Effects of Dyadic Parent–Child Mandala Painting During Chemotherapy on Caregiver Burden Psychological Well-being and Child Fear and Pain: A Randomized Controlled Trial

INTRODUCTION: Chemotherapy places a dual burden on pediatric patients and their caregivers, yet few non-pharmacological interventions simultaneously target both. This study aimed to evaluate the effectiveness of a dyadic parent–child mandala coloring intervention on caregiver burden, psychological well-being, and children’s fear and pain during chemotherapy.
METHODS: In this two-arm, parallel-group trial, 54 parent–child dyads involving children aged 5–12 years receiving chemotherapy were randomly assigned to either a six-session mandala coloring intervention delivered over two weeks or standard care. Outcomes were assessed using the Wong–Baker Faces Pain Scale, Children’s Fear Scale, Zarit Caregiver Burden Scale, and Depression Anxiety Stress Scale-21 (DASS-21). Data were analyzed using independent t-tests, ANCOVA, and effect size calculations.
RESULTS: Groups were homogeneous at baseline. Post-intervention, the mandala group showed significantly lower pain (mean 2.14 vs. 3.14; p < 0.001; d = 0.74) and fear scores (mean 1.55 vs. 3.85; p < 0.001; d = 0.76) compared to controls. Caregiver burden decreased markedly (mean 58.14 vs. 73.92; p < 0.001; d = 0.81). Parental depression, anxiety, and stress scores improved significantly, with the largest effect in stress (d = 0.68). Improvements remained significant after adjusting for baseline anxiety.
DISCUSSION AND CONCLUSION: Dyadic mandala coloring during chemotherapy significantly reduced children’s fear and pain while improving parental well-being and caregiver burden. The intervention is low-cost, feasible, and aligns with family-centered pediatric oncology care. Its dual focus offers a novel, holistic approach for integration into routine supportive care protocols.

Keywords: Caregiver burden, Mandala coloring, Pediatric oncology, Psychological well-being, Randomized controlled trial, Fear, Pain