medicines

Review
Music Therapy and Other Music-Based Interventions
in Pediatric Health Care: An Overview
Thomas Stegemann 1,2, * , Monika Geretsegger 3 , Eva Phan Quoc 2 , Hannah Riedl 2 and
Monika Smetana 1,2
1 Department of Music Therapy, University of Music and Performing Arts Vienna, 1030 Vienna, Austria;
[email protected]
2 WZMF—Music Therapy Research Centre Vienna, University of Music and Performing Arts Vienna,
1010 Vienna, Austria; [email protected] (E.P.Q.); [email protected] (H.R.)
3 GAMUT—The Grieg Academy Music Therapy Research Centre, NORCE, 5008 Bergen, Norway;
[email protected]
* Correspondence: [email protected]




Received: 30 November 2018; Accepted: 11 February 2019; Published: 14 February 2019


Abstract: Background: In pediatric health care, non-pharmacological interventions such as music

therapy have promising potential to complement traditional medical treatment options in order
to facilitate recovery and well-being. Music therapy and other music-based interventions are
increasingly applied in the clinical treatment of children and adolescents in many countries
world-wide. The purpose of this overview is to examine the evidence regarding the effectiveness
of music therapy and other music-based interventions as applied in pediatric health care. Methods:
Surveying recent literature and summarizing findings from systematic reviews, this overview covers
selected fields of application in pediatric health care (autism spectrum disorder; disability; epilepsy;
mental health; neonatal care; neurorehabilitation; pain, anxiety and stress in medical procedures;
pediatric oncology and palliative care) and discusses the effectiveness of music interventions in these
areas. Results: Findings show that there is a growing body of evidence regarding the beneficial
effects of music therapy, music medicine, and other music-based interventions for children and
adolescents, although more rigorous research is still needed. The highest quality of evidence for the
positive effects of music therapy is available in the fields of autism spectrum disorder and neonatal
care. Conclusions: Music therapy can be considered a safe and generally well-accepted intervention
in pediatric health care to alleviate symptoms and improve quality of life. As an individualized
intervention that is typically provided in a person-centered way, music therapy is usually easy to
implement into clinical practices. However, it is important to note that to exploit the potential of
music therapy in an optimal way, specialized academic and clinical training and careful selection of
intervention techniques to fit the needs of the client are essential.

Keywords: music therapy; music medicine; music-based intervention; pediatrics; developmental

medicine; pediatric neurology

1. Introduction
Music therapy is an evidence and art-based health profession which uses music experiences
within a therapeutic relationship to address clients’ physical, emotional, cognitive, and social needs [1].
A recent worldwide survey among professional members of organizations affiliated with the World
Federation of Music Therapy (n = 2495) revealed that music therapists mainly worked in mental
health settings, schools, geriatric facilities, and private practice [2]. About half of the respondents
reported working with children/preteens (50.6%), and teens (45.7%), whereas 38.2% indicated working

Medicines 2019, 6, 25; doi:10.3390/medicines6010025 www.mdpi.com/journal/medicines

Medicines 2019, 6, 25 2 of 12

with infants/children. In the ranking of specific populations served, autism spectrum disorder,
developmental disabilities, and depressive disorder are amongst the top three. Although music
therapy with children and adolescents constitutes a huge and important part of music therapy practice
since the beginnings of the profession, there is a dearth of scientific evidence—particularly when
compared to music therapy with adults—and more rigorous research is needed.
The purpose of this overview is to examine the evidence regarding the effectiveness of music
therapy and other music-based interventions as applied in pediatric health care.

1.1. Definitions
This overview defines and contrasts three music-based approaches used in health care: music
medicine, music therapy, and other music-based interventions (see Figure 1).

Figure 1. Types of music-based interventions in health care.

In addition to the definition by the American Music Therapy Association (see above), music
therapy (MT) can be described as “a systematic process of intervention wherein the therapist helps the
client to promote health, using music experiences and the relationships that develop through them
as dynamic forces of change” [3]. With these tailored music experiences provided by credentialed
music therapists, music therapy can be contrasted to interventions which are “categorized as ’music
medicine’ when passive listening to pre-recorded music is offered by medical personnel” [4], especially
before, during and/or after medical interventions, and other music-based interventions such as
musically-based activities like choir singing or playing drums that are provided by musicians or health
professionals other than credentialed music therapists.
In MT, four main methods are usually distinguished which overlap in clinical practice or may
be combined: improvising, listening, recreating, and composing [5]. Depending on the underlying
MT model (see Section 1.2.), the spontaneous creation of music by means of the voice, body, or simple
musical instruments may be seen as the ‘via regia’ to the unconscious and may facilitate contact,
communication, and emotional expression. Receptive methods (listening to music and responding
verbally or in another modality) typically aim to activate or relax a client, to evoke specific body
responses, memories, and fantasies, or to stimulate self-knowledge and reflection. Recreating methods
encompasses any kind of pre-composed music that the client learns to play or sing. Composition
means that the therapist helps the client to create (and to record or perform) music such as instrumental
pieces, lyrics, and songs.
Medicines 2019, 6, 25 3 of 12

1.2. Fields of Application and Music Therapy Approaches

The first documentation of MT in children and adolescents comes from shortly after the Second
World War, when pioneers in the USA, and from the late 1950s onwards also in Europe, started to use
music for treating mentally ill people within various clinical fields [6].
Apart from various clinical areas (see Section 3), MT for children and adolescents is currently
also applied in other health care fields such as chronic illness, as well as in non-medical and
community contexts such as schools (special education, prevention) or refugee centers (integration,
migration, trauma).
Music therapy is especially indicated when verbal language is not, or only limitedly, available or
when music as a non-verbal medium enables access to one’s own feelings in cases where improved
processing of emotions may help to decrease symptoms. Music therapy can also help to regulate
activity and tension and positively influence mood and motivation. In music interventions, it is not
necessary for clients to have any musical background such as musical talent, the ability to play an
instrument, or to read music; it is one’s individual engagement with the music experience which is a
key factor.
Functional and behavioristic approaches typically use the activating or relaxing effects of music for
stimulation or calming, and to enhance learning of specific skills and behaviors. Humanistic approaches
(represented by pioneers such as Juliette Alvin [7], or Paul Nordoff and Clive Robbins [8]) emphasize
creativity and expression of the self within improvisational music making and the development
of positive relationships by allowing the child to find his or her own musical way without fixed
rules. Analytically-oriented MT (pioneered by Mary Priestley [9]) employs the symbolic content of
improvised music in order to connect with emotions, thoughts, images, or bodily sensations that
cannot be verbalized.
In addition to individual and group therapy settings, family-based approaches have been
increasingly used in MT with children and adolescents within the last couple of years [10].

2. Methods
To evaluate the current evidence for the effectiveness of MT, music medicine, and other
music-based interventions in selected fields of pediatric health care, we conducted database searches
for systematic reviews published within the last five years (November 2013 to October 2018) using
PubMed/Medline, Cinahl, PsycINFO, Scopus, and Web of Science. The following search terms were
used: (1) music therapy/music intervention/music-based intervention or arts-based therapy combined
with (2) children/pediatrics and with (3) respective fields of application as listed in Section 3 of this
article. Based on screening of titles and abstracts, we retrieved eligible systematic reviews. We included
those systematic reviews where full-texts were available in English. Findings from systematic reviews
and meta-analyses are briefly presented along with a descriptions of assumed working mechanisms
and specific goals of music interventions in the Results section.
Included articles were assessed regarding their quality and validity using AMSTAR 2 (A
MeaSurement Tool to Assess systematic Reviews) guidelines [11]. AMSTAR 2 is a critical appraisal tool
for systematic reviews that include randomized or non-randomized studies of healthcare interventions,
or both. It includes 16 items on domains such as “adequacy of the literature search”, “justification for
excluding individual studies”, “appropriateness of meta-analytical methods”, and “consideration of
risk of bias when interpreting the results of the review”. Based on a scheme for interpreting weaknesses
detected in critical and non-critical items, the overall confidence in the results of the review can then
be categorized as “high”, “moderate”, “low”, or “critically low”. All of the systematic reviews and
meta-analyses included in our overview were assessed and rated independently by two of the authors.
Any disagreements were discussed further in order to reach mutual consent between the two authors.
Medicines 2019, 6, 25 4 of 12

3. Results
We included a total of 13 systematic reviews/meta-analyses—published within the last five
years—across the following fields of pediatric health care (in alphabetical order; in parentheses;
number of systematic reviews included): autism spectrum disorder (2); disability (1); epilepsy (1);
mental health (2); neonatal care (3); neurorehabilitation (1); pain, anxiety, and stress in medical
procedures (2); pediatric oncology and palliative care (1). Key characteristics of the studies and an
assessment of quality according to the AMSTAR 2 guidelines are summarized in Table 1.

3.1. Autism Spectrum Disorders

Music therapy has been applied in the field of autism since the mid-1940s [12]. The latest update of
a Cochrane review on music therapy for people with autism spectrum disorders (ASD) [13] summarizes
results from 10 studies examining the short- and medium-term effect of MT interventions (one week
to seven months) with a total of 165 participants who were all between two and nine years of age.
Findings provide evidence for moderate to large effects of MT as compared to ‘placebo’ therapy
or standard care in outcome areas constituting the core of the condition such as social interaction,
non-verbal communicative skills, initiating behavior, and social–emotional reciprocity. Music therapy
may also help to improve verbal communication, social adaptation, joy, and the quality of parent–child
relationships. Due to low numbers of study participants and other study design issues, the quality
of the evidence was assessed as moderate to low. Therefore, the review authors suggest that future
studies need to be larger, more rigorous, and should also evaluate outcomes for people with ASD above
nine years of age. Based on AMSTAR 2 criteria, the confidence in these results can be assessed as “high”
(i.e., the SR provides an accurate and comprehensive summary of the results of the available studies).
Another meta-analysis that focused on randomized controlled trials (RCTs) published in
Chinese [14] also came to favorable conclusions regarding MT for ASD, but only reached a rating
of “low” confidence according to AMSTAR 2 (i.e., it has a critical methodological flaw and may not
provide an accurate and comprehensive summary of the available studies). Summarizing the findings
of six studies with a total of 300 children with autism, the authors found significant effects of MT (six
weeks to three months) as compared to other forms of therapy on mood, language, sensory perception,
behavior, and social skills. The risk of bias for all six included studies was assessed as moderate.
The potential of MT as an intervention within ASD, where difficulties with social interaction
and communication are at the core by definition, is explained by processes that naturally occur
in musical interactions within the relationship between client and therapist, where music is used
as an expressive and communicative means. Behaviors necessary for social engagement such as
joint attention, eye contact, and turn-taking are characteristic events in shared, active music making
and therefore inherent components of MT processes. Structures in improvised or pre-composed
music also provide opportunities to experience both predictability and flexibility, and attention and
enjoyment typically increase in individuals when presented with musical as opposed to verbal stimuli.
Music therapy for individuals with ASD is often provided as individual therapy, but there are also
group-based, peer-mediated and family-based forms [13].

3.2. Disability
In MT, work with children and adolescents with disabilities is one of the traditional fields of
application [6]. Children with ASD, trisomy 21, Rett syndrome, or Williams syndrome are known to be
very responsive to music listening and musical activities. Thus, MT is applied for assessment as well
as for fostering communication, social competencies, emotional regulation, and motor skills [15,16].
Although MT is a quite common approach in special education, there is still a dearth of research, in
particular with respect to effectiveness studies.
Only one SR met our inclusion criteria [17]. This publication on “music research in inclusive school
settings” covered the period from 1975 to 2013 and found evidence that music-based interventions
Medicines 2019, 6, 25 5 of 12

in preschool settings positively influence reading/literacy outcomes in children with and without
disabilities. Due to the high level of heterogeneity in study methodologies and outcomes, no other
summary statements could be made. As a conclusion, the authors stress the necessity to conduct more
studies in inclusive music settings. Due to several critical flaws in the review, the confidence in its
results was rated as “critically low” according to AMSTAR 2 criteria, which means that it should not
be relied upon to provide an accurate and comprehensive summary of the included studies.

3.3. Epilepsy
Musicogenic epilepsy, i.e. epileptic seizures induced by music, has been known of since at least
the late 1930s, as Oliver Sacks mentions in his book “Musicophilia” [18]. At the same time, music
has the potential to reduce seizure activity: “The dichotomous effect of music on seizures may be
explained by modification of dopaminergic circuitry or counteractive cognitive and sensory input
in ictogenesis” [19]. In a recent systematic review [20], eight publications were identified in which
the influence of music by W.A. Mozart on seizures in children was studied. Although there is some
substantial and serious doubt about the existence of a ‘Mozart effect’ as such, classical pieces of the
‘Wunderkind’ are still very popular stimuli in this type of research. Noteworthily, seven of the eight
included studies were from the same research group in Taiwan. Brackney and Brooks [20] summarize
their findings: “The evidence for the efficacy of the Mozart Effect on seizure activity in children is
promising but not conclusive”. According to AMSTAR 2 criteria, the confidence in the systematic
review’s results is rated as “critically low”. Seven of the studies were classified as “quasi-experimental”.
In the only RCT [21], the treatment group (n = 24) listened to Mozart’s sonata for two pianos in D major
K.448 daily before bedtime for six months, while the control group (n = 24) received treatment as usual
(patients were between 8 and 13 years of age). Results showed that during the follow-up period of
approximately one and a half years on average, eight of the 22 patients in the treatment group suffered
seizure recurrence, while 18 of the 24 patients in the control group had seizure recurrence. Further,
significant decreases in epileptiform discharges after one, two, and six months compared with EEGs
before listening to music have been observed in the treatment group.

3.4. Mental Health

Mental health care for children and adolescents is one of the main clinical fields of music therapists.
Music therapy with children and adolescents can include active methods such as improvisation or
working with songs (song writing, performing of pre-composed songs) as well as receptive methods
such as listening to pre-recorded music [5].
A Cochrane review on music therapy for depression [22]—for which the AMSTAR 2 level of
confidence in the results was rated as “high”—included nine RCTs (total n = 421), of which two studied
the effectiveness of “music therapy techniques” in high school students [23,24]. However, as it was
not clear whether a trained music therapist was providing the interventions [22], these studies are
categorized as music-based intervention studies according to our definitions provided above. Findings
from these two studies suggest that the group music intervention in comparison to cognitive behavioral
therapy is significantly more effective as measured by self-rating (Beck Depression Inventory).
The findings of a recent meta-analysis [25] on different music-based interventions (including MT,
music medicine, and other music-based interventions) to reduce internalizing symptoms in children
and adolescents also suggest that these interventions are beneficial, but due to a relatively small sample
size (only five trials with a combined sample size of n = 100), the authors draw these implications with
caution. The confidence in the results according to AMSTAR 2 criteria was estimated as “low”.

3.5. Neonatal Care

Music therapy and music interventions are of growing importance in neonatal intensive care
units (NICUs) as documented by two recent publications: a systematic review of RCTs on various
music-based interventions by van der Heijden and colleagues [26], and a meta-analysis on music
Medicines 2019, 6, 25 6 of 12

therapy for infants and their parents by Bieleninik, Ghetti, and Gold [27]. Progress in medicine and new
technical developments allow for higher survival rates in preterm newborns. However, the survival
of preterm babies who are more premature and vulnerable also calls for better and more efficient
integrated care as early as possible. This explains why there is a growing awareness for environmental
factors influencing the newborn’s health and well-being, e.g. acoustic stimuli in the NICU. Van der
Heijden and colleagues state: “Where unpredictable noise adversely affects sleep and physiologic
stability, meaningful auditory stimulation, such as music, might contribute to the neurodevelopment
of premature infants” [26].
Summarising the main findings of the two reviews—based on RCTs only, and both assessed
as justifying “moderate” confidence in their findings according to AMSTAR 2 (i.e., they include
weaknesses, but no critical flaws, so that they may provide an accurate summary of the results of
included studies)—MT and other music-based interventions in NICUs lead to a reduction in heart and
respiratory rate, improve the infant’s sleep and food intake, and reduce the anxiety of mothers [26,27].
Interestingly, not only from an economical point of view, a recent systematic review of RCTs [28] found
that length of stay can be significantly reduced through music therapy interventions. In addition,
O’Toole et al. [28] reported that music medicine interventions yield positive effects of pain management
in preterm infants. However, the confidence in this review’s results had to be rated as “critically low”
according to AMSTAR 2 criteria due to several critical flaws in its methodology.
Regardless of whether live or pre-recorded music is played, the ‘golden rules’ of music
interventions in the NICU are “less is more”, and “minimal change, minimal range”. The former
being true for duration and the number of musical instruments used, the latter applies to all musical
parameters: “minimal change” in rhythm, harmony, dynamics, and volume, and “minimal range” in
melody and pitch range—“like a lullaby” [29]. Thus, in live interventions, music therapists primarily
use their voice (infant directed singing), accompanied maybe by a harp, a guitar or a small percussion
instrument. For recorded acoustic interventions, music or the mother’s voice is played softly through
loudspeakers inside or outside of the incubator.

3.6. Neurorehabilitation
A recent Cochrane review on MT for acquired brain injury came to the following conclusion: “The
results suggest that music interventions using rhythm may be beneficial for improving walking in
people with stroke, and this may improve quality of life. ( . . . ) Music interventions that use a strong
beat within music may be more effective than interventions where a strong beat is used without music.
Treatment delivered by a trained music therapist might be more effective than treatment delivered by
other professionals” [30]. The quality of the evidence was assessed as “generally low” by the review
authors [30]. The confidence in these results can be assessed as “high” based on AMSTAR 2 criteria.
In the context of our focus on pediatric health care, it has to be noted however that it was not possible
to determine the number of adolescents who were included based on the information given in the
review. According to the selection criteria of the review, “studies that included people older than
16 years of age” were examined. Most of the studies report a mean age of more than 50 years of age,
so the applicability of the review’s results to children and adolescents remains unclear.

3.7. Pain, Axiety, and Stress in Medical Procedures

A systematic review by Yinger and Gooding [31] on music-based interventions for procedural
support identified 50 studies meeting the inclusion criteria, but only eight of them included children
and adolescents. The confidence in the results of this systematic review according to AMSTAR 2 criteria
was rated as “moderate”, i.e., it includes weaknesses, but no critical flaws, so that it may provide
an accurate summary of the results of included studies. The authors came to the conclusion that the
majority of studies (84%) were at high risk of bias and revealed limitations in adequate intervention
reporting. Interestingly, two of the eight studies with a low or moderate risk of bias were music
Medicines 2019, 6, 25 7 of 12

therapy studies involving pediatric participants [32,33], with significant effects for the reduction of
pain and anxiety.
In a systematic review from 2016, Kim and Stegemann [34] searched the literature of the last 35
years with regard to music listening as an intervention for children and adolescents. The authors
identified 36 studies of which 18 were from the field of pediatrics, encompassing 12 studies with
pediatric patients undergoing either surgery or needle insertion procedures. Accordingly, pain, anxiety,
and stress were the main outcome measures.
Pain perception in the context of medical procedures was investigated in 12 RCTs, of which nine
found a significant decrease of pain in the music condition compared to the non-music condition or
treatment as usual. In most of the studies, the music condition included recorded music (e.g., lullabies,
classical music, pop) presented via loudspeaker or earphones. The largest effect sizes were reported in
a study by Nguyen and colleagues [35] who investigated the reduction of pain and anxiety in children
with cancer undergoing lumbar puncture (LP). Pain, heart and respiratory rates were significantly
reduced in the music group during and after the LP (pain reduction: d = 1.53 (huge effect) during and
d = 1.08 (large effect) after the LP).
Besides pain, anxiety plays a major role as a stressor for children in medical procedures. The effect
of music listening in reducing anxiety was measured in 11 studies, of which seven favored the music
condition while four studies found no significant difference between groups. Effect sizes for anxiety
reduction ranged between d = 0.61 (medium effect) and d = 1.5 (huge effect). Kristjánsdóttir and
Kristjánsdóttir [36] studied the effect of a specific music medicine intervention (a musical distraction
strategy) in adolescents receiving immunization. They found the odds of participants experiencing
“no pain” during the immunization if listening to music to be approximately 2.8 times higher than
those of participants receiving standard nursing care. The authors concluded that musical distraction,
pre-immunization fear and anxiety, and expected immunization pain were significant predictors of
adolescent immunization pain sensation.
The effects of music listening on stress perceived by children and adolescents during painful
medical procedures were measured by observational parameters (e.g., video analysis) as well as
physiological parameters (e.g., heart rate, blood pressure, respiratory rate). The majority of the studies
(four out of seven) were in favor of the music condition, while the other three studies found no
significant differences. Results of an earlier RCT by Malone [37] who used live music interventions
with children in a preoperative setting revealed that participants in the music condition showed
significantly shorter duration of stress signs with a large effect size (d = 1.01).
Only two of the 36 studies reviewed by Kim and Stegemann [30] were categorized as “relatively
low risk of bias”; both of these studies [35,38] showed strong results in favor of the music medicine
intervention. The confidence in the results of this systematic review by Kim and Stegemann [30]
according to AMSTAR 2 criteria was also rated as “moderate”.

3.8. Pediatric Oncology and Palliative Care

In several countries, music therapy services are well-established in the field of pediatric oncology,
and some treatment guidelines include creative arts therapies for this specific client population, as
for instance in Germany [39]. Music therapists in pediatric oncology and palliative care have to deal
with various somatic and psychological symptoms of their patients and often, therapy is provided for
children together with their family members. Due to ethical concerns and feasibility issues regarding
such vulnerable times in life, RCTs are scarce in this field, particularly within palliative care.
Medicines 2019, 6, 25 8 of 12

Table 1. Key characteristics and ratings of overall confidence in the results (based on AMSTAR 2) of
included systematic reviews.

Number of
Field of Author(s), Year (Type(s) of Confidence in the
Studies/Participants (Primary) Outcomes
Application Intervention Studied) * Results
(Total)
Social interaction;
non-verbal and verbal communicative
Geretsegger et al., 2014 [13]
10/165 skills; High
Autism Spectrum [MT]
initiating behavior;
Disorders
social–emotional reciprocity
Shi et al., 2016 [14] Mood; language; behavior; sensory
6/300 Low
(MT) perception; social skills
Jellison and Draper, 2015 [17] Behavior in the categories: music,
Disability 22/> 562 1 Critically low
(MT, MBI) social, academic, motor, on-task
Brackney and Brooks, 2018
Seizure frequency; epileptiform
Epilepsy [20] 8/268 Critically low
activity (EEG)
(MM, MBI)
Aalbers et al., 2017 [22] Clinician-rated and patient-reported
9/421 2 High
Mental Health (MT, MBI) depressive symptoms
Geipel et al., 2017 [25]
5/195 Internalizing symptoms Low
(MT, MM, MBI)
van der Heijden et al., 2016 Physiological parameters; growth and
[26] 20/1128 feeding; behavioral state; relaxation Moderate
(MT, MM, MBI) Outcomes and pain
Physiological and behavioral
Bieleninik et al., 2016 [27]
Neonatal Care 16/1071 3 parameters; maternal anxiety; Moderate
(MT)
service-level outcome
Physiological indicators; feeding
O’Toole, 2017 [28] 12/918 Critically low
behaviors; length of stay; pain
(MT, MM, MBI)
Neuro-rehabilitation Magee et al., 2017 [30] 29 4 /775 Gait, upper extremity function High
(MT, MM, MBI)
Yinger and Gooding, 2015 [31] Pain and anxiety during medical
50 5 /4379 Moderate
Pain, Anxiety and (MT, MM) procedures
Stress in Medical Three categories: pediatrics (e.g., pain,
Procedures Kim and Stegemann, 2016 [34]
36/1990 anxiety, stress); mental health; Moderate
(MT, MM)
miscellaneous
Pediatric Psychological outcomes (e.g.,
Bradt et al., 2016 [40]
Oncology and 52 6 /3731 depression, anxiety); physical High
(MT, MM)
Palliative Care outcomes (e.g., fatigue, nausea, pain)
* MT = music therapy; MM = music medicine; MBI = other music-based interventions. 1 In some of the included
studies, the numbers of participants were not indicated or unclear. 2 In two of the nine publications [35,36],
adolescent patients were studied (total n = 82). 3 Number of infant participants; in addition, 286 parent participants
were included. 4 According to the selection criteria of the review, “studies that included people older than 16
years of age” were examined; based on the information given in the review it is not possible to indicate how many
adolescents were included; most of the studies report a mean age > 50 years of age. 5 Eight of the 50 studies
involved pediatric participants (total n = 705). 6 Five of the 52 publications were conducted in pediatric patients
(total n = 201).

A Cochrane review by Bradt and colleagues [40]—for which the AMSTAR 2 level of confidence
in the results was assessed as “high”—on music interventions for improving psychological and
physical outcomes in cancer patients included studies with children, but only five of the 52 reviewed
studies were conducted in pediatric fields. Outcomes of these studies varied from impact on immune
system functioning [41] through to anxiety and pain management [35,42] and children´s coping
behavior [43,44]. Due to the low number of studies in pediatrics, no overall conclusions were drawn.
Findings from single studies indicate some benefits of MT and music-based interventions, particularly
on anxiety, pain, and coping behaviors.

4. Discussion
According to the results from systematic reviews and meta-analyses, the evidence for the
effectiveness of music therapy and other music-based interventions in areas relevant to pediatric
health care can be summarized as displayed in Table 2.
Medicines 2019, 6, 25 9 of 12

Table 2. Summary of findings regarding evidence for the effectiveness of music therapy (MT), music
medicine (MM) and other music-based interventions (MBI) in selected fields of applications relevant to
pediatric health care.

Field of Application Findings

MT can improve social interactions, non-verbal communicative
skills, initiating behavior, and social–emotional reciprocity
Autism Spectrum Disorders (moderate to strong effects) [13]
MT can improve verbal communication, social adaptation, joy, and
the quality of parent–child relationships [13]
MT can improve mood, language, sensory perception, behavior,
and social skills [14]
MBI can positively influence reading/literacy outcomes in
Disabilities
children with and without disabilities [17]
MBI can reduce epileptiform discharges [20]
Epilepsy
Evidence for the efficacy of music medicine interventions using
the Mozart Effect on seizure activity in children is promising but
not conclusive [20]
MBI in an educational setting can have an anti-depressive effect in
Mental Health adolescents [22]
MT/MM/MBI can reduce internalizing symptoms [25]
MT/MM can decrease heart and respiratory rate [26,27]
MT can improve infant sleep [26,27] and food intake [26–28]
Neonatal Care
MT/MM can reduce the anxiety of mothers [26,27]
MT can reduce the length of stay in hospital [28]
MM can reduce pain during blood-drawing procedures [28]
Effects of MT/MM/MBI on adolescents are unclear due to missing
Neurorehabilitation
differentiation/data for the age group 16–18 years [30]
MT/MM can decrease pain [31]
Pain, Anxiety and Stress in
Medical Procedures MT/MM can reduce anxiety [31,34]
MT/MM can decrease levels of stress parameters (heart and
respiratory rate) [34]
MT can improve pain management [40]
Pediatric Oncology and
Palliative Care MT can improve children’s coping behavior [40]
MT can improve immunological status (increase of IgA level) [40]

Music therapy (MT) and other music-based interventions are applied and have shown to be
beneficial in a broad variety of fields and seem effective especially in combination with other treatment
forms and within a multimodal therapy approach—but they are certainly not the ‘magic bullet’ working
for everyone at any time.
The growing body of evidence for MT and other music-based interventions (including music
medicine) in childhood and adolescence indicates that MT is particularly effective in improving mood
and affect regulation, communication, social skills, and quality of life; music medicine approaches
are successfully applied in medical settings to alleviate pain, anxiety, and stress. As documented by
meta-analyses, the best evidence regarding the effectiveness of MT today is reported in neonatal care
and in children with autism spectrum disorders. In other fields, especially in children with disabilities,
there is a clear need for more and better-quality research—which is of course not only a challenge
for MT but holds true for medical and special education interventions in childhood and adolescence
in general.
Medicines 2019, 6, 25 10 of 12

“Where words fail, music speaks”, as the writer Hans Christian Andersen put it. Thus,
music-based interventions can open doors, especially for people who are not capable of communicating
through spoken language. The communication beyond words is a unique feature of arts therapies
such as MT—this may be one reason why MT works in NICUs and for people with ASD.
Music therapy can be considered a safe and generally well-accepted intervention in pediatric
health care to alleviate symptoms and improve quality of life. None of the included systematic reviews
reported adverse effects of music-based interventions for children and adolescents. This is in line
with the findings of a study on the acceptance of specific complementary and alternative medicine
modalities, where acceptance was highest for music therapy [45].
As an individualized intervention that is typically provided in a person-centered way, music
therapy is usually easy to implement into clinical practices. In addition, it is important to note that to
exploit the potential of music therapy in an optimal way, specialized academic and clinical training
and careful selection of intervention techniques to fit the client’s needs are essential. More rigorous
research on MT, music medicine, and other music-based interventions is still needed to determine
what types of interventions work best for whom and under which circumstances.

Author Contributions: T.S. took the initiative for the study and coordinated study activities; T.S., M.G., and M.S.
developed the concept and methodology; H.R. and E.P.Q. helped to revise the concept and methodology; T.S.,
M.G., and M.S. drafted the initial manuscript; H.R. and E.P.Q. conducted literature searches and helped in revising
the manuscript. M.S., H.R., and E.P.Q. rated the systematic reviews according to AMSTAR 2 criteria. All authors
extracted and analyzed data from eligible search results, summarized and interpreted findings, and approved the
final version of the manuscript.
Funding: This research received no external funding.
Conflicts of Interest: The authors declare that the article was written in the absence of any commercial or
financial relationships that could be construed as a potential conflict of interest. All authors are clinically trained
music therapists.

References
1. American Music Therapy Association. What Is Music Therapy. 2018. Available online: https://www.
musictherapy.org/about/musictherapy/ (accessed on 28 November 2018).
2. Kern, P.; Tague, D.B. Music therapy practice status and trends worldwide: An international survey study.
J. Music Ther. 2017, 54, 255–286. [CrossRef]
3. Bruscia, K.E. Defining Music Therapy; Barcelona: Gilsum, NH, USA, 1998; ISBN 978-1-89-127-807-5.
4. Bradt, J.; Dileo, C.; Shim, M. Music interventions for preoperative anxiety. Cochrane Database Syst. Rev. 2013.
[CrossRef] [PubMed]
5. Stegemann, T.; Geretsegger, M. Music therapy methods. In Music in the Social and Behavioral Sciences;
Thompson, B., Ed.; Sage: Thousand Oaks, CA, USA, 2014; Volume 2, pp. 700–702, ISBN 978-1-4522-8303-6.
6. Davis, W.B.; Gfeller, K.E. Music therapy: Historical perspective. In Introduction to Music Therapy: Theory
and Practice, 3rd ed.; Davis, W.B., Gfeller, K.E., Thaut, M.H., Eds.; American Music Therapy Association:
Silverspring, MD, USA, 2008; pp. 17–39, ISBN 978-1-8849-1420-1.
7. Alvin, J. Music for the Handicapped Child; Oxford University Press: Oxford, UK, 1965; ISBN 978-019314912-0.
8. Nordoff, P.; Robbins, C. Creative Music Therapy: Individualized Treatment for the Handicapped Child; John Day
Co.: New York, NY, USA, 1977; ISBN 978-038-197-100-7.
9. Priestley, M. Music Therapy in Action; St. Martin’s Press: New York, NY, USA, 1975; ISBN 978-009-459-900-0.
10. Jacobsen, S.L.; Thompson, G. (Eds.) Music Therapy with Families. Therapeutic Approaches and Theoretical
Perspectives; Jessica Kingsley: London, UK, 2017; ISBN 978-1-84905-630-4.
11. Shea, B.J.; Reeves, B.C.; Wells, G.A.; Micere, T.; Candyce, H.; Julian, M.; Moher, D.; Tugwell, P.; Welch, V.;
Kristjansson, E.; et al. AMSTAR 2: A critical appraisal tool for systematic reviews that include randomised
or non-randomised studies of healthcare interventions, or both. BMJ 2017, 358, j4008. [CrossRef] [PubMed]
12. Reschke-Hernández, A.E. History of music therapy treatment interventions for children with autism. J. Music
Ther. 2011, 48, 169–207. [CrossRef] [PubMed]
13. Geretsegger, M.; Elefant, C.; Mössler, K.A.; Gold, C. Music therapy for people with autism spectrum disorder.
Cochrane Database Syst. Rev. 2014. [CrossRef] [PubMed]
Medicines 2019, 6, 25 11 of 12

14. Shi, Z.M.; Lin, G.H.; Xie, Q. Effects of music therapy on mood, language, behavior, and social skills in
children with autism: A meta-analysis. Chin. Nurs. Res. 2016, 3, 137–141. [CrossRef]
15. Hintz, M. (Ed.) Guidelines for Music Therapy Practice in Developmental Health; Barcelona: Gilsum, NH, USA,
2013; ISBN 978-1-937440-45-9.
16. Lathom-Radocy, W.B. Pediatric Music Therapy, 2nd ed.; Charles C Thomas: Springfield, IL, USA, 2014;
ISBN 978-039-808-787-6.
17. Jellison, J.A.; Draper, E.A. Music research in inclusive school settings: 1975 to 2013. J. Res. Music Educ. 2015,
62, 325–331. [CrossRef]
18. Sacks, O. Musicophilia. Tales of Music and the Brain; Picador: London, UK, 2007; ISBN 978-033-041-837-9.
19. Maguire, M. Music and its association with epileptic disorders. Prog. Brain Res. 2015, 217, 107–127. [CrossRef]
20. Brackney, D.E.; Brooks, J.L. Complementary and alternative medicine: The Mozart Effect on childhood
epilepsy—A systematic review. J. Sch. Nurs. 2018, 34, 28–37. [CrossRef]
21. Lin, L.C.; Lee, M.W.; Wei, R.C.; Mok, H.K.; Yang, R.C. Mozart K.448 listening decreased seizure recurrence
and epileptiform discharges in children with first unprovoked seizures: A randomized controlled study.
BMC Complement. Altern. Med. 2014, 14, 17. [CrossRef]
22. Aalbers, S.; Fusar-Poli, L.; Freeman, R.E.; Spreen, M.; Ket, J.C.F.; Vink, A.C.; Maratos, A.; Crawford, M.;
Chen, X.J.; Gold, C. Music therapy for depression. Cochrane Database Syst. Rev. 2017. [CrossRef] [PubMed]
23. Hendricks, C.B.; Robinson, B.; Bradley, B.; Davis, K. Using music techniques to treat adolescent depression. J.
Humanist. Couns. Educ. Dev. 1999, 38, 39–46. [CrossRef]
24. Hendricks, C.B. A study of the use of music therapy techniques in a group for the treatment of adolescent
depression. Diss. Abstr. Int. 2001, 62, 472.
25. Geipel, J.; Koenig, J.; Hillecke, T.K.; Resch, F.; Kaess, M. Music-based interventions to reduce internalizing
symptoms in children and adolescents: A meta-analysis. J. Affect. Disord. 2018, 225, 647–656. [CrossRef]
[PubMed]
26. Van der Heijden, M.J.E.; Oliai Araghi, S.; Jeekel, J.; Reiss, I.K.M.; Hunink, M.G.M.; van Dijk, M. Do
hospitalized premature infants benefit from music interventions? A systematic review of randomized
controlled trials. PLoS ONE 2016, 11, e0161848. [CrossRef]
27. Bieleninik, Ł.; Ghetti, C.; Gold, C. Music therapy for preterm infants and their parents: A meta-analysis.
Pediatrics 2016, 138. [CrossRef] [PubMed]
28. O’Toole, A.; Francis, K.; Pugsley, L. Does music positively impact preterm infant outcomes? Adv. Neonatal
Care 2017, 17, 192–202. [CrossRef]
29. Nöcker-Ribaupierre, M. Premature Infants. In Guidelines for Music Therapy Practice in Pediatric Care; Bradt, J.,
Ed.; Barcelona: Dallas, TX, USA, 2013; pp. 66–115, ISBN 978-1-937440-48-0.
30. Magee, W.L.; Clark, I.; Tamplin, J.; Bradt, J. Music interventions for acquired brain injury. Cochrane Database
Syst. Rev. 2017. [CrossRef]
31. Yinger, O.S.; Gooding, L.F. A systematic review of music-based interventions for procedural support. J. Music
Ther. 2015, 52, 1–77. [CrossRef]
32. Noguchi, L.K. The effect of music versus nonmusic on behavioral signs of distress and self-report of pain in
pediatric injection patients. J. Music Ther. 2006, 43, 16–38. [CrossRef]
33. Whitehead-Pleaux, A.M.; Baryza, M.J.; Sheridan, R. The effects of music therapy on pediatric patients’ pain
and anxiety during donor site dressing change. J. Music Ther. 2006, 43, 136–153. [CrossRef] [PubMed]
34. Kim, J.; Stegemann, T. Music listening for children and adolescents in health care contexts: A systematic
review. Art Psychother. 2016, 51, 72–85. [CrossRef]
35. Nguyen, T.N.; Nilsson, S.; Hellström, A.L.; Bengtson, A. Music therapy to reduce pain and anxiety in children
with cancer undergoing lumbar puncture: A randomized clinical trial. J. Pediatr. Oncol. Nurs. 2010, 27,
146–155. [CrossRef] [PubMed]
36. Kristjánsdóttir, Ó.; Kristjánsdótti4, G. Randomized clinical trial of musical distraction with and without
head-phones for adolescents’ immunization pain. Scand. J. Caring Sci. 2011, 25, 19–26. [CrossRef] [PubMed]
37. Malone, A.B. The effects of live music on the distress of pediatric patients receiving intravenous starts,
venipunctures, injections, and heel sticks. J. Music Ther. 1996, 33, 19–33. [CrossRef]
38. Hartling, L.; Newton, A.S.; Liang, Y.; Jou, H.; Hewson, K.; Klassen, T.P.; Curtis, S. Music to reduce pain
and distress in the pediatric emergency department: A randomized clinical trial. JAMA Pediatr. 2013, 167,
826–835. [CrossRef] [PubMed]
Medicines 2019, 6, 25 12 of 12

39. Schröder, H.; Lilienthal, S.; Schreiber-Gollwitzer, B.; Griessmeier, B.; Leiss, U. Psychosoziale Versorgung in
der Pädiatrischen Onkologie und Hämatologie. Available online: https://www.awmf.org/uploads/tx_
szleitlinien/025-002l_S3_Psychosoz-Versorgung-Paed-Onkol-Haematol-2013-abgelaufen.pdf (accessed on
9 June 2018).
40. Bradt, J.; Dileo, C.; Magill, L.; Teague, A. Music interventions for improving psychological and physical
outcomes in cancer patients. Cochrane Database Syst. Rev. 2016, 8, 1–169. [CrossRef]
41. Duocastella, A.C. Effect of music on children with cancer. Rev. Enferm. 1999, 22, 293–298.
42. Bufalini, A. Role of interactive music in oncological paediatric patients undergoing painful procedures.
Minerva Pediatr. 2009, 61, 379–389.
43. Burns, D.S.; Robb, S.L.; Haase, J.E. Exploring the feasibility of a therapeutic music video intervention in
adolescents and young adults during stem-cell transplantation. Cancer Nurs. 2009, 32, 8–16. [CrossRef]
44. Robb, S.L.; Burns, D.S.; Stegenga, K.A.; Haut, P.R.; Monahan, P.O.; Meza, J.; Stump, T.E.; Cherven, B.O.;
Docherty, S.L.; Hendricks-Ferguson, V.L.; et al. Randomized clinical trial of therapeutic music video
intervention for resilience outcomes in adolescents/young adults undergoing hematopoietic stem cell
transplant: A report from the Children’s Oncology Group. Cancer 2014, 120, 909–917. [CrossRef] [PubMed]
45. Trifa, M.; Tumin, D.; Walia, H.; Lemanek, K.L.; Tobias, J.D.; Bhalla, T. Caregivers’ knowledge and acceptance
of complementary and alternative medicine in a tertiary care pediatric hospital. J. Pain Res. 2018, 11, 465–471.
[CrossRef] [PubMed]

© 2019 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access
article distributed under the terms and conditions of the Creative Commons Attribution
(CC BY) license (http://creativecommons.org/licenses/by/4.0/).