Spina Bifida (SB) is considered to be the most com- mon disorder in the developmental defect of the ner- vous system, which is due to the lack of closure of the end of the neural tube during the third to fourth weeks of the juncture (Amini, & Pashmdarfard, 2017). It seems that a combination of Genetic factors (a his- tory of neural tube defect in previous generations; if following to the birth of a child with this disorder, the probability that a child born with the same dis- order is 40%), and the environmental factors (con- sumption Valproic Acid and Carbamazepine in the first trimester of pregnancy, the wrong diet, diabetes, severe fever in early pregnancy, the use of a hot wan bath in early pregnancy, alcohol consumption dur- ing pregnancy) can affect this condition (Guilbaud et al., 2019). Generally Spina Bifida is divided into two general types: Spina Bifida occulta and Spina Bifida cystica. Spina Bifida cystica is divided into two types too; the meningocele and myelomeningocele (Ferri, 2017). Spina Bifida occulta, which is also referred to as the hidden Spina Bifida, has no apparent symp- toms, but in the type of Spina Bifida cystica the spinal cord and meninges protrude from the neural tube and show different motor symptoms (Ferri, 2017). The prevalence of this disorder in the world is between 0.3 and 4.5 per 1,000 live births (Amini, & Pashmdarfard, 2017). Different statistics in different regions of Iran report the prevalence of this disorder 1.6 per 1,000 live births (Ketabchi, Ghodsi, & Nejat, 2001). In 90% of patients, there is also a manifestation of myelo- meningocele in the hydrocephalus (Shurtleff, 2012). The physical symptoms of Spina Bifida may include: weakness and lower limb paralysis, orthopedic abnor- malities (Club foot, Scoliosis), urinary incontinence and stool, urinary tract infections, and poor kidney function (Juranek, & Salman, 2010). The presence of multiple physical problems and apparent abnormali- ties in these children have resulted in behavioral dis- orders and severe anxiety (Amini, & Pashmdarfard, 2017). Anxiety is a common, unpleasant and vague feeling of panic with unknown origin that one experi- ences, including uncertainty, frustration, and physio- logical excitation (Mosavi, & Khodabakhshi Koolaee, 2016). Early childhood anxiety disorder is a predictor of psychiatric disorders during adolescence (Mosavi, & Khodabakhshi Koolaee, 2016). Anxiety disorders are one of the most common forms of pathology in children and adolescents. The disorder has six symp- toms: restlessness, extreme fatigue, difficulty in con- centration, irritability, muscle tension and sleep disor- der (Khodabakhshi koolaee, Sabzian, & Falsafi nejad, 2015). In recent years, researchers have been strug- gling to introduce effective interventions for anxiety disorders. Although there are several interventions for treating anxiety, but the new methods such as art ther- apy (poetry, painting therapy, theater therapy, music therapy) has become very important in recent decades (Mosavi, & Khodabakhshi Koolaee, 2016). Many studies showed the positive effect of poetry therapy on a range of physical and psychological disorders, such as reducing anxiety in cancer patients, reducing pain, addiction and other mental disorders (Mosavi, & Khodabakhshi Koolaee, 2016; Khodabakhshi koo- laee, Sabzian, & Falsafi nejad, 2015). Poetry therapy was officially recognized in 1969, until then, little research was done on its different applications and therapeutic efficacy. The therapeutic goals expected of therapeutic poetry are: to empower the feeler, pro- mote self-expression and spread group discussion. Of course, the choice of proper lyrics and time should also be taken into consideration. Poetry therapy, like Freud’s psychotherapy, leads to emotional liberation, which is rooted in depression and anxiety and individ- ual stress. (Khodabakhshi koolaee, Sabzian, & Falsafi nejad, 2015). In addition to the curriculum, rhythmic movements’ therapies are also known as one of the effective methods for reducing anxiety disorders (Khodabakhshi koolaee, Sabzian, & Falsafi nejad, 2015). Since rhythmic movements’ therapy, like poet- ry, provide a way to express feelings, particularly for children who are verbally insufficient to express their feelings. Their movement symbols are a reflection of their inner feelings, in other words, rhythmic move- ments’ therapy can play the role of their language (Mohammadian et al., 2011). Therefore, this study was designed to assess the effect of poetry therapy and rhythmic movements’ therapy on reducing anxi- ety of a child with myelomeningocele.

 

Case Report

This study is about the effect of Poetry therapy and rhythmic movements’ therapy on reducing anxiety of a 12 years old boy (he was born in 2004) with myelo- meningocele and IQ of 104% in 2018. The child has entered third elementary school; his parents have got divorced and the child is now not under the care of any of his parents being cared in the children care center. In this study, an anxiety scale (The Spence Children Anxiety Scale (SCAS): child report and caregiver re- port) was used to assess the anxiety of the child.

The Spence Children Anxiety Scale (SCAS)

This scale was developed by Spence in Australia in 1997 according to the DSM-IV diagnostic classi- fication (Spence, & Barret, 2003). The Spence Chil- dren Anxiety Scale consists of 45 phrases, 38 phrases are scored and six phrases which are positive are not scored and computed. Spence Children Anxiety Scale also has an open question that the child will respond in an explanatory way and can be provided for 8 to 15 years old children. The Spence Anxiety Scale has 6 sub-scales that are as follows :

    

  01. Panic and fear of open space: 

       This scale is evaluated in questions 13-21-28-30-32-34-36-37-39.
 

       02. Separation anxiety:

       This scale is evaluated in questions 5-8- 12- 15- 16-44.
 

      03. Fear of physical damage:

      This scale is evaluated in questions 2-18-23-25-33.
 

      04. Social phobia (phobia):

      This scale is evaluated in questions 6-7-9-10-29-35.
 

      05. Obsessive-Compulsive:

      This scale is evaluated in questions 14-19-27-40-41-42.
 

      06. General anxiety:

       This scale is evaluated in questions 1- 3- 4 20- 22- 24. The scoring of this scale is based on a 4-point Likert scale, never (0), sometimes (1), often (2), and always (3). The test retest reliability of the original version of this scale was reported by Spence et al. in 1998 for general anxiety (ICC=0.92)(10).
The internal consistency of this scale in Iran was reported by Mousavi et al in 2007 with Cronbach’s alpha between 0.62 and 0.89 (0.62<α<0.89), and the 6 sub-scales were confirmed by confirmatory factor analysis (Mousavi et al., 2007).

Poetry therapy and rhythmic movements’ therapy

Due to certain conditions (myelomeningocele) of this boy the purposes of rhythmic movements’ therapy in this study , were gross and fine motor movements of the hands, fingers, head, and trunk, lower limb, ly- ing and sitting. In this study, the poetry therapy and rhythmic movement therapy were conducted in 10 sessions with specific topics (45 to 60 minutes each session) (9) In this study, poetry and rhythmic move- ments therapy were performed in 45 days (2 sessions per week and 45 to 60 minutes in each session), which is described in detail in Table 1.

 

Results

This study was performed to assess the effect of poetry and rhythmic movements’ therapy on reduc- ing child anxiety with myelomeningocele. Poetry and rhythmic movements’ therapy were conducted in ac- cordance with the specific instructions during 10 ses- sions. In each session a specific topic was presented individually to the child. After ten sessions, the re- sults showed the effectiveness of Poetry and rhythmic movements’ therapy for reducing the anxiety of the child. Interventions have been able to reduce the fear of open space, separation anxiety, fear of physical damage, social phobia, and general child anxiety, but the results didn’t show the effectiveness of Poetry and rhythmic movements’ therapy on reducing the ob- sessive-compulsive anxiety. Regarding these results, Poetry and rhythmic movements’ therapy have been effective in reducing the anxiety of the child with my- elomeningocele (Table 2).
 

Table2. The therapeutic areas were assessed and treated by occupational therapists in children with
autism spectrum disorder*

was t4).

 

Discussion

This case study, showed the effect of poetry and rhythmic movements’ therapy on reducing child anxi- ety with myelomeningocele. Several studies have been done on the effect of poetry and rhythmic move- ment’s therapy on children anxiety (Khodabakhshi koolaee, Sabzian, & Falsafi nejad, 2015; Mosavi, & Khodabakhshi Koolaee, 2016), in a study conducted among preschoolers, by Khodabakhshi et al., poetry and rhythmic movements therapy was proposed as a low cost and efficient intervention method in reducing the aggression and anxiety of children (Khodabakhshi koolaee, Sabzian, & Falsafi nejad, 2015). Mohamma- dian et al., also considered poetry therapy to reduce anxiety, depression and aggression of children (2011). Pouyamanesh and Faryabi also showed that poetry and rhythmic movements’ therapy reduce the aggres- sion in mentally retarded children and children with learning disabilities (2015). The point to consider in this study was that these interventions have been per- formed on a child with myelomeningocele. Since the child was not under the care of any of the parents and was kept at a care center for children with physical disabilities, the child therapist’s hypothesis was that the child’s anxiety would be due to his difficult cir- cumstances; In this regard proper steps were taken to help with the child’s anxiety. The results of the study showed that poetry and rhythmic movement’s therapy can be effective in reducing the anxiety of this child. In a study by Amini and Pashmdarfard to investigate the effect of painting therapy on reducing child ag- gression with myelomeningocele, it has been shown that painting therapy is effective in reducing aggres- sion (Amini & Pashmdarfard, 2017). Considering this study, as well as similar studies, one can conclude that providing services such as poetry therapy, rhythmic movements’ therapy, painting therapy can be effective in reducing the distressing psychological symptoms of children, especially children with special needs.

 

Conclusion

Poetry and rhythmic movements therapy was an effective treatment to reduce the anxiety of children with myelomeningocele. However, since this study was performed only on a person, in order to increase its generalizability and widespread use, more studies are needed with more sample size. But since these therapies, including non-invasive, simple and cost- effective therapies can be suggested along with other therapeutic and rehabilitation methods for these chil- dren, in addition to the sensory-motor disorders of these children, we also have a step toward eliminating behavioral disorders in these children.

 

Acknowledgements

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. The authors appreciate the child and Nasim care center’s Personnel especially Mrs. Mohammadi who was the Nasim care center’s director.

 

Conflict of Interest

Authors declared no conflict of interest.