Children and cancer

Childhood cancer is common throughout the world. About one in every 600 children develops cancer before the age of fifteen, yet relatively little is known about its causes (Stiller, cited in Plowman, 1992). Cancer is the most common cause of death from disease among children in New Zealand. From the moment children are diagnosed their lives change radically. Leukaemia is the most common type of childhood cancer, representing about one third of all cancers in children under fifteen years old. Children who have cancer may face specific emotional challenges and traumatising events such as the initial diagnosis, their projection of what that means to them and the loneliness and seclusion of being in isolation for protection from infection. They may have fear about their future, confusion about procedures and raised anxiety from the effects of drug therapy (New Zealand Child Cancer Foundation, 2004). Anxiety, depression and instability of self-esteem and body image are widely reported to occur in cancer patients. Anxiety may be further raised due to drug induced confusion and to the continued effects that drug therapy may have on them (e.g. hair loss, painful sores and ulcers, physical impairments and general changes) (Councill, 1993).

Cancer specific stress in children

Santrock (1999, p.269) described stress as “the response of individuals to the circumstances and events (called “stressors”) that threaten them and tax their coping abilities”. Cognitive appraisal is Lazarus’s term for people’s interpretations of events in their lives as harmful, threatening or challenging depending on whether they feel they have the resources to effectively cope with events (cited in Santrock, 1999). Therefore, a patient’s experience of and approach to illness, will largely depend on their already established coping abilities.

Golden (1983; cited in Rode, 1995) identified major sources of stress in children who are ill and hospitalised: separation from the parents or caregivers, relocation to a new environment, the loss of independence and control which accompanies illness and hospitalisation and fears and anxieties about medical procedures which may cause harm or pain.

The most successful means of helping young patients who are in such psychological distress, is by addressing the “negative disorganised feelings and images of the unconscious fight” with the illness, such as separation, loss of independence and control (Prager, 1993). By encouraging children and adolescents to express difficult feelings through art, they may then communicate, recognise and potentially organise them (Councill, 1993; Rode, 1995; Russell, 1995). Expression through art allows the young patient to “accept raw, primary process material and to help externalize and organize it through artistic expression” (Prager, 1993, p.2). Children learn and increase their sense of the world by participating actively and playing out their investigations into reality (Sturges-Nadler 1983). Brunner (1970) explains that by using metaphor to make connections with confrontational issues, the patient may solve problems in a less stressful manner “Metaphor joins dissimilar experiences by finding the image or symbol that unites them at some deeper emotional level of meaning. Its effect depends on its capacity for getting past the literal mode of connecting” (p.63 cited in Sturges-Nadler, 1983).

Sturges-Nadler describes how anxieties of hospitalised children and adolescents that come from fantasy are often much greater than those arising from reality. She makes the point that by making these fantasies tangible, the patient’s medical treatment and emotional care are made easier. She continues that children must be allowed to develop images of fantasy and reality, through safe, structured, supervised art therapy experience to bring out all the elements of their traumatic experience. The child should eventually arrive at a finished externalised form of their experiences through exploration and the introduction of image or object, which can then act as an incentive for dialogue.

Dreifuss (cited in Jeppson, 1982) tells us that the fears and fantasies connected to cancer are unique and are related to particular images. She tells us that, independent of diagnosis, prognosis, course of illness and related therapy, many patients feel defeated by a destructive process for which they have no defence and which appears to destroy them from within. Councill (1993) shows that through rehearsal of troubling events and working out concepts of the self through art expression, children and adolescents can master their feelings and fantasies about their illness and treatment.

Rollins (cited in Councill, 1993) tells us that, while patients come to hospitals primarily for medical treatment, art therapy may be seen as a uniquely humanising influence in the midst of an experience that threatens the child’s sense of self and trust in the world. Art making in hospital environments can bring familiar and mostly enjoyable experiences. The art therapist holds no threat of unwelcome interventions and even offers the choice to participate in the sessions, thereby gaining trust and developing a unique relationship with patients. Councill (1993) proposes that the art therapy session can be one of the few avenues of communication with hospital staff left open when children and young adolescents are overwhelmed by their hospitalised situation. It creates a bridge of communication between patients and medical staff. In this way, art therapy may provide medical staff with new insights into the client’s perception. It may also offer insight to staff as to the degree of anxiety in the patient and opportunities to correct misconceptions if they have arisen. Young patients may also arrive at a level of acceptance of their situation that may not have been accessible in a normal working relationship of patient/ medical staff.

Art therapy in the field of oncology

Paediatric cancer patients may benefit from early psychosocial intervention, including art therapy, based on the principle that the initial diagnosis of cancer and following treatments represent stressors that warrant such interventions (Jeppson, 1983). Art therapy can coexist alongside several other psychosocial programmes to support patients during their hospital experience (Rode, 1995). Tracy Councill (1999) who works as an art therapist and paediatric oncology team member outlines the following as specific goals of art therapy with paediatric cancer patients: inviting emotional expression, encouraging symbolic representation of physical states, developing personal imagery, expressing expectations of treatment outcomes, facilitating coping through diversion and finally building a sense of competence and control.

Robert Rice (cited in Jeppson, 1983) provided art therapy activities for cancer patients and their families to reinforce their self-belief and re-establish their self-esteem. Art therapy also offers a bridge between present understanding and future possibilities of insight (Jeppson, 1983). By offering activities to cancer patients through an art therapy programme in hospital waiting rooms, Jeppson outlined three ways with which the patients used the art, therapy experiences: some sought to stay busy, because the waiting increased their anxiety (diversion), some sought to relieve their pain (distraction) and some discovered new skills, which could be further pursued at home (resilience) (Jeppson 1983).

Purpose of research

The rationale of the research reported here, was to implement a visual arts programme with children and adolescents in a hospital setting so that the researcher could:

1. Measure the reduction of levels of anxiety and discomfort in young oncology patients using art therapy during their treatment while either at hospital or as outpatients

2. Explore their feelings about their illness and circumstances during this time.

3. Examine the benefits of this Visual Art Programme for both the patients and medical staff.

The researcher’s main responsibility during these sessions was to facilitate the art programme from a humanistic, client-centred perspectives encouraging spontaneous art expression and offering technical art guidance where required by participants. It was also to provide pre- and post-test questionnaires and to observe the responses of the participants to their art process and art product. The close proximity of the researcher to participants during individual sessions allowed for direct study. However, this disclosed observational role and the requirement of filling out a questionnaire pre- and post-session may have had an I effect on some participants’ initial approaches to art making, for example, this may have inhibited their natural creative expression.

Participants

Patients were primarily identified by their medical diagnosis of cancer, their ages and their attendance at Christchurch Hospital. The overall recruitment of participants was at the discretion of the medical staff, with health state as the main criteria. Oncology patients were chosen as a population to research as the length, frequency and discomfort levels were all higher than with other child patient populations. There were no ethnic or cultural restrictions on the population of participants, nor was their socioeconomic status taken into account. All participants available at the time of the study were Pakeha or non-Māori descent.

As the participants had been diagnosed with varying forms of cancer prior to their hospital stay they were all receiving chemotherapy. They were all at different stages of their treatments. Participants were chosen between the ages of eight and nineteen years of age because of their level of cognitive development and coordination skills. Amy was a sixteen-year-old female with newly diagnosed bone cancer from out of the region.

Amy was very upset at her changing body image as she had a goal of being a model. Her social lite was more important to her than her medical treatment.

Missy was a ten-year-old female diagnosed with leukaemia; she was also from out of the region. Missy was initially a very shy girl who did not readily express emotion, was physically tense and often held her breath, She liked privacy and hated being the centre of attention which her medical condition often required.

Karen was nineteen and in the middle of her treatment for bone cancer; her mother remained with her as a companion as they lived out of the region. Prior to her diagnosis Karen had been a successful athlete. The bone cancer had seriously disrupted this life path. While she never discussed her illness, she never appeared daunted by any of her circumstances.

Gwen was a sixteen-year-old female diagnosed with leukaemia; she was nearing the end of her treatment. She went home before the last session. Her mother cared for her whilst living at Ronald McDonald house as they lived out of the region. Her mother’s sight had begun to fail and so the pair was reliant on each other.

For the purposes of this article, I will highlight one case study.

John was a fourteen-year-old male diagnosed with leukaemia. He was nearing the end of his chemotherapy treatments and was in air-locked isolation for the duration of his five sessions in the bone marrow unit. He was from Christchurch and had both parents caring for him. John was released before his final session. He was an intelligent jovial boy with a very sharp wit, had a passion for motorbikes and was a keen motorcyclist before his diagnosis. John struggled with his confinement in isolation. He was always interested in his temperature, blood count and neutrophil levels (immune system) as they indicated his physical state and therefore his potential release from hospital. John was also aware of bodily changes such as heart palpitations, anaphylactic shock symptoms and numbness as these had been the early warning signs for some of his health crises in the past.

Research methods

As many variables were involved in properly exploring the above issues raised for this enquiry, three methods of research were used:

1. The quantitative measurement of anxiety with the pre- and post-STAIC questionnaires or the “State-Trait Anxiety Inventory for Children”.

2. Qualitative journaling for case studies by the researcher after each session in the role of art therapist as an observer.

3. Collecting images of art works produced by participants was also important to visually support the findings.

Quantitative research

The quantitative element of this research was the STAIC or the ‘State-Trait Anxiety Inventory for Children”. The STAIC is useful in situations where a swift, routine assessment of a child or adolescent’s problems is required with minimum impact. It assesses the major dimensions of anxiety in young persons from the ages of 8+ years and is administered by self-report. This measure is currently used by hospital staff and so provided a recognised and credible measure in this setting.

The STAIC measure consists of two scales. The A-State (C1) scale consists of twenty statements that ask children how they feel at a particular moment in time. It measures transitory anxiety states, that is, subjective, consciously perceived feelings of apprehension, tension and worry that vary in intensity and fluctuate over time. The A-Trait (C2) scale consists of twenty statements that ask children how they generally feel. It measures relatively stable individual differences in anxiety proneness, that is, differences between children in the tendency to experience anxiety states (Platzek, 1973).

The STAIC questionnaire was administered at the beginning and end of each session. Prior to the first session, the participant was asked to fill out STAIC questionnaires; C1 and C2. At the end of the session, the participant was asked to complete only C1. For subsequent sessions, the participant was only asked to fill out the questionnaire C1 before and after each session. This was normally completed in three to five minutes. Each questionnaire was then added to score between 20 (lowest anxiety level) and 60 (highest anxiety level).The results were then transferred to a profile form which was kept in a secure file along with case study notes pertaining to the individual participant.

Calculating results

A dependant sample “t-Test” was used to quantify the results as the pre and post scores were from the same person and therefore related to each other. This method was used to examine the differences between one group of participants, on one or more variables and to compare if there was a significant difference between the means of the variables studied. Using a quantitative method allowed a degree of objectivity and a means of substantiating any qualitative findings (Gantt & Goodman, 1997). It is the duty of artists working within therapeutic situations to articulate as fluently as possible in order to communicate with as well as understand the medical/ helping professions (Moon, 1997; Rode 1995).

Quantitative results

Data was collected from the participants through 28 sessions over a six-month period. Three participants attended all six sessions. The remaining two were discharged from the hospital after the fifth session as their treatment had ended.