Receiving vaccinations is a part of growing up; however, as necessary as vaccinations are, many children find them to be frightening and painful. Music has been examined as a potential distraction during pediatric medical procedures, but research findings have been mixed, due, in part, to the fact that children were primarily instructed to merely 'listen to the music.' The present study sought to determine if a focus of attention activity involving music would affect levels of distress and perceptions of pain in pediatric injection patients. Sixty-four 4- to 6 �-year old children receiving routine immunizations were randomly assigned to one of three conditions: musical story, spoken story, or standard care/control. Children in the two treatment conditions listened to a recorded story and pointed at corresponding pictures throughout the injection process. Observational data on distress and pain were collected, in addition to the child's self-rating of pain. Participants in the musical story condition tended to be less distressed and report less pain than participants in the other two conditions, although these differences were not statistically significant. Subsequent analysis indicated that children who received more injections tended to benefit more from the music intervention, in terms of their perceived pain.
According to the current recommendations of the Childhood Immunization Support Program of the American Academy of Pediatrics (2004), a child should receive more than 20 immunizations before his/her sixth birthday. From a public health perspective, immunizations against preventable communicable diseases are necessary; however, many children find them to be frightening, as well as painful, due to the involvement of needles. One study reports that 92.7% of 15- to 18-month old children and 44.4% of 4- to 6-year old children exhibit signs of serious distress during routine vaccinations (Jacobson et al., 2001).
Distraction, defined as any technique which 'divert[s] attention from a noxious stimulus through passively redirecting the subject's attention or by actively involving the subject in the performance of a distractor task' (Kleiber & Harper, 1999, pp. 44-45), is the most commonly used technique with children undergoing invasive medical procedures. The specific methods used to distract the pediatric patient from an ongoing procedure have varied greatly: they range from deep breathing and air-blowing (Bowen & Dammeyer, 1999; Peretz & Gluck, 1999; Sparks, 2001) to television/movie watching (Cassidy et al., 2002; Cohen, 2002; Cohen, Blount & Panopoulos, 1997) to interactive electronic toys (Dahlquist, Busby, et al., 2002; Dahlquist, Pendley, Landthrip, Jones, & Steuber, 2002).
A handful of research studies exist within the medical and psychological fields on the use of music as distraction for children undergoing invasive medical procedures. Studies by Fowler-Kerry and Lander (1987) and Megel, Houser, and Cleaves (1998) found that 4- to 6-year old children had significantly lower pain self-ratings and behavioral distress when they listened to music during immunizations. Arts et al. (1994), however, reported that music did not alleviate pain from intravenous cannulation as well as EMLA (a topical anesthetic cream) did, and that there was 'no discernable benefit from music distraction' (p. 800). Upon further examination of this study, though, it becomes evident that the age-appropriateness of music was not considered: the same piece of 'appealing and distracting music (contemporary, up-beat music)' (p. 798) was used for participants ranging in age from 4 through 16 years, calling into question the validity of the study's findings.
What these three music studies have in common is that they all involve passive listening; that is, the participants were simply provided with headphones and instructed to listen to the music. What is problematic about this is that attention to music tends to wane during passive listening (Madsen & Geringer, 2000), and this is especially true for children, as it has been documented that selective attention in children improves with age (Davies, Jones, & Taylor, 1984).
The presence of a music therapist to provide live music may serve to hold the attention of a pediatric patient, and thus provide distraction, during painful procedures. Music therapists have been reporting success in their work with pediatric patients during invasive procedures (Malone, 1996; D. Walworth, personal communication, 2 November 2002; N. Briggs & A. Kendelhardt, personal communication, 22 November 2003). However, the reality is that only a small percentage of clinical settings have the luxury of music therapy services. In addition, many pediatric clinics are so busy that having a music therapist work with children receiving injections is neither practical nor cost-effective. As such, music interventions which are simple, do not require much training on the part of the child, and can be administered by individuals other than music therapists would be more applicable to such settings.
Using recorded music is one way in which this specialized population can be served. For optimal engagement in music listening, however, the listener should be instructed to attend to certain elements within the music (Madsen & Geringer, 2000). It is reasonable to believe that if the child were instructed to listen for an auditory cue (for example, a particular word within the song lyrics) and respond to it in some way (motioning with his/her hand), the task would be even more engaging. It has been noted by a number of researchers that it is best if distraction interventions involve more than one sensory modality and require active participation on the part of the participant (Cassidy et al., 2002; Dahlquist, Busby, et al., 2002; Dahlquist, Pendley, et al., 2002; Sparks, 2001).
The purpose of this study was to determine the effectiveness of a focused listening task meeting the above criteria (used by Wolfe & Noguchi, 2004) as a distraction for children receiving injections. In addition, the difference between music and non-music was examined: is a task involving music more engaging to a pediatric injection patient than one which does not involve music?
Method
Participants
The participants in this study were pediatric patients who had been brought by a parent or guardian to one of three medical clinics in a large, culturally diverse metropolitan area in the western region of the United States. Children were eligible to participate in the study if they: (a) were between 4 and 6 � years of age; (b) would be receiving one or more injections; and (c) were able to comprehend English well enough to understand and complete the focus of attention task. Based on a randomly-generated sequence of numbers, participants were assigned to one of three conditions: music, nonmusic/spoken, or standard care/control.
Each participant received at least one of the following injections: Diphtheria, Tetanus, Pertussis (DTaP); Inactivated Poliovirus (IPV); Measles, Mumps, Rubella (MMR); Hepatitis A; Hepatitis B; and Purified Protein Derivative (PPD; tuberculosis skin test). These injections were administered intramuscularly by a medical professional in the upper arm or in the thigh, with the exception of the PPD injection, which was delivered in the forearm.
Sixty-four children, ranging in age from 4 to 6 years (M= 4.55; SD = 0.65), took part in the study. The 38 boys and 26 girls received 1 to 6 injections each, with an average of 3.21 injections (SD= 1.30) per participant. All parents/guardians reported that their children had received all scheduled immunizations to date, and eight parents/guardians reported that their children had also received other injections, such as for influenza and allergies.
The final analysis consisted of data for 62 participants: 21 in the music condition, 21 in the nonmusic condition, and 20 in the control condition.
Materials
A focus of attention task used in a study by Wolfe and Noguchi (2004) was designed around a musical recording for children entitled 'Little Squirrel' (Kindermusik, 1996), which contained lyrics that told a story about a little squirrel and the things he did one day. The song was performed by a male vocalist and included an instrumental accompaniment. The nonmusic/spoken version of the story was recited at the same tempo by a male volunteer, and was recorded onto a CD-R. These selections, each 1 minute and 56 seconds in duration, were presented to the participants via portable CD player and headphones. For the purpose of infection control, the headphones were wrapped with fresh pieces of plastic wrap each time they were used by a participant.
Visual aids depicting events and characters in the story were created using clip art. There were five event visuals: squirrel shaking tail, squirrel wiggling nose, squirrel digging a hole, squirrel cracking a nut, and squirrel taking a nap. There were also five character (animal) visuals: mouse, owl, rabbit, bee, and dog. Velcro backings were placed on the ten laminated visuals, and were presented to the participants on a Velcro board.
The Observational Scale of Behavioral Distress (OSBD) of Jay and Elliott (1986) classifies children's distress behaviors from medical procedures into eight categories: information seeking, cry, scream, restraint, verbal resistance, emotional support, verbal pain, and flail. Categories are weighted based on the level of intensity of the distress behavior; thus, level of distress is determined by dividing the frequency of behavior occurrences by the number of intervals observed and multiplying this number by the intensity weight. Trained observers, who were blind to the study hypotheses, recorded occurrences of behaviors in the eight distress categories at 15-second intervals for the duration of the injection procedure. Observation was divided into three phases: (a) preinjection phase, which began when the nurse left the room to prepare the syringe (s) and ended when the first injection was administered; (b) injection phase, beginning with the first injection and ending with the last injection; and (c) postinjection phase, which was the time between the last injection and the departure of the participant from the exam room or the passing of 2 minutes, whichever occurred first. Distress scores were generated for each of these phases, and a total OSBD score was generated by adding the three phase scores. The OSBD has been utilized extensively within this area of research (Dahlquist, Busby, et al., 2002; Dahlquist, Pendley, et al., 2002; Jay, Elliott, Katz & Siegel, 1987; Megel et al., 1998; Pringle et al., 2001) due to its reported reliability and validity (see Jay & Elliott, 1986).
The Faces Pain Scale, designed by Bieri, Reeve, Champion, Addicoat, and Ziegler (1990), was selected due to its reported reliability and validity, as well as its applicability to young children. In addition, the Faces Pain Scale differentiates between pain and mood, which is a reported shortcoming of other similar pain scales (Cassidy et al., 2002). The scale consists of seven faces depicting progressively increasing levels of pain; each face corresponds with a numeric value, with the face furthest to the left being 0 (no pain) and the face furthest to the right being 6 (most pain possible). Once the injection procedure was completed, the child was shown the scale and asked to point at the picture which indicated his/her pain from the injection (s). The experimenter and trained observer used this same rating scale to assess their perception of the child's most severe facial expression of pain from the injection (s).
In the two treatment conditions (music and nonmusic/spoken), the child's involvement in the listening and pointing task was measured. A correct response was recorded when the child clearly pointed at or touched the picture depicting the event or character being referred to within 3 seconds of its presentation in the CD recording. Motions which did not specifically indicate recognition of the target picture (e.g., waving finger in the air), pointing at the target picture more than 3 seconds after its presentation, and pointing at a nontarget picture were not counted as correct responses. The number of incorrect pointing responses was also recorded, as this indicated that the child was attempting to stay focused on the task; these behaviors involved pointing at the wrong picture or pointing at the correct picture more than 3 seconds after it was presented. The data considered in the final analysis involved percent accuracy on the task, calculated by dividing the number of correct responses by the number of possible correct responses, and the total number of pointing responses, which was the sum of correct and incorrect pointing responses.
Procedure
Prior to the data collection process, the medical professionals at the three participating clinics were briefed about the nature of the study. Staff members were asked to indicate to the experimenter whether or not a child was eligible to participate based on the aforementioned selection criteria. If eligible, the child and his/her parent or guardian were approached by the experimenter, who introduced herself and provided a brief verbal explanation of the study, along with the informed consent form. A Spanish version of the informed consent form was provided to those parents/guardians who preferred one in Spanish. In addition to written consent from the parent/guardian, verbal assent from the child was obtained. For those participants who had been randomly selected to be videotaped for the purpose of establishing interrater reliability, additional video consent and assent were obtained at this time.
The following information was then gathered from the parent/ guardian: the child's age, whether or not the child had received all of his/her routine vaccinations, and whether or not the child had received other injections (e.g., influenza, allergy). The experimenter took leave of the child and parent/guardian until the commencement of the injection process.
Treatment conditions (music and nonmusic/spoken). The experimenter and observer entered the exam room when the nurse left the room to prepare the syringe (s). The observer, who was not aware of which treatment condition the child was assigned to, began recording preinjection OSBD data at this time. The child was told by the experimenter that he/she would be listening to 'a story about a little squirrel who did many things and saw many animals while he was running around.' The experimenter then labeled the squirrel action visuals one at a time, stating what action was taking place (e.g., 'he shook his tail') and pointing at the corresponding picture on the Velcro board. The experimenter asked the child to state what was happening in each picture. In situations when the child did not state the action, the experimenter asked a yes/no question (e.g., 'Is he wiggling his nose in this picture?') and restated what action was taking place. The five animal visuals were presented in a similar manner.
The participant was then told the following:
When you listen to the story, you're going to hear the man say that the squirrel did something. It's very important that you listen carefully, because I would like you to point at the picture that shows me what the squirrel did. So, if you hear the man say, 'he shook his tail,' point to the picture of the squirrel shaking his tail, just like this.
The experimenter modeled the correct behavior, and subsequently gave the child the opportunity to practice by saying the actions out loud so he/she could respond by pointing. This process was repeated with the animal visuals. When it was determined that the child understood the task, the experimenter stated:
The nurse has to do her work now, but we have our work to do, and that's to listen to the story and point at the pictures! It's very important that you look at the pictures, listen to the story, and point while the nurse is doing her work.
The experimenter placed the headphones over the child's ears, and pressed the 'play' button on the portable CD player, starting the musical or spoken story recording. If the nurse had already returned with the syringe(s), the injection process commenced at this point. In instances where the nurse had not yet reentered the room with the syringe(s), the child was given the opportunity to practice listening to the CD recording and pointing, until the nurse arrived and was ready to administer the injection(s).
OSBD data and frequency of pointing were recorded during the injection process; the child's most extreme facial expression of pain was also noted. If the child became distracted from the task by the injection process, the experimenter attempted to redirect the child to the activity by using phrases such as 'Keep pointing' and 'Look at the pictures.' In instances when the injection procedure lasted longer than the CD recording, the recording was replayed. The child was reinforced by the experimenter throughout the procedure for pointing behaviors ('Good pointing!'), and provided with reassurance ('It's almost done, you're doing a good job.') as warranted. In cases where the child began to move around so much that he/she could potentially become tangled in the headphone cord and/or the child needed to be restrained, the experimenter removed the child's headphones and suspended the focus of attention task.
Upon completion of the injection procedure, the experimenter turned off the CD player, noting the point in the recording when this took place. The observer proceeded to collect postinjection OSBD data, while the experimenter asked the child to rate his/her pain from the injection(s) on the Faces Pain Scale, pointing at each face, beginning with the face furthest to the left, and offering the following explanation:
This picture shows someone who felt no hurt at all (Face 0). This person felt a little bit of hurt (Face 1). This one felt a little more (Face 2) . . . a little more (Face 3) . . . a little more (Face 4) . . . a little more (Face 5) . . . and this person felt A LOT of hurt (Face 6). Point at the face which shows me how much you hurt from your shot(s).
The experimenter offered the child a sticker as a reward.
Standard care/control condition. When the nurse left the room to prepare the syringe(s), the experimenter and observer positioned themselves in the doorway of the exam room, in an attempt to keep their interactions with the parent/guardian and child to a minimum. The observer gathered preinjection OSBD data until the first injection was given. Due to the absence of the intervention procedure, it was not possible for the trained observer to be blind to the group assignment of the participants in this condition. Data collection proceeded as in the treatment conditions.
Results
Interrater reliability. The three observers who assisted with data collection viewed all 13 videotaped sessions. The observer who had taken OSBD data for the participant on-site was asked to record the number of times the participant pointed at the Velcro board, to calculate reliability with the experimenter. The other two observers viewed the video and recorded OSBD data.
An analysis of the OSBD scores generated by the three observers yielded a Cronbach's alpha value of .97, indicating high interrater reliability. In addition, the number of agreements for each of the eight behaviors in each observed interval was divided by the sum of agreements and disagreements, resulting in percent agreement scores. Agreement amongst the three observers ranged from 80.21 percent (Crying) to 97.40 percent (Information Seeking), with a mean agreement score of 90.49 percent. Correlation between the experimenter and the observer on the number of pointing responses recorded was found to be .98.
Preliminary analyses. The two treatment groups and the control group were examined for homogeneity across the demographic variables of gender, age, and number of injections received. The three groups did not vary significantly in age, F(2,59) = 2.00, p > .05, or the number of injections they received, F(2,59) = 0.14, p > .05. The groups were found to be significantly different in terms of the proportion of female to male participants (chi-square, (2) = 6.16, p < .05). While the music group had more female participants than male (13 girls and 8 boys), both the nonmusic and control groups had fewer female participants than male (6 girls and 15 boys for nonmusic; 6 girls and 14 boys for control). This difference was taken into consideration in later analyses. Injection history variables were not found to significantly affect behavioral distress, and were thus eliminated from further analysis.
Behavioral distress. In order to control for the length of time of the pre and post injection phases, only data for the four observations prior to and following the injection(s) were used to calculate OSBD phase scores. Chronologically, these observation intervals corresponded to the 1 minute immediately before and the 1 minute immediately after the injection(s). Due to the varying number of injections administered, it was not possible to standardize the number of observations/length of time of the injection phase. The number of intervals observed in the injection phase ranged from 1 to 21 (M = 7.24, SD = 5.03), equaling 15 seconds to 5 minutes 15 seconds.
Mean OSBD scores by experimental condition across the procedural phases are presented in Figure 1. In the preinjection phase, children in the music group exhibited more distress (M = 0.59, SD = 2.15) than their counterparts in the nonmusic group (M = 0.17, SD = 0.47) but less distress than those in the control group (M = 0.71, SD = 1.14). While the injections were being administered, participants who listened to the musical story had an average OSBD score of 3.11 (SD = 3.02), which was lower than the 3.52 (SD = 2.68) of the nonmusic participants and the 3.98 (SD = 3.51) of the control group participants. During the postinjection phase, the music group participants showed the least amount of distress (M = 0.94, SD = 1.16). The nonmusic and control group participants had similar distress scores (M = 1.41, SD = 1.38 & M = 1.43, SD = 1.23, respectively) after the injection(s).
A 3 � 3 mixed-design ANOVA was conducted to determine the effects of experimental condition (music, nonmusic, and control) and procedure phase (preinjection, injection, and postinjection) on distress scores. A significant main effect for procedure phase was found, where OSBD scores were significantly higher during the injection(s) (M = 3.53, SD = 3.05), than both before or after the procedure (M = 0.49, SD = 1.43 and M = 1.26, SD = 1.26, respectively; F(1,59) = 10.38, p < .01). The difference between pre and postinjection scores was also found to be significant. The main effect for experimental condition was not statistically significant, F(2,59) = 0.60, p > .05, and no interaction was found between condition and procedure phase, F(2,59) = 1.16, p > .05.
The total OSBD score was, on average, 5.27 (SD = 4.41). Children in the music condition averaged 4.64 (SD = 4.82) while the children in the nonmusic condition averaged 5.10 (SD = 3.78). The children in the control condition displayed the most distress, with a mean score of 6.12 (SD = 4.64). However, a one-way ANOVA indicated that this difference was not significant, F(2,59) = 0.60, p > .05.
Pain. The experimenter and observer ratings of participant pain were examined for correlation. It was found that the two were strongly correlated (r(59) = .89, p < .01), with the experimenter and observer making similar assessments of the child's pain. The variable of observer rating was dropped and the experimenter rating was used to represent bystander assessment of participant pain in subsequent analyses, as the experimenter was present for all of the observed sessions.
The children, on average, rated their pain as 3.39 (SD = 2.71) on the 6-point Faces Pain Scale, indicating a moderate level of pain. Overall, this appeared to be in line with the experimenter rating, which was a mean of 3.98 (SD = 2.04). However, as displayed in Figure 2, the children's ratings were bimodally distributed, with ratings which gravitated towards the endpoints of 0 and 6, and no reports of 4s and 5s. The experimenter ratings were, with the exception of a high number of 6s, normally distributed. The Spearman rho correlation coefficient for child and bystander pain ratings was .48, which was significant at the .01 level.
Participants in the music condition tended to report less pain (M = 2.67, SD = 2.79) than participants in the nonmusic (M = 4.00, SD = 2.55) and control (M = 3.53, SD = 2.76) conditions. Similarly, experimenter ratings were lowest in the music condition (M = 3.62, SD = 2.31), followed by the nonmusic (M = 3.86, SD = 1.68) and control (M = 4.53, SD = 2.09) conditions. A Kruskal-Wallis test was used to examine if these differences were significant across the conditions. Neither the child ratings (H(2) = 2.39, p > .05) nor the experimenter ratings (H(2) = 2.78, p > .05) were found to be significantly different from each other.
Focus of attention task performance. Accuracy on the pointing task was low in general, with children pointing correctly only 15.82% (SD = 22.58) of the time, although accuracy ranged from 0.00 to 92.31% correct. The children who listened to the musical story were less accurate (M= 14.13, SD = 24.17) than the children who listened to the spoken version of the story (M = 17.50, SD = 21.33). This difference, however, was not statistically significant (t(40) = 0 -0.48, p .05).
On average, the children pointed at the pictures 4.40 times (SD = 7.64), regardless of accuracy. Frequency of pointing varied greatly, where some children did not point at all and one child pointed 43 times. When broken down into the two treatment conditions, the children in the music group tended to point more (M = 5.43, SD = 10.16) than the children in the nonmusic group (M = 3.38, SD = 3.78), but the difference did not reach statistical significance (t(40) = 0.87, p > .05).
Additional analyses. Due to the unbalanced nature of the three conditions on the variable of gender, t-tests and ANOVAs were conducted to determine if male and female participants varied in their distress scores and performance on the focus of attention task. In addition, Kruskal-Wallis tests were conducted on the pain ratings made by the children and the experimenter. No significant differences between the genders were found.
To allow for comparisons on the variable of age, the ages of the participants, which had been recorded at half-year intervals, were recoded to one-year intervals, creating three age categories (4, 5, and 6 years). It was found that across all three phases, the 4 year olds had higher OSBD scores than the 5 year olds, who had higher OSBD scores than the 6 year olds, although the difference did not reach statistical significance F(2,54) = 2.45, p = .10 (see Figure 3).
Because the participants received anywhere from 1 to 6 injections, the potential impact of the number of injections received was examined. The average total OSBD score for a child receiving 1 shot was 5.76 (SD = 6.46). OSBD scores were lower for children who had 2 shots (M = 4.55, SD = 2.42), and lower still for children who had 3 shots (M = 3.94, SD = 2.60). As can be seen in Figure 4, there was a jump in overall distress levels at 4 shots (M = 5.66, SD = 4.28) and distress peaked at 5 shots (M = 6.50, SD = 6.50). The 1 participant who received 6 shots had a total OSBD score of 5.73. Based on these means, the decision was made to compare children who received 1 to 3 shots to those children who received 4 or more shots.
The effect of number of shots on distress scores and focus of attention task performance was calculated using Mests. OSBD scores and frequency of pointing were not found to differ between the two injection groups. There was a significant difference in accuracy on the pointing task (t(40) = 2.30, p < .03), with participants who received 1 to 3 shots being more accurate (M = 24.20, SD = 28.94) than those who received 4 to 6 shots (M = 8.89, SD = 12.42). Kruskal-Wallis analyses indicated that the children who received 3 or fewer shots rated their pain as being significantly less (M= 2.67, SD= 2.69) than those who received 4 or more shots (M= 4.11, SD = 2.58) (H(1) = 3.74, p= .053), even though the experimenter's ratings did not differ between the two groups.
As displayed in Figure 5, the participants in the music group reported the least amount of pain (M= 2.70, SD= 2.87), followed by the control group (M= 4.89, SD = 2.26) and the nonmusic group (M= 5.00, SD = 1.93), although the difference did not reach statistical significance (H(2) = 4.64, p = .10). In the control group, the children who received 4 or more shots reported a significantly higher level of pain (M= 4.89, SD= 2.26) than the children who received 3 or fewer shots (M= 2.30, SD= 2.67) (H(1)= 4.05, p < .05). No such difference was found for either of the treatment conditions. Statistically significant findings were not detected for experimenter ratings.
Discussion
It is apparent, from the significant main effect for injection phase, that getting injections is distressing for children. This finding was not at all surprising, considering the extensive body of literature which addresses methods for reducing the distress children experience as the result of receiving necessary immunizations. It was the hope of the experimenter that a music-related focus of attention task might serve this purpose. While in general, the participants assigned to the music condition tended to show the least amount of distress when compared to the participants in the nonmusic and control conditions, these differences were not found to be significant. This may be due, in part, to the small sample size: the treatment effect may have been a subtle one, which may have been more readily detected by a larger sample and effect size.
Another possible explanation for the lack of significant findings on behavioral distress is the nature of the OSBD measurement. When compared to the OSBD, the Child-Adult Medical Procedure Interaction Scale (CAMPIS) covers more subtle behaviors, such as verbal fear and verbal emotion, as opposed to overt behaviors, such as flail and restraint. The Behavioral Approach-Avoidance and Distress Scale (BAADS) involves the assessment of the child's attempt to escape or avoid the medical procedure, as well as a global assessment of the child's distress on a five-point scale. It is possible that the intervention may have had a more subtle effect on child distress than the OSBD was able to capture, as was the case in a study by Blount and colleagues (1992).
Both child and experimenter ratings of pain were lowest in the music group, but again, they were not significantly different from those of the nonmusic and control groups. From a research standpoint, it was problematic that the children's pain ratings tended to gravitate towards the endpoints, with most responses being either '0' (no hurt) or '6' (a lot of hurt). Some possible explanations for these findings are that the children were not able to assess their pain accurately due to cognitive immaturity (Arts et al., 1994) or were confusing the concept of pain with other feelings, such as fear or distress (Cohen, 1998).
While one may be likely to assume that the young children in this study were inaccurate in their ratings of pain, drawing such a conclusion would be premature. Varni, Walco, and Katz (1989) indicate that researchers do not question the ability of adults to assess pain, even when their ratings do not correlate well with those of observers, so it is unfair to assume that children are not able to accurately assess pain. Pain is subjective, and therefore, any study examining the effect of an intervention on pain would be lacking if the participant is not asked to rate his/her pain, providing the participant is capable of giving a response to such a question. But what is apparent from this study is that it is crucial to utilize other measurements, such as behavioral assessments, to determine the efficacy of a treatment designed to moderate pain perception, especially in studies involving young children.
The musical and nonmusical versions of the focus of attention task were not found to differ significantly, in terms of accuracy or frequency of pointing responses. These findings were somewhat unexpected, given the findings of Wolfe and Noguchi (2004), where in the presence of distraction, children in the music group stayed more focused on the pointing task than the children in the non-music group. Clearly, the intensity level of the distraction in Wolfe and Noguchi (sounds from a stereo) is only a fraction of the intensity of receiving injections, which involves multiple sensory modalities, including pain. It may be that receiving an injection is too distressing an event for many children to ignore, despite the interactive nature of the focus of attention task. It is important to keep in mind, however, that injections are extreme, in terms of the level of fear and pain involved for the child. Children undergo many other medical procedures which are not as invasive or distressing, such as x-rays and dressing changes, and a musical focus of attention intervention may be effective in these situations.
There are a number of other possibilities in terms of explaining the lack of engagement in the focus of attention task. It has been found that the ability to attend to stimuli and filter out distractions improves with age during childhood (Hagen, 1967; Davies et al., 1984). While it is relatively easy to ignore sounds coming from a stereo, attempting to ignore injections may be beyond the attentional abilities of some young children. Another plausible explanation is that for some children, distraction from the injection procedure was not contingent upon pointing at the pictures in response to the auditory cues. A number of participants were observed listening to the recording and looking at the pictures intently without pointing, while a couple of participants pointed at pictures quickly and randomly. Within the framework of this study, engagement in the task was measured through accuracy and the number of times the child pointed, but it appears that these statistics do not tell the whole story. An alternate method, used by Cassidy et al. (2002) for measuring the effectiveness of the distraction, may be to compare the amount of time the child spends looking at the needles to the time spent looking away from them.
High levels of distress amongst preschool children receiving injections has been attributed to immaturity, in terms of understanding the purpose and process of the medical procedure (Jay, 1988). Jacobson et al. (2001) found that younger participants exhibit more distress throughout the injection process than older participants; this tended to be true in the present study, however, not significantly so. Interestingly, while other studies have also shown that younger children tend to report more pain than older children (Arts et al., 1994; Fowler-Kerry & Lander, 1987; Sparks, 2001), the age effect was not significant for pain ratings in this study, neither from the child nor the bystander.
The number of shots received was a significant factor in the level of accuracy on the attention task, with children receiving 1 to 3 shots being 24.20% accurate and children receiving 4 to 6 shots being only 8.89% accurate in their pointing. This finding points to the difficult nature of staying focused on the activity amidst repeated injections: it may be beyond the attentional abilities of young children to ignore that many injections and do the activity. LaBerge (1995) states that in order to maintain attention to a given stimulus, the information flow from that stimulus must be greater than that coming from other competing stimuli. It may be that while a couple of injections might not demand much attention while a child is engaged in an activity, the sensory stimuli from 4 or more injections exceeds the information coming in from the activity, causing the child to switch his/her attention to the injections.
The finding that the participants who received 4 or more shots reported significantly higher levels of pain than the participants who received 3 or fewer shots indicates that part of the sensory information being processed is likely pain. Upon closer examination, it was determined that this was true specifically for the children in the control condition, where the average pain rating leaped from 2.67 to 4.89. While the music and non-music group participants' pain ratings did also increase with the number of shots, the increases were not significant. This is not surprising when one considers the Gate Control Theory of pain (Melzack & Wall, 1965), which posits that nociception is not automatically interpreted and perceived as pain: the amount of pain stimuli which reaches the brain and is processed as pain is affected by higher level brain processes (the gate). In the treatment conditions, the pointing activity provided competition for the child's attention and likely prevented some of the intense pain stimuli from being processed, while in the absence of the activity, the pain sensation from all the injections may have streamed in uncontested.
Among the children who received 4 to 6 shots, the participants who listened to music tended to report the least amount of pain. In light of the finding that accuracy on the pointing task was, in general, poor for the children who received 4 or more injections, it appears that other factors associated with music moderated the perception of pain. Novelty of the task is one possibility: while children are accustomed to listening and responding to spoken words, many of the children were probably not used to listening and responding to song lyrics. Distraction techniques are believed to be more effective when they involve novel materials and/or activities (Slifer, Tucker, & Dahlquist, 2002), as they are better able to hold the attention of the young child, and this may have been the case with music in this study. It is also possible that actively listening to the music required a high level of engagement on the part of the child. Madsen and Geringer (2000) indicate that changes in musical elements, such as volume, tempo, and instrumentation, tend to command attention. The flip side of this is that when sounds are predictable and continuous, people tend to filter them out. The children who listened to the musical version of the story had to maneuver through the musical elements in order to hear the vocal cues and respond to them, which required a great deal of concentration on the part of the children and likely served as a potent distraction from the pain of the injections. However, the children who listened to the spoken version of the story only heard a male voice, and after a while, they may have become accustomed to hearing the voice and were thus, more easily distracted from the activity, especially when they received many injections.
Certain variables not examined in this study may have affected the research findings. First, the medical personnel involved in the administering of injections varied within and across clinics. It was observed that some nurses encouraged the children to 'look at the pictures' and 'listen to the story' in the treatment conditions, and suggested other coping behaviors, such as counting or holding onto the parent, in the standard care condition. For the purpose of comparison, it would have been better to have the nurse not suggest these behaviors, because nurse promotion of coping has been found to be a predictor of decreased immunization pain in young children (Sweet & McGrath, 1998). However, it was determined that having the nurses change their regular routines would not constitute 'standard care,' and would have denied the children the level of care that patients were entitled to receive at the clinic. Therefore, the nurses were instructed to help their patients through the injection process as usual, but to try not to go above and beyond what they normally do in terms of trying to distract the children.
A second variable which may have affected the outcome of the study was the child's preparation before the injection procedure. Some parents/guardians chose not to inform their children ahead of time about the injections, and this may have impacted the level of distress experienced by the children. In general, it has been found that children who are not warned about an impending medical procedure tend to experience more stress and anxiety as the result of the procedure than those children who are told ahead of time (Jay, 1988; Jacobson et al., 2001). Some parents/guardians told the experimenter and/or the nurse that their children did not know about the injections ahead of time, but this information was not sought from all the parents/guardians, and thus, was not examined in this study.
Additional child variables which may have affected the children's responses to the injection process are previous medical experience and temperament. A number of researchers have indicated that a child's distress from injections is correlated to having had a prior bad medical experience, and that it is the nature of the previous medical experience rather than the number of experiences which influences the child's distress (Jacobson et al., 2001; Kleiber & Harper, 1999). Child temperament was mentioned by some of the nurses giving injections to children in this study as a factor which may have affected how the children reacted to the injection process. The relationship between child temperament and distress has been examined in a number of studies, but the relationship between temperament and pain has yet to be studied (Kleiber & Harper, 1999).
Some parents/guardians told the experimenter that their children 'really like music;' one parent indicated that his child plays the drums. Experience with music and preference for musical activities could have affected the study findings, where some children who were randomly assigned to the music condition may not have particularly enjoyed music or have been able to engage in active music listening. This illustrates the importance of conducting an assessment prior to a medical procedure, particularly if it is a painful and/or lengthy procedure. Wolfe and Waldon (2004) recommend conducting activities with pediatric patients which require them to respond to musical cues to determine their ability to focus on music. Those children who demonstrate the ability to focus on music and be engaged in it may be better able to attend to musical activities during painful medical procedures, subsequently experiencing less pain. For the short amount of time injections require to administer and the busy clinic settings in which they take place, such an in-depth assessment is not practical, but nonetheless, it is important to take child preference for and attention to music into consideration. Within a hospital setting where medical procedures are typically scheduled ahead of time, however, music therapy assessments can be easily and quickly administered prior to the procedures to determine if a music intervention is appropriate for a particular pediatric patient. While one might like to believe that music is an appropriate and potent intervention for all pediatric patients, not all children seem to be engaged by music.
It is evident from this study that, although routine, children find immunizations to be distressing and painful, and at present, there are no viable alternatives to delivering these immunizations. As such, efforts should be focused on finding effective methods for helping children cope with injections and other medical procedures. This area of study is deserving of research attention, as it has been found that adult avoidance of medical services has been associated with medical fear and pain in childhood (Megel et al., 1998). Coping well with medical procedures in childhood can foster not only a positive view of medical services and professionals, but a positive self-image as well. While the results of this study are intriguing, it is only one small-scale examination of music as a distraction during injections. It is the hope of the experimenter that this study spawns further research in this area.
[Sidebar]
This study was conducted in partial requirement for the Master of Arts in Music Therapy degree at University of the Pacific, under the supervision of Dr. David E. Wolfe. The author would like to extend her gratitude to the following individuals: Dr. Ruth Brittin, Dr. Roger KaU, Judy Guthrie, Dr. Michael Y. S. Wong, Dr. Cesar Pabustan, Dr. Randhir Singh, Rebeca Vcntura, Brittany Duggan, and Ryoko Fukagawa.
[Reference]
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[Author Affiliation]
Laura K. Noguchi, MA, MT-BC
University of the Pacific
