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J Res Med Sci 2023,  28:13

The physical and psychological outcomes of art therapy in pediatric palliative care: A systematic review

1 Student Research Committee, School of Nursing and Midwifery, Mashhad University of Medical Sciences, Mashhad, Iran
2 Nursing and Midwifery Care Research Center; Department of Medical-Surgical Nursing, School of Nursing and Midwifery, Mashhad University of Medical Sciences, Mashhad, Iran
3 Nursing and Midwifery Care Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
4 Department of Pediatric Hematology and Oncology, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran

Date of Submission09-Apr-2022
Date of Decision28-Aug-2022
Date of Acceptance14-Sep-2022
Date of Web Publication16-Mar-2023

Correspondence Address:
Dr. Hossein Karimi Moonaghi
Nursing and Midwifery Care Research Center, Mashhad University of Medical Sciences, Daneshgah Street, Mashhad
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jrms.jrms_268_22

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Background: The integration of art therapy in health care is a growing trend in the care of cancer patients. Therefore, this study aimed to identify the physical and mental benefits of art in children with cancer. Materials and Methods: A systematic review of English articles using Google Scholar, MEDLINE via PubMed, Scopus, the Cochrane Database of Systematic Reviews, and the Web of Science was conducted. Relevant keywords for cancer, child, art therapy and their synonyms were used accordingly. All searches were conducted to December 31, 2021.Relevant articles were included studies published in English and involving children aged 0–18 years. Studies evaluated the effects of art therapy in children with cancer. Results: Seventeen studies had inclusion criteria, of which 12 studies were performed by clinical trial and 5 studies were performed by quasi-experimental method. Sixteen studies evaluated one type of art-therapy intervention, while one study used a combination of art-therapy approaches.The results showed that art-based interventions in the physical dimension lead to more physical activity, stability in breathing, and heart rate, and these children reported less pain. In the dimensions of psychology had less anxiety, depression, and anger but at the same time had a better quality of life and more coping-related behaviors. Conclusion: It seems that the use of art therapy in pediatric palliative care with cancer can have good physical and psychological results for the child, but it is suggested to evaluate the effects of these interventions in children at the end of life.

Keywords: Art therapies, cancer, neoplasm, pediatric

How to cite this article:
Motlagh EG, Bakhshi M, Davoudi N, Ghasemi A, Moonaghi HK. The physical and psychological outcomes of art therapy in pediatric palliative care: A systematic review. J Res Med Sci 2023;28:13

How to cite this URL:
Motlagh EG, Bakhshi M, Davoudi N, Ghasemi A, Moonaghi HK. The physical and psychological outcomes of art therapy in pediatric palliative care: A systematic review. J Res Med Sci [serial online] 2023 [cited 2023 Mar 20];28:13. Available from: https://www.jmsjournal.net/text.asp?2023/28/1/13/371841

  Introduction Top

Compared to the 1980s, the incidence of cancer in children has increased by 13%.[1] Each year 400,000 children under the age of 19 are diagnosed with cancer each year.[2] There are estimated to be 6 to 7 million cases of childhood cancer in the world between 2015 and 2030.[3]

Children with cancer often receive invasive chemotherapy, radiation, and surgery. These treatments have several physical side effects including fatigue, sleep disorders, nausea, and vomiting.[4] On the other hand, children experience various psychosocial effects following loneliness and isolation, including sadness,[5] anxiety and stress, depression,[6] and anger.[7] Also, pain as a major problem for cancer patients.[8] In 49 to 62% of children, it is experienced as a constant pain[9] which can lead to problems in the child's mental health.[5]

Palliative care can be used to relieve pain and other symptoms of the patient's anxiety such as anxiety and depression, which seeks to increase the quality of life of the child and family by providing holistic care.[10] Complementary and alternative medicine (CAM), as part of the palliative care of children with cancer, refers to a group of various medical and health-care methods that are currently none other than Western conventional medicine.[11] CAM can include the use of meditation, herbal remedies, homeopathy, hypnosis, and prayer.

Children and families seek noninvasive methods with easy access and cheap access to control complications and sometimes to complete treatment. 6%–91% of children with cancer[12] use CAM.[13]

Given that families usually do not inform the treatment staff about the use of these therapies,[14] the biggest concern about the use of CAM is the unknown interaction between CAM and cancer treatment regimens;[15] therefore, it is necessary to use methods that do not have these adverse effects.

The study by Sanchez et al (2015) showed that art therapy is one of the most common complementary medicine used by children with cancer .[16] In the meantime, in addition to not having to worry about drug interactions, art therapy has been introduced as a useful tool to deal with stressful situations and increase self-esteem,[17] which can lead to the provision of person-centered care.[18] Art can be defined as music, performing arts (theater and dance), and visual and literary arts.[19] Art therapy is defined by the American Art Therapy Association as the creative process of art production that can improve and enhance the physical, mental, and emotional well-being of individuals.

Although art therapy is accepted as one of the CAMs by medical rehabilitation centers around the world, few institutions use this method.[20]

The results of the research show that most of the review studies have examined the effect of art therapy in adults with cancer, while children are not small adults and differ in the level of development and communication needs of adults,[21] and they face communication barriers such as limitations in vocabulary and cognitive capacity. Therefore, the current literature lacks evidence to support art therapy in the population of children with cancer shows the need to review studies in this field.

The aim of this study was to identify the types of art therapy interventions and their effects in children with cancer.

  Methods Top

Search strategy

In this study, in order to find related articles, research questions based on Patient, Intervention, Comparison, and Outcome were defined. The participants were patients under the age of 18 who are undergoing cancer treatments (chemotherapy, radiotherapy, surgery, or other medical procedures), the intervention was art interventions, comparisons were routine management (i.e. routine care and standard medical care) or no intervention, and outcomes were the results of the intervention on the physical, psychological, and other dimensions of the patients' lives.

Then, a comprehensive search was performed on MEDLINE via PubMed, Scopus, the Cochrane Database of Systematic Reviews, and the Web of Science. In order to avoid the search bias, only articles that were in English were entered in the time frame between 2000 and December 31, 2021. The keywords of cancer, child, and art therapy were used. These keywords were combined using operators (AND, OR, NOT). Referrals and references for original articles and related reviews were also searched. The International clinical trials registry platform, conferences, and congresses were also reviewed. Due to the difficulty of accessing unpublished studies in dissertations and articles published in low-cost sources, they were not reviewed. Duplicate studies and reports were eliminated based on screening titles.

Inclusion criteria

Experimental and semi-experimental studies that have been conducted on children with any type of cancer. published in English and involving children aged 0–18 years. Children receive art therapy intervention

Exclusion criteria included

Case studies or study protocols were excluded. Studies that provided intervention to families of children with cancer were also excluded

Study selection

This study was adjusted using the Preferential Items for Systematic Reviews and Meta-Analyses statement.[22] All articles were retrieved by one reviewer (MF) using the electronic databases. After removing duplicate articles, titles and abstracts were screened for fulfilling the study inclusion and exclusion criteria. All potential full-text articles were retrieved and evaluated by the two reviewers independently. Although the level of agreement between the two reviewers was not specifically calculated, any disagreement on inclusion/exclusion of full-text articles was resolved by discussion [Figure 1].
Figure 1: Flow diagram

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Data extraction was carried out by two reviewers independently on the basis of a premade data extraction form. The following relevant data were collected: first author, country of intervention, year of publication, study design, participants, topics, duration of intervention, and subjective evaluations. Disagreements were discussed and judged by the third reviewer.

Quality assessment of study

The quality of the included studies was assessed with the “Standard Quality Assessment Criteria for Evaluating Primary Research from a Variety of Fields.”[23] In [Table 1], the results of quality assessment are presented. Since all values are above the cutoff point, no articles have been excluded. Values ranged from 0.63 to 0.96, documenting an overall good quality of the studies included.
Table 1: Quality of included studies

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The risk of bias[24] was calculated for each included study, referring to the following types of bias: selection bias, performance bias, detection bias, attrition bias, reporting bias, and other biases.

  Results Top


Seventeen studies have been included in this review, including six studies on painting, one study on rhythmic movements, nine studies on music therapy, and a combined study of painting and music therapy.

A total of 729 children participated in these studies, of which 311 children were in painting studies, 31 children were in rhythmic movements, 5 children were in a combination of music and painting, and 382 children were in the music therapy group.

The sample size in these studies varied between 5 and 83 children in each study; in one study alone, the sample size was 5 children (on the drawing),[25] in one study, the sample size was 16 children (music therapy),[26] but the sample size in 11 studies was between 20 and 60 people,[27],[28],[29],[30],[31],[32],[33],[34],[35],[36],[37] and the sample size was more than 60 people in four studies.[38],[39],[40],[41]

The age of participants in this study ranged from 0 to 17 years; the majority of studies were between 7 and 18 years old (n = 10),[25],[27],[28],[29],[30],[33],[34],[37],[40],[41] in three studies, the age of participants was 0 to 18 years,[35],[36],[38] and in four studies, the age of participants was between 2 and 17 years.[26],[31],[32],[39]

Two studies were conducted on children undergoing bone marrow transplantation,[35],[36] and two studies were conducted when the child was undergoing surgery.[34],[31]

Study designs and quality assessment

In this review, 12 studies were performed randomized clinical trial (RCT)[26],[28],[31],[32],[33],[34],[35],[36],[37],[40],[41] and 5 studies were performed without a control group and as a comparison before and after a group,[25],[29],[30],[32],[38] of which one study in painting,[29] one study in rhythmic movements,[30] and two studies in music therapy,[32],[38] and one study was a combination of painting and music.[25]

In these studies, Abdulah and Abdulla examined the effect of group art therapy on these children[28] and Purrezaian et al. and Robb et al. examined the effect of family-centered art therapy.[25],[26]

In the RCTs that worked on the painting, the children in the control group received routine care that did not involve painting.[27],[28],[33],[41] In the study of Palvan et al (2021), children in the intervention group drew in response to the drawings they received from their healthy peers, but in the control group, children did not receive drawings from their healthy peers.[40]

In music therapy RCTs, the control group received different care; in the Nguyen et al.'s study, headphones were placed on the ear of the control group without playing a song.[34] In Uggla et al.'s study, the control group received the intervention after discharge from the hospital.[35] In Robb et al. and Robb et al.'s studies, children listened to an audio storybook.[26],[39]

Blinding in three studies, Nguyen et al. blinded the researcher and physicians,[34] Gürcan and Atay Turan blinded the statistical analyst,[27] and Palvan et al. blinded the participants.[40] The random allocation method has been clearly stated in Nguyen et al.,[34] Robb et al.(2008)[39], Robb et al.(2017)[26], and Abdulah and Abdulla[25] using opaque envelopes, block making, and random allocation table, respectively.

[Table 1] presents the results of the quality assessment. No article has been deleted since all values are above the cutoff point.

Types of art therapy intervention

Types of interventions

The studies included in this review can be divided into four categories: drawing/painting, music, rhythmic movements, and a combination of painting and music [Table 2]:
Table 2: Study characteristics.

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The studies in this group have used various approaches, but the basic intervention has been painting.

In the studies of Abdullah et al.[28] and Khodabakhshi Koolaee et al.,[33] children made handicrafts with wood or play dough and designed collages based on their drawings.

In the Tahmasebi et al.'s study, the children in the intervention group drew in groups, but the method of grouping and performing the intervention was not clarified.[41]

In Altay et al (2017) study, with the aim of identifying the child's psychological problems, they were asked to draw a picture of a child in the hospital.[29] In the Gürcan et al. (2021) study evaluate the effectiveness of the effectiveness of mandala drawing. This type of painting starts from a central point and expands to infinity with nested circles.[27]

The Palvan et al.'s (2016) study investigated the effect of painting exchange between children with cancer and healthy children. The intervention group painted in response to these paintings of their healthy peers.[40]

Rhythmic movements

In this Ebadinejad et al.'s study group, children participated in six sessions of 45 min to perform rhythmic movements in hip-hop style.[30]


Different approaches have been used to use music in these children:

Two studies, Nguyen et al. and Giordano et al., were performed on children under stressful LP conditions and before surgery,[31],[34] but different approaches were used. Nguyen et al.'s study listened to music using headphones 10 min before the operation, but Giordano et al.'s study developed an interactive approach for the child that included active techniques using different musical instruments, free improvisation, singing, and composing.

Two Uggla et al. and Uggla et al.'s studies were performed on children undergoing bone marrow transplantation; in these studies, the approach of selecting and conducting sessions was patient centered based on the child's initiatives.[35],[36]

In Robb et al.'s study, the intervention was presented in the form of parent-delivered active music engagement. In the sessions between the parents and the therapist, active music engagement activities were modeled based on the child's behavioral points.[26]

Robb et al study (2008) three approaches Compared; active music engagement, listening to music, and listening to audiobooks. Children in the active music engagement group can choose and play from instruments or choose from the prepared songs and listen.[39]

Barrera et al. in their study with an interactive approach have distinguished age groups in music selection; as adolescents and school-age children tended to write, improvise, and listen to prerecorded music, toddlers often became involved in playing instruments. Infants and toddlers participated in singing, playing songs, lullabies, and playing instruments.[38]

Piasai et al. examined the effect of guided imagination and computer drawing-storytelling in which about 10 min of classical nonverbal music was used at the beginning and end of the recorded sound-guided imagination.[37]

In Wong's study, children underwent music therapy as part of a rehabilitation program. In this regard, based on the preferences, ability, and age of the child, the therapist provided the appropriate music program to the child.[32]


The Purrezaian et al.'s study used different approaches to painting, coloring, and listening to music for children that were family-centered interventions. In this approach, the predominant intervention was Mandela's painting, coloring, and drawing, in which the child listened to music at the same time. Furthermore, in this intervention, children made handicrafts with colored dough based on their painting.[30]

Outcome measurements and results

The results obtained in these studies can be presented based on the interventions as follows:


Most of the studies in this category have been done on the child's psychological variables such as anxiety and depression. Studies by Altay et al.,[26] Khodabakhshi Koolaee et al.,[33] and Gürcan and Atay Turan[24] using a self-administered questionnaire on children's anxiety showed that painting has a significant effect on reducing child anxiety.

Studies by Gürcan and Atay Turan,[24] Tahmasebi et al.[32] on children's depression have shown that the results of painting intervention are effective in improving children's depression.

Khodabakhshi Koolaee et al.'s study using a self-administered questionnaire showed that painting significantly reduces child anger,[33] but Palvan et al.'s study using a self-administered questionnaire showed that drawing with peers has no effect on children's happiness.[40]

Abdullah's study (2018) showed that the group receiving the painting intervention were more energetic and active, had less anxiety and depression, and participated more in social activities, but had no difference in cognitive capacities from the control group.[28]

Rhythmic movements

A study by Ebadinejad et al. on children's anxiety showed that the results support a significant reduction in child anxiety following rhythmic movements, and follow-up of children 3 weeks later found this reduction to be significant.[30]


Studies by Giordano et al.[31] and Nguyen et al.[34] assessed child anxiety in stressful preoperative and painful procedures. The results showed that music is effective in reducing child anxiety.

Studies by Nguyen et al. and Barrera et al. showed that pain was significantly reduced in the group receiving music therapy,[34],[38] but in Uggla et al., the pain was reduced in the music therapy group after the intervention, but it was not statistically significant compared to the control group.[36]

Piasai et al.'s study showed that listening to nonverbal classical music significantly increases children's happiness and relaxes the child.[37]

Uggla et al.'s study showed that the music therapy group had a higher level of physical performance and the school performance score had a nonsignificant increase compared to the control group.[35] Barrera et al. showed that adolescents and preschool children had better performance in the play, which shows the positive effect of music therapy on their physical activities.[38]

Studies by Nguyen et al., Uggla et al., and Piasai et al. showed that art therapy significantly reduces heart rate and respiration rate and has no significant effect on SpO2.[34],[35],[36],[37] The Piasai et al.'s study showed a significant reduction in BP,[37] but this difference was not significant in the Nguyen et al. and Uggla et al.'s studies.[34],[36]

Behaviors related to patient coping were examined in studies by Robb et al. and Robb et al.[26],[39] An observational checklist was completed by the evaluators which showed that positive coping-related behaviors in the intervention group were significantly higher than the control groups.

In Robb's (2017) showed that playing music by the child was not effective in improving the mood of mothers and even caused more stress to the mother.[26]

Wong's study (2021) showed that children children in the intervention group were successful in managing stress and had more interaction with their peers and the treatment staff.[32]


The results of Purrezaian et al.'s study using a self-administered questionnaire showed that children receiving the family-centered intervention and a combination of painting and music anxiety and depression were significantly less than before the intervention.[25]

  Discussion Top

The present study was conducted to identify and collect various types of art therapy interventions and their effects in children under 18 years of age with cancer. Finally, 17 studies were included in this review. The results of the review generally indicate the positive effect of art therapy on physical health including increases children's activity levels while increasing their energy and the psychological items of the hospitalized child, including anxiety, depression, relaxation, and while physiological variables reduce heart rate and respiration rate, improve the quality of life and behaviors of coping related.

Diagnosis and treatment of cancer are associated with many stressful experiences for the child.[29] Children with cancer experience high levels of depression and anxiety due to their physical symptoms, consequences, and treatment.[27] Decreased energy level and fatigue in children following chemotherapy prevents them from doing daily activities and is a common side effect. These results are in line with Kievisiene et al.'s study and Tang et al., which supports the positive effects of art therapy in controlling the physical side effects of chemotherapy, including fatigue.[42],[43]

The psychological effects of cancer have far-reaching outcomes on a child's quality of life and communication skills and can harm symptom management and adherence to treatment.[44] The results of the present review support the positive role of art therapy in improving psychological variables and improving the quality of life of children, which is consistent with the Facchini and Ruini review study that showed that music therapy can improve the feeling of well-being and psychological consequences in this group of patients.[45] The results of the research showed that most of the studies have been done on adults with cancer, which also support the positive role of art therapy in adults with cancer and believe that art therapy can have psychological consequences[46],[47] and fatigue[46],[48] and improve the quality of life of these people.[46],[48] Since it is difficult for children to express feelings and emotions,[49] art, as one of the oldest means of communication,[50] helps to express feelings and conflicts,[51] so it has been effective in reducing psychological problems in adults and children.

Children's happiness has been evaluated in two studies with conflicting results.[37],[40] It seems that in the Piasai et al.'s[37] study, the aim is to study the effect of guided imagery and it cannot be said that the results are due to listening to music. Therefore, due to the heterogeneity of the type of interventions, differences in the duration of the intervention, sample size, and tools used, it cannot be said that art therapy has an effect on the child's happiness or is not effective.

Children who are hospitalized for cancer treatment feel lonely and entrapment.[50] The results of the present review show the strengthening of interaction between children with family and other treatment staff, participation in social activities, improving social relationships, and successful management of stress and behavior following art therapy interventions. In this regard, the results of the Aguilar review also showed that art therapy can increase the communication of children with cancer with their families and health-care providers, and these children, in addition to developing coping skills, express their feelings better.[50]

Pain is considered one of the worst experiences of this group of children.[52] If left untreated or not treated well, pain often leads to long-term changes in the child's behavior, self-concept, and other psychological problems.[34] The results of Li et al.'s meta-analysis on 381 adult patients with cancer showed that music therapy can be effective in reducing pain in these patients.[53]

Kievisiene et al. showed that music therapy improves the quality of life of women with breast cancer and reduces the pain of these patients.[42] However, contrary to the evidence that shows the positive effect of CAM in improving the condition of children with cancer, especially during painful procedures,[54] the effect of art therapy has been studied in limited studies. In Nguyen et al. and Barrera et al.'s study, the intervention was effective.[34],[38] Only Nguyen et al.'s study evaluated a child's pain during invasive procedures. Uggla et al.[35] and Barrera et al.[38] are two pilot studies with limited sample sizes and conflicting results. Therefore, considering the importance of the issue of pain in children, the results of the present review cannot confirm the effect of art therapy in controlling and improving the pain of children with cancer.

Children with hematological diseases are more likely to have posttraumatic stress disorder (PTSD),[55] which is one of the most common symptoms of PTSD.[36] The results of the present review showed that music-based art therapy interventions can reduce heart rate and respiration rate in children with cancer.

In a review of the pain and anxiety of children receiving invasive procedures, Klassen et al. showed that music can reduce the heart rate and respiration rate of these children.[56] The results are also consistent with Mojtabavi et al.'s study, which found that music stimulates the cardiovascular autonomic nervous system, which can lead to increased parasympathetic activity and heart rate variability (HRV).[57] It seems that the use of art therapy interventions for the child can lead to a relaxation response that reduces heart rate and respiration rate.[58]

Although the results confirm the positive effect of family-centered art therapy on the child,[25],[26] but Robb's study (2017)[26] shows that Mothers in the intervention group had more stress and endured more energy because they had to encourage their children to play music. Since family-centered art therapy can teach families how to communicate with their children in the hospital[25] and has significant benefits for children, it is important to consider the effects and benefits of family-centered art therapy on the family as well.


In this review, intervention studies from all types of pilot and non-RCT studies have been included, which can affect the overall conclusion due to the low sample size and the lack of a control group. On the other hand, only studies in English were included. Heterogeneity in the type of interventions and study design in addition to reducing the scope of generalization; studies cannot be examined in the form of meta-analysis.

  Conclusion Top

According to the general result of this review, it can be said that art therapy has positive results on children with cancer. Because children's health-care workers seek comprehensive care for children with cancer, they need to transfer different and cost-effective approaches to physical and psychosocial care, such as art therapy, in their usual ways. Art therapy can be suitable for entering the clinic, but due to the heterogeneity of interventions and study plans, it is suggested that the interventions are standardized and people be trained to provide these interventions, and trained people be used in this field.

However, due to the importance of pain in children with cancer and child in the end of life, it seems that the importance of this issue has been ignored in the above studies and limited studies in this area were found that there is insufficient evidence. Therefore, it is necessary to evaluate the effectiveness of these interventions in studies with high sample size and quality of material.

Ethical issues

This study was conducted by reviewing the articles, therefore, no human or animal participated in it, therefore, taking an ethics approval was not required.

Financial support and sponsorship

This project was approved by the Vice Chancellor for Research, Mashhad University of Medical Sciences, Iran (No: IR.MUMS.NURSE.REC.1400.001).

Conflicts of interest

There are no conflicts of interest.

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  [Figure 1]

  [Table 1], [Table 2]


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