The reality we encounter in pediatric hospitals is intertwined with many variables: on the one hand, the situation of families, who feel overwhelmed by their child's hospitalization, and the children, who experience many things that can lead to pain and suffering. Pediatric patients, especially the youngest ones, lack the emotional maturity necessary to understand, assimilate, and manage everything they are experiencing.
The work objectives are mainly two:
- Reduce anxiety and stress in children and their families by facilitating emotional expression and promoting positive changes in mood.
2. Reduce the perception of pain.
We work with live music, based on research that supports this methodology. The intervention techniques we use include live music listening, song repertoire work, and musical improvisation.
Music therapy is the clinical intervention using music to achieve therapeutic goals by a licensed professional. It is a stable healthcare profession that utilizes music and the therapeutic relationship to treat the patient's physical, psychological, cognitive, emotional, and social functions. Studies have shown very favorable results when interventions are aimed at reducing pain, anxiety, and depression. Music therapy is particularly adaptive to all human conditions. Music has the ability to energize or relax, facilitate thought or distract our attention. It helps us connect with reality or facilitate spaces for developing creativity and fantasy. Music therapy sessions promote emotional expression by giving meaning to an individual's personal circumstances. In Spain, the discipline is at the beginning of its proliferation, initially demonstrating its potential to healthcare personnel and conducting research to consolidate it. Currently, different teams of music therapists work in hospitals in Barcelona and Madrid with adults and children in different services.
Hospital context
The situation facing families in the hospital is complex, and each family experiences it differently. But it is a reality and a common aspect that when a child is hospitalized, parents feel overwhelmed. Parents take turns being with their child and receive support from family, friends, and organizations. At the time of hospitalization, they focus all their energy on their sick child. The entire family enters a crisis, and changes occur throughout its structure: in siblings, parents, grandparents, and the hospitalized child. The crisis is underpinned by the fear, anxiety, and helplessness that everyone carries in the face of a situation they cannot manage, in which they play little active role, and which, ultimately, overwhelms them. They are in a space where they believe they can do nothing, because they are not doctors or nurses, and they have no knowledge of what is happening to their child, nor do they know what could happen to them. How can they successfully navigate this situation that provokes feelings of guilt, anxiety, and fear... not knowing very well how to approach your children?
Likewise, children also experience all of this in addition to the feeling of loneliness due to normalized social isolation. Furthermore, they are living in an unfamiliar and uncomfortable environment, where they endure many experiences that can lead to pain and suffering. Surgery, ICU stay, isolation ward, rehabilitation, medication, treatment, the comings and goings of medical personnel... A constant bombardment of sensory stimuli and completely mechanized areas where children are passive subjects of their healing process. Children, especially young children, lack the emotional maturity necessary to understand, assimilate, and manage everything that is happening to them and around them. There is extensive documentation showing that hospitalization is one of the most stressful aspects a child can experience (Langford, 1961; Belmont, 1970; Menke, 1981; Froehlich, 1984, in Dun 1995). For hospitalized children, music therapy can be an alternative means of communication, as it gives them the opportunity to express their emotions without, in principle, having to put them into words. Sometimes, it is difficult for children to explain what their experience is like, especially for very young children, since their language skills are not yet developed (McDonnell, 1984, in Dun, 1995). Studies indicate that infants under three months of age show symptoms of anxiety when separated from their mothers. Separation in children as young as six months can produce states of distress or continuous crying (Petrillo and Sanger, 1980, in Marley, 1984). Young children between one and three years of age show a great deal of stress during separation. At this age, their dependence on their mothers is very strong. Their greatest fear is being abandoned (Petrillo and Sanger, 1980, in Marley, 1984).
Music therapy sessions provide an experience for children and their families that helps them normalize and become familiar with the strange and sometimes hostile hospital environment. The experience with music gives them the opportunity to interact with situations unrelated to the hospital world, providing positive stimulation and a sense of security because they are an active part of something: singing, playing instruments, or moving to the rhythm of the music.
Once we are aware of all the cognitive, physical, and emotional variables surrounding children and their families in the hospital setting, we can plan objectives for music therapy intervention.
Work objectives
- Reduce anxiety and stress in children and their families by facilitating emotional expression and promoting positive changes in mood.
Many parents express the feeling of being unable to help, or of being unable to do anything for their children. Healthcare personnel are treating their children while they, those who know them best, are unable to assist. Therefore, it is important to involve parents in music therapy sessions. To assist children who cannot speak to the music therapist, parents are asked about their favorite songs and what music they listen to at home, and are invited to join the session. When invited, they usually respond affirmatively. On the one hand, it helps them feel useful by actively doing something positive for their child. Furthermore, it gives them the opportunity to interact with their child in a way that is different from what is usual in a hospital setting. Creativity, play, and music activate mechanisms that help alleviate the stress and anxiety they are experiencing.
“Music therapy has been used with hospitalized children to provide relief and security and a sense of normalcy for patients and their families. It can also be very helpful in reducing stress for both families and patients” (Bailey, 1986, in Dun 1995)
“Listening to your musical preferences has been shown to be effective in reducing stress and increasing relaxation in a study where the main stimulus was musical listening” (Davis and Thaut, 1989, in Dun 1995)
In addition, reducing anxiety helps you feel more in control of the situation.
2. Reduce the perception of pain
The factors that affect the perception of pain according to Wepman are the following:
Cognitive factors: positive or negative expectations of pain and feelings of control or helplessness.
Emotional factors: anxiety and “vigilance,” which is a survival mechanism closely linked to anxiety and causes an increase in the perception of stimuli.
Symbolic factors: They play an important role in the perception of pain, when the pain has special symbolic connotations.
It could be argued that the pain threshold depends largely on the patient's mood and emotional state. These factors are the basis for music therapy research and treatment. Music can be used to reduce the perception of pain as an active focus of attention or as a distraction using positive ambient musical stimuli.
“Using a musical stimulus during a medical intervention significantly reduces the perception of pain by distracting the patient towards the musical stimulus.” (Malone, 1996)
Sound stimulation as a form of pain control is used in various hospital settings. The use of music as an effective pain reliever is known as "audioanalgesia." Its effectiveness has been demonstrated in dental surgeries, and its effectiveness is currently being tested in other settings (Gadner et al. 1960).
“The beneficial effect of music was observed in children during the postoperative period of heart surgery, on heart rate, lung capacity, and pain reduction (using the Facial Pain Scale). However, more in-depth studies are needed” (Hatem et al. 2006).
The immersive musical stimulation, tailored to the child's tastes, shifts the pain threshold, creating a calm and more relaxed atmosphere during the procedure, which also facilitates the work of the medical staff. In this way, and whenever the medical staff requests it, we have provided musical accompaniment during catheter and intravenous line removal, treatment, and the performance of various nursing procedures. Through music, a different atmosphere is created, where music is the means of expression and channeling of pain.
Work at the plant
Preliminary phase
Case information under nursing supervision: The music therapists' work is supported by hospital staff and those responsible for the pediatric cardiology department. This facilitates their work, making it easier and more effective.
Upon arrival at the ward, they meet with the nurses who can care for us at that time and inform us about the situation that day. They inform us about the children admitted and their condition, any new discharges and/or discharges, and they indicate the ideal candidates for music therapy that day. Priority is typically given to the following cases:
Children under two years old.
Long-stay hospitalized children who have undergone the Fontan procedure.
Children who have just been admitted to the ICU or are about to be taken to the operating room.
Children suffering from withdrawal syndrome.
Children who are going to have a specific intervention that afternoon: dressing, changing an IV line, removing a catheter, etc.
Children with symptoms of weakness, nervousness, anxiety or depression.
We record the information on forms, keeping the patient's personal data anonymous:
Age and sex.
Reason for intervention: Nervousness, lack of sleep, SA, depression…
The patient's current situation: before or after surgery, whether they are accompanied, long or short stay, etc.
Information for families and informed consent: Each of the families to be served is explained what our work entails, the specific goals we hope to achieve with the intervention, and how we will implement them. Any questions we may have are addressed, and the family members decide whether they want us to participate or not. If the answer is affirmative, they must sign an informed consent form, which will be filed with the intervention documentation, such as the monitoring and vital signs records.
Before starting the session, we briefly speak with the child if they have language skills, to conduct a preliminary assessment of their physical and mental abilities. We also speak with family members, asking them if they'd like to do anything special musically: a specific song, a specific style, etc. We've had different situations in this regard, such as children learning a musical instrument, another young man passionate about flamenco who was studying guitar, parents who are fans of classical music, and, of course, current hits.
Session development
With all the information previously gathered at the medical and psychological levels, and taking into account the specific moment the child and family are experiencing, we decide what we believe the patient needs and what is the best intervention to perform:
Instrumentation of songs.
Instrumental improvisations: melodic or percussion.
Vocal improvisations: with or without text.
Specific songs.
Activities that involve movement or body expression.
Music to induce sleep.
Song creation.
Musical relaxation, etc.
During the session, the monitor is monitored for any significant changes in the patient's vital signs that should be recorded or evaluated later.
Information gathering and monitoring
After each intervention, the session is evaluated by completing two forms: one medical and one specific to music therapy and the patient's approach. In the medical form, we primarily consider heart and respiratory rates, as well as oxygen saturation. The values before and after the intervention are recorded. In the music therapy form, we note the activities we performed and describe the musical nature of the session and the patient's response: tonality, scales, tempo, rhythm, dynamics, etc., and how it affected the patient's mood, emotion, relaxation, or activation. Everything is recorded and archived.
Music therapy techniques
Importance of live music: Live music can be tailored to the present moment and immediately adapt to what is happening at that moment, to the rhythm of each child or group participating in the session. This allows for a richer sound impact and allows all participants to access the music regardless of their internal rhythm, tonality, and accompanying physical and/or cognitive reality. In music therapy, the priority is to be able to guide the patient's needs and problems through music. Thus, music is selected or created for its clinical relevance, usefulness, and appeal to the subject (Patxi del Campo, 2000). Furthermore, musical quality encourages participation by creating creative and rewarding experiences.
In the hospital setting, we work with live music instead of recorded music, based on research that supports this methodology. These studies compare values such as anxiety, vigor, tension, fatigue, and so on before and after a music therapy session with recorded or live music. The changes in these values are much more significant when the session includes live music.
With live music, the music therapist can interact with the patient, instantly becoming aware of every change they experience. This constant feedback helps us incorporate the necessary changes to achieve the proposed goal.
Techniques used
Musical Improvisation: In musical terms, improvisation is defined as the art of spontaneously creating music while playing, rather than performing a pre-written composition. Improvisation as a technique is used in various clinical settings, including hospital settings. Improvisation is an active technique, where the patient and therapist play together. Although musical listening has clinical benefits, active and improvised music-making engages the child's attention, leads to active and personal engagement, and allows for emotional expression in an artistic and creative way (Kenneth Bruscia, 1999). The flexibility of improvisation does not require musical aptitude to participate, so it is not limited to any age group or developmental level (Kenneth Bruscia, 1999).
Live Musical Listening: In this technique, the patient plays a passive role, as it does not involve any specific performance. They do not play instruments or sing, but rather play a more receptive role. Music therapists play or sing, capturing the mood of the present moment and guiding the musical activity. Musical listening can be very effective as a relaxation guide or sleep aid. The patient's preferences and usual listening environment (family musical preferences or habits), age, etc. are assessed. Music that promotes relaxation is chosen. For example, a steady, slow beat, long chords, or notes with a predictable structure and form can promote slow, deep breathing.
A wide variety of musical styles and structures are used. We strive to offer the broadest and most varied range of possibilities possible to reach all types of patients, regardless of their background, age, social status, abilities, or pathology. Depending on each specific session, we will use stimulating or sedative music, sad or happy music, based on high or low tones, minor or major tones, and a variety of styles, from jazz, flamenco, pop, classical, and more, from older songs to the latest hits. The choice within this mix will depend on the patient's needs at that moment and the goal to be achieved.
Literature
Betés del Toro, M., et al. (2000): “Fundamentals of music therapy”. Morata.
Bruscia K. (1999): “Models of improvisation in music therapy”. Vitoria: Agruparte.
Egfeller, K., B. Davis, W., Thaut, M. (2000): “Introduction to music therapy theory and practice”. Boileau.
Thayer Gaston, E., et al. (1989): “Treatise on Music Therapy”. Paidós.
Yoshiko, F. (2006): “Music therapy for asthma.” Art and Process.
Beth Dun (1995): “A Different Beat: Music Therapy in Children's Cardiac Care.” Royal Children's Hospital, Melbourne, Australia. Music Therapy Perspectives, vol.13, (35 – 39)
Collen A. Lorch, Vochien Lorch, Allan O. Diefendorf, Patricia W. Earl (1994): “Effect of Stimulative and Sedative Music on Systolic Blood Pressure, Heart Rate, and Respiratory Rate in Premature Infants.” University of Tennessee Medical Center Knoxville. Journal of Music therapy, XXXI (2), (106 – 118).
Driskell Chetta, H. (1981): “The Effect of Music and Desensitization on Preoperative Anxiety in Children.” The Florida State University. The Journal of Music Therapy, XVIII (2), (74 – 87)
Gardner, WJ, Licklider, JCR, & Weisz, AZ (1960): “Suppression of pain by sound.” Science, 132, (32-33).
Malone, AB (1996): “The effects of live music on the distress of pediatric patients receiving intravenous starts, venipunctures, injections, and heel sticks.” Florida State University. Journal of Music Therapy, 33(1), 19-33.
Mangeil Bailey, L. (1983): ”The Effects of Live Music versus Tape-Recorded”. Memorial Sloan-Kettering Cancer Center. Music Therapy; The Journal of the American Association of Music Therapy VOL. 3, No. 1, (17 – 28).
Marley, Linda S. (1984): “The Use of Music with Hospitalized Infants and Toddlers: A Descriptive Study.” Miller Children's Hospital, Long Beach. Journal of Music Therapy, XXI (3), (126 – 132).
Thamine P. Hatem, Pedro IC Lira, Sandra S. Mattos (2006): “The Therapeutic Effects of music in Children following cardiac surgery.” Journal of Pediatrics. (Rio, J.) 84 (3), (186 – 92)
Sheri L. Robb, Ray J. Nichols, Randi L. Rutan, Bonie L. Bishop, Jayce C. Parker (1995): “The Effects of Music Assisted Relaxation on Preoperative Anxiety.” Shrinars Burns Institute, Galveston, Texas. Journal of Music Therapy, XXXII (1), (2 – 21)
"World Federation of Music Therapy. Definition of Music Therapy." www.musictherapyworld.de (January 20, 2003).
Text revised and adapted by Cristina Oroz Bajo
Original documentation in MUSE