Music Therapy and Child Life: Collaborating Goals and Interventions

to Effectively Promote the Psychosocial

Development of Pediatric Patients during Hospitalization

Katherine E. Goforth, MM, MT-BC, NICU MT

Presentation Objectives Define the profession and role of music therapy within

the pediatric medical setting.

Understanding of evidence-based music therapy interventions to achieve non-musical goals related to physiological and psychosocial goals of pediatric patients during hospitalization.

Educate upon implications of music therapy and child life collaborative outcomes in pediatric patients during hospitalization through evidence-based research.

Learn how collaboration occurs, identifying needs for collaboration and frequency of collaboration.

WHAT IS MUSIC THERAPY?

“Music Therapy is the clinical and evidence-based use of music interventions to accomplish

individualized goals within a therapeutic relationship by a credentialed

professional who has completed an approved music therapy program

(AMTA, 2015).”

ROLE OF PEDIATRIC MUSIC THERAPIST 1. Assess and implement evidence-based music interventions

within an individualized or group setting to achieve non-musical goals of pediatric patients during hospitalization.

2. Document patient progress towards physiological and/or psychosocial goals in Electronic Medical Record (EMR).

3. Advocate for optimal physical and comfort of pediatric patients and families.

4. Serve as a member of the interdisciplinary team.

5. Serve as internship supervisor through the development, coordination and implementation of a medical music therapy internship for graduate and undergraduate level students.

6. Participate and earn Music Therapy Continuing Education (CMTE) credits to facilitate professional growth and development.

MUSIC THERAPY PHYSIOLOGICAL AND PSYCHOSOCIAL OUTCOMES

Music can be utilized as an anxiolytic medium as a method of distraction, relaxant and to promote sleep by creating a peaceful environment.

Music affects the body via entrainment.

Music affects the sympathetic nervous system and therefore reduces: heart rate, respiration rate, oxygen saturation, metabolism, muscle tension, gastric and sweat gland activity.

Reduced heart and respiration rates lead to less anxiety and facilitate relaxation and elevate mood.

Music enhances the parent/caregiver relationship to the patient.

Music utilized as a distraction technique decreases procedural anxiety and perceived pain during painful procedures.

Patient preferred music is most effective.

(Austin, 2010)

MUSIC THERAPY IN THE PEDIATRIC MEDICAL SETTING: WHAT WE KNOW

Primary Goals: Pain Reduction and ManagementAnxiety ReductionIncrease Coping SkillsNausea ReductionChemotherapy SupportHemodialysis SupportElevate MoodReduce Developmental Regression Reinforce Developmental Milestones

(Standley & Whipple, 2003)

WHAT WE KNOW – Continued

MT actively elicit engaging behaviors at a greater frequency than other hospital activities while providing a supportive and therapeutic environment. (Robb, 2000)

A single 30 minute music therapy session have been found to significantly increase the salivary immunoglobulin A (IgA) antibody in pediatric oncology patients prior to induction of chemotherapy. (Lane, 1996)

WHAT WE KNOW – Continued

Through evidence-based musical structured play activities, a pediatric patient’s environment is normalized to promote goals related to:

Psychological

Social

Physiological

(Bishop, Christenberry, Robb, & Rudenberg, 1996)

PEDIATRIC PAIN REDUCTION AND MANAGEMENT

Non-pharmacological Interventions

Examples:

Visual and Auditory Distraction

Procedural Preparation

Tactile Stimulation

Breathing Exercises

Positive Reinforcement,

Behavior Rehearsal

Guided Imagery

(Kallay, 1997; McCready, Macdavitt, & O’Sullivan, 1991)

Evidence-Based Research

Whitehead, Zebrowski, Baryza, and Sheridan (2007) investigated the effects of music on pediatric procedural pain.

Qualitative Data: Interviews were conducted with the subject, parent/guardian, nurse and the pediatric music therapist to assess perception of pain, anxiety, relaxation, compliance, and satisfaction.

Quantitative Data: Measured before, during and after each procedure to access pain, anxiety and physiological measure.

Results from the study concluded:Active engagement in music therapy reduced

behavioral distress in pediatric patients during procedures.

Subjects fifteen years and older experienced the greatest effects from music therapy, as well as twelve year old subjects in behavioral distress.

Subjects eight years old experienced little benefit from music therapy for behavioral distress.

Established MT Procedural Protocols Implemented: Patients experiencing acute or chronic pain and/or undergoing medical procedures.Goals:Redirect a patient’s attention away from the pain and anxiety.

Engage focus of attention to the music. Efficacy: Each protocol’s effectiveness is measured by patient self-report of pain and anxiety,

Heart rate, pulse rate, verbal feedback from patient and family, and behavioral observations by staff.

Song Phrase Cued Response (SPCR)

Adapted Progressive Muscle Relaxation (APMR)

Music Based-Imagery (MBI)

Relaxation Response Elicitation (RRE)

(Prensner, Yowler, Smith, Steele, & Fratianne, 2001)

PEDIATRIC ANXIETY REDUCTION

Procedural Support

Goals: Decrease anxiety Decrease perceived pain Decrease amount or use of sedation

Support may begin before, during or after the pediatric patient’s medical procedure.

Before a medical procedure, procedural support includes education, relaxation and breathing exercises paired with music to assist with coping.

During procedural support, music is implemented through the use of distraction and the iso-principle.

Distraction: Utilizes patient preferred live music to refocus attention away from medical procedures to a non-threatening stimulus.

Iso-principle: Matches the patient’s anxiety or behavioral state to facilitate change to the desired patient anxiety or behavioral level through the use of live music.

Following the procedure, music interventions may continue to soothe the patient who has lost the ability to effectively utilize coping skills independently.

(Turry, 1997; Walworth, 2003)

PEDIATRIC ANXIETY REDUCTION-Continued

Preoperative Preparation

Goals: Preoperative Education Relaxation techniques

Pediatric Patients Fears…medicationsneedlespaindisfigurementseparationloss of controldeath

(Chetta,1981; Jarred, 2003; Robb, Nichols, Rutan, Bishop & Parker, 1995)

EVIDENCE-BASED RESEARCH Robb, Nichols, Rutan, Bishop & Parker (1995) investigated the

use of Music Assisted Relaxation (MAR) on preoperative anxiety.

Measured the decrease in physiological indicators of stress.

Control Group: Pediatric patients received standard preoperative instruction that did not include music.

Experimental Group: Pediatric patients MAR interventions during preoperative preparation. ◦ Music listening, Deep Diaphragmatic Breathing, Imagery and Progressive Muscle

Relaxation.

Results:

Significant decrease for anxiety was found in the experimental group who received MAR interventions.

Control Group did not display any signs of reduction in anxiety level.

MUSIC THERAPY TREATMENT OBJECTIVES

Decrease Pain Decrease Anxiety Decrease Respiratory Distress Decrease Procedural Anxiety Decrease Confusion Increase Relaxation Increase Range of Motion Increase Gross/Fine Motor Skills Increase Autonomy/Control Increase Coping Skills Increase Parent/Child Bonding Assist with Anticipatory Grief Assists with Bereavement Elevate Mood Normalization of Environment Enhance Neural Development and Maturation of Premature

Infants

EVIDENCE-BASED MUSIC THERAPY INTERVENTIONS

ISO-Principle Songwriting Auditory Stimulation Tactile Stimulation Vestibular Stimulation Purposeful Instrumental Play Lyric Analysis Movement Activity Music Video Recording Project Breathing Techniques Bereavement Support Pacifier Activated Lullaby Neuro-Developmental Stimulation NICU Parent Training

Music Therapy & Child Life: Together???

MUSIC THERAPY & CHILD LIFE Hoffman (1975) was the first to investigate and document the

collaboration between pediatric music therapists and child life specialists.

Multiple reasons for collaboration to occur between music therapists and child life specialists:

Each is a complementary field to the other.

Music is a non-threatening familiar stimulus that is adaptable and accessible to pediatric patients.

Facilitates the development of therapeutic rapport andcoping skills through musical play.

Musical play has been found to significantly elicit more verbalization responses in pediatric patients than medicalplay alone.

(Ghetti, 2007; Robb, 2000; Froehlich, 1984)

MUSIC THERAPY & CHILD LIFE - Continued

Goals for collaboration can include:Ventilator Extubation

Enhancing Self-ExpressionIncreasing Mastery and Control

Decreasing IsolationSibling SupportBereavement

Increasing Parent and Infant BondingIncreasing Medical Compliance

Increasing Coping Skills Relaxation Techniques

Mask Distressing Sounds of the Hospital Environment Supporting other Therapeutic Services

Preoperative Preparation Procedural Support

(Avirett, Cowan, & Neill, 2008; Sims & Burdett, 1996; Bishop et. al, 1996; Rudenberg & Royka, 1989)

MASTER’S THESIS

Collaborating Goals and Interventions to Effectively Promote Psychosocial

Development of Pediatric Patients During Hospitalization:

A Survey of Music Therapists and Child Life Specialists

(Goforth, 2008)

PURPOSE OF STUDY

Investigate goals and methods utilized by music therapists and child life specialists in a pediatric medical setting.

Establish how collaboration occurs.

Identify collaboration for promoting psychosocial development of pediatric patients during hospitalization.

Ascertain how often collaboration occurs.

HOW COLLABORATION OCCURS Collaboration choices

include:

Referrals

Direct Patient Contact with Music Therapy and

Child Life Present

Combination of Referrals and Direct Patient Contact

with Music Therapy and Child Life Present

Results from 32(78.0%) of 41 MT-BC and 46(74.2%) of 62 CCLS respondents indicated a combination of referrals and direct patient contact with the presence of both therapies is the highest frequency form of collaboration between MT-BC and CCLS.

Referrals were the next form of collaboration used most often between the two therapies with 8(19.5%) MT-BC and 17(27.4%) CCLS responses.

The final form of collaboration indicated by 5(12.2%) MT-BC and 13(21.0%) CCLS was direct patient contact with music therapy and child life present.

GOALS FOR COLLABORATIONGoals Pediatric MT-BC

  % %

Normalization of Environment

85.4 35

Decrease Anxiety 80.5 33

Provide Developmentally Appropriate Activities

80.5 33

Decrease Isolation 78.0 32

Provide Emotional Support for Patient and Family

78.0 32

Increase Coping Skills 78.0 32Decrease Procedural Anxiety

73.2 30

Sibling Support 73.2 30Decrease Pain 68.3 28

Increase Autonomy and Control

68.3 28

Increase Expression 68.3 28Elevate Mood 68.3 28Decrease Emotional Distress

65.9 27

Increase Relaxation 63.4 26Assist with Bereavement 63.4 26

Promote Mastery of Environment

46.3 19

Parent Education & Training

41.5 17

Patient Education & Training

41.5 17

Increase Parent/Infant Bonding

41.5 17

Increase Gross and Fine Motor Skills

36.6 15

Provide Psychological Preparation

36.6 15

Decrease Confusion 36.6 15Increase Range of Motion 26.8 11Preoperative Preparation 26.8 11

Decrease Respiratory Distress

24.4 10

Skipped Question   9Total Answered Question   41

Goals CCLS  % %

Decrease Anxiety 93.5 58Decrease Emotional Distress

90.3 56

Increase Relaxation 87.1 54

Normalization of Environment

83.9 52

Increase Expression 82.3 51

Provide Emotional Support for Patient and Family

80.6 50

Elevate Mood 80.6 50

Provide Developmentally Appropriate Activities

75.8 47

Increase Coping Skills 75.8 47Decrease Pain 72.6 45

Increase Autonomy and Control

72.6 45

Increase Gross and Fine Motor Skills

67.7 42

Decrease Isolation 66.1 41

Promote Mastery of Environment

58.1 36

Sibling Support 50.0 31Increase Range of Motion 48.4 30Decrease Procedural Anxiety

46.8 29

Decrease Respiratory Distress

38.7 24

Assist with Bereavement 38.7 24

Increase Parent/Infant Bonding

37.1 23

Decrease Confusion 24.2 15Patient Education & Training

24.2 15

Parent Education & Training

19.4 12

Provide Psychological Preparation

17.7 11

Preoperative Preparation 8.1 5Skipped Question   43Total Answered Question   62

COLLABORATIVE INTERVENTIONSInterventions Pediatric MT-BC

  % #

Purposeful Instrumental Play 95.9 47

Instrumental Improvisation 91.8 45

Auditory Stimulation 87.8 43

Music-Assisted Relaxation 87.8 43

Song Writing 87.8 43

Distraction 85.7 42

Pain Management 83.7 41

Music & Movement 81.6 40

Breathing Techniques 75.5 37

Vocal Improvisation 71.4 35

Lyric Analysis 69.4 34

Tactile Stimulation 67.3 33

Recording Project 63.3 31

Multimodal Stimulation 59.2 29

Treatment Based Education 28.6 14

Orff-Schulwerk 22.4 11

Nordoff-Robbins 18.4 9

GIM 14.3 7

Skipped Question   1

Total Answered Question   49

Goals CCLS

  % #

Positive Reinforcement 97.9 95

Procedural Preparation/Support 97.9 95

Medical Play 96.9 94

Therapeutic Play 95.9 93

Behavioral/Cognitive Distraction 95.9 93

Breathing Exercises 93.8 91

Bereavement Support 89.7 87

Modeling 89.7 87

Comfort Positioning 87.6 85

Pre-Surgery Tours 83.5 81

Imagery 82.5 80

Relaxation Training 70.1 68

Therapeutic Art 68.0 66

Therapeutic Use of Music 63.9 62

Therapeutic Touch 47.4 46

Progressive Muscle Relaxation 39.2 38

Recording Project 17.5 17

Skipped Question   8

Total Answered Question   97

FREQUENCY OF COLLABORATION

21(56.8%) MT-BC of 37 and 33(56.9%) of 58 CCLS respondents, each indicated collaboration to occur 3-5 times per week.

13(35.1%) MT-BC and 16(27.6%) CCLS

respondents reported collaboration occurring 1-2 times per day.

3(8.1%) MT-BC and 9(15.5%) CCLS respondents indicated collaboration occurring 6 or more times per week.

Examples: Collaboration with Specific

Populations

Cystic Fibrosis

Hematology/Oncology

Developmental Disabilities

Out Patient

Cystic Fibrosis Shawn’s Schedule8:00 Wake up! 8:30-10:00 Take pillsEat breakfast (at least ½ of tray)Clean roomGet dressed, brush teeth, etc. 10:30-11:20 English Class

11:20-12:40 HomeworkEat lunch (at least ½ of tray) 12:40-1:30 Algebra Class 1:30-2:20 US History 2:30-3:30 Homework 3:30-5:30 Free time (Child Life, Music Therapy, Godly Play, etc.) 5:30-10:00 Eat dinner (at least ½ of tray)ShowerFree time

10:00 Lights out! *Wednesdays: No class but schoolwork should be done from 10:30-12:30!*Drink at least 4 Glucerna’s throughout the day*Compliant with all respiratory treatments

Hematology/Oncology: “You Can Go A-L-L the Way”I’m just sitting here in this bed

Everyday is just passing me by

It feels like, a rollercoaster

Spinning around like I’m losing my mind

Not knowing which way that I’m going

Up or down, side or side,

Either way I know your right by me… 

Hey you, sitting over in that chair

What makes you wanna come around here?

Is your mind wondering, pondering if I’m going to be alright,

I promise you, I’ll get home one night. 

I’m just sitting here in this bed

Hoping & wanting for this day

To come, now it’s here

You don’t have to shed, no more tears… 

Hey you, sitting over in that chair

What makes you wanna come around here?

Is your mind wondering, pondering if I’m going to be alright,

I promise you, I’ll get home one night. 

It’s been a long hard, thirty-two days

Now it’s a day of praise

Get out of, that chair

We don’t have to be here

I’m keeping my promise; it’s time to go home…

Hey you, sitting over in that chair

What makes you wanna come around here?

Is your mind wondering, pondering if I’m going to be alright,

I promise you, I’ll be home tonight.

Developmental Disabilities

Out Patient – Procedural Support

VIDEO CLIPS

QUESTIONS?????

REFERENCES Austin, D. (2010). The psychophysiological effects of music therapy in intensive care units. Pediatric Nursing, 22(3), 14-20.

Avirett, J., Cowan, K., & Neill, J. (2008). Music and play as medicine: Collaboration between music therapy and child life in providing family-centered care. Presentation at the Florida Child Life Conference, Tampa, Florida.

Bishop, B., Christenberry, A., Robb, S., & Rudenberg, M. (1996). Music therapy and child life interventions with pediatric burn patients. In M. Froehlich (Ed.), Music therapy with hospitalized children: A creative arts child life approach (pp. 87-108). Cherry Hill, NJ: Jeffery Brooks.

Chetta, H. (1981). The effect of music and desensitization on preoperative anxiety in children. Journal of Music Therapy, 18(2), 74-87.

Froehlich, M. (1984). A comparison of the effect of music therapy and medical play therapy on the verbalization behaviors of pediatric patients. Journal of Music Therapy, 21, 2-15.

Froehlich, M. (1996). Child life and creative arts therapy. In M. Froehlich (Ed.), Music therapy with hospitalized children: A creative arts child life approach (pp. 13-15). Cherry Hill, NJ: Jeffery Brooks.

Ghetti, C. (2007). Wearing two hats: Combining music therapy and child life approaches in the pediatric intensive care unit. Presentation at the National American Music Therapy Conference, Louisville, Kentucky.

Goforth, K. (2008). Collaborating goals and interventions to effectively promote psychosocial development of pediatric patients during hospitalization: A survey of music therapists and child life specialists. Electronic Theses, Treatises and Dissertations. Paper 4212.

Jarred, J. (2003). Music assisted surgery: Preoperative and postoperative interventions. In S. Robb (Ed.), Music therapy in pediatric healthcare: Research and evidence-based practice (pp. 147-162). Silver Spring, MD: AMTA.

Kallay, V. (1997). Music therapy applications in the pediatric medical setting: Child development, pain management and choices. In J. Loewy (Ed.), Music therapy and pediatric pain (pp 33-42). Cherry Hill, NJ: Jeffery Brooks.

Lane, D. (1996). Music therapy interventions with pediatric oncology patients. InM. Froehlich (Ed.), Music therapy with hospitalized children: A creative arts child life approach (pp. 109-116). Cherry Hill, NJ: Jeffery Brooks.

McCready, M., Macdavitt, K., & O’Sullivan, K. (1991). Children and pain: Easing the hurt. Orthopaedic Nursing, 10(6), 33-42.

Prensner, J., Yowler, C., Smith, L., Steele, L. & Fratianne, R. (2001). Music therapy for assistance with pain and anxiety management in burn treatment. Journal of Burn Care and Rehabilitation, 22, 83-88.

Robb, S., Nichols, R., Rutan, R., Bishop, B., & Parker, J. (1995). The effects of music assisted relaxation on preoperative anxiety. Journal of Music Therapy, 32, 2-21.

Robb, S. (2000). The effect of therapeutic music interventions on the behavior of hospitalized children in isolation: Developing a contextual support model of music therapy. Journal of Music Therapy, 37(2), 118-146.

Rudenberg, M. & Royka, A. (1989). Promoting psychosocial adjustment in pediatric burn patients through music therapy and child life therapy. Music Therapy Perspectives, 7, 40-43.

Sims, M. & Burdett, R. (1996). Music therapy and child life therapy: Reducing preoperative anxiety in pediatric renal transplant patients. In. Froehlich (Ed.), Music therapy with hospitalized children: A creative arts child life approach (pp. 125-135). Cherry Hill, NJ: Jeffery Brooks.

Standley, J. & Whipple, J. (2003). Music therapy with pediatric patients: A meta-analysis. In S. Robb (Ed.), Music therapy in pediatric healthcare: Research and evidence-based practice (pp. 1-18). Silver Spring, MD: AMTA.

Turry, A. (1997). The use of clinical improvisation to alleviate procedural distress in young children. In J. Loewy (Ed.), Music therapy and pediatric pain (pp 45-68). Cherry Hill, NJ: Jeffery Brooks.

Walworth, D. (2003). Procedural support: music therapy assisted ct, ekg, eeg, x-ray, iv, ventilator and emergency services. In S. Robb (Ed.), Music therapy in pediatric healthcare: Research and evidence-based practice (pp. 137-146). Silver Spring, MD: AMTA.

Whitehead, A., Zebrowski, N., Baryza, M., & Sheridan, R. (2007). Exploring the effects of music therapy on pediatric pain: Phase 1. Journal of Music Therapy, 44(3), 217- 241.