Art Therapy as a Means to Promote Stress Reduction Within Hospital and Outpatient Settings

Introduction

Pediatric physical wellness long-term atmospheric condition (LTCs) have a childhood onset, require ongoing management over a long menses of time, are often multi-system, and typically crave complex treatments with both medications and non-pharmacological interventions and services (Mokkink et al., 2008; DoH, 2012). Pediatric physical wellness LTCs require significant psychological adjustments to symptoms, medical regimes, and pain and may detrimentally touch the well-being of children relative to salubrious peers (Denny et al., 2014; Kazak et al., 2015). Children may be isolated from peers during hospital stays and miss participating in activities that contribute to quality of life, and research suggests that children with physical health LTCs are susceptible to poor mental health (Knight et al., 2015; Butler et al., 2018). The prevalence of anxiety and depression is high, and mental health and well-beingness difficulties are up to four times higher in children with physical health LTCs than in healthy peers (Hysing et al., 2007; Pinquart and Shen, 2011a,b; Ferro, 2016; Brady et al., 2017). Mental health is a key predictor of a successful clinical course; for example, baseline depression in children with rheumatic diseases was associated with higher levels of pain and disability 4 years later (Colver et al., 2018; Gray et al., 2018; Hanns et al., 2018). Good childhood mental wellness optimizes engagement in daily activities for children and families; facilitates psychosocial evolution, educational attainment, and increased life-course opportunity; and protects confronting developed mental health issues (DoH, 2011; Colver et al., 2018; Tollisen et al., 2018). Additionally, parents of children with concrete health LTCs are prone to loftier levels of stress/distress, and poor mental health of their child may be an additional burden on them and on child mental health services, which are under-resourced (Hunker et al., 2019; Rosenberg et al., 2019).

Given the potential burden of poor mental health, UK statutory guidance identifies integration of psychological back up into pediatric physical health settings as an indicator of service quality (DoH, 2011; Foster et al., 2017; Parsons et al., 2017; NHSE, 2018). However, evidence suggests that services for pediatric physical health LTCs are not routinely set up in this manner, staff time and resources are express, access to psychological support is patchy, and there are long wait lists for child and boyish mental wellness services (Wiener et al., 2015; Cruikshank et al., 2016; Davis et al., 2017). Farther, in that location are currently pregnant gaps in the evidence base for the best blazon of psychological support for children with physical wellness LTCs (Kazak et al., 2015; Knight et al., 2019).

A review evaluating psychological interventions for feet and depression in children with physical health LTCs found cognitive behavioral therapy (CBT) constructive under certain circumstances—in the short-term for balmy/moderate symptoms of low (Thabrew et al., 2018). A recent evidence synthesis evaluated a range of mental health interventions for children with physical wellness LTCs, for instance, parenting interventions, play therapy, relaxation, and emotional intelligence training (Moore et al., 2019). The review utilized meta-ethnography and identified benefits from the perspectives of patients, families, and practitioners experiencing the interventions (Moore et al., 2019; Shaw et al., 2019). The authors developed a conceptual model of constructs (e.g., empowerment) important for enabling do good from mental health interventions for children with concrete wellness LTCs (Moore et al., 2019; Shaw et al., 2019). Although some evidence of effectiveness was institute for CBT, the review as well highlighted an overall lack of quantitative evidence of the effectiveness of mental wellness interventions for children with physical health LTCs and the absence of trials conducted in the UK (Moore et al., 2019).

The aim of the current review is to inform preparation for a feasibility trial of arts-based therapies in the United kingdom National Health Service (NHS). Prissy defines arts-based therapies as psychotherapeutic techniques combined with creative activities to facilitate self-expression and recommends their provision in the direction of children with psychosis (Squeamish, 2016). Arts-based therapies involve using creative media to develop a therapeutic human relationship and can be an alternative to talking-therapies through facilitating the expression of inner states that are difficult to articulate verbally (American Art Therapy Association, 2018; Fancourt and Finn, 2019). Although the benefits of arts-based therapies in mental health settings suggest the potential for transferability to physical health services, arts-based therapies are non routinely available equally a psychological support in UK NHS concrete health settings.

Research has demonstrated some positive effects of arts-based therapies for children with physical health LTCs; however, the evidence base is pocket-sized (Cohen-Yatziv and Regev, 2019). Previous reviews relevant to this clinical grouping include two reviews of visual art therapy—one for children with a range of physical health conditions (Clapp et al., 2018) and one focusing on children with cancer (Aguilar, 2017). A systematic review of music interventions for patients with cancer was not specific to children (too included adult samples) and included studies evaluating physical health outcomes (without measurement of mental wellness outcomes) and studies evaluating music as a lark (Bradt et al., 2016). These reviews identified some pocket-size bear witness of effectiveness and some bias in the design of previous studies, and our review builds on the findings of these reviews. Our specific focus is evaluating the potential of arts-based therapies as a psychological back up for pediatric physical health settings and the identification of methodological characteristics important to consider in designing future robust research studies to contribute to building an evidence base (Cohen-Yatziv and Regev, 2019). In preparation for a feasibility trial of arts-based therapies in the U.k. NHS, we reviewed existing arts-based therapy studies in guild to help design the trial.

Aims of the Study

The aims of this systematic review are to (i) place studies evaluating the effectiveness of arts-based therapies for improving the mental health of children with physical health LTCs and (two) examine the quality of the identified studies using a formal assessment tool.

Methods

A systematic review was reported in accordance with PRISMA guidelines (Preferred Reporting Items for Systematic Reviews and Meta-analyses) (Moher et al., 2009). The protocol was published on PROSPERO (CRD registration number: 42019134461).

Inclusion Criteria

Inclusion criteria for the review and PICO components (population, intervention, comparator, and outcome) are shown in Table 1A. Inclusion criteria comprised the following: studies recruiting participants ≤eighteen years of age with pediatric physical health LTCs, defined every bit requiring ongoing direction with medication and/or other treatment interventions over a long menstruum of time (Mokkink et al., 2008; DoH, 2012); studies evaluating arts-based therapies, defined as systematic interventions implemented by a therapist with the aim of improving wellness through creative expression (for example, cartoon, play, photography, movement, music) and a therapeutic relationship promoting advice, connection, and cocky-sensation (Overnice, 2016; Hackett et al., 2017; American Art Therapy Association, 2018); additionally, but articles published after the year 2000 given rapid developments in medical settings and treatment interventions; and finally, those using a published outcome measure or structured assessment (e.g., time sampling) of mental wellness or well-being.

Table 1A. Inclusion criteria.

We conducted the searches in May 2020, and Tabular array 1B shows the information sources. We searched 4 electronic databases, conducted hand searches of two key journals, searched reference lists of relevant reviews, and conducted forward/back citations searches of articles meeting inclusion criteria. The search strategy for Medline is shown in Tabular array A1.

Table 1B. Information sources.

Report Choice

One researcher (SW) screened titles and abstracts of manufactures identified in the searches, with 10% independently screened past a 2d reviewer (AZ), and the level of agreement was 96%. Ambiguous articles were included. 98 articles were selected for full-text screening. SW carried out full-text screening, with 10% screened independently by a second reviewer (AZ). Agreement was 100%. Figure ane shows the selection process to make up one's mind the eligibility of articles for inclusion in the review.

Figure i. The PRISMA flowchart showing study selection process.

Synthesis

Due to loftier heterogeneity in study design, quantitative synthesis of information was not possible, and nosotros used a narrative synthesis of intervention effectiveness incorporating four elements—intervention conceptualization and theoretical model, tabulation of data, exploring patterns inside and across studies, and assessment of methodological quality (Popay et al., 2006).

Intervention Conceptualization and Theoretical Model

Various conceptualizations of arts-based therapies occur in the literature. In this review, we focus on arts-based therapies (visual, drama, music, and play) that include interaction, development of a therapeutic human relationship, and facilitating communication and expression (NICE, 2016; Hackett et al., 2017; American Art Therapy Association, 2018). We excluded manufactures evaluating employ of fine art media for distraction, (e.g., while having an injection), for leisure (eastward.g., listening to music), or for education. The purpose of the review was to inform the design of a randomized feasibility study of arts-based therapies in the Britain NHS. We congenital a logic model (Figure 3) showing areas nosotros felt may be important in a trial evaluating the effectiveness of arts-based therapies in pediatric physical health settings in order to guide information extraction and estimation of the review findings, and nosotros developed the model informed by the synthesis (Popay et al., 2006).

Assessment of Methodological Quality

Studies were assessed for risk of bias by SW using the Effective Public Health Do Projection (EPHPP) Quality Assessment Tool (Thomas et al., 2004). JB and AZ independently rated 20%, and agreement was 80%.

Results

Cardinal Characteristics of Studies

Three m 3 hundred and fifty articles were identified from the electronic database searches after removal of duplicates. Later championship/abstract screening, 98 articles were screened in full, and xvi manufactures were selected for inclusion in the review. Information was extracted and tabulated, with Tables 2, 3 showing report characteristics and Table 4 showing significant findings from the selected articles.

Tabular array 2. Participant, study, and intervention characteristics.

Table 3. Intervention characteristics.

Table 4. Consequence measures and results.

Eight studies were conducted in the Usa (Robb, 2000; Colwell et al., 2005, 2013; Robb et al., 2008, 2014; Beebe et al., 2010; Madden et al., 2010; Stafstrom et al., 2012), two studies were carried out in Canada (Barrera et al., 2002; MacDonald et al., 2019), one in Iraq (Abdulah and Abdulla, 2018), i in Hong Kong (Li et al., 2011), two in Iran (Khodabakhshi Koolaee et al., 2016; Tomaj et al., 2016), one in Italian republic (Giordano et al., 2020), and one study in Sweden (Uggla et al., 2018).

Quality of Studies Included in This Review

The quality of studies was appraised using structured criteria relevant for intervention effectiveness evaluations, and Figure 2 shows a summary of the quality assessments (Thomas et al., 2004). None of the studies had global ratings of high quality, 13 studies had a moderate global rating, and iii studies had weak ratings of quality. All studies had some strong components (due east.1000., describing participant randomization, use of a published effect measure); however, the global quality rating of all articles was reduced by specific pattern limitations. These included confounding variables, a narrow recruitment pool (due east.g., one inpatient unit), or a lack of blinding. The purpose of the quality appraisal was to place areas to address when designing a future trial, and potential bias in the studies reviewed is integrated into the narrative synthesis beneath and informs the model in Effigy 3.

Figure 2. Quality assessment of studies included in the review.

Figure 3. Conceptual model of characteristics of import for future enquiry trials evaluating effectiveness of arts-based therapies for mental health and well-being in pediatric concrete health settings.

Narrative Synthesis

Given that prove of the effectiveness of psychological interventions for private pediatric physical health conditions is limited (Moore et al., 2019), we present the results co-ordinate to health condition.

Arts-Based Therapies for Children With Cancer

Nine studies evaluated arts-based therapies for children with cancer. Six studies had controlled designs, three of those describing a randomization process and the remainder having cohort designs.

Children With Cancer: Arts-Based Therapies Using Visual Media

Two studies evaluated visual/craft media (Khodabakhshi Koolaee et al., 2016; Abdulah and Abdulla, 2018). In the first study, parent-reported health-related quality of life measured using a curt (ten-particular) questionnaire improved after a group intervention, though a limitation of the study was no measurement of child-reported outcomes (Abdulah and Abdulla, 2018). The authors stated that the intervention was not provided during chemotherapy, and this level of detail is important information for replication in hereafter inquiry and practise. The second study using visual media demonstrated significantly more reductions in acrimony and feet for the intervention group; a forcefulness of the study was the specific inclusion criteria (scoring higher up the mean on standardized measures of anxiety and anger) and provision of an intervention schedule (Khodabakhshi Koolaee et al., 2016). The study demonstrated statistically significant post-intervention improvements but did non report whether changes were clinically significant. Both studies recruited narrow age groups relative to other studies reviewed, and this is a strength given developmental differences, though scant detail on intervention components or where to find detailed intervention schedules was a limitation.

Children With Cancer: Arts-Based Therapies Using Music

Five studies evaluated the effectiveness of music-based therapies for children with cancer (Robb, 2000; Barrera et al., 2002; Colwell et al., 2005; Robb et al., 2008; Giordano et al., 2020). The first study provided a detailed protocol and demonstrated that music elicited significantly more engaging behavior merely no improvements on an outcome measure of affect (Robb, 2000). Music-based therapy was associated with improvements in feelings (due east.g., "It made my nausea go away") for actively involved Canadian pediatric hematology inpatients (Barrera et al., 2002). A limitation was the single-group single-site design, while a strength was the employ of kid- and parent-reported outcome measures and qualitative cess of acceptability (Barrera et al., 2002). A tertiary written report evaluating music-based therapy for children with cancer recruited from an inpatient service demonstrated significant improvements in cocky-concept, though the command grouping had fine art activities, which may have been a confounder (Colwell et al., 2005). Strengths of the written report were the use of a board-certified therapist and a estimator music programme, suggesting potential for replication. Giordano et al. (2020) evaluated pre-operative music therapy for children with leukemia and parents and plant less anxiety relative to a control grouping, and acceptability to medical staff was high. Finally Robb et al. (2008) demonstrated significantly more positive coping behaviors including grin and active engagement in music group participants compared to two control groups. Although published outcome measures were non used, the study was included in the review because outcomes were assessed using a formalized behavioral rating organization with integrated reliability checks. A strength of the study was the multi-site randomized controlled trial (RCT) pattern and the use of intervention commitment guides.

Children With Cancer: Composite Arts-Based Therapies (Music, Movement, and Art) and Virtual Reality Play Therapy

One report evaluating a composite arts-based intervention (music, movement, and art) described very specific participant inclusion criteria—those with a encephalon tumor, receiving treatment for at to the lowest degree three months, no less than weekly (Madden et al., 2010). The development of psychological interventions for children with specific physical health weather condition has been recommended (Moore et al., 2019). This is therefore a force of the study, compared to other studies reviewed recruiting children with a heterogeneity of conditions. A limitation was the wide age range of participants, while another written report forcefulness was a mixed methods design, including qualitative perspectives of service providers. Service provider perspectives were positive, while kid-reported mood and parent-reported hurting improved significantly (Madden et al., 2010).

One study evaluated virtual reality play therapy using published measures of anxiety and depression (Li et al., 2011). This is a study strength in relation to other included studies, as limited availability of reliable psychological interventions specifically for anxiety and low in children with physical health LTCs has been described (Thabrew et al., 2018). There were significantly more reductions in depression symptoms in the intervention group (Li et al., 2011).

In summary, nine studies examined the effectiveness of arts-based therapies on the mental well-being of children undergoing treatment for cancer. Overall, the studies indicated some positive impact; however, the heterogeneity of intervention content and implementation, the outcomes measured, and limitations regarding study quality (e.g., presence of confounding variables, lack of randomization, and single-site evaluations) make information technology difficult to draw firm conclusions and generalizations or to replicate studies.

Arts-Based Therapies for Children With Blood Disorders and Other Health Weather condition

Children With Claret Disorders and Other Health Atmospheric condition: Arts-Based Therapies Using Visual Media

Three studies evaluated interventions for children with asthma, epilepsy, and insulin-dependent diabetes (Beebe et al., 2010; Stafstrom et al., 2012; MacDonald et al., 2019).

The first study using visual craft media demonstrated improved mood and quality of life in children with asthma, recruited from a schoolhouse outpatient clinic (Beebe et al., 2010). Report strengths were measuring child- and parent-study perspectives, providing an intervention schedule, apply of health condition–specific outcome measures, controlled design, and data drove 6 months mail-intervention.

In the second report, xvi children with epilepsy reported positively on art therapy received; notwithstanding, outcome measures showed no improvements (Stafstrom et al., 2012). Lastly, 80% of participants with diabetes rated arts-based therapies positively in a satisfaction survey; yet, participants were required to attend weekly from remote/rural locations, and compunction was high (MacDonald et al., 2019).

Children With Blood Disorders and Other Health Conditions: Music Media and Play Therapy

Children with a range of health conditions receiving ane-to-one music-based therapy demonstrated significant reductions in feet or hurting simply no more so than control groups (music listening/composition) (Colwell et al., 2013). A multi-site music therapy evaluation (n = 113) for children with hematopoietic stem cell transplants demonstrated social, family, and spiritual improvements 3 months mail service-intervention (Robb et al., 2014). A force of the study was a process for assessing intervention fidelity across sites/therapists.

An RCT of music-based therapy for children receiving hematopoietic stem prison cell transplants showed improved physical function postal service-intervention. A report forcefulness was describing parent interest and the wait-listing control pattern, and then all participants had access to the intervention (Uggla et al., 2018).

Finally self-concept was improved 1 month mail service-intervention (eight play therapy sessions) for 60 children with thalassemia major across two hospital sites (Tomaj et al., 2016).

In summary, seven studies examined the effectiveness of arts-based therapies on the mental well-existence of children undergoing handling for blood disorders and other health atmospheric condition. In one case once more, the studies indicated some positive impact, but significant heterogeneity of intervention characteristics (e.g., whether private or grouping format), variety of outcomes measured, and design limitations hateful that firm conclusions nearly effectiveness across studies are not possible.

Discussion

The review identified and appraised 16 articles evaluating the effectiveness of arts-based therapies for improving the mental health of children with physical health LTCs. Some improvements were demonstrated in articles selected, including, for example, improved quality of life, coping behaviors, self-concept, improved mood, and reduced feet. Participants included children with a range of concrete health LTCs, and interventions comprised arts-based therapies utilizing music, play, and visual media in the context of a therapeutic human relationship. However, the heterogeneity in intervention characteristics and design limitations identified hateful that it is non possible to make conclusions most effectiveness across studies. Further, the review highlights that the existing show base for the effectiveness of arts-based therapies as a psychological intervention for pediatric physical health settings is sparse and requires development (Cohen-Yatziv and Regev, 2019).

A lack of post-intervention positive changes on published effect measures, in some studies, assorted with measures of satisfaction (where used), which did indicate benefits. This is in accord with the findings of a recent evidence synthesis of mental wellness interventions for children with physical health LTCs, which found meta-ethnographic evidence of do good just a lack of effectiveness evidence (Moore et al., 2019). This underlines the importance of measuring outcomes using quantitative and qualitative methods across a range of indicators (e.g., school attendance) and from a range of perspectives when designing hereafter evaluations of arts-based therapies for children with concrete health LTCs. The strengths and limitations of the studies reviewed informed a logic model (Figure 3), and we utilise this to make suggestions to guide the design of future inquiry evaluations of the effectiveness of arts-based therapies for children with physical health LTCs in order to help develop the field (Cohen-Yatziv and Regev, 2019). For case, none of the studies reviewed assessed if changes reached minimum thresholds for clinically significant or meaningful alter (de Vet et al., 2006); farther, most of the effectiveness evaluations in the studies reviewed are cantankerous-sectional. In future studies, quantitative prospective assessments would facilitate evaluating sustained effects subsequently the intervention, and the employ of outcome measures with published norm/cut-scores would facilitate more accurate interpretation of whatsoever changes in scores resulting from interventions. Nigh studies recruited participants from a unmarried site. Future enquiry recruiting from multiple sites should contain processes for ensuring intervention consistency betwixt sites, evaluation of intervention effectiveness across sites, and feasibility of sustainable integration of arts-based therapies into pediatric physical health LTC service structures, including identification of barriers and facilitators. Most of the studies were conducted in the USA and generalizability to the Britain NHS or health services in other countries cannot exist causeless, given different wellness service structures and funding.

Review Strengths and Limitations

Limitations of the review include pocket-size numbers of studies identified and heterogeneity in their pattern, and then quantitative pooling of results across studies or health conditions was not possible. Arts-based therapies may require tailoring for children with different physical health LTCs; however, an in-depth synthesis of findings on the effectiveness of arts-based therapies for specific health conditions was not possible.

We have taken a reductionist perspective of effectiveness; our inclusion benchmark was studies using published mental health outcome measures, and we excluded qualitative studies. We admit that this definition of effectiveness will not capture all furnishings, mechanisms, and dynamic processes of change occurring during arts-based therapies (Gerber et al., 2018). We did not screen gray literature or include end-user consultation, and nosotros did not have resources to consummate full independent screening and quality appraisals or translate and include articles non published in English language. These are potential sources of bias in our review.

The aim of the review was to explore the effectiveness of arts-based therapies to improve mental health for children with physical health LTCs. Only i RCT of an arts-based therapy (music) was identified in a recent review of psychological interventions for children with physical wellness LTCs (Moore et al., 2019). Given this, we looked broadly and included cohort and within-subject designs, which are, however, not strong indicators of effectiveness. Elevated mental wellness symptoms were non an inclusion criterion for our review, and merely ane report (Khodabakhshi Koolaee et al., 2016) recruited participants scoring above the mean on standardized measures (of anxiety and acrimony); this is a limitation of our review with regard to assessing improved mental health. However, given the long wait times for access to child mental health services, information technology is of import to explore the effectiveness of reducing sub-threshold mental wellness symptoms and whatever preventative potential of arts-based therapies, and this is a strength of the review (NHS Digital, 2019).

Study Implications and Future Research

The review identified a number of design limitations of import to address in future research, and we accept summarized these in a model. Futurity trials would benefit from including end-user consultation in intervention design and service integration and could evaluate the involvement of parents and online formats of delivery to support transferring caused/internalized coping skills outside/afterward intervention and for children in remote locations.

The pick of evidence-based psychological interventions available for children with physical health LTCs is currently small (Moore et al., 2019). Arts-based therapies present a potential choice; however, the findings from the review confirm that research is required prior to any sustainable integration into physical heath settings. The review has highlighted some areas to clarify in future research. None of the studies reviewed distinguished between using arts-based therapies as preventative or treatment interventions. Given health service resource constraints, it is unlikely that arts-based therapies can be available to all children in physical wellness LTC settings, so this distinction requires consideration in hereafter studies. Future research should evaluate how arts-based therapies might be integrated into assessment processes to support clinical teams in identifying mental health difficulties and facilitate children accessing the support they crave early. In future research, economic assay could facilitate examining whatever savings made by avoiding treatment complications through providing arts-based therapies (Seid et al., 2004; Shaw, 2016). In the absence of whatever extra health service funding, economic evaluations including an invest-to-salvage analysis will be important to demonstrate whatever reduced costs from integrating arts-based therapies in the NHS, e.yard., fewer referrals to child and adolescent mental wellness services (Shaw, 2016). Participant inclusion criteria were not e'er articulate in the studies reviewed. Once again, limited health service resource will influence decisions almost access to psychological interventions, and identifying the characteristics of children who may benefit most from arts-based therapies is important to analyze in hereafter enquiry and could be explored using mixed methods approaches.

Conclusions

Integration of psychological support into pediatric physical health settings is an indicator of service quality (DoH, 2011; Foster et al., 2017; Parsons et al., 2017; NHSE, 2018). However, there is limited evidence-based psychological support available for children with concrete wellness LTCs, and this is a barrier to the provision of integrated services (Thabrew et al., 2018; Moore et al., 2019). The findings from this systematic review of effectiveness demonstrated that replication of interventions and outcomes across studies was absent, so conclusions about the effectiveness of arts-based therapies for improving the mental well-existence of children with physical health LTCs cannot be made. The findings also highlight design characteristics important to contain when developing future trials evaluating the effectiveness of arts-based therapies. If futurity robustly designed research studies tin demonstrate the effectiveness of arts-based therapies for children with concrete health LTCs, commissioning is more than likely, and this could potentially create increased selection of psychological interventions for children and families, be an alternative to talking-based therapies for children who might find it hard to speak near their difficulties, and increase the resources available for service providers.

Information Availability Statement

All datasets presented in this written report are included in the commodity/supplementary fabric.

Author Contributions

SH, SW, PW, AZ, and SJ conceptualized the review. SW, AZ, and JB analyzed results. SW wrote the first draft of the manuscript. All authors contributed to editing, commenting, and revising manuscript versions, read and canonical the submitted version.

Funding

We are grateful to Newcastle upon Tyne Hospitals NHS Charity (reg. 1057213) for funding this written report.

Conflict of Involvement

The authors declare that the enquiry was conducted in the absenteeism of any commercial or financial relationships that could be construed as a potential conflict of interest.

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Appendix

Table A1. Search strategy used for the EBSCO interface and Medline database.

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Source: https://www.frontiersin.org/articles/10.3389/fpsyg.2020.01771/full