An experimental study to assess the effect of selected raga of music on aggression in children admitted in Child Psychiatry Center NIMHANS, Bangalore

 

Jesna. C.A.¹, Radha Krishnan², John Vijay Sagar K³

¹Staff Nurse, NIMHANS, Bangalore

²Assistant Professor Department of Nursing, NIMHANS, Bangalore

³Additional Professor, Department of Child and Adolescent Psychiatry, NIMHANS, Bangalore

 

ABSTRACT:

Title:  An experimental study to assess the effect of selected raga of music on aggression in children admitted in Child Psychiatry Center NIMHANS, Bangalore.

Aim: To evaluate the effect of the selected raga of music on aggression in children admitted in Child Psychiatry Center, NIMHANS.

Methodology: A study design with experimental group (Treatment group) and control group (Treatment as Usual group) was adopted. After the pilot study, 40 subjects who met the inclusion criteria were recruited for the study consecutively. Aggression level was measured with Modified Overt Aggression Scale (MOAS), Visual Analogue Scale by parents and children and functioning level was assessed through Children Global Assessment Scale. Music intervention based on Raga Shankarabharanam was administered for 20 minutes twice daily for two weeks. Level of aggression measured in the four time points, prior to the intervention, 7^th day, 14^th day and 21^st day. RMANOVA was used to find out the effect the of music intervention across four time points.

Results: Findings revealed that significant reduction in aggression scores were measured with MOAS from prior to the intervention, 7^th day, 14^th day and 21^st day noted in both the groups. (f- Statistic =31.35, p<0.001)  No significant difference in reduction on aggression scores between Treatment Group and Treatment as Usual Group, were noted (f-statistic=1.19 p=0.282). In visual analogue scale by parents and visual analogue scale by subject’s scoring also showed significant reduction in aggression (f- statistics =19.83, p-value<0.001, f- statistics=25.69, p<0.001) but no significant reduction in aggression score between Treatment Group and Treatment as Usual Group (f-statistics= 0.017 and p value 0.898, f-statistics=2.14, and p=0.155). So present study findings pointing that Raga Shankarabharanam has very minimal effect on aggression among children with mental illness. Conclusion: This study has proven that music therapy is practical, feasible and helpful in maintaining therapeutic environment among children with mental illness. Indian music therapy is unique and cultural and open great scope for further prove and studies. More intensive and improvised music therapy can be conducted among children with mental illness.

 

 

INTRODUCTION:

Music a wonderful and divine blessing has healed the human mind and soul since time immemorial. Being one of the finest abstract and primitive art forms, it has been entwined and enmeshed all across the culture and human psyche. Music has always been a beautiful and sacred medium for expression of emotions and feelings experienced, right from the dawn of human civilization, be it elation, despair, aggression or love. Music is an art, defined by classical music which got recognized around 11^th century and gained popularity due to the systematic notation system that it began using. Indian Classical Music is the soul of all music. Classical Music greatly affects the brain activity; it has a positive effect on the hormone system and acts as a dominant mood enhancer.^4,5

 

Aggression in child and adolescent age group may reflect impaired developmental capacity to regulate behavior. It is linked to impulsivity and poor affect regulation. (Connor et al. 2012) In the past several decades, child aggression has become a major concern since self-reported aggressive and violent behavior continues to rise among children.^1,2,3

 

BACKGROUND OF THE PROBLEM:

Worldwide, the prevalence of clinically significant psychiatric disorder in children is at least 7%. This rate rises in socially disadvantaged and densely populated urban areas. It also increases by 3%–4% after puberty. ^6,7The issue of childhood psychiatric morbidity is more serious in middle and low income countries because these countries have a much larger proportion of child and adolescent population; much lower levels of health indices; poorer infrastructure and resources to deal with problems. According to World Health Report (2000), 20% of children and adolescents suffer from a disabling mental illness worldwide and suicide is the third leading cause of death among adolescents. In India studies shows that the incidence rate of the Child and Adolescent disorder is about 18/1000/yr (Malhotra et al.2009).^9,10

 

The rates of maladaptive aggression in youth diagnosed with Conduct Disorder have been estimated at approximately 20%, with boys displaying significantly higher rates than girls. In Developmentally Delayed individuals, aggression is a frequent occurrence with rates of self-directed aggression estimated at 4% to 5%, destructive aggression against property estimated at 7%, towards the self (4-5%) and towards property (7%).  Over half all behaviors rated as problematic included components of aggression against self or others, while one-third included destruction of property.^1,2,3

 

NEED FOR STUDY:

According to Preeti et al. (2013)¹¹ study finding mentioned that aggression by children and adolescents in an in-patient setting can be a confusing and difficult problem for their care-givers and the staff to handle. Effective parent management training, emphasizing consistency in application of behavioural principles and effective discipline strategies, as well as facilitating supportive parent child relationships could potentially mitigate aggressive behaviour. Individual sessions with the child/adolescent emphasizing prosocial behaviours and anger control strategies may decrease the severity of aggression. Psychosocial interventions in conjunction with medications are essential for the holistic management of in-patient aggression.

 

Increasing incidence of aggressive behavior in pediatric population is becoming a big challenge for the nurses who working in child psychiatry unit. Psycho therapies/ behavioural therapies are found to be time consuming and sometimes pediatric population itself not willing to sit for the every day sessions. So music therapy is good option for the nurses for managing aggressive children. The nurse can easily take up this task and function independently. However, there is a little clinical research on the effect of the music on aggression among pediatric population in India.

 

In India awareness about the music therapy should be intensified on a larger scale.

 

As the evidence supporting the utility and effectiveness of music therapy continues to accumulate, stronger research designs are needed to directly compare music therapy with other child therapies. The rigor of this type of testing is at the core of the evidence-based practice movement.¹² There have been few published works done in Indian settings on the effect of music in aggression of the pediatric population. Present study helping to attempt at helping the child to reduce the aggression and divert the mind in relaxed state.

 

STATEMENT OF THE PROBLEM:

An experimental study to assess the effect of selected raga of music on aggression among children admitted in Child Psychiatry Center, NIMHANS, Bengaluru.

 

AIM:

To evaluate the effect of Raga Shankarabaranam on aggression among children admitted in Child Psychiatry Center.

 

OBJECTIVES:

·         To assess the level of aggression among the study subjects.

·         To compare the pre and post intervention aggression level between Treatment group and Treatment as Usual Group.

·         To find out association between selected socio- demographic variables with pre intervention aggression score among the study subjects.

 

RESEARCH DESIGN:

Experimental - time series design was used for conducting study. In this design the aggression among study subjects were measured using standardized tools and random allocation of study subjects to Treatment Group and Treatment As Usual Group. Treatment group were allowed to listen Raga Shankarabharanam of Classic Carnatic music with supervision of the researcher, continuously for two weeks and targeted behavior (aggression) was measured on time series method. The assessments were done on 7^th day of intervention, 14^th day (Immediate post intervention) and 21^st day (1 week after the withdrawal of intervention). Permission was taken from the Nursing Department, Child and Adolescent Department NIMHANS. Ethical clearance obtained from Institute Ethical Committee NIMHANS, before the data collection. Permission was taken for the tool for using in study subjects.

 

Treatment group:

 

 

Treatment as usual group

 

SETTING OF THE STUDY:

The study subjects were selected from Child Psychiatry Center at NIMHANS Bengaluru.

 

POPULATION:

The population of this study comprised of Children admitted in Child Psychiatry Centers in India.

 

SAMPLE:

The sample for the study comprised of both male and female Children, who were willing to participate in the study and admitted in Child Psychiatry Center, NIMHANS, Bengaluru.

 

SAMPLE SIZE:

As per pilot study conducted on 12 subjects (6 in Treatment Group, 6 in Treatment as Usual group) in August, 2015, the sample size was determined to be 40 through power analysis at 5% level of significance.

 

SAMPLING TECHNIQUE:

The subjects were recruited for the study based on the predetermined inclusion and exclusion criteria as listed below. Consecutive sampling technique was used. Random allocation of the subjects in Treatment group and Treatment as Usual Group were done.

SAMPLING CRITERIA:

The subjects were selected based on the following pre- determined criteria.

 

INCLUSION CRITERIA:

·         Age limit 5-15yrs.

·         Those who given consent and assent.

·         Those who are scoring Modified Overt Aggression Scale more than 2 irrespective of the primary diagnosis.

 

EXCLUSION CRITERIA:

·         Children with any sensory impairment like hearing loss.

·         Children with active psychotic symptoms.

 

RESEARCH TOOL:

1.        Socio demographic profile

2.        Modified Overt aggression scale (Ratey and Gutheil, 1991)¹⁹

3.        Visual Analogue Scale

4.        Children Global Assessment Scale. (Shaffer et al.1980)¹⁸

 

MUSIC INTERVENTION:

Music intervention includes allowing the children to listen the Raga Shankarabharanam from Classic Carnatic Music for 20 minutes twice daily for 14 days. Before selecting Raga Shankarabharanam researcher consulted with various musicians and music therapists for suggestions about Raga Shankarabharanam. Famous three expert musician’s instrumental music on Raga Shankarabharanam selected and compiled on a Compact Disc (CD). 

 

Instrumental music on Raga Shankarabharanam included in the CD is listed below.

1.        Dr. Ramani Flute on Raga Shankarabharanam

2.        Madurai Mani English note on Raga Shankarabharanam

3.        Lalgudi Jayaraman violin on Raga Shankarabharanam (3)

 

The CD was validated with various experts for its audibility, clarity and relevancy and appropriateness to the pediatric population.

 

RESULTS:

Section no.1. Description of socio-demographic variables of study subjects

Socio demographic variables like, age group, temperament, duration of illness, diagnosis of the subjects, were presented in frequencies and percentages. To verify the homogeneity of the socio demographic characteristics of the subjects in Treatment as usual Group and Treatment Group, Independent t test and Chi- square tests were used.

Table no.1 distribution subjects based on age group

 

Table No.2. Distribution of subjects based on temperament and duration of illness

 

Table no. 3 Distribution of subjects based on diagnosis

 

Section 2: Level of aggression among Treatment Group and Treatment as Usual Group prior to the administration of music.

Table no.4. Level of aggression among study subjects

 

Table no.5.  Domain wise distribution of aggression

 

Section.3: Effect of music intervention on aggression among children admitted in Child Psychiatry Center.

Table No.6. Effect of music intervention on aggression measured through MOAS

MOAS= Modified Overt Aggression Scale, ^* significant at p<0.05 level, NS- Not significant

 

Table No.7. Effect of music intervention on aggression measured through VAS by parents

VAS-p- Visual Analogue Scale by parents, * significant at  p<0.05,          NS- Not significant

 

Table No.8. Effect of music intervention on aggression measured through VAS by Child

Scale used	Treatment Group			Treatment as Usual Group			f-statistics	p-value	Between the study groups
	Mean	SD		Mean		SD			f-statistics	p-value
VAS child-1 ( 1st day)	8.93		1.07	7.93	1.38		25.69	0.0001*	2.14	0.16 NS
VASchild-2 (14th day)	7.36		1.45	6.87	1.30
VAS child-3 (21st day)	6.79		1.31	6.33	1.98

VAS- Visual Analogue Scale     * significant at  p<0.05        NS- Not significant.

DISCUSSION:

As a part of the this study, music intervention included 28 sessions, the effect of music on aggression was measured using three scales, MOAS, VAS by parents and VAS by children. The present study findings reveal that both the Treatment Group and Treatment as Usual Group had significant reduction in MOAS aggression scores (f-statistic =31.35, p<0.001).No significant reduction in aggression scores between the study groups, were noted (f-statistic=1.19 p=0.28). 

 

Level of aggression measured with Visual Analogue Scale by parents showed significant reduction in aggression within the study groups (f- statistics =19.83, p-value<0.001) but there was no significant reduction in aggression between the study groups (f-statistics= 0.017 and p value 0.89).

 

Level of aggression measured with Visual Analogue Scale by children showed significant reduction in the aggression score within the study groups (f- statistics=25.69, p<0.001). But there was no significant reduction in aggression between the study groups (f-statistics=2.14, p=0.16).

 

Overall findings of this study suggest that, within the group’s aggression score reduced significantly, this could be due to the effective treatment strategies and therapeutic environment provided in the Child Psychiatry Center. Between the groups reduction in the aggression was not significant; it indicates that Raga Shankarabharanam had no definite effect on aggression.

 

This study finding coincides with the study conducted by  Rickson DJ et al.(2003)¹³,on 15 children, with receptive group music therapy (16 sessions),the findings showed music had no definite treatment effects for aggression could be detected when compared to control group. He suggested a more highly structured program and smaller group numbers may be advantageous for adolescents who have attention deficit hyperactivity disorders.

 

The present study findings differs with the findings of the study conducted by Al-Na Choi et al. (2008)¹⁵ in South Korea, with 45 children, in which Active group music intervention was given for the subjects with 30 sessions. At the end of the intervention there was a significant reduction in the aggression scores and increase in the self esteem score (p<0.001).Music intervention includes singing songs, analysis of libretto, making musical instrument, playing instruments such as pianos and hand bells, song drawing and song writing. This study emphasized more on the Active Group Therapy Model.

 

In the present study receptive group music therapy approach was used. Children were allowed to move around freely doing activities they were interested in. Few children choose to spend time in painting, some were found sitting idle, few were moving around the room and few others enjoyed dancing. After one week of intervention researcher observed an increase in the verbalization behavior.

 

Although considerable research work has been devoted in the area of music therapy, less attention has been paid to raga based music therapy. In this study the researcher used raga based approach, choosing Raga Shankarabhanam, which is currently an evolving trend in Indian music therapy. Literature by music expert Anuradha Mahesh (2013)¹⁷, supported the effect of Raga Shakarabharanam on mood. But the present study findings reveals that Raga Shakarabharanam has no definite effect on aggression among children with mental illness. However, this finding differs with findings of the study conducted by Ram.K.et al. (2012)¹⁶ in which Indian classical music was found to be more effective on emotional status as compared to rock music.

 

Current study finding reveals that Raga Shakarabharanam has no definite effect on aggression among children with mental illness. The researcher considered various factors that may have affected the study results. One of the factors can be inclusion of the subjects with broad range of diagnosis. In Treatment Group 30% of subjects were diagnosed as Disruptive Behavioral Disorders and in Treatment as Usual Group 30% of subjects were diagnosed as Affective Disorders. According to hospital policy, for the patient with Disruptive Behavioral Disorders as a first line treatment regimen, behavioral techniques are implemented. But for the affective disorders first line treatment regimen includes initiating psychotropic medications. So, effect of medications could have played a role in the reduction of aggression among Treatment as Usual Group.

 

In the meta-analysis with eleven studies by Christian Gold et al. (2004)¹⁴, found that children with behavioural or developmental disorders, or with multiple psychopathologies, may benefit from music therapy. Christian Gold et al. (2004)¹⁴ suggested that Individualized music therapy, where a therapist chooses from a variety of music therapy techniques to match the individual client’s needs, may be more helpful than a fixed treatment regimen. Researchers also suggest that the effect of music therapy in general may depend on the specific combination of diagnosis, type of music therapy, and type of outcome. Music therapy for children and adolescents with psychopathology appears to be especially helpful when techniques from different music therapy approaches are combined.

 

This study finding differs with the study conducted by Montello et al. (1999)²² in which compared the active and passive music therapy approach in pre adolescent group (n=16) and concluded that there was no significant difference between active and passive music therapy group, in both group ,aggression score is significantly reduced.

 

Recently there has been a growing interest in the long term effect of music therapy. In this study the follow up period was for 1 week so the long term effects of Raga Shankarabharanam on aggression could not be assessed. Alison. J. Ledger et al. (2007)²⁰ conducted a RCT  in Australia with forty five subjects, with long term follow up of three months , 6months, and 1 yr. Findings revealed that there were no significant differences between the groups over time, may indicate that music therapy has only immediate effects on agitated behaviours. No other studies supported this finding further.

 

In the current study, after 2 weeks of music intervention 1 week withdrawal period for the intervention was given for the subjects and then assessments were carried out. Assessment after withdrawal period not revealed any significant effect of Raga Shankarabharanam between Treatment Group and Treatment as Usual Group. This finding was not supported by the findings of the study by A. Ragilo et al. (2010)²⁴among 60 subjects where Agitation was significantly reduced in the experimental group. The main improvements in the experimental group emerged at the end of the treatment, with a maintenance of these results after 1month of the withdrawal period. This indicates that the lasting effect of the music therapy was present after 1 month period.

 

Kattryn, Garland et al. (2007)²¹ conducted a RCT study among 30 subjects, the study concluded that placebo group also has shown reduction in the agitated behavior than expected. Researchers concluded that any activities that engage the brain helps to reduce the aggression in a person with mental illness. On a more positive note, the finding suggests that even simple technologies can enrich patient’s lives and alleviate the distress.

 

One of the benefits suggested by most of the researchers is that music is easy to administer and is acceptable to most of the patients with apparently no side effects and burden to the patients. Music intervention being form of non-pharmacological approaches has several advantages such as it addresses the psychosocial as well as environmental aspects for managing behavioural problems. Music intervention, therefore, may have provided an avenue for appropriate expression of negative emotions. Participation in group music also provides those with mental illness a channel for communication and social interaction. This helps the patient to get rid of stigmas and reduce the burden of the hospitalization.

In the present study, none of the selected socio-demographic variables showed any significant association with pre intervention aggression score. However, the researcher has reviewed following studies that found association between aggression and some socio-demographic variables. The findings of the study by DC Chukwujekwu et al. (2011)⁹ mentioned that male were getting more aggression than females. The study findings by Lochman et al. (2003)²⁵, high school students are showing more aggression than other children.  The study finding by the Preeti et al. (2013)¹¹ showed that 71% of the subjects with aggressive behavior had difficult temperament. The study findings by Sukhodolosky et al. (2005)²³ revealed that aggressive behavior was significantly associated with length of hospitalization.

 

LIMITATIONS OF THE STUDY:

1.        Broad range of diagnosis was taken for the study, so treatment regimen followed for each subjects was also different.

2.        Sample size was small, limiting the generalization of the finding.

3.        Long term follow up was not undertaken due to time factors.

4.        Subject’s age also was in broad range 5-15 yrs.

5.        Music sessions were limited to 28 sessions only due to time factors.

 

RECOMMEDATIONS:

1.        Long term effects  can be calculated with further follow up studies

2.        The study can be generalized and replicated in a larger sample for making a more valid generalization.

3.        Biophysical markers such as EEG, Cortisone level in blood, functional MRI etc can be used to find out the effect of music.

4.        Active / improvisational music therapy model / individual music therapy model can be used to reduce the problem behavior of the children and adolescent.

5.        A similar kind of study with different raga/ on a particular diagnosis can be conducted.

6.        An effort should be taken to educate and train the staff working in the in-patient settings.

7.        A similar kind of study can be conducted in different settings like schools, day care centers etc.

 

STRENGTHS OF THE STUDY:

1.        Nurses are involved in caring for the children in various settings, yet there is a lack of sufficient nursing literature on mental health, this study conducted by nurse, thus contributes to nursing research in the area of Child Mental Health and Raga Based Music Therapy.

2.        Homogeneity of study groups with respect to socio-demographic characteristics was maintained.

3.        Random allocation of the subjects into Treatment Group and Treatment as Usual Group were done.

4.        A music intervention package with Raga Shankarabharanam was compiled and validated with experts.

 

CONCLUSION:

An experimental study to effect of selected raga of music on aggression among children admitted in Child Psychiatry Center was undertaken with aim to find out effect of raga based music therapy on aggression children with mental illness. This study has proven that Raga Shankarabharanam had no definite effect on aggression among children with mental illness. But this study revealed that music therapy among pediatric population is practical, feasible and helpful in maintaining therapeutic environment. Music contains rhythmic, melodic, harmonic and dynamic structure which, when applied systematically and skillfully, can be effective in engaging children.

 

ACKNOWLEDGEMENT:

Authors would like to thank all the professors in Department of Nursing NIMHANS and Department of Child and Adolescent Psychiatry NIMHANS for their valuable suggestions and guidance.

 

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Received on 27.08.2016          Modified on 06.09.2016

Accepted on 21.12.2016         © A&V Publications all right reserved