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Hindawi Publishing CorporationEvidence-Based Complementary and Alternative MedicineVolume 2011, Article ID 464759, 18 pagesdoi:10.1155/2011/464759
Review Article
The Effectiveness of Music in Pediatric Healthcare:A Systematic Review of Randomized Controlled Trials
Karline Treurnicht Naylor,1 Shauna Kingsnorth,1, 2, 3 Andrea Lamont,1, 4
Patricia McKeever,1, 2 and Colin Macarthur1, 3
1 Bloorview Research Institute, Holland Bloorview Kids Rehabilitation Hospital, Toronto, ON, Canada M4G 1R82 Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, ON, Canada M5T 1P83 Department of Paediatrics, Faculty of Medicine, University of Toronto, Toronto, ON, Canada M5S 1A84 Department of Music Therapy, Faculty of Music, Wilfrid Laurier University, Waterloo, ON, Canada N2L 3C5
Correspondence should be addressed to Shauna Kingsnorth, [email protected]
Received 1 January 2010; Revised 7 April 2010; Accepted 1 July 2010
Copyright © 2011 Karline Treurnicht Naylor et al. This is an open access article distributed under the Creative CommonsAttribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work isproperly cited.
The aim of this study was to systematically review the effectiveness of music on pediatric health-related outcomes. Five electronicdatabases were searched for randomized controlled/crossover trial designs published between 1984 and 2009. Eligible studiesused music as a therapy or intervention, included participants 1 to 18 years, and focused on at least one health-related outcome(with the exclusion of procedural pain). Seventeen studies met the inclusion criteria. Quantitative synthesis was hampered by aninability to aggregate data arising from heterogeneity of interventions, outcomes and measurement tools. Qualitative synthesisrevealed significant improvements in one or more health outcomes within four of seven trials involving children with learning anddevelopmental disorders; two of three trials involving children experiencing stressful life events; and four of five trials involvingchildren with acute and/or chronic physical illness. No significant effects were found for two trials involving children with mooddisorders and related psychopathology. These findings offer limited qualitative evidence to support the effectiveness of music onhealth-related outcomes for children and adolescents with clinical diagnoses. Recommendations for establishing a consensus onresearch priorities and addressing methodological limitations are put forth to support the continued advancement of this popularintervention.
1. Introduction
Formally defined, music therapy is the systematic useof music or musical elements—along with the resultinginterpersonal relationship with a trained music therapist—to achieve optimal health outcomes for a client or group ofclients [1–3]. Musical interventions include passive listeningto prerecorded music and active music making [2]. Bothtypes of interventions have been applied in diverse patientpopulations [2, 4–24]. Long considered a “universal lan-guage” that can be perceived early in development [25, 26],the noninvasive, pleasurable, flexible, and dynamic nature ofmusic make it particularly relevant as a treatment mediumfor children and adolescents [5, 6, 12, 14, 16–18].
Six meta-analyses examining the use of music in thecontext of pediatric healthcare have been published [2, 12,14, 16–18]. Two of these reviews focused exclusively on the
effectiveness of music on reducing procedural pain. Standleyand Whipple conducted a meta-analysis of 29 observationalstudies involving infants, children, and adolescents under-going invasive and noninvasive medical procedures andconcluded that musical interventions reduced pediatric pain,anxiety, and distress [14]. Likewise, Klassen et al. calculateda small to medium effect of music in this context from 19randomized control trials (RCTs) [18]. These findings areconsistent with meta-analyses examining the effects of musicon pain, anxiety, and other indicators of stress in hospitalizedadults [2, 11, 19–21]. Dileo and Bradt conducted a broadmeta-analysis of medical music therapy, combining RCTsand observational studies within 11 medical specialties; theycited a moderate effect within the subspecialty of pediatricsfrom 11 trials largely related to medical procedures [2].
The three remaining meta-analyses focused on specificpopulations. Consistent with reviews in adult mental health
2 Evidence-Based Complementary and Alternative Medicine
[7–9, 15], Gold et al. reported a large positive effect of musictherapy on objective outcomes including developmentalmilestones and problem behavior, and a medium positiveeffect on subjective outcomes including self-concept andsocial skills for children and adolescents with behavioral,emotional, and/or developmental disorders [12]. A largeeffect of musical interventions on cognitive skill and socialbehavior in autistic children was reported by Whipple,based on 9 observational studies identified in a narrowliterature review [16]. Neither Whipple [16] nor Gold etal. [12] provide a comprehensive description of steps takento minimize bias in study selection and data extraction[27, 28]. Using more rigorous methodology and focusingexclusively on RCTS, Gold et al. reported a medium effectof music therapy on nonverbal communication and a smallto medium effect on verbal communication in children withautism and related pervasive developmental disorders [17].
Although these meta-analytic findings are supportiveof the effectiveness of music, the reviews are narrow infocus. For example, of notable absence are children withacquired and/or congenital physical disabilities despite theuse of music therapy as a habilitation tool with thesepopulations [23, 24, 29]. To build on the findings of previouspapers, we undertook a comprehensive systematic review ofrandomized controlled trials of music therapy and musicalintervention in pediatric healthcare. This paper does notfocus on particular clinical populations or specific outcomes,but examines the effectiveness of music on health-relatedoutcomes in children and youth with a variety of clinicalconditions in a variety of settings (educational, outpatient,inpatient, and research).
2. Methods
A systematic review of the peer-reviewed literature wasundertaken following the guidelines outlined in the PRISMA(Preferred Reporting Items for Systematic reviews and Meta-analyses) Statement. This statement includes a 27-itemchecklist to improve the conduct of systematic reviewsand meta-analyses of health care interventions by ensuringtransparent and complete reporting [30, 31].
2.1. Search Strategy. The search strategy and database selec-tion were developed through consultation with a researchlibrarian. The search strategy contained a broad series ofsubject headings and keywords relating to music or musictherapy and outcome-driven research design. Previouslypublished meta-analyses were also reviewed to guide thedevelopment of the search strategy and identify pertinentpublications [12, 14, 16–18]. The following internationalelectronic databases were searched on the 4th March 2009:Ovid Medline (Medical Literature Analysis and RetrievalSystem Online), 1950 to February, Week 3, 2009; Embase,1980–2009, week 9; PsycInfo, 1967 to February, Week 42009; AMED (Allied and Complementary Medicine), 1985–February 2009; and CINAHL (Cumulative Index of Nursingand Allied Health Literature), 1983–2008. There were nolanguage restrictions. The search was limited to the timeperiod 1984–2009 inclusive and by age (0–18 years) using
(music or music therapy).mp. and exp treatment outcome/ or exp “outcomeassessment (health care)”/ or exp program evaluation/ or exp clinical trial/ orexp controlled clinical trial/ or exp randomized controlled trial/ or expcomparative study/ or exp evaluation studies/ or control groups/ or randomallocation/ or ((control or comparison or treatment or experiment$ orintervention) adj5 (group$ or subject$ or patient$)).tw. or(effect$ or efficacy orbenefit$ or beneficial).tw.limit to (humans and yr=“1984–2009” and “all child (0 to 18 years)”)
Figure 1: Example of series of keywords and descriptors used tosearch the Ovid Medline database.
filters unique to each database. An example of the searchstrategy is provided in Figure 1; minor modifications weremade as required within individual databases.
2.2. Study Selection. Retrieved records were importedinto RefWorks and duplicates removed [32]. Non-Englishabstracts and full-text records were translated. Two reviewers(KTN and SK) independently screened titles and abstractsfor relevance; potentially relevant studies were reviewedindependently in full by KTN and AL. Studies were includedif they met the following 6 criteria: (1) examined theeffectiveness of a music intervention, (2) involved a clinicalpopulation in a healthcare, research, or education setting, (3)involved children and adolescents between 1 and 18 years ofage (or reported a mean age within this range), (4) used aRCT design (parallel or crossover), (5) reported at least onequantifiable outcome measure, and (6) published between1984 and 2009.
The focus of this paper was to determine the effectivenessof music as an intervention or therapy, regardless of deliverymode (i.e., by a trained music therapist, health professional,or researcher). Thus, studies examining music education,acoustic or auditory stimulation, or nonmusical sounds (e.g.,white noise) were excluded. Given the recent systematicreview examining RCTs for procedural pain and anxietyin children [18], trials of the effectiveness of music forchildren undergoing a medical or dental procedure werealso excluded. Ineligible studies were filed with a reason forexclusion, and discrepancies between reviewers were resolvedthrough discussion until consensus was reached.
2.3. Data Extraction. Data from included studies wereextracted and compiled by KTN and verified by SK andAL using a standard form. Table 1 includes informationabout each study (authorship, year of publication, country,recruitment setting, and experimental design), participants(sample size, gender, population, and age), intervention(treatment, delivery, participant involvement, and dosage),and quality rating. Table 2 describes outcomes, measurementtools, analyses, and key findings for each study.
2.4. Data Analysis. Data quality was assessed (SK and AL)using the PEDro Scale [50]; a comprehensive and reliablemeasure of the methodological quality of clinical trials [51–53]. This scale assigns a total possible score of 10 based onthe following criteria: (1) random allocation, (2) concealedallocation, (3) baseline similarity, (4) blinding of all subjects,
Evidence-Based Complementary and Alternative Medicine 3
Ta
ble
1:C
har
acte
rist
ics
ofel
igib
lest
udi
es.
Stu
dyPa
rtic
ipan
tsIn
terv
enti
onD
osag
eQ
ual
ity
Firs
tA
uth
or,
Year
Cou
ntr
yR
ecru
itm
ent
sett
ing
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dyde
sign
N (n mal
es)
Clin
ical
popu
lati
on
Age
ran
ge(y
ears
)Tr
eatm
ent
Mu
sic
deliv
ery∞
Mu
sic
typ
e±Pa
rtic
ipan
tin
volv
emen
t×D
eliv
ery
form
at•
Inte
rven
tion
form
at≈
No.
ofse
ssio
ns
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e)
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wee
ks
PE
Dro
scor
e(s
um
/10)
Lear
nin
gan
dde
velo
pmen
tald
isor
ders
Ald
ridg
e,19
95[3
3]G
erm
any
Pri
vate
prac
tice
clin
ic
Cro
ssov
erR
CT
8 (2)
Dev
elop
men
tal
dela
y4–
6.5
Gro
up
1(n=
5):
Mu
sic
ther
apy
(Nor
doff
&R
obbi
ns
adap
tati
on);
Gro
up
2(n=
3):I
nit
ial
non
-tre
atm
ent
grou
p;cr
oss-
over
occu
rred
3ti
mes
MT
LA
OI
24(3
0m
)48
5
Cla
uss
en,
1997
[34]
USA
Spec
ial
edu
cati
onfa
cilit
y
Para
llel
RC
T21 (1
2)Le
arn
ing
disa
bilit
ies
9–11
Gro
up
1:Fa
mili
arm
usi
c;G
rou
p2:
Ver
balc
ondi
tion
;bo
thgr
oups
reh
ears
edm
ult
iplic
atio
npr
oble
ms
RR
PO
S1
(<60
m)
<1
3
Bu
day,
1995
[35]
USA
Pu
blic
sch
ool
(spe
cial
edu
cati
onpr
ogra
m)
Cro
ssov
erR
CT
10 (8)
Au
tism
4–9
Gro
up
1(n=
5):
Mu
sic
con
diti
on;
Gro
up
2(n=
5):
Rhy
thm
con
diti
on;
5tr
ials
/day
RR
PO
S8
(n/a
)2
6
Kim
,20
08[3
6]K
orea
Am
bula
tory
care
clin
icC
ross
over
RC
T10 (1
0)A
uti
stic
diso
rder
3–5
Gro
up
1(n=
5):
Blo
ckof
impr
ovis
atio
nal
mu
sic
ther
apy
(in
stru
men
tal)
+bl
ock
ofpl
ay(t
oys)
;Gro
up
2:R
ever
sed
bloc
kor
der
MT
LA
OI
12(3
0m
)24
4
4 Evidence-Based Complementary and Alternative Medicine
Ta
ble
1:C
onti
nu
ed.
Stu
dyPa
rtic
ipan
tsIn
terv
enti
onD
osag
eQ
ual
ity
Firs
tA
uth
or,
Year
Cou
ntr
yR
ecru
itm
ent
sett
ing
Stu
dyde
sign
N (n mal
es)
Clin
ical
popu
lati
on
Age
ran
ge(y
ears
)Tr
eatm
ent
Mu
sic
deliv
ery∞
Mu
sic
typ
e±Pa
rtic
ipan
tin
volv
emen
t×D
eliv
ery
form
at•
Inte
rven
tion
form
at≈
No.
ofse
ssio
ns
(tim
e)
No. of
wee
ks
PE
Dro
scor
e(s
um
/10)
Pra
tt,
1995
[37]
Can
ada
Com
mu
nit
yPa
ralle
lR
CT
19 (17)
AD
Dor
AD
HD
6–18
Neu
rofe
edba
ckse
ssio
ns
wit
hor
wit
hou
tba
ckgr
oun
dcl
assi
calm
usi
c
RR
PO
S39
(<60
m)
133
Ric
kson
,20
03[3
8]N
ewZ
eala
nd
Spec
ial
edu
cati
onre
side
nti
alfa
cilit
y
Para
llel
RC
T15 (1
5)
Inte
llect
ual
,so
cial
and
emot
ion
alde
fici
tsin
clu
din
gA
DD
/AD
HD
11–1
5
Gro
up
1(n=
4):
Wai
tlis
tco
ntr
olgr
oup;
Gro
up
2(n=
6)&
Gro
up
3(n=
5):M
usi
cth
erap
yse
ssio
ns
(fav
orit
em
usi
c;in
stru
men
tala
nd
rhyt
hym
base
dac
tivi
ties
).
MT
L&
RA
&P
GS
&I
16 (30–
45m
)8
3
Ric
kson
,20
06[3
9]N
ewZ
eala
nd
Spec
ial
edu
cati
onre
side
nti
alfa
cilit
y
Cro
ssov
erR
CT
13 (13)
AD
HD
and
oth
erco
mor
bid
diso
rder
s11
–16
Gro
up
1(n=
5):
Wai
tlis
tco
ntr
olgr
oup.
Gro
up
2(n=
4):1
bloc
kof
impr
ovis
atio
nal
+1
bloc
kof
inst
ruct
ion
alm
usi
cth
erap
y.G
rou
p3
(n=
4):r
ever
sed
orde
r
MT
LA
GS
&I
16 (30–
45m
)20
2
Stre
ssfu
llif
eev
ents
Bak
er,
2006
[40]
Au
stra
liaE
SLse
con
dary
sch
ool
Cro
ssov
erR
CT
31 (11)
New
lyar
rive
dim
mig
ran
tan
dre
fuge
ead
oles
cen
ts
11–1
6
Gro
ups
1(n=
15):
2bl
ocks
mu
sic
ther
apy
(in
stru
men
tala
nd
son
gba
sed
acti
viti
es)
+2
bloc
ksn
om
usi
cth
erap
y;G
rou
p2
(n=
16):
reve
rsed
orde
r
MT
L&
RA
&P
GS
&I
20 (30–
40m
)20
6
Evidence-Based Complementary and Alternative Medicine 5T
abl
e1:
Con
tin
ued
.
Stu
dyPa
rtic
ipan
tsIn
terv
enti
onD
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eQ
ual
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Firs
tA
uth
or,
Year
Cou
ntr
yR
ecru
itm
ent
sett
ing
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dyde
sign
N (n mal
es)
Clin
ical
popu
lati
on
Age
ran
ge(y
ears
)Tr
eatm
ent
Mu
sic
deliv
ery∞
Mu
sic
typ
e±Pa
rtic
ipan
tin
volv
emen
t×D
eliv
ery
form
at•
Inte
rven
tion
form
at≈
No.
ofse
ssio
ns
(tim
e)
No. of
wee
ks
PE
Dro
scor
e(s
um
/10)
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uci
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aack
,20
07[4
1]U
SAE
lem
enta
rysc
hoo
l
Clu
ster
para
llel
RC
T
134
(67)
Ch
ildre
nfr
omdi
vorc
edan
d/or
sepa
rate
dfa
mili
es
5–10
Gro
up
1(n=
60):
Mu
sic
inte
rven
tion
(son
gba
sed)
;G
rou
p2
(n=
74):
Trad
itio
nal
psyc
hoe
duca
tion
HP
RA
GS
8(4
5m
)8
3
Hill
iard
,20
07[4
2]U
SAE
lem
enta
rysc
hoo
ls
Clu
ster
Para
llel
RC
T
26 (14)
Ch
ildre
nex
peri
enci
ng
bere
avem
ent
5–11
Gro
up
1(n=
8):
Orff
-bas
edm
usi
cth
erap
y;G
rou
p2
(n=
9):
Trad
itio
nal
soci
alw
ork
inte
rven
tion
s;G
rou
p3
(n=
9):
wai
tlis
tco
ntr
olgr
oup
MT
&H
PL
AG
S8
(60
m)
84
Moo
ddi
sord
ers
and
rela
ted
psyc
hop
ath
olog
y
Fiel
d,19
98[4
3]U
SAA
mbu
lato
ryca
recl
inic
Para
llel
RC
T28 (0
)C
hro
nic
depr
essi
on14
–19
Gro
up
1(n=
14):
Mu
sic
inte
rven
tion
(Roc
km
usi
c);
Gro
up
2(n=
14):
Self
-rel
axat
ion
inte
rven
tion
RR
PO
S1
(23
m)
<1
3
Woo
ten
,19
92[4
4]U
SAIn
pati
ent
psyc
hia
tric
faci
lity
Cro
ssov
erR
CT
35 (14)
Psyc
hop
ath
olog
y(a
ffec
tive
,be
hav
ior,
orsu
bsta
nce
abu
se)
12–1
8
Gro
up
1(n=
17):
Mu
sic
inte
rven
tion
(198
0sh
eavy
met
alm
usi
c+
1980
spo
pula
rm
usi
c);
Gro
up
2(n=
18):
reve
rsed
orde
r.B
oth
grou
psbe
gan
inba
selin
e(r
eadi
ng
mat
eria
l)
RR
PO
S2
(20
m)
<1
3
Acu
tean
d/or
chro
nic
phys
ical
illn
ess
Col
wel
l,20
05[4
5]U
SAIn
-pat
ien
tPa
ralle
lR
CT
24 (15)
Acu
teor
chro
nic
illn
ess
(>75
%on
colo
gy)
7–18
Gro
up
1(n=
12):
Art
(dra
win
g)co
mpo
siti
ongr
oup;
Gro
up
2(n=
12):
Mu
sic
(com
pute
rize
din
stru
men
tal)
com
posi
tion
grou
p
MT
LA
OI
1(4
5–60
m)
<1
3
6 Evidence-Based Complementary and Alternative Medicine
Ta
ble
1:C
onti
nu
ed.
Stu
dyPa
rtic
ipan
tsIn
terv
enti
onD
osag
eQ
ual
ity
Firs
tA
uth
or,
Year
Cou
ntr
yR
ecru
itm
ent
sett
ing
Stu
dyde
sign
N (n mal
es)
Clin
ical
popu
lati
on
Age
ran
ge(y
ears
)Tr
eatm
ent
Mu
sic
deliv
ery∞
Mu
sic
typ
e±Pa
rtic
ipan
tin
volv
emen
t×D
eliv
ery
form
at•
Inte
rven
tion
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at≈
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ofse
ssio
ns
(tim
e)
No. of
wee
ks
PE
Dro
scor
e(s
um
/10)
Rob
b,20
08[4
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SAIn
-pat
ien
tPa
ralle
lR
CT
83 (n/a
)C
hro
nic
illn
ess
(100
%on
colo
gy)
4–7
Gro
up
1(n=
27):
Act
ive
mu
sic
enga
gem
ent
(AM
E);
Gro
up
2(n=
28):
Mu
sic
liste
nin
g(M
L)an
dG
rou
p3
(n=
28);
Au
dio
stor
yboo
ks(A
SB)
form
edtw
oco
ntr
olgr
oups
MT
&H
PL
&R
A&
PO
S1
(15–
20m
)<
13
Froe
hlic
h,
1984
[47]
USA
In-p
atie
nt
Para
llel
RC
T39 (2
2)A
cute
orch
ron
icill
nes
s5–
12
Gro
up
1(n=
20):
Mu
sic
ther
apy
(in
stru
men
tala
nd
son
gba
sed
acti
viti
es);
Gro
up
2(n=
19):
Med
ical
play
ther
apy
(sto
rybo
ok&
free
play
)
HP
LA
OS
1(3
0m
)<
14
Gra
sso,
2000
[48]
Au
stra
liaA
mbu
lato
ryca
recl
inic
Para
llel
RC
T21 (1
0)C
ysti
cfi
bros
is0.
38–2
Gro
up
1(n=
10):
Un
fam
iliar
inst
rum
enta
ltr
eatm
ent
for
2bl
ocks
;Gro
up
2(n=
11):
No
mu
sic
(Blo
ck1;
con
trol
)an
dfa
mili
arch
ildre
n’s
mu
sic
(Blo
ck2;
plac
ebo)
.B
oth
grou
psre
ceiv
edro
uti
ne
ches
tph
ysio
ther
apy.
MT
RP
OS
42–1
68(3
0m
)12
5
Evidence-Based Complementary and Alternative Medicine 7
Ta
ble
1:C
onti
nu
ed.
Stu
dyPa
rtic
ipan
tsIn
terv
enti
onD
osag
eQ
ual
ity
Firs
tA
uth
or,
Year
Cou
ntr
yR
ecru
itm
ent
sett
ing
Stu
dyde
sign
N (n mal
es)
Clin
ical
popu
lati
on
Age
ran
ge(y
ears
)Tr
eatm
ent
Mu
sic
deliv
ery∞
Mu
sic
typ
e±Pa
rtic
ipan
tin
volv
emen
t×D
eliv
ery
form
at•
Inte
rven
tion
form
at≈
No.
ofse
ssio
ns
(tim
e)
No. of
wee
ks
PE
Dro
scor
e(s
um
/10)
Oel
kers
-A
x,20
08[4
9]G
erm
any
Com
mu
nit
yPa
ralle
lR
CT
58 (40)
Mig
rain
eM
ean=
10
8-w
eek
base
line
con
diti
on;G
rou
p1
(n=
19):
Bu
tter
bur
root
extr
act;
Gro
up
2(n=
20):
Mu
sic
ther
apy
(ada
ptat
ion
ofth
eH
eid
lebe
rgm
odel
);G
rou
p3
(n=
19):
Pla
cebo
MT
LA
OS
12(n
/a)
286
RC
T:R
ando
miz
edco
ntr
olle
dtr
ial.
∞M
T:M
usi
cth
erap
ist;
R:R
esea
rch
er;H
P:H
ealt
hpr
ofes
sion
al.
± R:P
rere
cord
edm
usi
c;L:
Live
mu
sic.
× A:A
ctiv
ein
volv
emen
tof
part
icip
ant
(e.g
.,in
stru
men
tali
mpr
ovis
atio
n,s
ong
lear
nin
gan
dsi
gnin
g,et
c);P
:Pas
sive
pres
enta
tion
topa
rtic
ipan
t(e
.g.,
liste
nin
g).
• G:S
essi
ons
offer
edto
grou
p;O
:Ses
sion
soff
ered
one-
to-o
ne.
≈ S:S
tan
dard
ized
inte
rven
tion
;I:I
ndi
vidu
alis
edin
terv
enti
on.
8 Evidence-Based Complementary and Alternative Medicine
Ta
ble
2:O
utc
ome
mea
sure
san
dre
sult
sof
elig
ible
stu
dies
.
Stu
dyO
utc
ome
Fin
din
gsTr
ial
Mea
sure
Scal
eA
nal
ysis
Res
ult
P-v
alu
eLe
arn
ing
and
deve
lopm
enta
ldis
orde
rsC
han
gefr
omba
selin
e:G
rou
pA
(MT
)=
7.96
Gro
up
B(n
oM
T)=
4.60
.045
Ald
ridg
eet
al.,
1995
[33]
Dev
elop
men
talm
ilest
ones
(loc
omot
orde
velo
pmen
t;p
erso
nal
-soc
ial;
hea
rin
gan
dsp
eech
;han
d-ey
eco
ordi
nat
ion
;pe
rfor
man
cete
sts;
prac
tica
lrea
son
ing)
Gri
ffith
sSc
ale
Rep
eate
dm
easu
res
AN
OV
A
Ch
ange
afte
rcr
osso
ver:
Gro
up
A(n
oM
T)=
3.92
Gro
up
B(M
T)=
5.83
NS
Cla
uss
enan
dT
hau
t,19
97[3
4]
Rec
alla
ccu
racy
ofm
ult
iplic
atio
nta
bles
Test
ofm
ult
iplic
atio
npr
oble
ms
AN
CO
VA
Mea
nac
cura
tere
spon
ses
(SE
):P
rePo
st
Mu
sic
0.9
(.46
)3.
5(.
59)
.000
1V
erba
l1.
6(.
48)
2.1
(.62
)
Bu
day,
1995
[35]
Nu
mbe
rof
corr
ectl
yim
itat
edsi
gned
and
spok
enw
ords
Scor
edby
inde
pen
den
tob
serv
erA
NO
VA
Gro
up
mea
ns
(SD
)fo
rco
rrec
tly
imit
ated
wor
ds:
Mu
sic
Rhy
thm
Sign
5.10
(2.8
9)4.
00(2
.83)
<.0
5Sp
eech
4.20
(3.3
6)3.
20(2
.94)
<.0
2
Kim
etal
.,20
08[3
6]
Join
tat
ten
tion
skill
san
dpr
o-so
cial
beh
avio
rs;n
onve
rbal
soci
alco
mm
un
icat
ion
skill
s
Perv
asiv
eD
evel
opm
enta
lDis
orde
rB
ehav
iou
rIn
ven
tory
-C(P
DD
BI)
;Ear
lySo
cial
Com
mu
nic
atio
nSc
ales
(ESC
S);
Vid
eoan
alys
is
Rep
eate
dm
easu
res
AN
OV
A
Eff
ect
size
(95%
CI)
for
mu
sic
ther
apy
vs.p
lay
sess
ion
:P
DD
BI:
0.79
(−0.
14to
+1.
71)
NS
ESC
S:0.
97(+
0.20
to+
1.74
)<
.05
Du
rati
onof
beh
avio
rs:
Eye
con
tact
:MT>
Pla
y<
.000
1Tu
rnta
kin
g:M
T>
Pla
y<
.000
1
Pra
ttet
al.,
1995
[37]
EE
Gfr
equ
ency
ban
dac
tivi
ty;s
ever
ity
ofA
DD
/AD
HD
;ada
ptiv
ean
dm
alad
apti
vebe
hav
iou
rs
EE
Gsi
gnal
(A62
0A
sses
smen
tSo
ftw
are)
;M
cCar
ney
Test
(par
ents
);Li
kert
scal
e(p
aren
ts)
Wilc
oxon
sign
ed-r
ank
test
Pre
-pos
tch
ange
inE
EG
pow
erfo
rA
DD
child
ren
:B
and
Act
ivit
yM
usi
cN
om
usi
cB
eta
ban
d−1
.54
−1.2
9N
SA
lph
aba
nd
−2.7
4−3
.49
NS
Th
eta
ban
d−3
.66
−0.7
3N
SM
cCar
ney
Test
NS
Like
rtR
atin
gsN
S
Ric
kson
and
Wat
kin
s,20
03[3
8]A
ggre
ssiv
ebe
hav
iou
rs:d
isru
ptiv
ean
dan
tiso
cial
Dev
elop
men
talB
ehav
iou
rC
hec
klis
t(D
BC
);V
ideo
anal
ysis
Rep
eate
dm
easu
res
AN
OV
A
Mea
nch
ange
for
DB
CSu
bsca
le�
:Te
ach
erPa
ren
tG
rou
p1
(Con
trol
)−1
.00
−6.0
0G
rou
p2
(MT
)−1
.80
−1.8
0N
SG
rou
p3
(MT
l)+
2.83
+1.
00N
SPo
siti
ve&
neg
ativ
eev
ents
:G
rou
p1
vsG
rou
p2
vsG
rou
p3
NS
Evidence-Based Complementary and Alternative Medicine 9
Ta
ble
2:C
onti
nu
ed.
Stu
dyO
utc
ome
Fin
din
gsTr
ial
Mea
sure
Scal
eA
nal
ysis
Res
ult
P-v
alu
e
Ric
kson
,20
06[3
9]
Mot
orim
puls
ivit
ySy
nch
ron
ised
tapp
ing
task
(ST
T);
Con
ner
s’R
atin
gSc
ales
(tea
cher
rate
d)
Un
pair
edt-
test
san
dm
ult
i-w
ayA
NO
VA
Gro
up
(Mea
n#
ofer
rors
):P
rePo
st
(1)
NO
mu
sic
20.1
322
.43
(2)
AB
(Im
prov
/In
stru
ct)
20.9
111
.56
.02
(3)
BA
(In
stru
ct/I
mpr
ov)
20.8
912
.18
.02
Con
ner
’sD
SMIV
Tota
l:G
rou
p1>
(Gro
up
2+
Gro
up
3).0
2C
onn
er’s
Glo
balI
nde
xSc
ale:
Gro
up
1>
(Gro
up
2+
Gro
up
3).0
3St
ress
full
ife
even
ts
Bak
eran
dJo
nes
,20
06[4
0]
Cla
ssro
ombe
hav
iou
rs:e
xter
nal
isin
g,in
tern
alis
ing,
sch
ool,
Beh
avio
ral
Sym
ptom
Inde
x(B
SI),
adap
tive
skill
s
Teac
her
sco
mpl
eted
Beh
avio
ur
Ass
essm
ent
Syst
emfo
rC
hild
ren
(BA
SC)
MA
NC
OV
A
F-st
atis
tic
(df=
21)
for
Trea
tmen
t(m
usi
c/n
om
usi
c)×
tim
e:
Ext
ern
alis
ing:
2.21
.01
Inte
rnal
isin
g:0.
32N
SB
ehav
ior
Sym
ptom
Inde
x:2.
57.0
7Sc
hoo
lpro
blem
s:0.
89N
SA
dapt
ive
skill
s:0.
53N
S
DeL
uci
a-W
aack
and
Gel
lman
,20
07[4
1]
Bel
iefs
abou
tdi
vorc
ean
daff
ecti
vem
easu
res
Rev
ised
Ch
ildre
n’s
Man
ifes
tA
nxi
ety
Scal
e(R
CM
AS)
;Ch
ildre
n’s
Dep
ress
ion
Inve
nto
ry(C
DI)
;Ch
ildre
n’s
Bel
iefs
abou
tPa
ren
talD
ivor
ceSc
ale
(CB
PD
S)
MA
NO
VA
Trea
tmen
t(m
usi
cth
erap
y/ps
ych
oedu
cati
on)
×ti
me:
An
xiet
yD
epre
ssio
nIr
rati
onal
Bel
iefs
F(6
,127
)=
0.48
7N
SF
(10,
123)
=1.
416
NS
F(1
2,11
1)=
0.98
8N
S
Hill
iard
,20
07[4
2]G
rief
sym
ptom
san
dbe
hav
iou
rald
istr
ess
Beh
avio
ur
Rat
ing
Inde
xfo
rC
hild
ren
(BR
IC);
Ber
eave
men
tG
rou
pQ
ues
tion
nai
refo
rPa
ren
ts(B
P)
Wit
hin
-gr
oup
Wilc
oxon
sign
ed-r
anks
test
s
Ch
ange
inB
RIC
:C
ontr
olN
SM
usi
cth
erap
y.0
1So
cial
wor
k.0
4
Ch
ange
inB
P:
Con
trol
NS
Mu
sic
ther
apy
.01
Soci
alw
ork
NS
Moo
ddi
sord
ers
and
rela
ted
psyc
hop
ath
olog
y
Fiel
det
al.,
1998
[43]
Beh
avio
ur;
moo
d;st
ress
;lef
tfr
onta
lac
tiva
tion
1)B
ehav
iou
rO
bser
vati
onSc
ale
(BO
S);
(2)
Dep
ress
ion
Adj
ecti
veC
hec
klis
t(D
AC
L);
(3)
Saliv
ary
Cor
tiso
l;(4
)EE
Gre
cord
ing
Rep
eate
dm
easu
res
MA
NO
VA
and
post
hoc
test
s
Mea
nsc
ores
for
mu
sic
grou
p(c
ontr
olgr
oup)
:B
efor
eD
uri
ng
Aft
er(1
)14
.0(1
5.1)
14.2
(14.
9)14
.7(1
4.8)
NS
(2)
9.5
(8.9
)—
(–)
9.7
(9.1
)N
S(3
)1.
3(1
.5)
—(–
)0.
5(1
.3)
.02
(4)−.1
5(−.
13)
−.07
(−.1
1)−.
08(−
.11)
.05
10 Evidence-Based Complementary and Alternative Medicine
Ta
ble
2:C
onti
nu
ed.
Stu
dyO
utc
ome
Fin
din
gsTr
ial
Mea
sure
Scal
eA
nal
ysis
Res
ult
P-v
alu
e
Woo
ten
,19
92[4
4]
Flu
ctu
atio
ns
inm
ood
Posi
tive
and
Neg
ativ
eA
ffec
tSc
ales
(PA
NA
S)R
epea
ted
mea
sure
sA
NO
VA
Neg
ativ
eaff
ect
Trea
tmen
t(n
one,
rock
orh
eavy
met
al)×
tim
e:F
(2,2
04)=
0.25
,N
S
Posi
tive
affec
tTr
eatm
ent
(non
e,ro
ckor
hea
vym
etal
)×
tim
e:F
(2,2
04)=
1.28
NS
Acu
tean
d/or
chro
nic
phys
ical
illn
ess
Col
wel
let
al.,
2005
[45]
Self
-con
cept
Pie
rs-H
arri
sC
hild
ren’
sSe
lfC
once
ptSc
ale
(PH
CSS
)∗M
AN
CO
VA
Pre
-to
post
-tes
tm
ean
diff
eren
ces:
Mu
sic
com
posi
tion
2.08
Art
com
pos
itio
n2.
00N
S
Rob
bet
al.,
2008
[46]
Freq
uen
cyof
copi
ng
rela
ted
beh
avio
rs
Tim
esa
mpl
ing
ofob
serv
edbe
hav
iou
rs:
Rep
eate
dm
easu
res
AN
OV
Aan
dpo
sth
octe
sts
AM
EM
LA
SB
Posi
tive
faci
alaff
ect
18.6
3(1
3.0)
7.7
(7.5
)2.
0(2
.3)
AM
E>
ML
,A
SB;
<.0
001
Act
ive
enga
gem
ent
26.0
3(4
.1)
15.6
5(6
.2)
15.1
7(4
.9)
AM
E>
ML
,A
SB;
<.0
001
Act
ive
init
iati
on14
.19
(8.3
)15
.89
(11.
2)7.
43(6
.6)
AM
E,
ML>
ASB
;<
.05
Froe
hlic
h,
1984
[47]
Ver
baliz
atio
nof
hos
pita
lexp
erie
nce
sSt
anda
rdiz
edqu
esti
onn
aire
san
dco
din
gsy
stem
tora
tequ
alit
yof
resp
onse
sC
hi-
Squ
are
%of
resp
onse
sco
ded:
Mu
sic
ther
apy
Pla
yth
erap
y
An
swer
90%
62%
<.1
0N
oan
swer
10%
38%
Gra
sso
etal
.,20
00[4
8]
En
joym
ent
and
perc
epti
onof
tim
e7-
poin
tbi
pola
rLi
kert
-typ
eC
hild
∗&
Pare
nt
En
joym
ent
scal
e(p
roxy
)an
dC
areg
iver
Perc
epti
onof
Tim
esu
rvey
Kru
skal
-W
allis
Med
ian
(ran
ge)
grou
pch
ange
for
Ch
ilden
joym
ent:
Trea
tmen
tm
usi
c(T
M)
Fam
iliar
mu
sic
(FM
)N
om
usi
c(N
M)
+1.
25(−
1.0
to+
4.0)
+0.
75(−
3.5
to+
3.0)
−0.5
(−4.
0to
+2.
0)
TM
vsN
M;.0
3FM
vsN
M;N
S
Evidence-Based Complementary and Alternative Medicine 11
Ta
ble
2:C
onti
nu
ed.
Stu
dyO
utc
ome
Fin
din
gsTr
ial
Mea
sure
Scal
eA
nal
ysis
Res
ult
P-v
alu
e
Oel
kers
-Ax
etal
.,20
08[4
9]
Rel
ativ
ere
duct
ion
inh
eada
che
freq
uen
cyC
hild
-ada
pted
daily
hea
dach
edi
ary
%re
duct
ion
from
base
line◦
:B
utt
erbu
r,P
lace
bo,
Mu
sic
Rep
eate
dm
easu
res
Post
-tes
t36.1±
57.3
,28.8±
39.5
,65.7±
31.0
M>
P;.0
05(a
tT
1)an
d.0
18(a
tT
2)
AN
OV
AFo
llow
-up
58.7±
34.6
,31.4±
41.8
,63.2±
33.9
B>
P;N
S(a
tT
1)an
d.0
44(a
tT
2)
N
osi
gnifi
can
teff
ects
repo
rted
for
AD
HD
child
ren
.�
Sim
ilar
fin
din
gsfo
rA
nti
soci
alSu
bsca
le.
∗ On
lych
ild-r
elat
edou
tcom
em
easu
rere
port
edon
.◦ O
nly
data
for
trea
tmen
tco
mpl
eter
sre
port
edon
.
12 Evidence-Based Complementary and Alternative Medicine
(5) blinding of all therapists, (6) blinding of all assessors,(7) participant retention and data collection, (8) intentionto treat analysis, (9) between-group statistical analysis, and(10) sufficiency of statistical reporting [50].
Because of heterogeneity in the study populations,interventions used, and outcome measures applied, it wasneither feasible nor appropriate to conduct a meta-analysis.Therefore, the findings were synthesized in a qualitative man-ner. To facilitate this synthesis, the final studies were groupedinto four broad categories based on the primary diagnoses orconditions of the study participants. “Learning and develop-mental disorders” includes children with autistic spectrumdisorders, attention deficit-hyperactivity disorder, learningdisabilities, and developmental delay. The category “stressfullife events” includes children experiencing losses or traumasuch as bereavement, divorce, or refugee status. A thirdcategory—“mood disorders and related psychopathology”—includes children diagnosed with depression or other psy-chiatric conditions. The final category “acute and/or chronicphysical illness” was reserved for children with physicalillnesses or conditions.
3. Results
3.1. Study Characteristics. Of the 2411 titles identified, 17studies met the inclusion criteria [33–49]; Figure 2 describesthe flow of studies through the selection process. The finalsample comprised 9 parallel (randomization of individuals),2 cluster parallel (randomization of groups of individuals),and 6 crossover RCTs.
Selected trials included a total of 575 participants;approximately 50% were male (1 study did not provide databy gender). Sample sizes ranged from 8 to 134 participantswith a median trial sample size of 22. With the one exceptionof a trial involving participants less than 2 years of age[48], the trials focused heavily on elementary school agechildren [33–36, 41, 42, 46, 47, 49], adolescents [43, 44], or acombination [37–40, 45]. Reflecting the diagnostic range ofparticipants, recruitment settings included the community[37, 49], hospital inpatient units [45–47], outpatient clinics[33, 36, 43, 48], schools [34, 35, 40–42], and residentialeducational [38, 39] and psychiatric [44] facilities.
Outcomes included observed behavior and performance[34–36, 38, 39, 43, 46], physiological signal detection[37, 43], documentation of clinical symptoms and relatedbehaviors [33, 36–40, 42, 49], and participants’ self-reportedperceptions and beliefs [41–45, 47, 48]. Trials employedfrequency counts [34–36, 39, 46, 49], validated question-naires [33, 36–45], and other nonvalidated tools or ratings[36–38, 47, 48] completed by parents, teachers, youth,and/or raters. Although 11 trials involved multiple collectionperiods [33, 35, 36, 39–41, 43, 44, 46, 48, 49], only 2 trialsassessed durability of change beyond the immediate endof treatment; Oelkers-Ax et al. assessed outcomes 8 weekspostintervention [49] and DeLucia-Waack and Gellman, at3 months postintervention [41].
Methodological quality was poor with an overall medianPEDro score of 3 (min = 2, max = 6); classifying the studies,
175 full-text articles assessed
1971 titles excluded
265 abstracts excluded
158 articles excluded
440 abstracts screened for inclusion
2411 titles identified after duplicatesremoved
17 RCT nonprocedural musicintervention studies
Figure 2: Flow of studies through the systematic review process.
9 were of low quality (score≤3) and 8 of moderate quality (4≤ score ≤ 6). Although all reported random allocation, twostudies allocated at the level of the group (i.e., by school orby counselor) [41, 42], one study reported using sequentialassignment tables [46], and two studies did not achievegroup equivalency [33, 38]. Failure to provide adequatedetails of key baseline descriptors [34, 35, 37–39, 44–48] andto undertake appropriate statistical analyses [41, 42] was alsonoted. Dropout was an issue for five studies with final samplesizes less than 85% of the original number allocated to groups[33, 36, 38, 44, 49]; six studies failed to provide sufficientinformation to render this determination [34, 37, 39, 41,43, 46]. Only one study concealed treatment allocation [49],and three studies employed blinding in outcome assessment[33, 35, 46].
3.2. Intervention Characteristics. Study objectives variedgreatly; music was used to influence cognitive functioning[34, 35], improve social skills and the achievement of otherdevelopmental milestones [33, 36], ameliorate coping andaffect [40–48], and reduce physical and physiological symp-toms [37, 43, 49] and maladaptive behaviors and beliefs [36–43]. To determine effectiveness, musical interventions werecompared to no music [33, 37–40, 42, 48], standard clinicalpractice such as psychoeducation, social work, medical play,and pharmacology [41, 42, 47, 49], or other musical andnonmusical therapies or interventions such as free play,verbal rehearsal, art, or self-relaxation [34–36, 43–46, 48].
Seven trials exclusively employed prerecorded music [34,35, 37, 41, 43, 44, 48]. With the exception of DeLucia-Waack and Gellman [41], these particular interventionsinvolved passive listening by participants, guided by theresearcher or health professional. Seven trials employed livemusic consisting of a range of percussion instruments, songs,and rhythm-based activities and promoted active initiation,improvisation, and music creation by participants [33, 36,39, 42, 45, 47, 49]. Three trials employed a combination ofthese presentation modalities [38, 40, 46].
Sessions were offered one-to-one with individual partic-ipants [33–37, 43–49] or to small groups [37–41]. Withinthese sessions, there was great variability in treatment
Evidence-Based Complementary and Alternative Medicine 13
“dosage”, ranging from a single session of 15 to 20 minutesin duration [46] to 30-minute sessions twice daily over 12weeks [48]. Delivery of musical interventions varied but waspredominantly provided by music therapists [33, 36, 38–40, 45, 48, 49], other allied health care professionals (e.g.,social worker) [41, 47], or a combination [42, 46]. In theremaining studies, a researcher provided the intervention[34, 35, 37, 43, 44].
3.3. Qualitative Synthesis: Clinical Diagnosis
3.3.1. Learning and Developmental Disorders. Two trialsinvestigated the influence of music therapy on norma-tive development and cognitive functioning in childrenwith developmental delay [33, 34]. No significant effectof improvisational music therapy on the achievement ofdevelopmental communication-related goals was reported ina moderate quality trial by Aldridge et al. [33]. Claussen andThaut found that exposure to familiar music resulted in asignificantly higher recall accuracy of multiplication tablescompared with verbal rehearsal in a trial of low quality [34].
Two small trials (N = 10) of moderate quality examinedthe effect of music on cognitive functioning and socialbehavior in children with autism [35, 36]. Buday et al.showed that children exposed to recorded music were morelikely to remember and imitate signed and spoken wordscompared with those given rhythm cues. The difference,however, amounted to an average of only one word [35]. Kimet al. examined improvisational music therapy versus playsessions on joint attention behaviors in autistic boys [36]. Alarge and significant effect size was found for the Early SocialCommunication Scales—a structured assessment of individ-ual differences in nonverbal communication skills [54]—driven by positive impacts of music therapy on quality andquantity of eye contact and turn-taking behaviors relativeto gesturing and behaviors indicating intent. No significantdifference was found using the Pervasive DevelopmentalDisorder Behavior Inventory [55]—a pediatric measure ofmaladaptive and adaptive behavior [36].
Impulsivity and related behavioral outcomes were thefocus of three low quality trials involving youth withattention deficit disorders [37–39]. Pratt et al. examined theeffect of neurofeedback training with or without prerecordedbackground classical music on physiological responding,disorder severity, and behavior including impulsivity inchildren with ADHD or ADD; no significant differencesin symptomatology were found [37]. Rickson and Watkinsfound no differences between music therapy (songwriting,instrumental- and rhythm-based activities) and controlgroups on a parent and teacher measure of antisocial anddisruptive behavior among adolescent boys with varieddeficits including ADD and ADHD [38]. In contrast, Ricksonexamined the effects of instructional versus improvisationalmusic therapy on motor impulsivity among adolescent boyswith ADHD and other comorbid disorders. Compared towait-list controls, both types of music therapy (instructionaland improvisational) resulted in a significant increase inaccuracy on a motor task and a significant reduction in theteacher-rated Conner’s Global Index Restless-Impulsive Scale
and the Conner’s DSM-IV Hyperactive-Impulsive Scale [56].No differences were found between the two types of musictherapy [39].
3.3.2. Stressful Life Events. Coping was the focus of threetrials of low to moderate quality involving children whohad experienced a major upheaval in their lives [40–42].Baker and Jones showed that music therapy emphasizingsong writing and singing significantly reduced externalizingbehaviors, such as aggression, hyperactivity, and conductissues among newly arrived immigrant and refugee youthas compared to a control group. No significant differences,however, were found for measures of internalizing behaviors,school problems, or adaptive skills [40]. DeLucia-Waackand Gellman reported no significant effects of a song-basedmusic intervention with respect to anxiety, depression, orirrational beliefs compared to traditional psychoeducationalapproaches in a large trial of 134 children experiencingparental divorce [41]. Positive effects were reported byHilliard in a comparison of music therapy (songs and instru-ments) and social work (art and play therapy) approachesto deliver a standardized grief-based curriculum. Whileboth groups experienced a significant decrease in behavioraldistress, only the music therapy group experienced a decreasein grief symptoms [42].
3.3.3. Mood and Related Psychopathology. Two low qualitytrials involving adolescents with mood and related affectivedisorders produced unclear findings [43, 44]. Field et al.examined the effect of popular music on the mood of chron-ically depressed female adolescents. Relative to a controlgroup, the music group showed a significant decrease insalivary cortisol and EEG activity; however, and of moreclinical significance, no differences in observed affectivebehavior or self-reported mood were found [43]. Similarly,no main effects of popular music (heavy metal versus rock)on self-reported affect using the Positive and Negative AffectSchedule (a measurement of fluctuations in mood) [57] werereported by Wooten [44].
3.3.4. Acute and/or Chronic Physical Illness. Three low tomoderate quality trials examined the effects of music therapyon coping among hospitalized children [45–47]; two trialsfocused primarily on children with cancer [45, 46]. A com-parison of the effects of creating visual art and composingelectronic music by Colwell et al. found no significantdifference between the groups on self-concept from pre-to post-test [45]. In contrast, Robb et al. examined theeffect of active music engagement (AME) consisting of songsand instrumental activities on observable coping-relatedbehaviors compared to listening to recorded children’s music(ML) or the use of recorded audio storybooks (ASB). OnlyAME resulted in significant increases in positive facial affectand active engagement; however, both AME and ML ledto higher rates of initiation (a measure of a child’s envi-ronmental exploration and interaction) as compared withASB [46]. Positive effects were also reported by Froehlichamong children with varied diagnoses. Significantly moreverbalizations about the experience of being hospitalized
14 Evidence-Based Complementary and Alternative Medicine
were made during music therapy than during play therapy[47].
Grasso et al. examined the effects of “treatment” music(specially composed by a music therapist) or familiarchildren’s music compared with no music on child andparent experiences of chest physiotherapy in infants andtoddlers with cystic fibrosis. This moderate quality trialfound treatment music resulted in a significantly morepositive experience for parents and children as compared tofamiliar music or no music. Neither type of music changedparents’ perceptions of time taken to complete therapy [48].
Last, symptomatology was the focus of a trial of moderatequality by Oelkers-Ax et al. comparing the effect of individu-alized music therapy emphasizing relaxation and techniquesfor coping with pain, butterbur root extract, or a placeboin combination with education and symptomatic pain treat-ment on the frequency and severity of migraine headaches.Relative to the placebo, both interventions reduced migrainefrequency over an extended period. Music therapy, however,had a more immediate and lasting impact compared tothe pharmacological approach, with significant reductionsin migraine frequency posttreatment and on follow-up[49].
3.4. Qualitative Synthesis: Outcome
3.4.1. Cognitive Functioning. Two trials with low to moderatequality PEDro scores targeted cognitive functioning andreported improvements in recall accuracy of multiplicationtables [34], signs, and spoken words [35] following passiveexposure to recorded music.
3.4.2. Social Skills and Other Developmental Milestones. Twotrials with similar moderate PEDro scores examined theacquisition of social skills and achievement of developmen-tal milestones using standardized assessments of observedbehavior following music therapy [33, 36]. No evidencesupporting change in social behavior, communication,and other developmental milestones as assessed by theGriffiths Scale [58] and by the Pervasive DevelopmentalDisorder Behavior Inventory [55] is found [33, 36]. Asignificant improvement in nonverbal communication onthe Early Social Communication Scales [54] was reported[36].
3.4.3. Coping and Affect. Coping and affect were the focus ofnine trials [40–48]. No significant differences in affect usingself-report or observed affect and behavior were found intwo low quality trials involving passive listening to rock andother types of popular music [43, 44]. In contrast, two musictherapy trials with low to moderate PEDro scores yieldedpositive effects of observed affect, frequency of engagementand initiation [46], and verbalizations [47]. Listening to aspecially recorded “treatment” music composition also hada positive effect on parental reports of children’s experienceof cystic fibrosis chest treatments (PEDro score = 5) [48].However self-created music compositions did not improvescores on the Piers-Harris Children’s Self Concept Scale [59](PEDro score = 3) [45].
Differential findings were evident for three low tomoderate quality trials assessing internalizing and exter-nalizing behaviors using standardized measures [40–42].Significant effects of song- and instrumental-based activitieson externalizing behaviors using the Behavior AssessmentSystem for Children [60] (a teacher report of classroom andplayground behaviors) and the Behavior Rating Index forChildren [61] (a parental report of behavior problems) werereported for both music therapy trials [40, 42]. Although asignificant difference in frequency of internalizing behaviors(e.g., anxiety, depression, and beliefs) was found using theBereavement Group Questionnaire for Parents [42, 62], nodifferences were found using the teacher rated BehaviorAssessment System for Children [40, 60]. The music inter-vention (song-based activities) also reported no differencesin internalizing behaviors using three self-report measures:the Children’s Beliefs about Parental Divorce Scale [63],the Revised Children’s Manifest Anxiety Scale [64], and theChildren’s Depression Inventory [41, 65].
3.4.4. Symptomatology. Five trials targeted frequency ofsymptoms related to clinical diagnoses with varied success[36–39, 49]. In a study with a moderate PEDro score of 6,significant reductions in migraine frequency were reportedvia a self-report diary following music therapy [49]. Four lowto moderate quality studies examined the effects of musicon impulsivity and related behavioral symptoms [36–39].Improvements in accuracy in a tapping task and teacherratings on Conner’s Global Index and DSM-IV subscales[56] were found as a measure of reduced impulsivityfollowing song- and instrumental-based music therapy [39].In contrast, no changes in disorder severity and relatedbehaviors (maladaptive or antisocial and disruptive) usingparental and/or self-report measures were found followingexposure to classical music [37] or varied music therapyactivities [36, 38].
3.4.5. Physiological Measures. Two trials with similar lowPEDro scores examined change in affective patterns of EEGresponding following passive listening to recorded music[37, 43]. No significant changes were reported by Pratt et al.[37]. In contrast, Field reported significant differences inEEG patterns accompanied by decreased levels of salivarycortisol; the clinical significance of these changes is not clear[43].
3.5. Qualitative Synthesis: Other Comparisons. No clearinfluence of participant involvement (active versus passive)or dosage (length of exposure in minutes) was identifiedamong the treatment effects. Interventions led by a musictherapist were more likely to yield significant effects thaninterventions led by a health professional or researcher.
4. Discussion
4.1. Summary of Findings. Over a 25-year period, 17 RCTsexamining the effectiveness of music on health-relatedoutcomes in children were identified. While methodologicallimitations and clinical heterogeneity preclude drawing
Evidence-Based Complementary and Alternative Medicine 15
firm conclusions, a qualitative synthesis of findings suggestsome effectiveness of music as an intervention in pediatrichealthcare. Reviewing findings as a function of diagnosticcategory, treatment effects were mixed for children withlearning and developmental disorders [33–39]. For example,significant effects were reported for both studies involvingchildren with autism [35, 36], one of two studies involvingchildren with learning or developmental delays [34], and oneof three studies involving children with ADD or ADHD [39].More promising trends were noted for children experiencingstressful life events [40, 41] and for children with acuteand/or chronic physical illness [45–49], with positive effectsin two of three trials [40, 42], and four of five trials [46–49],respectively. No evidence was found among adolescents withmood disorders and other psychopathology [43, 44].
Turning to clinical outcomes, exposure to music pos-itively affected cognitive functioning and was associatedwith higher recall accuracy [34, 35]. Clinical symptomswere also improved with significant reductions in migrainefrequency [49] and motor impulsivity [39]. As to physi-ological proxies for clinical outcomes, decreased levels ofsalivary cortisol were found [43] but changes in affectiveEEG patterns were inconsistent [37, 43] with one of twostudies reporting a significant effect [43]. No other changeswere found in direct or proxy measures of the severity of theclinical disorders studied [36–38]. With respect to coping,music had a significant impact with demonstrated increasesin coping behaviors [46–48] and reduced frequencies ofbehavior problems associated with grief and distress [40, 42].However, the effects of music on internalized symptomsrelated to coping were unclear [40–42, 45]; only one ofthree studies reported a significant improvement in grief-related symptoms [42], and there was no significant impacton self-concept [45]. Similarly, the impact of music onclinical affect was also unclear [43, 44, 46], with one of twotrials reporting improvements in observed affect [46], butno effects noted when changes in affect were self-reported[43, 44]. Finally, inconsistent findings were reported forsocial behaviors and developmental achievements [33, 36]with one of two trials reporting significant improvements innonverbal communication [36].
Although previous papers have explored the influenceof intervention characteristics [4, 7, 14, 66] and noteddifferential effects of participant involvement [14], delivery[14], and type of music [4], no clear trends were discerniblein the current review. Consistent with Dileo’s finding ofgreater effects for music therapy [66], significant resultswere reported more often for trials employing the systematicuse of music with a trained music therapist than for trialsemploying no music therapist. In the absence of a meta-analysis, however, the size of these treatment effects cannotbe established.
4.2. Strengths and Limitations. To address the limitations ofprevious systematic papers [12, 14, 16, 18], we undertookan international search following the strict guidelines ofthe PRISMA reporting statement [30, 31] and guided by aresearch librarian. The search was not limited by language,
clinical diagnosis, or outcome, and it focused solely onRCTs—the gold standard of experimental design. Qualitywas ascertained using the PEDro rating system [50] which iswell-suited to assess studies evaluating clinical interventions[51–53]. Despite efforts to enhance generalizability throughbroad definitions of musical interventions and health (whichincluded social, physical, and mental well-being), the finalsample comprised a narrow range of diagnostic conditions.
Within this sample, variation in outcomes and/or out-come measures precluded formal aggregation of the resultsand completion of a meta-analysis—thereby limiting defini-tive conclusions of the effectiveness of musical interventions.Despite the systematic design of this paper, the exclusivefocus on published trials does raise the risk of a publi-cation bias and overestimation of treatment effects [67];previous meta-analyses, however, have failed to find suchevidence [12, 18]. Of greater concern is the relatively weakmethodological quality of the trials included as based onthe PEDro scores; the highest score obtained was 6 out of10 [35, 40, 49]. Very few trials provided detailed accountsof methods of randomization and allocation; significantbaseline differences were noted between comparison groupsin two trials [33, 38]. Quality of statistical analysis andreporting were also poor; for example, both DeLucia-Waackand Gellman, and Hilliard failed to account for clustering intheir statistical analyses [41, 42].
The issue of methodological quality has been raisedrepeatedly in both the pediatric and adult literature aroundmusic therapy. It is, however, but one of the issues impedingmeta-analytic synthesis of the music literature. Of perhapsequal concern is the lack of standardization of interventions,including both music therapy and musical interventions,and appropriate controls. Further limiting the task is theextensive outcome and measurement heterogeneity withinand across diagnostic groups [5, 9, 12, 13, 15, 17, 19–21].
4.3. Future Directions. Collectively, these factors restrict thecollection of definitive data on the effectiveness of musicin pediatric healthcare. The issue is not simply a lack ofresearch but rather a lack of high quality research. Asother authors have noted, the field would benefit from astrict adherence to methodological quality [5, 7, 12, 51–53],transparent reporting and use of published guidelines (e.g.,CONSORT Statement) [68–72], and consensus on researchpriorities [73–75]. Priority issues are larger sample sizes,standardized interventions, consistent outcome measures,simpler (parallel-group) designs, and high quality execution.Many of the studies identified involved complex cross-over designs, multiple interventions with multiple outcomemeasures, and small sample sizes putting them at higherrisk for methodological errors and uncertainty around thestatistical power of the comparisons. In addition, clinicallyrelevant validated outcome measures are required, and theseoutcomes need to be measured over time to establishdurability of change; none of the studies included long-termfollow-up assessments. In the absence of methodologicalrigor, the literature will remain heterogeneous and the
16 Evidence-Based Complementary and Alternative Medicine
opportunity to define the evidence supporting (or not) theeffectiveness of music therapy will be lost.
5. Conclusion
This paper is the first systematic review to examine theeffectiveness of music among varied pediatric conditions andsettings. The findings offer limited qualitative evidence tosupport the effectiveness of music for children with learningand development disorders and acute and/or chronic physi-cal illness, and children experiencing stressful life events. Noevidence to support the effectiveness of music for childrenwith mood disorders and related psychopathology wasfound. From a health outcomes perspective, music may beused to enhance cognitive abilities [34, 35], facilitate verbal[47] and nonverbal communication [36], and influencephysiology [43]. The emotive qualities of music may reducethe effects of trauma and facilitate coping strategies fordifficult environments [40, 42, 46–48]. Music may alsoreduce symptomatology, such as maladaptive behaviors [39,40, 42] and migraine frequency [49]. Current understandingof the potential benefits of music in pediatric healthcare iscompromised, however, by methodological limitations.
Funding
No funding was received for this project.
Acknowledgment
The authors would like to thank Pui Ying Wong for herassistance with the literature search. K. Treurnicht Naylorand S. Kingsnorth have contributed equally to this work.
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