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Citation: Zanchi, B.; Trevor-Briscoe, T.;
Sarti, P.; Rivi, V.; Bernini, L.; Burnazzi,
J.; Ricci Bitti, P.E.; Abbado, A.;
Rostagno, E.; Pession, A.; et al. The
Impact of Music Therapy in a
Pediatric Oncology Setting: An Italian
Observational Network Study.
Healthcare 2024,12, 1071. https://
doi.org/10.3390/healthcare12111071
Academic Editor: Edward J. Pavlik
Received: 15 March 2024
Revised: 2 May 2024
Accepted: 21 May 2024
Published: 24 May 2024
Copyright: © 2024 by the authors.
Licensee MDPI, Basel, Switzerland.
This article is an open access article
distributed under the terms and
conditions of the Creative Commons
Attribution (CC BY) license (https://
creativecommons.org/licenses/by/
4.0/).
healthcare
Article
The Impact of Music Therapy in a Pediatric Oncology Setting:
An Italian Observational Network Study
Barbara Zanchi
1,2,3,†
, Timothy Trevor-Briscoe
1,2,3,†
, Pierfrancesco Sarti
4, †
, Veronica Rivi
4
, Lorenzo Bernini
2,3
,
Jenny Burnazzi 2, Pio Enrico Ricci Bitti 1,5, Alessandra Abbado 2, Elena Rostagno 6, Andrea Pession 7,
Johanna M. C. Blom 4, 8,* and Dorella Scarponi 9
1Conservatorio Bruno Maderna, 47521 Cesena, Italy; b.zanchi@consmaderna.org (B.Z.);
timothy.trevor@unibo.it (T.T.-B.); pioenrico.riccibitti@unibo.it (P.E.R.B.)
2Fondazione Policlinico Sant’ Orsola, 40138 Bologna, Italy; berninilorenzo1@gmail.com (L.B.);
burnazzi.jenny@iiscervia.it (J.B.); alessandra.abbado@gmail.com (A.A.)
3MusicSpace Italy Association, 40122 Bologna, Italy
4Department of Biomedical, Metabolic, and Neural Sciences, University of Modena and Reggio Emilia,
41125 Modena, Italy; pierfrancesco.sarti@unimore.it (P.S.); veronica.rivi@unimore.it (V.R.)
5Department of Psychology, University of Bologna, 40127 Bologna, Italy
6Oncoematologia Pediatrica, IRCCS Azienda Ospedaliero Universitaria di Bologna, 40138 Bologna, Italy;
elena.rostagno@aosp.bo.it
7Department of Medical and Surgical Sciences, University of Bologna, 40126 Bologna, Italy;
andrea.pession@unibo.it
8
Centre for Neuroscience and Neurotechnology, University of Modena and Reggio Emilia, 41125 Modena, Italy
9IRCSS AOU Sant’ Orsola, 40138 Bologna, Italy; dorella.scarponi@aosp.bo.it
*Correspondence: joan.blom@unimore.it; Tel.: +39-059-2055373
†These authors contributed equally to this work.
Abstract: Background: Music Therapy (MT) is a non-pharmacological, art-based intervention that
employs music experiences within a therapeutic alliance to attend to clients’ physical, emotional,
cognitive, and social requirements. This is the first study aiming at investigating the impact of MT on
the psychological facets of children suffering from cancer. Methods: The study, combining the AQR
and m-YPAS assessment tools, evaluated behavioral, sound–musical, and interactive parameters in
pediatric oncology patients undergoing MT sessions during hospitalization. Fifty patients admitted
to the Paediatric Oncology and Haematology Unit at Policlinico S. Orsola Hospital in Bologna, Italy,
were enrolled, irrespective of their treatment regimen. Data collection occurred on the first day of
the MT session between 3 p.m. and 5 p.m., with observations conducted by independent observers.
In addition to traditional statistical analysis, network analysis was used to explore the combined
interactions of all parameters, effectively discerning the distinctive roles played by each one during
therapy sessions and their influence on all others. Results: Network analysis highlighted distinct
patterns of interactions among parameters during the various sessions, emphasizing the role of
positive emotions and a calm setting, the child’s ability to take the initiative in sessions, their sense of
agency, and the parent’s role in guiding them. Significant differences were recorded at each time point
between all variables considered. Conclusions: The results of this innovative study may pave the
way for future multicenter studies aimed at further exploring the role of MT in children undergoing
both curative and palliative treatments for cancer.
Keywords: MT; agency; coping strategies; relationship with parents; network analysis; caregivers;
taking the initiative
1. Introduction
A cancer diagnosis has significant physical and psychological consequences and
presents an existential challenge for patients, their families, and the healthcare professionals
involved [
1
–
5
]. This is especially true for pediatric cancers whose diagnosis at a young age
Healthcare 2024,12, 1071. https://doi.org/10.3390/healthcare12111071 https://www.mdpi.com/journal/healthcare
Healthcare 2024,12, 1071 2 of 14
often evokes profound emotional and psychological responses, potentially resulting in the
development of trauma and psychosomatic symptoms [6]. These experiences may persist
into adulthood and contribute to the onset of psychiatric disorders later in life [6].
Over the last two decades, new trends and holistic approaches have been included in the
oncology setting [
1
,
4
]. Among them, Music Therapy (MT) represents a non-pharmacological,
art–based approach that uses music experiences within a therapeutic relationship to address
clients’ physical, emotional, cognitive, and social needs [
7
]. An essential element of all types
of MT intervention is the sound–music synergy, which aims at enhancing the expressive
abilities and resources of each patient [
2
,
3
,
5
]. This approach has been shown to have a
profound impact on patients’ well-being, offering relief from physical and psychological
symptoms [
8
,
9
]. In particular, its positive effects on patient anxiety, stress, mood, perceived
quality of life, and sense of isolation [
1
,
9
], make it particularly suitable for use in pediatric
oncology [
3
]. Importantly, the interventions can be tailored to the patient’s needs to facilitate
emotional expression, communication, and social interaction, allowing them to express
their (positive and negative) feelings in a safe and non-judgmental environment [
10
–
12
]
and interact with peers going through similar experiences, thus promoting social skills
useful to contrast the loneliness that accompanies the hospitalization period [
13
–
15
]. MT
not only benefits patients but also offers opportunities for family bonding and emotional
support for caregivers [
15
]. Involving parents and family members in MT sessions helps
create a robust network of support for pediatric patients throughout their illness [16].
Despite advancements in MT techniques, studies focusing on pediatric oncology are
limited, highlighting the need for further research in this area [
17
]. While innovative meth-
ods in MT have been explored for both pediatric and adult patients within multidisciplinary
teams, research on MT’s effects in oncology and palliative care has predominantly focused
on adults. This underscores the necessity for additional investigation specifically in the
pediatric oncology setting. In 2009, MT was introduced to the “UnitàOperativa Pediatrica
Pession Paediatric Oncology and Haematology, Policlinico S. Orsola Hospital in Bologna”
(Italy), thanks to funding from the Mozart 14 Association led by Alessandra Abbado. Since
its introduction, MT has been practiced continuously with pediatric oncology patients
and their families by a team of professional music therapists from the MusicSpace Italy
Association. The therapy follows an interactive-relational approach, adapting to patients’
changing needs.
The primary aim of this study was to investigate the potential of MT in counteracting
emotional withdrawal and disengagement among patients within the same therapy session.
This could result in heightened active involvement, diminished anxiety levels, and an
increased adoption of positive coping mechanisms. Our study particularly focused on
the assessment of behavioral indicators (i.e., arousal, the capability of making choices,
eye contact, and facial expressions), sound–musical aspects (i.e., interactions with objects,
instruments, and musical elements), and interactive dynamics (both with music therapists
and within group settings) within pediatric oncology patients undergoing MT sessions.
Changes in the children’s psycho-behavioral parameters were recorded at five different
time points during the MT session. As these sessions were carried out in a controlled
clinical environment, changes in the indices measured, compared to T0 (pre-assessments in
a pre-post intervention study), could primarily be attributed to MT.
The truly innovative aspect of the study involved the development and testing of
a novel assessment framework. This framework combined the “AQR—Assessment of
the Quality of Relationships” and the “m-YPAS, Yale Preoperative Anxiety Scale”. This
integrated approach enabled the evaluation of diverse psychological parameters, including
arousal levels, eye contact, and verbal and physical interactions with parents and medical
professionals, in a quicker and more targeted manner, considering the unpredictable
behavior of children while maintaining the same level of accuracy.
To our knowledge, this is the first use of network analysis to analyze parameters
collected during MT sessions in a pediatric oncology setting. Together, the new evaluation
Healthcare 2024,12, 1071 3 of 14
grid and the methodological approaches used in this study could pave the way for future
studies aimed at promoting the use of MT in the onco-pediatric setting.
2. Materials and Methods
2.1. Study Design
The study conducted is a prospective observational type in which the effects of the
intervention were evaluated by following the young patients from the beginning of the
music therapy session (pre-intervention—T0) to its conclusion (post-intervention—T4).
The music therapist team follows an interactive-relational approach based on the
clinical sound–music therapy “free improvisation” model. This model was put forward by
J. Alvin and is based on the assumption that when environmental conditions promote the
freedom to choose and play without any pre-imposition (free improvisation), the person’s
characteristics, pathology and problems will be reflected in the music [
18
]. This model is
close to the concept of “free associations” in Freudian psychoanalysis and sees music as a
means of projection. Furthermore, this model takes into account both listening to music
and actively making music through instruments or vocalizations.
At a pediatric age, joint improvisation between therapist and child allows aspects of
interaction and attachment to be identified [19,20].
Due to patient complexities and privacy concerns, sessions could not be filmed, and
collected material was later analyzed. The efficacy of the therapy was assessed, focusing
on a single session lasting up to 60 min.
During a session, two independent observers (trained music therapists) could complete
a minimum of three and a maximum of five assessments: T0—beginning of the session,
T1—15 min, T2—30 min, T3—45 min, and T4—60 min. The number of assessments
depended on how long the child expressed a willingness to stay within the session. The
MT sessions were consistently scheduled in the afternoon, from 3 p.m. to 5 p.m., ensuring
uniformity in timing across all sessions. It is pertinent to note that all patients included in
the study were receiving medication and were not in the terminal phase of their illness.
Within the designated MT room, two music therapists were present to facilitate interactions
with the children, offering flexibility in engagement based on individual needs. While
one therapist assumed the primary role, the other acted as a co-therapist, with these
roles dynamically shifting based on the evolving dynamics of each therapeutic encounter.
Importantly, these roles were not predetermined but rather adapted organically to suit
the unique requirements of each patient interaction. Simultaneously, two independent
observers, both trained music therapists, conducted their observations remotely from
separate rooms, ensuring an impartial assessment of each child participating in the study.
This approach maintained consistency and objectivity in data collection while allowing for
a comprehensive evaluation of the therapeutic process.
Moreover, considering ethical concerns and existing stress, we aimed to evaluate the
impact of MT effectively. Since it was not possible to exclude this procedure from the
standard protocol for pediatric cancer patients receiving treatment, nor to omit to propose
it to parents, it was impractical to attain a uniform and sufficiently large control group.
Consequently, in the statistical analysis and discussion of the findings, we designated the
T0 phase of the study as the pre-intervention time point, so the assessment was conducted
before the onset of the MT sessions. By employing this approach, the results illustrate the
alterations within the same session compared to T0.
Importantly, MT adheres to the Standardized Instrument for Pediatric Oncology (SIPO)
guidelines, which provide a framework for evaluating interventions and outcomes in
pediatric oncology settings. MT aligns with these guidelines by incorporating standardized
instruments like the AQR and m-YPAS to assess various parameters, such as behavioral,
sound–musical, and interactive aspects, in pediatric oncology patients undergoing therapy
sessions. This adherence ensures that MT interventions are aligned with established
standards and facilitates a reliable evaluation of their effectiveness in improving patient
outcomes within the pediatric oncology context.
Healthcare 2024,12, 1071 4 of 14
2.2. Development of a New Evaluation Grid
In our study, we conducted a thorough literature review on MT in pediatric and
oncology settings, identifying two scales to assess specific parameters of interest: the
“AQR—Assessment of the Quality of Relationships” [
21
] and the “m-YPAS, Yale Preop-
erative Anxiety Scale” [
22
]. These scales cover aspects like arousal, eye contact, choice-
making, and interactions with parents and physicians, addressing concerns observed
during clinical sessions.
The “AQR-Tool for the Assessment of the Quality of Relationship” was developed
by music therapist Schumacher K. and psychologist Calvet C., primarily for children
with an autism spectrum disorder [
21
]. It evaluates the patient–therapist relationship
across developmental stages using four scales: instrumental engagement, vocal-pre-speech
engagement, physical–emotional engagement, and therapist intervention appropriateness.
The “m-YPAS” is an observational checklist measuring preoperative anxiety and assessing
behaviors in hospital and operating room settings. While we could not use these scales in
their original form due to limitations (like no video recording), we adapted their concepts
to create an observation grid specific to MT at St. Orsola Hospital. This customized tool
evaluates real-time parameters: behavior, sound–musical aspects, and interactions. The
observation grid (Table 1) was collaboratively designed by music therapists, clinicians, and
researchers and includes eight parameters/items, indicating patient progress during the
session. Parameters one to seven are rated on a five-point Likert scale (0 = low, 4 = high),
while the eighth and most specific parameter to MT, “Use of Music in the Relationship”
(Table 2), uses an eight-point scale to assess the child’s engagement with music. This
parameter is based on the AQR scale. The two tools with their respective a priori parameters
were combined in one single observation group.
Table 1. Description of each one of the observational grid parameters scored by the music therapists
at each time point.
(1)
Arousal. Refers to how alert the child is. Measured by observing how the child looks
around and how they react to the music therapist’s actions and sounds. The scale ranges
from a minimum value—when the patient’s body is withdrawn and contracted, when they
avert their gaze or when the gaze is absent, or if they wince about sounds while in the
setting—to a maximum value—when the patient’s body is relaxed, their gaze attentive, and
they have a pleasant reaction to sounds.
(2)
Eye contact. Refers to the frequency with which the child makes eye contact with the music
therapist, with other children, or with other persons involved during the session. The scale
ranges from a minimum value indicating total absence/avoidance of eye contact to a
maximum value corresponding to the presence of eye contact with no avoidance of gaze.
(3) Positive facial expression. Refers to facial expressions demonstrating positive emotions and
affects. The minimum value indicates a total absence of facial relaxation and smiles, a
prevalence of expressions indicating emotions such as anger, sadness, fear, or disgust; the
maximum value indicates a marked frequency over time of expressions showing happiness
and/or serenity.
(4)
Making choices. Refers to the participant’s ability to make choices. The choice is defined as
the indication of a preference manifested verbally or through a gesture. The scale ranges
from a minimum value indicating no choices to a maximum value indicating making
many choices.
(5)
Taking the initiative. Refers to when the participant initiates a conversation or addresses a
question to another person without this being a response to a request or indication. It also
includes indicating an object or a person or initiating a musical/sound conversation. The
scale ranges from a minimum value indicating the absence of such behavior to a maximum
value indicating a strong presence.
Healthcare 2024,12, 1071 5 of 14
Table 1. Cont.
(6)
Vocalization, verbal interaction. Refers to the participant’s use of their voice. The scale
ranges from a minimum value that indicates the absence of verbal response, even when
crying, to a maximum value that indicates the child’s engagement in producing sound (or in
actively listening if s/he does not or cannot speak while taking part in an activity such as
playing a musical instrument), asking questions, or making comments. If the child is too
young to speak, then laughter, babbling, or sound production in a calm state are associated
with a maximum value.
(7)
Relationship with parents. Refers to the child’s behavior towards their parent. The scale
ranges from a minimum value when an anxious, insecure, and ambivalent type of
attachment is observed, to a maximum value for a secure attachment that allows the child to
engage in play and age-appropriate behavior without the need to turn to the parent, with
whom he/she may nevertheless interact if the interaction is initiated.
(8)
Use of music in a relationship. The use of music in a relationship is measured through
eight different levels/modes of relationship that the patient establishes with the musical
instruments, their sounds, and those produced by the music therapist. These modes range
from no contact at all to a musical and verbal relationship. As with the previous seven
parameters, the observer also notes down every 15 min which of the eight modes best
defines the use of music in a relationship for each child.
Table 2. Possible evaluations of the observer concerning parameter 8, “Use of Music in the Relation-
ship”, of the observational grid.
(0)
“No contact”: Patient’s total disinterest in the instruments in the room; no contact or
relationship with them.
(1)
“Minimal contact”: The patient develops an initial contact with the instruments. This occurs
briefly after making a sound by chance. The instrument is touched and then totally disregarded.
(2)
“Functional sensorial contact”: The patient makes sensory, destructive, or stereotyped use
of the instrument. Sensorial use is defined as the instrument being explored through touch,
taste, or smell instead of through sound. Destructive use is defined as if the instrument is in
danger of being damaged. A monotonous, unchanging, and meaningless way of playing is
read as stereotyped.
(3)
“Sense of self—use of the instrument as one’s own”: The patient explores the instrument
by recognizing it as a musical instrument and treats it with appropriate effect.
(4)
“Contact with others”: The patient plays the instrument appropriately and the resulting
sound is related to the sounds produced by the music therapist.
(5)
“Interaction”: The patient plays the instrument in the context of a dialog, as in a
question-and-answer game; often, instrumental production is associated with
verbal expressions.
(6)
“Shared experience-shared affectivity”: The patient plays the instrument with pleasure and
with constantly positive emotions. Playing can also lead to associations. The use of the
instrument helps to demonstrate an affective state in a fun way.
(7)
“Verbal musical space”: The use of the instrument triggers emotional changes and
imaginative content, leading to verbalization (reflection/description).
To finalize the evaluation grid, a 6-month pilot study was conducted to train indepen-
dent music therapist observers. During the first month, training took place with the two
observers, followed by 20 observation sessions, one per week. Independent observations
made by the two observers on eleven patients were recorded: ten were undergoing treat-
ment and one had just been diagnosed and was about to start treatment. All observations
were supervised by a senior music therapist to define and apply the grid in the best way
possible. From these observations, an acceptable level of inter-reliability was achieved,
which measured 93% between the two observers.
Healthcare 2024,12, 1071 6 of 14
To ensure the integrity of the subscales within the original questionnaires, items from
various scales assessing the same construct were not utilized. This was to prevent any
potential multicollinearity between the scores of the scales and to preserve the internal
validity of the subscales.
2.3. Participants
A total of 76 children (mean age 6.6
±
4.3) were recruited for this study (43 females, mean
age 6.6, and 33 males, mean age 6.5). All these children had a diagnosis of onco-hematological
disease. To be considered eligible for the study, the young patients needed to
- Have a diagnosis of an onco-hematological disease;
-
Be undergoing treatment in the pediatric onco-hematological ward of S. Orsola Hospital;
-
Have conducted the music therapy session not in their own room but in the space of
the ward designated for this intervention;
-
Have remained inside the room in which music therapy was carried out for at least
30 min (thus having collected at least three assessments of the child);
-
Have received informed consent to the research from the parents/legal guardians of
the hospitalized children.
All patients who did not meet the inclusion criteria were therefore excluded but, of
course, MT continued to be included as part of their care. Out of 76, only 50 (21 males
and 29 females) were considered eligible. A family member was always present during
the sessions, most often mother and father but in some cases also grandparents or siblings.
9 out of 50 children
had no relatives present in the room together with the music therapists.
All parents of the participants were fully informed about the study, its methods, data
processing, and the possibility of publishing the data in such a way as to maintain the
anonymity of the patients involved. They agreed to participate and signed the Informed
Consent to Participation and Data Processing for publication.
2.4. Statistical and Network Analysis
First, data were analyzed for the assumption of normality using the Kolmogorov–
Smirnov one-sample test for normality (K-S distance and P) and the Shapiro–Wilk test for
normality. Preliminary analyses were then carried out to test the homogeneity of variances
between groups and independence using Levene’s test. We processed the scores of the
eight scales of the observational grid (i.e., arousal, eye contact, positive facial expression,
making choices, taking the initiative, vocalization/verbalization, and relationship with
parents) and compared them with those from each time point.
The Friedman one-way repeated-measures analysis of variance by ranks (Friedman’s
test) was used to analyze the results between T0, T1, T2, T3, and T4. The post hoc analysis
was conducted by comparing the results of two possible options after using Friedman’s
test using the Conover test for multiple comparisons of mean rank sums and the Wilcoxon
signed-rank test. All tests were defined as significant at p< 0.05. Data were presented as
mean ±standard error.
A first level of stratification was performed by analyzing the performance of male and
female patient scores separately to check for significant differences between the various
time points. All statistical analyses were performed using SPSS v. 28.0 (IBM Corp., Armonk,
NY, USA) and R software (version 4.0.3/2020-10-10), while graphs were generated using
GraphPad Prism v. 9.00e for Windows®(GraphPad Software, Inc., La Jolla, CA, USA).
To understand the importance of each variable and consider all the other parameters,
five network models [
23
] were constructed to analyze the partial correlations between the
variables and, using the centrality indices [
24
], identify which were the most influential
variables at each time point that mediated part of the variation of the others. The network
models represented were implemented using R software (version 4.0.3/10 October 2020).
The package “psychometrics” [
25
] was chosen to calculate the network models. This pack-
age allows for the creation of a Gaussian Graphical Model (GGM) [
26
] based on the input
data, which is then extracted and represented using the “graph” package [
27
]. The GGM
Healthcare 2024,12, 1071 7 of 14
forms an undirected network model in which edges represent partial correlation coeffi-
cients. A Gaussian Graphical Model (GGM) visually depicts the conditional relationships
among variables using a graph. In this graph, each node represents a variable, while the
edges between nodes signify conditional dependencies or nonzero partial correlation coef-
ficients. By generating a network that graphically represents the interaction of the variables
considered, the centrality measures of “Strength” and “Betweenness” were extracted to
define and understand which node (variable), at each time of the study, was the one with
the greatest importance in the network. The initial metric denotes the quantity of links a
node possesses with others. In a weighted network such as the ones in this article, it is
determined by multiplying the number of nodes connected to a given node by the average
weight of these connections, modified by a tuning parameter. The second measure assesses
the extent to which a node participates in the shortest routes between other nodes. It helps
identify nodes that are probable connectors between other nodes, thus indicating which
nodes are most likely to facilitate connections within the network. More information on
these indices can be found elsewhere [16,28].
3. Results
The analyzed sample of children with haemato-oncological disease consisted of
50 patients (mean age 6.6
±
4.3): 21 males (mean age 6.5
±
3.1) and 29 females (mean age
6.6 ±4.9).
For all parameters observed by two independent trained observers, there was an
increase in the score from the beginning of the MT sessions to detection after 60 min. The
only two parameters to decrease in the transition from T3 to T4 (between 45 and 60 min)
were “Arousal”, dropping from a score of 3.40 to 2.70 (highly significant), and “Relationship
with Parents” from 3.30 to 3.10 (not significant). All mean scores for each survey time are
shown in Table 3. Friedman’s test indicated multiple significance for all variables taken
into consideration by the evaluation grid when the sample of 50 children was analyzed.
No significant differences were identified between males and females after comparing the
scores at each time point. As the pattern of scores between the two sexes is not the same for
each parameter investigated, this requires more attention with a larger sample of subjects.
Table 3. Means of each variable entered in the evaluation grid at each time point. The maximum
values reached are shown in bold. T0 = start of session, T1 = 15 min, T2 = 30 min, T3 = 45 min,
T4 = 60 min. For each variable, the separate values of males and females have also been reported.
This Means at Each Time Point
PARAMETERS T0 T1 T2 T3 T4
Males 1.83 2.69 2.71 3.36 2.31
Arousal 2.01 2.70 2.90 3.40 2.60
Females 2.14 2.71 3.03 3.43 2.81
Males 2.71 3.17 3.02 3.52 3.14
Relationship with Parents 2.80 2.91 3.09 3.30 3.10
Females 2.86 2.72 3.14 3.14 3.07
Males 2.07 2.38 2.67 2.88 3.05
Taking the Initiative 2.10 2.65 2.69 3.13 3.29
Females 2.12 2.84 2.71 3.31 3.47
Males 2.02 2.31 2.81 2.60 3.24
Making Choices 2.19 2.59 2.73 2.99 3.31
Females 2.31 2.79 2.67 3.28 3.36
Males 1.88 2.05 2.45 2.48 2.88
Positive Facial Expressions 1.90 2.52 2.48 2.85 3.16
Females 1.91 2.86 2.50 3.12 3.36
Healthcare 2024,12, 1071 8 of 14
Table 3. Cont.
This Means at Each Time Point
PARAMETERS T0 T1 T2 T3 T4
Males 2.29 2.64 2.69 3.31 3.52
Eye Contact 2.24 2.92 2.78 3.25 3.44
Females 2.21 3.12 2.84 3.21 3.38
Males 1.95 1.95 2.43 2.36 3.36
Vocalization/Verbalization 1.84 2.17 2.41 2.75 3.25
Females 1.76 2.33 2.40 3.03 3.17
Males 2.17 3.02 2.88 3.45 4.24
Use of Music 2.27 3.03 3.15 3.88 4.22
Females 2.36 3.03 3.34 4.19 4.21
As shown in Figure 1, Friedman’s test shows a gradual increase in most parameters,
which, compared with T0, become increasingly significant. All variables except “Arousal”,
“Positive facial expressions” and “Eye contact” have scores that become significantly differ-
ent from T0 around 45 and 60 min (T3 and T4).
Healthcare2024,12,xFORPEERREVIEW8of14
Males 1.882.052.452.482.88
PositiveFacialExpressions1.902.522.482.853.16
Females 1.912.862.503.123.36
Males 2.292.642.693.313.52
EyeContact2.242.922.783.253.44
Females 2.213.122.843.213.38
Males 1.951.952.432.363.36
Vocalization/Verbalization1.842.172.412.753.25
Females 1.762.332.403.033.17
Males 2.173.022.883.454.24
UseofMusic2.273.033.153.884.22
Females 2.363.033.344.194.21
AsshowninFigure1,Friedman’stestshowsagradualincreaseinmostparameters,
which,comparedwithT0,becomeincreasinglysignificant.Allvariablesexcept“Arousal”,
“Positivefacialexpressions”and“Eyecontact”havescoresthatbecomesignificantlydif-
ferentfromT0around45and60min(T3andT4).
Figure1.EffectsoftheMTsectionondifferentparameters,measuredatdifferenttimepoints:atthe
beginningofthesession(T0),15min(T1),30min(T2),45min(T3),and60min(T4)later.Datahave
beenanalyzedusingnon-parametricrepeated-measuresANOVAofeachvariableenteredintothe
evaluationgrid.p-valuesarelistedwhensignificant:***p<0.001,**p<0.01;*p<0.05.Subfigures
(A–H)representtheeightparametersseparately.Thecolourcodingofeachparameterissubse-
quentlyreflectedinthenodesofFigure2.(A):Arousal;(B):Relationshipwithparents;(C):Tak ing
theinitiative;(D):Makingchoices;(E):Positivefacialexpression;(F):Eyecontact;(G):Vocaliza-
tion/verbalinteraction;(H):Useofmusicintherelationship.
Althoughnotsignificant,theseparateanalysisofthemeanscalescoresformaleand
femalepatients(Table3)showedthatgirlshavehigherscoresinarousallevels(bothinitial
andfinal),takingtheinitiative,makingchoices,andshowingpositivefacialexpressions.
Boys,althoughinitiallyseekinglessofarelationshipwiththeirparents,enduplooking
formoreatT3;theyverballyarticulatemoreduringthesessionanduse/manipulatemu-
sicalinstrumentsmoretowardtheendoftherapy.
Figure 1. Effects of the MT section on different parameters, measured at different time points: at the
beginning of the session (T0), 15 min (T1), 30 min (T2), 45 min (T3), and 60 min (T4) later. Data have
been analyzed using non-parametric repeated-measures ANOVA of each variable entered into the
evaluation grid. p-values are listed when significant: *** p< 0.001, ** p< 0.01; * p< 0.05. Subfigures
(A–H) represent the eight parameters separately. The colour coding of each parameter is subsequently
reflected in the nodes of Figure 2. (A): Arousal; (B): Relationship with parents; (C): Taking the initia-
tive; (D): Making choices; (E): Positive facial expression; (F): Eye contact;
(G): Vocalization/verbal
interaction; (H): Use of music in the relationship.
Healthcare 2024,12, 1071 9 of 14
Healthcare2024,12,xFORPEERREVIEW9of14
Figure2showsthenetworkmodelsthathavebeengeneratedusingthe“psychomet-
rics”package.Thecentralityvaluesreturnedbythemodelsshowthatthemostimportant
variableinthenetwork(theonewiththehighestbetweennessandstrengthvalues)isdif-
ferentateachtimepoint,exceptforT3andT4,wherethemostimportantcharacteristicis
thechangeinsignoftheedgesthatconnectnode3(relationshipwithparents)withthe
nodes;thisindicatesanevolutionovertimeinemotionalinvolvement.AttimeT0,the
mostimportantvariableisnode6(positivefacialexpression)withabetweennessof1;at
timeT1,themostimportantvariableisnode5(makingchoices)withavalueof1,followed
bynode4(takingtheinitiative);andatT2,themostimportantvariablesarenodes7and
8(eyecontactandvocalization)withrespectivevaluesof1and0.28.AttimeT3,themost
importantvariableisnode3(relationshipwithparents)withavalueof1,andfinally,at
timeT4,themostimportantvariablesarenodes7and2(relationshipwithparentsand
arousal),whichhavevaluesof1and0.71.
Figure2.Representationofthefivenetworkmodels,oneforeachdetectiontime.Thenodesrepre-
senttheevaluationgridvariablesandthevariable“A g e ” . ThenodecolorsreflectthoseinFigure1.
Thelinksbetweenthenodes(edges)indicatethepresenceofapartialcorrelationbetweenthetwo
variables.Thethickertheline,thegreaterthecorrelationvalue.Blackedgesindicateapositivepar-
tialcorrelationwhilereddashededgesindicateanegativeone.Thesizeofeachnoderepresentsits
valueofbetweennesscentrality:thebiggerthenode,thehigherthevalue.
Nosignificantchangesinconnectiondensityoradecreaseinthenumberofedges
wereidentified.Allnetworksarehighlydense(edgedensity=1)andarethereforehighly
plasticandpronetochangefollowingexternalperturbations(bothpositiveandnegative).
Figure 2. Representation of the five network models, one for each detection time. The nodes represent
the evaluation grid variables and the variable “Age”. The node colors reflect those in Figure 1.
The links between the nodes (edges) indicate the presence of a partial correlation between the two
variables. The thicker the line, the greater the correlation value. Black edges indicate a positive partial
correlation while red dashed edges indicate a negative one. The size of each node represents its value
of betweenness centrality: the bigger the node, the higher the value.
Although not significant, the separate analysis of the mean scale scores for male and
female patients (Table 3) showed that girls have higher scores in arousal levels (both initial
and final), taking the initiative, making choices, and showing positive facial expressions.
Boys, although initially seeking less of a relationship with their parents, end up looking for
more at T3; they verbally articulate more during the session and use/manipulate musical
instruments more toward the end of therapy.
Figure 2shows the network models that have been generated using the “psychomet-
rics” package. The centrality values returned by the models show that the most important
variable in the network (the one with the highest betweenness and strength values) is
different at each time point, except for T3 and T4, where the most important characteristic
is the change in sign of the edges that connect node 3 (relationship with parents) with the
nodes; this indicates an evolution over time in emotional involvement. At time T0, the
most important variable is node 6 (positive facial expression) with a betweenness of 1; at
time T1, the most important variable is node 5 (making choices) with a value of 1, followed
by node 4 (taking the initiative); and at T2, the most important variables are nodes 7 and 8
(eye contact and vocalization) with respective values of 1 and 0.28. At time T3, the most
important variable is node 3 (relationship with parents) with a value of 1, and finally, at
time T4, the most important variables are nodes 7 and 2 (relationship with parents and
arousal), which have values of 1 and 0.71.
Healthcare 2024,12, 1071 10 of 14
No significant changes in connection density or a decrease in the number of edges were
identified. All networks are highly dense (edge density = 1) and are therefore highly plastic
and prone to change following external perturbations (both positive and negative). This
aspect underlines how the model of the MT session setting, shown in Figure 3, resulting
from the interpretation of network analysis models, is extremely valuable.
Healthcare2024,12,xFORPEERREVIEW10of14
ThisaspectunderlineshowthemodeloftheMTsessionseing,showninFigure3,re-
sultingfromtheinterpretationofnetworkanalysismodels,isextremelyvaluable.
Figure3.SummaryoftheevolutionofMTsessionsthroughtheapplicationofnetworkmodels.The
colorsoftheboxesandcirclesmatchthenodesinFigure2withthehighestvaluesofbetweenness
centrality.
ThenetworksdemonstratedamethodforstructuringMTsessionsthatgraduallypri-
oritizedaspectsdirectlylinkedtothechild(suchasinitiative-taking,positivefacialex-
pressions,andeyecontact)asthesessionprogressed.Additionally,aentionwasgivento
relationalaspects,includinginteractionswithparentsandhospitalstaff,aswellasutiliz-
ingmusictoexpressoneselfandfosterconnections.
Moreimportantly,thesessionsshowedacriticalpointafter30min,when26outof
76children(34%)werenolongerabletocontinue.
Thenetworkanalysisshowedhow,atthistimepointandtheninthefollowingses-
sions,inthechildrenwhocontinued,itwaspossibletointegrateintrinsic(vocalizations
andeyecontact)andextrinsic(activesearchforthepresenceoftheparent)relationalas-
pects.
4.Discussion
Inthisexploratorystudy,weusedanovelevaluationgridbymergingthe“A Q R —
AssessmentoftheQualityofRelationships”and“m-YPAS,YalePreoperativeAnxiety
Scale”toassesscrucialparameterslikearousal,eyecontact,andinteractionwithparents
andphysicians.Thisinnovativegriddemonstratedhighadaptability,reliability,andease
ofadministration,enablingtheefficientcollectionofvitalpsychologicalandbehavioral
data,meticulouslyexaminedthroughstatisticalandnetworkanalysis.Toourknowledge,
thisisthefirsttimeemployingsuchanapproachtoevaluateMT’simpactonthemental
well-beingofyoungpatientswithinpediatriconcology.
Moreover,thenetworkanalysismanagedtotrackthedynamicevolutionofvariables
throughoutmusictherapysessions,representinganadditionalinnovativeapproachtothe
study.Byvisualizingtheprogressivesuccessionofvariablesandtheirinteractions,thera-
pistsandclinicianscangaininvaluableinsightsintotheemotionalgrowthoftheirclients.
Thismethodnotonlyenhancescomprehensionbutalsooffersamorenuancedunder-
standingofthetherapeuticprocess,potentiallyleadingtomoreeffectiveinterventions
andoutcomes.
Overall,theresultsindicateapositivetrajectoryacrossallevaluatedparametersdur-
ingMTsessions.Theobservedincreaseintheseparametersstronglyalignswiththeex-
istingliterature,correlating“eyecontact”,“positivefacialexpressions”,“decision-mak-
ing”,“initiative-taking”,“vocalization”,and“parentalinteraction”withenhanced“active
Figure 3. Summary of the evolution of MT sessions through the application of network models. The colors
of the boxes and circles match the nodes in Figure 2with the highest values of betweenness centrality.
The networks demonstrated a method for structuring MT sessions that gradually
prioritized aspects directly linked to the child (such as initiative-taking, positive facial
expressions, and eye contact) as the session progressed. Additionally, attention was given
to relational aspects, including interactions with parents and hospital staff, as well as
utilizing music to express oneself and foster connections.
More importantly, the sessions showed a critical point after 30 min, when 26 out of
76 children (34%) were no longer able to continue.
The network analysis showed how, at this time point and then in the following sessions,
in the children who continued, it was possible to integrate intrinsic (vocalizations and eye
contact) and extrinsic (active search for the presence of the parent) relational aspects.
4. Discussion
In this exploratory study, we used a novel evaluation grid by merging the “AQR—
Assessment of the Quality of Relationships” and “m-YPAS, Yale Preoperative Anxiety
Scale” to assess crucial parameters like arousal, eye contact, and interaction with parents
and physicians. This innovative grid demonstrated high adaptability, reliability, and ease
of administration, enabling the efficient collection of vital psychological and behavioral
data, meticulously examined through statistical and network analysis. To our knowledge,
this is the first time employing such an approach to evaluate MT’s impact on the mental
well-being of young patients within pediatric oncology.
Moreover, the network analysis managed to track the dynamic evolution of variables
throughout music therapy sessions, representing an additional innovative approach to
the study. By visualizing the progressive succession of variables and their interactions,
therapists and clinicians can gain invaluable insights into the emotional growth of their
clients. This method not only enhances comprehension but also offers a more nuanced
understanding of the therapeutic process, potentially leading to more effective interventions
and outcomes.
Overall, the results indicate a positive trajectory across all evaluated parameters
during MT sessions. The observed increase in these parameters strongly aligns with
the existing literature, correlating “eye contact”, “positive facial expressions”, “decision-
making”, “initiative-taking”, “vocalization”, and “parental interaction” with enhanced
“active engagement” strategies and positive control over their environment, fostering
emotional self-regulation abilities [13,29–31].
Our analysis revealed a single decrease in the scores of arousal and the relationship
with parents during the transition between T3 and T4, possibly due to patient fatigue or
Healthcare 2024,12, 1071 11 of 14
heightened calmness. For patients in this age group, engaging in therapies that extend
beyond highly interactive sessions can become very demanding. Notably, substantial
score improvements were primarily observed between T0 and T4, with significant dif-
ferences across other intervals. As sessions progressed, children experienced benefits in
re-establishing a sense of “normality”, manifested as heightened eye contact, improved
decision-making, positive emotions, and proactive behavior linked to a regained sense of
agency and self-efficacy. These gains occurred despite an initial perception of an unpre-
dictable and uncertain environment—a critical consideration within pediatric oncology
where patient vulnerability is an everyday reality [
32
–
34
]. This is particularly relevant in a
pediatric oncology setting, as the capacity and opportunity to exercise influence over their
surroundings hold immense significance for these young patients given the daily percep-
tion of vulnerability due to their physical conditions and the uncertainty that accompanies
their future [13,14,35,36].
Network analysis enabled the identification of specific roles of variables at each time
point, allowing for the delineation of a pattern of children’s behavior throughout the MT
sessions (see Figure 3). This pattern can be utilized to optimize outcomes during the sessions.
-
T0: Since it is not possible to actively intervene, in an identical and controlled manner,
before the sessions begin, it is important to set aside time to put the child at ease and
in a positive state of mind to promote their activation and interest in the activity.
-
T1: The child’s resourcefulness becomes evident as they realize they are in a space
where they can exert control, deciding how to behave and interact with the objects
around them. At this point, it becomes essential to encourage their initiative and allow
them to make choices independently.
-
T2: At 30 min, the phase begins in which the child seeks a relationship with others,
particularly through eye contact and vocalizations. The child seeks involvement and
judgment from others (adults) in the room, in particular from the parents/parents present.
-
Critical moment: Between T2 and T3, there is a transitional phase where relational
behavior “markers” shift from being intrinsic to extrinsic. The child actively looks
for the caregiver, and the relationship with the caregiver becomes central at T3. The
parent plays a pivotal role.
-
T4: If the “crisis” is resolved positively, the network at T4 illustrates that the node
representing the relationship with parents has changed the direction of all connections
previously negative, with nodes like “Arousal”, “Making choices”, and “Vocaliza-
tion,” and strengthened some of those already established. This underscores how the
relationship with the parent/caregiver is essential in enabling the child to complete
60 min of the session and achieve the maximum increase in scores on most of the
evaluated scales.
There are two main limitations of this study: the first limitation is the absence of a
control group that underwent a different activity during the sessions compared to MT.
Unfortunately, this was not feasible, as already mentioned in the “Methods” section, due
to guidelines on treating pediatric oncology patients. T0, the initial assessment before the
session began, was used as the control group. Statistical analyses were chosen taking this
aspect into account.
The second limitation concerns the use of a multivariate non-parametric repeated-
measures test to simultaneously assess the effect of the time points and patients’ gender
(given the differences in means). The test used was the Scheirer–Ray–Hare test (a non-
parametric test used for a two-way factorial design). Due to its limited use and the choice
not to perform individual non-parametric t-tests between time points considering only
“gender” as a comparison, the authors preferred to omit the discussion of ‘patterns’ in the
presence of non-significant differences.
Healthcare 2024,12, 1071 12 of 14
5. Conclusions
The results of this innovative study approach lay the groundwork for future multi-
centric investigations and analyzing the differences while stratifying for gender and, with
adequately sized samples, other variables such as the presence of parents or other relatives,
tumor type, and aspects related to children’s resilience. Overall, the aim was to study the
role of MT by addressing the multifaceted needs of children undergoing cancer treatment,
encompassing physical, emotional, social, and developmental dimensions, both in curative
and palliative contexts.
Our new approach allowed for an exploration of MT’s impact on the psychological
facets of children facing cancer. A comprehensive literature review was followed by the
identification of two assessment scales (AQR and m-YPAS) to evaluate parameter changes
during MT sessions. Rigorous statistical analyses demonstrated positive trends, further
elucidated through network analysis.
This strategic approach unveiled the intricate interplay among all eight parameters,
illuminating the distinct “roles” each parameter assumed during the sessions. Furthermore,
this method facilitated the exploration of centrality indices, guiding the trajectory of the
MT sessions.
Future research should prioritize expanding the scope of variables investigated to the
fullest extent possible, particularly given the high-risk nature of this patient population.
This will enable a more comprehensive understanding of the interplay between socio-
cultural, demographic, and economic factors in shaping various behavioral and resilience
profiles. Additionally, it will be crucial to explore the long-term effects of cycles of music
therapy sessions on young cancer patients to ascertain whether this approach could offer
broader applicability in oncology as an alternative therapy.
Author Contributions: Conceptualization, B.Z. and T.T.-B.; Data curation, P.S. and V.R.; Formal
analysis, P.S. and V.R.; Investigation, T.T.-B., L.B. and J.B.; Methodology, B.Z., T.T.-B., L.B., J.B. and
P.E.R.B.; Software, P.S.; Supervision, B.Z., A.P. and D.S.; Validation, P.S., V.R. and J.M.C.B.; Writing—
original draft, B.Z., T.T.-B., P.S. and V.R.; Writing—review and editing, A.A., E.R., J.M.C.B. and D.S.
All authors have read and agreed to the published version of the manuscript.
Funding: This research received no external funding.
Institutional Review Board Statement: This study was performed in line with the principles of
the Declaration of Helsinki. The study presented did not require approval by the Ethics Committee
for the following reason: MT sessions are part of the non-pharmacological interventions of the
clinical and care practice offered to young patients and their parents when recovered in the Paediatric
Oncohematology department of the St. Orsola Hospital in Bologna. The St. Orsola’s Paediatric
Oncohaematology Department is one of the AIEOP centers (Associazione Italiana di Ematologia
Oncologia Pediatrica) that has incorporated the MT approach into normal therapeutic practice for
pediatric patients [
37
]. MT is also part of the “Activity and Therapy” that must be present as
stated in the “European Standards of Care for children with cancer” “https://siope.eu/european-
research-and-standards/standards-of-care-in-paediatric-oncology/ (accessed 10 May 2024)”. The
Italian guidelines on clinical practice in pediatric psycho-oncology that allow the use of MT in
oncology are published on the website of the Italian Society of Psycho-Oncology (SIPO) “https:
//siponazionale.it/documenti-e-linee-guida/ (accessed 10 May 2024)”. However, for additional
rigor and to protect our young patients, informed consent was sought from their parents to participate
in the sessions, to analyze and treat the data exclusively in an aggregate format, and to only gain
knowledge on whether the intervention offered as part of the care package was successful.
Informed Consent Statement: Informed written consent was obtained from all parent’s subjects
involved in the study. In the informed consent forms, patients and parents were also informed that
the collected data would be published only in an anonymous manner.
Data Availability Statement: The possibility of sharing raw data is only considered following a
formal request to the corresponding author (Johanna M. C. Blom).
Healthcare 2024,12, 1071 13 of 14
Acknowledgments: The authors would like to thank all patients, family members, and hospital staff
for their contribution to this study. The authors would like to thank the Association Mozart14 for
initiating the Tamino Project for MT in pediatric wards from 2009 to 2021 and for giving their support
to the present work. They would also like to thank the Fondazione Policlinico S. Orsola of Bologna
which currently continues to support and promote MT interventions in pediatric wards at the IRCCS
Sant Orsola di Bologna.
Conflicts of Interest: The authors declare no conflicts of interest.
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