A Systematic Review of Randomized Controlled Trials Using Music Therapy for Children

Abstract

Background:

Music therapy is a promising approach widening the potential applications of psychotherapy. Music influences both, psychologic and physiologic parameters, and children are especially responsive to this form of therapy. Many aspects of its action mechanisms remain to be elucidated, underscoring the need for evidence-based medicine (EBM) for clinical use of music therapy.

Aims:

This review seeks to highlight some of the issues of music therapy research and to initiate a discussion about the need for international multicenter cooperation to bring scientifically sound evidence of the benefits of music therapy in pediatric patients.

Methods:

Scientific bibliographic databases were searched for randomized controlled trials on use of music therapy for children. Identified articles were evaluated according to criteria for scientific quality.

Results:

Twenty-eight studies were identified. Most of the trials were biased by the number of participants, and some trials showed the need to improve design of control groups. Indeed, the novelty of this area of study has produced a large number of different studies (with variability in diagnoses, interventions, control groups, duration, and/or outcome parameters), and there is a need for a more homogeneous and systematic approach. Available studies highlight the need to address reproducibility issues.

Conclusions:

This analysis identifies the need for a subsequent series of clinical studies on the efficacy of music in the pediatric population, with more focus on eligibility criteria with respect to EBM and reproducibility.

Introduction

M usic therapy is a psychotherapeutic approach that uses a wide range of musical activities with the intention to treat mental or somatic illnesses.¹ Research on the use of music in medicine is a multidisciplinary field involving natural, social, and behavioral sciences, arts, and even mathematics.² Cardiovascular and respiratory effects of music have been proven and found to be related to tempo in a study comparing different music styles.³ Synchronization of autonomic responses with music was studied further in a recently published follow-up study.⁴ Although some of the effects of music on physiologic parameters, including cognitive functions, are known, the mechanism of action on cellular or molecular level is still unclear. The goal of our review is to highlight some of the issues in the field of music therapy and to initiate a discussion about the need for international multicenter cooperation to bring scientifically sound evidence of the benefits of music therapy. It seems that this is the major obstacle hindering a wider use and acceptance of music therapy in routine clinical medicine.⁵

Music therapy can be classified using various criteria (Table 1). According to the participation of patients, music therapy can be either passive or active. The active form includes improvisation, playing a musical instrument, singing, and even writing lyrics or a whole song. Active music therapy can be spontaneous or instructional (in which the patient follows the instructions of the therapist). In passive music therapy, the patient is asked to listen to music or specific sounds that can be reproduced from a recording, or directly played by the music therapist—this is live music therapy. Similar to other forms of psychotherapy, different models of therapy—psychodynamic, humanistic, behavioral, and eclectic can be used—and individual and group sessions have their indications and advantages.⁶

Table 1.

Main Approaches in Music Therapy

Criteria	Variants
Involvement of participants	Active	Passive
Position in art therapy	Stand-alone	Combinational
Played music	Live	Recorded
Duration of intervention	Single session	Long-term
Music therapy method	Improvised	Instructional
Number of participants in a session	Individual	Group

One of the hypotheses that attempts to explain the therapeutic effects of music is based on increased neuroplasticity, which is considered to be one of the crucial mechanisms behind changes in memory performance. According to electroencephalography (EEG) studies, music therapy may improve learning abilities by increasing oscillatory synchronization in learning-related networks.⁷ Using imaging techniques, Schlaug et al.⁸ revealed structural and functional differences in the brains of adult instrumental musicians compared to nonmusician controls. Factors influencing the variability of these differences included intensity and duration of training and practice, as well as the type of musical instrument played. Some of these researchers recognize the effect of music on fine motor skills. Enhancement of speed and accuracy of motor reactions to different stimuli and improved fine motor discrimination were found in music therapy trials.^8,9 Furthermore, Schlaug et al.⁸ noticed an improvement of visual–spatial, verbal, and mathematical performance in children after long-term musical training. The researchers suggest that music notation plays an important role, because it requires a range of spatial and mathematical skills. But other factors, including attention, motivation, and different daily activities may influence this enhancement.

Music attracts attention effectively. This phenomenon is widely used in practice as a distractive, relaxing, and anxiolytic tool, although the mechanism behind this effect is unknown.² Results of a recent important clinical trial in adults after stroke show that poststroke recovery of attention and memory were improved and depressive behavior induced by the insult was reduced in patients in the music therapy group, compared to controls.¹⁰

Music seems to be an efficient tool for reducing symptoms of depression.¹¹ However, this is dependent on both the listener and the music played. The complex effects of music on emotions have been studied thoroughly, but the detailed mechanism of action localized mainly in limbic and paralimbic structures is still unclear.² Various approaches have been used for studying the effects. Dissonant music evokes unpleasant sensations by altering neuron activity and blood flow in specific brain areas as shown on positron-emission tomography (PET) and functional magnetic resonance imaging (fMRI) scans.^12,13 Blood oxygen level–dependent signals in related brain structures, and so-called “musical chills” were used as a marker of positive or negative emotions.^13,14 Some of the neurologic mechanisms induced by music have been reviewed recently.^15,16

The ultimate goal of mechanistic research is the molecular understanding of music therapy. Although the goal is far from being achieved, there are already some hypotheses and results of interest (Fig. 1). Music induces endocrine changes, which might mediate some of the clinically relevant effects. Listening to self-chosen music for 30 minutes decreases the main stress hormone cortisol.¹⁷ The effects on testosterone levels seem to be gender-specific—increasing in women and decreasing in men.¹⁸ In both genders, testosterone and its metabolite estradiol alter the physiology of neurons by so called organizing and activating effects. In a recently published hypothesis, Fukui and Toyoshima proposed that the alteration of steroid hormone levels and the expression of their specific receptors might be responsible for the effects of music on neuroplasticity, probably mediated by regulating the production of growth factors.¹⁹ Brain-derived neurotrophic factor (BDNF) is crucial for synaptogenesis and neuroplasticity. Music does not only increase BDNF production, but also increases the sensitivity to BDNF by inducing the expression of BDNF receptor and an associated downstream signal transducer—tyrosine kinase receptor B.¹⁰ Whether this will be the main molecular mechanism of music therapy is not clear because there are few studies in this area and they remain to be confirmed. However, what has been found so far points toward molecular neuroscience as the most important research area in music therapy (Fig. 2).

FIG. 1

Molecular mechanisms hypothesized to mediate the effects of music therapy on a cellular level.

FIG. 2.

Research areas that will enable mechanistic understanding of music therapy.

Potential therapeutic targets of music therapy can be identified by analyzing the results of published studies. Music is used to treat a variety of mental and somatic disorders. Music therapy can influence emotions in multiple ways. Anxiety, stress level, and perception of pain during invasive medical procedures can be decreased; symptoms of several psychiatric illnesses, such as schizophrenia, depression, autism, and other developmental and behavioral disorders can be alleviated; physical, literacy, cognition, and communication skills can be improved^{6,10,20

–23}; and better sleep and feeding of preterm infants can be achieved.^24,25

Music therapy should not be seen as an alternative to standard complex medical care, but this therapy can be used to address some conditions as an additional therapeutic approach. If large, long-term clinical trials provide evidence of benefits, music therapy will surely gain wider acceptance and will be used for some specific cases and/or conditions.²¹

The aim of this article is to review published randomized clinical trials on the effects of music therapy in children and to identify key issues that should be solved or prevented in future studies.

Methods

Scientific databases (PubMed/MEDLINE,^® Web of Science, and Google Scholar) were searched, using the key words music therapy, music AND (children OR pediatric), music AND (trial OR study) in November 2009. Target studies were articles with original data on the use of music therapy in children. Limits included randomized control trials (RCTs), publications in English, and research involving children and adolescents age ≤18. Full texts of the articles were obtained from the library of Comenius University, Bratislava, Slovak Republic, or were requested directly from the corresponding authors via e-mail. Other relevant literature sources and cited articles were searched manually. Studies without a control group or studies on healthy children were excluded.

Data extraction was performed (M.M.) and design of the studies, as well as availability of the full-text articles, were evaluated (P.C.). Because of the variability of the studies, a meta-analysis could not be performed.

Results

Twenty-eight studies on music therapy with children were identified. Various diagnoses and conditions were investigated, ranging from minor depression to burns and cystic fibrosis (Table 2).^{25

–52} Most of the trials were characterized by a low number of participants, with 25 of 28 studies having <100 involved children, which is insufficient for evidence-based medicine (EBM) criteria for the specific diagnoses. The duration of intervention was widespread from a single session to several months; in some cases duration was not reported clearly. Questionnaires and psychometric tests were mostly used to assess the effectiveness of music therapy. Twenty-three of twenty-eight identified studies showed a positive effect. The PubMed search was performed with limits set to age <18 and article type randomized control trials. Incorrect identification of studies on PubMed is possible and should be checked manually at least for clinical trials. It cannot be ruled out that, by using this search strategy, some published RCTs might have been missed.

Table 2.

Main Characteristics of Included Studies of Music Therapy with Pediatric Patients

Study & year	Treated condition	# of participants	Intervention length	Main outcome parameter	Result
Field et al., 1998	Depression	28	1–2 sessions;	Right frontal EEG; salivary cortisol level	Benefit
Megel et al., 1998	Immunization	99	Single session	Distress score	Benefit
Standley, 1998	Preterm infants	40	Variable	Weight gain; days to discharge	Benefit
Mudford et al., 2000	Autism	16	10 days	Behavior	No benefit
Grasso et al., 2000	Cystic fibrosis	21	3 months	Compliance with physiotherapy	Benefit
Frantianne et al., 2001	Burns	25	Single session	Pain	Benefit
Hilliard, 2001	Depression	18	8 sessions	Depression	Benefit
Standley, 2003	Preterm infants	32	Single session	Feeding	Benefit
Robb, 2003	Visual impairment	12	2 sessions within 2 week period	Behavior	benefit
Rickson & Watkins, 2003	Aggressive ADHD	15	16 sessions	Prosocial behavior	No benefit
Register, 2004	Low socioeconomic background	86	17 days	Literacy skills	Not clear
Kain et al., 2004	Outpatient surgery	123	5 sessions	Perioperative anxiety	Benefit
Lai et al., 2006	Preterm infants	30	3 days	Sleep; crying	Benefit
Rickson, 2006	ADHD	13	10 weeks	Motor impulsivity	No benefit
Noguchi, 2006	Immunization	64	Single session	Pain	Benefit
Arnon et al., 2006	Preterm infants	31	3 days	Heart rate; sleep	Benefit
Register et al., 2007	Reading disabilities	41	12 sessions	Reading skills	Benefit
Hilliard, 2007	Depression	26	8 weeks; 8 sessions	Depression	Benefit
Jeffs, 2007	Allergy testing	32	Single session	Pain	No benefit
Liu et al., 2007	Small surgical procedures	69	Single session	Anxiety	Benefit
Caprilli et al., 2007	Venipuncture	108	Single session	Anxiety	Benefit
Hendon & Bohon, 2008	Traumatology patients	60	Single session	Mood	Benefit
Kim et al., 2008	Autism	10	12 sessions	Joint attention behavior	Benefit
Kim et al., 2009	Autism	10	12 weeks; 12 sessions	Interpersonal responsiveness	Benefit
Katagiri, 2009	Autism	12	8 sessions	Emotional understanding	Benefit
Sussman, 2009	Developmental disabilities	9	4 sessions	Sustained attention	Benefit
Choi et al., 2008;e-pub ahead of print.	Aggressive behavior	48	15 weeks; 30 sessions	Aggression; self-esteem	Benefit
Yu et al., 2009	Acupuncture	60	Single session	Anxiety	Benefit

EEG; electroencephalograph; ADHD, attention-deficit hyperactivity disorder.

For therapeutic intervention, both, active and passive approaches were chosen (Table 3).^{25

–52} Nine studies used an active music therapy approach, and thirteen used a passive music therapy approach. In five studies, both types of intervention were used, and, in one study, the music therapy approach used was not reported clearly. Children were asked to listen to music reproduced from a recording or live performed by the music therapist. Music therapy was provided individually in thirteen studies and in groups in fourteen studies, depending mostly on the treated condition. In one study, the therapeutic approach was not reported clearly. A specific music style was used and reported in only six studies. In other studies, therapy was structured or improvised; the music style for the passive approach was chosen by the patient or by the therapist. Critically, for interpreting the effects of music therapy, there was a great variability between the control groups—ranging from no intervention to spoken words or video intervention (Table 4).

Table 3.

Characteristics of Intervention Types in Studies of Music Therapy with Pediatric Patients

Study & year	Active/passive	Group/individual	Live/recorded	Music style
Field et al., 1998	Passive	Group	Recorded	Varied (rock & classical)
Megel et al., 1998	Passive	Individual	Recorded	Lullabies
Standley, 1998	Passive	Individual	Live	Lullabies
Mudford et al., 2000	Passive	Group	Recorded	NA
Grasso et al., 2000	Passive	Individual	Recorded	Varied
Frantianne et al., 2001	Passive	Individual	Live	Varied (improvised)
Hilliard, 2001	Active & passive	Group	Live & recorded	Varied (self-selected)
Standley, 2003	Passive	Individual	Recorded	Lullabies
Robb, 2003	Active	Group	Live	Varied (instructional)
Rickson & Watkins, 2003	Active & passive	Group	Live & recorded	Varied (self- selected; improvised)
Register, 2004	Active	Group	Live	Varied
Kain et al., 2004	Active & passive	Individual	Live	NA
Lai et al., 2006	Passive	Individual	Recorded	Lullabies
Rickson, 2006	Active	Group	Live	Varied (instructional & improvised)
Noguchi, 2006	Passive	Individual	Recorded	Not clear
Arnon et al., 2006	Passive	Group	Live & recorded	Lullabies
Register et al., 2007	Active & passive	Group	Live & recorded	Varied
Hilliard, 2007	Active	Group	Live	Varied (improvised)
Jeffs, 2007	Passive	Group	Recorded	Varied (self- & investigator-selected)
Liu et al., 2007	Passive	Individual	Recorded	Lullabies
Caprilli et al., 2007	Not clear	Individual	Live	NA
Hendon & Bohon, 2008	Active	Group	Live	Varied (improvised)
Kim et al., 2008	Active	Unclear	Live	Varied (improvised)
Kim et al., 2009	Active	Individual	Live	Varied (instructional & improvised)
Katagiri, 2009	Passive & active	Individual	Live & recorded	Varied (instructional)
Sussman, 2009	Active	Group	Live	Varied (improvised)
Choi et al., 2008:e-pub ahead of print	Active	Group	Live	Varied
Yu et al., 2009	Passive	Individual	Recorded	Varied (self-selected)

Note: NA = not available, because not reported in the article.

Table 4.

Methodology and Access to Published Studies on Music Therapy with Pediatric Patients

Study & year	Control group	Replicability	Access	Notes
Field et al., 1998	Relaxation	C	+	Diagnosis not clear
Megel et al., 1998	Standard care	A	++	None
Standley, 1998	Standard care	C	+	Multimodal stimulation
Mudford et al., 2000	Standard care	C	+	No variability reported
Grasso et al., 2000	Standard care & familiar music	A	++	Multiple comparison
Frantianne et al., 2001	Standard care; crossover	A	++	Wide age range
Hilliard, 2001	Standard care	C	+	Variable interventions
Standley, 2003	Standard care	B	++	Multiple comparison
Robb, 2003	Play therapy	B	+	Multiple comparison
Rickson & Watkins, 2003	Standard care	C	+	Low number of participants
Register, 2004	Standard care & video education	A	+	None
Kain et al., 2004	Standard care & midazolam	A	+++	Different results according to therapist
Lai et al., 2006	Standard care	A	++	None
Rickson, 2006	Standard care	A	+	Phenotype variability
Noguchi, 2006	Standard care & spoken story	A	+	None
Arnon et al., 2006	Standard care	B	++	None
Register et al., 2007	Standard care	B	+	Multiple comparison
Hilliard, 2007	Social intervention	C	+	None
Jeffs, 2007	Standard care	B	++	Variable intervention
Liu et al., 2007	Standard care	C	++	None
Caprilli et al., 2007	Standard care	C	++	Intervention not clear
Hendon & Bohon, 2008	Play therapy	A	++	None
Kim et al., 2008	Play therapy; crossover	A	++	None
Kim et al., 2009	Toy play	A	++	None
Katagiri, 2009	Contact control	B	+	Several control groups
Sussman, 2009	Standard care	C	+	Complicated design
Choi et al., in press	Standard care	B	+++	None
Yu et al., in press	Standard care	C	++	Missing information about patients

Note: Replicability was assessed subjectively based on the reported and not reported procedures.

A, high replicability; B, medium replicability; C, low replicability.

Access to full-text articles: +++, free access; ++, access with subscription to major publishers; +, access with subscription to minor publishers.

All of the abovementioned characteristics or parameters of the trials and corresponding articles contribute to an important issue of the music therapy field—the lack of replicability. Without a thorough description of the methods including patients, intervention and statistics, it is difficult to replicate the results of the research or to apply such results in the clinical setting.

Discussion

Studies on the effects of music therapy on children have one common feature—variability. Investigators use active and passive music therapy and so, music is played from a recorder or performed live by the therapist. Sometimes the children are involved in choosing the music style or in playing music actively. Music styles vary from improvised to instructional approaches; recorded music is selected by the patients or by the therapists. But, more importantly, in several studies, the music type is not clearly defined or not reported at all, which makes it difficult to replicate the study. Length of each intervention is difficult to estimate from the information provided in the methods section of such articles. The researchers often either mention only the number of sessions or the length of the whole study period. Both data are, however, needed to calculate the total cumulative time spent with patients. This variability and lack of information leads to difficulties with replicating and comparing studies or with performing meta-analyses that might partially resolve another issue of music therapy trials—the low number of participants.⁵

Performing underpowered studies is widespread in the field of music therapy. Other interventions might be seen under similar circumstances as problematic.⁵³ Fortunately, music therapy is seen in general as noninvasive and safe. Nevertheless, the involvement of patients in such studies without a real informative outcome is questionable. Larger studies with enough statistical power to detect the expected small differences are needed.

In one of the investigated trials, the researchers revealed that their results differed between two therapeutic groups, each of which was led by another therapist. It was concluded, that the response to therapy depends on individual skills of the music therapist.³⁶ A highly variable response to therapy is very likely among patients. Furthermore, this variability might also stem from the lack of clear replicable intervention protocol. Different effects of music therapy may be caused by a varied combination of diagnosis, type of music therapy, and type of analyzed outcome. Some conditions are probably difficult to treat, for example as seen with the low responsiveness to music therapy of children with attention deficit hyperactivity disorder (ADHD).⁶ Using vague readouts that are characterized by subjectivity and, thus, lack of reproducibility may lead to misinterpretations of results by both, researchers and readers.

Most of the analyzed studies yielded positive results. However, benefits without a mechanistic explanation are difficult to apply in the clinic. As Oliver Sacks pointed out, “we have … scarcely touched the question of why music, for better or worse, has so much power.”⁵⁴ There is a need for more basic research in the field to uncover the therapeutic mechanisms induced by playing or listening to music. This will not only satisfy our curiosity, but more importantly, deep understanding will enable improved targeting and efficiency of music therapy.² In addition, extensive and complete reporting of interventions in publications reporting the effects of music therapy might enable replication of the studies and application of the results into clinical practice, taking into account the variability between cultures, therapists and health care settings.

Conclusions

Analysis of relevant published studies enables identification of key issues regarding current research in the field of music therapy for children. Several of the problems substantially decrease the informative value of the results, make a replication of the study impossible, and make a comparison or a meta-analysis very difficult. Further research should be focused on identifying the mechanism of action, as well as on clinical confirmation of positive effects via large multicenter randomized controlled trials that meet criteria for EBM.

Footnotes

Disclosure Statement

There are no financial conflicts to disclose.

References

Nickel

, Hillecke

, Argstatter

, Bolay

. Outcome research in music therapy: A step on the long road to an evidence-based treatment. Ann N Y Acad Sci, 2005; 1060:283–293.

Hillecke

, Nickel

, Bolay

. Scientific perspectives on music therapy. Ann N Y Acad Sci, 2005; 1060:271–282.

Bernardi

, Porta

, Sleight

. Cardiovascular, cerebrovascular, and respiratory changes induced by different types of music in musicians and non-musicians: The importance of silence. Heart, 2006; 92:445–452.

Bernardi

, Porta

, Casucci

et al. Dynamic interactions between musical, cardiovascular, and cerebral rhythms in humans. Circulation, 2009; 119:3171–3180.

Lopez

. Music therapy: The long way to evidence-based methods—pending issues and perspectives. Ann N Y Acad Sci, 2005; 1060:269–270.

Gold

, Voracek

, Wigram

. Effects of music therapy for children and adolescents with psychopathology: A meta-analysis. J Child Psychol Psychiatry, 2004; 45:1054–1063.

Thaut

, Peterson

, McIntosh

. Temporal entrainment of cognitive functions: Musical mnemonics induce brain plasticity and oscillatory synchrony in neural networks underlying memory. Ann N Y Acad Sci, 2005; 1060:243–254.

Schlaug

, Norton

, Overy

, Winner

. Effects of music training on the child's brain and cognitive development. Ann N Y Acad Sci, 2005; 1060:219–230.

Costa-Giomi

. Does music instruction improve fine motor abilities? Ann N Y Acad Sci, 2005; 1060:262–264.

10.

Särkämö

, Tervaniemi

, Laitinen

et al. Music listening enhanced cognitive recovery and mood after middle cerebral artery stroke. Brain, 2008; 131:866–876.

11.

Maratos

, Gold

, Wang

, Crawford

. Music therapy for depression. Cochrane Database Syst Rev, 2008; 23:CD004517.

12.

Blood

, Zattore

, Bermudez

, Evans

. Emotional responses to pleasant and unpleasant music correlate with activity in paralimbic brain regions. Nat Neurosci, 1999; 2:382–387.

13.

Koelsch

. Investigating emotion with music: Neuroscientific approaches. Ann N Y Acad Sci, 2005; 1060:412–418.

14.

Zatorre

. Music and the brain. Ann N Y Acad Sci, 2003; 999:4–14.

15.

Levitin

. The neural correlates of temporal structure in music. Music Med, 2009; 1:9–13.

16.

Levitin

, Tirovolas

. Current advances in the cognitive neuroscience of music. Ann N Y Acad Sci, 2009; 1156:211–231.

17.

Khalfa

, Bella

, Roy

et al. Effects of relaxing music on salivary cortisol level after psychological stress. Ann N Y Acad Sci, 2003; 999:374–376.

18.

Fukui

, Yamashita

. The effects of music and visual stress on testosterone and cortisol in men and women. Neuro Endocrinol Lett, 2003; 24:173–180.

19.

Fukui

, Toyoshima

. Music facilitates the neurogenesis, regeneration and repair of neurons. Med Hypotheses, 2008; 71:765–769.

20.

Talwar

, Crawford

, Marratos

et al. Music therapy for in-patients with schizophrenia: Exploratory randomized controlled trial. Br J Psychiatry, 2006; 189:405–409.

21.

Gold

, Wigram

, Elefant

. Music therapy for autistic spectrum disorder. Cochrane Database Syst Rev, 2006; 19:CD004381.

22.

Whipple

. Music in intervention for children and adolescent with autism: A meta-analysis. J Music Ther, 2004; 41:90–106.

23.

Wigram

, Gold

. Music therapy in the assessment and treatment of autistic spectrum disorder: Clinical application and research evidence. Child Care Health Dev, 2006; 32:535–542.

24.

Standley

. A meta-analysis of the efficacy of music therapy for premature infants. J Pediatr Nurs, 2002; 17:107–113.

25.

Standley

. The effects of music-reinforced nonnutritive sucking on feeding rate of premature infants. J Pediatr Nurs, 2003; 18:169–173.

26.

Field

, Martinez

, Nawrocki

et al. Music shifts frontal EEG in depressed adolescents. Adolescence, 1998; 33:109–116.

27.

Megel

, Houser

, Gleaves

. Children's responses to immunizations: Lullabies as a distraction. Issues Compr Pediatr Nurs, 1998; 21:129–145.

28.

Standley

. The effects of music and multimodal stimulation on responses of premature infants in neonatal intensive care. Pediatr Nurs, 1998; 24:532–538.

29.

Mudford

, Cross

, Breen

et al. Auditory integration training for children with autism: No behavioral benefits detected. Am J Ment Retard, 2000; 105:118–129.

30.

Grasso

, Button

, Allison

, Sawyer

. Benefits of music therapy as an adjunct to chest physiotherapy in infants and toddlers with cystic fibrosis. Pediatr Pulmonol, 2000; 29:371–381.

31.

Frantianne

, Prensner

, Huston

et al. The effect of music-based imagery and musical alternate engagement on the burn debridement process. J Burn Care Rehabil, 2001; 22:47–53.

32.

Hilliard

. The effects of music therapy–based bereavement groups on mood and behavior of grieving children: A pilot study. J Music Ther, 2001; 38:291–306.

33.

Robb

. Music interventions and group participation skills of preschoolers with visual impairments: Raising questions about music, arousal, and attention. J Music Ther, 2003; 40:266–282.

34.

Rickson

, Watkins

. Music therapy to promote prosocial behaviors in aggressive adolescent boys—a pilot study. J Music Ther, 2003; 40:283–301.

35.

. The effects of live music groups versus an educational children's television program on the emergent literacy of young children. J Music Ther, 2004; 41:2–27.

36.

Kain

, Caldwell-Andrews

, Krivutza

et al. Interactive music therapy as a treatment for preoperative anxiety in children: A randomized controlled trial. Anesth Analg, 2004; 98:1260–1266.

37.

Lai

, Chen

, Peng

et al. Randomized controlled trial of music during kangaroo care on maternal state anxiety and preterm infants' responses. Int J Nurs Stud, 2006; 43:139–146.

38.

Rickson

. Instructional and improvisational models of music therapy with adolescents who have attention deficit hyperactivity disorder (ADHD): A comparison of the effects on motor impulsivity. J Music Ther, 2006; 43:39–62.

39.

Noguchi

. The effects 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.

40.

Arnon

, Shapsa

, Forman

et al. Live music is beneficial to preterm infants in the neonatal intensive care unit environment. Birth, 2006; 33:131–136.

41.

, Darrow

, Standley

, Swedberg

. The use of music to enhance reading skills of second grade students and students with reading disabilities. J Music Ther, 2007; 44:23–37.

42.

Hilliard

. The effects of Orff-based music therapy and social work groups on childhood grief symptoms and behaviors. J Music Ther, 2007; 44:123–138.

43.

Jeffs

. A pilot study of distraction for adolescents during allergy testing. J Spec Pediatr Nurs, 2007; 12:170–185.

44.

Liu

, Mehta

, Armstrong

et al. A randomized prospective study of music therapy for reducing anxiety during cast room procedures. J Pediatr Orthop, 2007; 27:831–833.

45.

Caprilli

, Anastasi

, Grotto

et al. Interactive music as a treatment for pain and stress in children during venipuncture: A randomized prospective study. J Dev Behav Pediatr, 2007; 28:399–403.

46.

Hendon

, Bohon

. Hospitalized children's mood differences during play and music therapy. Child Care Health Dev, 2008; 34:141–144.

47.

Kim

, Wigram

, Gold

. The effects of improvisational music therapy on joint attention behaviors in autistic children: A randomized controlled study. J Autism Dev Disord, 2008; 38:1758–1766.

48.

Kim

, Wigram

, Gold

. Emotional, motivational and interpersonal responsiveness of children with autism in improvisational music therapy. Autism, 2009; 13:389–409.

49.

Katagiri

. The effect of background music and song texts on the emotional understanding of children with autism. J Music Ther, 2009; 46:15–31.

50.

Sussman

. The effect of music on peer awareness in preschol age children with developmental disabilites. J Music Ther, 2009; 46:53–68.

51.

Choi

, Lee

. Group music intervention reduces aggression and improves self-esteem in children with highly aggressive behavior: A pilot controlled trial. Evid-Based Complement Alternat Med, 2008 July 17e-pub ahead of print.

52.

, Liu

, Li

, Ma

. Effects of music on anxiety and pain in children with cerebral palsy receiving acupuncture: A randomized controlled trial. Int J Nurs Stud, 2009; 46:1423–1430.

53.

Halpern

, Karlawish

, Berlin

. The continuing unethical conduct of underpowered clinical trials. JAMA, 2002; 288:358–362.

54.

Sacks

. The power of music. Brain, 2006; 129:2528–2532.