Journal of Pediatric Nursing 36 (2017) 173–178

Contents lists available at ScienceDirect

Journal of Pediatric Nursing

The Efficacy of Art Therapy in Pediatric Oncology Patients: An Integrative

Literature Review
Bree A. Aguilar, MSN, RN
DePaul University (Rosalind Franklin University of Medicine and Science Campus), North Chicago, IL 60064, United States

a r t i c l e i n f o a b s t r a c t

Article history: Problem: Children undergoing cancer treatment experience detrimental adverse side effects that may be ad-
Received 29 August 2016 dressed with complementary and alternative medicine (CAM) such as art therapy. The purpose of this research
Revised 16 June 2017 was to examine the effects of art therapy in pediatric patients living with cancer.
Accepted 20 June 2017 Eligibility criteria: An integrative literature review was conducted using the CINAHL, OVID Medline, and PsycINFO
Available online xxxx
databases. Studies were included if they were a primary source utilizing an art therapy intervention in children
with cancer age birth to 18 years old, was published between the year 2000 and 2016, and written in the English
Keywords:
Pediatric
language.
Children Sample: Seven primary sources met inclusion criteria.
Oncology Results: Few studies were reported in this review. Findings of this review suggest that children who participated
Cancer in various forms of drawing interventions exhibited enhanced communication with family members and
Art therapy healthcare providers. Additionally, children were able to better express underlying emotions, developed more ef-
Drawing fective coping skills, and experienced a reduction in adverse side effects.
Conclusions: Implementing a drawing intervention or other forms of art into the holistic care of a pediatric oncol-
ogy patient may assist in maximizing quality of life and allow for a more tolerable lifestyle.
Implications: Acquiring a means of proper communication with children through art allows nurses to gain insight
on the needs of this special patient population, resulting in a higher quality plan of care.
© 2017 Elsevier Inc. All rights reserved.

Contents

Background and Significance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 174

Purpose. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 174
Research Question . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 174
Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 174
Design . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 174
Literature Search Strategy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 174
Data Evaluation and Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 174
Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 175
Study Characteristics and Quality. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 175
Emotional Expression/Communication . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 176
Coping Skills/Distraction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 176
Reduced Symptoms and Improved Well-Being. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 176
Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 177
Limitations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 178
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 178
Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 178
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 178

E-mail address: baguil2@gmail.com.

http://dx.doi.org/10.1016/j.pedn.2017.06.015
0882-5963/© 2017 Elsevier Inc. All rights reserved.
174 B.A. Aguilar / Journal of Pediatric Nursing 36 (2017) 173–178
Childhood cancer affects one in 285 children in the United States
yearly, equating to an estimated 15,980 children living with cancer
each year (American Childhood Cancer Organization [ACCO], 2015).
Globally, over 250,000 children from birth to age 20 years old are diag-
nosed with some form of cancer every year, with a diagnosis being
made on an average of every 3 min (ACCO, 2015). The most common
types of cancer diagnosed in the pediatric population include leukemia,
lymphoma, brain and central nervous system tumors, bone cancer, and
neuroblastoma (American Cancer Society [ACS], 2015). Although sur-
vival rates have improved, cancer remains to be the leading cause of
death by disease in American children. These patients often undergo
rigorous treatments that may include chemotherapy, radiation, surgery,
and targeted therapy (ACCO, 2015). The aggressive nature of these
treatments can result in short and long-term adverse side effects such
as pain, fatigue, distress, nausea, and an alteration in sleep and mood
(Kanitz, Camus, & Seifert, 2012; Sencer & Kelly, 2007). It is important
to remember that although children are smaller in stature, they may ex-
perience the same levels of pain or discomfort as adults receiving similar
treatment.
A reduction in adverse side effects due to treatment and an improve-
ment of overall health have been reported by 91% of adult oncology pa-
tients that have utilized complementary and alternative medicine
(CAM) such as art, music, and dance therapy (Somani, Ali, Ali, &
Lalani, 2014; Tomlinson, Hesser, Ethier, & Sung, 2011). Additionally,
findings of previous research have indicated that the use of CAM and
other mind-body therapies has had positive effects on the quality of
life in pediatric oncology patients (Ott, 2006). While there is a signifi-
cant amount of research on the effects of CAM on quality of life, current
literature lacks evidence on the specific effects of art therapy in the pe-
diatric oncology patient population. The American Art Therapy
Association (AATA) (2013) defines art therapy as improving and en-
hancing the physical, mental, and emotional well-being of individuals
through the creative process of art production. This intervention has
been used widely as adjuvant therapy for a variety of conditions includ-
ing cancer (Hart, 2010).
Background and Significance
The incidence of childhood cancer has been rising over the past few
decades; however, advances in cancer treatments have increased the
survival rate in more than 80% of children (ACS, 2015). Though majority
of childhood cancers respond well to treatment, it unfortunately comes
with the cost of detrimental adverse side effects. Due to their resilient
nature, a child's body recovers much quicker than adults, leading
them to potentially undergo more intensive treatment and higher
doses of chemotherapy (Malchiodi, 2013). With the encompassing na-
ture that cancer treatment imposes on a child's everyday life, it is vital
for healthcare providers to assess their patient's physical, emotional,
psychosocial, and developmental needs. A holistic assessment will
allow an appropriate plan of care to be developed to maximize patient
quality of life. Unlike adult patients, it is plausible that the assessment
of these needs are more likely to be difficult in children and adolescents
due to communication barriers such as a limited vocabulary or cognitive
capacity to express their thoughts and emotions (Rollins, 2005). Like-
wise, as a result of normal developmental stages, the cognitive capacity
of children is evolving every day with the necessity to change or adapt
to their needs more often than that of an adult.
Art therapy has been demonstrated as a helpful tool in coping with
stressful and traumatic situations, increasing self-esteem, and reducing
stress and anxiety (AATA, 2013; Hart, 2010). The production of art itself
has been one of the longest standing forms of communication. Adrian
Hill first discovered the therapeutic effects of using art therapy as a
form of communication in 1938 during his recovery from tuberculosis.
In 1942, he published his findings on the benefits and effectiveness on
a wide range of medical conditions and later became the first employed
art therapist (Bitonte & De Santo, 2014). Malchiodi (2013) explains that
the goals of art therapy in the health care setting include, but are not
limited to, “psychosocial care, rehabilitation, health benefits, and
reauthoring the dominant narrative of illness” (p. 5). Regardless of the
advancements of art therapy throughout the years, the intervention ap-
pears to be an underutilized tool (Bitonte & De Santo, 2014) that may
possess the potential in producing significant benefits in the pediatric
population.
Purpose
The purpose of this research was to conduct an integrative review of
the literature that was recently published between 2000 and 2016 to
examine the effects of art therapy in children living with cancer. The
synthesized findings from the research are intended to provide pediat-
ric oncology nurses with the knowledge to better assess, understand,
and care for these young patients. The research methodology, results,
discussion, and the implications for future practice and research are
discussed in this integrative literature review.
Research Question
An integrative literature review approach was used to answer the
following question: What are the effects of art therapy in pediatric on-
cology patients?
Methods
Design
The integrative literature review was approached using the frame-
work of Whittemore and Knafl (2005) by following the steps of problem
identification, literature search, data evaluation, data analysis, and pre-
sentation. This design allows the researcher to combine experimental,
non-experimental, theoretical, and empirical data to gain insight on a
topic of concern (Whittemore & Knafl, 2005). Data reviewed included
both qualitative and quantitative literature making this design the
most optimal for the purposes of this research.
Literature Search Strategy
A search of the literature was conducted via the CINAHL, OVID
Medline, and PsychINFO databases. Inclusion criteria for this study
consisted of: (a) primary sources that discussed an art therapy interven-
tion; and (b) art therapy interventions that were applied to pediatric
oncology patients age birth to 18 years old. Key terms entered into
each database were MH Exact Subject Heading “art therapy” AND “on-
cology”, explode Art Therapy/AND explode Neoplasms/, and MJ Word in
Major Subject Heading “art therapy” AND “oncology”, respectively. The
search results were limited to: (a) publication year between 2000 and
2016; (b) English language; and (c) age birth to 18 years old, yielding
a total of 48 sources. After reviewing the abstracts of the literature, ex-
clusion criteria were applied as seen in Fig. 1, resulting in seven total pri-
mary sources obtained for analysis. The abstracts of the 41 excluded
articles were read twice to ensure that they did not meet the inclusion
criteria of this study.
Data Evaluation and Analysis
The resulting seven articles from the systematic literature search
were separated into subgroups of six qualitative sources and one quan-
titative source. Sources were read in their entirety twice to determine
quality. While reading thorough each source, data were extracted and
entered into qualitative and quantitative matrices with guidance from
components of the Critical Appraisal Skills Programme (CASP) (2013)
checklist. Each data matrix listed the article source, purpose/problem,
sample, framework, method/design, themes/results, instruments, and
 B.A. Aguilar / Journal of Pediatric Nursing 36 (2017) 173–178
Fig. 1. Literature search strategy.
limitations. Organization of the two data matrices facilitated the process
of analyzing the data to compare between sources, revealing relation-
ships, themes, and concepts for interpretation.
Keele's (2010) ten steps of analyzing qualitative and quantitative
data guided the evaluation process to determine overall quality of
each article as: excellent, good, fair, or poor. Each of the ten steps had
the potential to be designated a maximum of five points. The quality
of the source was also taken into consideration when interpreting the
extracted data. An article was of excellent quality if the total score was
between 39 and 50, good quality was a score of 26–38, fair quality
was 13–25, and poor quality was a total score between 0 and 12
(Keele, 2010). After quality of each article was determined, the data
were analyzed and common themes emerged from the literature.
Results
Study Characteristics and Quality
A total of at least 316 children and adolescents age two to 19 years
old with various cancer diagnoses participated in art therapy interven-
tions across six of the seven studies. One study by Nesbitt and Tabatt-
Haussmann (2008) did not report the sample size or specific ages of
their participants, although the title “The Role of the Creative Arts Ther-
apies in the Treatment of Pediatric Hematology and Oncology Patients”
indicates that the participants were indeed children. Of note, the study
by Madden, Mowry, Gao, Cullen, and Foreman (2010) contained three
separate phases in which solely participants from phase one were in-
cluded into the total of 316 children and adolescents for this literature
review. All other data from phase two and three of Madden et al.
(2010) were excluded due to the inclusion criteria for this literature
175
review. Phase one participants included children diagnosed with a
brain tumor and undergoing active treatment. Phase two consisted of
a combination of hematology and oncology participants, while phase
three focused on qualitative interviews with medical and nursing staff
members (Madden et al., 2010).
Two of the seven studies were conducted in an inpatient setting
(Rollins, 2005; Woodgate, West, & Tailor, 2014) and the remaining
five studies in an outpatient setting (Cowell, Herron, & Hockenberry,
2011; Favara-Scacco, Smirne, Schilirò, & Di Cataldo, 2001; Madden et
al., 2010; Massimo & Zarri, 2006; Nesbitt & Tabatt-Haussmann, 2008).
The participants in all seven studies were undergoing some form of can-
cer treatment at the time of the art therapy intervention. Drawing was
the art medium of choice across all studies with a variation in drawing
tools such as paper, markers, colored pencils, and a handheld computer
equipped with a drawing program.
According to Keele's (2010) criteria, five of the seven studies
obtained an excellent quality rating (Favara-Scacco et al., 2001;
Madden et al., 2010; Massimo & Zarri, 2006; Rollins, 2005;
Woodgate et al., 2014). Nesbitt and Tabatt-Haussmann (2008) re-
ceived a good quality rating, while Cowell et al. (2011) was of fair
quality. Good or fair quality ratings were assigned due to the lack
in specificity of study participants or intervention. Findings from
these studies were presumably deemed less significant in compari-
son to the other five studies.
On analysis of the results reported in the seven articles reviewed, re-
sults appeared to coalesce across three key themes, namely that art
therapy supported: (a) Emotional Expression/Communication; (b) Cop-
ing Skills/Distraction; and (c) Reduced Symptoms and Improved Well-
Being. A summary of these themes and their coinciding evidence are
presented in Table 1.
176 B.A. Aguilar / Journal of Pediatric Nursing 36 (2017) 173–178
Table 1
Emerging themes and associated evidence from the literature.
Theme Sources
Emotional Cowell et al., 2011; Favara-Scacco et al., 2001; Massimo and Zarri,
Expression/Communication 2006; Nesbitt and Tabatt-Haussmann, 2008; Rollins, 2005;
Woodgate, West, and Tailor, 2014
Coping Skills/Distraction Cowell et al., 2011; Favara-Scacco et al., 2001; Madden et al., 2010; Better understanding of disease process, reconnection with family and
Nesbitt and Tabatt-Haussmann, 2008; Rollins, 2005; Woodgate et friends, development of metaphorical symbols, improved tolerance of
al., 2014
Reduced Symptoms and Favara-Scacco et al., 2001; Massimo and Zarri, 2006; Madden et al., Reduced anxiety, tension, pain, stress, nausea
Improved Well-Being 2010; Nesbitt and Tabatt-Haussmann, 2008; Woodgate et al., 2014
Emotional Expression/Communication
Enhanced communication between the pediatric patient, their fam-
ily, and healthcare providers were facilitated through the expression of
emotions through art therapy. Six of the seven studies demonstrated
that methods of art assisted patients in sharing their emotions of anxi-
ety, pain, the fear of death, the longing for normalcy, and the expression
of near death experiences (Massimo & Zarri; 2006; Rollins, 2005;
Woodgate et al., 2014). Drawings of painful body parts, cemeteries, pre-
viously enjoyed activities, and out of body experiences coincided with
the children's emotions when asked to explain their drawings. The feel-
ings of entrapment and loneliness in the hospital were depicted in
drawings of being confined to their bed or stuck in jail. Two teenage
children expressed their concern of being a burden and the cause of
stress upon their family through pictures drawn of crying family mem-
bers. These children expressed their desire to use their “wish” from wish
granting organizations on their parents, rather than themselves
(Woodgate et al., 2014). Favara-Scacco et al. (2001) explored the free
drawings of children who portrayed questions or confusing aspects of
their disease process, which further led to increased communication
about their illness. Additionally, underlying feelings of happiness were
expressed when children were asked to explain theirdrawings of their
family, friends, pets, and school (Cowell et al., 2011; Nesbitt &
Tabatt-Haussman, 2008). When asked about the knowledge of these
underlying emotions, family members were mostly unaware of the
emotional extent at which the patient was experiencing.
Coping Skills/Distraction
In six of the studies, the use of art therapy allowed for distraction and
the development of coping skills before, during, and after the interven-
tion were completed. For example, a 15-year-old girl diagnosed with a
brain tumor found that drawing metaphorical symbols that she shared
with her family helped her cope with missing them while she was in
the hospital (Woodgate et al., 2014). Furthermore, drawings that chil-
dren produced assisted them to better understand the connections be-
tween their illness and physical symptoms. A nine-year-old boy who
previously played football prior to his diagnosis believed that he was
no longer a good player since he “felt tired all the time” (Rollins, 2005,
p. 217). After being asked to explain and have a conversation about
his football drawing, it occurred to him that he was tired due to his can-
cer treatments and was able to better cope with the situation and his
physical symptoms (Rollins, 2005).
Art therapy utilized as a form of distraction allowed children to cope
with painful or stressful situations. Woodgate et al. (2014) explained
that drawing served as a therapeutic intervention that “provided a
Evidence
Fear, missing out, dying, out of body experiences, disconnected, burden,
sad, afraid, trapped, hopeless, confusion, perception of disease
Enhanced communication with inner-self, family, healthcare providers
treatments, prevention of permanent trauma
Provided a sanctuary/escape from the “cancer world”, deterred pain during
treatments or procedures
Increased self-esteem, relaxation, quality of life, happiness
Increased socialization, sense of control, empowerment, comfort, strength,
satisfaction, collaboration, compliance with treatments or procedures
sanctuary or escape from existential worry and the feeling of isolation”
(p. 154). These drawings depicted imaginary places that the child de-
sired to be transported to in order to temporarily escape the real
world that they faced every day. In another study, patients who partic-
ipated in an art therapy intervention before undergoing a lumbar punc-
ture (LP) or bone marrow aspiration (BMA) developed better coping
mechanisms during and after the procedure in comparison to patients
in a control group (Favara-Scacco et al., 2001). The ability to distract
these young patients with art therapy may also assist in preventing per-
manent trauma from treatments, procedures, or the illness itself
(Favara-Scacco et al., 2001; Madden et al., 2010; Nesbitt &
Tabatt-Haussmann, 2008).
In contrast, Rollins (2005) used a projective drawing technique to
gain insight on a child's coping ability and resourcefulness with the in-
terpretation of a licensed art therapist. With this technique, children
were asked to create a Drawing of a Person Picking an Apple from a
Tree (PPAT). No time limit was allotted for the drawing and if the
child asked questions about how to draw the picture, the directions
for the activity were simply repeated. Upon completion, a licensed art
therapist scored the drawings by using the Scores for Scale 8, the Prob-
lem-Solving Scale. This scale is one of the 14 scales of the Formal Ele-
ments Art Therapy Scale (FEATS) and is the only one that is validated
and reliable for use in pediatrics (Rollins, 2005). Scores revealed that
the majority of participants demonstrated adequate coping ability and
resourcefulness based on the PPAT drawing.
Reduced Symptoms and Improved Well-Being
Five studies demonstrated an improvement in symptoms and be-
havior as a direct result of an art therapy intervention before, during,
or after a child's cancer treatment. A combination of self-reporting, ob-
servation, and interpretation of drawings indicated that participants ex-
perienced a reduction in anxiety, tension, pain, stress, and nausea
(Favara-Scacco et al., 2001; Madden et al., 2010; Nesbitt &
Tabatt-Haussman, 2008). Likewise, there were an increase in self-es-
teem, excitement, relaxation, and happiness amongst participants
(Massimo & Zarri, 2006; Nesbitt & Tabatt-Haussman, 2008). An im-
provement in overall quality of life and mood were evidenced by scores
of The PedsQL 4.0 Cancer Module, a reliable and valid instrument for the
pediatric oncology patient population (Madden et al., 2010).
Art therapy provided participants with a sense of control, empower-
ment, satisfaction, comfort, and strength (Favara-Scacco et al., 2001;
Woodgate et al., 2014). These patients drew pictures such as their battle
with cancer or themselves as a superhero (Woodgate et al., 2014).
Alongside these behavior changes, participants were able to demon-
strate increased compliance and tolerance during treatment with less
crying, fear, anxiety, and pain (Favara-Scacco et al., 2001). An
 B.A. Aguilar / Journal of Pediatric Nursing 36 (2017) 173–178
improvement in socialization after art therapy were seen in participants
who began to engage in more activities and gain friendships with other
participants, allowing them to have a sense of normalcy and prevent
isolation (Favara-Scacco et al., 2001; Nesbitt & Tabatt-Haussman, 2008).
Discussion
The emerging themes of (a) emotional expression/communication;
(b) coping skills/distraction; and (c) reduced symptoms and improved
well-being illustrate the effects of art therapy in pediatric oncology pa-
tients. Following art therapy interventions, children demonstrated en-
hanced communication skills, ability to express emotions, developed
better coping skills, distractibility, and improvements in symptomology
and behavior towards their illness. As demonstrated by the literature,
the main findings of art therapy resulted towards positive effects to-
wards pediatric patients living with cancer. Furthermore, these results
have implications that art therapy may also assist nurses in better
assessing and addressing the needs of their patients.
With the limited vocabulary and cognitive capacity children have to
express their thoughts, emotions, and feelings (Rollins, 2005), it is par-
amount for nurses to acquire a means of communication to understand
and care for pediatric patients with cancer. Since nurses are the fore-
front of patient care, allowing for proper communication can ensure
that oncology nurses address the individual patient needs, thereby im-
proving and maximizing quality of life. Communication through various
forms of art has been demonstrated to be an appropriate tool for chil-
dren, especially drawing which has often been referred to as the univer-
sal language for children (Rubin, 1984). Without ideal means of
emotional expression and communication, there is a possibility for chil-
dren to retain and suppress emotions that can otherwise cause them to
physically give up on themselves or their illness. This may be due to
poorer performance and a decrease in motivation that is associated
with negative emotions in an individual (Gillet, Vallerand, Lafrenière,
& Bureau, 2013). Art production provided patients with an opportunity
to create an outlet to express emotions and feelings that otherwise may
not have been accessible prior to the intervention.
The ability for art therapy to provide children with coping mecha-
nisms and distraction techniques benefits these patients by allowing
Fig. 2. Diagram of The Gate Control Theory describing factors that open and close the gates to the perception of pain (a). Diagram applying an art therapy intervention to open and close the
gates to the perception of the negative side effects (b).
177
nurses to better prioritize their care. The removal of added stress and
pain that the patients previously experienced allows the nurse to per-
form a more focused and accurate assessment on a calmer child, ulti-
mately leading to a higher quality plan of care. As a child becomes
more relaxed and content, there is a greater chance that they will also
become more active and participate freely in their daily activities in-
volving interprofessional team members. By addressing the symptoms
that come along with cancer and its treatments with an art therapy in-
tervention, the improvement in patient care provided by oncology
nurses can lead to an increased quality life and assist in making a nega-
tive experience more tolerable.
One possible explanation on how art therapy may affect the percep-
tion and experience of adverse side effects caused by cancer or its asso-
ciated treatments is The Gate Control Theory of Pain proposed by
Ronald Melzack and Patrick Wall in 1965. The Gate Control Theory sug-
gests that a neurological gating mechanism exists in the spinal cord that
either allows or inhibits the perception of pain to be experienced by the
individual (Melzack & Wall, 1965). The pain response and its perception
are influenced by psychological factors such as past experiences, atten-
tion, and emotion. Fig. 2 shows that pain is perceived at a higher extent
when the gates are opened by stress, tension, distraction, or during a
lack in activity where a painful stimulus is more focused upon. Gates
are closed when an individual is relaxed, content, active, or applies a
distracting stimulus resulting in a decreased perception of pain
(Chesterfield PCT Health Psychology Service, 2012; Melzack & Wall,
1965).
Kwekkeboom (1999) suggested that art therapy and other mind-
body therapies improved chronic cancer pain by creating a
distracting sensation to close the neuronal gating mechanism, there-
fore diminishing the perception of pain. As seen in Fig. 2, the art ther-
apy intervention may play a role in children by opening or closing
these gates, affecting the perception on pain and other negative ad-
verse side effects that they may encounter on a daily basis.
Implementing an art therapy intervention may have the potential
to facilitate the closing of the neuronal gating mechanism of Melzack
and Wall's Gate Control Theory of Pain (1965) to the negative per-
ceptions of cancer in response to the child becoming more relaxed,
content, active, and distracted.
178 B.A. Aguilar / Journal of Pediatric Nursing 36 (2017) 173–178
Limitations
The seven studies included in this integrative literature review de-
fined their art therapy intervention as a means of drawing. Therefore, it
is unknown whether other forms of art will have the same impact in the
pediatric oncology patient population. Along with limitations in study
designs, two studies took place in an inpatient setting, while the re-
maining five were at outpatient settings. Results may vary between set-
tings due to several factors. An inpatient setting where a child is
hospitalized is a far more stressful experience compared to a child mak-
ing outpatient visits. These patients are required to be away from their
family, friends, school, and other aspects of normal daily living. Addi-
tionally, patients who are hospitalized are subjected to painful proce-
dures more often such as daily venipuncture, as well as other stressful
events such as sleep deprivation.
Other limitations for this literature review include the interpretation
of drawings due to its highly subjective nature in regards to the individ-
ual assessing the drawing, as well as the drawing itself. Massimo and
Zarri (2006) note that a child's drawings may not always directly relate
to their actual experience or their feelings at that very moment in time.
Obtaining a more quantifiable tool to measure the effects of art therapy
could strengthen the data obtained for this review. The variety in study
designs across the literature provides a difficult foundation to generalize
the efficacy of art therapy to this specific population.
Due to the limitation of exclusively studying a drawing intervention,
a gap in knowledge remains in regards to the efficacy on other modes of
art such as painting, photography, sculpting with clay, or creating other
types of crafts. Additionally, it is unknown whether the study setting
plays a role in the efficacy of art therapy in pediatric patients living
with cancer.
Conclusion
Although art therapy as a whole yielded inconclusive results due to
the limitations of the literature review, all seven studies utilized a
form of drawing that facilitated insight and useful knowledge to not
only benefit the patient, but the nurse as well. It is concluded that if a
drawing intervention, rather than art therapy in general, were to be im-
plemented in the pediatric population, it is probable that it may result in
positive outcomes on quality of life and become beneficial to nurses. Im-
plications for future practice may be for pediatric oncology nurses to
discuss the options and benefits of drawing with the patient and their
family. These young patients may be more encouraged to participate if
provided with paper, a notebook, sketchbook, or journal, along with a
variety of writing utensils to enable them to draw freely on their own.
Children who are severely ill, hospitalized, or have other communica-
tion barriers may benefit more than others. Encouraging a child to
draw would benefit nurses by allowing them to gain insight on the un-
derlying needs and emotions of this special patient population. This can
be made possible with special training for the nurses on how to inter-
pret these drawings, or receiving the input of a certified art therapist.
Implications for future research include implementing different types
of art, utilizing a more quantifiable tool to measure efficacy, and to stan-
dardize the setting in which the study takes place. In conclusion, it is
strongly suggested that drawing or other forms of art be taken into con-
sideration as part of the holistic standard of care for pediatric oncology
patients.
Acknowledgments
I would like to express my sincere gratitude to Dr. Lori Fewster-
Thuente, PhD, RN and Dr. Jennifer Greenwood, PhD, CRNA for their
assistance, guidance, insight, and knowledge throughout the research
process. Additionally, I would like to thank the editor and anonymous
reviewers for the constructive feedback that highly enhanced this man-
uscript, as well as my family and friends for the love and support. This
research did not receive any specific grant from funding agencies in
the public, commercial, or not-for-profit sectors.
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