quality of
life.2,3,5Y8 Children in the pediatric oncology setting who are re-
ceiving treatment face many challenges that are not part of typical
age-related experiences. They are often subject to painful pro-
cedures. They may have lost control over their bodies and must
comply with those prescribing the procedures they must undergo,
which may occur at unexpected intervals. The familiar is dis-
rupted; they have been removed from home, family, school, and
friends. They may not have adequate parental support.9Y11 Social,
emotional, and physical constraints may be so overwhelming and
incomprehensible that they hamper a working language for com-
munication with the treatment team.3 These issues present par-
ticularly difficult challenges for pediatric oncology patients as
they search for ways to adapt to the treatment environment and
authentically express themselves to their healthcare providers,
family, and community while at the same time exercise their de-
veloping capacities and build an identity outside their illness.
Pediatric oncology nurses often care for children with diffi-
culties adjusting to their treatment protocols. Whether their pa-
tients are experiencing intractable pain, social isolation, lack of
communication skills, or fear and anxiety, nurses are required to
seek interventions that are meaningful to children in a broad span
of age groups and developmental stages in order to assist their
patients on a personal level.
Lazarus and Folkman12 defined coping as behavioral and
cognitive efforts to manage external and/or internal demands
that are appraised as exceeding the person’s resources. The majority
of research on coping in children/adolescents has evolved from
the pioneering work of Lazarus and Folkman.12 The focus of a
child’s/adolescent’s coping effort is aimed at trying to meet the
demands of the situation or controlling his/her emotions.3 Cop-
ing strategies are used to adapt to the environment or to change
it.13On the conceptual level, according to Lazarus and Folkman’s12
stress and coping model, effective coping in children and ado-
lescents is linked to adaptational outcomes, which include having
a sense of physical and/or emotional well-being, control, and ap-
propriate resources for communication of needs, concerns, and
social interaction.12 According to this framework, the scientific
literature suggests that art interventions, that is, the making of
tangible visual art, which includes both art therapy and art mak-
ing, are appropriate coping strategies for the pediatric oncology
population as they can assist children from preschool ages through
late adolescence and early young adulthood adapt to or modify
some of the physical and psychosocial difficulties of cancer treat-
ment.2,3,14Y17 Art therapy, by definition, is administered by an
E2 n Cancer NursingTM, Vol. 39, No. 6, 2016
Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.
art therapist and is an intervention based on the belief that the
creative process involved in artistic self-expression improves and
enhances individuals’ physical, mental, and emotional well-
being.18,19 Art making does not require a certified art therapist,
and participants work with tactile materials to facilitate emotional
expression.19Y22 On the psychological level, art has long been
known as a form of projective play wherein children project their
subconscious feelings onto their artwork, thus maintaining a safe
psychological distance from overwhelming emotions.17 Art inter-
ventions in the pediatric hospital setting can serve multiple ther-
apeutic purposes, including providing a form of play that not only
serves to enhance affiliation with peers, release tension, advance
cognitive development, and increase exploration but also provides
a safe haven for expression by projection and mastery of anxieties
and fears on the activities.17 Given the helplessness and con-
finement that many children experience in the hospital, art in-
terventions can be an important coping strategy that helps to
normalize this very abnormal experience and thereby promote a
sense of well-being.
Although there is generalized clinical acceptance regarding the
therapeutic value of art therapy and art making in pediatric cancer
care and recent interest by the National Institutes of Health re-
garding research in this area as applied to palliative care,23 a gap
in the literature exists regarding an evidence-based synthesis and
review of this topic for the pediatric cancer population specifically.
However, in the adult cancer population, there are 2 systematic
reviews24,25 and 1 evidence-based synthesis26 of the literature
available that can inform the current study. Findings from these
reviews demonstrate that art interventions help adults with cancer
cope with their treatment through decreasing anxiety, fear, depres-
sion, and pain and by promoting self-expression, social interac-
tion, and personal growth.24Y26
Little is known regarding how art therapy and art making can
be a helpful coping strategy for children with cancer undergoing
cancer treatment or which, if any, of the proposed therapeutic
mechanisms is clinically important. The purpose of this liter-
ature review is to assess and synthesize research evidence regarding
the role of art therapy/art making for promoting the well-being of
pediatric oncology patients going through their treatment-related
challenges. Systematic data-based research can contribute to the
development of a deeper understanding of the link between the
making of tangible visual art and improved health outcomes for
the pediatric oncology population. Evidence for art interventions
as a coping strategy that leads to improved health outcomes can
add enhanced credibility to the integration of art interventions
into the care of children undergoing cancer treatment.
n Methods
A search strategy was developed to create an inclusive database
(Figure 1). The inclusion criteria included the age groups in
Derman and Deatrick
Figure 1 n Methods-search strategy.
which children with cancer are treated in a pediatric facility and
are also of sufficient age to participate in an arts intervention,
that is, aged 2 to 21 years. Using the conceptual framework of
coping according to Lazarus and Folkman,12 effective coping in
children and adolescents is linked to an adaptational outcome,
which includes having a sense of physical and/or emotional well-
being, control, and appropriate resources for communication of
needs and concerns.12 Improved health outcomes as a result of
such strategies were therefore operationalized by the demonstra-
tion that an art intervention (coping strategy) that primarily in-
volved the making of tangible visual art, implemented during a
treatment for a childhood cancer, enhanced individuals’ physical,
mental, or emotional well-being, such as reducing fear, pain, and
anxiety; achieving a sense of control; and enhancing communi-
cation with the treatment team, self-expression, social interaction,
or personal growth.
Retrieval Strategy
There were initially 266 references retrieved from the databases.
This resulted in 5 references from databases and 1 reference from
manual review of reference lists (Figure 2). The following fea-
Well-being During Treatment for Childhood Cancer
Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.
tures were extracted from each study: purpose; location; design;
participants (characteristics, recruitment, and consent); interven-
tion (model, content, duration, and frequency, delivered by, and
setting); symptoms investigated; health outcome measures; find-
ings reported; methodological issues; and clinical comments
(Table 1).
Data Appraisal
The quality of each study (Table 1) was assessed by the authors
on 10 points of congruity between the research methodology and
the procedural rigor for the given study design. The authors con-
structed a list of 10 appraisal criteria that would be relevant
for assessing qualitative, quantitative, and mixed methodologies.
These criteria are a nuanced adaptation of the quality measures
to evaluate qualitative research as suggested by Cesario et al.33
Although Cesario and colleagues’33 work is primarily intended
for appraising qualitative research, the authors found this frame-
work a useful guide for devising a criteria scale to address mixed
methodologies as well as pilot studies. The authors’ 10-point ap-
praisal criteria are presented in Table 2. One full point was as-
signed to each of the appraisal criteria. Each individual study was
Cancer NursingTM, Vol. 39, No. 6, 2016 n E3
Figure 2 n Methods retrieval strategy.
rated as high quality, if 8 of 10 points of congruity were satisfied;
good quality if 7 of 10 points were satisfied; low if 6 or fewer of
10 points were satisfied. In the authors’ appraisal, all discrepancies
in grading were reconciled by consensus discussion, resulting in
100% agreement.
The classification of research designs outlined by the Johns
Hopkins Nursing Evidence-Based Practice Rating Scale (JHNEBP)34
provided a framework for appraisal of the totality of evidence of
retrieved studies. The JHNEBP quality-of-evidence scale is speci-
fically a nursing evidence-based scale. It was chosen to analyze this
review because of its favorable considerations of the nonexpe-
rimental elements that are inherent to qualitative studies with
psychosocial outcomes, outcomes that can inform nurses’ advocacy
of patients. Corresponding to the developmental nature of this
science and the small number of studies, which also included pilot
studies, the leveling criteria themselves are not used.
Meta-inference was used to grade the totality of the evidence
according to the JHNEBP framework.34 Conclusions were gen-
erated by integrating inferences obtained from the entire body of
literature to create an overall summary grade. The authors used
the JHNEBP classification34 designations of high, good, and low
E4 n Cancer NursingTM, Vol. 39, No. 6, 2016
Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.
to judge whether the quality of evidence provides a substantial
foundation/building block or basis that warrants further explo-
ration and/or immediate clinical application for art interven-
tions as a coping strategy for promoting well-being in pediatric
oncology patients in treatment. When appraising the totality of
evidence, required elements to achieve a JHNEBP grade of good
or higher were reasonable consistency of results among studies,
sample sizes appropriate for the tradition/methodology of each
study, inclusion of at least 1 study with a control group, and de-
finitive conclusions that flow from the analysis or interpretation
of the data.34
Of note, in the appraisal of the totality of evidence, sample
sizes were considered adequate for qualitative studies if appropriate
for the qualitative tradition of the study and if the sample generated
enough in-depth data such that a pattern or dimension of a cop-
ing phenomenon under study could be illuminated. In studies
wherein quantitative research with quasi-experimental or experi-
mental formats was intrinsic to the design, sample sizes were con-
sidered sufficiently large if they supported statistical conclusions.
Sample sizes for pilot studies resulting from pragmatic recruitment
were judged as appropriate, if they could provide good-quality,
Derman and Deatrick
 Table 1 & Table of Evidence
Reference and Outcome Quality
Country Purpose Design Participants Interventions Measures Findings Appraisal
Councill27 (1993), 1. Assess recurrent Qualitative: multiple n = 8, 6 male Individualized and Thematic analysis: Diagnosis and early Qualitative
Washington, DC themes in artwork case studies. 2 female; multiple client-centered recurrent themes treatment phase of study
created by pediatric Interviews and 5Y20 y old; art therapy sessions from interviews cancer treatment: art Appraisal: high
oncology patients thematic analysis of malignancy with experienced art surrounding artwork focused on body image, quality
within a hospital patients’ art by type: various therapist during in each of the identity and self- esteem
setting and in experienced art diagnosis and early 3 different stages Middle phase of treatment:
various phases of therapist (expert) treatment, middle identified art reflected long term
disease and Setting: pediatric phase of treatment Process analysis: specific stress of treatment
treatment process hospital cancer and relapse, and identification of such as boredom,
to illustrate treatment and palliative care therapeutic coping separation, and
psychological research center Choice of materials benefit of art therapy missed milestones
characteristics, (inpatient outpatient) and color (clay, interventions Relapse and Palliative
issues, and coping Duration: 1.5 years paint, pencils, Care phase: Elevated
mechanisms Control Group: pens, crayon) uncertainly, anger
2. To demonstrate None Time frame of art and isolation

Well-being During Treatment for Childhood Cancer

therapeutic benefit Ethics institutional intervention Demonstration of art
of art therapy review board (IRB) not noted interventions’ efficacy
interventions in or informed consent: through the following
the pediatric none listed therapeutic benefits:
oncology patients Samples: represent each 1. Active creativity
phase of treatment facilitated through
patients’ choice of
art materials
2. Communication with
the care team maintained
throughout emotionally
charged situations
3. Visual communication

Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.

established helping
mitigate the isolation of
the hospital experience
4. Rehearsing troubling
events and working
out concepts of self,
supported sense of
mastery over feelings
of illness and treatment

Cancer NursingTM, Vol. 39, No. 6, 2016

(continues)

E5 n
 Table 1 & Table of Evidence, Continued
Reference and
Country Purpose
Favara-Scacco Explore use of art
et al28 (2001), therapy (AT)
Catania, Italy interventions among
children with leukemia
to prevent anxiety and
fear during painful
interventions (lumbar
puncture [LP], bone
marrow aspiration
[BMA]) and prevent
E6 n Cancer NursingTM, Vol. 39, No. 6, 2016
prolonged
emotional distress
Madden et al29 1. Does creative arts therapy
(2010), (CAT) improve the
Colorado, USA quality of life for pediatric
brain tumor patients
in treatment?
Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.
2. Does CAT in a group
setting improve mood of
children receiving
outpatient infusion?
3. How is CAT perceived by
health professionals in
an outpatient infusion
center?
Derman and Deatrick
Outcome Quality
Design Participants Interventions Measures Findings Appraisal
Non-randomized Experimental group Multiple arts Behavioral rating Those in the CG Quasi-experimental
prospective study: (EG): n = 32, modalities Efficacy of AT exhibited resistance study, pilot
pilot qualitative/ 2Y14 y old offered approach evaluated and anxiety during study, appraisal:
quantitative mixed Malignancy type: Art making supervised by comparing and after painful good quality
methods leukemia and by trained art observed behavioral procedures
Setting: inpatient candidates for therapist; delivered styles of children in Those in EG, from
hospital an LP or BMA by trained play EG with those in first hospitalization,
Duration: 1 y Comparison group worker, parent, or CG according to exhibited cooperative
(1997Y1998) (CG): n = 17Vfirst other hospital staff behavioral ratings behaviors and asked
Control group: yes hospitalization The AT: clinical before, during, and for AT when
Ethics IRB or informed prior to September dialog to calm after LP or BMA: procedures repeated
consent: none listed 1997; CG received children before 15 Positive behaviors 2- to 5-y EG 64% (n = 7)
Data collection: no art therapy painful procedures; indicated better good responders
baseline before support visual imagination cooperation with compared with
painful procedure, during procedure; painful procedures; CG (0%)
then during, and after and various art children who 6- to 10-y-Old age
painful procedure modalities before adopted Q8 positive group EG 71%
Sample: pragmatic and after procedures: behaviors = ‘‘good (n = 10) good
recruitment; sample structured drawing responders’’; responders vs CG
size not based on and free drawing e8 = ‘‘poor 25% (n = 2); 11- to
power analysis responders’’ 14-y-old age group
Statistical significance: EG 86% (n = 6)
not recorded good responders vs
CG 17% (n = 1)
Mixed-methods pilot First arm: RCT First arm: each First arm: mixed-effect First arm: RCT Small randomized
(3 arms): quantitative n = 18, 14 males group tested measures used to statistically significant trial with
using validated and 4 females, before, during, examine the trend improvement over controls (also
instruments and 2Y18 y old and and after the of effects of CAT on comparative group includes
qualitative methods their parents intervention outcome measure (per the PedsQL nonrandomized
First arm: quantitative Malignancy type: Experimental Group: per the PedsQL parent proxy report) aspect without
2-group brain tumor, received Second arm: scoring for parent report of controls)
repeated-measure active treatment individualized of the Emotional child’s hurt (report Pilot study
RCT design compared continuing for CAT; had six 1-h Reactions Checklist of pain) and parent Appraisal: good
CAT with a at least 3 mo and at weekly CAT sessions and Faces Scale report of child’s quality
volunteer’s attention least 6 consecutive with 2 sessions each Third arm: analysis of nausea; parent
using PedsQL and infusions 1 wk apart of body movement, focus group of nurses interviews quoted,
demographic sound to graphic from audio-taped in general, an
(drawing) transcripts enjoyable experience
(continues)
 Table 1 & Table of Evidence, Continued
Reference and
Country Purpose Design
Qualitative parent
and patient
interview after 6th
and final infusion
Setting: Outpatient
pediatric hospital
Duration: 1 y
Control Group: Yes
IRB approval: yes
Second arm: quantitative
nonrandomized phase
using the Faces Scale
(<7 y old) and the
Emotional Reactions
checklist (>7 y old)
Well-being During Treatment for Childhood Cancer
and demographic
form for preinfusion
and postinfusion
data collection
Setting: outpatient
pediatric hospital
Duration: 1 y
Control Group: Yes
Ethics IRB or informed
consent: yes
Third arm: qualitative,
narrative analysis: focus
group of providers
Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.
Massimo and 1. Examine how children Qualitative descriptive
Zarri 30 (2006), with cancer cope by analysis of patient’s
Genova, Italy expressing themselves artwork, qualitative
through drawings and interviews, and
by using them as a written explanations
stage to dramatize of patient artwork
needs, wishes,
anxieties, and joys
Cancer NursingTM, Vol. 39, No. 6, 2016
E7 n
Outcome Quality
Participants Interventions Measures Findings Appraisal
Second arm: Control Group: Second arm:
nonrandomized received a volunteer’s nonrandomized
n = 32, 18 males attention (reading, phase using Faces
and 14 females, talking, etc) Scale showed
3Y21 y old Interventionist was a improved mood with
Malignancy type: master’s prepared statistical significance
varied malignancies dance therapist on the Faces Scale
and therapies with experience in art (P < .01), and patients
included therapy. were more excited
chemotherapy, Second arm: (P < .05), happier
transfusions and nonrandomized: the (P < .02), and less
non-chemotherapy CAT therapist nervous (P < .02) on
infusion provided 1-h group the Emotional
Third arm: focus art/drawing session Responses Checklist
group of primary for patients in Third arm: provider
nurses for patient hematology/oncology focus groups revealed
who received CAT infusion room positive experiences
and 1 physician each week
Tested before and after
group intervention
Third arm: after 1-y
focus group for staff
nurses involved in
the patients’ care:
group discussion and
open-ended questions
Tape recorded and notes
taken
n = 50 Italian Supportive Thematic analysisV Thematic analysis: Qualitative
children 4Y14 y psychotherapy; recurrent feelings drawings showed study
old, 27 males, children drew in evident in the 2 main themes of Appraisal:
23 females 3 situations: (1) drawings self-expression and good quality
Malignancy type: spontaneously when Process analysisVpatient decreased barriers to
leukemia or cancer alone, (2) with play mood in response to show feelings related
in different stages workers, (3) with narrative and written to illness
psychologist descriptions surrounding
the artwork
(continues)
 Table 1 & Table of Evidence, Continued
Reference and Outcome Quality
Country Purpose Design Participants Interventions Measures Findings Appraisal
2. Examine if any Comparisons between Malignancy type: Child free to choose Process analysisVpatient 1. Drawings related
differences in expression images and leukemia or cancer both topic and mood in response to to the past; children
exist when art is descriptions (verbal in different stages technique (paint, narrative and written represent themselves
performed alone or and written) made pencil, pen); ‘‘Can descriptions surrounding as physically normal
with witnesses when drawing you draw me a the artwork with normal
alone, with play picture?’’ ‘‘Can you relationships with
workers and with make up a story friends, parents, and
the psychologist with a picture?’’ other adults
Setting: outpatient Each drawing 2. Drawings that showed
children’s hospital accompanied by their perception of

E8 n Cancer NursingTM, Vol. 39, No. 6, 2016

Duration: 1-h art interview and written disease and of
sessions over the description by child; themselves as sick
course of 1 y (2003) if this was not children. Physical
Control group: no possible, the written depiction was more
Ethics IRB or description provided realistic and related to
informed consent: by play worker or by fear of physical
none listed psychologist destruction and
Sample: sampling current self-concept;
methods unknown drawings of others
showed vulnerability,
loss of sense of self,
and dependence
on adults
Process analysis:
reduction of social and
emotional constraints
and fulfilled need
for self-expression

Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.

Psychologists’
interpretations:
1. regardless of the
setting, patients had
desire to communicate
with themselves, and
art therapy fulfilled
need for self-expression
resulting in self-healing

(continues)

Derman and Deatrick

 Table 1 & Table of Evidence, Continued
Reference and Outcome Quality
Country Purpose Design Participants Interventions Measures Findings Appraisal
2. In 2 scenarios with play
workers or psychologist,
additional benefit to
solitary drawing
noted: exposed
feelings with nonverbal
symbols in artwork
and then through
narration of artwork’s
meaning to play workers
or psychologists, or
those in treatment
environment, higher
self-concept assessments
recorded-coping

Well-being During Treatment for Childhood Cancer

due to resource for
communication of
needs and concerns
and also yielding
support and validation
from others
Rollins31 (2005), 1. Explore and compare Quantitative and n = 22, 7Y18 y old, Participant given Quantitative: scores for Quantitative: PPAT Qualitative
UK, USA nature of stressors of qualitative 13 males, 9 females colored markers and a problem solving from FEATS scoring: 46% study
everyday life and disease methods collected from UK and USA piece of white paper the PPAT Formal of the UK and USA Appraisal:
that children with simultaneously with 46% of the UK using the projective Elements Art Therapy participants indicated high
cancer in UK and grounded theory sample and 54% technique, PPAT Scale (FEATS) scoring adequate coping ability quality
USA experience approach (includes of USA (Person Picking an (0Y5) indicating Qualitative themes:
2. Explore and compare drawings interviews Malignancy type: Apple From a Tree) coping ability children, regardless of

Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.

the coping measures and observations) acute lymphoblastic 1. Child asked to Qualitative: thematic ethnicity and other
they use to manage Setting: inpatient leukemia ‘‘draw a person analysis and process cultural considerations
these stressors hospital (UK Ethnicity: for the total picking an apple analysis of the respond to cancer
and USA) sample, 60% white, from a tree; illuminative drawings experience similarly, and
Duration: data 18% Hispanic, 22% drawings scored 0Y5 demonstrating coping art reduces constraints
collected over black/African to assess problem behaviors surrounding of self-expression:
6 mo in 2000 American/other solving and coping patients’ artwork
ability

Cancer NursingTM, Vol. 39, No. 6, 2016

n
(continues)

E9
 Table 1 & Table of Evidence, Continued
Reference and Outcome Quality
Country Purpose Design Participants Interventions Measures Findings Appraisal
3. Examine the use of Control group: no 2. Child asked to 1. Must learn to negotiate
drawing to enhance IRB approval for USA complete the Scariest cancer roadmap (any
communication. and NHS Trust Image Drawing and feature of cancer and its
Ethics Committee when complete treatments); examples:
for UK asked to ‘‘Please tell pain, nausea,
Sample: sampling me about your vomiting, hair loss
methods unknown drawing’’ 2. Cope with feelings
6 Validated instruments 3. Child asked to of exclusion (social,
used: background complete a closure developmental,
information, drawingV‘‘Draw and educational

E10 n Cancer NursingTM, Vol. 39, No. 6, 2016

interviews (audio a picture of wherever milestones); example:
taped and ranged in you would like to be driver’s license, dating,
time from 30 min right now’’; once graduation, death
to 2 h), observation, completed asked 3. Drawing can be
projective drawing ‘‘Please tell me about used as symbolic
technique, and your drawing’’ communication and
2 illuminative drawing Art intervention and as a means to help
techniques analysis by trained art discover difficult
therapist and issues in a safe way
author (RN, PhD) Process: use of
drawing enhanced
communication
with those present in
treatment environment
through direct visual
expression and/or
verbal expression of
the drawings content

Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.

via the "campfire
effect" (result of an
activity or experience
that provides a focal
point shared by
individuals and serves
to increase conversation
in both quantity and
intensity)

(continues)

Derman and Deatrick

 Table 1 & Table of Evidence, Continued
Reference and Outcome Quality
Country Purpose Design Participants Interventions Measures Findings Appraisal
Soanes et al32 1. Gain understanding Qualitative descriptive, n = 10, 4Y13 y old, 3 Age-appropriate Thematic and process Four themes identified Qualitative
(2009), UK of both child’s and Longitudinal, exploratory 5 males, 5 females validated collection analysis: 5-stage that underscored a study
parent’s perceptions descriptive case studies, 70% White British techniques: validated process to need for self-expression Appraisal:
of current care services multiple methods of Malignancy type: 1. Modified mosaic highlight recurrent and art as an outlet good
at London regional data collection, multiple brain approach poster themes or processes for voicing concerns: quality
cancer unit as expressed 3 age-appropriate validated malignancies 70% built over time for coping evident in 1. The process of
in art for children collection techniques: (n = 7) surgery, 2. Draw and write artwork or descriptions receiving and seeking
or interviews 1. Modified mosaic radiation, and technique: asked to of artwork information was a
2. Gain understanding of approach: poster chemotherapy; 30% draw a picture first challenge for both
their views on coping making with (n = 3) surgery and and discuss drawings patients and parents
with current cancer care photography, radiation with researcher or 2. A need for support from
services as expressed in drawings, and 9 Mothers and play specialist 1 consistent individual
art or interviews text for children 9 fathers 3. Child informal to help families find
3. Map needs of children 4Y6 yVchildren semistructured their way through
with brain tumors and given disposable cameras interviews for those the complexity

Well-being During Treatment for Childhood Cancer

their parents from to record important >12 y old; of healthcare
diagnosis to end of life experiences 1Y2 h in duration 3. The importance of
treatment as expressed 2. Draw and write Supervised by researchers expressing how life
in art or interviews technique with (psychologists) that is affected
children aged 6Y12 y observed and took 4. The importance
3. Interview children notes. Art techniques of identifying who and
over 12 y old; (mosaic, and draw what helps
semistructured and write) provided Understanding gained:
interviews with parents by trained play art-making data
Setting: inpatient hospital specialists collection methods
Duration: 1 y at defined used for brain tumor
points during treatment patients aged 4Y11 y

Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.

(diagnosis, treatment 1, demonstrated that art
treatment 2, transition is a helpful venue to
from one treatment cope with the
to another) treatment environment
Control group: no and serves as an outlet
Ethics IRB or informed for voicing concerns
consent: yes; NHS and mitigating
Trust ethics committee and frustrations with the
written/informed consent healthcare system
Sample: convenience

Cancer NursingTM, Vol. 39, No. 6, 2016

n
Abbreviations: NHS, National Health Service; PedsQL, Pediatric Quality of Life Scale; RCT, randomized control trial.

E11
 Table 2 & Appraisal Criteriaa for Individual Studies
1. There is congruity between the stated philosophical perspective and the research methodology.
2. There is congruity between the research methodology and the research question or objectives.
3. There is congruity between the research methodology and the methods used to collect data.
4. There is congruity between the research methodology and the representation and analysis of data.
5. There is congruity between the research methodology and the interpretation of results.
6. There is a statement locating the researcher culturally or theoretically.
7. The influence of the researcher on the research, and vice versa, is addressed.
8. Participants and their voices are adequately represented.
9. The research is ethical according to current criteria, or for recent studies, there is evidence of ethical approval by an appropriate body.
10. Conclusions drawn in the research report do appear to flow from the analysis or interpretation of the data.
a 33
Criteria based on Cesario et al and adapted by the authors for qualitative, quantitative, and mixed methodologies

critical and clinically meaningful insights in context, given the
nature and constraints of the included patient population.
n Results
Design
Six primary research papers addressing art therapy/art-making in-
terventions for a cancer population aged 2 to 21 years undergoing
treatment in a hospital setting met inclusion criteria for this lit-
erature review. Studies included 3 using qualitative methods27,30,32
and 3 using mixed quantitative and qualitative methodologies,28,29,31
1 of which included a randomized control trial,29 and 1 was a non-
randomized control trial.28 Two studies were pilot studies.28,29
Sample
Sample sizes ranged from 8 to 50 participants, with 2 studies
involving 10 or less subjects27,32 and 4 studies with 16 to 50 par-
ticipants.28Y31 All studies involved both male and female sub-
jects. Three studies included participants older than 14 years,27,29,31
and 3 of the studies did not include older adolescents.28,30,32
Diagnoses included leukemia predominately (n = 3),28,30,31 brain
tumors exclusively (n = 1),32 brain tumors predominately (n = 1),29
and various malignancies (n = 1).27
Setting
ualized art interventions facilitated by either an art therapist or
trained play-worker,28,30Y32 1 study reported on both individ-
ualized and group art interventions facilitated by either an art
therapist or trained play-worker,29 and 1 study reported on
individualized art interventions facilitated by a certified art
therapist only.27
Outcomes Measures
Promotion of a healthy outcome was measured by the demon-
stration that an art intervention implemented during treatment
enhanced individuals’ physical, mental, or emotional well-being
such as decreasing anxiety, fear, depression, and pain or by pro-
moting communication with the treatment team, self-expression,
social interaction, and personal growth. Quantitative outcome
measures used to assess this therapeutic benefit were quantitative
(validated Faces Scale, Emotional Response Checklist) responses
to questionnaires,29 validated quality-of-life measurements (Pe-
diatric Quality of Life Scale [PedsQL]) before and after art in-
terventions,29 and a quantitative behavioral rating scale measuring
enhanced well-beingVauthors’ own.28 Qualitative outcome mea-
sures used to assess this therapeutic benefit were thematic and/or
process analysis of patients’ artwork demonstrating enhanced
well-being as a recurrent theme or process in the artwork
itself27,30Y32 and thematic and process analysis demonstrating
enhanced well-being as a recurrent theme or process in struc-
tured and unstructured interview and/or written description sur-
rounding patients’ artwork.27,30Y32

Three studies involved art interventions in an inpatient treat-
ment setting in a children’s hospital,28,31,32 1 in Italy,28 the
United Kingdom and United States,31 and in the United Kingdom
only.32 Two studies took place in the outpatient treatment
setting in a children’s hospital,29,30 1 in the United States,29
and 1 in Italy.30 One study took place in both the inpatient and
outpatient settings of a children’s hospital in the United States.27
Interventions
Two studies involved structured art interventions that were
theoretically based.31,32 The art intervention for 1 study had a
conceptual basis and reported on prescriptive structured and free
drawing.28 Three studies used free-drawing and free-form art-
making interventions.27,29,30 Four studies reported on individ-
Findings: Roles of Art Interventions for
Promotion of Enhanced Well-being
Three prevailing themes emerged from the data that outline the
potential health outcomes of art therapy/making. Art therapy or
art-making interventions implemented in either an inpatient or
outpatient hospital treatment setting, facilitated by an art ther-
apist or trained play worker, and administered before, during, or
after treatments, may promote the well-being of pediatric oncology
patients of both genders (aged 2Y21 years) undergoing treatment
by (1) reducing anxiety, fear, and pain and promoting cooperative
behavior for painful or invasive treatment protocols; (2) by
enhancing patient communication with the treatment team; (3)
and by counteracting the disruption of selfhood that cancer treat-
ment evokes.

E12 n Cancer NursingTM, Vol. 39, No. 6, 2016 Derman and Deatrick

Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.

Reduction in Anxiety, Fear, and Pain
Effective coping is linked to achieving a sense of physical and
psychosocial well-being by meeting the demands of the situation
or controlling emotion.12 One of the first and most enduring
areas of pediatric psycho-oncology research have been how to
help children cope with treatments and especially procedure-
related distress for invasive medical procedures.3 Art interven-
tions may promote well-being by reducing anxiety, fear, and pain
before, during, and after cancer treatments.28,29 The nonrandom-
ized controlled study by Favara-Scacco et al28 demonstrated that
children provided with art therapy intervention from their first
hospitalization exhibited cooperative behaviors and asked for art
therapy when treatments for painful procedures had to be re-
peated. By contrast, children in the control group who had no art
therapy interventions exhibited resistance and anxiety during and
after lumbar puncture and bone marrow aspiration. This pilot
study of Italian children with a diagnosis of acute leukemia con-
cludes that art therapy can provide support for children with
difficulties engaging coping skills spontaneously during painful
procedures in the inpatient hospital setting.28 Madden and col-
leagues’29 pilot study found that the effects of individualized
and group creative art therapies have a positive impact on the
quality of life of patients with brain tumor receiving outpatient
infusion treatment in a hematology/oncology tertiary care pe-
diatric hospital in the United States. In the assessment of the
patients aged 2 to 18 years receiving individualized creative art
therapy in the randomized controlled trial component, statistically
significant improvement in parent report of child’s pain (P = .03)
and child’s nausea (P = .0061) was seen over the comparative
group where trained volunteers sat at the patient’s bedside in
the infusion room and paid attention to them through reading,
talking, or watching TV. In the nonrandomized phase wherein
patients aged 3 to 21 years were provided with group drawing
arts sessions, a statistically significant improvement occurred in
mood as measured by the Faces Scale (P < .01), and patients
were happier (P < .02), more excited (P < .05), and less nervous
(P < .02) as measured by the Emotional Response Checklist.29
Enhancing Communication With the
Treatment Team
Studies have demonstrated that children with cancer want to
have a venue for communicating with their health professional
caregivers.3 Without communication, children may feel isolated
and afraid, intuiting the information, but lacking a way to ask
questions or process it emotionally with their caregivers.3 Effec-
tive coping is linked to achieving psychosocial well-being by
having appropriate resources for communication of needs and
concerns.12 The essence of art therapy is communication; effec-
tive coping may occur by reducing social, emotional, and physi-
cal constraints and encouraging self-expression with those in
the treatment environment.27,30Y32 Councill27 assessed recur-
rent themes in artwork created by pediatric oncology patients
with various malignancies in several phases of the disease and
treatment. The study reveals that even when relationships with
the healthcare team or care givers are strained by anger or
Well-being During Treatment for Childhood Cancer
Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.
withdrawal or fatigue, or when feelings are too emotionally
charged for verbal expression, ‘‘art expression can be helpful to
continue the process of development through visual communi-
cation, supporting social and mental growth and mitigating the
isolation of the hospital experience.’’29(p87)
Twenty-two ethnically diverse children hospitalized in the
United States and United Kingdom, who were undergoing in-
patient treatment for acute lymphoblastic leukemia or various
other malignancies were studied by Rollins.31 The investigators
found that drawing is a form of symbolic communication with
those present in the treatment environment, and can be used as
a safe way to identify difficult issues regardless of gender, age,
ethnicity, socioeconomics, and other cultural considerations.
Much like sitting around a campfire, ‘‘sitting around the drawing
so to speak, allowed the drawing and not the child to serve as an
object of focus.’’34(p213) This transfer of focus from the child to
the drawing relaxed the child by relieving the pressure of being
the object of direct verbal communication and served to increase
conversation in both quantity and quality.31
Individualized spontaneous drawing activities of 50 Italian
children in outpatient treatment for leukemia or other cancers
were studied by a team of psychologists who subsequently eval-
uated the drawings.30 The drawings were completed in three
settings: when the children were alone, with play workers, and
with a psychologist. The psychologists’ interpretations of the
children’s artwork revealed that graphic and pictorial communi-
cation hold great importance for sick children undergoing treat-
ment whether in a solitary setting or with adult witnesses. The
key to benefit with adult witnesses was in the child’s ability to
expose their feelings to those caring for them in the treatment
environment, first through the non-verbal symbols inherent in
their artwork, and then through narrating their story through
their art.
Individualized art-making sessions with validated collection
techniques (Modified Mosaic Approach and the Draw and Write
technique) were used to gather perceptions about coping with
cancer care services from children ages 4 to 11 years who were
undergoing combined modalities of treatment for brain tumors.32
This study from the United Kingdom found that art methods
used were helpful ways for children to cope with their treatment
environment by serving as an outlet for voicing what they found
either distressing and/or beneficial and by mitigating their frus-
tration with the treatment team and healthcare system.
Enhancing Self-esteem and Promoting Mastery
A major stressor for children with cancer in the treatment envi-
ronment is the loss of a sense of mastery related to losses of con-
trol, identity, and self- esteem.3 Art interventions as a coping
strategy, may play a powerful role for achieving psychosocial
well-being by maintaining a familiar, positive identity in cancer
and promoting personal growth.27,30 Councill27 found that when
analyzing artwork of pediatric oncology patients who were at
different points in their treatment, issues of body image, iden-
tity, and self-esteem were encountered. The efficacy of art inter-
ventions was demonstrated through a direct therapeutic benefit
with respect to patients’ issues of selfhood. Whatever forms the
Cancer NursingTM, Vol. 39, No. 6, 2016 n E13
art intervention took, it was a venue for children and young
adults to seize control over their environment and normalize the
abnormal childhood experiences of being a cancer patient by
simulating play, school, or recreating negative experiences into
positive ones. The creative process was a way of coping by re-
solving emotional conflicts and by fostering self-awareness and
personal growth. Patients controlled their own choices of art
materials, subject, and verbalization regarding their artwork.
This enabled them to ‘‘experience themselves as active creators
as opposed to victims of disease or helpless recipients of
treatment.’’27(p86)
In Massimo and Zarri’s30 study, children who were in treat-
ment drew with adult witnesses. Process analyses revealed higher
self-concept assessments due to support and validation from
others. The authors explain that the opportunity for children to
express themselves through drawings and other creative art forms
means that they are their own, self-healing therapeutic agents.
This benefit may be further guided, however, when in a setting
with facilitators because there is ongoing verbal interaction, which
in turn leads to both enhancement of full expressive possibilities
and to a positive feedback on their self-image.
n Assessment of the State of the Science
According to JHNEBP,34 adapted for this literature review, the
totality of evidence warrants a good rating as it includes a good
basis for further investigation of the use of art interventions as a
coping strategy that promotes the well-being of pediatric oncology
patients undergoing treatment. Considerable heterogeneity existed
in the designs of a paucity of studies, and there were variations in
the content of art interventions yielding diverse descriptions of
their outcomes. However, the results consistently aligned them-
selves according to the therapeutic mechanisms presented.
Whereas heterogeneity can present a challenge in practical
clinical guidelines, it does have benefit when illuminating psy-
chosocial information that can guide the healing of a particular
patient population. Quality information is revealed that may
not otherwise be assessed, because of lack of standardized or
validated tools for measurement. This review serves to extrapolate
the interpretation of the outcomes to various treatment settings
in an attempt to generalize the findings to pediatric cancer popu-
lations. At the same time, this type of assessment is a limitation
as it may lead to bias and overestimate or underestimate of in-
tervention effectiveness due to the heterogeneity of the outcome
measures. The supportive psychotherapeutics that were an aspect
of the art therapy in 2 studies28,30 may have confounded the
effect of the art intervention. The variations in model and con-
tent of the arts interventions introduce the question of replica-
bility. Thus, no standard for making specific recommendations
as to type or timing of art interventions could be given.
Another limitation was the inclusion of 2 pilot studies,28,29
making assessment of their quality challenging. The primary role
of a pilot study is to examine the feasibility of a research endeavor.
For instance, feasibility of recruitment, randomization, interven-
tion implementation, blinded assessment procedures, and reten-
tion are all examined in good-quality pilots.35
E14 n Cancer NursingTM, Vol. 39, No. 6, 2016
Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.
The authors circumvented this assessment challenge by apprais-
ing the mixed-methods research pilot studies, as pilot studies
would be graded: grading the debate over feasibility of art inter-
ventions as a coping strategy for promoting the well-being of
pediatric oncology patients in the treatment environment and/or
identifying modifications needed in design of larger ensuing
hypotheses-testing studies.
The 2 pilot studies28,29 illustrate good-quality pilot technique:
experiments integrated with operations, using pragmatic recruit-
ment.35 In the pediatric oncology treatment environment, there
is difficulty with accruing, randomization, and retaining partici-
pants because of the fallout inherent in the morbidity of the
diagnostic and therapeutic phases of certain cancers, making
pragmatic recruitment necessary. Sample sizes of good pilot
studies may be justified on the basis of a rationale other than power
analysis. Sample sizes resulting from pragmatic recruitment of
good-quality pilots may not support the small P values necessary
for statistical power, but can provide appropriate critical and
clinically meaningful insights in context, given the nature and
constraints of the included patient population.
For example, the pilot study of Madden et al29 provided a
good foundation for research by offering insights for intervening
with brain tumors. An important insight gleaned from the study
by Madden et al29 is that a smaller than optimal sample size in
brain tumor subjects may need to be anticipated owing to the
attrition during the early therapeutic phases of treatment. The
investigators concluded that if their pilot study were to be repli-
cated with brain tumor patients with the intent of achieving
intragroup statistical significance, it would need to consider the
attrition characteristics of the brain tumor population, and many
more patients would need to be recruited to achieve a sufficiently
large sample size to increase the power to detect differences in
the groups.
Favara-Scacco et al28 provided interventions for the leukemia
population, and Madden et al29 investigated the brain tumor
population. The pilot studies of Favara-Scacco et al28 and Madden
et al29 each demonstrated art interventions as strategies that
promote well-being in the specific group of pediatric oncology
patients studied and provided clinically meaningful examples
of scalable infrastructure for provision of art interventions in a
cancer treatment environment. Thus, an advantage to assessing/
appraising these as ‘‘Good’’ pilot studies is that they have good
potential for demonstrating and accelerating research in this area
for pediatric oncology patients in general and for providing clini-
cally meaningful results, which, although not entirely empirically
based, can be useful to clinicians who treat the specific patient
population studied.
Because of the heterogeneity of the 6 studies, appraisal of the
consistency of the evidence results is a narrative synthesis of as-
sessments according to each of the 3 prevailing outcome categories
rather than quantitatively assessing effect sizes or further qualitative
synthesis. Although the reviewed studies show consistent results,
the validity of the review is threatened because of the limiting
characteristics of the multiple tool measures; outcomes were not
measured or analyzed in a uniform fashion, there was a lack of
validated outcome measures in one of the controlled trials,28 and
1 study did not seem to build on the science created by the other.
Derman and Deatrick
 Despite the methodological limitations, paucity of studies,
and heterogeneity of the reviewed studies, further exploration
of the clinical use of art interventions is warranted in the pediatric
oncology treatment arena to promote anxiety relief, communi-
cation with the treatment team, and self-esteem. The favorable
outcomes aligned themselves in consistent categories with defi-
nitive conclusions. No evidence exists that art interventions cause
harm. Sample sizes are appropriate for the tradition/methodology
of each study and support conclusions, and 2 studies with control
subjects and preintervention and postintervention evaluations
were included.28,29 The most recent studies29,32 used validated
measurements for detecting, quantifying, and analyzing outcomes,
and therefore there is a trend toward higher-quality data since
2009. Likewise, documentation of ethical research considerations,
including consent of participants, was a more recent phenome-
non.29,31,32 This review suggests that further research with more
contemporary research methodologies is needed to better under-
stand the short- and long-term outcomes.
Although the current review included studies of children/
adolescents between the ages of 2 and 21 years, only half of the
studies included older adolescents.27,29,31 Future art intervention
studies should consider targeting adolescents specifically, as they
are cognitively and emotionally processing the implications of a
life-threatening disease at a different developmental stage than
their younger cohort.3 Also, a research consideration must be
given to children/adolescents who do not enjoy art and would
not want to participate in such an intervention. Although art
interventions may be a relatively low-cost intervention in
resource-poor countries, art making may not be a part of cultural
common practice. Therefore, cross-cultural considerations in such
research would be needed to address applicability to various cul-
tural groups and countries.
Does the body of evidence support a culture of clinical trials
in which frontline researchers and clinicians can turn these in-
sights into more rigorous research protocols and/or clinical pro-
cesses? The review’s answer to this question is yes; there is a good
basis for these pursuits. This is the assessment of the state of the
science that was determined by adapting the JHNEBP framework
for this literature review.
How can healthcare providers respond to this mode of assess-
ment of the combined body of evidence? The JHNEBP grade of
‘‘Good’’ is used to highlight both research and clinical opportu-
nities; that is, it identifies that there is a good basis for further
investigation, and that although many research questions still re-
main, the imperfections of these studies should not inhibit the
use of art interventions at this time, as a sensible strategy for
pediatric oncology patients in treatment.
Methods being used to examine art interventions and their
benefits must become more sophisticated in order to have more
precise and informative answers and build on the current infor-
mation with a goal toward more empiricism. Future studies on
the efficacy and effectiveness of art intervention should consider
using standardized art interventions, multicenter randomized
controlled design with larger sample sizes to increase power and
detect differences in groups, validated and uniform measurements
for preintervention and postintervention outcome assessment,
and ethical procedural rigor to confirm a benefit.
Well-being During Treatment for Childhood Cancer
Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.
n Implications for Nursing Practice
and Research
Art interventions may be tools that facilitate communication
with the treatment team, control pain and anxiety, and promote
a positive self-image. Although current scientific evidence is sparse
and developmental in nature, the paucity of existing evidence
suggests that consideration should be given for the integration of
art interventions into the nursing care plan of pediatric oncology
patients undergoing treatment to help their patients cope with
elements of their challenges, which may be modifiable.
Nurses recognize the therapeutic nature of art interventions
in the oncology treatment setting and perceive it as a venue for
promoting cooperative behaviors during treatment.28,29 Favara-
Scacco and colleagues’28 and Madden and colleagues’29 investi-
gations encourage interdisciplinary collaboration among health
professionals and suggest that nurses and art therapists alike
should be well versed with a variety of art interventions in order
to provide synergistic management of the pain and anxiety in-
herent in the treatment setting.
Art making accompanied by commentary provides a broad
approach to establish and maintain direct and honest commu-
nication with children undergoing treatment for cancer.27,30Y32
Rollins31 suggests that nurses, child-life specialists, and play
workers can all promote projective drawing by the distribution
of sketchbooks for every child with cancer in treatment and that
some form of simple art interventions could be included in their
care plan.
Massimo and Zarri30 pointed out that the ongoing verbal
interaction during art making between the art facilitator/witness
and the pediatric oncology patient leads to an enhancement of a
child’s self-esteem through support and validation from others.
This raises the question as to how to specifically educate nurses
and those most intimately involved with patients to provide ap-
propriate comments and interactions surrounding patient artwork.
Although interpretative art education is not currently a part of
nursing education, nurses and art therapists can offer a team ap-
proach by actively communicating and reciprocally educating one
another so that as many patients as possible can potentially benefit
from such interventions.
Pediatric oncology nurses who are interested and willing to
learn new approaches may become involved more significantly
in researching and promoting art activities with their patients.
Walsh and Weiss36 and Walsh et al37 describe the implemen-
tation and evaluation of a creative arts intervention that was
‘‘infused’’ into nursing care at the bedside of adult cancer pa-
tients. Combined orientations from the fields of nursing and
art therapy can enhance the capacity to address a broader
spectrum of patient needs from physical, psychosocial, to
existential. If art therapy/art making is going to be considered
an evidence-based strategy for children with cancer to cope
with the challenges of treatment, there will need to be in-
terdisciplinary research among art therapists, play workers, men-
tal health professionals, and nurses using more contemporary
standardized assessment tools. This collaboration may lead to
better scientific methods aimed at understanding the therapeutic
Cancer NursingTM, Vol. 39, No. 6, 2016 n E15
physiological and biochemical targets that art interventions
activate.
n Conclusion
There remains a substantial amount of work to be undertaken
to adequately meet the psychosocial and medical needs of pedi-
atric oncology patients in treatment settings. The answer lies not
in which discipline is the most superior to meet needs, but in-
stead in how disciplines can work collaboratively and efficiently
to organize and prioritize their efforts to achieve optimal out-
comes. A paucity of empirical evidence suggests that art inter-
ventions may be useful in determining what each individual
uniquely perceives as stressful and serve as a venue for coping with
the challenge. As nurses, we stand alongside our patients’ suffer-
ing and should consider the facilitation of art making as part of
our privileged presence. Although many art interventions have
been undertaken by fully trained art therapists and child-life
workers, nurses can further promote the integration of arts in-
terventions into their pediatric oncology patients’ care plan to
encourage self-expression, maintain communication with the
treatment team, reduce pain, and promote positive coping strate-
gies. Nursing education should address the value of interdisci-
plinary collaboration with art therapists and child-life specialists.
The current evidence suggests that art making, attentive listen-
ing, and discussion can support the work of healing and should
be readily available. Further and higher-quality research is required
before evaluating the feasibility and practicality of integrating
routine and standardized art interventions into the treatment
protocols for children with cancer.
References
1. Ward E, DeSantis C, Robbins A, Kohler B, Jemal A. Childhood and
adolescent cancer statistics. CA Cancer J Clin. 2014;64(2):83Y103.
2. Apter A, Farbstein I, Yaniv I. Psychiatric aspects of pediatric cancer. Child
Adolesc Psychiatr Clin N Am. 2003;12(3):473Y492.
3. Askins MA, Moore BD 3rd. Psychosocial support of the pediatric cancer patient:
lessons learned over the past 50 years. Curr Oncol Rep. 2008;10(6):469Y476.
4. Alderfer MA, Navsaria N, Kazak AE. Family functioning and posttraumatic
stress disorder in adolescent survivors of childhood cancer. J Fam Psychol.
2009;23(5):717Y725.
5. Baggott C, Cooper BA, Marina N, Matthay KK, Miaskowski C. Symptom
cluster analyses based on symptom occurrence and severity rating among
pediatric oncology patients during myelosuppressive chemotherapy. Cancer
Nurs. 2012;35(1):19Y28.
6. Hockenberry M, Hooke MC. Symptom clusters in children with cancer.
Semin Oncol Nurs. 2007;23(2):152Y157.
7. Kinahan KE, Sharp LK, Seidel K, et al. Scarring, disfigurement, and
quality of life in long term survivors of childhood cancer: a report from the
Childhood Cancer Survivor Study. J Clin Oncol. 2012;30(20):2466Y2474.
8. Zeltzer LK, Recklitis C, Buchbinder D, et al. Psychological status in child-
hood cancer survivors: a report from the childhood cancer survivor study.
J Clin Oncol. 2009;27(14):2396Y2404.
9. Cordaro G, Veneroni L, Massimino M, Clerici CA. Assessing psychological
adjustment in siblings of children with cancer. Cancer Nurs. 2012;35(1):
E42YE50.
10. Deatrick JA, Mullaney EK, Mooney-Doyle K. Exploring family manage-
ment of childhood brain tumor survivors. J Pediatr Oncol Nurs. 2009;26(5):
303Y311.
11. Nelson AE, Deatrick JA, Knafl KA, Alderfer MA, Ogle SK. Consensus
E16 n Cancer NursingTM, Vol. 39, No. 6, 2016
Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.
statements: the family management style framework and its use with families
of children with cancer. J Pediatr Oncol Nurs. 2006;23(1):36Y37.
12. Lazarus R, Folkman S. Stress, Appraisal, and Coping. New York, NY:
Springer; 1984.
13. Folkman S, Moskowitz JT. Coping: pitfalls and promises. Annu Rev Psychol.
2004;55:745Y774.
14. Nesbitt LL, Tabatt-Huassman K. The role of the creative art therapies in the
treatment of pediatric hematology and oncology patients. Prim Psychiatry.
2008;15(7):56Y62.
15. Sourkes B. Truth to life: art therapy with pediatric oncology patients and
their siblings. J Psychosoc Oncol. 1991;9(2):81Y96.
16. Teufel ES. Terminal stage leukemia: integrating art therapy and family
process. Art Ther J Am Art Ther Assoc. 1995;12:51Y55.
17. Walker C. (1989). Use of art and play therapy in pediatric oncology.
J Pediatr Oncol Nurs. 1989;6(4):121Y126.
18. American Art Therapy Association: history and background. 2010. http://
www.americanarttherapyassociation.org/aata-history-background.html.
Accessed December 12, 2014.
19. Lawson LM, Williams P, Glennon C, et al. Effect of art making on cancer-
related symptoms of blood and marrow transplantation recipients [online
exclusive]. Oncol Nurs Forum. 2012;39(4):E353YE360.
20. Collie K, Bottorff JL, Long BC. A narrative view of art therapy and art
making by women with breast cancer. J Health Psychol. 2006;11(5):761Y775.
21. Collie K, Bottorff JL, Long BC, Conati C. Distance art groups for women
with breast cancer: guidelines and recommendations. Support Care Cancer.
2006;14(8):849Y858.
22. Walsh SM, Radcliffe RS, Castillo LC, Kumar AM, Broschard DM. A pilot
study to test the effects for art-making classes for family caregivers of patients
with cancer [online exclusive]. Oncol Nurs Forum. 2007;34(1):38.
23. National Institutes of Health. PAR-14-294: arts-based approaches in pallia-
tive care for symptom management (R01). http://grants.nih.gov/grants/guide/
pa-files/PAR-14-294.html. Accessed February 2, 2015.
24. Puetz TW, Morley CA, Herring MP. Effects of creative arts therapies on
psychological symptoms and quality of life in patients with cancer. JAMA.
2013;173(11):960Y969.
25. Wood MJ, Molassiotis A, Payne S. What research evidence is there for the
use of art therapy in the management of symptoms in adults with cancer?
A systematic review. Psychooncology. 2011;20(2):135Y145.
26. Geue K, Goetze H, Buttstaedt M, Kleinert E, Richter D, Singer S. An
overview of art therapy interventions for cancer patients and the results of
research. Complement Ther Med. 2010;18(3Y4):160Y170.
27. Councill T. Art therapy with pediatric cancer patients: helping normal
children cope with abnormal circumstances. Art Ther J Am Art Ther Assoc.
1993;10(2):78Y87.
28. Favara-Scacco C, Smirne G, SchilirJ G, Di Cataldo A. Art therapy as sup-
port for children with leukemia during painful procedures. Med Pediatr Oncol.
2001;36(4):474Y480.
29. Madden JR, Mowry P, Gao D, Cullen PM, Foreman NK. Creative arts
therapy improves quality of life for pediatric brain tumor patients receiving
outpatient chemotherapy. J Pediatr Oncol Nurs. 2010;27(3):133Y145.
30. Massimo LM, Zarri DA. In tribute to Luigi Castagnetta-drawings. A narrative
approach for children with cancer. Ann N Y Acad Sci. 2006;1089:xviYxxiii.
31. Rollins JA. Tell me about it: drawing as a communication tool for children
with cancer. J Pediatr Oncol Nurs. 2005;22(4):203Y221.
32. Soanes L, Hargrave D, Smith L, Gibson F. What are the experiences of the child
with a brain tumour and their parents? Eur J Oncol Nurs. 2009;13(4): 255Y261.
33. Cesario S, Morin K, Santa-Donato A. Evaluating the level of evidence of
qualitative research. J Obstet Gynecol Neonatal Nurs. 2002;31(6):708Y714.
34. Newhouse R, Dearholt S, Poe S, Pugh LC, White K. The Johns Hopkins
Nursing Evidence-Based Practice Rating Scale. Baltimore, MD: The Johns
Hopkins Hospital; Johns Hopkins University School of Nursing; 2005.
35. Leon AC, Davis LL, Kraemer HC. The role and interpretation of pilot
studies in clinical research. J Psychiatr Res. 2011;45(5):626Y629.
36. Walsh SM, Weiss S. Art interventions with family, caregivers and patients
with cancer [online exclusive]. Oncol Nurs Forum. 2003;30(6):E115YE120.
37. Walsh SM, Martin SC, Schmidt LA. Testing the efficacy of a creative-arts
intervention with family caregivers of patients with cancer. J Nurs Scholarsh.
2004;36(3):214Y219.
Derman and Deatrick