theeffectivenessofmusicinpediatrichealthcare...

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,

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ther

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(in

stru

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nd

son

gba

sed

acti

viti

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2(n=

19):

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play

ther

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(sto

rybo

ok&

free

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HP

LA

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)<

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2000

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up

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fam

iliar

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for

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;Gro

up

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11):

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mu

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(Blo

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)an

dfa

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n’s

mu

sic

(Blo

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grou

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ther

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5


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kers

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58 (40)

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Bu

tter

bur

root

extr

act;

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up

2(n=

20):

Mu

sic

ther

apy

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ptat

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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

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dtr

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T:M

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erap

ist;

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P:H

ealt

hpr

ofes

sion

al.

± R:P

rere

cord

edm

usi

c;L:

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mu

sic.

× A:A

ctiv

ein

volv

emen

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part

icip

ant

(e.g

.,in

stru

men

tali

mpr

ovis

atio

n,s

ong

lear

nin

gan

dsi

gnin

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liste

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g).

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essi

ons

offer

edto

grou

p;O

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sion

soff

ered

one-

to-o

ne.

≈ S:S

tan

dard

ized

inte

rven

tion

;I:I

ndi

vidu

alis

edin

terv

enti

on.


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

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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

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-pos

tch

ange

inE

EG

pow

erfo

rA

DD

child

ren

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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

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kin

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8]A

ggre

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ebe

hav

iou

rs:d

isru

ptiv

ean

dan

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cial

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elop

men

talB

ehav

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hec

klis

t(D

BC

);V

ideo

anal

ysis

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dm

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res

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OV

A

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nch

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le�

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ach

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rou

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rou

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SG

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l)+

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siti

ve&

neg

ativ

eev

ents

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rou

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rou

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rou

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Ta

ble

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nu

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atis

tic

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21)

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tim

e:

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rnal

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me:

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xiet

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iefs

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(10,

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2,11

1)=

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S

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iard

,20

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2]G

rief

sym

ptom

san

dbe

hav

iou

rald

istr

ess

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avio

ur

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ing

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xfo

rC

hild

ren

(BR

IC);

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eave

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rou

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tion

nai

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ts(B

P)

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hin

-gr

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oxon

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ontr

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cial

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k.0

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ange

inB

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trol

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sic

ther

apy

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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

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(3)

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NO

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and

post

hoc

test

s

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nsc

ores

for

mu

sic

grou

p(c

ontr

olgr

oup)

:B

efor

eD

uri

ng

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er(1

)14

.0(1

5.1)

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(14.

9)14

.7(1

4.8)

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(8.9

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ble

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ult

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92[4

4]

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ctu

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ns

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tive

and

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ativ

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mea

sure

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ativ

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ent

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etal

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e:F

(2,2

04)=

1.28

NS

Acu

tean

d/or

chro

nic

phys

ical

illn

ess

Col

wel

let

al.,

2005

[45]

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-con

cept

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rs-H

arri

sC

hild

ren’

sSe

lfC

once

ptSc

ale

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CSS

)∗M

AN

CO

VA

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-to

post

-tes

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ean

diff

eren

ces:

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sic

com

posi

tion

2.08

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com

pos

itio

n2.

00N

S

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bet

al.,

2008

[46]

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uen

cyof

copi

ng

rela

ted

beh

avio

rs

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esa

mpl

ing

ofob

serv

edbe

hav

iou

rs:

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dm

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res

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OV

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dpo

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sts

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EM

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tive

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ect

18.6

3(1

3.0)

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0(2

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001

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ive

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ent

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3(4

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ive

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[47]

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baliz

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anda

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aire

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(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


“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


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


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


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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