Music Therapy and Hearing Impairments

The concept of providing music therapy for those who have hearing impairments or use a cochlear implant seems like a far-off and impractical concept to many people. This is a big misconception because most people believe that a large percentage of individuals with hearing impairments can not hear at all, which is not true. Although having a hearing impairment is a far greater communication and sensory handicap that hearing people realize, there are still many challenges that can be overcome. Alice Ann Darrow (1989, p. 61) writes that “blindness” is ‘an environmental handicap’ while deafness is a social disorder that keeps one from people”. This post is going to cue in on how individuals with cochlear implants are able to enjoy music and what methods of music therapy work best when working with these individuals.

Cochlear implants (CI) focus on transmitting only sounds that are essential to speech recognition. This means that most aspects of music are not transmitted, making it difficult for individuals with CIs to percieve timber and pitch (Hidalgo, Pesnot, Marquis, Roman, & Schön, 2019). The one aspect of music that is transmitted the best is rhythm (Gfeller & Knutson, 2003). Rap music is a common preference of teenagers with implants and line dancing music is a common preference of adults with implants because both rap and line dancing music usually have strong, steady beats (Gfeller & Knutson, 2003). Rap music also typically has rhythmically spoken lyrics over the steady beat. This is important to note because the rhythmicity of the words make the songs more easily recognizable. Individuals with cochlear implants have an easier time identifying songs with lyrics and a harder time identifying instrumental songs.

(http://www.vancouversun.com/health/should+cochlear+implant/7502865/story.html)

Since cochlear implants focus mainly on speech, individuals with cochlear implants can also have a hard time discriminating timber of instruments, tone quality, and pitches. These difficulties can vary based on relative health of the auditory nerve, the cause of deafness, whether a full insert of the implant was possible, whether all the implant channels are active, the age at implantation, cognitive and perceptive abilities, etc. For implant users, it is easier to compare the timbre of instruments to each other rather than listening to an instrument alone. The skill of instrument identification could possibly strengthen after listening practice (Gfeller & Knutson, 2003). Some people with cochlear implants say that the tone quality of most instruments sound “unnatural or tinny” (Gfeller & Knutson, 2003). Differentiating pitches, when listening or singing, is perceived to be one of the most difficult aspects of music listening for implant recipients. Studies show that adults with CIs are more self-conscious than children about singing in public and that they find it very difficult to sing along with an external pitch (Gfeller & Knutson, 2003). 

Listening to music and having repeated exposure to music stimuli can play a major role in how music can affect someone’s life (Gfeller & Knutson, 2003). With repeated exporesure, music would be able to be used in daily life and be more easily enjoyed by individuals with CIs. There is already emerging evidence that specific music training is able to improve music perception for people who use CIs (Jiam, Deroche, Jiradejvong, & Limb, 2019). The existing studies have used in-person training models and have not tapped into online resources yet (Jiam, Deroche, Jiradejvong, & Limb, 2019).

Music therapy can be extremely beneficial for those utilizing cochlear implants. One thing music therapists’ have to be very specific about when doing music therapy with individuals with CIs is the environment. Unlike when recording an acapella piece or singing with a choir, a music therapist would not want a very acoustic room. The room should be filled with many things that will absorb sounds and echoes. Without things like carpets and curtains, the sound will bounce around and cause distortion (Gfeller & Knutson, 2003). It is also important for therapists to dive into their patient musical preference. Just like individuals without CIs, individuals with CIs all like listening to different types of music. Music therapists’ want the patients to enjoy what they are listening to, not be turned away from it.

The four basic types of music therapy interventions used for patients with CIs are listening to music, moving to music, singing, and playing instruments (Gfeller & Knutson, 2003). Listening to music can be functional in many ways, such as providing opportunities for social interaction or even working on speech recognition. Moving to music also is a great avenue for increasing social interaction in a group setting. Singing can target many different essential areas, like socialization, articulation, and exploring one’s voice. Joining a choir can be a very social experience. Singing or saying rhythmic chants like “Going on a Bear Hunt” or “5 Little Ducks” can focus on the range of their speaking voice and articulation of speech. Using vocal exercises or therapeutic singing, music therapists can assess vocal intonation, vocal quality, range, awareness of nasal quality, volume of speech and singing voice, pitch matching, melody imitation, free vocalization, and can also exercise the diaphragm (Darrow, 1989, p. 64). Playing musical instruments is a fun way to work on understanding the sounds you are listening to and specifically focusing on those musical elements like instruments, tone quality, and pitches.

Music therapy can benefit those with hearing impairments in so many ways, especially when it comes to speech, language, and socialization. It is crucial as a music therapist when working with someone with a cochlear implant to understand how the implant works, what other factors in their life could affect therapy, and what objectives are most realistic for the patient to try and achieve.

-Amanda Brennen, MT Intern

References

Darrow, A. A. (1989). Music therapy in the treatment of the hearing-impaired. Music Therapy Perspectives, 6, 61–70.

Gfeller, K., & Knutson, J. F. (2003). Music to the Impaired or Implanted Ear.

Hidalgo, C., Pesnot-Lerousseau, J., Marquis, P., Roman, S., & Schön, D. (2019). Rhythmic Training Improves Temporal Anticipation and Adaptation Abilities in Children with Hearing Loss during Verbal Interaction. Journal of Speech, Language, and Hearing Research, 62(9), 3234–3247

Jiam, N. T., Deroche, M. L., Jiradejvong, P., & Limb, C. J. (2019). A Randomized Controlled Crossover Study of the Impact of Online Music Training on Pitch and Timbre Perception in Cochlear Implant Users. Journal of the Association for Research in Otolaryngology : JARO, 20(3), 247–262.

http://www.vancouversun.com/health/should+cochlear+implant/7502865/story.html (image)

Pediatric Music Therapy and Pain Management

One of the big responsibilities of music therapists in pediatric hospitals is to help work on pain management. There are multiple different types of pain that children may experience: procedural and postsurgical pain, pain from sickle cell disease, hemophilia, cystic fibrosis, cancer related pain, and trauma related pain (Bradt, 2013). Music therapy can’t replace the typical pain medications but can be used in conjunction to help manage the pain. Bradt states that a child's understanding of pain depends on the cognitive development of the child. These different stages can affect how you may implement music therapy with a child. Children in the preoperational stage (ages 2-7) have a more passive attitude towards pain. Children in the concrete operational stage (ages 7-12) begin to understand the negative emotions that come with pain. Children in the formal operational stage (above 12 years of age) possess the capability to reflect on pain in a more abstract way (22). Children tend to perceive most of their treatment as out of their control, “three categories of control-enhancing techniques have proven to be effective in the pediatric setting: behavioral, decisional, and cognitive control” (22). The biggest emotional things that children experience related to pain are anxiety/fear and depression.

There are various scales used to rate the amount of pain a child is feeling. Some examples include The Visual Analogue scale (VAS), Graphic rating scales and multidimensional pain scales. The VAS is “a 100-mm line, the length of which represents the continuum of an experience such as pain” (26). Graphic ratings scales involve the use of numeric ratings, word graphics, pain thermometers, and/or facial scales. Multidimensional pain scales are geared at mearing various dimensions of the pain experience. A music therapy assessment of pain will often assess more than the pain itself. It will also assess the patient's emotional state, developmental level, cognitive understanding, musical preferences, etc. “The assessment should also include information about the musical qualities of the pain. Many attributes of pain can be easily translated into musical parameters”  two examples of this would be pulse (how fast is the pain) and timbre (instruments that have a sharp sound/dull sound). 

There are various different types of music therapy methods that are designed to help with pain management. Those methods include Receptive music therapy, improvisational music therapy, Re-creative music therapy, and compositional music therapy. Some examples of interventions within each of these methods are as follows (31):

• Receptive MT

  • Music Guided Imagery: Use of imagery supported by music to help children relax, find refuge from pain, escape hospital environments, and be empowered in the healing process.

  • Vibroacoustic Therapy: Use of sound in the audible range to produce mechanical vibrations that are applied directly to the body, resulting in relaxation and analgesic effects. 

• Improvisational MT

  • Tonal Intervallic Synthesis: The purposeful use of tones and timbres that resolve dissonance into consonance to influence circulation, release, integration, pain, and physical perception.

  • Improvised music for Integration: The use of drumming, toning, and chanting in an improvisatory style to help the child integrate the hurt.

• Re-creative MT

  • Singing songs: Singing favorite songs to shift the child's focus away from the pain, improve perceived level of control, normalize sterile hospital environment and encourage interaction with others. 

• Compositional MT

  • Songwriting: the use of songwriting to give the child the opportunity to articulate their feelings and direct them into a creative form, provide cognitive reframing, and to enhance the child's understanding of pain and/or procedure. 

Bradt states that inadequate treatment of pain in the hospital can have a severely negative impact on a child and create long-term negative effects, “Music therapists play an important role in assuring that children's pain management needs are adequately addressed” (53). Music Therapy can be an amazing tool for children to help contextualize and deal with their pain. 

-Sara Demlow, MT Intern

Sources:

Bradt, J. (2013). Guidelines for music therapy practice in pediatric care. Gilsum, NH: Barcelona.

Music Therapy & Hearing Impaired

Researchers, clinicians, and cochlear implant (CI) manufacturers are engaged in ongoing work to understand what makes music sound like music to a person with a CI. The nature of music experiences and the skill set achievable by children using CIs are debated, but after researching the effects of music on auditory learning and the positive effects music therapy can have on those with cochlear implants. Reifinger conducted a study to determine whether a treatment program using music notation would improve the verbal rhythmic and intonational accuracy of hearing impaired children, and to determine the degree of transfer to other reading and verbal skills. Thirty-five children with hearing impairment, ages 3 through 12 years, participated in a treatment program for 40 consecutive days. The study was initiated to investigate the use of music notation training in facilitating non-linguistic elements of speech with children with hearing impairment. This study also sought to determine the degree of improvement and transfer in speech rhythm and inflection in these children when music notation was paired with spoken and written language. The study found positive results were obtained in speech prosody, stimulation, generalization, and music learning, all areas which enhance the personal esteem of the children with hearing impairment (Reifinger, 2018). 

Auditory stimulation is essential during infancy and early childhood for the normal development and maturation of the central auditory neural pathways. Neural responses in the auditory pathways of most children receiving a cochlear implant after age three and a half reportedly do not typically reach normal levels, even after years of experience with the implant. Darrow (1989) and her colleagues began to focus research on children who had received a cochlear implanted between thirteen and twenty-four months because they had significant language delay. One of the most consequential topics within their research is to develop post-implant auditory training programs that use music to help optimize the hearing acuity attained by cochlear implant recipients. Darrows research study analyzed the results of eighteen experimental studies involving children ranging in age from four to nine years and concluded that students who received music training experienced significantly greater gains in phonological skills compared to peers who did not participate in music. 

Another area of study is the effect music can have on improving one’s ability to distinguish background noise after receiving a cochlear implant. Hearing background noise is accomplished by following the particular pitch range and timbre of a target voice, such as that of the teacher’s voice in a noisy classroom. It is also accomplished by focusing on the direction of the sound, which can be aided by bilateral implants. Music therapy can focus on improving pitch and timbre perception with musical sounds and therefore may improve pitch and timbre perception of speech sounds. Interventions included exploring vocal and instrumental timbres, moving to musical sounds, remembering and producing rhythmic patterns and timbres, determining emotional content of pieces, and writing and performing simple rhythm pieces are exercises used in Reifinger’s studies. Results indicated that compared with peers having similar hearing impairments who received no music instruction, the group of students that participated in music education showed significantly greater ability to discriminate between two similar vowel or consonant speech sounds, which is particularly important because it suggests that a sharpening of the language perception skills of children with hearing impairment may be achieved with music training.

Barton and Robbins (2015) working as clinicians with young children with CIs  see the potential that music has to jumpstart the mechanisms required to process and produce spoken language, as well as other important developmental skills. The Oxford dictionary defines ‘jumpstart’ as: ‘to give an added impetus to something that is proceeding slowly’. They view music as valuable, not just at the initial stages of CI use, but across the lifespan of the listener. Barton and Robbins broke down the effects music can have on increasing hearing capabilities after a cochlear implants into core values music therapists aim to achieve. 

The first value Barton mentions is attention. The assumption is that music as an auditory stimulus has the ability to attract attention. Music training provides a mechanism for education in the auditory domain, enhancing the ability to direct “spotlight.” This is a critical skill, because what we hear is determined by how well we listen and by our capacity to direct our attention to the input of highest interest while monitoring our surroundings for changes that require immediate attention. The second assumption is that music can modulate and regulate emotion. The ability to identify and understand emotion is the very essence of communication. Unfortunately, children with CIs often have difficulty extracting the subtle emotional cues that are present in spoken language. Because music embodies a wide range of emotions and has the capacity to evoke moods and feelings, explored the notion that music could provide more salient emotional cues than spoken language for CI children (Barton, 2015). 

Growing evidence indicates that experience with sound may provide a sort of scaffolding for the development of general cognitive skills that depend on the representation of temporal or sequential patterns. Hearing is the primary gateway for perceiving sequential patterns of input that change over time (rather than over space, as in vision). 

The image above (Staum, 1987) shows an example of music interventions that can be used to build or “scaffold” language into rhythmic interventions. By beginning with simple rhythmic patterns therapists can help patients to hear and feel this rhythm. Therapist will help patients by adding simple syllables to the rhythmic patterns. As patients begin to feel more comfortable with identifying and pronouncing sounds like “pah” “mah” or “tah”, the therapists can start to add simple words to the rhythmic pattern. As the patients vocabulary grows, the music therapists can begin to add different simple rhythms together to create sentences. Even though it is a process starting with clapping simple rhythms, the outcome can help patients with CI speaking in full sentences. 

There is also the assumption that music has the potential to condition and prompt behavior without requiring conscious will. Perception, the assumption is that music training can affect the perceptual mechanisms necessary for language comprehension. This is especially relevant for children with receptive and expressive language impairments. CIs are designed to provide sufficient information for the user to attain high levels of speech recognition and production (Crain, et al 2017). However, music requires more fine structure timing and pitch cues than speech. Thus, for children using CIs, pitch discrimination and production can be difficult because of spectral limitations of the device. Some studies have shown that music training can improve pitch perception in children with CIs. Even though we are in the beginnings of learning more and more about the effect music can have on improving those with hearing impairments, research continues to back up to significant success music therapy can have on discerning background noise, increasing discernment in emotional tone, and rhythmic patterns and timbres. 

-Macy Fehl, Music Therapy Intern

References

Barton, C., & Robbins, A. M. (2015). Jumpstarting auditory learning in children with cochlear implants through music experiences. Cochlear Implants International: An Interdisciplinary Journal, 16, S51–S62. https://doi.org/10.1179/1467010015Z.000000000267

Crain, K. L., LaSasso, C., & Leybaert, J. (2010). Cued Speech and Cued Language for Deaf and Hard of Hearing Children. Plural Publishing, Inc.

Darrow, A. A. (1989). RMT-BC, Music Therapy in the Treatment of the Hearing-Impaired, Music Therapy Perspectives, (6)1, 61–70 https://doi.org/10.1093/mtp/6.1.61

Reifinger, J. L. (2018). Music Education to Train Hearing Abilities in Children with Cochlear Implants. Music Educators Journal, 105(2), 57–63. https://doi.org/10.1177/0027432118809404

Staum, M. J. (1987). Music Notation to Improve the Speech Prosody of Hearing Impaired Children. Journal of Music Therapy, 24(3), 146–159.

MT for Adults with TBI

The brain is made up of three main sections: the cerebrum, cerebellum, and brain stem. Together these sections make up the central nervous system that helps to transfer electric signals to the rest of the body. Within the cerebrum, there are four lobes that are responsible for different brain functions different jobs that are focused within the lobes. The frontal lobe is where Broca’s area is located, known to help control expressive speech and language. The frontal lobe also has an effect on music and the ability to sing. The temporal lobe is home to Wernicke’s area, which is responsible for the auditory processing and the comprehension of speech. This area of the brain is vital to language because impulses from the auditory system create an electrical signal-producing sound. Classic parietal lobe functions include sensory integration, memory retrieval, and mental rotation. In the domain of music, these mental functions translate to cognitive and perceptual manipulations with musical materials, such as learning and memory of sequences of pitches and rhythms. The supramarginal gyrus, near the temporal-parietal junction, is a region within the parietal lobe that has appeared in several studies on learning and memory. Activity in the supramarginal gyrus was significantly associated with memory performance, especially in musically trained subjects (Gabb, 2006). The occipital lobe is responsible for vision and visual perception.

 There is a theory that a person can be either “right-brain dominant” or “left-brain dominant.” The right side of the brain is connected with artistic expression and creativity, while the left brain is connected with logical and verbal skills. This has led people to assume that musical abilities and engagement are only connected to the right side of the brain. While there is no proof to back up this theory, there is robust evidence that music is involved with all parts of the brain because melody & rhythm—the elements of music—stimulate both sides of the brain at one time. The left hemisphere is involved with skills such as rhythmic sequences and identification from the premotor cortex, instrument play, and reading music. The right side focuses on pitch and timbre quality recognition, melodic representation, performance skills and the ability to track rhythm. While it is true that the right side of the brain is heavily involved in music-making or music-listening in regards to analyzing pitches and creative expression--music involves both sides of the brain as well as the cerebellum. This increases the ability for the sides to “communicate” with one another.

Because different aspects of music are located in many different spots (are process by different spots rather than “lcoated”) along both hemispheres of the brain, music can be used to help aid patients with traumatic brain injuries (TBI)  by creating new neural pathways in the brain to relearn skills lost due to damaged areas of the brain to create new ways of relearning where old neuron pathways are no longer functioning. (Thompson, 2014 does this citation belong to the prviosu sentence? ) Webster (1806) defines a traumatic brain injury as a “non-degenerative, non-congenital insult to the brain from an external mechanical force, possibly leading to permanent or temporary impairment of cognitive, physical, and psychosocial functions, with an associated diminished or altered state of consciousness”. Period goes inside quotation. TBI arises when the mechanics within the frontal lobe are not able to regulate the controls it was designed to control. These injuries threaten the function of neurological, physiological, cognitive, psychological and social dysfunction (Vik, Skeie, Vikana, Specht, 2018).

Because of the drastic life change, depression is a common side effect for those working through the process of rehabilitation with a TBI. Patients become withdrawn and apathetic to the rehab process. These feelings prevent engagement in social relationships, meaningful interaction, and commitment to the rehab process. By adding music therapy into these patients’ rehab team opportunities can decrease agitation and increase relaxation by helping focus on eye contact and relearning language and daily activities. Patients are given multiple different types of therapy each supporting the client’s growth through different means of structure. 

Music Therapy is defined as “the therapeutic application of music to cognitive, sensory, and motor dysfunctions due to disease of the human nervous system” (Magee, 2005). Like other therapies, there are different techniques used to use music as a form of rehabilitation, but one therapy style continues to be utilized with those diagnosed with a TBI. Neurologic music therapy is defined as an advanced form of music therapy that utilizes evidence-based techniques to treat the brain. (Magee, 2005) These techniques emphasize the use of music and rhythm to achieve non-musical goals in the areas of cognition, physical movement, and speech (Gardiner & Horwitz, 2015). 

Neurological music therapy (give NMT acronym here after stating what it is the first time) focuses on research which has demonstrated that music and rhythm affect many different areas of the brain at the same time, and the brain that engages in music is actually changed by that engagement (Baker, 2007). Music can help build new neural connections in the brain through experience and exposure which improves rehabilitative potential and the ability to create new neural pathways after trauma or injury. This allows individuals to lead more productive and functional lives. “Research has shown rhythmic cues provide comprehensive optimization information to the brain for re-programming movement. This makes it important that patients enter the rhythmic period because the period template contains critical information to optimize motor planning and motor execution” (Thaut, Mcintosh, & Hoemberg, 2015). Introduce and fold the quote in--prepare the audience for what you are talking about like “in a 2015 essay about NMT research Thaut, Mcintosh, and Hoemberg explain the use of rhythm in motor planning: “

In 2005, Magee began to study case studies of patients of all ages with varying severity of TBI injuries and observe the effect music therapy had on the individuals. She found treatments that place “greater emphasis on relationship factors may be more likely to engage and or re engage patients with TBI who are resistant to behavior change.” (Magee, 2005 pp.5). For example, a music therapist worked with a forty-four-year-old man 14 months post-TBI. It was noted he had no regular visitors and no family for support. At the beginning of therapy, the music therapists could not stay longer than two minutes before J would become abusive and the therapist would need to leave for her safety. When the therapist noticed J's main habit of smoking, she used this as a way to communicate. The therapists and client began to write songs about what smoking made him feel and escape from. After 6 months of therapy, J went from a 2-minute session to a 45-minute session. Nurses confirmed J was calmer and had learned an outlet to channel frustration, songwriting (Magee, 2005). Comma doesn’t work after fruststration, Use an em dash “frustration--songwriting” 

Music therapy targets pragmatic communication skills such as turn-taking, listening, and eye contact. Evidence of music’s ability to increase attention, memory, and executive function, all are features of neurobehavioral disorders, have been tested with varying clients. M. is a 26-year-old man who sustained a severe TBI in a motor vehicle accident. Becoming agitated upon any movement or sound in his room, the music therapist focused on using music to reduce agitation. Music was tailored to match M’s behavior. M. did not react well to music in the beginning, but over the next five sessions, he improved becoming more alert and conscious of his surroundings and was beginning to make eye contact with the therapist. Two weeks later he began to sing and tap along to the music, attempting to communicate with the therapist. Music listening was found to enhance cognitive recovery and mood of individuals who have recently experienced a middle cerebral arterial stroke, and greater orientation and abilities to learn and retain new information. Separate those two sentences “Music listening was also show to lead to great orientation..” Patients can become more aware of and engage in strategies that increase their attention and tolerance levels. Music can be used as a way to recall information like creating a song to know how long to brush your teeth or how to get dressed in the morning. Rhythm and melody provide structure to organize, chunk and remember verbal information. (Magee, 2005)

Music’s ability to be used globally throughout the brain gives music therapy the power to be a successful source in the rehabilitation process. Studies have extensive research confirming the benefits of music-supported therapy in other areas of neurologic music therapy (Vik, Skeie, Vikana, Specht, 2018). Music therapy continues to recreate nerve pathways that have become blocked or destroyed by brain injury giving patients a new way to do old activities. Music gives structure to clients who need to be reminded how to brush their teeth, walk with proper gait, and need a positive outlet of expression. Depression and anxiety are common with TBI, but with music, clients are able to move past the difficult transition into a new way of living with coping activities and support groups. It is important that continual research is conducted in the field of neurological music therapy is needed to continue to make connections with music’s ability to be used as a new way to “rewire” pathways severed in the brain. Fix this last sentence--not sure what you were trying to say, but I think if you read it out loud, you will hear that it has some grammatical errors and doesn’t quite make sense. Also the NMT does conduct continual research--maybe here just suggest some resources/journals that people can read to be updated on current research.

-Macy Fehl, Music Therapy Intern

References

Baker, M., (2007). Music moves the brain to pay attention. In M. T. van Dijk, A. A. Fenton (Eds.), Neuron (pp. 832–845). Amsterdam, Netherlands: Elsevier Inc.

Gaab, N., Schulze, K., Ozdemir, E., & Schlaug, G. (2006). Neural correlates of absolute pitch differ between blind and sighted musicians. Neuroreport, 17(18), 1853–1857. 

Gardiner, J. C., & Horwitz, J. L. (2015). Neurologic music therapy and group psychotherapy for treatment of traumatic brain injury: Evaluation of a cognitive rehabilitation group. Music Therapy Perspectives, 33(2), 193-201. doi:10.1093/mtp/miu045

Magee, W., & Baker, M. (2009). The use of music therapy in neuro-rehabilitation of people with acquired brain injury. British Journal of Neuroscience Nursing, 5(4), 151-156.

Magee, W. (2005). Music therapy methods with children, adolescents, and adults with severe neurobehavioral disorders due to brain injury. Music Therapy Perspectives, 29(1), 5-13.

Vik, B., Skeie, G., Vikana, E., Specht, K. (2018). Effects of music production on cortical plasticity within cognitive rehabilitation of patients with mild traumatic brain injury. Brain Injury, 32(5), 634-643. doi:10.1080/02699052.2018.1431842

Thaut, M. H., Mcintosh, G. C., Hoemberg, V. (2015). Neurobiological foundations of neurologic music therapy: Rhythmic entrainment and the motor system. Frontiers in Psychology, 5(1) doi:  10.3389/fpsyg.2014.01185

Thompson, W.F. (2014). Music, thought, and feeling: Understanding the psychology of music (2nd ed.). New York: Oxford University Press.

This is Your Brain on Music: The Science of Human Obsession by Daniel J. Levitin

MT in the NICU

Music Therapy for Premature Infants in the NICU

Every year, approximately 9.6% of infants in the United States, and 15 million worldwide are born prematurely (Scott et al., 2018). For those born prematurely, many are diagnosed with illnesses or disabilities that hinder physiological and mental development. Several studies have been conducted to gather data in an attempt to improve the well-being of parents who have an infant in a neonatal intensive care unit, as well as increase the premature infant’s health (Ettenberger et al., 2017). By using several approaches, music therapy is proven to have positive effects not only on the health and development of these infants but on the parents and the parent-child relationships as well (Haslbeck, 2012).

         The neonatal intensive care unit, also commonly referred to as the NICU, is home to many infants born prematurely, or before 37 weeks (O’Toole et al., 2017). Premature infants have a lower survival rate since they are not able to fully mature during the remainder of the third trimester, a vital time for organ maturity (Haslbeck, 2012; O’Toole et al., 2017). Unfortunately, there are several stressors in the NICU that can harm infant growth. Besides having difficulties feeding and motor abilities, infants are often overstimulated by sound. This is putting infants in situations of sensory overstimulation that can overstress their bodies. Infant overstimulation can have detrimental effects on their health and should be further considered during interactions with family and doctors, as well as therapies and techniques for premature infants. Besides potentially harmful NICU environments, premature infants often develop neurological disabilities, developmental disabilities, and behavioral problems (Scott et al., 2018). Since they are more susceptible to neonatal illnesses such as intraventricular hemorrhage or sepsis, they are at a higher risk for these long-term effects. Along with these risks, individuals born prematurely were found to have behavioral problems involving internalizing, externalizing, and attention which increased social withdrawal and depression, lower academic performance, increased attention deficit hyperactivity disorder, and aggression compared to those born non-prematurely (Scott et al., 2018). According to Aylward (2005), over 50% of low birth weight infants will need special education, up to 20% will repeat grades, and 16% to 47% will experience symptoms of attention deficit hyperactivity disorder. Even though the odds of these problems increase for these infants, the cause-effect relationship between birth weight and cognitive disorders can be confounded by other factors related to those conditions.

         Music has potential to drastically affect the body in psychological and physiological ways, especially for infants. Through methods of reporting and physiological measurements, music has been proven to lower the perception of pain, positively affect heart rate, increase learning and behavior, lower stress levels, and produce more desirable states (Haslbeck, 2012; O’Toole et al., 2017). These positive aspects of music stimuli affect the development of infants by reducing physical stressors on their bodies and increasing brain maturity. One important effect is an increase in oxygen saturation level. Cevasco and Grant (2005) conducted a two year study of 188 infants that investigated several factors regarding music, specifically lullabies, and premature weight gain. Although weight gain prior to post intervention in the hospital was not statistically significant, their results found that music provided positive sucking patterns for infants, increasing oxygen saturation level. Increased levels of oxygen saturation lead to better eyesight, calmer states, faster times to fall asleep, increased initiation of nutritive sucking, and faster weight gain. Furthermore, the researchers found infants who listened to lullabies had lower weight loss, lower behaviors of stress, and a short length of stays in isolettes, NICU, and hospital overall due to the positive impacts on oxygen saturation rate, as well as heart and respiratory rates.

         With music being a universal healing method, techniques in the field of music therapy became popularly used for premature infants in the NICU as well as in various other settings. Due to the challenges that can arise while being in a NICU setting, such as overstimulation, music therapists’ have to be NICU-MT certified to practice in the NICU. In the neonate setting, music therapy is used “as an intervention based on music and auditory stimulation that incorporates musical elements such as rhythm and melody or sounds based on the acoustic intrauterine environment...used by either music therapists or other healthcare professionals in neonatal care” (Haslbeck, 2012, p. 205)

(Miami Herald, 2019)

One big challenge that families can face while their baby is in the NICU is feeding. In order to go home from the NICU, babies need to be able to receive their nutrients by not fully relying on gavage feedings (forced feedings). Jayne Standley, a music therapy professor at Florida State University, knew that feeding in the NICU could be a long and difficult process, and she decided that she was going to find a way that music could help the baby progress. The Pacifier-Activated-Lullaby (PAL) is a music therapy method developed by Jayne Standley to promote non-nutritive sucking (sucking when there is no fluid being produced) for infants, therefore leading to better nutritive feeding abilities and self-regulation (Haslbeck, 2012; Standley et al., 2010). The PAL uses electrical signals to an attached cassette and provides music only when an infant sucks, growing the suck-swallow-breathe reflex that is essential to weight gain and growth (Haslbeck, 2012). The original researcher conducted a randomized study that included three trials with 68 premature infants, and the results showed a shorter length of gavage feedings as well as female infants learning how to nipple feed faster than male infants (Standley et al., 2010). Additionally, Cevasco and Grant (2005) studied the PAL music therapy method in their two year study. By placing speakers in the corners of infants’ isolettes or cribs, infants were assigned to four groups corresponding to the number of trials, and each used the PAL for fifteen minutes per trial. The researchers studied their suckling in an attempt to see if it went along with the music, specifically how many times they stopped, and for how long. Despite not reaching statistical significance and having music played at 65 dB, which is above the recommended level, infants increased their sucking time, showed improvement in learning, coordination, and endurance. Furthermore, Cevasco and Grant (2005) found infants using the PAL stayed awake and alert, but still calm, after feedings instead of agitated or sleepy like those not using PAL.

         In recent studies of music therapy in the NICU, researchers have begun to focus on the effects of using the mother’s voice and its comparison to recorded singing. Cevasco and Grant (2005) conducted a study with the PAL and found that infants, even as young as one day old, increased their sucking rate when hearing their mother’s voice compared to another female's voice. Similarly, Haslbeck (2012) found live music of female voices to be more beneficial than recorded, engaging the infant to enjoy an activity with the mother and initiate a bond between them. 

         Parents with premature infants in the NICU can have several concerns that impact their mentality as well as their relationship with their infant. After observing hospitalized children separated from their parents in the 1930s, John Bowlby and Mary Ainsworth developed attachment theory which showed infant-parent bonding as essential to healthy development (Bretherton, 1992). Despite often being focused on the child’s relationship with the mothers, there have been other studies suggesting alternate figures such as fathers, siblings, and daycare providers can provide the satisfaction of an intimate relationship that an infant needs in its first year of life (Bretherton, 1992). Infant-parent bonding is difficult for premature infants in the NICU since parents are often physically separated from their infants through isolettes or rooms. This physical separation along with parent’s trauma and emotional struggles due to the end of pregnancy, survival uncertainty, and feelings of fear and guilt can cause negative parental stress, affecting their attachment process (Haslbeck, 2012).

         Two common methods - kangaroo care and kinesthetic stimulation - are often used in the NICU to help with the attachment process. Kangaroo care provides premature infants with skin-to-skin contact with parents, often lying on their chests. Haslbeck (2012) also stated if an infant is too fragile to be touched, kinesthetic stimulation allows for rocker-beds to sway infants’ mattresses back and forth, often timed with music that is played through the crib. This added element of music can provide additional development and growth that would not be achieved with the methods alone. In addition to standard care such as kangaroo care and kinesthetic stimulation, music therapy benefitted infants’ feeding habits overall (O’Toole et al., 2017). Having positive feeding habits helps babies in the NICU go home sooner, and being well enough to go home is what you want to help with bonding. In Ettenberger et al. (2017), a treatment group using music therapy along with kangaroo care was compared to a control group of standard care alone. Although the study with thirty-six infants was not statistically significant, the infants in the music therapy group went home approximately 60 days sooner and reported 50% re-hospitalizations four months after discharge than the group without music therapy.

         Different music therapy techniques can not only benefit the infant, but also benefit parents and the relationship with their infant. Whipple (2000) used observation of interaction through stress behaviors and parent self-reports of twenty sets of parents and premature, low birth weight infants, to see if training parents with an hour of music instruction and techniques would affect interaction. The study found parents with the instruction reported spending more time with their infants as well as shorter hospitalization stay and greater weight gain. However, the results were not statistically significant due to the small sample size and a follow-up one month after discharge showed little difference between the control and experimental groups. Without knowing what the home environment was after discharge, further research with longitudinal studies could show how increased parent training could provide long term benefits.  Promoting parental presence through music therapy can encourage bonding and lower anxiety and fear that comes with being in a hospital environment (Ettenberger et al., 2017; O’Toole et al., 2017). Translating those skills to the home setting is essential for continuing the benefits of music therapy after being discharged from the hospital.

Many babies in the NICU are diagnosed with illnesses or disabilities that hinder physiological and mental development. The NICU environment can be very stressful for the babies and their families. There are many positive aspects of music stimuli, such as increased learning and behavior and lower stress levels, that affect the development of infants by reducing physical stressors on their bodies and increasing brain maturity. Music therapy can be an essential part of the growth and development for a baby in the NICU.

-Amanda Brennen, MT Intern

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