M us ic Ther ap y an d M u si c M e d i c i n e f o r C h i l d re n an d Adolescents Olivia Swedberg Yinger,
PhD, MT-BC*,
Lori Gooding,
PhD, MT-BC
KEYWORDS Music therapy Music medicine Child and adolescent psychiatry Mental health Research KEY POINTS Neuroimaging research indicates that listening to preferred music activates reward circuitry in the brain and active musical participation engages more areas of the brain than passive listening. Music therapy is an established health care profession in which music is used within a therapeutic relationship with a music therapist to accomplish nonmusic goals. Emerging research indicates probable effectiveness of specific approaches to music therapy with children and adolescent mental health consumers; however, further research is necessary.
INTRODUCTION Defining Music Therapy and Music Medicine
The American Music Therapy Association (AMTA) defines music therapy as: “.the clinical and evidence-based use of music interventions to accomplish individualized goals within a therapeutic relationship by a credentialed professional who has completed an approved music therapy program.”1 Music therapists use music within a therapeutic relationship to attend to individuals’ physical, emotional, cognitive, and social needs. Although music therapists work with various populations, including individuals of all ages with medical/surgical needs or intellectual disabilities, more music therapists work with persons who have behavioral/emotional disorders than any other single population.2
Funding Sources: Johnson & Johnson/Society for the Arts in HealthCare (O.S. Yinger); National Institute of Aging (L. Gooding). Conflict of Interest: None. University of Kentucky School of Music, College of Fine Arts, 105 Fine Arts, Lexington, KY 40506-0022, USA * Corresponding author. E-mail address: [email protected] Child Adolesc Psychiatric Clin N Am - (2013) -–http://dx.doi.org/10.1016/j.chc.2013.03.003 1056-4993/13/$ – see front matter Published by Elsevier Inc.
childpsych.theclinics.com
2
Yinger & Gooding
Music therapists must complete either a 4-year undergraduate program or a 2-year graduate equivalency program in music therapy at an AMTA-approved college or university. Music therapy degree programs include course work in musical foundations, clinical foundations, and music therapy foundations and principles, as specified in the AMTA Professional Competencies. In addition to course work, music therapy degree programs include 1200 hours of clinical training, culminating in a supervised internship, which typically lasts for 6 months. After completing an AMTA-approved degree program, prospective music therapists are eligible to take the national board certification examination to earn the credential Music Therapist-Board Certified (MT-BC). The MT-BC credential is granted by the Certification Board for Music Therapists (CBMT), a separate, accredited organization.3 After becoming board certified, training in advanced music therapy competencies is offered through mandatory continuing education courses, with the option for training at the master’s and doctorate level. Music medicine, which constitutes the bulk of the literature on the use of music to accomplish nonmusic objectives, is defined as passive listening to prerecorded music provided by medical personnel.4,5 In music medicine treatment, listening interventions are often administered via headphones, and patients may or may not be involved in selecting the music.5 Although music-based interventions are used in both music medicine and music therapy, it is important to understand the difference between the 2, because of variations in the level of training in musical foundations and their therapeutic applications, with music therapists receiving specialized training in these domains.5 Although training and certification are required to practice music therapy, no such specialized training and certification exists for the practice of music medicine. Mechanism of Therapeutic Action: Music and the Brain
To understand the reasons behind the effectiveness of music in augmenting treatment of children and adolescents receiving psychiatric treatment, it is important to first understand the effects of music on the brain. Recent research on the effects of music on cognition, emotional processing, anxiety, and stress has shed light on how music therapy can enhance mental health treatment. There is no single center for musical processing in the brain. Music listening engages multiple areas of the brain, both subcortical (including the medial geniculate body in the thalamus and the amygdala) and cortical (such as the left and right primary auditory cortex). Musical participation also engages the cerebellum, basal ganglia, and cortical motor area.6,7 The fact that active musical participation engages more areas of the brain than passive music listening may explain in part why numerous studies have shown music therapy to be more effective than music medicine at augmenting treatment of neuropsychiatric disorders.7 It seems that active musical participation or engagement with the therapist are integral in the success of music therapy, in addition to the music itself. The effectiveness of music therapy is in part caused by the effects of music on the brain, and in part by the interaction between the client and the music therapist. Stefan Koelsch8 provided an overview of ways in which music modulates attention, emotion, cognition, behavior, and communication. Readers wishing to learn in greater detail about the effects of music, and specifically music therapy, on the brain are referred to the works of Koelsch, Lin, and Taylor, among others.6–8 Neuroimaging techniques are helping researchers understand ways in which music listening and participation affect neural plasticity.6–8 Recent neuroimaging studies have shed light on the activation of the reward circuit in the brain and the role that dopamine plays in musical response. In a study by Blood and Zatorre,9 in which participants listened to self-selected music that gave them chills while undergoing positron emission tomography (PET) scans, increases in cerebral blood flow were
Music Therapy for Children and Adolescents
observed in the left ventral striatum, left dorsomedial midbrain, right thalamus, and anterior cingulate cortex. In addition, decreases in cerebral blood flow were found in the right amygdala, left hippocampus/amygdala, and ventromedial prefrontal cortex. These areas have been associated with brain reward circuitry. Chills were also associated with increases in heart rate, electromyography, and respiration. The control condition in this study consisted of participants listening to music that had been selected by others but that did not elicit chills in the participant. This study shows the importance of musical preference in eliciting desired results within music medicine or music therapy.9 Results from a study by Menon and Levitin10 of 13 participants between the ages of 19 and 24 years, who listened to researcher-selected classical music while undergoing functional magnetic resonance imaging (fMRI), showed that listening to music strongly modulates activity in mesolimbic structures responsible for reward processing, such as the nucleus accumbens (NAc) and the ventral tegmental area (VTA), along with the hypothalamus and insula. Correlations between responses in the NAc and the VTA found in this study indicate that dopamine response may be associated with musical response. The activation of the hypothalamus corroborates what has been previously documented, that music listening has an impact on physiologic responses controlled by the autonomic nervous system. Although the music used in this study was not selected by participants and it is unclear whether it gave them chills, the musical excerpts were rated as highly pleasant by a sample of similar individuals. Results from a more recent study by Salimpoor and colleagues11 support the findings of Menon and Levitin. In Salimpoor and colleagues’11 study, 8 participants between the ages of 19 and 24 years listened to self-selected music that gave them chills while undergoing PET scans. Endogenous dopamine release was found in the striatum during music listening at the time of peak emotional arousal. Follow-up fMRI revealed that the caudate was more involved during anticipation, whereas the NAc was more involved during peak emotional arousal. Physiologic responses measured during music listening showed a relationship between increases in heart rate, skin conductance, and respiration, along with decreases in temperature and blood volume pulse amplitude as the reported intensity of chills increased. Research showing the role of music listening in activating the reward circuitry in the brain has important implications for treatment of addictions, although more research remains to be done in this area. Because music activates reward circuitry in the brain that is also activated by food, drugs, and sex, future research should explore whether music can be used as a substitute for potentially harmful addictive behavior, or as a cue for adaptive coping behavior as an alternative to addictive behavior. In addition to addiction, music neuroscience research has implications for psychiatric treatment with other various disorders, including disorders typically diagnosed in childhood (such as autism), affective disorders, and eating disorders. Research on the neurophysiologic effects of music for each of these populations are discussed. Diagnostic terminology used in this article reflects that used by the investigators of the individual studies reported, which may be based on the Diagnostic and Statistical manual of Mental Disorders, Third Edition (DSM-III), DSM-IV, or DSM-IV Text Revision, depending on when and where the article was published. Readers wishing to know more about diagnostic criteria for participants in the studies reviewed are referred to the original articles. Although awareness of a client’s diagnosis is an important component of music therapy research and guides treatment planning, music therapy treatment is designed based on the individual needs of the client, regardless of their diagnosis. For this reason, several studies reviewed here include descriptions of music therapy treatment of groups of clients with various diagnoses that have similar needs.
3
4
Yinger & Gooding
Autism
A recent study by Emanuele and colleagues12 compared dopamine receptor expression in peripheral blood lymphocytes in adult healthy musicians with age-matched and gender-matched nonmusicians (controls) and adults with autism spectrum disorders (ASD). Significant differences in DRD4 mRNA expression were found between the control group and both experimental groups (musicians and adults with ASD; P.05).12 The finding that adults with ASD were similar to musicians in their levels of DRD4 mRNA may help explain the pronounced interest in music that many individuals with ASD display and provides a rationale for further research into the use of music therapy with this population. Wan and colleagues13 proposed that music may serve as an effective treatment of social communication in individuals with ASD by activating the mirror neuron system, although more research in this area remains to be done. Affective disorders
In a study by Field and colleagues,14 28 depressed adolescent females showed increased activation of the right frontal lobe (a characteristic of chronic depression) during pretest electroencephalography (EEG). Fourteen participants were randomly assigned to listen to upbeat rock music while undergoing EEG. The other 14 participants served as a control group and were asked to relax their minds and their muscles for the same period of time that the treatment group listened to music. The treatment group showed significantly decreased right frontal lobe activation and increased left frontal lobe activation during and after listening to the music (P.05). The control group did not show significant changes on any of the measures. The 3 participants in the treatment group whose EEGs showed frontal lobe shifts further to the right while listening to rock music reported preferring classical music over rock. When these 3 participants were tested again while listening to classical music, they showed frontal lobe shifts to the left. This study shows the importance of considering preference when designing music interventions.14 Koelsch and colleagues15 speculated that changes in anterior hippocampal activity induced by music listening are relevant for individuals with depression or posttraumatic stress disorder, who show reduced hippocampal volume. In their 2010 study, Koelsch and colleagues15 showed that participants who participated in socially directed music-making showed improvements in mood compared with control participants, who maintained a steady beat but lacked both the rich musical experience and the social experience within the study condition. The results of the study by Koelsch and colleagues may indicate the role of dopamine in socially directed musicmaking. In animal research, zebra finches showed significant increases in dopamine after socially directed singing compared with no singing or singing that was not directed at another finch (P
PhD, MT-BC*,
Lori Gooding,
PhD, MT-BC
KEYWORDS Music therapy Music medicine Child and adolescent psychiatry Mental health Research KEY POINTS Neuroimaging research indicates that listening to preferred music activates reward circuitry in the brain and active musical participation engages more areas of the brain than passive listening. Music therapy is an established health care profession in which music is used within a therapeutic relationship with a music therapist to accomplish nonmusic goals. Emerging research indicates probable effectiveness of specific approaches to music therapy with children and adolescent mental health consumers; however, further research is necessary.
INTRODUCTION Defining Music Therapy and Music Medicine
The American Music Therapy Association (AMTA) defines music therapy as: “.the clinical and evidence-based use of music interventions to accomplish individualized goals within a therapeutic relationship by a credentialed professional who has completed an approved music therapy program.”1 Music therapists use music within a therapeutic relationship to attend to individuals’ physical, emotional, cognitive, and social needs. Although music therapists work with various populations, including individuals of all ages with medical/surgical needs or intellectual disabilities, more music therapists work with persons who have behavioral/emotional disorders than any other single population.2
Funding Sources: Johnson & Johnson/Society for the Arts in HealthCare (O.S. Yinger); National Institute of Aging (L. Gooding). Conflict of Interest: None. University of Kentucky School of Music, College of Fine Arts, 105 Fine Arts, Lexington, KY 40506-0022, USA * Corresponding author. E-mail address: [email protected] Child Adolesc Psychiatric Clin N Am - (2013) -–http://dx.doi.org/10.1016/j.chc.2013.03.003 1056-4993/13/$ – see front matter Published by Elsevier Inc.
childpsych.theclinics.com
2
Yinger & Gooding
Music therapists must complete either a 4-year undergraduate program or a 2-year graduate equivalency program in music therapy at an AMTA-approved college or university. Music therapy degree programs include course work in musical foundations, clinical foundations, and music therapy foundations and principles, as specified in the AMTA Professional Competencies. In addition to course work, music therapy degree programs include 1200 hours of clinical training, culminating in a supervised internship, which typically lasts for 6 months. After completing an AMTA-approved degree program, prospective music therapists are eligible to take the national board certification examination to earn the credential Music Therapist-Board Certified (MT-BC). The MT-BC credential is granted by the Certification Board for Music Therapists (CBMT), a separate, accredited organization.3 After becoming board certified, training in advanced music therapy competencies is offered through mandatory continuing education courses, with the option for training at the master’s and doctorate level. Music medicine, which constitutes the bulk of the literature on the use of music to accomplish nonmusic objectives, is defined as passive listening to prerecorded music provided by medical personnel.4,5 In music medicine treatment, listening interventions are often administered via headphones, and patients may or may not be involved in selecting the music.5 Although music-based interventions are used in both music medicine and music therapy, it is important to understand the difference between the 2, because of variations in the level of training in musical foundations and their therapeutic applications, with music therapists receiving specialized training in these domains.5 Although training and certification are required to practice music therapy, no such specialized training and certification exists for the practice of music medicine. Mechanism of Therapeutic Action: Music and the Brain
To understand the reasons behind the effectiveness of music in augmenting treatment of children and adolescents receiving psychiatric treatment, it is important to first understand the effects of music on the brain. Recent research on the effects of music on cognition, emotional processing, anxiety, and stress has shed light on how music therapy can enhance mental health treatment. There is no single center for musical processing in the brain. Music listening engages multiple areas of the brain, both subcortical (including the medial geniculate body in the thalamus and the amygdala) and cortical (such as the left and right primary auditory cortex). Musical participation also engages the cerebellum, basal ganglia, and cortical motor area.6,7 The fact that active musical participation engages more areas of the brain than passive music listening may explain in part why numerous studies have shown music therapy to be more effective than music medicine at augmenting treatment of neuropsychiatric disorders.7 It seems that active musical participation or engagement with the therapist are integral in the success of music therapy, in addition to the music itself. The effectiveness of music therapy is in part caused by the effects of music on the brain, and in part by the interaction between the client and the music therapist. Stefan Koelsch8 provided an overview of ways in which music modulates attention, emotion, cognition, behavior, and communication. Readers wishing to learn in greater detail about the effects of music, and specifically music therapy, on the brain are referred to the works of Koelsch, Lin, and Taylor, among others.6–8 Neuroimaging techniques are helping researchers understand ways in which music listening and participation affect neural plasticity.6–8 Recent neuroimaging studies have shed light on the activation of the reward circuit in the brain and the role that dopamine plays in musical response. In a study by Blood and Zatorre,9 in which participants listened to self-selected music that gave them chills while undergoing positron emission tomography (PET) scans, increases in cerebral blood flow were
Music Therapy for Children and Adolescents
observed in the left ventral striatum, left dorsomedial midbrain, right thalamus, and anterior cingulate cortex. In addition, decreases in cerebral blood flow were found in the right amygdala, left hippocampus/amygdala, and ventromedial prefrontal cortex. These areas have been associated with brain reward circuitry. Chills were also associated with increases in heart rate, electromyography, and respiration. The control condition in this study consisted of participants listening to music that had been selected by others but that did not elicit chills in the participant. This study shows the importance of musical preference in eliciting desired results within music medicine or music therapy.9 Results from a study by Menon and Levitin10 of 13 participants between the ages of 19 and 24 years, who listened to researcher-selected classical music while undergoing functional magnetic resonance imaging (fMRI), showed that listening to music strongly modulates activity in mesolimbic structures responsible for reward processing, such as the nucleus accumbens (NAc) and the ventral tegmental area (VTA), along with the hypothalamus and insula. Correlations between responses in the NAc and the VTA found in this study indicate that dopamine response may be associated with musical response. The activation of the hypothalamus corroborates what has been previously documented, that music listening has an impact on physiologic responses controlled by the autonomic nervous system. Although the music used in this study was not selected by participants and it is unclear whether it gave them chills, the musical excerpts were rated as highly pleasant by a sample of similar individuals. Results from a more recent study by Salimpoor and colleagues11 support the findings of Menon and Levitin. In Salimpoor and colleagues’11 study, 8 participants between the ages of 19 and 24 years listened to self-selected music that gave them chills while undergoing PET scans. Endogenous dopamine release was found in the striatum during music listening at the time of peak emotional arousal. Follow-up fMRI revealed that the caudate was more involved during anticipation, whereas the NAc was more involved during peak emotional arousal. Physiologic responses measured during music listening showed a relationship between increases in heart rate, skin conductance, and respiration, along with decreases in temperature and blood volume pulse amplitude as the reported intensity of chills increased. Research showing the role of music listening in activating the reward circuitry in the brain has important implications for treatment of addictions, although more research remains to be done in this area. Because music activates reward circuitry in the brain that is also activated by food, drugs, and sex, future research should explore whether music can be used as a substitute for potentially harmful addictive behavior, or as a cue for adaptive coping behavior as an alternative to addictive behavior. In addition to addiction, music neuroscience research has implications for psychiatric treatment with other various disorders, including disorders typically diagnosed in childhood (such as autism), affective disorders, and eating disorders. Research on the neurophysiologic effects of music for each of these populations are discussed. Diagnostic terminology used in this article reflects that used by the investigators of the individual studies reported, which may be based on the Diagnostic and Statistical manual of Mental Disorders, Third Edition (DSM-III), DSM-IV, or DSM-IV Text Revision, depending on when and where the article was published. Readers wishing to know more about diagnostic criteria for participants in the studies reviewed are referred to the original articles. Although awareness of a client’s diagnosis is an important component of music therapy research and guides treatment planning, music therapy treatment is designed based on the individual needs of the client, regardless of their diagnosis. For this reason, several studies reviewed here include descriptions of music therapy treatment of groups of clients with various diagnoses that have similar needs.
3
4
Yinger & Gooding
Autism
A recent study by Emanuele and colleagues12 compared dopamine receptor expression in peripheral blood lymphocytes in adult healthy musicians with age-matched and gender-matched nonmusicians (controls) and adults with autism spectrum disorders (ASD). Significant differences in DRD4 mRNA expression were found between the control group and both experimental groups (musicians and adults with ASD; P.05).12 The finding that adults with ASD were similar to musicians in their levels of DRD4 mRNA may help explain the pronounced interest in music that many individuals with ASD display and provides a rationale for further research into the use of music therapy with this population. Wan and colleagues13 proposed that music may serve as an effective treatment of social communication in individuals with ASD by activating the mirror neuron system, although more research in this area remains to be done. Affective disorders
In a study by Field and colleagues,14 28 depressed adolescent females showed increased activation of the right frontal lobe (a characteristic of chronic depression) during pretest electroencephalography (EEG). Fourteen participants were randomly assigned to listen to upbeat rock music while undergoing EEG. The other 14 participants served as a control group and were asked to relax their minds and their muscles for the same period of time that the treatment group listened to music. The treatment group showed significantly decreased right frontal lobe activation and increased left frontal lobe activation during and after listening to the music (P.05). The control group did not show significant changes on any of the measures. The 3 participants in the treatment group whose EEGs showed frontal lobe shifts further to the right while listening to rock music reported preferring classical music over rock. When these 3 participants were tested again while listening to classical music, they showed frontal lobe shifts to the left. This study shows the importance of considering preference when designing music interventions.14 Koelsch and colleagues15 speculated that changes in anterior hippocampal activity induced by music listening are relevant for individuals with depression or posttraumatic stress disorder, who show reduced hippocampal volume. In their 2010 study, Koelsch and colleagues15 showed that participants who participated in socially directed music-making showed improvements in mood compared with control participants, who maintained a steady beat but lacked both the rich musical experience and the social experience within the study condition. The results of the study by Koelsch and colleagues may indicate the role of dopamine in socially directed musicmaking. In animal research, zebra finches showed significant increases in dopamine after socially directed singing compared with no singing or singing that was not directed at another finch (P
