M us ic Ther ap y an d M u si c

M e d i c i n e f o r C h i l d re n an d
Adolescents
Olivia Swedberg Yinger, PhD, MT-BC*, Lori Gooding, PhD, MT-BC

KEYWORDS
 Music therapy  Music medicine  Child and adolescent psychiatry  Mental health
 Research

KEY POINTS
 Neuroimaging research indicates that listening to preferred music activates reward cir-
cuitry in the brain and active musical participation engages more areas of the brain
than passive listening.
 Music therapy is an established health care profession in which music is used within a
therapeutic relationship with a music therapist to accomplish nonmusic goals.
 Emerging research indicates probable effectiveness of specific approaches to music ther-
apy with children and adolescent mental health consumers; however, further research is
necessary.

INTRODUCTION
Defining Music Therapy and Music Medicine
The American Music Therapy Association (AMTA) defines music therapy as: .the
clinical and evidence-based use of music interventions to accomplish individualized
goals within a therapeutic relationship by a credentialed professional who has
completed an approved music therapy program.1 Music therapists use music within
a therapeutic relationship to attend to individuals physical, emotional, cognitive, and
social needs. Although music therapists work with various populations, including indi-
viduals of all ages with medical/surgical needs or intellectual disabilities, more music
therapists work with persons who have behavioral/emotional disorders than any other
single population.2

Funding Sources: Johnson & Johnson/Society for the Arts in HealthCare (O.S. Yinger); National
Institute of Aging (L. Gooding).
Conflict of Interest: None.
University of Kentucky School of Music, College of Fine Arts, 105 Fine Arts, Lexington, KY
40506-0022, USA
* Corresponding author.
E-mail address: [email protected]

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2 Yinger & Gooding

Music therapists must complete either a 4-year undergraduate program or a 2-year

graduate equivalency program in music therapy at an AMTA-approved college or
university. Music therapy degree programs include course work in musical founda-
tions, clinical foundations, and music therapy foundations and principles, as specified
in the AMTA Professional Competencies. In addition to course work, music therapy
degree programs include 1200 hours of clinical training, culminating in a supervised
internship, which typically lasts for 6 months. After completing an AMTA-approved de-
gree program, prospective music therapists are eligible to take the national board cer-
tification examination to earn the credential Music Therapist-Board Certified (MT-BC).
The MT-BC credential is granted by the Certification Board for Music Therapists
(CBMT), a separate, accredited organization.3 After becoming board certified, training
in advanced music therapy competencies is offered through mandatory continuing
education courses, with the option for training at the masters and doctorate level. Mu-
sic medicine, which constitutes the bulk of the literature on the use of music to accom-
plish nonmusic objectives, is defined as passive listening to prerecorded music
provided by medical personnel.4,5 In music medicine treatment, listening interventions
are often administered via headphones, and patients may or may not be involved in
selecting the music.5 Although music-based interventions are used in both music
medicine and music therapy, it is important to understand the difference between
the 2, because of variations in the level of training in musical foundations and their
therapeutic applications, with music therapists receiving specialized training in these
domains.5 Although training and certification are required to practice music therapy,
no such specialized training and certification exists for the practice of music medicine.

Mechanism of Therapeutic Action: Music and the Brain

To understand the reasons behind the effectiveness of music in augmenting treatment
of children and adolescents receiving psychiatric treatment, it is important to first
understand the effects of music on the brain. Recent research on the effects of music
on cognition, emotional processing, anxiety, and stress has shed light on how music
therapy can enhance mental health treatment. There is no single center for musical
processing in the brain. Music listening engages multiple areas of the brain, both
subcortical (including the medial geniculate body in the thalamus and the amygdala)
and cortical (such as the left and right primary auditory cortex). Musical participation
also engages the cerebellum, basal ganglia, and cortical motor area.6,7
The fact that active musical participation engages more areas of the brain than
passive music listening may explain in part why numerous studies have shown music
therapy to be more effective than music medicine at augmenting treatment of neuro-
psychiatric disorders.7 It seems that active musical participation or engagement with
the therapist are integral in the success of music therapy, in addition to the music itself.
The effectiveness of music therapy is in part caused by the effects of music on the
brain, and in part by the interaction between the client and the music therapist.
Stefan Koelsch8 provided an overview of ways in which music modulates attention,
emotion, cognition, behavior, and communication. Readers wishing to learn in greater
detail about the effects of music, and specifically music therapy, on the brain are
referred to the works of Koelsch, Lin, and Taylor, among others.68
Neuroimaging techniques are helping researchers understand ways in which music
listening and participation affect neural plasticity.68 Recent neuroimaging studies
have shed light on the activation of the reward circuit in the brain and the role that
dopamine plays in musical response. In a study by Blood and Zatorre,9 in which
participants listened to self-selected music that gave them chills while undergoing
positron emission tomography (PET) scans, increases in cerebral blood flow were
 Music Therapy for Children and Adolescents 3

observed in the left ventral striatum, left dorsomedial midbrain, right thalamus, and
anterior cingulate cortex. In addition, decreases in cerebral blood flow were found
in the right amygdala, left hippocampus/amygdala, and ventromedial prefrontal cor-
tex. These areas have been associated with brain reward circuitry. Chills were also
associated with increases in heart rate, electromyography, and respiration. The con-
trol condition in this study consisted of participants listening to music that had been
selected by others but that did not elicit chills in the participant. This study shows
the importance of musical preference in eliciting desired results within music medicine
or music therapy.9
Results from a study by Menon and Levitin10 of 13 participants between the ages of
19 and 24 years, who listened to researcher-selected classical music while under-
going functional magnetic resonance imaging (fMRI), showed that listening to music
strongly modulates activity in mesolimbic structures responsible for reward process-
ing, such as the nucleus accumbens (NAc) and the ventral tegmental area (VTA), along
with the hypothalamus and insula. Correlations between responses in the NAc and the
VTA found in this study indicate that dopamine response may be associated with
musical response. The activation of the hypothalamus corroborates what has been
previously documented, that music listening has an impact on physiologic responses
controlled by the autonomic nervous system. Although the music used in this study
was not selected by participants and it is unclear whether it gave them chills, the
musical excerpts were rated as highly pleasant by a sample of similar individuals.
Results from a more recent study by Salimpoor and colleagues11 support the
findings of Menon and Levitin. In Salimpoor and colleagues11 study, 8 participants be-
tween the ages of 19 and 24 years listened to self-selected music that gave them chills
while undergoing PET scans. Endogenous dopamine release was found in the striatum
during music listening at the time of peak emotional arousal. Follow-up fMRI revealed
that the caudate was more involved during anticipation, whereas the NAc was more
involved during peak emotional arousal. Physiologic responses measured during mu-
sic listening showed a relationship between increases in heart rate, skin conductance,
and respiration, along with decreases in temperature and blood volume pulse ampli-
tude as the reported intensity of chills increased. Research showing the role of music
listening in activating the reward circuitry in the brain has important implications for
treatment of addictions, although more research remains to be done in this area.
Because music activates reward circuitry in the brain that is also activated by food,
drugs, and sex, future research should explore whether music can be used as a sub-
stitute for potentially harmful addictive behavior, or as a cue for adaptive coping
behavior as an alternative to addictive behavior.
In addition to addiction, music neuroscience research has implications for psychiat-
ric treatment with other various disorders, including disorders typically diagnosed in
childhood (such as autism), affective disorders, and eating disorders. Research on
the neurophysiologic effects of music for each of these populations are discussed.
Diagnostic terminology used in this article reflects that used by the investigators of
the individual studies reported, which may be based on the Diagnostic and Statistical
manual of Mental Disorders, Third Edition (DSM-III), DSM-IV, or DSM-IV Text Revision,
depending on when and where the article was published. Readers wishing to know
more about diagnostic criteria for participants in the studies reviewed are referred
to the original articles. Although awareness of a clients diagnosis is an important
component of music therapy research and guides treatment planning, music therapy
treatment is designed based on the individual needs of the client, regardless of their
diagnosis. For this reason, several studies reviewed here include descriptions of music
therapy treatment of groups of clients with various diagnoses that have similar needs.
4 Yinger & Gooding

Autism
A recent study by Emanuele and colleagues12 compared dopamine receptor expression
in peripheral blood lymphocytes in adult healthy musicians with age-matched and
gender-matched nonmusicians (controls) and adults with autism spectrum disorders
(ASD). Significant differences in DRD4 mRNA expression were found between the con-
trol group and both experimental groups (musicians and adults with ASD; P<.05). No
significant differences in DRD4 mRNA levels were found between musicians and adults
with ASD, nor were any significant differences found between groups in DRD3 mRNA
levels (P>.05).12 The finding that adults with ASD were similar to musicians in their levels
of DRD4 mRNA may help explain the pronounced interest in music that many individuals
with ASD display and provides a rationale for further research into the use of music ther-
apy with this population. Wan and colleagues13 proposed that music may serve as an
effective treatment of social communication in individuals with ASD by activating the
mirror neuron system, although more research in this area remains to be done.
Affective disorders
In a study by Field and colleagues,14 28 depressed adolescent females showed
increased activation of the right frontal lobe (a characteristic of chronic depression)
during pretest electroencephalography (EEG). Fourteen participants were randomly
assigned to listen to upbeat rock music while undergoing EEG. The other 14 partici-
pants served as a control group and were asked to relax their minds and their muscles
for the same period of time that the treatment group listened to music. The treatment
group showed significantly decreased right frontal lobe activation and increased left
frontal lobe activation during and after listening to the music (P<.05), both of which
are more typical of those without depression. The treatment group also showed signif-
icantly decreased salivary cortisol after listening to rock music (P 5 .02), although their
observed and reported mood did not change significantly (P>.05). The control group
did not show significant changes on any of the measures. The 3 participants in the
treatment group whose EEGs showed frontal lobe shifts further to the right while
listening to rock music reported preferring classical music over rock. When these 3
participants were tested again while listening to classical music, they showed frontal
lobe shifts to the left. This study shows the importance of considering preference when
designing music interventions.14
Koelsch and colleagues15 speculated that changes in anterior hippocampal activity
induced by music listening are relevant for individuals with depression or posttrau-
matic stress disorder, who show reduced hippocampal volume. In their 2010 study,
Koelsch and colleagues15 showed that participants who participated in socially
directed music-making showed improvements in mood compared with control partic-
ipants, who maintained a steady beat but lacked both the rich musical experience and
the social experience within the study condition. The results of the study by Koelsch
and colleagues may indicate the role of dopamine in socially directed music-
making. In animal research, zebra finches showed significant increases in dopamine
after socially directed singing compared with no singing or singing that was not
directed at another finch (P<.05).16 Although further research is necessary examining
the role of dopamine in socially directed music-making in humans, current findings
generally support the use of group music therapy over individual music therapy
when treating individuals with affective disorders. Information regarding group music
therapy is highlighted in relation to specific disorders later in the text.
Eating disorders
In a study by Uher and colleagues,17 women with eating disorders and healthy con-
trols were asked to rate line drawings of underweight, normal weight, and overweight.
 Music Therapy for Children and Adolescents 5

Women with eating disorders showed weaker responses in the lateral fusiform gyrus
and the parietal cortex (measured by fMRI) when compared with healthy controls while
viewing line drawings of underweight, normal weight, and overweight female bodies.
Activity in the right medial apical prefrontal cortex was positively correlated with rat-
ings of fear and disgust reported by the participants with eating disorders.17 Because
decreases in ventromedial prefrontal cortex activity have been noted when partici-
pants listen to preferred music that gives them chills, further research regarding the
effectiveness of music therapy in treating eating disorders is warranted, as is research
into the therapeutic mechanism of music specific to treating this population.9
Although more neuroimaging research studying children and adolescents with spe-
cific psychopathologies is warranted, the current research suggests that the ability of
certain preferred music to activated neural reward circuits supports the use of music
therapy in mental health care. Box 1 summarizes important considerations when using
music in music therapy or music medicine, based on current neuroimaging research.

Music Therapy and Mental Health Overview

Approximately 20% of music therapists report working in mental health settings; this
number represents the single largest specific client population category in music
therapy.18 Individual music therapists may approach treatment from different psycho-
logical orientations, including cognitive-behavioral, behavioral, humanistic, or psycho-
dynamic. For a more thorough description of different approaches to music therapy
treatment, readers are referred to the text by Darrow.19 According to a survey con-
ducted by Silverman,18 many psychiatric music therapists use behavioral techniques
with mental health consumers, most psychiatric music therapists use cognitive-
behavioral or psychodynamic approaches, and most psychiatric music therapists
believe that the cognitive-behavioral approach will be most used in the future.20 Com-
mon goal areas included socialization, communication, self-esteem, coping skills, and
stress management/reduction. Commonly used music-based interventions include
music-assisted relaxation, improvisation, songwriting, lyric analysis, and movement
to music. These music interventions are often paired with common psychotherapeutic
techniques, including humor, redirection, reinforcement, empathy, and affirmation.18
Table 1 categorizes the effectiveness of music therapy approaches with children
and adolescent mental health consumers, based on current research.
The research literature suggests that group work is the predominant delivery model
for music therapy in mental health settings, that music therapy can be effectively incor-
porated in both inpatient and community-based settings, and that group work is effec-
tive in promoting group cohesion, interaction, and emotional expression.18,5659 In
terms of treatment duration, slight improvements can be seen with a few sessions
(310), but larger gains are found with more frequent sessions or longer courses of
music therapy.58

Box 1
Summary of recommendations based on music neuroscience research

 Musical preference is an important consideration when designing music therapy or music

medicine interventions
 Active musical participation engages more areas of the brain than passive music listening and
enhances mood to a greater degree
 The social aspect of making music in a group enhances mood to a greater degree than
individual music-making
 6
Table 1
Evidence-based treatment evaluations
Intellectual/
Emotional/ Develop- Various Basis in Youth
Treatment/ Aggressive Bereave- Eating Behavioral mental Juvenile Substance Psychopa- (Best Available
Approach Abuse/Trauma ADHD Behavior At-Risk Autism ment Disorders Disorders Disabilities Delinquents Abuse thologiesa Data)
b
Active music Fair/ Fair/ Fair/ Fair/ Fair/rec.25 Fair/rec.2628 Fair/rec.29 Fair/rec.30 Randomized
therapy insufficient21 insufficient22 rec.23 rec.24 controlled
(no psycho- study
therapeutic Controlled
approach clinical trial
given) Case study
Qualitative case
study
Cognitive- Fair/ Fair/rec.3234 Fair/rec.35 Fair/rec.36 Fair/rec.37 Controlled
behavioral rec.31 clinical trial
music therapy Case study
Eclectic music Fair/ Fair/ Fair/ Fair/rec.42 Fair/rec.43 Fair/ Meta-analysis
therapy rec.38 rec.3840 no data41 rec.30,38,44,45 Systematic review
Content analysis
Controlled
clinical trial
Case study
Humanistic Fair/ Fair/rec.47 Fair/ Fair Fair Fair/rec.38,52 Meta-analysis
music therapy rec.46 rec.48 /no data49 /insufficient50,51 Controlled clinical
(creative/ trialcase study
Nordoff- Outcomes
Robbins; Orff; research
improvisa- Pilot study
tional)
Passive music Fair/ Fair/rec.54 Controlled clinical
therapy rec.53 trial
(music
listening)
Psychodynamic Fair/ Case study
music therapy insufficient55
(analytical)

Abbreviation: Rec, recommend.

a
Studies placed under the heading of Various psychopathologies consisted of subjects with differing diagnoses. Only clinical studies were included.
b
Blank cells indicate no data.
 Music Therapy for Children and Adolescents 7

Music therapists work with individuals of all age groups and with a wide range of
diagnoses, including children and adolescents with attention deficit/hyperactivity dis-
order (ADHD), posttraumatic stress disorder (PTSD), developmental delays/learning
difficulties, and anxiety disorders, patients with chronic mental illness, adults with sub-
stance abuse disorders and chemical dependence, victims of intimate partner
violence, and couples in counseling.37,46,47,57,6065 Music therapists work in a variety
of settings, including inpatient (acute and chronic), outpatient, and community
venues.37,61,62,65,66 Music therapists are often asked to work in situations in which
psychopharmacologic treatments have shown limited success. These situations
include working with individuals who present with negative symptoms, poor social
interactions, low motivation, and flattened or blunted affect.58,67 Referrals are often
made for patients with low motivation, and music therapy has been consistently
shown to be effective with individuals considered to be poor candidates for verbal
group therapies. Research suggests that this situation is in part caused by the ac-
tivation of basic perceptual and arousal mechanisms, which are associated with
an emotional response from individuals. The therapist can then use this affective-
motivational nature of music57(p69) to guide therapeutic change or behavioral
change.57,6769
Music therapy can facilitate symptom management and allow individuals to ex-
press feelings related to their experiences.68 Research increasingly shows its ef-
fectiveness in several areas of mental health treatment, including increased
participation, improved compliance, increased motivation during treatment, and
improved attendance (A Davis, unpublished masters thesis, State University of
New York at New Paltz, 2008).58,61,68 It has even been found to reduce symptoms,
increase competencies, and improve quality of life.44 Patients themselves often
have a positive response to music therapy. When surveyed, inpatients valued the
use of music therapy and found it helpful in improving aspects of psychiatric deficit
areas.59,62,70 Music therapy has been rated as more pleasurable than other forms of
treatment, and has been viewed by participants as an effective tool for recovery
(A Davis, unpublished masters thesis, State University of New York at New Paltz,
2008).71
Studies can be found involving music therapy treatment with a wide range of disor-
ders usually first diagnosed in childhood (including behavior disorders, ADHD, intellec-
tual disabilities, learning disabilities, and autism), as well as chemical dependence/
substance abuse, mood/anxiety disorders, and eating disorders. The next section
provides an overview of research on music therapy for children and adolescents
with mental health needs.

Effectiveness Research
Disorders typically diagnosed in childhood
According to a meta-analysis conducted by Gold and colleagues,38 music therapy has
a medium to large positive effect (d 5 .61, P<.001) on clinically relevant outcomes, and
children and adolescents with behavioral disorders, developmental disorders, and
multiple psychopathologies may benefit from music therapy. Specific goal areas for
individuals with childhood disorders are also addressed in the research literature,
including the effect of music therapy on attention and hyperactivity symptoms, the
impact of music therapy on self-esteem, and the impact of music therapy on self-
expression.22,30,33,38,50,53,72 Additional areas studied include the impact of music ther-
apy on social skills development, the effect of music therapy on aggressive behaviors,
and the effectiveness of music therapy in improving symptoms and quality of
life.22,26,32,37,52
8 Yinger & Gooding

Results from the literature have shown music therapy to be effective with a wide
variety of childhood diagnoses in22,23,26,28,30,32,37,50,52,53:
1. Reducing aggression and hostility
2. Reducing motor activities and increasing on-task behavior
3. Improving social functioning
4. Increasing attention and motivation
5. Improving self-concept
6. Improving symptoms and quality of life
The results of several key studies in this area are summarized here.

Aggressive behaviors
Choi and colleagues22 studied the effects of group music intervention on aggression
and self-esteem in children with highly aggressive behavior using a pretest/posttest
control group design. Significant differences were found between posttreatment
groups in scores of aggression (P<.001) and self-esteem (P<.05). A study by Montello
and Coons30 found that preadolescents with emotional, learning, and behavioral dis-
orders who received passive music therapy for 12 weeks followed by active music
therapy for 12 weeks showed significant improvements in attention, motivation, and
hostility (all P<.024). Participants who received active music therapy followed by
passive music therapy showed an initial increase in hostility (P<.05) during the active
music therapy phase, followed by a significant decrease in hostility during the passive
music therapy phase (P<.05). Because the groups in this study were made up of
preadolescents with diverse needs, the results indicate that the type of music therapy
treatment should be tailored to the individual needs of the clients.

ADHD
Cripe53 used a repeated measures factorial design to study the effects of rock music
on 8 males between the ages of 6 and 8 years with attention deficit disorder (the diag-
nostic terminology used at the time; most likely from DSM-III). Although no significant
changes in attention span were observed, participants showed significant reductions
in the number of motor activities performed during the music periods of the study
(P<.05). Gooding37 studied the effects of a music therapy-based social skills interven-
tion program on social competence of children and adolescents with a variety of diag-
noses including ADHD (using the DSM-IV definition) through 3 experiments with
participants in school, residential, and after-school care settings. Results indicated
significant improvements in on-task behavior in all 3 settings after 5 sessions, as
measured by behavioral observations (P<.05). Participants from all 3 settings also
showed improvements in social functioning as measured by either self-report or the
report of the researcher or a case manager (P<.05).

General emotional and behavioral disorders

Chong and Kim26 investigated the effects of an after-school education-oriented music
therapy (EoMT) program on students emotional and behavioral problems and
academic competency. A paired-samples t-test revealed that students showed signif-
icant improvements between pretest and posttest in 3 areas of social skills (assertive-
ness, self-control, and cooperation; all P<.0001) and problem behavior (P 5 .004), but
not in academic competency (P>.05). Johnson35 studied the effects of incorporating
objective and concrete evidence of goal achievement within music-related activities
for residents of a juvenile detention center. Participants were randomly assigned to
either a treatment group that received the above treatment, or a control group that
participated in subjective music-related activities with no reinforcement. Participants
 Music Therapy for Children and Adolescents 9

in the treatment group showed significant improvements in self-concept (P<.025)

relative to the control group, and perceived significantly fewer rebellious and distrust-
ful traits in themselves (P<.05).
A pilot study by Gold and colleagues52 described the music therapy treatment given
to 5 children between the ages of 4 and 11 years with mental and behavioral problems.
Children who received music therapy treatment (431 sessions over the course of
25 months) showed improvements in symptoms, competencies, and quality of life,
although the small sample size precluded the use of statistical analyses. Taken as a
whole, the results of the aforementioned studies suggest that music therapy can be
a valuable medium in treating children and adolescents with mental health needs.

Autism
Research on music therapy for children with autism has received much attention from
music therapy researchers in recent years.24,40,7377 In 2011, Reschke-Hernandez77
published a historical review of music therapy treatments from 1940 to 2009 for
children with autism, which indicated that although research in this area has improved,
there is a need for more high-quality studies. Although it included few studies, a meta-
analysis conducted by Whipple40 suggests that music therapy is an effective treat-
ment of children and adolescents with autism, with an overall effect size of d 5 .77.
Outcomes of music therapy treatment of children with autism included improvements
in social behaviors, communication, and cognitive skills. Five of the 10 studies
included in Whipples meta-analysis were conducted by music therapists, whereas
the other 5 were conducted by occupational therapists, educators, or psychologists
using music medicine techniques. Two studies used a group treatment approach,
whereas the remaining 8 provided individual treatment. Four studies used a develop-
mental social pragmatic approach; 4 studies used a discrete trial-traditional behav-
ioral approach, and 2 studies used a contemporary applied behavioral analysis
approach. In this meta-analysis, all 3 approaches (developmental social pragmatic,
discrete trial-traditional behavioral, and contemporary applied behavioral analysis)
were found to be equally effective when incorporating music therapy treatment.40
Regardless of the positive outcomes noted in Whipples meta-analysis, further
research on the use of music therapy in treatment of children and adolescents with
autism is warranted, given the small number of studies.

Intellectual or learning disabilities

Jellison78 surveyed the music therapy literature published between 1975 and 1999 and
conducted a content analysis of music research with children and adolescents who
have disabilities. Her analysis revealed that most of the research in this area focused
on children with intellectual disabilities or learning disabilities. Jellisons content anal-
ysis included studies in which music educational objectives were targeted, as well as
studies in which a music therapist addressed nonmusical objectives. When addressing
nonmusical outcomes, Jellison describes 3 functions of music: (1) as a stimulus cue or
prompt to facilitate learning, (2) as a structure or activity to provide a desired learning
outcome, or (3) as a contingency. Outcomes of music therapy treatment included im-
provements in social, academic, motor, and verbal skills.78 In an updated systematic
review of literature on children and adolescents with disabilities between 1999 and
2009, Brown and Jellison39 found that 34% of experimental studies on the effects of
music therapy on social, motor, academic, and communicative objectives reported
effective results and 47% of studies reported partially effective (mixed) results. Because
of the variety of populations and dependent variables included in the studies in these
systematic reviews, statistical procedures to determine the degree of effectiveness
10 Yinger & Gooding

were not appropriate. Most of the studies that reported effective or partially effective
results used music therapy to address social skills (81%) or academic skills (19%).

Substance abuse
According to current research, music therapy is effective in engaging patients in sub-
stance abuse treatment regardless of age (25 years and younger vs 25 years and
older) and substance use (alcohol only vs other drugs).79 When asked if they would
continue participation, 83% of individuals in a study conducted by Dingle and col-
leagues79 said Yes, with no differences because of age in motivation to participate
(X2(4) 5 7.44, not significant). Jones80 also found that music therapy can be effective in
evoking emotional change in substance abuse patients (P<.05). In addition, the data
suggest that music therapy can promote a healthy attitude toward self and recovery.29
James29 found that music therapy activities positively influenced adolescents
perceived locus of control and facilitated positive attitudes toward themselves and re-
covery. He studied the effects of values clarification within music therapy on adoles-
cents with substance abuse or dependency diagnoses, using a pretest-posttest
control group design. Significant differences between the experimental and control
groups were found in posttest scores (P<.05).29 Music therapy has even been shown
to be effective in promoting on-task behaviors (off-task during music 5 1%; 1.3%) in
women and adolescents with chemical addictions.36 Music therapy has been linked to
longer treatment stays. In a study by Ross and colleagues43 of dually diagnosed pa-
tients, those who attended more than 6 music therapy sessions had significantly
longer treatment stays (P<.05) than those who attended 6 or fewer, with attendance
being predictive of successful follow-up.

Mood/anxiety disorders
In 2008, Baker and Bor81 examined the relationship between music preference and
mental status in adolescents. The investigators concluded that there is limited support
for a connection between music preference and mental health status, stating that
music preference may indicate emotional vulnerability. There has also been some
research that suggests that music-based interventions can positively affect mood
and attitudes. Wooten54 examined the effects on adolescents of listening to preferred
music and found significant increases in positive affect after listening to preferred
music only (P 5 .038). Likewise, James29 found that music therapy activities positively
influenced adolescents perceived locus of control and facilitated positive attitudes
toward themselves and recovery.
Music therapy as an intervention for individuals with specific mood or anxiety disor-
ders has also been addressed in the literature. Hilliard31,48 examined the impact of mu-
sic therapy groups on mood and behavior in grieving children. Results of his studies
suggest that music therapy was effective in reducing grief symptoms. In his 2007
study on the effects of Orff-based music therapy and social work groups on childhood
grief symptoms and behaviors, Hilliard reported that a Wilcoxon signed rank test
revealed that children randomly assigned to a music therapy group showed significant
improvements in behaviors and grief symptoms (P<.05), whereas children who partic-
ipated in a social work group showed reductions in behavioral problems (P<.05) but
not grief symptoms (P>.05), and children in a wait-list control group did not improve
significantly in either area (P>.05). Likewise, Gardstrom51 investigated the use of
clinical music improvisation with adolescents ages 12 to 17 years with PTSD, bipolar
disorder, major depressive disorder, and other diagnoses in a partial hospitalization
program, in a qualitative study. She concluded that music was effective in evoking
emotions and allowing expression of feelings. Henderson27 studied the effects of a
 Music Therapy for Children and Adolescents 11

music therapy program on mood awareness, group cohesion, and self-esteem in ad-
olescents diagnosed with adjustment reaction to adolescence. He found significant
improvements in use of group pronouns (as opposed to personal pronouns; P<.05)
and agreement on mood or emotion expressed in music (P 5 .01) for participants in
the music therapy treatment group.
Eating disorders
Research on music therapy and individuals with eating disorders is limited but shows
promise in using music therapy as an intervention for individuals with eating disorders.
In her 1994 article, Justice82 highlighted ways in which music therapy can be used to
treat individuals with anorexia and bulimia in inpatient treatment, including providing
support, facilitating self-regulation and coping, and promoting awareness. Robarts41
discussed the use of improvisation within music therapy to help adolescents with
anorexia develop assertiveness and a sense of self. McFerran49 highlighted how mu-
sic therapy can be used during group work to promote expression among individuals
with anorexia nervosa. In a retrospective study using a modified content analysis
approach, McFerran and colleagues25 identified themes discussed in songs written
by adolescents with anorexia that support the idea that songwriting can be used to
develop a sense of identity and positive self-talk. The themes most commonly used
by participants in this study during songwriting were identity formation (28.2% of
lyrics), relationship dynamics (17.4% of lyrics), and emotional awareness (17.2% of
lyrics). These investigators noted that songs were often effective in eliciting informa-
tion from participants that had not been disclosed to other team members. Partici-
pants were more willing to self-disclose information during music therapy sessions
than at other times during treatment.25 Results from a study investigating the effect
of cognitive-behavioral music therapy on females ages 14 to 45 years with eating
disorders suggest that music therapy was well received by patients, families, and pro-
fessionals, that music therapy was motivating, and that music therapy enhanced pa-
tients positive affect about the treatment process.83 The research that could be found
on the use of music therapy to treat eating disorders consisted of outcomes research
with a qualitative measure. Future research in this area should include the use of con-
trol groups or conditions and quantitative measures.

SUMMARY

In music therapy for mental health treatment of children and adolescents, the stron-
gest outcome findings are currently for children with intellectual disabilities, emotional
and behavioral disorders, and learning disabilities, but mainly because there is less
research in other areas of child and adolescent mental health, such as autism,
mood/anxiety disorders, substance abuse, and eating disorders.38,39,77,78 Research
indicates that the most effective clinical treatments using music tend to be those
implemented by music therapists, compared with approaches using music medicine
treatments.7 Although music may be used successfully by other health care profes-
sionals to augment mental health treatment, this treatment should be carried out
with the utmost care or, as Taylor says, If administered independently of its relation-
ship to the therapist, it [music] may serve to intensify the pathology with which the pa-
tient is afflicted.6(p83) Given that musical choices may indicate mental health status
and emotional vulnerability, it is advisable for the health care professional or therapist
to screen patients self-selected music before therapeutic intervention.81
Some music therapists provide consultations for other health care professionals on
ways in which to use music in mental health treatment. The CBMT Web site, http://
www.cbmt.org, has a feature that allows anyone to search for board-certified music
 12
Table 2
Authors recommendations
Intellectual/
Emotional/ Develop- Various
Treatment/ Abuse/ Aggressive Bereave- Eating Behavioral mental Juvenile Substance Psychopa-
Approach Trauma ADHD Behavior At-Risk Autism ment Disorders Disorders Disabilities Delinquents Abuse thologies Investigators Opinion
Active music Fair/rec. Fair/ Fair/rec. Fair/rec. Fair/rec. Can be used to address
therapy insufficient self-concept self-
(no psycho- regulation, cognitive
therapeutic functioning, and social/
approach emotional functioning
given) Active music therapy in
adults has been shown
to improve attendance,
participation, percep-
tions of helpfulness,
and learning
Cognitive- Fair/rec. Fair/rec. Fair/rec. Fair/rec. Can be used to address
behavioral self-esteem, social skills
music deficits, developmental
therapy objectives, self-
confidence,
communication,
behaviors, self-esteem,
cognitive functioning;
and motor skills
Cognitive-behavioral MT
research in adults
suggests that it is highly
effective across a broad
range of objectives
 Eclectic music Fair/ Fair/rec. Fair/rec. Fair/rec. Fair/rec. Can be used to address
therapy rec. communication,
behaviors, cognitive
functioning, musical or
motor skills, and
psychosocial functioning
The most mental health-
based music therapists
report use of an eclectic
approach.
Humanistic Fair/ Fair/ Fair/rec. Fair/ Fair/rec. Fair/ Fair/ Fair/rec. Can be used to address joint
music insufficient rec. insufficient no data insufficient attention, social/
therapy emotional functioning,
(creative and motivation
Nordoff- Can be used to decrease
Robbins; aggression and improve
Orff; self- esteem
improvisa-
tional)
Passive music Fair/ Fair/rec. Can be used to address self-
therapy rec. regulation, behavior
(music Research suggests that
listening) music therapy is more
effective when patients
actively participate
Psychodynamic Fair/ All studies that used
music insufficient psychodynamic ap-
therapy proaches in children also
(analytical) used other approaches or
provided case study data
only; as a result,
recommendations for use
of a psychodynamic- only
approach cannot be
made

Abbreviation: Rec, recommend.

13
14 Yinger & Gooding

therapists in their state. The authors offer the following evidence-based recommenda-
tions for health care professionals seeking to use music in mental health treatment of
children or adolescents:
 Use high-quality, client-preferred music. Ask them what kind of music they like
and bring music as close to their preference as possible.
 Allow clients to bring in their own music (listen to it before playing it for the group
to screen for appropriateness of content) or give them a choice of several artists
or genres.
 If you are uncomfortable performing music, use professional recordings.
Become familiar with copyright restrictions to ensure compliance for you and
your practice/facility.
The strengths of music therapy as a treatment of children and adolescents with
mental health concerns include the fact that music therapy is known to benefit clients
with a wide variety of diagnoses and can be effectively administered in group format,
making it a safe, cost-efficient treatment. An increasing number of insurance providers
offer reimbursement for music therapy as a biopsychosocial treatment.84,85 One weak-
ness of music therapy treatment of children and adolescents is that the mechanism by
which it is effective is not completely understood and requires more research with ran-
domized controlled studies. The bulk of the neuroimaging research that seeks to under-
stand how music listening and participation affect the brain has focused on adults, so
caution must be taken when interpreting results of this research with regards to children
and adolescents. Although future research will better illuminate how music therapy
functions, the existing research on music therapy treatment overwhelmingly indicates
that music therapy does function in mental health treatment of children and adoles-
cents. In addition, it requires a trained professional (music therapist) to effectively
administer treatment; without effective administration, the use of music in mental health
treatment may serve to worsen patients conditions.6 Music therapy may be contrain-
dicated for individuals with profound hearing loss, who have musicogenic seizures (a
rare occurrence), or who can no longer actively participate in music because of health
constraints. Many individuals with mild, moderate, or even severe hearing loss do enjoy
listening to music and can benefit from music therapy.86 In addition to the aforemen-
tioned contraindications, certain types of music may be contraindicated for certain
populations. For instance, an individual receiving treatment of substance abuse would
be advised not to listen to music that they once listened to while getting high, because
this type of music may serve to intensify cravings caused by evaluative conditioning.6
Although there is a growing body of research on music therapy in adult mental
health treatment, further research is needed on the use of music therapy in treating
child and adolescent psychiatric disorders, particularly autism, mood and anxiety dis-
orders, substance abuse, and eating disorders in children and adolescents through
randomized controlled studies. Double-blind placebo studies are not possible in
music therapy because interaction with the therapist is an inherent part of the treat-
ment and there is no way to blind participants as to whether or not they receive music
therapy. However, single blind studies in which the researcher does not know which
participants received music therapy are desirable. Using a variety of measures simul-
taneously (self-report, behavioral observation, and physiologic measurements) in
research on the effects of music therapy is also recommended to help eliminate the
possibility of bias. This research is warranted given the effectiveness of music therapy
with adults who have these disorders and the promising nature of initial pilot studies on
children and adolescents. Table 2 summarizes recommendations based on the
current clinical research and the authors clinical experience.
 Music Therapy for Children and Adolescents 15

Music is a useful tool in treating children and adolescents with psychiatric disorders
because of the engagement of multiple areas of the brain that occur during music
listening. Music therapy treatment involves active musical participation and the inclu-
sion of therapeutic techniques by a music therapist, which provide additional levels of
neural engagement and lead to successful outcomes for children with various needs in
the social, behavioral, emotional, cognitive/academic, motor, and verbal domains.

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