Kids With Cancer: Music Therapy Ups Well-Being, but Underused

Kristin Jenkins

January 22, 2020

"Music therapy can shift a patient's perspective," said David Knott, MT-BC, MM, supervisor of the Creative Arts Therapies program at Seattle Children's Hospital, Washington.

"Once this begins, we can help them get new insight into what's happening with them," he told Medscape Medical News.

"Music therapy is an important part of the overall supportive care service," he said.

However, recent findings from an American Music Therapy Association (AMTA) membership survey, which Knott headed, indicate there are not enough music therapists in the United States to meet the needs of pediatric patients.

Music-Based Interventions

In 2002, Knott was hired as the first dedicated music therapist at the Seattle Children's Hospital. Since then, he has seen music-based interventions increase patients' emotional and psychological well-being, helping them manage pain and improving their communication and coping skills. This has increased patients' motivation, cooperation, and ability to adapt in the face of uncertainty, he commented.

David Knott, music therapist at Seattle Children's Hospital.

Knott was a 3-year veteran of the US Army with a knack for building musical instruments, such as the dulcimer and the harp, when he discovered music therapy.

After reading a seminal text on the topic, he returned to school, received a bachelor's degree in music therapy, and became board certified. He subsequently received a masters degree in music and a fellowship in the Academy of Neurologic Music Therapy.

"I have had a lot of very rich life experiences before I became a music therapist," Knott emphasized. "There hasn't been a more difficult or rewarding job in my life."

Although he carries a guitar, Knott favors the ukulele, calling it "an ideal hospital instrument — small, light, and cleanable." It offers an unobtrusive introduction to music therapy that encourages patients and families to listen, sing along, improvise, compose their own lyrics, or play another instrument.

"I may not be able to play any song the patient wants in a way that dazzles them," Knott explained. "That's not my role. My role is to develop a relationship through music that helps patients build resilience, complete painful physical therapy exercises, or address a neurological condition or illness that causes decompensation."

Some patients may cry or become completely withdrawn at first, and music-based interventions can help them overcome negative emotions that are often exacerbated by cancer treatment and its side effects.

Knott vividly recalls one of his earliest patients, a shy 6-year-old who was finally singing along with him and then suddenly began to vomit. The child's mother took swift action, and Knott continued playing the ukulele quietly in support. But he found himself questioning whether the music was too much. As soon as the vomiting ended, he got his answer. "Let's sing some more," the little girl told him.

"I can't say that I did anything in relation to her nausea, but music can help support patients through these things," he said. "It can help them recover and get back to baseline."

Not Enough Music Therapists?

As previously reported by Medscape Medical News, studies show that music-based therapeutic interventions can reduce anxiety in patients with cancer who are undergoing chemotherapy as well as decrease treatment-related side effects, such as fatigue, loss of appetite, and brain fog.

In the United States, most large pediatric medical centers or children's hospitals have at least one board-certified music therapist on staff, notes Kimberly Bell, MT-BC, a music therapist at Children's Hospital New Orleans in Louisiana.

There are also music therapists in larger pediatric hospitals in Canada, the United Kingdom, the European Union, and Australia, she told Medscape Medical News.

However, the recent findings from the AMTA membership survey suggest there are not enough music therapists working specifically with youngsters in the United States.

That study, with Knott as lead author, was published online in the Journal of Music Therapy.

The cross-sectional study, launched to establish national benchmark data for pediatric music therapy in medical settings, shows that almost 75% of members work in acute care settings, primarily pediatric intensive care units. Patients may have cancer, a brain injury, or medically complex needs that require mechanical ventilation.

Most music therapists reported being responsible for approximately 100 patient beds, providing an average of four to six individual music therapy sessions daily.

"When taken together, these results demonstrate a shortcoming in the availability of music therapy services for vulnerable populations that might need them most," said Knott, who led the AMTA Pediatric Music Therapy Resource Group that conducted the survey.

"Based on our findings, we recommend the development of best practice recommendations that stipulate optimal therapist-to-patient ratios in order to ensure best quality of care," Knott said. "We recommend that clinicians and institutions explore how tiered service delivery models could expand availability of services."

The survey revealed that 30% of AMTA members were the only music therapist in their setting. Half reported that their position was funded philanthropically, not through the hospital operating budget.

Music therapists need the support of the multidisciplinary cancer care team to develop standardized systems that prioritize music therapy on the basis of patient need, Knott explained. This would help the music therapists support rehabilitative and respiratory care goals of the cancer care team and explore music as a nonpharmacologic approach to pain management.

Like Knott, Bell is a fellow in the Academy of Neurologic Music Therapy. She provides music therapy services to rehabilitation, acute care, and critical care units, including level IV neonatal intensive care units.

Bell said that in the 30 years since she began her practice, the profession has evolved significantly. "Not only are music therapists available during the acute hospitalization phase, but often treatment can be continued during follow-up visits or subsequent hospitalizations," she said.

Bell has seen music-based therapeutic interventions motivate a young patient to get out of bed and walk in order to lead a parade of family and unit staff. For a teenaged patient who had decided to end treatment, songwriting helped him express his feelings. And for the family of a child receiving end-of-life care, composing a legacy song that featured their child's heartbeat sustained them, she recalls.

Cecelia Bartosiewicz, MT-BC, a music therapist serving with the cancer care unit at Seattle Children's, knows the hospital can be frightening for young children, who often become wary of staff and procedures. During the course of a single music therapy session, apprehensive children can become more interactive, expressive, and compliant, Bartosiewicz told Medscape Medical News.

"I've used music as a tool to connect with patients to create safe and familiar moments during their hospital stay," she explained. "They pick songs or instruments to play, and I often follow the pace they set for the music."

Music-based interventions are highly effective in group settings, too. For the youngest patients receiving cancer care, Busy Bees at Seattle Children's offers peer learning under the guidance of an art therapist, a child life specialist, and a member of the rehabilitation team. For school-age and teenage patients, music-based activities in a hospital classroom provide the added bonus of social engagement, Knott commented.

Knott said that when he is confronted by an angry adolescent demanding hard-core rap, he puts his ukulele aside (at least temporarily) and draws upon the beat-boxing skills he has picked up from patients. This vocal percussion style popular in hip-hop and rap music culture has allowed him to connect with the most uncooperative teens when others cannot.

"I've ventured out onto thin ice with these patients by doing beat-boxing," Knott admitted, and added: "I've had huge success."

A few sessions in, the most recalcitrant teens will agree to practice relaxation exercises while Knott gets back to playing the ukulele. Many ask him to teach them how to play the ukulele, which he does. This becomes another music-based option for patients in hospital that they can take home when they leave, he pointed out.

Irresistable to Hospital Staff

The siren call of the little ukulele has also proved irresistible for hospital staff at the Seattle Children's Hospital. The staff ukulele choir, made up of people from 40 departments who have no music experience, performed pop-up concerts around the hospital after only 6 weeks of once-weekly rehearsals. They got rave reviews, Knott said. Staff members told him that the ukulele choir increased their appreciation of the work environment and improved their understanding of the impact that music therapy has on patients and families.

Cecelia Bartosiewicz (far left) and the Staff Ukulele Choir at Seattle Children's Hospital.

"All these things add up to show us how can we use music and, more broadly, the arts to inform the lived experience of people coming to the hospital," said Knott.

He recommends that anyone interested in starting a music therapy program contact the AMTA. Local board-certified music therapists can be reached through the Certification Board for Music Therapists.

Knott, Bell, and Bartosiewicz have disclosed no relevant financial relationships.

J Music Ther. Published online on January 4, 2020. Abstract

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