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clinic, we describe parents' attitudes about music for pédiatrie oncology outpatients. ... and Public Health Sciences, Wake Forest University School of Medicine,.
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Parents' Attitudes and Expectations about Music's Impact on Pédiatrie Oncology Patients Kathi J. Kemper, MD, MPH, and Thomas W. McLean, MD

Clinicians often have positive attitudes about the clinicai effects of music. To better understand barriers to providing music in the clinic, we describe parents' attitudes about music for pédiatrie oncology outpatients. A cross-sectional survey was conducted between January 2005 and October 2007 in a pédiatrie oncology clinic in a tertiary hospital. Eligible subjects were one parent of pédiatrie leukemia patients. Surveys were distributed at a routine clinic visit as part of a study on the effects of music on subjective and objective well-being. Of the 67 eligible families, 45 (67%) parents responded; 82% reported playing music for the patient at home within the previous week. The most common reasons to use music for the patient were to entertain (88%), keep the patient company (71%), help the patient feel better (76%), or provide comfort (69%); fewer used music to distract the patient from pain (16%) or nausea (11%). Parents expected that music during clinic visits would have positive effects: relaxation (64%), comfort (42%), and/or distraction (33%); none expected negative effects. Parents often play music for their children, and they hold favorable attitudes about playing it in the clinic. Parents' attitudes are not barriers to providing music in the clinic. Key words: attitudes, complementary, music, oncoiogy, pédiatrie

usic, an intentional auditory stimulus with organized elements, including melody, rhythm, harmony, timbre, form, and style, is often used therapeutically in oncology settings.' Music can improve mood, anxiety, and comfort in oncology patients^"'*; by reducing stress and the need for sedation and pain medications, music can also reduce the costs of care.^ Music may benefit pédiatrie patients through direct physical or psychological mechanisms^"'* or indirectly through positive effects on parents or staff.'^"^° Although many patients and staff members have favorable attitudes and expectations about it,^'^' music has not been routinely incorporated into clinical settings. Barriers and facilitators for providing music in clinical settings are poorly understood.

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Kathi J. Kemper and Thomas W. McLean: Departments of Pediatrics and Public Health Sciences, Wake Forest University School of Medicine, Winston-Salem, NC. This study was funded by National Institutes of Health (NIH) National Center for Complementary and Alternative Medicine (NCCAM) K24AT2207. The views expressed are those of the authors and not necessarily those of the NIH or NCCAM. Reprint requests: Kathi J. Kemper, MD, MPH, Department of Pediatrics, Wake Forest University Health Sciences, Medical Center Blvd., WinstonSalem, NC 27157; e-mail: [email protected].

DOI 10.2310/7200.2008.0025

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Specifically, little is known about parents' attitudes and expectations about music. Parents' attitudes are important because they may influence children's responses to music and the success of initiatives to provide music in pédiatrie clinical settings. Because parents' attitudes and expectations might bias the results of studies on the effect of music in pédiatrie patients, it is important to understand their attitudes. As part of a study on the effect of music on pédiatrie oncology patients, we surveyed parents to describe their use of music for themselves and for their children and to elicit their expectations about the impact of music if played for their child in the clinic.

Methods Parents were surveyed in the Brenner Children's Hospital (BCH) Pédiatrie Oncology Clinic between February 2005 and October 2007. Parents were eligible if they spoke and read English and if their child had been diagnosed with acute lymphoblastic leukemia, received their primary oncology care at BCH, and had completed the induction phase of therapy. Potential subjects were identified by the pédiatrie oncologist (T.W.M.). Patients were approached for participation by a research assistant at a regular elinie visit; eonsent and assent were obtained from parent and patient, respeetively. Patient age, gender, diagnosis, and

Journal of the Society for Integrative Oncology, Vol 6, No 4 (Fall), 2008: pp 146—149

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Kemper and McLean, Parents' Attitudes and Expectations about Music's Impact on Pédiatrie Oncology Patients

treatment information were extracted from the medical records. The two-page survey included 14 questions regarding how parents had used music for themselves and for their child in the previous week; the kind of music the parent preferred to listen to at home; one question about how many minutes, on average, they provided music for the child in the previous week; and how often the patient usually listened to music during oncology clinic visits. Parents were asked which kind of music they thought the child would find most comforting (they could pick more than one type) and what kinds of effects they expected the child would have from listening to music during an oncology clinic visit (they might expect more than one effect). The survey took less than 15 minutes to complete. Survey responses were entered into a Microsoft Excel spreadsheet and verified to ensure accuracy. Simple descriptive statistics (means, medians, standard deviations, and percentages) were determined using Excel. Because this was a descriptive study, no statistical testing was performed. The study was approved by the Wake Forest School of Medicine Institutional Review Board.

Results Responses were received from 45 of 67 eligible parents. Patients' characteristics are described in Table 1. They had an average age of 9.1 (± 5) years, and about half were male. Two parents were fathers; the rest were mothers. Most (82%) parents reported playing music for their children at home in the week prior to the survey, typically for about 30 minutes daily. However, most parents (67%) rarely or never played music for or listened to music with their child during a pédiatrie oncology clinic visit. Parents themselves most often listened to pop, country, rock, and/or religious music (Table 2). They thought that a Table 1. Patient Description Patients Age, mean (yr) ± SD Male gender Race African American Caucasian Mixed/other Hispanic ethnicity Music for patient in past week Median length of music daily

n (%) 45 (100) 9.1 ± 5.1 23 (51) 9 (20) 34 (76) 2 (4) 2 (4) 37 (82) 30 min

Table 2. Use of Music at Home

Jtem Pop Country Rock Religious Classical Lullabies Nursery rhymes Rap Jazz New Age

Most Comforting for Patient (%)

Listened to by Parent (%)

36

47

33

49

27

51

27

42

27

18 4

27 18

4

16 7

22 9 4

4

variety of kinds of music would be comforting for the patients. Pop and country led the list; rock, religious music, classical music, and lullabies were tied for third place in terms of being expected to be the most comforting. Few parents listened to New Age music or thought it would be comforting for their children. One parent each specifically listed opera, rhythm and blues. Sesame Street, and the Wiggles as being comforting music for their child. Table 3 describes the reasons parents listen to music themselves and the reasons they played it for their children. The most common reason parents listened to and provided music was for entertainment (an average of 4.2 days per week for parents and children), followed by

Table 3. Parents' Reasons for and Frequency of Using Music at Home Item Music used to help the parent Entertain me Feel better Keep me company Distraction Sleep Music used to help the patient Entertainment (88%) Feel better (76%) Keep patient company (71%) Comfort (69%) Teaching/educational (49%) Inspiration (47%) Help patient sleep (42%) Distract from pain (16%) Distract from nausea (11%)

Days/wk Mean (median) 4.2 3.2 2.0 2.1 1.2

(3.5) (1.5) (1.5) (0) (0)

4.2 (3.5) 3.0 (3.5) 2.8 (2.5) 2.6 (1.5) 1.7 (1.5) 2.0 (0) 1.4 (0) 0.8 (0) 0.6 (0)

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helping them to "feel better" and keeping the parent or patient company. Most parents (69%) also thought that music would comfort the child; fewer than half used it specifically to help with sleep, pain, or nausea. When asked what effect they thought music would have on the patient during a pédiatrie oncology visit, most parents (82%) thought it would have some positive effect, with many parents citing more than one effect: relaxation (64%), comfort (42%), distraction (33%), energizing (20%), reassuring (16%), or sedating or easing into sleep (16%). Fewer parents expected that music would help ease pain (13%) or nausea (4%); none thought it would be annoying, confusing, or irritating to their child (Table 4).

Discussion Parents' expectations about music are important because these attitudes may affect both the availability of music and caretaking behavior. We found that parents frequently played music for patients at home and generally held positive views about its effects, although it was seldom provided during clinic visits. Few parents expected music for patients to have specific health benefits, such as decreasing pain or nausea or improving sleep. The views expressed by parents in this study were similar to those of hospital staff in expecting that music would not cause adverse effects and would generally be beneficial; however, staff had more specific expectations about the clinical benefits of music for patients. For example, in an earlier study, staff reported that they Table 4. Parents' Expectations about Music Therapy for Pédiatrie and Adolescent Oncology Patients What effects do you expect music during a clinic visit will have on the patient? Relax Comfort Distract Energize Reassure Sedate (ease into sleep) Ease pain Revitalize Increase activity Ease nausea Improve concentration Not sure None Annoy, confuse, irritate

% .

64 42 33 20 16 16 13 9 7 4 2 18 18 0

expected music could help relieve pain and improve Parents also differed from the earlier studies of hospital staff in terms of the kinds of music they thought would be most beneficial to patients. Parents were most likely to cite the kinds of music they listened to themselves, that is, pop, country, rock, and religious music, whereas staff members were more likely to have positive expectations about classical and instrumental music. For music to be accepted by staff and families, a variety of developmentally and culturally appropriate options should be provided so that patients, families, and staff can choose the type of music that best meets their needs. Parent and staff expectations about the effects of music are supported by research on the benefits of music in clinical settings.'^'^^ For example, a 2006 Cochrane review concluded that listening to music can reduce pain levels and requirements for opioid medications.^'' Music therapy can reduce pain and distress during routine venipuncture.^'' Music is comforting and can also reduce anxiety and stress.^^ Music played at low to moderate volumes has almost no documented adverse effects. Given its low cost and numerous benefits, music offers an attractive option that is supported by clinical research and parents' and staff members' attitudes toward it. This study has several limitations. It was conducted in one medical center in the southern United States in which recreational therapy often provides live music in the waiting area and in which a study of the effect of music was under way. Results may differ for other clinical settings in which music is played less often or is not specifically under study. The study did not measure actual parental behavior but relied on self-report, which is imperfect but less expensive than home monitoring. Furthermore, this was not an evaluation of the actual impact of music on the child but on the attitudes of parents, which may differ from the attitudes of patients. Future research assessing the effects and mechanisms of music should consider the results of this study. Parents are not neutral with regard to music. They desire it and expect that it will positively affect patients in general, although they do not commonly expect specific clinical benefits. These expectations can certainly contribute to a desirable placebo effect through changes in caregivers' attitudes, moods, and behavior. For example, parents with positive expectations may be more relaxed or more attentive to patients if their preferred music is provided. Staff should not assume that one kind of music will fit all families. Music is complex. Its effects on pédiatrie patients are also complex, and many of these effects and the

Kemper and McLean, Parents' Attitudes and Expectations about Music's Impact on Pédiatrie Oncology Patients

mechanisms by which they occur have not been evaluated. Researchers and clinicians need to account for indirect effects on caregivers and music's direct acoustical effects to better understand the mechanisms by which it enhances clinical outcomes. Research on barriers to routinely providing music therapy should focus on factors other than parents' attitudes.

11. 12. 13. 14. 15.

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