An Art Therapy Workbook for Pediatric Patients with Cancer Receiving Palliative Care: Program Design and Effects

Abstract

Purpose

This study aims to develop an art therapy workbook for pediatric patients with cancer receiving palliative care and evaluate its effects on anxiety and stress.

Methods

A one-group pretest–posttest quasi-experimental design was employed. The art therapy workbook comprised six sessions structured along a sequence of introduction, emotional expression, and discovery of hope. Participants were pediatric patients with cancer receiving palliative care at S Hospital, affiliated with C University; data from 14 patients who completed at least five of the six sessions were analyzed. Anxiety and stress were assessed using the Numeric Rating Scale (NRS), and stress-coping ability was assessed using the Person-in-the-Rain (PITR) drawing test. Data were analyzed using the Wilcoxon signed-rank test.

Results

Following application of the workbook, participants’ anxiety (Z=-3.20, P<0.01) and stress (Z=-3.07, P<0.01) scores decreased significantly. Although the change in PITR scores was not statistically significant (Z=-0.81, P=0.42), counseling and drawing analyses confirmed that the children externalized helplessness and negative emotions associated with the illness and experienced positive psychological changes.

Conclusion

The art therapy workbook was confirmed as a useful intervention for reducing anxiety and stress in pediatric patients with cancer receiving palliative care. As a flexible program that enables children with substantial physical limitations to express their emotions safely, it may serve as a psychosocial intervention model for children diagnosed with various illnesses in both clinical and home settings.

INTRODUCTION

1. Background

A diagnosis of cancer during childhood can impose substantial physical, psychological, and emotional burdens on affected children and significantly affect their quality of life throughout the course of treatment [1,2]. For children with cancer, palliative care can be initiated at diagnosis and continued regardless of whether they receive active disease treatment [3]. Unlike palliative care for adults, palliative care for children with cancer should consider their developmental stage and level, including their communication abilities and their understanding of the illness and the meaning of death [4,5]. Furthermore, because pediatric palliative care encompasses diverse diseases, the disease trajectory and characteristics of each condition must be taken into account [6].

Children with cancer receiving palliative care become directly or indirectly aware of their disease status and experience complex emotional responses, including anxiety, depression, anger, helplessness, and fear of death [7]. These responses may further intensify both disease-related physical suffering and psychosocial crises encountered in the course of development [8,9]. Given that children frequently receive inpatient and outpatient treatment concurrently, emotional interventions require flexible adjustment according to the treatment environment and the child’s physical condition [10].

Art therapy enables children with cancer to reveal their emotions through artistic rather than verbal expression and, through its emphasis on spontaneity and creativity, can be an effective intervention for establishing therapeutic trust and promoting emotional healing [11,12]. As art activities allow the expression of emotions that are difficult to articulate verbally, art therapy serves as a psychosocial intervention that supports psychological coping with illness-related difficulties [13]. For children with cancer, art therapy can promote ego growth by enabling them to explore feelings that are difficult to express, facilitate therapeutic work through the analysis of materials that reveal invisible thoughts, and alleviate negative emotions embedded in the unconscious through the enjoyment experienced during art activities [11,14]. Previous studies have reported that art therapy is a useful tool for coping with stressful and traumatic experiences, enhancing self-esteem, and reducing stress and anxiety [13,15]. However, art therapy for children with cancer has primarily been conducted in individual or group formats through face-to-face sessions with therapists. No workbook-based program has been developed that allows children receiving palliative care, for whom face-to-face participation is difficult because of their health status, to engage with it independently, without time and place constraints. Therefore, this study seeks to develop a new art therapy workbook that enables children with cancer receiving palliative care to participate at their convenience, at their own pace, and in accordance with their health conditions [12,14].

Previous studies have reported that art therapy reduces negative self-perceptions, fosters positive self-concept among children with cancer [16], and plays an essential role in relieving emotional distress during treatment [17]. The present art therapy workbook was designed with a focus on two functions: a self-care function, through which children with cancer receiving palliative care voluntarily attend to their own emotions, and an interactive function, through which they communicate emotionally with a therapist based on their completed work. The art therapy workbook guides children sequentially through themes of expressing emotions, reflecting on the meaning of life, sharing illness experiences, and exploring thoughts about death, thereby facilitating the process of safely expressing their inner emotions and understanding themselves. In particular, one-to-one interaction with an art therapy specialist following workbook activities may promote the child’s self-understanding and emotional stability while simultaneously providing families and healthcare providers with greater insight into the child’s psychological state [14].

Although several international studies have reported that art therapy reduces anxiety, improves self-esteem, and enhances quality of life among children with cancer [11,12,15], empirical research on workbook-based art therapy for children with cancer receiving palliative care remains limited. In Korea, art therapy has likewise been reported as a psychosocial intervention that helps recipients of hospice and palliative care express emotions and improve their quality of life [13]. However, most studies have involved adults, and research involving applications of art therapy to children with cancer receiving palliative care is scarce. Studies involving children in diverse circumstances of concurrent inpatient and outpatient treatment are particularly scarce, highlighting the need for a practical model applicable to clinical settings.

Accordingly, this study aims to develop and apply an art therapy workbook for children with cancer receiving palliative care and examine its effects on anxiety and stress, thereby proposing an integrated intervention model for emotional support and quality of life improvement. These findings are expected to serve as meaningful baseline evidence for establishing and expanding psychosocial interventions for children with cancer in palliative care settings.

2. Purpose

The purpose of this study is to develop an art therapy workbook for children with cancer receiving palliative care and evaluate its effects on participants’ anxiety and stress after its application. The specific aims of this study are as follows:

First, to develop an art therapy workbook that considers the participants’ characteristics.

Second, to identify changes in participants’ anxiety and stress levels following application of the developed art therapy workbook.

METHODS

1. Study design

This study employed a one-group pretest–posttest quasi-experimental design to develop and apply an art therapy workbook for children with cancer receiving palliative care and evaluate its effects on anxiety and stress.

2. Participants

The required sample size was estimated using a rule of thumb based on the sample-size rationales reported in previous one-group pretest–posttest and pilot studies [18]. Assuming a large effect size and power of 80%, 20 participants were required; accordingly, 10 children (aged 7~12 years) and 10 adolescents (aged 13~18 years) were recruited.

This study was conducted on children with cancer receiving palliative care at S Hospital, which is affiliated with C University. The inclusion criteria were as follows:

1) Children with cancer receiving palliative care at S Hospital, affiliated with C University, including children aged 7~12 years and adolescents aged 13~18 years

2) Children who provided consent to participate in the study and to the use of their art therapy workbook activity materials for research purposes

3) Children whose parents provided consent to their child’s participation in the study and to the use of the art therapy workbook activity materials for research purposes

4) Children who completed the pretest and posttest and participated in at least five of the six art therapy workbook sessions

Children who did not consent to participate, those with communication impairments, or those who were expected to be discharged within three weeks of enrollment were excluded. In addition, participants who provided consent but did not meet the workbook completion criteria were considered dropouts and excluded from data collection and analysis.

During the program period, 10 children and 10 adolescents were enrolled. However, three children and three adolescents who did not complete the pretest and posttest or failed to meet the workbook completion criteria were excluded as dropouts, and only data from 14 participants (seven in each group) were analyzed.

3. Data collection methods

1) Development of the art therapy workbook

The art therapy workbook used in this study, titled “Wise Hospital Life,” is an art therapy program for children diagnosed with cancer, with separate versions for children and for adolescents to accommodate developmental differences. The content for the art therapy workbook for children with cancer receiving palliative care was developed by a team of four art therapy specialists, each with more than 10 years of experience providing art therapy and psychological counseling to children with cancer, their families, and bereaved families. Drawing on their extensive experience in art activities and psychological counseling with children with cancer at a university hospital, the Korea Childhood Leukemia Foundation, and a palliative care team, the team focused on activities that children and adolescents could perform simply and independently at the bedside.

(1) Principles underlying the development of the art therapy workbook

The workbook was developed based on the use of art therapy as an intervention, recognizing that the disease, medical procedures, and hospitalization experienced by children with cancer provoke extreme stress and hinder their development and emotional growth. An unexpected diagnosis of a serious illness, followed immediately by medical procedures and hospitalization, can constitute a crisis for the child according to his or her developmental stage and become a source of severe stress [7,19,20]. Additionally, children may experience emotional difficulties arising from the stress of medical procedures and frequent hospital admissions and discharges, with this stress becoming more severe when the disease recurs [21]. Therefore, it was deemed necessary for children to perceive the illness not as an object of fear and dread but as something to be actively dealt with. Consequently, the workbook was developed so that they could correctly understand their current illness and actively cope with the illness-related stress. Talking freely about the illness and its symptoms was considered the first step toward developing such awareness. The illness and its treatment process influence the child’s physical and emotional perceptions and produce different symptoms according to the developmental stage [19]; art therapy enables children to visualize and verbalize these symptoms, thereby facilitating the discovery of unconscious symbols [22]. Discovering these unconscious symbols provides children with an inner purification process that expands their consciousness, allowing them to safely face and accept their lived experiences [22,23].

Accordingly, the art therapy workbook activities were intended to encourage children to actively explore how illness had altered their lives by confronting emotions felt upon encountering the disease, accepting the reality altered by it, and discovering themselves as they adapt to it.

(2) Composition of the art therapy workbook

Considering developmental differences across age groups, separate workbooks were developed for children and adolescents, with distinct age-appropriate approaches to exploring illness. The workbook for children featured a warmer and more familiar cover design than that offor the adolescent version to stimulate their curiosity. In both versions, pretests and posttests were conducted using the Person-in-the-Rain (PITR) drawing test [24]. Decisions regarding the number and content of sessions were finalized through repeated discussions among a research team comprising a pediatric palliative care advanced practice nurse, four art therapy specialists, and a nursing professor. Given that children in hospital settings are usually admitted for short periods, ranging from a few days to two weeks, the program was designed to ensure that participants could complete the program without dropping out during brief hospital stays while maintaining a therapeutic arc of introduction, exploration, expression, and closure, within a limited number of sessions. This approach reflected the experience of the art therapy team and the perspectives of art therapists reported in a previous study [25]. Following these discussions, the final art therapy workbook comprised six sessions structured along the sequence of “introduction—expression of immediate emotions (fear, anger, desires, and so forth)—discovery of the healthy inner self.” Sessions 1 and 4 were differentiated by developmental stage. In Session 1, children traced various forms of lines (“Doodle with lines”) as an accessible route to the scribble drawing technique, allowing emotions expressed in the lines and the shapes embedded within them to reveal the children’s inner symbols. In contrast, adolescents expressed their worries through drawings and selected colors appropriate to their emotions (“Worry mandala”). Session 4 was based on the concept of children attributing the meaning of a “worry doll” to a small doll. Children were provided with an outline of a human figure to create a secret friend, whereas adolescents used their imagination to create and depict a sub-character. Sessions 2, 3, 5, and 6 were common to both versions and focused on recognizing the realities of hospital life, relieving stress arising from dietary restrictions during chemotherapy, expressing the child’s own perception of the world, and preparing the mind to live a life altered by the illness. The themes, goals, and contents of each session are listed in Table 1. The art therapy workbook was bound as a single picture book, and all materials used for the workbook and its activities were non-toxic and safe for human use, enabling children with cancer, who are vulnerable to infection, to use them safely.

Table 1.

Program Contents of Art Therapy.

Session	For children				For adolescents			Duration
	Themes	Goals and contents	Workbook design		Themes	Goals and contents	Workbook design
Pretest	Orientation	Explain the research purpose and objectives; introduce the program Obtain informed consent Complete NRS (anxiety and stress) and PITR			Orientation	Explain the research purpose and objectives; introduce the program Obtain informed consent Complete NRS (anxiety and stress) and PITR		40 min
1	Doodle with lines	Drawing warm-up: lines, circles, and doodling Freely explore the emotions expressed in the drawing			Worry mandala	Recognize reality and cope with anxiety during treatment Express worries through drawings Choose colors that represent their emotions and paint them		40 min
2	My hospital life	Recognize reality Assess acceptance of reality Draw a picture of what parents, doctors, nurses, and the participants are doing in the hospital			My hospital life	Recognize reality Assess acceptance of reality Draw a picture of what parents, doctors, nurses, and the participants are doing in the hospital		40 min
3	If you go on a picnic	Express and relieve stress related to dietary restrictions Engage in enjoyable activities Make a picnic lunchbox Fill the lunchbox with food stickers			If you go on a picnic	Express and relieve stress related to dietary restrictions Engage in enjoyable activities Make a picnic lunchbox Fill the lunchbox with food stickers		40 min
4	My secret friend	Relieve the burden of illness Complete a human body pattern Fill out your profile card Create an imaginary companion with whom to share worries and stories amidst restricted social interactions and the isolated hospital environment			My sub-character	Relieve the burden of illness Express another imaginary self (sub-character) Use imagination to create a sub-character and write a profile Record activities they would like to do with the sub-character or stories they would like to share		40 min
5	My own world	Understand emotions associated with living with illness Imagine and draw the world they would like to see if they opened the window Express the scenery they would most like to see			My own world	Understand emotions associated with living with illness Imagine and draw the world they would like to see if they opened the window Express the scenery they would most like to see		40 min
6	My wishes	Accept life with illness Discover self and embrace the future Write wishes on flower petals Draw their wish on a flower petal as if they had a magic wand Make a wish			My wishes	Accept life with illness Discover self and embrace the future Write wishes on a tree Decorate the wishing tree with ribbons of wishes Make a wish		40 min
Posttest	Evaluation	Evaluation and counseling Complete NRS (anxiety and stress) and PITR			Evaluation	Evaluation and counseling Complete NRS (anxiety and stress) and PITR		40 min

NRS: Numeric Rating Scale, PITR: Person-in-the-Rain.

4. Instruments

This study developed and provided an art therapy workbook for children with cancer receiving palliative care and evaluated its effects on anxiety and stress. Anxiety and stress were measured twice, before and after the workbook activities. The variables measured and the specific methods used were as follows:

1) Measurement of anxiety: Numeric Rating Scale (NRS)

Participants’ anxiety was assessed using the NRS. Scores range from “not anxious at all” (0 points) to “extremely anxious” (10 points), with higher scores indicating greater anxiety.

(1) Numeric Rating Scale (NRS) for stress

Stress was assessed using the NRS, with scores ranging from “no stress at all” (0 points) to “extremely severe stress” (10 points), with higher scores indicating higher levels of stress.

(2) Person-in-the-Rain (PITR) drawing test

The PITR drawing test measures stress and coping ability by examining the level of stress experienced by the person who produces the drawing and the manner in which he or she copes with stress [24]. The person depicted in the drawing represents the self, whereas the rain signifies the difficulties or stressful situations imposed from the outside. The test enables indirect identification of both stress experienced by the participant and the resources available for coping with it. Drawings are evaluated using a standardized scoring system that measures the level of stress (16 items), the resources available for coping with stress (16 items). Coping ability is calculated by subtracting the stress score from the stress-resource score; a positive (+) score indicates that resources for coping with stress have been secured, whereas a negative (-) score indicates the presence of stress. Higher coping-ability scores indicate fewer expressions of stress and more adequate coping resources. However, the numerical score is less important than the meaning conveyed through the drawing, because counseling-based examination of the psychological state that a drawing represents can reveal aspects that cannot be fully expressed in numbers. Because this test permits a freer expression of psychological states than questionnaire-based instruments for measuring stress, it is useful for assessing the stress status and use of resources among children and adolescents who are not yet skilled at understanding and responding to the survey items. In this study, the four art therapists involved in the research independently scored the participants’ PITR drawings using the evaluation criteria and reached consensus on the final scores during a seminar.

5. Data collection

The data were collected between August 2024 and January 2025. After the purpose and methods of the study were explained to the palliative care team at S Hospital, affiliated with C University, and permission to proceed was obtained, the participants were recruited. The researchers visited participants’ hospital rooms, explained the purpose of the study to the children and their caregivers, and provided the art therapy workbook and instructions for its use to 10 children (aged 7~12 years) and 10 adolescents (aged 13~18 years) who consented to participate. Art therapy was exclusively delivered by one of the researchers, an art psychotherapist with more than 20 years of experience providing art therapy to children and adolescents with cancer and their families. Participants underwent a pretest comprising the PITR drawing test and NRS assessments of anxiety and stress, after which they proceeded through Sessions 1~6 of the art therapy workbook; a posttest was conducted after completion of Session 6. Participants carried out art activities sequentially at times convenient to them, while researchers visited them twice a week to encourage participation and answer questions. Only data from participants who participated in at least five of the six sessions were included in the analysis. Because the drawings produced in the workbook reflect the participants’ thoughts and may, therefore, be interpreted differently or distorted depending on the viewer, the researcher conducted an individual counseling session centered on the completed drawings after each participant completed the workbook to clarify the meanings expressed in the products of the art activities.

6. Data analysis

Differences in participants’ anxiety and stress levels and PITR scores before and after application of the art therapy workbook were analyzed using IBM SPSS 26.0. Given the small sample size, the non-parametric Wilcoxon signed-rank test was used. In addition, the skewness and kurtosis of the data were examined, which confirmed that the assumption of normality was not adequately met. Therefore, the Wilcoxon signed-rank test was additionally conducted separately for the two age groups, children (n=7) and adolescents (n=7), to analyze changes within each subgroup. The interpretation of the PITR drawing test results was carried out directly by a researcher who was an art therapy specialist. Following completion of the workbook activities, the researcher conducted additional counseling sessions with the participants to analyze the meanings conveyed in the drawings, and the information obtained was incorporated into the analysis and interpretation.

7. Ethical considerations

This study was approved by the Institutional Review Board of S Hospital, affiliated with C University (IRB No.: KC24FISE0494). For recruitment, children with cancer receiving palliative care who expressed interest in the study, together with their parents, were informed of the study purpose, procedures, and anticipated benefits. Additionally, they were informed that they could refuse or discontinue participation at any time if they so wished; written consent was obtained from all participants and their parents who agreed to participate. Participants were informed that the collected data would not be disclosed or used for purposes other than research, and that their personal information would be kept confidential.

RESULTS

1. General characteristics of the participants

The median age was 9 years among the children (n=7) and 16 years among the adolescents (n=7); nine participants were boys and five were girls. The diagnoses included acute lymphoblastic leukemia in eight participants, acute myeloid leukemia in four, and other conditions in two. Time since diagnosis ranged from 1 month to 3 years and 9 months.

2. Differences in anxiety and stress before and after application of the art therapy workbook

Following application of the art therapy workbook, NRS-measured anxiety and stress scores decreased significantly, whereas PITR scores showed no significant change (Tables 2 and 3).

Table 2.

General Characteristics and the Level of Anxiety, Stress, and PITR.

Group	Age (yr)	Gender	Diagnosis	Anxiety (NRS)			Stress (NRS)			PITR
				pre	post		pre	post		pre	post
Children (n=7)	9	M	AML	4	2		4	3		-8	-3
	9	M	AML	4	4		6	6		-1	-8
	9	M	ALL	5	4		5	4		-8	0
	9	M	ALL	6	5		6	6		-8	-5
	11	F	ALL	8	6		9	5		7	4
	12	M	Lymphoma	5	2		5	2		7	4
	12	F	ALL	6	3		6	3		-23	-6
Adolescents (n=7)	13	M	ALL	9	4		9	3		1	-5
	13	F	MDS	8	6		8	3		-4	6
	16	M	AML	6	3		7	3		-3	1
	16	F	ALL	5	3		6	4		5	6
	18	M	ALL	10	4		7	4		-10	-6
	18	F	ALL	6	5		6	5		6	-3
	18	M	AML	5	4		6	5		-9	Missing

NRS: Numeric Rating Scale, PITR: Person-in-the-Rain, AML: Acute Myeloid Leukemia, ALL: Acute Lymphoblastic Leukemia, MDS: Myelodysplastic Syndromes.

Table 3.

Differences in Anxiety, Stress, and PITR by Group After Application of an Art Therapy Workbook.

Group	N	Characteristics	Pre-test (M±SD)	Post-test (M±SD)	Z	P
Total	14	Anxiety (NRS)	6.36±1.82	3.79±1.37	-3.20	<0.01
	14	Stress (NRS)	6.50±1.45	3.86±1.23	-3.07	<0.01
	13	PITR*	-3.00±8.61	-1.15±4.93	-0.81	0.42
Children	7	Anxiety (NRS)	5.43±1.40	3.71±1.50	-2.20	0.03
	7	Stress (NRS)	5.86±1.57	4.14±1.57	-2.02	0.04
	7	PITR	-4.86±10.45	-2.00±4.80	-0.85	0.47
Adolescents	7	Anxiety (NRS)	7.29±1.80	3.86±1.35	-2.37	0.02
	7	Stress (NRS)	7.14±1.07	3.57±0.79	-2.37	0.02
	6	PITR*	-0.83±6.05	-0.17±5.34	-0.31	0.84

NRS: Numeric Rating Scale, PITR: Person-in-the-Rain.

*The PITR test for the Adolescents group was analyzed excluding one missing case.

Anxiety scores measured with the NRS ranged from 4 to 10 at pretest and from 2 to 6 at posttest. Of the 14 participants, 1 showed no change between the pretest and posttest anxiety scores, whereas 13 had lower posttest than pretest scores. Stress scores ranged from 4 to 9 at pretest and from 3 to 6 at posttest, with 12 participants showing lower posttest than pretest stress scores (Table 2). The Wilcoxon signed-rank test indicated statistically significant differences before and after the application of the art therapy workbook in both anxiety (Z=-3.20, P<0.01) and stress scores (Z=-3.07, P<0.01). Among children, both anxiety (Z=-2.20, P=0.03) and stress (Z=-2.02, P=0.04) decreased significantly; among adolescents, anxiety (Z=-2.37, P=0.02) and stress (Z=-2.37, P=0.02) also decreased significantly (Table 3).

The PITR scores increased from pretest to posttest in four children and four adolescents (Table 2); however, the overall pretest-to-posttest difference was not statistically significant (Z=-0.81, P=0.42) (Table 3). The PITR drawing scores ranged from -23 to 7 at pretest and from -8 to 6 at posttest. Five participants obtained negative scores on both the pretest and the posttest, reflecting a low ability to cope with stress. In addition, two participants showed positive (+) scores at pretest but negative (-) scores at posttest (Table 2). Examples of the participants’ PITR drawing test results are shown in Figure 1.

Figure 1.

Person-in-the-Rain test.

PITR: Person-in-the-Rain.

3. Results of the art therapy workbook activities

Examples of the participants’ art therapy workbook activities are shown in Figure 2. In Session 1 (“Doodle with lines” and “Worry mandala”), participants were guided to represent their psychological states through drawings. The children first warmed up through line drawing activities and then drew pictures of their own choosing, whereas the adolescents expressed the worries they felt during treatment and selected achromatic colors to represent negative emotions. In Session 2 (“My hospital life”), the participants depicted themselves in difficult treatment situations, such as injections, procedures, and treatments, represented healthcare providers’ actions in each scene, and depicted themselves as helpless beings. In Session 3 (“If you go on a picnic”), participants imagined going on a picnic amid the many restrictions of hospital life and completed a lunchbox they wished to take with them. Some participants drew foods not included among the prepared food stickers and expressed, through words or writing, the people they wished to accompany them and the places they wished to visit. In Session 4 (“My secret friend” and “My sub-character”), the participants created companions with superpowers who would listen to their stories, fulfill their wishes, and never fall ill. In Session 5 (“My own world”), most participants drew beautiful natural landscapes containing flowers, trees, birds, clouds, and rainbows, and reported that they had drawn places they wished to visit after being discharged from the hospital. In Session 6 (“My wishes”), participants wrote their wishes on magic flower petals or decorated a wishing tree with ribbons, and reported that health and the happiness of their families were the wishes they most wanted to see fulfilled.

Figure 2.

Contents and artwork of the art therapy workbook.

DISCUSSION

This study developed an art therapy workbook for children with cancer receiving palliative care and examined its effects on anxiety and stress following its application. The final analysis included data from 14 participants (seven children and seven adolescents) who met the analysis criteria.

The art therapy workbook comprised six sessions, with its structure determined by the length of hospital stay for children with cancer receiving inpatient palliative care. Following discussions between the palliative care advanced practice nurse and the art therapy team, a six-session format was considered appropriate for delivering art therapy and evaluating its effects, given that the participants in this study were hospitalized for approximately two weeks. This decision was further supported by a previous study based on interviews with art therapists [25], which emphasized the effectiveness of a short-term art therapy model adapted to the fluid hospital environment for hospitalized children. The content was likewise structured to follow a sequence of rapport building, expression of immediate “here and now” emotions, and discovery of the “healthy part and hope” within the child. The art therapy workbook offered several advantages, including flexible use across time and place, and the opportunity for participants to choose whether to take part in an activity according to their condition on a given day, thereby fostering a sense of choice and initiative. In addition, the workbook, which was produced in the form of a picture book, required no special art materials, and participants reported that emotions could be adequately expressed using only colored pencils.

Most participants had lower NRS scores for anxiety and stress after completing the six-session art therapy workbook. Regarding PITR results, apart from two participants whose scores changed from positive to negative, all participants demonstrated a shift toward more positive posttest scores, indicating alleviated stress; however, negative scores at both pretest and posttest indicated that stress persisted. A previous study of mothers caring for children with cancer [26] found that participants’ psychological state was influenced not by whether art therapy had been applied, but by the child’s health status and treatment circumstances. In this study, administering the PITR test alongside the NRS to measure stress facilitated a more comprehensive understanding of the complex aspects of the participants’ psychological states that were otherwise difficult to identify. Because participants’ drawings reflected fluctuations in their stress levels, mood, and health status at the time of assessment, consistent with their constantly and rapidly changing physical and psychological conditions, caution is required in interpreting positive changes based solely on numerical NRS scores. Anxiety and stress in children with cancer receiving palliative care are not simple problems that can be adequately expressed in a single word [27,28]. Rather, their assessment must incorporate a variety of factors, including disease severity, the level and stage of treatment, the individual’s negative emotions, limited support resources, and the stress arising from the environment surrounding the participant [2,29]. Therefore, rather than evaluating anxiety and stress in children with cancer solely through questionnaires or instruments, it is essential to understand the participants’ emotional and psychological states in the context of related factors [9,30].

The art therapy workbook used in this study was developed in separate versions for children and adolescents, considering their developmental stages. The children reduced tension and revealed their emotions naturally through relatively simple, play-based activities such as Session 1, “Doodle with lines.” This approach is consistent with the view that for children in a period dominated by concrete thinking, play and visual expression provide developmentally appropriate channels for safely externalizing emotions [4,19,20]. In Session 4, “My secret friend,” children similarly used the human-figure outline to give form to a dependable being, thereby supplementing emotional support constrained by hospitalization. By contrast, the adolescents chose achromatic colors in Session 1, “Worry mandala,” to express anxiety about an uncertain future involving death or disease progression, reflecting the cognitive maturity of adolescence that enables them to perceive the meaning and prognosis of illness more clearly. Moreover, in Session 4, the adolescents created their own sub-characters rather than using the provided outline, a response that corresponds to the developmental task of adolescence—exploring alternative selves and forming a self-identity. Through these activities, the adolescents attempted to integrate their illness experiences into their own identity, consistent with previous research indicating that adolescents receiving palliative care have psychosocial needs distinct from those of children and therefore require tailored attention [10].

During the six sessions of the art therapy workbook, participants sometimes spontaneously acknowledged that they had discovered the word “hope.” Through this process, they discovered and expressed positive feelings that had been obscured by the difficult and distressing negative emotions they experienced. By enabling participants to recognize and represent, as they drew for themselves, emotions that had previously remained unexpressed, the art therapy workbook helped them disclose their feelings to some degree and experience catharsis even without concurrent counseling from a psychological specialist. The art therapy workbook may therefore be readily applicable not only to children with cancer but also to children experiencing other illnesses, and may be used in both clinical and home settings. The workbook developed in this study offers a meaningful intervention for children with cancer receiving palliative care: It can be used according to their health status, without constraints of time and place, to express their inner emotions and foster self-understanding, thereby helping them live well through the terminal stage.

This study had several limitations. First, because the study focused on developing and applying an art therapy workbook, and included a small number of participants (seven children and seven adolescents), the findings provided limited evidence regarding the effects of the intervention. Second, because participants completed the activities irregularly in response to changes in their disease status, the intervention program could not be delivered intensively. Finally, although various standardized instruments are available for assessing anxiety and stress, the NRS was used to reduce the response burden on the children and facilitate repeated assessment. While the NRS offers ease of application, it does not sufficiently reflect measurement sensitivity or multidimensional assessment. Accordingly, it is not appropriate to conclude in dichotomous terms that the art therapy workbook used in this study is either “effective” or “not effective.”

SUPPLEMENTARY MATERIALS

Supplementary materials can be found via https://doi.org/10.14475/jhpc.2026.29.3.88.