European Journal of Oncology Nursing 28 (2017) 1e6

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European Journal of Oncology Nursing

journal homepage: www.elsevier.com/locate/ejon

The effect of drawing and writing technique on the anxiety level of

children undergoing cancer treatment
Naime Altay, PhD RN *, Ebru Kilicarslan-Toruner, PhD RN, Çigdem Sari, RN
Gazi University Health Sciences Faculty Nursing Department, Ankara, Turkey

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

Article history: Purpose: To determine the effect of the drawing and writing technique on the anxiety level of children
Received 17 March 2016 undergoing cancer treatment in hospital.
Received in revised form Method: Research was conducted in the haematology-oncology clinic of a university hospital, using a
3 February 2017
quasi-experimental design (pre-and-post intervention evaluations of a single group). The sample
Accepted 20 February 2017
comprised 30 hospitalised children aged 9e16 years. Data were collected with Socio-demographic form,
clinical data form, and the State Anxiety Inventory. The institution gave written approval for the study
Keywords:
and parents provided written consent. Drawing, writing and mutual story-telling techniques were used
Cancer
Child
as part of a five-day programme. Children were asked to draw a picture of a hospitalised child and write a
Anxiety story about this drawing. After drawing and writing, mutual storytelling were used to more constructive
Drawing story with positive feelings. The drawing, writing techniques was implemented on the first and third
Writing days of the programme and mutual storytelling was implemented on the second and fourth days. Data
Mutual storytelling were reported as percentages and frequencies and the intervention effect analysed with the Wilcoxon
test.
Results: The average age of children was 12.56 years ± 2.67 and 76.7% were girls. The mean age diagnosis
and mean treatment duration were 11.26 years ± 3.17 and 16.56 months ± 20.75 respectively. Most of the
children (50%) had leukaemia and were receiving chemotherapy (66.7%). In most cases (76.7%) the
mother was the primary caregiver. Scores on the State Anxiety Inventory were lowereindicating lower
anxiety-after the intervention (36.86 ± 4.12 than before it (40.46 ± 4.51) (p < 0.05).
Conclusion: The therapeutic intervention reduced children's state anxiety.
© 2017 Elsevier Ltd. All rights reserved.

1. Introduction children for lengthy periods (Harper et al., 2015). Hospitalisation

The diagnosis and treatment of children's cancer is an important
health problem that involves many stressful experiences for child
patients. The incidence of childhood cancer is 138.5 and 169 per
million in Europe and the USA respectively (National Cancer
Institute, 2011; Stiller et al., 2006) and in Turkey it is 115.6 per
million (Stiller et al., 2006). The survival rate for children's cancer is
increasing in line with developments in cancer treatment (Robison
et al., 2009).
The nature of the diagnosis and treatment process and the
likelihood of complications make it necessary to hospitalise
* Corresponding author. Gazi University, Health Sciences Faculty, Nursing
Department, 06500 Besevler, Ankara, Turkey.
E-mail addresses: naimealtay@gazi.edu.tr (N. Altay), ebrutoruner@gazi.edu.tr
(E. Kilicarslan-Toruner), cigdemsari@gazi.edu.tr (Ç. Sari).
can be a frightful, irritating and unpleasant experience for children.
Children undergo extreme stress during the process of diagnosis
and treatment which involves long periods of hospitalisation (Hicks
and Lavender, 2001; Penkman et al., 2006); it is a particularly
challenging period for children and affects them physically, socially,
emotionally and psychologically (Durualp and Altay, 2012; Enskar
and Von Essen, 2008; Kim and Im, 2015; Kucukoglu and
Celebioglu, 2013).
Changes occur in hospitalisation and a number of physical and
psychological indications come into view while monitoring chil-
dren for longer periods (Enskar and Von Essen, 2008; Muglia-
Wechsler et al., 2014; Stam et al., 2006; Williams et al., 2006).
Research on the physical, emotional and psychological effects of
cancer on children (Li et al., 2010) found that children experienced
a high level of anxiety during cancer treatment. The same research
showed that more than half of the children were at high risk for
depression. Furthermore, most of the children undergoing

http://dx.doi.org/10.1016/j.ejon.2017.02.007
1462-3889/© 2017 Elsevier Ltd. All rights reserved.
2 N. Altay et al. / European Journal of Oncology Nursing 28 (2017) 1e6
treatment in hospital said during the interviews that they were sad
and anxious (Li et al., 2010). Hospitalisation of children diagnosed
with cancer causes stress and anxiety (Coyne and Conlon, 2007; Li
et al., 2007).
Factors which contribute to children's anxiety about hospital-
isation include the unfamiliarity of the hospital environment and
its formalities, the new routine and concerns about abandoning
their friends and families (Buckley and Savage, 2010; Coyne, 2006;
Tunney and Boore, 2013). Anxiety disorders affect both the healing
process and coping skills, and also cause behavioural changes (Li
and Chung, 2009). Children can find it difficult to give voice to
their feelings and emotions (Rollins et al., 2012; Wilson et al., 2010)
and so verbal and non-verbal therapeutic communication tech-
niques such as drawing and storytelling are sometimes used to
evaluate the psycho-social conditions of children.
Asking children to do a drawing and write a story about what
has been drawn is a commonly used therapeutic communication
technique which gives children an opportunity to express their
perceptions of the disease and their feelings visually as well as
verbally (Malchiodi, 2012; Goldner et al., 2015). Children of school
age prefer to express their feelings and thoughts by means of
drawings rather than words (Durualp and Altay, 2012; Matsumori,
2005). Durualp and Altay (2012) showed in that drawing helped
children with cancer to express their feelings and communicate
better with their peers. Mutual storytelling could be used as a
method of communicating with the children. The child is asked to
tell a self-created story with a beginning, a middle, and an end.
While listening to the story a counselor analyses its themes and
psychological meaning for children. The counselor than responds
with a story in which the characters are the same and the plot is
similar, but in which the ending represents a healthier resolution
than the ending child's story. (Slivinske and Slivinske, 2014). These
technique can be applied by health professional who are experts
and educated in the field about the subject in order to interpret the
child's drawings and writings appropriately in many environments
such as school, hospital, home.
Children may refrain from asking questions and verbalising
their feelings because of the disease, treatment process, or fear of
the unknown. They are unable to form a clear picture of their dis-
ease owing to their stage of development and draw their emotions
(SenBeytut et al., 2009; Çavuşog
lu, 2013). They can experience
frequent, intense emotional changes owing to, for example, anxiety
about the unknown. It has been suggested that children's drawings
and accompanying stories can be used to evaluate emotional
changes in children with cancer who have been hospitalised for
treatment, and to plan appropriate treatment for such changes. The
aim of this study was to determine the effect of storytelling, using
the combined drawing and writing technique, on the anxiety levels
of children undergoing cancer treatment in a hospital. The hy-
potheses were as follows.
H0: There is no difference between the state anxiety of children
before and after using the combined drawing and writing
technique for storytelling.
H1: There is a difference between the state anxiety levels of
children before and after using the combined drawing and
writing technique for storytelling.
2. Methods
2.1. Sample and study design
The research was carried out in the haematology and oncology
clinic of a university hospital between 6th January 2015 and 30th
June 2015 using a quasi-experimental design (pre- and post-
intervention evaluations of a single group). All the children who
met the research criteria were included in the sample. The inclusion
criteria were as follows: a) the child agreed to take part in the
research and his or her parents gave written consent to the child's
participation; b) age between 9 and 16 years; c) had already
received two or more courses of chemotherapy. The exclusion
criteria were as follows: a) child had experienced significant life
event other than his or her disease (such as parents' divorce, death
of a parent, moving house etc.) within the last six months; b) had
not received more than one course of chemotherapy; c) in the
terminal phase. Exclusion criteria were selected according the
factors which could affect the child's anxiety level including
important life-events, terminal stage of illness and aggressive
treatment (Compas et al., 2012). Thirty-five children who met the
criteria between the dates given above were eligible to take part;
however two were unable to draw and three declined to partici-
pate. The sample thus consisted of 30 children.
2.2. Data collection
Descriptive data were collected and the State Anxiety Inventory
was administered. All data collection forms were completed by the
researchers during face-to-face interviews with the children.
2.3. Descriptive data collection form
The descriptive data collection form consisted of questions
about socio-demographic variables (age, gender, family structure
and schooling; four questions) and questions the about the disease
and treatment process (age at diagnosis, treatment, hospitalisation
period and information about caregivers; six questions). This form
was completed on the first day of the research after consent had
been obtained from children and their families. The form took
about ten to 15 min to complete.
2.4. The state anxiety inventory for children
The State Anxiety Inventory was used to examine how the state
anxiety of the five days program is changed. The child's anxiety can
change instantaneously in stressful environments such as hospitals
(Karlsson et al., 2014). The State Anxiety Inventory was developed
€
by Spielberger (1973) and translated into Turkish by Ozusta (1995).
The inventory can be adapted for the 9e16 years age group. There is
no time limit for completion of the Inventory and it can be
administered to groups or on an individual basis. The Inventory
consists of 20 items describing emotions and behaviours; re-
spondents indicate how often they experience each using a four-
scale where 1 ¼ ‘never’, 2 ¼ ‘sometimes’, 3 ¼ ‘a lot’ and
4 ¼ ‘always’. Scores on the Inventory vary from 20 to 80 and high
values indicate high anxiety. A validation study showed that mean
scores for state anxiety were higher in a group diagnosed with
anxiety disorder than in a control group. A study of the validity and
reliability of the Turkish version of the Inventory reported Cron-
€
bach's alpha ¼ 0.81 (Ozusta, 1995). The Inventory was administered
on the first and fifth days of the intervention, which was designed
to reduce anxiety in children with cancer undergoing a treatment.
The inventory takes ten minutes to administer.
2.5. Procedure
A five-day therapeutic programme was used to reduce the
anxiety of children undergoing cancer treatment. Instead of one
therapeutic play, we preferred to implement a programme to un-
derstand the effect of continuous therapeutic play. The drawing and
 N. Altay et al. / European Journal of Oncology Nursing 28 (2017) 1e6 3

writing and mutual storytelling techniques were used to reduce programme.

children's anxiety. These activities took place in the child's room at
a time that had been pre-arranged with the child to ensure that
interruptions would be minimal. The child, the researcher and the
child's parents were present in the room during these therapeutic
activities. The researchers provided every child with an A4 drawing
book, 12 crayons, pencils, a pencil sharpener and an eraser for the
drawing activity; they were given these to keep at the end of the
activity. They were also allowed to keep the drawings and the
stories created during the research if they wished to do so. Only two
of the 30 children who participated in the research wanted to keep
the drawings. The drawing and writing techniques was imple-
mented on the first and third days of the programme and mutual
storytelling was implemented on the second and fourth days. The
phases of the research are shown in Table 1.
In the literature, there are different types of interventions
(techniques and durations) used therapeutic communication to
reduce the anxiety in children (Fortier et al., 2010; Sorenson and
Card, 2009). Therefore, the five-day program was constituted by
researchers to measure the effects of interventions on children
anxiety level. More than one week interventions could reduce their
interest (Malchiodi, 2012).
2.6. Therapeutic techniques used in the research
The techniques of a) drawing and writing and b) mutual story-
telling were used in the research.
2.7. Drawing and writing technique
This is a technique that enables children to express their emo-
tions in a non-verbal, artistic form. The technique of getting chil-
dren to do a drawing and then write about what they have drawn
and discuss it enables us to access the inner world of children (Piko
and Bak, 2006). Children have their own way of seeing the world
and this is reflected in their expressions of their perceptions.
Children reflect a part of their inner world in their drawings
(Plitteri, 2014; Yavuzer, 2011). The aim of this study was to gain
insight into the experiences and perceptions that children with
cancer have about their health-care environment and the disease
process, and to investigate the efficacy of therapeutic techniques
for reducing their anxiety (Driessnack and Furukawa, 2012). We
asked children to draw a picture of ‘a hospitalised child’ to gain
insight into how they perceived the hospitalisation and treatment
process. The children were given an opportunity to change or
amend their drawings. Sufficient time should be given to children
for their drawings (Einarsdottir, 2007). As to our research, sufficient
time was provided to the children to create drawings in the
The narrative qualities of children's drawings are of particular
importance. They originate in the skill in presenting their inner
worlds, reactions to the environment in their personal stories and
also the content of their drawings as a manner of communication
suitable in terms of their development (Lee et al., 2007). Children's
ability to draw mental pictures goes well beyond their drawing
ability; for this reason combining drawing with writing has the
potential to provide greater insight into their thoughts and feelings.
Drawing, telling stories based on drawings, and discussing the
drawing and stories are ways of enriching children's narration and
can be used to gain an understanding of their life experiences
(MacDonald, 2009). The stories emerging from drawings provide
an effective narration and make the drawing technique more
valuable (Ehrlen, 2009).
2.8. The mutual storytelling technique
This is a technique used to discover the emotions and fears of
children. The child is asked tell a story linked to her/his drawing.
The nurse subsequently tells another, more constructive, story,
similar to that of a grown-up child, having a problem solving
quality and featuring positive feelings (hope, courage, love, happi-
ness, etc.) other than the problems specified (Hockenberry et al.,
2014; Kotmann, 2014). Let us assume that a child tells a story
about hospitalisation and being deprived of seeing her/his friends;
in response the adult might tell a story about a child (in different
circumstances and with a different name from the child involved in
the exercise) who is undergoing treatment in a hospital, and whose
friends come to visit her/him in the hospital. We also asked chil-
dren to write a story related to the drawings they created in our
study. Afterwards a researcher spoke to each child about her/his
story and created a mutual story based on the story that emerged
out of the child's drawing.
2.9. Data analysis
The research data were analysed using the SPSS 17 (Chicago,
USA) statistical package. Socio-demographic variables are reported
as frequencies and percentages. The Kolmogorov-Smirnov test was
used to assess whether pre- and post-intervention scores on the
State Anxiety Inventory were normally distributed (Hayran and
Hayran, 2011). Although the pre-intervention data were normally
distributed (K-S ¼ 0.08; p ¼ 0.20), the post-intervention data were
not (K-S ¼ 0.178; p ¼ 0.01) and so the Wilcoxon test was used to
compare pre- and post-intervention scores (Erdog
an et al., 2014;
Rubin, 2013). The confidence interval was accepted as 95% in the
research and findings were considered to be statistically significant

Table 1
The phases of the research.

Day Activities

First day 
Meeting and greeting the children and parents, informing them about the research and obtaining the related consents.

Collection of socio-demographic and clinical data and administration of the State Anxiety Inventory.

Delivery of an A4 drawing book, crayons in 12 colours, pencils, a pencil sharpener and an eraser to all children.

Asking the children to draw the picture of ‘a child in hospital’' and write a self-created story with a beginning, a middle, and an end about his/her drawing.
Second 
Use of the mutual storytelling technique. While listening to the story of child's (about his/her drawing of a child in hospital) resercher analyses its themes and
day psychological meaning for child. The resercher than responds with a story in which the characters are the same and the plot is similar, but in which the
ending represents a healthier resolution than the ending child's story.
Third day  Asking the children to draw anything they wanted (free drawing) and write a self-created story with a beginning, a middle, and an end about his/her
drawing.
Fourth  Use of the mutual storytelling technique. While listening to the story of child's (about his/her free drawing) researcher analyses its themes and psychological
day meaning for child. The resercher than responds with a story in which the characters are the same and the plot is similar, but in which the ending represents a
healthier resolution than the ending child's story.
Fifth day  Administration of the State Anxiety Inventory for the second time.
4 N. Altay et al. / European Journal of Oncology Nursing 28 (2017) 1e6

if the p-value was less than 0.05. typically painful, invasive and relatively prolonged (Abrams et al.,
2007; Muglia-Wechsler et al., 2014). In such cases it is important
2.10. Ethical considerations to understand how children view the effects of hospitalisation and
to help them to cope with them. Drawing and writing, and mutual
We started the research after obtaining written permission from storytelling are therapeutic techniques that can help children to
the institution involved and approval from the Ethics Committee express their inner world. They are effective tools for communi-
for Non-Invasive Clinical Research (No:121, 09.03.2015). The chil- cating with children, especially in cases where verbal communi-
dren provided verbal consent to participation and their parents cation falls short (Franck et al., 2008; Rollins et al., 2012).
provided written consent. Children undergoing cancer treatment can have a relatively high
levels of anxiety due to of hospitalisation, painful interventions and
3. Results their isolation from school and their circle of friends (Aldiss et al.,
2009; Gibbins et al., 2012; Kim and Im, 2015; Long and Marsland,
The average age of the children was 12.56 years ± 2.67 and 76.7 2011). Durualp et al. (2012) concluded from pictures drawn by
per cent of them were girls. The mean age of children at diagnosis hospitalised children of pre-school age that the interventions used
was 11.26 years ± 3.17, the mean treatment duration was 16.56 had been traumatic for the children and that as a result they had
months ± 20.75 and the mean duration of hospitalisation was 16.56 developed a generally negative, fearful attitude to the hospital
days ± 20.75. Most of the children (86.7%) were part of a nuclear environment. We observed in our research that the values relating
family. Eighty per cent of the children did not attend school regu- to state anxiety in children were high (42.63 ± 4.64) (Table 3)
larly and 20 per cent of them had left school because of their illness. compared to the time before the application of drawing and
The majority of children (50%) had been diagnosed with leukaemia writing, and the mutual storytelling technique. Allen et al. (1997)
and were receiving chemotherapy (66.7%). In most cases (76.7%) reported similar anxiety levels in adolescents undergoing cancer
the primary caregiver was the mother (Table 2). treatment (43.14 ± 8.6 in girls; 39.14 ± 10.57). A number of other
Five-day therapeutic programme was implemented to children researchers have also reported that children undergoing cancer
and anxiety levels of children were evaluated first and the fifth day treatment suffer high anxiety (Giannakopoulos et al., 2009; Hatano
of the programme. According to results, the State Anxiety Inventory et al., 2014; Koçkar and Gurol, 2013). Cihangir and Kilicarslan-
mean score (38.63 ± 4.38) of children after the programme were Toruner (2007) examined pictures by children suffering under
decreased when we compare the mean score of beginning acute and chronic diseases and the emotional indicators in
(42.63 ± 4.64) (Z ¼ 4.57, p < 0.05) (Table 3). oncology patients were higher than other group (Cihangir and
Kilicarslan-Toruner, 2007). A study which investigated children's
perceptions of cancer and health using drawing and writing tech-
4. Discussion
niques found that negative emotional effects were higher than
others (Knighting et al., 2010). The authors commented on the
Hospitalisation is an unpleasant and stressful event for children
limited number of studies dealing with therapeutic techniques to
(Kortesluoma et al., 2008; Lindeke et al., 2006; Wilson et al., 2010).
explore stress and ways of coping with it in children. Our study has
The effects of hospitalisation can especially severe when the reason
also shown that children undergoing a treatment for cancer suffer
for hospitalisation is a disease like cancer, for which treatment is
severe anxiety; however some studies indicate that hospitalisation
is not considered a source of stress by patients with acute and
Table 2 chronic disorders (Lindeke et al., 2006; Pelander and Leino-Kilpi,
Socio-demographic and clinical characteristics of the sample (n ¼ 30). 2010; Wilson et al., 2010).
Variable M (SD) Min-Max
There are a number of methods that help to reduce anxiety in
children who have been hospitalised because of a chronic disease;
Child's age (years) 12.56 ± 267 9e16
these include distraction, cognitive-behavioural techniques, artistic
Age at diagnosis (years) 11.26 ± 3.17 5e16
Duration of treatment (months) 16.56 ± 20.75 4e108 activities, games, therapeutic communication techniques etc.
Duration of hospital stay (days) 23.90 ± 35.55 2e120 (Bagnasco et al., 2012; Koller and Goldman, 2012; Nguyen et al.,
n % 2010; Sparapani et al., 2014; Sposito et al., 2013, 2015; Weinstein
and Henrich, 2013; Wu et al., 2014). A variety of methods have
Child's gender
Female 23 76.7
been successfully used to reduce anxiety in children with chronic
Male 7 23.3 disease: music therapy (Nguyen et al., 2010), virtual games
Family structure (Gershon et al., 2004) and music books, balloons and videos (Kazak
Nuclear family 26 86.7 et al., 1996). The drawing and writing technique has been reported
Extended family 4 13.3
to be particularly effective, especially for finding out the views of
School Attendance
Non attendant 24 80.0 children (Driessnack, 2006; Franck et al., 2008) and helping them
Left school 6 20.0 make sense of what they experience (Rollins et al., 2012).
Diagnosis of children In our study scores on the State Anxiety Inventory were lower
Leukaemia 15 50.0 after the therapeutic intervention (38.63 ± 4.38) than before it
Solid tumoura 10 33.3
Lymphoma 5 16.7
(42.63 ± 4.64;p < 0.05) (Table 3). Similarly Favara-Scacco et al.
Treatment (2001) stated that drawing therapy reduced the fears and anxiety
Chemotherapy 20 66.7 of children with leukaemia who were exposed to painful in-
Surgery and chemotherapy 5 16.7 terventions. However another study using the drawing technique
Bone marrow transplantation 4 13.3
found that anxiety levels were similar in healthy children and
Chemotherapy and radiotherapy 1 3.3
Caregiver children undergoing cancer treatment in hospital (Rollins, 2005).
Mother 23 76.7 Only a few studies have evaluated anxiety in children undergoing
Father 6 20.0 treatment in hospital after being diagnosed with cancer by means
Grandmother 1 3.3 of therapeutic communication techniques. Our study suggests that
a
Brain tumours (n ¼ 5), soft tissue sarcomas (n ¼ 3), osteosarcoma (n ¼ 2). both the drawing and writing technique and the mutual
 N. Altay et al. / European Journal of Oncology Nursing 28 (2017) 1e6
Table 3
Comparison of the mean scores on the State Anxiety Inventory before and after the therapeutic intervention.
Administration of State Anxiety Inventory M±SD
Pre-intervention 42.63 ± 4.64
Post-intervention 38.63 ± 4.38
storytelling technique are effective ways of finding out the views of
children and reducing their anxiety in sanitary environments
(Driessnack, 2006; Franck et al., 2008).
5. Strengths and limitations
A five-day therapeutic programme was implemented to chil-
dren with hemato-oncological problems. The study shows the ef-
fects of this program to reduce the anxiety levels of children. The
results made a contribution for evidence in the literature. The
limitation of the study is that the data relate to one particular
intervention in one hospital and the findings may not generalise to
other populations. The results could be changed by individuals and
cultures. On the other hand, the other factors such as duration of
hospitalisation, treatment type, personal characteristics could be
effected the anxiety levels of children. Therefore, studies with
control group could be recommended. The five-day programme
was constituted by researchers. So, it was performed first time in
the literature. However, the same therapeutic techniques were
used in the study, each child's drawing and story was different from
each other. Therefore, the mutual storytelling context changed
from one child to another and the contextual issues could affect the
results.
6. Conclusion
We showed the drawing and writing and mutual storytelling
techniques can be used to reduce the anxiety levels of children
undergoing cancer treatment in hospital. We think that these
techniques method can be useful both for children with cancer and
for paediatric nurses taking care of them. Nurses should use
drawing techniques as early as possible in a child's hospitalisation
in order to uncover his or her anxieties. Nurses and other health
professionals should be offered support and training to enable
them to use projective techniques which are known to be effective
for therapeutic communication with children, such as drawing and
writing and mutual storytelling. The five-day programme was
constituted by researchers; therefore, the time interval, in-
terventions could be enriched and reimplemented in future
research.
Declaration of conflicting interests
The authors declared no potential conflicts of interests, with
respect to the research, authorship, and/or publication of this
article.
Acknowledgement
We thank the children and families who took part in our study.
References
Abrams, A.N., Hazen, E.P., Penson, R.T., 2007. Psychosocial issues in adolescents with
cancer. Cancer Treat. Rev. 33, 622e630.
Aldiss, S., Horstman, M., O'Leary, C., Richardson, A., Gibson, F., 2009. What is
ımportant to young children who have cancer while in hospital? Chıldren
Socıety 23, 85e98.
Allen, R., Newman, S.P., Souhami, R.L., 1997. Anxiety and depression in adolescent
5
Minemax Z, p
33e51 Z ¼ 4.57
30e48 p ¼ 0.001
cancer: findings in patients and parents at the time of diagnosis. Eur. J. Cancer
33 (8), 1250e1255.
Bagnasco, A., Pezzi, E., Rosa, F., Fornonı, L., Sasso, L., 2012. Distraction techniques in
children during venipuncture: an Italian experience. J. Prev. Med. Hyg. 53,
44e48.
Buckley, A., Savage, E., 2010. Preoperative information needs of children under
going tonsillectomy. J. Clin. Nurs. 19, 2879e2887.
Çavuşog
lu, H., 2013. ÇocukSag
lıg

ıhemşirelig
i (Child Health Nursing) (In Turkish).
SistemOfsetBasimevi, Ankara.
Cihangir, N., Kilicarslan-Toruner, E., 2007. Determination of emotional conditions of
school age children with chronic and acute diseases by means of human figure
drawings. J. Hacettepe Univ. Sch. Nurs. 14, 1e8 (In Turkish).
Compas, B.E., Jaser, S.S., Dunn, M.J., Rodriquez, E.M., 2012. Coping with chronic
illness in childhood and adolescence. Annu. Rev. Clin. Psychol. 8, 455e480.
Coyne, I., 2006. Consultation with children in hospital: children, parents', and
nurses' perspectives. J. Clin. Nurs. 15 (1), 61e71.
Coyne, I., Conlon, J., 2007. Children's and young people's views of hospitalization:
‘it's a scary place’. J. Children’s Young People’s Nurs. 1 (1), 16e21.
Driessnack, M., 2006. Draw-and-tell conversations with children about fear. Qual.
Health Res. 16 (10), 1414e1435.
Driessnack, M., Furukawa, R., 2012. Arts-based data collection techniques used in
child research. J. Specialists Pediatr. Nurs. 17, 3e9.
Durualp, E., Altay, N., 2012. A comparison of emotional ındicators and depressive
symptom levels of school-age children with and without cancer. J. Pediatr.
Oncol. Nurs. 29, 232.
Durualp, E., Çiçenog
lu, S., Mümünog
lu, S., Kalkanlı, G., Altuntaş, Z., 2012. Hastane-
deyatmışolanokulo €ncesido € nemçocuklarınınyaptıklarıresimlerinincelenmesi
(An analysis of the pictures drawn by the hospitalized preschool children).
EgitimveOgretimArastirmalariDergisi 1 (3), 249e260 (In Turkish).
Ehrlen, K., 2009. Drawings as representations of children's conceptions. Int. J. Sci.
Educ. 31 (1), 41e57.
Einarsdottir, J., 2007. Research with children: methodological and ethical chal-
lenges. Eur. Early Child. Educ. Res. J. 15 (2), 197e211.
Enskar, K., Von Essen, L., 2008. Physical problems and psychosocial function in
children with cancer. Pediatr. Nurs. 20, 37e41.
Erdog
an, S., Nahçivan, N., Esin, N., 2014. Nursing Research Principles, Process,
_
Practice and Critical. Nobel Medicine Publisher, Istanbul (In Turkish).
Favara-Scacco, C., Smirne, G., Schillro, G., DiCataldo, A., 2001. Art therapy as support
for children with leukemia during painful procedures. Med. Pediatr. Oncol. 36,
474e480.
Fortier, M., Rosarıo, A., Martın, S., Kaın, Z., 2010. Perioperative anxiety in children.
Pediatr. Anesth. 20, 318e322.
Franck, L.S., Sheikh, A., Oulton, K., 2008. What helps when it hurts? children's views
on pain relief. Child Care, Health Dev. 34 (34), 430e438.
Gershon, J., Zimand, E., Pıckering, M., Rotbaum, B.O., Hodges, L., 2004. A pilot and
feasibility study of virtual reality as a distraction for children with cancer. J. Am.
Acad. Child Adolesc. Psychiatry 43 (10), 1243e1249.
Giannakopoulos, G., Kazantzi, M., Dimitrakaki, C., Tsiantis, J., Kolaitis, G., Tountas, Y.,
2009. Screening for children's depression symptoms in greece: the use of the
children's depression inventory in a nation-wide school-based sample. Eur.
Child Adolesc. Psychiatry 18, 485e492.
Gibbins, J., Steinhardt, K., Beinart, H., 2012. A systematic review of qualitative
studies exploring the experience of parents whose child is diagnosed and
treated for cancer. J. Pediatr. Oncol. Nurs. 29 (5), 253e271.
Goldner, L., Edelstein, M., Habshush, Y., 2015. A glance at children's family drawings:
associations with children's and parents' hope and attributional style. Arts
Psychotherapy 43, 7e15.
Harper, F.W.K., Peterson, A.M., Albrecht, T.L., Taub, J.W., Phipps, S., Penner, L.A., 2015.
Satisfaction with support versus size of network: differential effects of social
support on psychological distress in parents of pediatric cancer patients. Psy-
cho-Oncology. http://dx.doi.org/10.1002/pon.3863.
Hatano, Y., Yamada, M., Nakagawa, K., Nanri, H., Kawase, M., Fukui, K., 2014. Using
drawing tests to explore the multidimensional psychological aspects of children
with cancer. Jpn. J. Clin. Oncol. 44 (10), 1009e1012.
Hayran, M., Hayran, M., 2011. Basic Statistics for Health Researchers. Omega
Research, Ankara (In Turkish).
Hicks, M.D., Lavender, R., 2001. Psychosocial practice trends in pediatric oncology.
J. Pediatr. Oncol. Nurs. 18, 143e153.
Hockenberry, M.J., Wilson, D., Rentfro, A.R., McCampbell, L., 2014. Study Guide for
Wong's Nursing Care of Infants and Children, ninth ed. Elsevier Mosby, USA.
€ m, I., Enskar, K., Englund, A.D., 2014. Nurses' perspectives on
Karlsson, K., Rydstro
supporting children during needle-related medical procedures. Int. J. Qual.
Stud. Health Well-being 9, 230e263.
Kazak, A.E., Penati, B., Boyer, B.A., Himelstein, B., Brophy, P., Waibel, M.K.,
Blackall, G.F., Daller, R., Johnson, K., 1996. A randomized controlled prospective
6 N. Altay et al. / European Journal of Oncology Nursing 28 (2017) 1e6
outcome study of a psychological and pharmacological intervention protocol
for procedural distress in pediatricleukemia. J. Pediatr. Psychol. 21 (5), 615e631.
Kim, D.H., Im, Y.J., 2015. The influence of family management style on psychosocial
problems of childhood cancer survivors in Korea. Eur. J. Oncol. Nurs. 19,
107e112.
Knighting, K., Rowa-Dewar, N., Malcom, C., Kearney, N., Gibson, F., 2010. Children's
understanding of cancer and views on health-related behaviour: a ‘draw and
write’ study. Child Care, Health Dev. 37 (2), 289e299.
Koçkar, C., Gurol, A., 2013. Anxiety, aggression and self-esteem analysis through
pictures in children with cancer. Florence Nightingale HemşirelikDergisi 21 (1),
33e39 (In Turkish).
Koller, D., Goldman, R.D., 2012. Distraction techniques for children undergoing
procedures: a critical review of pediatric research. J. Pediatr. Nurs. 27, 652e681.
Kortesluoma, R.L., Punamakı, R.L., Nikkonen, M., 2008. Hospitalized children
drawing their pain: the contents and cognitive and emotional characteristics of
pain drawings. J. Child Health Care 12 (4), 284e300.
Kotmann, T., 2014. Play Therapy: Basics and beyond, second ed. Wiley, USA.
Kucukoglu, S., Celebioglu, A., 2013. Identification of psychological symptoms and
associated factors in adolescents who have a parent with cancer in Turkey. Eur.
J. Oncol. Nurs. 17 (1), 75e80.
Lee, C.Y., Chang, Y.Y., Huang, S.T., 2007. Prevalence of dental anxiety among 5 to
8yearold Taiwanese children. J. Public Health Dent. 67 (1), 36e41.
Li, H.C.W., Chung, O.K., 2009. Enhancing the efficacy of psychoeducational in-
terventions for paediatric patients in a randomized controlled trial: methodo-
logical considerations. J. Clin. Nurs. 18, 3013e3021.
Li, H.C.W., Chung, O.K., Chiu, S.Y., 2010. The impact of cancer on children's physical,
emotional and psychosocial well-being. Cancer Nurs. 33, 47e54.
Li, H.C.W., Lopez, V., Lee, T.L.I., 2007. Psychoeducational preparation of children for
surgery: the importance of parental involvement. Patient Educ. Couns. 65,
34e41.
Lindeke, L., Nakai, M., Johnson, L., 2006. Capturing children's voices for quality
improvement. Matern. Child. Nurs. 31, 290e295.
Long, K.A., Marsland, A.L., 2011. Family adjustment to childhood cancer: a system-
atic review. Clin. Child Fam. Psychol. Rev. 14 (1), 57e88.
MacDonald, A., 2009. Drawing stories: the power of children's drawings to
communicate the lived experience of starting school. Aust. J. Early Child. 34 (2),
40e49.
Malchiodi, A.C., 2012. Understanding Children's Drawings. The Guilford Press,
London.
Matsumori, N., 2005. Use of the drawing technique in nursing assessment.
J. Specialist Pediatr. Nurs. 10, 191e195.
Muglia-Wechsler, A., Bragado-Alvarez, C., Hernandez-Lloreda, M., 2014. Effective-
ness of psychological interventions intended to promote adjustment of children
with cancer and their parents: an overview. An. De. Psicol. 30, 93e103.
National Cancer Institute, 2011. Surveillance Epidemiology and End Results, Con-
tents of the SEER Cancer Statistics Review, 1975e2008. Available at: http://seer.
cancer.gov/csr/1975_2008/sections.html.
Nguyen, T.N., Nilsson, S., Hellstro € m, A.L., Bengtson, A., 2010. Music therapy to reduce
pain and anxiety in children with cancer undergoing lumbar puncture: a ran-
domized clinical trial. J. Pediatr. Oncol. Nurs. 27 (3), 146e155.
€
Ozusta, Ş., 1995. Çocuklar için durumluk-süreklikaygı envanteri'nin uyarlama,
geçerlik ve güvenirlik çalışması (Study on validity and reliability of the state
anxiety inventory for children). Türk Psikol. Derg. 10, 32e44 (In Turkish).
Pelander, T., Leino-Kilpi, H., 2010. Children's best and worst experiences during
hospitalization. Scand. J. Caring Sci. 24 (4), 726e733.
Penkman, L., Scott-Lane, L., Pelletier, W., 2006. A psychosocial program for pediatric
oncology patients: a pilot study of ‘the beaded journey.’. J. Psychosoc. Oncol. 24,
103e115.
Piko, B., Bak, J., 2006. Children's perceptions of health and illness: images and lay
concepts in preadolescence. Health Educ. 21, 643e653.
Plitteri, A., 2014. Maternal and Child Nursing: Care of the Childbearing and Child-
rearing Family, seventh ed. Lippincot Williams and Wilkins, China.
Robison, L.L., Armstrong, G.T., Boice, J.D., Chow, E.J., Davies, S.M., Donaldson, S.S.,
et al., 2009. The childhood cancer survivor study: a national cancer institute-
supported resource for outcome and intervention research. J. Clin. Oncol. 27
(14), 2308e2318.
Rollins, J.A., 2005. Tell me about it: drawing as a communication tool for children
with cancer. J. Pediatr. Oncol. Nurs. 22 (4), 203e221.
Rollins, J., Drescher, J., Kelleher, M., 2012. Exploring the ability of a drawing by proxy
intervention to improve quality of life for hospitalized children. Arts Health 4
(1), 55e69.
Rubin, A., 2013. Statistics for Evidence-based Practice and Evaluation, third ed.
Premedia Global, USA.
SenBeytut, D., Bolışık, B., Solak, U., Seyfioglu, U., 2009. Çocuklardahasta-
neyeyatmaetkilerininprojektifyo € ntemolanresimçizmeyoluylaincelenmesi (A
study of the influences of hospitalization on children through drawing as a
projective method). Maltepe Üniversitesi Hemşirelik Bilim ve Sanatı Derg. 2
(36), 35e44 (In Turkish).
Slivinske, J., Slivinske, L., 2014. Therapeutic Storytelling for Adolescents and Young
Adults. Oxford University Press, USA.
Sorenson, H.L., Card, C.A., 2009. Using a collaborative child life approach for
continuous surgical preparation. Assoc. Perioper. Registered Nurses 90,
557e566.
Sparapani, V.C., Jacob, E., Montigny, F., Pfeifer, L.I., Sposito, A.M.P., Lima, R.A.G.,
Nascimento, L.C., 2014. The use of puppets as a strategy for communicating
with children with type 1 diabetes mellitus. J. Nurs. Educ. Pract. 4 (2), 186e194.
Spielberger, C.D., 1973. Preliminary Manual for the State-trait Anxiety Inventory for
Children. Consulting Psychologists Press, Palo Alto, CA, USA.
Sposito, A.M.P., Silva-Rodrigue, F.M., Sparapani, V.C., Pfeifer, L.I., Lima, R.A.,
Nascimento, L.C., 2015. Coping strategies used by hospitalized children with
cancer undergoing chemotherapy. J. Nurs. Scholarsh. 47 (2), 143e151.
Sposito, A.M.P., Sparapani, V.C., Pfeifer, L.I., Lima, R.A.G., Nascimento, L.C., 2013.
Playful strategies for data collection with child cancer patients: an integrative
review. Rev. Enferm. 34 (3), 187e195.
Stam, H., Grootenhuis, M.A., Caron, H.N., Last, B.F., 2006. Quality of life and current
coping in young adult survivors of childhood cancer: positive expectations
about the further course of the disease were correlated with better quality of
life. Psycho-Oncology 15, 31e43.
Stiller, C.A., Marcos-Gragera, R., Ardanaz, E., Pannelli, F., Almar-Marquees, E., Can-
nada-Martinez, A., et al., 2006. Geographical patterns of childhood cancer-
incidence in Europe, 1988e1997: report from the ACCIS project. Eur. J. Cancer
42, 195e260.
Tunney, A.M., Boore, J., 2013. The effectiveness of a storybook in lessening anxiety in
children undergoing tonsillectomy and adenoidectomy in Northern Ireland.
Compr. Pediatr. Nurs. 36 (4), 319e335.
Weinstein, A.G., Henrich, C.C., 2013. Psychological interventions helping pediatric
oncology patients cope with medical procedures: a nurse-centred approach.
Eur. J. Oncol. Nurs. 17, 726e731.
Williams, P.D., Schmideskamp, J., Ridder, E.L., Williams, A.R., 2006. Symptom
monitoring and dependent care during cancer treatment in children. Cancer
Nurs. 29, 188e197.
Wilson, M.E., Megel, M.E., Enenbach, L., Carlson, K.L., 2010. The voices of children:
stories about hospitalization. J. Pediatr. Health Care 24 (2), 95e102.
Wu, L.M., Chiou, S.S., Sheen, J.M., Lin, P.C., Liao, Y.M., Chen, H.M., Hsiao, C.C., 2014.
Evaluating the acceptability and efficacy of a psycho-educational intervention
for coping and symptom management by children with cancer: a randomized
controlled study. J. Adv. Nurs. 70 (7), 1653e1662.
Yavuzer, H., 2011. Resimleriyleçocuk (Child with his Pictures), fifteenth ed. Remzi
_
Bookstore, Istanbul (In Turkish).