The effect of exchanging drawings with peers on the happiness of children with cancer, aged 7-11 years: A clinical trial.

INTRODUCTION: Improving the mental status of children with cancer is part of nurses' duties in planning nursing care and is achieved in different ways. This study attempts to combine drawing with peer interaction to improve the mental status of sick children and investigate the effect of exchanging drawings with peers on these children's happiness.
METHOD: This clinical trial was conducted on a sample of 66 children with cancer, ages 7-11 years, who were randomly assigned to two groups. The intervention was carried out over five weeks by the exchange of drawings between healthy children at school and children with cancer. Both groups of children drew one drawing each week. The children's happiness was measured by the researcher before and after the intervention (i.e., week five) using a questionnaire.
RESULTS: The results showed no significant differences between the two groups in terms of happiness after the intervention. The happiness score was 3.15 ±0.34 in the control group and 3.02 ±0.3 in the intervention group before the intervention; afterwards, this score was 3.022± 0.22 among the controls and 3.11± 0.25 among the patients. The comparison of the two groups using the t-test showed P = 0.075 before the intervention and P = 0.11 after the intervention.
CONCLUSION: Given the results obtained, future studies are recommended to administer lengthier interventions and enable the physical presence of healthy peers along sick children or to use the exchange of drawings with peers in combination with other psychological interventions so as to promote happiness in children with cancer.

Introduction

Studies have shown that developing cancer at a young age puts children at a higher risk of psychological disorders or other problems concerning their social compatibility with peers [1, 2]. Happiness is a psychological status that is reduced dramatically in children with cancer as a result of their frequent hospitalizations and their difficult, painful and prolonged treatment periods [3-5]. In sick children, happiness has the ability to reduce emotional and behavioral problems and control depression [6-8]. In general, happiness leads to a positive attitude toward life, mental health, emotional balance and a better functioning of the immune system in dealing with stresses [3, 9, 10]. Positive psychology is currently a promising approach for improving the quality of life in patients [3, 11, 12]. Happiness often diminishes dramatically in children with cancer due to the nature of the disease and its treatment, and since happiness has a major role in children’s growth and development, it is a vital part of nursing care [7, 8, 12–17]. Arts can be used as one of the ways to improve happiness [18].

Drawing can affect children’s feelings and enable the expression and release of emotions. Some studies have emphasized the effectiveness of drawing in improving children’s psychological status [18-21]. In drawing sessions, children express their negative feelings through drawing and regulate their emotions by projecting their feelings [4, 22, 23]. A child’s drawing is a message; that is, children express their emotional and affective world by means of drawing, which is a language for the expression of feelings [4, 22]. Drawing is therefore a way of expressing feelings for children that affects their mental status, and interaction with peers can further improve children’s mental status. Studies have shown that peers learn, help and complement one another [10, 18, 24]. A peer is someone who has similarities with the patient in a number of features, such as age, gender, occupation, socioeconomic status and health status [24, 25]. Several studies have demonstrated the effect of peer groups as a source of philanthropic, emotional and educational support and have recommended this complementary approach in conjunction with other care-promoting strategies [10, 26]. A meeting between peers is a source of relief and reassurance for patients that can encourage them to learn coping strategies to overcome their disease [24, 25]. Given the peer influence during childhood, this potential can probably help nurses further improve their care measures although no research has yet been conducted on the effect of healthy peers on sick children [27, 28]. Further studies are therefore required on how the provision of psychological and social support to patients, such as the support of peers, can improve the conditions of children with cancer. This study therefore combines two care measures, namely drawing and interaction with peers, and assesses their cumulative outcome.

Drawing is a means of expressing feelings in children that can be used to help with their psychological problems, as well [22]. School-aged children have a particular need for interacting with their peers, which can be disrupted as a result of illness and hospitalization, treatment and prolonged recovery [16, 24, 25]. To ensure the proper growth and development of children, nurses are responsible for facilitating children’s interaction with peers in their care planning [29]. Designing care procedures that simultaneously account for both of these interventions requires creativity and innovativeness. This study devised a care plan consisting of the exchange of drawings drawn by children with cancer and healthy children so as to convey happiness to children with cancer. This care plan was chosen to facilitate the children’s expression of feelings through drawing and to enable the sick children’s interaction with their peers through the messages conveyed by the drawings. The effectiveness of this case intervention, which has been less addressed in studies on children with cancer, is assessed based on positivist psychology and the measurement of the children’s happiness and the subsequent boost in their spirits. This study thus examines the effect of the exchange of drawings with peers on the happiness of children with cancer and assesses the effect of combining the drawing method and interaction with peers on the happiness of these children.

Materials and methods

For this clinical trial, 66 children with cancer aged 7–11 years were selected (based on sample size formula for comparison of two means). At a significance level of 0.05, test power of 80%, and also assuming that the effect of peer drawing on happiness of school-aged children with cancer is 1.8 (10% of the maximum score of the instrument), sample size was determined 30 children per group. Based on the range of happiness score from 0 to 87, standard deviation was estimated at 14. The sample size was increased by 10% to compensate possible withdraws. Thus, the final sample size per group was determined n = 33.

The children with cancer were selected through convenience sampling and were then randomly assigned to the control and intervention groups by block randomization, and two modes, A and B, were considered to indicate the control (A) and intervention (B) groups. The following six permutations were obtained for these two modes, including (1) BAAB; (2) ABAB; (3) AABB; (4) ABBA; (5) BBAA; and (6) BABA. Next, 17 blocks of four were randomly sampled by throwing a six-sided dice (17 modes for 66 children). Blocks were prepared by a statistician and sampling was carried out by the research team according to predetermined sequence with no bias. The samples were selected using convenience sampling method from hospitalized children in the oncology ward of Children’s Medical Center, such that eligible children were assigned to control (A) and intervention (B) groups. Sampling was carried out almost every day with inclusion of eligible children, who were allocated to a group on the day of admission.

The children in the peer group were selected through census sampling; that is, any child of the intended age range studying at the noted school and willing to take part in the study who had their parents’ informed consent was included. The Ministry of Education granted permission to conduct the study.

The study inclusion criteria for the intervention and control groups consisted of being aged 7–11 years, having a definitive diagnosis of ALL, having medical records available at the hospital, the elapse of at least three months from the diagnosis of cancer, having no physical or mental disability that impeded drawing and being hospitalized and receiving treatment and medications at the oncology ward at least every two weeks.

The exclusion criteria for intervention and control groups consisted of absence from more than two sessions of drawing.

The data collection tools included a demographic questionnaire and the Children’s Happiness Scale.

The demographic questionnaire inquired about the children’s age, gender, birth order, time of diagnosis of cancer, underlying diseases and interest in and habits concerning drawing.

The Children’s Happiness Scale was developed in 2014 by Dr. Rodger Morgan and consists of 20 graded items scored by children; that is, children check any items they agree with in relation to themselves, and the scores are then summed up. The sum of the scores obtained is then divided by the number of checked items to find the child’s happiness score. The highest score (i.e. happiest) is 4.25 and the lowest is 1.68.

The original tool was in English, and the tool developer gave the researchers permission to translate and use it. First, the tool was translated into Persian, and its translation was approved by three people familiar with English and Persian. To examine the validity of the scale, the face and content validity method was used. For this purpose, after translation, the scale was distributed among ten psychology and nursing professors to review and confirm its items. The experts’ comments were then collected and analyzed, and necessary modifications were made to the items in terms of wording. The scale reliability was assessed using test-retest method, such that it was distributed among ten sick children (they were excluded from the study) selected by convenience sampling, who completed the items at baseline and then again a week later. The correlation between the two measurements was 7.8, which indicates an acceptable reliability [7–9, 30]. The present study was approved by the Ethics Committee of School of Nursing and Midwifery and Rehabilitation of Tehran University of Medical Sciences on 11.9.2017. Validation of the tool began on 20.11.2017, and pilot sampling for assessing reliability began on 4.4.2018. The initial pilot study lasted a month, and sampling and intervention began on 7.9.2018. Since schools were closed on the anticipated date in RCT, and children’s peers first became available in school on 7.9.2018, the intervention and sampling lasted three months. Hence, the time lapse of sampling registration at RCT was due to the initial pilot study, and after obtaining the code of ethics and before final confirmation of RCT, sampling began for validity and reliability assessment of the tool and pilot study. Sampling began after the final confirmation of RCT. (Fig 1)

Fig 1

Participant flow chart.

Intervention

Healthy children’s drawing

The researcher visited the selected primary school holding an official permission from the local office of the Ministry of Education, explained the study objectives to the school authorities and then obtained the principal’s permission for the students to draw drawings for a group of children with cancer. A meeting was then arranged to brief the children’s teachers and parents on the study objectives and methods, and to obtain their informed consent. Once they signed informed consent forms and with prior arrangement with each teacher, 33 students were selected from the second to fourth grades for drawing period. After giving a simple explanation to them about the study objectives and methods in the presence of their teacher, they were asked to draw a drawing with any subject they desired for hospitalized children with cancer once a week for a total of five weeks during their art class. The researcher provided the children with all the necessary tools for drawing including A4 paper, black pencils, colored pencils, colored markers, and colored crayons. Additional pieces of A4 paper were given to them if they wanted to draw more than one drawing. The children finished their drawings over 20–25 minutes on average, and their drawings were collected at the end of each session. This protocol continued once a week for a total of five weeks, and the drawings were taken to the hospital by the researcher every week.

Children with cancer drawing

The researcher visited the ward with a letter of introduction from and prior arrangement with the hospital director and the authorities of the nursing office and oncology ward of the Children’s Medical Center. Convenience sampling was initially carried out for both the control and intervention groups (n = 33 per group) based on the study inclusion criteria. After briefing them on the study objectives and methods, the parents gave their informed written consent, and the children gave their informed verbal consent. Data were collected before the intervention. The demographic questionnaire was completed by one of each child’s parents, and the Children’s Happiness Scale was filled out by the children. The children’s happiness was also assessed a week after the end of the intervention in both the intervention and control groups.

Drawing sessions in the hospital

The drawing intervention was carried out over five consecutive weeks with one-week intervals. The researcher took 10–15 min to explain to the intervention group that they would receive drawings from their peers at a school once a week for a total five weeks and that, in response, they would draw a drawing on any subject of their choice to give to the researcher every week, too. The duration and conditions of the drawing sessions were the same in the hospital as in the school period. The only difference was the setting, as the sick children drew in the hospital’s play room. The control group drew under the same conditions as the intervention group, but they received no drawing from their peers and were not led to assume that they were drawing for their peers. The researcher took the intervention group’s drawings to the school every week and gave them to the peer group during their art class, and then collected the school children’s newest drawings and took them to the hospital for the intervention group children. This process continued for five weeks. The mothers’ phone numbers were collected to coordinate the next sessions. On a few occasions when the interval between the sessions was more than one week, the mothers were asked to show their children the drawings that their peers had drawn for them. In these cases, peer drawings were emailed to sick children and the researcher asked them to draw a drawing for their healthy peers, as per the plan, and to send the new drawing to the researcher or bring it to the next session.

To facilitate drawing in the hospital, the drawing sessions were held in the play room in the presence of the researcher. The drawing intervention sessions were held after the child had received their medications and been visited by the doctors to avoid disturbing the child during the process of drawing. The mothers and relatives accompanied the child in the play room when the child was drawing but they had been advised not to interfere with, guide, or comment on the child’s drawing. The intervention and its assessment were carried out by the researchers, including a psychiatric nurse, an expert nurse in use of play and an MSc nursing student.

The participants were blinded to their group allocation, and were only told that they were to draw for their peers. To avoid information contamination, the two groups’ children entered the play room separately. Researchers assigned children to two groups by block randomization, but were aware of type of intervention for each group, and efforts were made this would not affect children’s intervention and type of drawing through necessary training. All data were entered into the software by a blinded person, and test data were analyzed by a blinded statistician.

Statistical analysis

Data were analyzed in SPSS-16 (SPSS Inc. Released 2007. SPSS for Windows, Version 16.0. Chicago, SPSS Inc) using the independent t-test and paired t-test for comparison of the happiness scores between the two groups (2-tailed), the Chi-square test for comparison of the demographics, Fisher’s exact test for interest in drawing and paired t-test for comparison of the happiness scores in each group. Kolmogorov-Smirnov test was used to assess normal distribution of the data. Significance level was assumed 95% for all tests.

Ethical considerations

For the purpose of collecting data, the researcher first obtained permission from the ethics committee of Tehran University of Medical Sciences (IR.TUMS.FNM.REC.1396,3441) and registered the study (IRCT20150928024239N4).

Results

The Kolmogorov-Smirnov test showed the normal distribution of the data. The two groups were also compared using parametric tests. No significant differences were observed between the two groups in terms of demographic details and they matched in this regard (S1 Table).

The results showed no significant differences in the children’s happiness before and after drawing in the intervention and control groups. There were also no significant differences in the mean happiness scores between the intervention and control groups before and after the intervention (S2 Table).

Discussion

The results showed no significant differences between the control and intervention groups in terms of happiness before the intervention, and the level of happiness was not high in either group. The happiness score of the children in the control and intervention groups was indicative of the level of psychological damage to children with cancer, which reveals the urgent need of this group for help to boost their spirits and happiness if they are to make progress in their process of recovery from the disease [31].

Developing cancer in childhood can put the child’s mental health at risk. Children experience some painful side-effects as a result of cancer treatment, and because of illness, they can no longer attend their school or participate in the gatherings of their family and friends. Their life therefore undergoes enormous changes [32]. These children are also predisposed to infection and are continually hospitalized, which leads to their isolation from the family and society [21, 32]. These children are therefore denied of the particular sense of happiness that is characteristic of childhood; however, happiness and vitality make treatment more successful and increase life expectancy [33]. The results obtained by Sanjari et al. showed that, following the diagnosis of cancer, adolescents experience higher levels of anxiety and depression and lower levels of vitality and mental health [34].

There were no significant differences between the control and intervention groups in the level of happiness after the drawing intervention. The intervention consisting of the exchange of drawings with peers thus failed to exert any effect on the happiness of sick children. In the researcher’s view, the ineffectiveness of the intervention and the homogeneity of the happiness level between the two groups after the intervention could be due to the physical absence of the peer group. The results obtained in peer-based studies confirm this claim. When such interventions were conducted in the presence of both the peer and intervention groups, a significant difference was reported between the intervention and control groups [24, 28, 29].

The lack of a significant difference in the happiness of sick children after the drawing intervention can motivate future studies to use other interventions in combination with drawing, such as music therapy, relaxation exercises and play therapy. These combination interventions may increase happiness in children with cancer. The concurrent use of a number of interventions, such as drawing, music, puppet shows and games appears to have greater effects on the happiness of hospitalized children.

Given that more studies have confirmed the effectiveness of drawing in reducing anxiety and depression in sick children [19, 35], the non-significant effect obtained in the present study for drawing in relation to children’s happiness reveals a number of issues. First, the use of drawing might be promoted in healthcare settings, and the research group recommends at least 12 sessions, lasting 45 to 60 minutes each. In a study conducted by Lee, 14 weekly sessions of drawing therapy had positive effects on changing the behavior and emotions of children with behavioral problems [36]. Although the process and goals of drawing therapy and drawing are not similar, this research showed benefit of the process of drawing for reducing behavior problems. Moreover, meetings held between peers act as a source of relief and reassurance for patients and can encourage them to learn coping strategies to overcome the disease and have a greater chance in life.

In the present study, the sick children and their peers had no face-to-face contact with one another and only communicated through drawings, which appears to have not yielded a significant effect. Another issue that may explain why the exchange of drawings with peers had no significant effect on the happiness of the sick children is the use of drawing alone without any additional interventions.

As demonstrated in studies by Gariepy et al. and Barrera et al., combining drawing with play leads to significant positive effects [37, 38]. It can probably be concluded that the happiness of sick children cannot be promoted by the mere use of drawing and other methods should also be used in conjunction with drawing for the intervention to prove effective. Future studies are recommended to be conducted with a larger number of intervention sessions along with a longer follow-up instead of mere drawing. We recommend other methods in conjunction with drawing. Also, face-to-face interactions between sick children and their peers should be facilitated in order to increase the effect of the intervention and obtain the intended results.

Acting as intermediaries between healthy and hospitalized children, nurses can change the rules and initiate the presence of peers in hospital settings so as to turn these interactions into effective therapeutic contacts, and healthy children can also gain valuable experience about having a fruitful presence in the society through their interaction with patients.

Study limitations

The concurrent hospitalization of the intervention and control group children in the ward increased the possibility of being influenced by each other, which could not be avoided, as there were no similar settings available to separate the two groups. The novelty of the subject for the school children made interaction difficult in the first few days because they had no idea about drawing for sick children, but this issue was resolved over time. It would have been better if the drawings had been interpreted in terms of how they promoted happiness, since the interpretation of drawings might show changes in the level of happiness. The physical presence of peers could have increased the effectiveness of the intervention, but this measure was not possible due to the hospital’s visiting regulations. If, along with the positivist psychological factors, psychological problems such as anxiety and depression had also been measured, then the effectiveness of this intervention in reducing the psychological problems caused by disease could also have been assessed. Moreover, it would have been better if the healthy children’s happiness had also been measured before and after the drawing intervention.

Conclusion

Although the present study showed no significant differences between the two groups, this innovative technique can be developed through further studies after the shortfalls of this study are resolved. It can then be used as a way of interaction for these children and their healthy peers and to teach healthy individuals about proper interaction with sick children as part of their social responsibility.

CONSORT checklist.

(DOC)

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A comparison of the demographics variable.

(DOCX)

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A comparison of the happiness scores.

(DOCX)

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(DOC)

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(DOCX)

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27 Oct 2020

PONE-D-20-10349

The Effect of Exchanging Paintings with Peers on the Happiness of Children with Cancer, Ages 7-11 Years: Clinical trial

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Reviewer #1: The manuscript entitled ‘The Effect of Exchanging Paintings with Peers on the Happiness of Children with Cancer, Ages 7-11 Years: Clinical trial’ with the aim to examine the effect of the exchange of paintings with peers on the happiness of children with cancer and assesses the effect of combining the painting method and interaction with peers on the happiness of these children.

Comments

Materials and Methods

Sample size calculation

Page 6, information on the sample size calculation to be provided i.e. alpha, beta, 1 or 2 tailed test, outcome measure, attrition rate consideration etc

Page 6, information on who prepared the randomization block (sequence generation/allocation, concealment) and assigned to the groups to be clearly stated.

Page 6, the word control group or peer group to be used systematically. The write-up on the subjects selection to be placed on top first before the randomization process.

Page 7, the sentence 'The exclude their data from analysis for both groups consisted of absence from more than two sessions of painting or death of the child.' to be revised.

Page 7, the language version of the Children's Happiness Scale used in the study to be stated. If it is Iranian version the validation information to be provided/cited.

Page 7, information on blinding (providers, subjects, person assessing the outcome) to be stated.

Page 7, is the lowest score for Children's Happiness Scale 1.67 or 1.68?

Page 7, for the reliability test of the scale, the exact name of the correlation test to be stated. The range of the correlation values to be provided.

Page 10, the sentence ‘In this cases were sent peer’s painting through email’ & ‘Researcher ask their to draw a painting’ to be revised.

Statistical analysis

Page 10, a sub-title for the statistical analysis to be provided.

Page 10, proper citation of SPSS and publisher name to be provided. The use of the independent T-test, the Chi-square test, Fisher's exact test and the paired T-test and its purpose to be clearly stated.

The acceptance level of significance to be stated.

Page 10, study limitation to be placed in the discussion section.

Results

Page 12, Kolmogorov-Smirnov test to be stated in the statistical analysis section.

Page 12, the results with no significant differences in the children's happiness before and after painting in the control group to be stated in the text.

Page 12, the write-up of the results section is too short.

Page 19 N for each group to be stated for Table 1 and 2.

Page 19 Table 1, the alignment of the table and words to be improved. Decimal point for p value to be provided and standardized. Chi-square test, Fisher’s Exact Test to be denoted in table/table footnote. Symbol % for individual figure to be omitted since it has been highlighted in the group name. Word P value to be stated in the last column.

Page 19 Table 2, t-statistic value, df to be placed in another column/row from the p value. Alignment of the table and words to be improved.

It would be good to display/describe the number of subjects who were not happy/happy before intervention and after intervention other than describing the mean score of the scale.

Page 12 & 19, the focus to be more on within group comparison rather than comparison between the groups at each time period since the two groups of subjects are different. Mean difference (pre-post) from each group could be used for between group comparison. Effect size i.e. Cohen’s d and 95% confidence interval to be provided.

Page 19, more baseline characteristics of the study subjects to be provided such as types/ severity of cancer (stages), type of medications, severity of pain, surroundings/environment etc

Some references did not conform to the journal format. Bracket symbol ( ) for reference in the text to be replaced with [ ].

For the CONSORT Flow diagram, group name, assessment period, outcome measure(s) to be included.

The write-up of the manuscript can be further improved in terms of grammar and presentations.

Reviewer #2: Very creative, interesting, and well done study. Congratulations! Sorry that you didn't get the results you were hoping for, but you have done an excellent job in analyzing the limitations and how such a study could be done differently to possibly achieve more positive results.

A few comments:

1. The term "painting" is used throughout. However, the list of materials used does not include paint (or paint brushes), which defines painting for many people. From the materials used, I believe the term "drawing" is more accurate. Thus, the title would be "The Effect of Exchanging Drawings...." and other replacements for "painting" and "paintings" made throughout the manuscript.

2. Page 10, Line 10, "an expert in art-therapy." In many countries the term art therapy means something very specific: Art therapy is a regulated mental health profession that requires a master's or doctoral level education in Art Therapy, clinical hours, supervision. and licensure. There is a credentialing and certification process. As I did not see art therapy credentials after any of the authors' names, I'm assuming that to say art therapy could be misleading to an international audience. The phrase "an expert nurse in the therapeutic use of the arts" would be more accurate and help to avoid confusion and criticism from the art therapy community.

3. A question: the children were instructed that they could draw whatever they wanted. Were the school children told that the purpose of the drawings were to try to make children in the hospital happy? Please clarify.

4. Gender bias: avoid the use of "he" in the general sense, instead use "he/she" or "he and she" or rewrite the sentence in the plural and using "they."

I encourage you to continue to explore and expand on this exciting peer to peer intervention.

Reviewer #3: The purpose of this study is to examine the effect of exchanging paintings with peers on the happiness of children ages 7-11 years using a clinical trial. It sounds like an innovative technique to improve the happiness of children; however, the study design could not provide convincing results for health professionals to further investigate if this technique would really work. Therefore, better study design is needed to improve children’s psychological health.

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Reviewer #1: No

Reviewer #2: No

Reviewer #3: No

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

17 Dec 2020

Response to reviewer

Dear Editor,

We are grateful for your meticulous review of this manuscript, and your suggestions, which have been very helpful in improving its quality. We also thank the reviewers for their careful reading and valuable suggestions. All the comments we received on this study have been addressed and replied separately. We hope that these changes to the manuscript will facilitate the decision to publish this study in your journal.

reviewer comments Correction and responses Page and place

editor . Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. corrected All file

Please include additional information regarding the survey or questionnaire used in the study and ensure that you have provided sufficient details that others could replicate the analyses. For instance, if you developed a questionnaire as part of this study and it is not under a copyright more restrictive than CC-BY, please include a copy, in both the original language and English, as Supporting Information. If the original language is written in non-Latin characters, for example Amharic, Chinese, or Korean, please use a file format that ensures these characters are visible. If the questionnaire can not be published CC-BY, please include a reference They are attached and explained in the text

Thank you for submitting your clinical trial to PLOS ONE and for providing the name of the registry and the registration number. The information in the registry entry suggests that your trial was registered after patient recruitment began. PLOS ONE strongly encourages authors to register all trials before recruiting the first participant in a study.

As per the journal’s editorial policy, please include in the Methods section of your paper:

1) your reasons for your delay in registering this study (after enrolment of participants started);

2) confirmation that all related trials are registered by stating: “The authors confirm that all ongoing and related trials for this drug/intervention are registered”.

Please also ensure you report the date at which the ethics committee approved the study as well as the complete date range for patient recruitment and follow-up in the Methods section of your manuscript.

Corrected and added in methods Page9

Thank you for stating the following in the Acknowledgments Section of your manuscript:

"This study was part of a M.S. thesis supported by Tehran University of

Medical Sciences grant NO 9311700002 and IRCT registration number:

IRCT20150928024239N4" Thanks

Added in cover letter about funding

We note that you have provided funding information that is not currently declared in your Funding Statement. However, funding information should not appear in the Acknowledgments section or other areas of your manuscript. We will only publish funding information present in the Funding Statement section of the online submission form.

Please remove any funding-related text from the manuscript and let us know how you would like to update your Funding Statement. Currently, your Funding Statement reads as follows:

"no"

Please include your amended statements within your cover letter; we will change the online submission form on your behalf.

Your ethics statement should only appear in the Methods section of your manuscript. If your ethics statement is written in any section besides the Methods, please move it to the Methods section and delete it from any other section. Please ensure that your ethics statement is included in your manuscript, as the ethics statement entered into the online submission form will not be published alongside your manuscript.

Corrected Page 11

Please include captions for your Supporting Information files at the end of your manuscript, and update any in-text citations to match accordingly Corrected

Reviewer 1 Page 6, information on the sample size calculation to be provided i.e. alpha, beta, 1 or 2 tailed test, outcome measure, attrition rate consideration etc

Corrected Page7

Page 6, information on who prepared the randomization block (sequence generation/allocation, concealment) and assigned to the groups to be clearly stated.

Corrected Page7

Page 6, the word control group or peer group to be used systematically. The write-up on the subjects selection to be placed on top first before the randomization process. Corrected Page 7 &8

Page 7, the sentence 'The exclude their data from analysis for both groups consisted of absence from more than two sessions of painting or death of the child.' to be revised.

Corrected Page 8

Page 7, the language version of the Children's Happiness Scale used in the study to be stated. If it is Iranian version the validation information to be provided/cited.

Corrected Page8 &9 and supplement in the article the original version of tool

Page 7, information on blinding (providers, subjects, person assessing the outcome) to be stated.

Corrected Page12

Page 7, is the lowest score for Children's Happiness Scale 1.67 or 1.68?

Corrected Page8

Page 7, for the reliability test of the scale, the exact name of the correlation test to be stated. The range of the correlation values to be provided.

Corrected Page 9

Page 10, the sentence ‘In this cases were sent peer’s painting through email’ & ‘Researcher ask their to draw a painting’ to be revised.

Corrected Page12

Page 10, a sub-title for the statistical analysis to be provided.

Corrected Page 12

Page 10, proper citation of SPSS and publisher name to be provided. The use of the independent T-test, the Chi-square test, Fisher's exact test and the paired T-test and its purpose to be clearly stated.

Corrected Page 12

The acceptance level of significance to be stated. Corrected Page 12

Page 10, study limitation to be placed in the discussion section.

Corrected Page 17

Page 12, Kolmogorov-Smirnov test to be stated in the statistical analysis section.

Corrected Page 12

Page 12, the results with no significant differences in the children's happiness before and after painting in the control group to be stated in the text.

Corrected Page 13

Page 12, the write-up of the results section is too short.

Yes of course but I explain all criteria in tables

Page 19 N for each group to be stated for Table 1 and 2. Corrected In the file of table was corrected

Page 19 Table 1, the alignment of the table and words to be improved. Decimal point for p value to be provided and standardized. Chi-square test, Fisher’s Exact Test to be denoted in table/table footnote. Symbol % for individual figure to be omitted since it has been highlighted in the group name. Word P value to be stated in the last column.

Corrected In the file of table was corrected

Page 19 Table 2, t-statistic value, df to be placed in another column/row from the p value. Alignment of the table and words to be improved.

corrected In the file of table was corrected

It would be good to display/describe the number of subjects who were not happy/happy before intervention and after intervention other than describing the mean score of the scale.

The scale did not have a cutoff point to determine happy/unhappy children and only reported the mean level of happiness. Therefore, the research team could not divide the children into happy and unhappy groups.

Page 12 & 19, the focus to be more on within group comparison rather than comparison between the groups at each time period since the two groups of subjects are different. Mean difference (pre-post) from each group could be used for between group comparison. Effect size i.e. Cohen’s d and 95% confidence interval to be provided.

corrected Do in the file of table 2

Page 19, more baseline characteristics of the study subjects to be provided such as types/ severity of cancer (stages), type of medications, severity of pain, surroundings/environment etc

We collected and recorded the data that we found in the patients’ files such as the type of cancer (they were all ALL) and that all underwent chemotherapy, but no other information was recorded in their files and unfortunately, we could not report other data. Table 1 in the file of table

Some references did not conform to the journal format. Bracket symbol ( ) for reference in the text to be replaced with [ ].

Corrected

For the CONSORT Flow diagram, group name, assessment period, outcome measure(s) to be included. Corrected In the file of consort was attached

The write-up of the manuscript can be further improved in terms of grammar and presentations Did it In the all section of manuscript

Reviewer 2

Very creative, interesting, and well done study. Congratulations! Sorry that you didn't get the results you were hoping for, but you have done an excellent job in analyzing the limitations and how such a study could be done differently to possibly achieve more positive results.

Thanks for attention I hope in future research we reduce limitation and get positive results

. The term "painting" is used throughout. However, the list of materials used does not include paint (or paint brushes), which defines painting for many people. From the materials used, I believe the term "drawing" is more accurate. Thus, the title would be "The Effect of Exchanging Drawings...." and other replacements for "painting" and "paintings" made throughout the manuscript.

Corrected In the manuscript

2. Page 10, Line 10, "an expert in art-therapy." In many countries the term art therapy means something very specific: Art therapy is a regulated mental health profession that requires a master's or doctoral level education in Art Therapy, clinical hours, supervision. and licensure. There is a credentialing and certification process. As I did not see art therapy credentials after any of the authors' names, I'm assuming that to say art therapy could be misleading to an international audience. The phrase "an expert nurse in the therapeutic use of the arts" would be more accurate and help to avoid confusion and criticism from the art therapy community.

Thanks for your valuable points. All the mentioned points are correct and the manuscript was modified accordingly. Page 12

A question: the children were instructed that they could draw whatever they wanted. Were the school children told that the purpose of the drawings were to try to make children in the hospital happy? Please clarify. No, school children were only told to draw some pictures for children with cancer. The study objectives were explained to children and their parents when we were going to obtain informed consent.

Gender bias: avoid the use of "he" in the general sense, instead use "he/she" or "he and she" or rewrite the sentence in the plural and using "they."

Corrected Page 8

I encourage you to continue to explore and expand on this exciting peer to peer intervention.

Thank you for your kindness and valuable suggestion.

The purpose of this study is to examine the effect of exchanging paintings with peers on the happiness of children ages 7-11 years using a clinical trial. It sounds like an innovative technique to improve the happiness of children; however, the study design could not provide convincing results for health professionals to further investigate if this technique would really work. Therefore, better study design is needed to improve children’s psychological health.

________________________________________ Thanks for your great advice. The researchers noticed limitations during this study, too, which are mentioned in the Limitations section. Since this was the first experience of this kind of study in Iran, it certainly had some shortcomings that we hope will be eliminated in the future studies with improved designs. Nonetheless, we tried to clarify the ambiguities in the methods section during revision.

Best: Sadat Hoseini

Submitted filename: Response to reviewer.23-8.docx

Click here for additional data file.

13 Jan 2021

PONE-D-20-10349R1

The effect of exchanging drawings with peers on the happiness of children with cancer, ages 7-11 years: Clinical trial

PLOS ONE

Dear Dr. Sadat Hoseini,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

All the reviewers acknowledged the improvement in te paper, but still there are aspects (such the writing) that needs major work. Please consider are fully the suggestions of the reviewers.

Please submit your revised manuscript by February 10th. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.

A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.

An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: http://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols

We look forward to receiving your revised manuscript.

Kind regards,

Andrea Martinuzzi

Academic Editor

PLOS ONE

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: (No Response)

Reviewer #2: (No Response)

Reviewer #3: All comments have been addressed

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Partly

Reviewer #2: Yes

Reviewer #3: Partly

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: No

Reviewer #2: Yes

Reviewer #3: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: No

Reviewer #3: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Comments

Table 1, if the expected cells less than 5 more than 20% e.g. 'variable 'interested in drawing'' chi-square test is not suitable. Decimal point for p value to be standardized. At least one decimal point for percentage value, Cohen D to be denoted in table footnote or in statistical analysis section for what comparison. 'No'' to be replaced with n.

Table 2, the row for the paired t-test to be placed in the last row after mean difference. Decimal point for p value, SD, t value to be standardized. (%95Confidence Interval to be written as 95% Confidence Interval. *T-Test to be replaced with *Independent t-test

Ensure all the statistical tests used in the study are stated in the statistical analysis section.

Reviewer #2: The revision brings more clarity regarding the intervention and other methods. Several instances of "painting" have not been changed to "drawing" e.g., page. 9, line 15, page 10, line 14, page 15, lines 10 and 12, and perhaps others. Gender bias remains, page 11, line 5. Also check for typos. In the discussion session, some examples are given e.g., reference 38) that were facilitated by art therapists, which could account for success because although it may look the same, the process and goals can be different. If art therapy examples are going to be used, the difference needs to be identified.

Reviewer #3: Thank you for addressing the reviewers comments in your paper. The revised version has improved a greatly deal comparing with the previous version. However, much improvement, especially in academic writing is needed for the future revision. I attached the detailed comments for your reference.

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: No

Reviewer #2: No

Reviewer #3: No

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

18 Mar 2021

Response to reviewer

Dear Editor,

We are grateful for your meticulous review of this manuscript, and your suggestions, which have been very helpful in improving its quality. We also thank the reviewers for their careful reading and valuable suggestions. All the comments we received on this study have been addressed and replied separately. We hope that these changes to the manuscript will facilitate the decision to publish this study in your journal.

Reviewer 1

comment answer place

Table 1, if the expected cells less than 5 more than 20% e.g. 'variable 'interested in drawing'' chi-square test is not suitable. Decimal point for p value to be standardized. At least one decimal point for percentage value, Cohen D to be denoted in table footnote or in statistical analysis section for what comparison. 'No'' to be replaced with n. Was corrected Page 23 table 1

And file table

Table 2, the row for the paired t-test to be placed in the last row after mean difference. Decimal point for p value, SD, t value to be standardized. (%95Confidence Interval to be written as 95% Confidence Interval. *T-Test to be replaced with *Independent t-test Was corrected Page 23 table 2

And file table

Ensure all the statistical tests used in the study are stated in the statistical analysis section. Was added

using the independent t-test and paired t-test for comparison of the happiness scores between the two groups , the Chi-square test for comparison of the demographics, Fisher’s exact test for interest in drawing and paired t-test for comparison of the happiness scores in each group Page 13

Reviewer2

The revision brings more clarity regarding the intervention and other methods. Several instances of "painting" have not been changed to "drawing" e.g., page. 9, line 15, page 10, line 14, page 15, lines 10 and 12, and perhaps others. All of them was changed

I hope did all of them and have not mistake whole of paper

Gender bias remains, page 11, line 5. Also check for typos. Was corrected

The drawing intervention sessions were held after the child had received their medications and been visited by the doctors to avoid disturbing the child during the process of drawing.

Page 11

In the discussion session, some examples are given e.g., reference 38) that were facilitated by art therapists, which could account for success because although it may look the same, the process and goals can be different. If art therapy examples are going to be used, the difference needs to be identified. Was corrected

Although the process and goals of drawing therapy and drawing are not similar, this research showed benefit of the process of drawing for reducing behavior problems. Page 16

Reviewer3

Thank you for addressing the reviewers comments in your paper. The revised version has improved a greatly deal comparing with the previous version. Thanks for attention

However, much improvement, especially in academic writing is needed for the future revision. I attached the detailed comments for your reference. Was reedited

Unfortunately I did not received attach file. I send some email but I cannot get it. Whole of paper

Submitted filename: Response to reviewer.plos-palvan 28-12.docx

Click here for additional data file.

31 Mar 2021

PONE-D-20-10349R2

The effect of exchanging drawings with peers on the happiness of children with cancer, aged 7-11 years: A clinical trial

PLOS ONE

Dear Dr. Sadat Hoseini,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

Please address the last minor changes requested by the reviewers.

Please submit your revised manuscript by April 15th If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.

A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.

An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: http://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols. Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols.

We look forward to receiving your revised manuscript.

Kind regards,

Andrea Martinuzzi

Academic Editor

PLOS ONE

Journal Requirements:

Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: All comments have been addressed

Reviewer #2: (No Response)

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Partly

Reviewer #2: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: (No Response)

Reviewer #2: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: No

Reviewer #2: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Minor comments

The derived p value whether based on 1 or 2-tailed test to be stated.

List of references did not conform to the journal format.

Reviewer #2: Good revision! Instead of recommending "Minor Revision", my recommendation would more accurately be "Accept Pending." Just a few comments:

Page 12, line 5, “force” sounds too aggressive; suggest using “encourage.”

Page 14, line 8, change uppercase N to lower case n because it represents part of the total sample, N = 66, n =33.

Page 17, line 7-8, “brief the children’s teachers and parents on the study objectives…” Were the children told than an objective of the study was to make children with cancer happier?

Page 19, line 9, typo “ad” to “and”

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: No

Reviewer #2: No

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

1 Apr 2021

Response to reviewer

Dear Editor,

We are grateful for your meticulous review of this manuscript, and your suggestions, which have been very helpful in improving its quality. We also thank the reviewers for their careful reading and valuable suggestions. All the comments we received on this study have been addressed and replied separately. We hope that these changes to the manuscript will facilitate the decision to publish this study in your journal.

Reviewer1

comments answer place

The derived p value whether based on 1 or 2-tailed test to be stated. Was corrected In statistical section and table 2

List of references did not conform to the journal format. All references conform to the journal format and some mistake was corrected and one reference was deleted for duplication write References section

Reviewer2

Page 12, line 5, “force” sounds too aggressive; suggest using “encourage.” Was corrected Page 5

Page 14, line 8, change uppercase N to lower case n because it represents part of the total sample, N = 66, n =33. Was corrected Page 7

Page 17, line 7-8, “brief the children’s teachers and parents on the study objectives…” Were the children told than an objective of the study was to make children with cancer happier? Base on the consent form of TUMS the research team must be explain purpose and subject of research to participant and they must be sign this form .” I, , have been explained about the purpose & objectives of this research and I am aware of them. The purpose& objectives are as follows: This Survey is about the Effect of Exchanging Paintings with Peers on the Happiness of Children with Cancer” The consent form was attached the time of submission.

If it is necessary, I can write on the manuscript this sentence.(in the box of answer). Currently, I write on the manuscript “. A meeting was then arranged to brief the children’s teachers and parents on the study objectives and methods”.

Page 19, line 9, typo “ad” to “and” Was corrected

Journal Requirements:

Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice. All references was checked and conform to journal form.

One of the references was deleted for retyping

Some references were corrected and others were updated

All change show with highlighted References section

1. Jafroodi M. Epidemiologic evaluation of pediatric malignancies in 17 Shahrivar Hospital. Journal of Guilan University of Medecine Science. 2000;68:14-21. Persian.

2. Redig A, McAllister S. Breast cancer as a systemic disease: a view of metastasis: a view of metastasis. Journal of internal medicine. 2013;4(2):113-26.

3. Holder M, Coleman B, Singh K. Temperament and happiness in children in India. Journal of Happiness Studies. 2012;13(2):261-74.

4. Katz C, Hamama L. Draw me everything that happened to you”: Exploring children's drawings of sexual abuse. Children and Youth Services Review. 2013;35(3): 877-82.

5. Mehranfar M, Younesi J, Banihashem A. Effectiveness of mindfulness-based cognitive therapy on reduction of depression and anxiety symptoms in mothers of children with cancer. Iran J Cancer Prev. 2012;5(1):1-9. Epub 2012/01/01. PubMed PMID: 25780532; PubMed Central PMCID: PMCPMC4352519 Persian..

6. Verkooijen HM. [Happiness and cancer]. Ned Tijdschr Geneeskd. 2012;156(51):A5752. Epub 2012/12/20. PubMed PMID: 23249517.. Dutch.

7. Rogers MA, Zaragoza-Lao E. Happiness and Children’s Health: An Investigation of Art, Entertainment, and Recreation. Am J Public Health. 2003;93(2):288-9. doi: 10.2105/ajph.93.2.288.

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The effect of exchanging drawings with peers on the happiness of children with cancer, aged 7-11 years: A clinical trial

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7 Oct 2021

PONE-D-20-10349R3

The effect of exchanging drawings with peers on the happiness of children with cancer, aged 7-11 years: A clinical trial

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