The Effectiveness of Playing Therapy: Painting and Colouring on

Anxiety Levels Preschool Children before Chemotherapy Procedures

in Women and Children Hospital of Harapan Kita Jakarta

Widia Sari

, Ety Nurhayati

, Suhendar Sulaeman

and Nyimas Heny Purwanti

Nursing Departement, Esa Unggul University, Jakarta, Indonesia

Department of Nursing, Muhammadiyah Jakarta University, Jakarta, Indonesia

Keywords: painting, colouring, anxiety, preschoolers, chemotherapy.

Abstract: Cancer and its treatment will cause anxiety and various effects not only physically but also psychologically.

One of the things that matter to reduce anxiety in children is playing therapy: painting and coloring. The

purpose of this study is to determine the effectiveness of painting and coloring in reducing the anxiety level

of preschool children before undergoing chemotherapy at RSAB Harapan Kita Jakarta. This research is an

quasi-experimental research with non-equivalent without control group research design. This study used total

sampling technique with 16 preschool age children with cancer. The data measurement tool uses a HARS

questionnaire. The results of this study showed that there was an average difference in anxiety levels of

children before and after coloring interventions before chemotherapy procedures (p-value<0,000, Δ = -15.00)

and painting and coloring interventions also showed an average difference in children’s anxiety levels before

and after intervention before undergoing chemotherapy procedures (p-value<0,000, Δ = -13.00). The giving

of coloring interventions is more recommended to be applied as one of the nursing interventions to decrease

the anxiety of preschoolers with cancer before undergoing chemotherapy procedures.

1 INTRODUCTION

Cancer is one of the chronic diseases that often occur

in children. According to the National Care Institute

(NCI) (2014), it is estimated that 1 in 285 children in

the US are diagnosed with cancer before the age of

20. Based on data from the International Agency for

Research on Cancer (IARC) 1 in 600 children in the

world have cancer under the age of 16 years,and 80%

of children diagnosed with cancer come from

developing countries (IARC, 2014).

According to the International Confederation of

Childhood Cancer Parent Organization (ICCCPO,

2014 in IARC, 2014), an estimated 100,000 children

worldwide die from cancer each year. According to

the American Cancer Society (2016), most cases of

cancer in children are leukemia that is as many as 664

cases (27.3%), malignum lymphoma 85 cases (3.5%),

retinoblastoma as many as 81 cases (3.3%),

rhabdomyosarcoma 53 cases (2.2%) and

neuroblastoma as many as 50 cases (2.1%). Based on

Indonesian Child Oncology Foundation (YOAI)

(2014) an estimated 11,000 children in Indonesia

suffer from cancer yearly,and 650 cases of cancer in

children are found in Jakarta. The most common

types of cancer in children in Indonesia are leukaemia

and retinoblastoma.

Chemotherapy is one of the most effective

treatments for cancer in children (Hockenberry &

Wilson, 2009). It is not easy for cancer patients to

decide on chemotherapy with its uncomfortable side-

effects (Bowdeen & Greenberg, 2010).

Chemotherapy will have a physical and psychological

impact on children.

The psychological impact is anxiety. The anxiety

that occurs due to the pain caused, symptoms and side

effects of pot cancer treatments (Nikkhahet al., 2014).

This anxiety will lead to delayed chemotherapy in

children, so much so that nurses should be sensitive

to appropriate intervention.

The nurse may provide nursing interventions

through atraumatic care. Atraumatic action is one

form of a nurse’s caring towards clients. The nurse's

caring process takes place through how the nurse

understands a meaningful event in a person's life that

affects feelings and emotions. This is consistent with

2820

Sari, W., Nurhayati, E., Sulaeman, S. and Heny Purwanti, N.

The Effectiveness of Playing Therapy: Painting and Colouring on Anxiety Levels Preschool Children before Chemotherapy Procedures in Women and Children Hospital of Harapan Kita

Jakarta.

DOI: 10.5220/0009953128202826

In Proceedings of the 1st International Conference on Recent Innovations (ICRI 2018), pages 2820-2826

ISBN: 978-989-758-458-9

 2020 by SCITEPRESS – Science and Technology Publications, Lda. All rights reser ved

the theory of caring pioneered by Kristen Swanson

(Alligood, 2014).

During the treatment, the nurse not only meets the

physical needs of the child but also meets the

psychological and social needs (Jameset al., 2013).

One of it is by playing and non-pharmacological

intervention.

One of the non-pharmacological interventions is

art therapy. Art is a fun and non-threatening activity

for children to express the feelings and creativity of

children (Rollin,2005). Through art activities, the

child will express the idea, feelings that the child can

not express verbally. Also, the art also became one of

the non-verbal communication media of children.

Some fun art activities for children are painting and

coloring. Painting is a spontaneous image that gives

children the opportunity to communicate and express

non-verbal expressions (Rollin, 2005).

Painting can be a tool for children to express

emotions, thoughts, and problems. The child will

reflect on the perceived part through the drawing

experience. A child will draw as a window to describe

the emotional state of a sick child and coping

strategies, developmental maturity as well as

cognitive children. Research conducted by Khadar et

al. (2013) shows that art therapy paints lessen

symptoms of behavioral disorders in children.

This is in line with research conducted by Koolaee

et al. (2016) which states that painting therapy affects

the decrease of aggression and anxiety in children

with cancer. Also, art therapy also has a positive

impact on clients. Research conducted by Lin et al.

(2012), during art therapy performed, 70% of clients

reported feeling more relaxed,and 53.1% of clients

feel much better physically.

In addition to painting activities, coloring also

gives a positive impact on children who experienced

hospitalization. Research conducted by Wowiling, et

al. (2014) got the result that there is the influence of

coloring therapy to play image to the level of anxiety

at preschool age children who have hospitalization

with p-value = 0.000. Through the picture coloring

activities will provide a sense of fun for children and

basically preschool children are very active and

imaginative.

Based on the above problems researchers were

interested in researching the effectiveness of play

therapy: painting and coloring to decrease children's

anxiety with cancer before undergoing

chemotherapy.

The purpose of this study was to determine the

effectiveness of play therapy: painting and colouring

towards the anxiety level of preschool children with

cancer before undergoing chemotherapy procedure at

RSAB Harapan Kita Jakarta.

2 METHOD

This research is an quasi-experimental research with

non-equivalent without a control group (non-

randomized without control group pretest-posttest)

design. The total sample in this study were 16

children divided into 8 children in the coloring group

and 8 children in the group painting and coloring.

The inclusion criteria are children aged 3-6 years,

undergoing intravenous chemotherapy procedures.

3 RESULT

3.1 Respondent Characteristic

Table 1. Distribution of frequency of respondents by gender, chemotherapy experience and parent attendance at RSAB

Harapan Kita Jakarta May-July 2017 (n=16)

Variable Frequency Percentage (%)

1. Gender

- Colouring

a. Male

b. Female

- Painting and Colouring

a. Male

b. Female

62,5

37,5

62,5

37,5

2. Chemotherapy experience

- Colouring

a. 2

b. 3

c. 4

d. 5

- Painting and colouring

12,5

37,5

50,0

The Effectiveness of Playing Therapy: Painting and Colouring on Anxiety Levels Preschool Children before Chemotherapy Procedures in

Women and Children Hospital of Harapan Kita Jakarta

2821

a. 2

b. 3

c. 4

d. 5

37,5

25,0

3. Parent’s presence

- Colouring

a. Yes

b. No

- Painting and colouring

a. Yes

b. No

100

Based on table 1 above explains the

characteristics of respondents by gender is obtained

from 16 respondents, most of the respondents are

male as many as 10 respondents (62.5%), while the

experience of chemotherapy, the majority of

respondents possess the 5th experience,i.e. 6

participants (37.5%). All respondents in this study

were accompanied by parents i.e.as many as 16

respondents (100%).

3.2 Anxiety Levels before and after

Painting and Coloring

Interventions

Table 2: Average anxiety levels before and after coloring, painting and coloring interventions at RSAB Harapan Kita

JakartaMay-July 2017 (n = 16)

Variable Mean SD Minimum-

Maximum

95% CI

Anxiety level before

a. Colouring

b. Painting and colouring

25,63

24,13

4,104

3,137

22-31

21-30

22,19-29,06

21,50-26,75

Anxiety level after

a. Colouring

b. Painting and colouring

10,63

11,13

4,470

7,240

4-14

5-25

6,89-14,36

5,07-17,18

Based on table 2 above the average level of

anxiety before given the coloring intervention was

25.63 with SD 4.104. The results of the analysis also

found that in the 95% confidence range (95% CI) it is

believed the average anxiety level before the

intervention is in the range of 22.95 to 26.80. After

the coloring intervention, an anxiety level decreased

by an average of 10.63 with SD 4.470. The analysis

results obtained within the 95% confidence range

(95% CI) is believed to average the anxiety level after

the coloring intervention is in the range of 6.89 to

14.36.

The average level of anxiety before the painting

and coloring intervention was 24.13 with SD 3.137.

The results of the analysis also found that within 95%

confidence range (95% CI) it is believed the average

anxiety level before intervention is in the range of

21.50-26.75. After the intervention of painting and

coloring, there is a decrease in the level of anxiety

with an average grade of 11.13, SD 7,240. The

analysis results also found that within 95%

confidence range (95% CI) it is believed that the

average of anxiety level after the intervention is in the

range of 21.50-26.75.

3.3 Children’s Anxiety Level before

and after Intervention Coloring,

Painting and Coloring

Table 3: The average difference in anxiety levels of preschoolers before and after coloring, painting and coloring interventions

at RSAB Harapan Kita Jakarta

Variable Mean SD

95% CI p-

Value

a. Colouring

- Anxiety level before 25,63 3,137 0,000 8

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- Anxiety level after

- Difference

10,63

15.00

7,240

11,370-

18,630

b. Painting and colouring

- Anxiety level before

- Anxiety level after

- Difference

24,13

11,13

13.00

3,137

7,240

8,531-

17,469

0,000

Based on table 3 shows that in the group of

children given the coloring intervention decreased the

level of anxiety before and after the coloring

intervention. The value of the difference between

before and after the coloring intervention is -15.00.

The result of statistical test obtained p-value = 0.000

with 95% confidence degree (11,370-18,630), it can

be concluded there is a significant difference between

child's anxiety level before and after given coloring

intervention.

The table above also shows that in the group of

children with painting and coloring interventions

decreased anxiety levels before and after the painting

and coloring interventions. The value of the

difference between before and after the intervention

of painting and coloring is -13.00. The result of

statistical test obtained p-value = 0.000 with 95%

confidence degree (8,531-17,469), it can be

concluded there is a significant difference between

child's anxiety level before and after given

intervention of painting and coloring.

3.4 Differences in the Level of Anxiety

of Respondents before and after

Intervention between Groups

Coloring, Painting and Coloring

Table 4: Differences in the level of anxiety of respondents after intervention between coloring, painting and coloring groups

at RSAB Harapan KitaMay-June 2017 (n = 16)

Variable Colouring Painting andcolouring P Value

Anxiety level

a. Before Mean ± SD

b. After Mean ± SD

25,36±4,104

10,63±4,470

24,13±3,137

11,13±7,240

0,425

0,870

Difference

Mean ± SD

-15,00±4,342

-13,00±5,345

P Value 0,000 0,000

Based on table 4 depicting the average of anxiety

level before giving coloring intervention is 25,36 ±

4,104 while mean of anxiety level before giving

painting and coloring intervention is 24,13 ± 3,137.

This shows that in both intervention groups there was

no difference in anxiety levels before the color

intervention was given, painting and coloring

interventions (p = 0, 425).

After the intervention, the average anxiety level in

the group given the intervention coloring fell with a

value of 10.63 ± 4.470, while the average level of

anxiety in the intervening group of painting and

coloring was 11.13 ± 7.240. This shows that in both

intervention groups there is no difference in anxiety

level after the color intervention, and painting and

coloring intervention (p = 0,870).

4 DISCUSSION

4.1 Gender

The average respondent's gender is male constituted

of 10 respondents. The theory indicated that there is

no relationship between the gender of the child and

the level of anxiety. According to Monks, Knoers,

and Rahayu (2006), children experiencing more

anxiety and verbal skills are girls, while aggression,

activity, dominance, impulsivity, space observation

The Effectiveness of Playing Therapy: Painting and Colouring on Anxiety Levels Preschool Children before Chemotherapy Procedures in

Women and Children Hospital of Harapan Kita Jakarta

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skills and quantitative skills are more prevalent in

males. The child's reaction to the hospital is

influenced by gender factors (Hockenberry & Wilson,

2009).

4.2 Previous Chemotherapy

Experience

In this study, the average experience of young

chemotherapy is between 4 and 5 times. Children who

have previous experience will begin to form a coping

response compared with children who have not had

experience. This is because children who have been

treated previously in the same hospital will feel more

accustomed than the first timers in care and children

will respond to the pain more positively (Hockberry

& Wilson, 2009).

Thisis seen in children who underwent 4th,and5th

chemotherapy are already in the range of moderate

anxiety. This is different in the respondents who are

undergoing 2nd chemotherapy, where the level of

anxiety of the child is still severe, but after the

coloring intervention was given 4 times the children’s

anxiety level decrease to mild anxiety and the

children have started wanting to socialize with people

around.

4.3 Parental Presence

In this study, all respondents were accompanied by

parents, especially mothers. Mother is the person

closest to the child. According to Hockeberry &

Wilson (2009), preschoolers need and want guidance

or support from their parents, so in preschoolers, the

most feared is separation from parents. During

hospitalization children will show negative reactions

such as withdrawing from the nurses, losing interest

in hobbies, not wanting to connect with peers,

moodier and tearier.

4.4 Colouring Intervention

Effectiveness towards Decreased

Child Anxiety

The average level of anxiety of the child before the

coloring intervention was moderate and after the

coloringintervention, there was a decrease in anxiety

level with the average anxiety level (no anxiety).

From the result of the test of a dependentt-test

indicate that there is a difference of anxiety level of

the child before and after giving coloring intervention

(p value = 0,000) with Δ = -15,00. The decrease in

value is due to coloring is a fun method of diversion

for children. Through coloringactivities, the child will

divert the feelings of anxiety to the colors and pour

into an object image so that the brain will divert

anxiety to the object favored by the child.

The presence of anxiety caused the brain to

stimulate the autonomic nerves resulting in the

release of epinephrine by the adrenal glands. The

presence of a pleasurable sensory stimulus causes the

release of endorphins that can inhibit anxious

stimulus so that the anxious stimulus transmitted to

the brain is reduced (Potter & Perry, 2009). The

decrease in anxious stimuli transmitted to the brain

will enhance the feeling of relaxation and comfort.

In this study, the difference value is -15.00, and

when compared with the previous research that is -

9.50. This shows that the difference in the value of the

difference is quite high in this study because of the

time of giving different interventions. In the previous

study, the intervention was administered 2 times daily

for 3 days while in this study intervention was

administered for 4 times with intervention duration

10-15 minutes before the child underwent

chemotherapy. It shows that previous research had

longer intervention time, but the difference of

difference value higher in this research because of

another factor.

One of the factors that influenced the decrease of

child's anxiety level is the presence of parents where

previous research shows that majority of children

(40%) are attended by grandparents while in this

study all children are accompanied by mothers.

Researchers Murniasih and Rahmawati (2007)

proved that higher family support would lower the

child's anxiety. The existence of a parent will provide

support to the child as well as parents' attention is still

needed during the child's care, without overriding the

needs of the child.

Another factor that affects the decrease in anxiety

in this study is the experience of previous

chemotherapy. The majority of respondents have

previous 4-5 times chemotherapy experience. In

children who already have previous experience will

establish a coping mechanism of chemotherapy

procedures undertaken by children. The same

experience will provide an understanding of the child

related to the procedure,and the child already has

either positive or negative coping of the action to be

followed.

Children who are in the midst of anxiety range,

the child will probably focus on the important thing

and put aside the other (Stuart, 2002). The results of

this study were supported by a study conducted by

Sari (2012) who stated that coloring therapy is

effective in reducing hospitalization anxiety in

children (p = 0.000). The study was conducted on 20

ICRI 2018 - International Conference Recent Innovation

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preschool children (10 control groups and 10

experimental groups).

Playing activities in children can divert the pain to

the game and relaxation through fun and games. One

suitable game given to preschoolers is coloring

(Hockeberry & Wilson, 2009; James & Aswill,

2011). In preschool children have started to like and

know the color and recognize the forms of objects

around him. Coloring is one of the games that gives

children the opportunity to be free of expression and

very therapeutic as a healing game (Paat, 2010). Also,

in preschoolers are beginning to recognize the colors.

4.5 The Effectiveness of Painting and

Coloring Interventions to Decrease

Children's Anxiety

The same is true of painting and coloring

interventions, where there is a decrease in anxiety

levels of children before and after the intervention of

painting and coloring. Provision of this intervention

is given for 10 minutes for painting and coloring

interventions. The value of the decrease in the level

of anxiety is quite high. This suggests that this

intervention is also effective in lowering child's

anxiety levels before undergoing a chemotherapy

procedure (p = 0,000) with Δ = -13.00.

The majority of children in this intervention group

prefer coloring activity and continue it until

chemotherapy is complete. Also, children aged 3-4

years like coloring because children begin to express

the world through words and pictures. Coloring is

also a medium for children to pour all imaginations

and inspiration about everything they may have

touched or experienced. It shows that coloring

activity is more favored by children than painting or

drawing activities.

This study is in line with research conducted by

Koolaeet al. (2016) which states that painting therapy

has an effect on decreasing aggression and anxiety in

children with cancer who undergo hospitalization.

Through painting therapy will make the child's

communication tool to express feelings such as fear,

improve aggression management in children as well

as emotional perception learning with coping

responses, techniques and accurate coping responses

and so forth.

The study showed a change in the value of a fairly

high difference that is -20.00, when compared with

the current study is -13.00. This difference in the

difference value is due to the fatigue factor of the

child, the age of the respondent, and the time of longer

intervention in the previous study. Duration of time

of painting in previous research is 11 times with time

2 times a week for 60 minutes and respondents in this

study are school age children. The age difference of

respondents also influences the results of the

research, in which preschoolers have an undeveloped

concept of integrity and imaginative thinking. The

concept of preschool children's thinking that affects

the ability of children in painting so that painting can

make the burden on the child.

Art therapy is an act of caring-based atraumatic

care, where through this play the nurse will improve

cooperative children and children will be more

cooperative. According to Swanson (Alligood, 2014),

the role of nurses is in the process of becoming, where

nurses provide not only medical treatment, but also

partners in helping children closer to their goals (well

being)

5 CONCLUSIONS AND

RECOMMENDATIONS

In this study that there were differences in the anxiety

level of the children before and after the coloring

intervention (p = 0,000, Δ = -15.00), painting and

coloring interventions (p = 0,000, Δ = -13.00) .

It is expected that nurses can apply to play

therapy: painting and coloring in lowering anxiety

levels of preschoolers before chemotherapy

procedures. Painting and coloring therapy can be

applied by involving the family and caring concept as

one of the atraumatic care acts. Also, for the division

of coloring or painting activities, the nurse may

consider the child's age as well as the child's interest

in the activity.

For further research, it is expected to compare this

intervention with other art therapy interventions.

ACKNOWLEDGEMENTS

The researchwas supported by Department of

Nursing, Esa Unggul University and Muhammadiyah

Jakarta University.

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