Introduction: Frontal lobe Traumatic Brain Injuries (TBIs) are serious conditions that can have long lasting severe effects, even past the typical recovery period. One of the most common effects of a frontal lobe TBI is increased anger and impulsivity, which leads to out bursts of verbal or physical aggression, especially within adolescent patients whose brains are still developing. Consistent levels of elevated anger can often times lower quality of life and have a major interference with interpersonal relationships. Objective: The purpose of this study is to determine if soft soothing music can effectively help to reduce anger levels in adolescent patients. Methods: This study will follow a quantitative, cross-sectional, and correlational survey design. Participants (N= 108) will be selected through stratified random sampling from the population of current adolescent frontal lobe TBI patients receiving outpatient care at Children’s Hospital of Philadelphia (CHOP). Participants will take the Clinical Anger Scale inventory to measure their initial anger level, and will then be administered one of three music variables. These variables are low volume soft soothing piano music with no lyrics, low volume aggressive metal music with no lyrics, and no music at all. This will be implemented four times a week for six months, and the Clinical Anger Scale inventory will be given at the end of each week’s session to actively monitor anger levels. Results: Proposed results are to be determined. Implications: The results from this study would provide a deeper understanding of the role music plays on anger levels in adolescents with frontal lobe traumatic brain injuries, which would ultimately help to create new rehabilitation techniques in the future.
A common symptom experienced after a traumatic brain injury (TBI) is impulsive aggressive behavior (Dyer, 2009). Research has indicated that increased amounts of music therapy sessions have a positive influence on the mood of patients recovering from TBIs (Wheeler, 2009). However, some research suggests that music therapy alone can have an impact, but classic rehabilitation seems to have a greater impact (Hitchen 2010). The aim of this research study is to examine the effects soft soothing piano music has on the anger levels of adolescent patients, age 10 to 18, with frontal lobe traumatic brain injuries. This study will examine anger level outcomes within a population of adolescent outpatients from Children’s Hospital of Philadelphia.
An important part of adolescence is socialization and creating relationships.
Patients who exhibit consistent impulsive aggression often times experience a negative impact on the ability to socialize with peers. This can lead to a viscous cycle of frustration and increase overall anger levels (Dyer, 2009). One way that anger can be measured is through the Clinical Anger Scale (CAS), which is a set of twenty-one groups each consisting of four different statements. The patients reply to which statement they feel applies best to their current state of mind. It was shown that there is sufficient internal consistency as well as test retest stability (Snell, 1995). Monitoring anger with the CAS is important because it helps to show not only initial levels, but also can be used to show levels over time. The Clinical Anger Scale is therefore an adequate way to assess the levels of anger a patient may be experiencing.
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It is important to give patients the most impactful rehabilitation possible because that is how quality of life is increased. Everyone deserves the best quality of care in order to have the highest quality of life. Music therapy is one way that many research studies have seen a new and impactful way to improve aggression and anger. One study observed that there was a positive impact on mood and social interaction when music therapy sessions were implemented for patients with traumatic brain injuries (Wheeler, 2000). There were eighteen participants of mixed ages who received ten sessions of music therapy. In each session they listened to instrumental music so set the mood of the therapy. The participants were also encouraged to played with percussion instruments and sing. This study was later reconstructed, and indicated that as the number of music therapy sessions increased so did the moods and social interactions of the participants (Wheeler, 2009). So, not only does music therapy have a huge impact on participants, but so does increasing the number of sessions attended.
This information suggests that music therapy can be an amazing tool which can be used to aid in the rehabilitation process. However, there is also some research that indicates background music has the ability to help children improve behavior difficulties (Hallam, 2003). This study was not implemented with patients who have been diagnosed with traumatic brain injuries, but rather diagnosed with behavioral difficulties. Adolescents with behavior difficulties are similar to adolescents with traumatic brain injuries because in both cases there is an issue with frontal lobe misfunction and executive function difficulties. Executive function is what helps people control their impulses. Children with highly aggressive behavior also saw a reduction in aggression with the implementation of group music sessions (Choi, 2007). Overall, it is evident that even background music can help to improve aggression in adolescents who struggle with frontal lobe misfunction.
There is indication that music therapy, as well as background music, have positive impacts on aggression levels in patients with traumatic brain injuries. Other research also shows that after brief thirty-minute time periods of neurologic music therapy there are indications of a positive impact on the behavior and executive function of patients with brain injuries (Thaut, 2009). Classical music therapy is treatment that helps with emotion regulation, while neurologic music therapy is treatment targeted for individuals with neurological damage; this treatment helps with executive function as well as cognitive processes. This study shows that music, even while brief, can have helpful impacts for patients struggling with symptoms of impulsivity, aggression, and anger from traumatic brain injuries.
Most research studies which examine the effects of music on patients with TBIs tend to be small scale studies, and are highly debated (Hitchen 2010). This is likely due to the fact that music therapy is a fairly newer form of treatment recognized by the American Psychological Association, therefore, has had less time for larger scale studies implemented in a wider range of patients. Music therapy can help support emotional expression, however, there is not many published research studies showing interdisciplinary rehabilitation (Magee, 2011). Many of these studies do not include classical rehabilitation. Many times patients do not get the option of music therapy unless they become a participant in a research study. These studies are helpful and great starting points, but overall there is a need for more research showing how music therapy is implemented alongside with the classical rehabilitation treatment options.
Overall, it is clearly evident in these studies that music therapy, background music, and brief music implementation all have had positive impacts on patients who experience symptoms of aggression and anger due to frontal lobe misfunction. Not all of the studies were done with patients who have traumatic brain injuries; however, all patients had the similarities of frontal lobe misfunction and executive function issues. The previous research lays a solid ground work for the basis of this study. The aim is to examine the effect soft soothing piano music has on the anger levels of adolescent outpatients with frontal lobe traumatic brain injuries.
This study will include 108 participants who are adolescent children, from the age of 10 years old to the age of 18 years old, who have been diagnosed with a traumatic brain injury (TBI) in the frontal lobe. The participants will be recruited by their current medical professional from Children’s Hospital of Philadelphia, with the consent of both the participant and their parent or legal guardian. The inclusion criteria for this study is a minimum score of 36 on the Clinical Anger Scale administered by a Psychiatrist or other trained medical professional. Exclusion criteria for this study is anyone younger than 10 years of age, and anyone older than 18 years of age. Anyone with a traumatic brain injury not in the frontal lobe area will also be excluded. The demographics of the participants will come from all biological sexes, races, and ethnicities.
The Clinical Anger Scale (CAS) is an instrument developed to measure the construct of anger. The study of the CAS found that the internal consistency as well as test retest stability is consistent (Snell, 1995). This is a self-report inventory of 21 different groups of statements. There are four different options to choose from A, B, C, and D. A clear example of this would be “A. My feelings of anger do not interfere with my work”, “B. From time to time my feelings of anger interfere with my work”, “C. I feel so angry that it interferes with my capacity to work”, “D. My feelings of anger prevent me from doing any work at all”. It is scored on a scale of 0 to 3. A is a score of 0, B a score of 1, C a score of 2, and D a score of 3. Each category’s score should be added up to find the grand sum. The minimum score is a 0, and the maximum score is a 63. A score between 0 and 23 indicates the person shows signs of low anger. A score between 22 to 35 indicates a person is showing moderate levels of anger. Lastly, a score of 36 or higher indicates the person is showing signs of high or severe levels of anger.
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There will be three different variable groups. The first group will receive low volume soft soothing piano music containing no lyrics. The second group will receive low volume aggressive metal music with no lyrics. The third group will be the control group, and will receive no music at all. The music will be played at a low volume because patients who are recovering from traumatic brain injuries are often times very sensitive to loud noises, and it can also make recovery more difficult.
All adolescents between the ages of 10 and 18 who are currently outpatients at Children’s Hospital of Philadelphia (CHOP) for frontal lobe traumatic brain injury’s will be selected through stratified random sampling. Girls will be assigned a number from 1 to 108, and boys will also be assigned a number from 1 to 108. Research assistants will then draw a number using a randomized computer program. If the number is 5, then the girl and boy given the number of 5 will be contacted by their current CHOP medical professional to participate. Fifty-four numbers will be drawn creating an equal number of male and female participants.
After all the participants and their legal guardians are gathered, and have informed consent of the study, they will be randomly split up into three groups of 36 participants. Licensed psychiatrists will then give each participant the initial CAS inventory, and the initial data will be input into the SPSS statistical database by trained research assistants. The first group of thirty-six participants will then receive low volume soft soothing piano music containing no lyrics. The second group of thirty-six participants will receive low volume aggressive metal music with no lyrics. Lastly, the third group of thirty-six participants will receive no music at all. Low volume is implemented as to not hurt the patients, because they are still recovering. This will continue four times a week for six months. Licensed psychiatrists will give the participants the Clinical Anger Scale inventory before and after each music session. Each time the data will be stored into SPSS to keep track of each patient’s inventory score.
Trained undergraduate research assistants will implement the music condition to each participant four times a week in this child’s home. It will be done in the home where the participant is most familiar and comfortable. The participant should be in the music condition relaxing for fifteen minutes. There should be no distractions or other things going on while the music condition is being implemented. The control group will not have music implemented, but will still relax for fifteen minutes without distractions. If participants feel like they are easily distracted they will be advised to partake in breathing techniques. Once a week a licensed psychiatrist will visit the home to implement the Clinical Anger Scale inventory as to keep the participant comfortable. It will be done in private to keep confidentiality.
The parents of the participant will also take the Clinical Anger Scale (CAS). They should answer each group of questions in regard to how they feel their child’s behavior has been observed. The parents will take the CAS once a week for the entirety of the six-month duration of the study. Each time the parent takes the CAS the data will be collected and stored into SPSS to keep track of the scores. The patient’s current outpatient medical professional at Children’s Hospital of Philadelphia will also take the Clinical Anger Scale in regard to how they have observed the patient’s behavior. The medical professional will take the CAS once a week for the entire six months the patient participates in the research study. Each time the CAS is completed the scores will be stored in SPSS to keep track of the data.
This research study intends to discover if soft music can reduce anger in adolescent patients with frontal lobe Traumatic Brain Injuries (TBIs). It is expected that the condition in which patients receive soft soothing piano music will reduce clinical anger scale levels, while the patients under the condition of no music will have no significant increase or decrease in clinical anger scales. However, the patients who will receive the soft aggressive metal music are expected to show an increase in clinical anger scale scores.
The strengths of this study include the use of three separate variable groups, including a control group. This will be implemented in order to increase the reliability of the result outcomes. A control group will give a baseline to compare the variable groups in order to show the effect of the music treatment. Another strength of this study is having the patient, parent, and medical professional all take the Clinical Anger Scale. Parents monitor their children on a daily basis and are able to observe anger and behavior change. Medical professionals also have many years of training and experience and therefore may have a more in depth understanding of changes occurring. It also gives three different sets of data on the participants anger levels as to increase validity and reliability. Another strength of this study would be the significant potential to increase the standard of living for patients who are recovering from frontal lobe TBIs. Finding new and effective treatments for patients is important in increasing quality of life. Every patient deserves to have the best quality of care possible
The limitations of this study are evident in using self-report to measure the construct of anger. Self-report can lead to over estimating or under estimating levels. If the participant is struggling and having a particularly rough day their Clinical Anger Scale may not be indicative to their total progress. Also, if the participants parent is frustrated it could negatively affect the way they respond in the self-report. Medical professionals also do not get to see the patient on a daily basis, and they could possibly report a higher or lower score depending on if the patient is having a good or bad day. Finding another measurement of the anger construct could further strengthen this study.
The music in this proposed study does not include lyrics in the music. A future direction for a similar study would be the incorporation of lyrics within the music conditions. Words may have a significant impact upon the anger levels of patients with frontal lobe TBIs. Having participants pick out their own type of music may also be a possible direction. When the participant can enjoy the music as much as possible it could have a greater impact on reducing anger levels. Additionally, expanding the age range of patients may also be a possible future direction. The brains of adolescents and adults are very different, therefore, what may have an impact for adolescents may not have as strong of an impact for adults. Reducing anger overall helps with increasing quality of life, and patients with frontal lobe traumatic brain injuries often have high levels of anger and frustration. Therefore, finding a way to reduce anger levels in TBI patients would have a huge and important impact on their quality of life.
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