Culbert_Chapter33.pdf

A Pediatric Perspective on Creative Arts

Therapies

DEFORIA LANE, EMILY DARSIE, AND BARBARA DISCENNA

KEY CONCEPTS

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Music therapists and art therapists receive speci c training in

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their disciplines to address the physical, cognitive, and psycho-

social needs of their patients.

Research has established that music therapy and art therapy play

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a signi cant and positive role in pediatric healthcare.

Music therapy can reduce pain and anxiety surrounding medical

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procedures, while providing patients opportunities to cope with

the hospital environment.

Art therapy can enhance self-expression, increase locus of con-

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trol, and improve quality of life in pediatric patients.

Music and art therapy can improve physical and psychological

health, improving a patient’s ability to cope with disease and

treatment.

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Introduction

R ecent years have seen a surge in the incorporation of the creative arts thera-

pies within the pediatric healthcare setting. 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 (American Music erapy Association, 2008). Art

therapy is an established mental health profession that uses the creative process of

INTEGRATIVE PEDIATRICS

art-making to improve and enhance the physical, mental, and emotional wellbeing of

individuals of all ages. It is based on the belief that the creative process involved in

artistic self-expression helps people to resolve con icts and problems, develop inter-

personal skills, manage behavior, reduce stress, increase self-esteem and self-awareness,

and achieve insight (American Art erapy Association, 2008).

Music and art are inescapable companions that in uence our lives from the time of

birth. e sounds of water in the womb, a mother’s tender lullabies, and the shapes and

colors that greet virgin eyes at birth are the beginnings of form and vibration. Identifying

and measuring the therapeutic e ects of music and art on hospitalized children has

been the subject of a growing body of research. Clinical applications extend from their

use to reduce pain, focus attention, increase communication and cognitive function,

improve compliance and self-esteem, stimulate and synchronize motor movement, and

help increase relaxation. To present a clear explanation of the uses of art and music

therapy in the pediatric healthcare setting, this chapter will explore the multiple and

diverse roles of music therapy and art therapy in pediatric healthcare.

HISTORY

e healing e ects of music can be traced to ancient literature. One of the most familiar

examples of music’s impact is the biblical account of David skillfully playing his harp

to quiet the mental anguish of King Saul. roughout history, music has been woven

into society’s celebrations, ceremonies, and rituals. When soldiers returned home from

World War II to seek medical attention, physicians and healthcare professionals in the

Veterans’ Administration Hospitals became aware of the positive e ects of music on

patient behavior, which led to the initial research into music as a therapeutic disci-

pline. ough the structured application of music as therapy has been referenced since

Socrates, its formal genesis as a profession occurred in 1950. e profession’s o cial

association, the American Music erapy Association, now has a membership of over

5000 music therapists.

Similarly, the power of making art and visual images can be traced back to prehis-

toric times, when humans painted or etched gures on cave walls for empowerment and

expression (Junge, 1994). Over time, cultures across the globe have incorporated artistic

images in their rituals, from African masks to Tibetan and Native American sand paint-

ings. e healing and empowering e ects of art have been attributed to both the images

themselves as well as the creative processes involved in generating the images.

e eld of art therapy became established in the 1940s when Margaret Naumberg

began writing about her work with children at the Walden School, where she interwove

psychoanalytic concepts related to the expression of the unconscious with developmen-

tal processes in education. e use of art for self-expression was associated with sym-

bolic speech, dream work, and self-realization, as students were encouraged to begin

A Pediatric Perspective on Creative Arts Therapies

to interpret their own artwork. e American Art erapy Association emerged from

these beginnings in 1969.

Hill (1945) provided an early description of the use of art in the hospital setting from

the perspective of both an artist and a patient. He later introduced art to other patients

in a long-term hospital setting to help them to cope with their illness and the hospi-

tal environment. During the same time period, acclaimed art therapist Don Jones was

engaging institutionalized individuals in psychiatric hospital settings in New Jersey,

and later, in Kansas at the Menninger Clinic (Junge, 1994).

EDUCATION AND TRAINING

Michigan State University was the rst school to o er the baccalaureate in music therapy.

Today, nearly 70 colleges and universities throughout the United States and abroad have

established comparable undergraduate and graduate degree programs in music therapy.

Academic competencies focus on the in uence of music on behavioral, physiologi-

cal, psychological, cognitive, and psychomotor responses. Students also study human

growth and development, anatomy and physiology, psychology, and counseling. In

addition to ongoing practicum experiences, students must complete a 6-month intern-

ship and sit for the certi cation examination administered by the Certi cation Board

for Music erapists (CBMT). Continuing education credits are required to maintain

the Music erapist-Board Certi ed (MT-BC) credential. As the eld has developed,

several advanced levels of study have emerged, such as neurologic music therapy, ana-

lytic music therapy, guided imagery and music, and Nordo -Robbins improvisation. A

master’s or doctoral degree in music therapy expands the depth and breadth of clinical

skills in advanced and specialized elds of study such as supervision, college teaching,

administration, a particular method, or speci c population.

Training for art therapy currently requires the completion of a master’s-level pro-

gram. Undergraduate prerequisites include coursework both in studio art and in psy-

chology. At the graduate level, curricula include coursework in art therapy techniques,

child art therapy, group art therapy, ethics, art therapy assessment, family dynamics and

counseling techniques, in addition to a clinical internship. Clinical experiences must

include work within di erent settings such as geriatric, psychiatric, medical, hospice,

or schools.

e graduate training programs in art therapy require an initial eld experience of

100 hours that prepare students for one of two intensive internships. One requires a total

of 600 hours; however, if the program is combined with mental health counseling, it

requires a 900-hour internship.

e creative arts continue to increase in visibility, viability, and awareness within

the medical community through legislation and government hearings, recognition

by third party payers, and use of the Current Procedural Terminology (CPT) codes.

INTEGRATIVE PEDIATRICS

e publication of qualitative, quantitative, and collaborative research supports the

incorporation of the creative arts therapies within the pediatric healthcare setting.

THEORETICAL FOUNDATIONS

A 2003 meta-analysis of pediatric music therapy research identi ed 29 studies on the

e ectiveness of music therapy with pediatric patients. Studies that included both a

music therapy condition and a non-music control condition showed that music therapy

was an e ective intervention for major invasive procedures such as burn debridements

and bone-marrow aspirations, as well as in noninvasive settings such as newborn nurs-

eries, pre-operative units, and inpatient units. is analysis found documented support

for music therapy being used for managing and reducing pain and anxiety, pacifying

infants, decreasing respiratory distress, and promoting positive coping skills. Live

music that encouraged active participation was found to provide greater bene ts than

recorded music or passive listening (Standley & Whipple, 2003).

Although the majority of art therapy research has been conducted with adult sub-

jects, select studies do focus on work with pediatric patients. Within the theoretical

realm of art therapy, two distinct approaches have evolved. Art as therapy emphasizes

making art as a facilitator in healing and self-growth. Art psychotherapy, on the other

hand, places importance on art images as symbolic projections of thought, feelings, and

con icts. e goal is to promote verbalization and recognition of the symbolic content

through a dialogue with the therapist or through personal introspection, gaining new

insight and understanding. Many art therapists have combined and overlapped these

two approaches to meet individual patients’ needs and abilities.

Art is a natural form of expression for children, beginning roughly at age 2 with dis-

organized scribble images. e circle shape eventually emerges from the scribble and is

noted by some to symbolize the face of the mother or mother’s breast, the rst images

a child usually sees (Kramer, 1972). Lowenfeld (1947) outlined the relationship between

creative development and intellectual growth, detailing the stages of artistic develop-

ment through which children progress. e understanding of these stages is relevant to

both art educators and art therapists in that they can help the therapist know if a child is

developmentally on-track. e artwork can aid in identifying the child’s understanding

of their environment, relationship with others, stressors, self-image, self-esteem, and

maladaptive dynamics such as regression.

MUSIC THERAPY IN THE NEONATAL INTENSIVE CARE UNIT

In the neonatal intensive care unit, studies have shown that music is an e ective method

for masking ambient sounds. Music that maintains a consistent tempo and volume,

with a simplistic melody and accompaniment, helps mask aversive auditory stim-

uli (Standley, 1998). When music was played in the intensive care nurseries, infants

maintained homeostasis, increased oxygen saturation, and stabilized respiration rates

A Pediatric Perspective on Creative Arts Therapies

(Cassidy & Standley, 1995; Coleman, Pratt, Stoddard, Gerstmann, & Abel, 1997; Collins

& Kuck, 1991; Flowers, McCain, & Hilker, 1999; Moore, Gladstone, & Standley, 1994;

Standley & Moore, 1995). Length of hospitalization was reduced when infants were

exposed to recorded lullabies for one and one-half hours a day (Caine, 1991). In terms

of lasting e ects, Standley (1991) studied early music exposure in pre-term infants who

were in the NICU, and found that mothers of infants who were exposed to music rated

their children to be calmer at the age of 6 months, compared to the mothers of infants

who received no music intervention.

Pre-term infants are o en hypersensitive to stimuli due to an immature neurological

system. In addition to providing low-stimulatory music to infants as a means of mask-

ing aversive stimuli, the incorporation of multi-modal stimulation, a procedure that

combines so humming, and progressive tactile stimulation, has been utilized by music

therapists in work with pre-term infants. is method was found to promote tolerance

for increased levels of stimulation, as well as to support parent-child bonding (Standley,

1998; Whipple, 2000).

Music has also been incorporated in techniques used to increase non-nutritive

sucking in pre-term infants. Non-nutritive sucking provides both physiological and

behavioral bene ts for pre-term infants, such as increased oxygen saturation levels,

and reduced behavioral distress. e paci er-activated-lullaby system (PAL) consists

of a paci er tted with a pressure transducer and timer that allows for music to play

when the infant sucks on the paci er. Use of this product with pre-term infants brought

about improved feeding abilities, as well as increased non-nutritive sucking (Cevasco &

Grant, 2005; Standley, 2000, 2003).

MUSIC THERAPY AND PROCEDURAL SUPPORT

Music therapists o en incorporate strategies for refocusing attention when working

with children during medical procedures. ese strategies involve redirecting the

patient’s attention away from the distress source and engaging them in a music-based

intervention that requires focus of attention. Live music interventions, as opposed to

pre-recorded music, allow the music therapist to manipulate the music to maintain the

patient’s attention throughout the time of stress.

During routine immunizations and needle sticks, a signi cant decrease in behav-

ioral distress was seen when music was utilized during the procedure (Arts et al., 1994;

Fowler-Kerry & Lander, 1987; Malone, 1996; Megel, Houser, & Gleaves, 1998) Noguchi

(2006) found that children who participated in a musical story during vaccinations

reported less pain and appeared less distressed, as opposed to children who received

a spoken story or no intervention. In addition, when music was used pre- and post-

invasive procedures, anxiety and self-reported pain decreased (Pfa , Smith, & Gowan,

1989; Steinke, 1991). Preoperative anxiety was signi cantly reduced prior to reconstruc-

tive surgery in pediatric burn patients when music-assisted relaxation was provided to

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