What exactly is music and what is pediatrics?

According to the Merriam-Webster Online Dictionary, music is “the science or art of ordering tones or sounds in succession, in combination, and in temporal relationships to produce a composition having unity.” The American Heritage Dictionary describes pediatrics as “the branch of medicine that deals with the care of infants and children and the treatment of their diseases.” Despite these seemingly unrelated terms, there is a relationship that has formed between the two. Kids love music and listen to lots of it. Many of them have a talent to produce it at an early age. Health-care workers understand this and have found a variety of ways to use music in the care of their patients.

Music exists in virtually every culture and has been around longer than the printed word. It is probable that some aspects of music, such as rhythm and melody, predate spoken language. Most children grow up with some exposure to music, whether it is the beat of a drum, pluck of a sitar, nursery rhyme, rap tune, symphony, etc. To perform music, one needs significant physical dexterity and motor coordination. To compose music requires a command of the most complex areas of the cerebrum. To enjoy and to respond to music, however, one may not even need a brain (try a Google search for plants and music)!

Has music been used to help sick children?

Music has been used in the home and hospital to help children who are sick or in pain feel better. Until modern times, parents mainly provided music to their sick children by singing. Thomas Edison changed that in 1877 with the invention of the phonograph. From then on music could be played in every conceivable environment. Music eventually made its way into the hospital. Duke University Hospital, in the mid 20th Century, is credited with being the first hospital to provide music to their pediatric patients(1).

Stress and the hospitalized child

Over fifty years ago, D. Levy reported that the post-surgical child was at risk to develop night terrors, regressive symptoms, fear of the dark, and fear of strange persons or places (2). More recent studies in psychology (3) have shown that 1) infants younger than two months can distinguish between parents and strangers; 2) infants under three months of age exhibit symptoms of distress when separated from the mother; and 3) separation in six-month-old infants will even produce stages of grieving. Toddlers ages one to three years demonstrate the greatest amount of stress due to separation. By this age, attachment to the mother is very strong; yet the child’s ability to express himself or herself verbally is not well established. His or her greatest fear is of being abandoned (4). Thus, a child may experience significant anxiety after a period of hospitalization.

What studies have been conducted using music to help the hospitalized child?

In the 1980's, Helen Driskell Chetta sought a means to alleviate some of the anxiety associated with surgery. She conducted a study using 75 children, ages 3-8, who were admitted for elective surgery. She separated them into three groups. The first group received only verbal instructions about their pending surgery the night before. The second group received instructions and music therapy the night before. The third group received instructions and music the night before the surgery and music therapy just prior to the preoperative medication the following day. She found that the children in the group who received music therapy just prior to their surgery were consistently rated as less anxious before and during the administration of their preoperative medications (5) . The study was limited to that short time interval. It is unknown if the children who were exposed to the music therapy developed fewer longer-term problems.

An interesting study was done 15 years later in an emergency room and hospital floor in Florida. Forty children who had to have IVs placed were included in the study. Half of them received or participated in live music/music therapy before and during the procedure and the other half had no music. The children who received music therapy were observed to have less anxiety before and after the procedure. Unfortunately, the study witnessed no significant difference in their pain. The parents overwhelmingly (79%) approved of the music therapy and said that the music helped them and their “frazzled nerves (6).” Every physician or nurse who has worked in an emergency room understands this is very important. Often, the child has a far easier time with a painful procedure than the parent. Quite often, the parent volunteers to leave the room before the procedure is completed. (Author note: Many times, in my experience, the parent has wound up the patient as a result of his/her own anxiety.)

So, does the data prove that music helps children undergoing surgery?

However appealing some studies of music and music therapy on the pediatric surgical patient may sound, there is data that suggests that its physiological effects may be minimal and therapist-dependent. Kain, et al, conducted a randomized, controlled study involving 115 children undergoing outpatient surgical procedures. The children were placed into three groups. The first group received music therapy from a board-certified music therapist prior to their procedure. This continued until the anesthesia mask was placed on the children's faces and the children were rendered unconscious. The second group received oral midazolam, a drug related to Valium, and the third received no pre-anesthesia intervention. The researchers found that music therapy helped to relieve some of the anxiety experienced in the period before the anesthesia was introduced. It did not appear to have any benefit during the most stressful few moments as the masks were placed on the faces. The children receiving the midazolam were the least anxious of all (7).

Why, then, should we bother with music? E.R.’s bottom line

The above oral midazolam study seems to diminish the role of music and music therapy in effectively relieving anxiety in children. Midazolam has been used very effectively by this physician/musician to relieve pre-procedure anxiety. Given the choice of music, music therapy, or midazolam, I would unquestionably go with the medication. However, is there a role for a combination of music therapy and medication? Is there some non-measurable benefit to have a trained therapist use the art of music to accompany and soothe a child in a perceived threatening environment? Are there any benefits to the parents of these children? While I was at the Allen Memorial Library of Case Western Reserve University researching this chapter, I spent some time admiring their collection of historical photos, books and medical instruments. Actually, the Frankenstein-like photos of the early 20th century operating rooms horrified me. They appeared cold and brutal, with claustrophobia-inducing areas containing white-enameled basins, sharp metallic instruments and inflexible glass tubing. There were also priceless 14th and 15th century anatomy engravings on display at the library. These artists, though, used scenes of nature to soften the starkness of the dissected human. Much has been done to improve the aesthetics of the O.R. and treatment rooms since then. But why? Why bother to paint walls, hang pictures, improve acoustics and leave moronic but highly distracting reading materials? The real benefits of music and music therapy may lie in their art and not necessarily in their science. This does not make them any less valuable. Comfort and “patient satisfaction” are important, and competitive hospitals know that.

Music Therapy on the rise

Music therapy is being used increasingly in hospitals around the world. As eloquently described by Mary Ann Froehlich: music therapy “provides an excellent tool for helping patients to master the stress of hospitalization. The medium of music is comforting, non-threatening, and not associated with medical procedures. Since the music therapist is associated with the medium, a relationship of trust with the therapist is easily and quickly established, thus enabling the patient to share feelings. In addition, musical activities constitute a form of play; they thus offer normal avenues for growth and development and provide continuity between the hospital and the child’s outside world. Finally, the medium of music meets the child’s need for creative expression and channeling of anxiety. The framework of song provides structured moments for verbalization that are perceived as play by the patient and facilitates the expression of feelings and hospital experiences (8)."

Postscript, a heavy note:

Today, with the advent of iPods and tiny computerized music files, a library of music can be transported in a child’s pocket with his or her lunch money. Children can ‘self-administer’ music to either enhance a mood or create a new one. While most kids use music to sustain or induce positive and beneficial feelings, listening to some forms of music, notably ‘Heavy Metal’ may be associated with maladaptive thoughts and behaviors. In an excellent and detailed review in Adolescence, KR Scheel points out that, although there does not seem to be an increased suicide rate among listeners of heavy metal (and 40% of her Midwestern subjects reported they did listen to this genre), there may be a small subgroup of children who are angry to begin with and get angrier after listening to Heavy Metal. It has not been determined that they commit more suicides, although they do display more suicidal risk factors (9). This, however, may not just be limited to Heavy Metal. Quite possibly (and this was not studied) there are subsets of kids who listen to country, jazz or classical music who would fare just as poorly on psychological tests. The message we would like to convey is that if a child is preoccupied with the lyrics of songs which glorify anarchy, destruction and death, it’s probably not a good sign. It would be a very good idea to seek advice from a pediatrician, psychologist or psychiatrist.

We at E.R. Music are grateful to readers who inform us about new research involving music and pediatrics. We will review the studies and incorporate them into this chapter. Please join our mailing list if you would like to be informed of the latest developments.

Copyright 2008, E.R. Music, LLC

References

1) Taylor, “Music in General Hospital Treatment from 1900 to 1950,”Journal of Music Therapy, XVIII (2), 1981, 62-73

2) Levy D, American Journal of Disease of Children (1945, 69, 7-25)

3) Marley, “The Use of Music with Hospitalized Infants and Toddlers: A Descriptive Study,” Journal of Music Therapy, XXI (3), 1984, 126-132

4) Petrillo, Sanger, “Emotional Care of Hospitalized Children: An Environmental Approach,” 1980, Lippincott-Raven Publishers

5) Chetta, “The Effect of Music and Desensitization on Preoperative Anxiety in Children,” Journal of Music Therapy, XVIII(2), 1981, 74-87

6) Malone, “The Effects of Live Music on the Distress of Pediatric Patients Receiving Intravenous Starts, Venipunctures, Injections, and Heel Sticks,” Journal of Music Therapy, 33(1), 1996, 19-33

7) Kain, et al, “Interactive Music Therapy as a Treatment for Preoperative Anxiety in Children: A Randomized Controlled Trial,” Anesthesia Analgesia 2004;98:1260-6

8) Froehlich, “A Comparison of the Effect of Music Therapy and Medical Play Therapy on the Verbalization Behavior of Pediatric Patients,” Journal of Music Therapy, XXI(1), 1984, 2-15

9) Scheel, “Heavy Metal Music and Adolescent Suicidality: An Empirical Investigation,” Adolescence, Summer, 1999