A Randomized Control Trial of Guided-Imagination and Drawing-Storytelling in Children with Cancer


  • Kodchakon Piasai RN, PhD Candidate, Faculty of Graduate School, Prince of Songkla University, Thailand
  • Sasitorn Phumdoung RN, PhD, Professor, Faculty of Nursing, Prince of Songkla University, Thailand
  • Wantanee Wiroonpanich RN, PhD, Assistant Professor, Faculty of Nursing, Prince of Songkla University, Thailand
  • Thirachit Chotsampancharoen MD, Assistant Professor, Faculty of Medicine, Prince of Songkla University, Thailand


Guided imagination, therapeutic play, happiness, relaxation, cortisol, children, cancer, Drawing-storytelling


            Hospitalized school-age children with cancer are confronted with stressful and life-threatening situations which can cause them unhappiness, tension, and stress. This randomized control trial investigated the effects of guided-imagination and drawing- storytelling on the happiness, relaxation, and salivary cortisol levels among hospitalized school-age children with cancer. Participants were randomly assigned to the experimental group (n=20) or the control group (n=20). The participants in the experimental group received guided-imagination for 30 minutes, followed by 30 minutes of drawing-storytelling, while the participants in the control group received only usual care. The Happiness Face Scale was used for measuring happiness and the Relaxation Scale was used for measuring relaxation. Saliva was also collected for testing cortisol levels. Descriptive and inferential statistics were used to analyze the data.

              The results showed that the experimental group receiving guided-imagination and drawing-storytelling had statistically significant increased happiness and relaxation scores over time, compared to the control group. Even though cortisol levels decreased throughout the study, there were no significant differences between the two groups. These results demonstrate that guided-imagination and drawing-storytelling can enhance happiness and relaxation levels but may not decrease salivary cortisol levels. Thus, it is recommended that nurses provide the guided-imagination and drawing-storytelling to pediatric patients to increase their happiness and relaxation.


1. Rodriguez EM, Dunn MJ, Zuckerman T, Vannatta K, Gerhardt CA, Compas BE. Cancer-related sources of stress for children with cancer and their parents. J Ped Psychol. 2012; 37(2): 185-97.

2. Vindrola-Padros C. The everyday lives of children with cancer in Argentina: Going beyond the disease and treatment. Children & Society. 2012; 26(6): 430-42.

3. Cullen J. Because statistics don’t tell the whole story: A call for comprehensive care for children with cancer. CA Cancer J Clin. 2014; 64(2): 79-82.

4. Altay N, Kilicarslan-Toruner E, Sari Ç. The effect of drawing and writing technique on the anxiety level of children undergoing cancer treatment. Eur J Oncol Nurs. 2017; 28: 1-6.

5. Capurso M, Ragni B. Psycho-educational preparation of children for anaesthesia: A review of intervention methods. Patient Educ Couns. 2016; 99(2): 173-85.

6. Silva SGTD, Dantos MA, Floriano CMF, Damião EBC, Campos FV, Rossato LM. Influence of therapeutic play on the anxiety of hospitalized school-age children: Clinical trial. Rev Bras Enferm. 2017; 70(6): 1244-49.

7. Collingwood J. [internet]. The power of music to reduce stress. 2016 [cited 2017 Dec16]. Available from http:// psychcentral.com/lib/the-power-of-music-to-reducestress

8. Metzl E, Molissa M, Field A. A pilot outcome study of art therapy and music therapy with hospitalized children. Canadian Art Ther Assoc J. 2016; 29(1): 3-11.

9. Loewy J, Stewart K, Dassler A, Telsey A, Homel P. The effects of music therapy on vital signs, feeding, and sleep in premature infants. Ped. 2013; 131(5): 902-18.

10. Potasz C, De Varela MJ, DeCarvalho LC, DoPrado LF, DoPrado GF. Effect of play activities on hospitalized children’s stress: A randomized clinical trial. Scand J Occup Ther. 2013; 20(1): 71-9.

11. Ebrahimpour F, Sadeghi N, Najafi M, Iraj B, Shahrokhi A. Effect of playing interactive computer game on distress of insulin injection among type 1 diabetic children. Iran J Ped. 2015; 25(3): 1-6

12. Cain E. [internet]. Five activities to keep your kids happy while you work from home. 2015 [cited 2017 Nov10]. Available from http://homeofficecareers.com/blog/5activities-to-keep-your-kids-happy-while-you-workfrom-home

13. Colwell CM, Edwards R, Hernandez E, Brees K. Impact of music therapy intervention (listening, composition, orffbased) on the physiological and psychosocial behaviors of hospitalized children: A feasibility study. J Ped Nurs. 2013; 28(3): 249-57.

14. Grol M, Vanlessen N, DeRaedt R. Feeling happy when feeling down: The effectiveness of positive mental imagery in dysphoria. J Behav Ther Exp Psychiatry. 2017; 57:156-62.

15. Dossey BM, Keegan L. Holistic Nursing: A Handbook for Practice. 6th ed. Burlington, MA: Jones & Bartlett Learning; 2013.

16. vanAndel HW, Jansen LM, Grietens H, Knorth EJ, vander Gaag RJ. Salivary cortisol: A possible biomarker in evaluating stress and effects of interventions in young foster children?. Eur Child Adolesc Psychiatry. 2014; 23(1): 3-12.

17. Snyder M, Lindquist R. Complementary/alternative therapies in nursing. 4th ed. New York: Springer; 2002.

18. Woollard J [internet]. Imagination: The key to happiness. 2014 [cited 2017 Jul 11]. Available from: http://www. catalyzingchange.org/imagination-the-key-to-happiness

19. Pictet A, Coughtrey AE, Mathews A, Holmesa EA. Fishing for happiness: The effects of generating positive imagery on mood and behaviour. Behav Res Ther. 2011; 49(12): 885–91.

20. Thoma MV, Marca RL, Brönnimann R, Finkel L, Ehlert U, Nater UM. The effect of music on the human stress response. PLoS One. 2013; 8(8): e70156.

21. Lamme MB. The musical brain how music evokes emotions and related positive feelings [Master thesis]. Greece: Universiteit Utrecht; 2012.

22. Farhud DD, Malmir M, Khanahmadi M. Happiness & health: The biological factors-Systematic review article. Iran J Public Health. 2014; 43(11): 1468-77.

23. Stratton VN, Zalanowski AH. The relationship between music, degree of liking, and self-Reported relaxation. J Music Ther. 1984; 21(4): 184-92.

24. Linnemann A, Kappert MB, Fischer S, Doerr JM, Strahler J, Nater UM. The effects of music listening on pain and stress in the daily life of patients with fibromyalgia syndrome. Front Hum Neurosci. 2015; 9: 434.

25. Lieff J [internet]. Music stimulates emotions through specific brain circuits. 2014 [cited 2017 Jul 11]. Available from: http://jonlieffmd.com/blog/ music-stimulatesemotions- through-specific-brain-circuits

26. İbrahimoğlu Ö, Kanan N. The effect of progressive muscle relaxation exercises after endotracheal extubation on vital signs and anxiety level in open heart surgery patients. Turk J Intense Care. 2017; 15(3): 98-106.

27. Bhasin MK, Dusek JA, Chang BH, Joseph MG, Denninger JW, Fricchione GL et al. Relaxation response induces temporal transcriptome changes in energy metabolism, insulin secretion and inflammatory pathways. PLoS One. 2013; 8(5): 1-14.

28. William HCL, Chung JOK, Ho KY, Kwok BMC. Play interventions to reduce anxiety and negative emotions in hospitalized children. BMC Ped. 2016; 16(1): 1-9.

29. Shah P [internet]. 10 Benefits of storytelling for kids. 2017 [cited 2017 Jul 11]. Available from: http://www. momjunction.com/articles/benefits-story-telling-yorkids_0036903

30. Bratton SC, Ray D, Rhine T, Jones L. The efficacy of play therapy with children: A meta-analytic review of treatment outcomes. Prof Psychol Res Pract. 2005; 36(4): 376-90.

31. Cohen J. Statistical power analysis for the behavioral sciences. 2nd ed. New York: Psychology; 1988.

32. Griffin PR [internet]. Cushing’s Syndrome. 2008 [cited 2017 Jul 11]. Available from: https://www.niddk.nih. gov/ health-information/endocrine-diseases/cushings-syndrome

33. Holder MD, Coleman B, Wallace JM. Spirituality, religiousness, and happiness in children aged 8–12 years. J Happiness Studies. 2010; 11(2): 131–50.

34. ELSA Support [internet]. Relaxation thermometer. 2015 [cited 2017 Jul 11]. Available from: http://www.elsasupport.co.uk/relaxation-thermometer

35. Shaffer DR. Developmental psychology childhood and adolescence. 2nd ed. Pacific Grove, CA: Books/Cole Publishing; 1989.

36. Hunter PG, Schellenberg EG, Schimmack U. Feelings and perceptions of happiness and sadness induced by music: Similarities, differences, and mixed emotions. Psychol Aesthet Creat Arts. 2010; 4(1): 47-56.

37. Louie SW. The effects of guided imagery relaxation in people with COPD. Occup Ther Int. 2004; 11(3): 145-59.

38. Koelsch S, Fuermetz J, Sack U, Bauer K, Hohenadel M, Wiegel M et al. Effects of music listening on cortisol levels and Propofol consumption during spinal anesthesia. Front Psychol. 2011; 2: 58.

39. Vgontzas AN, Pejovic S, Zoumakis E, Lin HM, Bixler EO, Basta M et al. Daytime napping after a night of sleep loss decreases sleepiness, improves performance, and causes beneficial changes in cortisol and interleukin-6 secretion. Am J Physiol Endocrinol Metab. 2007; 292(1): 253-61.

40. Good M, Albert JM, Arafah B, Anderson GC, Wotman S, Cong X et al. Effects on postoperative salivary cortisol of relaxation/music and patient teaching about pain management. Biol Res Nurs. 2013; 15(3): 318-29




How to Cite

Piasai K, Phumdoung S, Wiroonpanich W, Chotsampancharoen T. A Randomized Control Trial of Guided-Imagination and Drawing-Storytelling in Children with Cancer. PRIJNR [Internet]. 2018 Sep. 28 [cited 2023 Dec. 9];22(4):386-400. Available from: https://he02.tci-thaijo.org/index.php/PRIJNR/article/view/99745