Music Therapy · "Music Therapy is the clinical and evidence-based use of music interventions to accomplish individualized goals within a therapeutic relationship by a credentialed

Danae Mollenkamp, MT-BC

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"Music Therapy is 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” (American Music Therapy Association).

Music Therapy Working with Hospitalized Children and Their Families

What is Music Therapy?

Music therapy involves:

● Assessing the needs and strengths of individuals referred to services

● Creating non-musical goals and objectives to address the unique physical, cognitive, academic,

emotional, and social needs of the individual

● Using the unique qualities of music to create engaging, structured and effective interventions

● Implementing evidence-based treatment techniques in one-to-one or group sessions

Though the AMTA appreciates all music-making efforts, the following music-based programs are not

considered clinical music therapy:

● Music education classes

● Playing background music or listening to music in headphones for therapeutic purposes

● Special music ensembles not led by a music therapist

● Professional musicians performing for students in schools

What are the Qualifications of a Music Therapist?

Music therapists are highly trained professionals whose degrees require knowledge in psychology,

medicine and music. Music therapists are trained to work with children with disabilities and have

extensive knowledge regarding the impact of disabilities and how to adapt for a student’s specific

abilities. Music therapy must be administered by a credentialed professional who has completed the

following:

● Completed a bachelor’s degree or higher at an AMTA approved school with 1200 hours of

clinical training, including a supervised internship

● Obtained the credential Music Therapy -Board Certified (MT-BC) by passing a standardized

certification exam given by the Certification Board for Music Therapists


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What Can a Music Therapist Do for Hospitalized Children and Their Families?

Music therapists can facilitate familiar and comfortable experiences for children and family members

through the use of music that not only provide comfort, but also can reduce the negative effects of

hospitalization, aid recovery, and benefit both the child and family (Ayson, 2008; Barrickman, 1989;

Baron et al., 2011; Bradt, 2013; Hendon & Bohon, 2008; Jacquet, 2011; Robb, 2003; Wolfe & Waldon,

2009).

• Provide opportunities for positive communication and expression of emotions

• Encourage and teach positive coping skills

• Provide opportunities for choices and control, improving social and emotional well-being

• Emphasize and build on the positive strengths of the child and family and empower them to be

active in treatment process

• Decrease stress, anxiety, and depression

• Promote typical development through normalization of the environment and age-appropriate

experiences

• Strengthen family relationships and decrease isolation

• Provide resources for parents to interact with their ill child

• Aid recovery process by decreasing negative emotions associated with increased heart rate, blood

pressure, and pain

• Increase positive emotions, hope, self-esteem, and quality of life

• Create a pleasurable atmosphere for respite and relaxation

CASE EXAMPLE

Sarah is an 11-year-old girl who is frequently hospitalized due to medical complications associated with a

developmental disability. Sarah also has an intellectual disability and problems with her airway, leading to

limited verbal communication skills. Sarah is able to communicate with her mother through sign language

with a few signs but struggles to communicate her wants and needs to her family and may become

frustrated when others cannot understand her. Sarah’s family members are often visiting with her in her

hospital room, but don’t know to engage with Sarah in positive ways. After receiving a referral from

Sarah’s nurse, the music therapist consults with Sarah and her mother. Sarah’s mother tells the music

therapist about songs she and daughter sing at home together and asks Sarah which songs she would like to

sing. Sarah signs her favorite songs for her mom to share with the music therapist and the music therapist

uses the guitar to accompany as she sings with Sarah and her mother. Sarah’s mom does actions with Sarah

during the songs and smiles and laughs with her daughter. By enabling Sarah and her mom to sing their

favorite songs together, the music therapist created a familiar and normalized environment for them,

provided them with an opportunity to positively interact, provided a positive distraction from the stressful

hospital environment, and gave Sarah the opportunity to express her preferences and make choices.


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Music therapists go through extensive training and follow established standards for professionalism

and accountability in order to provide quality and evidence-based clinical music therapy. While other

music professionals may have some of the same knowledge or skills that a music therapist does,

music therapy can only be practiced by credentialed music therapists.

Music Therapists: What to Expect

What are the Qualifications of a Music Therapist? A music therapist is an individual who has completed the educational and clinical requirements set by the

American Music Therapy Association (AMTA) and holds current board certification from the

Certification Board for Music Therapists (CBMT). Practicing music therapists must also follow AMTA

requirements for continuing education and standards of practice. An individual must have completed the

following steps in order to practice music therapy:

Educational and Clinical Training Requirements • Graduate with a bachelor’s degree (or its equivalent) or higher from a music therapy

program approved by AMTA

o This degree includes extensive work in music, psychology, and music therapy-

specific courses

• Complete a minimum of 1,200 hours of supervise clinical work including:

o Pre-internship training at an approved music therapy program

o A 6-month internship at an AMTA-approved National Roster or University

Affiliated internship program

• All educational programs address standardized Professional Competencies established by

the AMTA to ensure quality education and clinical training

Board Certification Requirements

“The purpose of board certification in music therapy is to provide an objective national standard

that can be used as a measure of professionalism and competence by interested agencies, groups,

and individuals” (AMTA). Music therapists must complete and pass an objective written test

administered by the CBMT in order to demonstrate that they possess the knowledge, skills, and

abilities to competently practice according to current music therapy standards.

Ongoing Requirements

Once a board-certified music therapist, an individual must:

• Adhere to the CBMT Code of Professional Practice

• Recertify every 5 years through a continuing education program or re-examination

• Adhere to the AMTA Standards of Clinical Practice and Code of Ethics


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Provide consistency and predictability

Collaborate with the Interdisplinary Team

Provide treatment based on the strengths

and needs of the patient and family

Provide opportunities for typical

development

Provide Resources and Advocate for Families

Coach Family Members to Interact

with the Ill Child

Treat based on family values and preferences

Create comfort, safety, familiarity, and normalization

Facilitate interaction between patients and

their families

Support Family Bonding

What Standards of Practice Does a Music Therapist Follow?

“Standards of Clinical Practice for music therapy are defined as rules for measuring the quality of

services” (AMTA). The Standards of Clinical Practice for music therapists are established by the AMTA

should be applied to all music therapy practice. All music therapists have a responsibility to adhere to

uphold these standards in their practices. This document contains:

• General Standards for music therapy practice, including procedures for:

o Referral and acceptance of clients

o Assessment of clients

o Treatment planning

o Implementation of interventions

o Documentation

• 10 additional categories containing standards of practice for specific settings and clientele

What is the Role of a Music Therapist While Working with Families in a Pediatric Setting?

How is music therapy delivered in a pediatric medical setting?

While the services offered by music therapists vary depending on the facility, music therapy always

involves:

- Referral → A health care team member identifies a need or caregiver may request services

- Assessment → The music therapist determines what the patient and family’s needs are, if they will

benefit from music therapy, and what delivery method is appropriate

- Treatment and Ongoing Assessment → The music therapist provides treatment as deemed

appropriate, assessing and documenting the patient’s progress throughout treatment

Group Music Therapy May be organized by age and available to all; family members may attend

Individual Sessions As needed with patient and/or family members

Support Groups Sibling and parent support groups; diagnosis-specific groups

Resource or Training Music therapist provides resources and training for caregivers to interact with child or

support family bonding


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In addition to the medical issues faced by hospitalized children, the hospital environment can disrupt not only

a child’s development, social interaction, and well-being, but also the overall well-being of the family.”The

onset of a diagnosis or illness can be likened to ‘a new member of the family’” (Wolfe & Waldon, 2009, p.

41). It presents new challenges and responsibilities within unexpected changes in family roles and

functioning. The hospital environment is often characterized by inconsistency, unpredictability,

unfamiliarity, lack of social support, and limited control over one’s own actions and activities (Robb,

2003). Hospitalization, whether short-term or long-term, can be a chaotic and stressful experience for both

children and their family members alike and can contribute to negative outcomes when their needs are unmet.

Hospitalized Child

Peer relations

Family relations

Academics

Emotional Well-Being

Development

Physical Well-Being

“When a child undergoes treatment for an illness, the disruptions in

everyday living patterns can have an effect on school attendance, peer

relations, family and sibling relations, emotional well-being, physiological

functioning, and self-concept.”

Wolfe and Waldon, 2009, p. 24

Hospitalized Children and Their Families: The Effects

How does hospitalization affect the child? Hospitalization is a potentially threatening situation for children who may not have previous experience or

knowledge on how to deal with painful situations, separation from family, and many new stressors in the

environment (Ferguson, 1984). Hospitalization can negatively impact multiple areas of life, and even

older or more experienced children are at risk. In fact, children with chronic conditions that require

frequent hospitalization are at an even greater risk for negative outcomes associated with hospitalization

(Burke et al., 1997). Hospitalization takes children out of their familiar environments and subjects them to

a series of new and often painful experiences that affect their well-being, development, social skills, and

future adjustment (Wolfe & Waldon, 2009, p. 24).


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Well-Being

• Increased distress and negative emotions during hospitalization are associated with:

o Stimulation of the sympathetic nervous system, including increased heart rate and blood

pressure, which can delay recovery (Hendon & Bohon, 2008)

o Increased risk for anxiety, depression, and emotional or behavioral issues (Hendon &

Bohon, 2008; Kariuki et al., 2016)

• May be unable to regulate emotions and express feelings, wants, and needs in a positive way,

instead responding to stressors with fear and negative behaviors (Barrickman, 1989; Bradt, 2013)

• Decreased interest or opportunities for play and preferred activities (The Phoenix Society)

• Limited opportunities to practice independence and choice-making, leading to lowered self-

esteem (Robb, 2003)

Development • Lack of typical experience and stimulation lead to developmental

delays or regression of skill already acquired (Robb, 2003)

• Absence of supportive adults/caregivers interrupt parent-child

bonding and attachment

• Limited opportunities to gain independence and control over their

own behaviors and external environment, leading to:

o Issues with developing coping skills

o Lowered self-esteem, depression, and withdrawal

o Aggressive or irritable behavior (Robb, 2003)

o Excess independence or dependence on caregivers

• Language development may be delayed due to lack of exposure,

limited energy to talk, or needs being met by hospital staff without

having to communicate them (Robb, 2003)

• Difficulties with cognitive, social, and academic skills

• Risk of negative developmental impact heightens during critical

periods, such as the first two years of life or puberty (Bradt, 2013)

Social Interaction

• May become withdrawn or isolated

• Lost opportunities to develop and maintain relationships with peers

• Separation from supportive adults may lead to a lack of emotional support needed to cope with

the stressors associated with hospitalization (Robb, 2003)

Future Impact

• First hospitalization experiences can strongly influence response to future hospitalizations (Bradt, 2013)

• Children who experience frequent hospitalizations have higher incidences of poor academic

performance, unstable employment, conduct disorders, and emotional issues (Robb, 2003; Wolfe

& Waldon, 2009, p. 24)

• Developmental delay or regression leads to deficits in many functional areas of life

“While the aims of

hospitalization are geared

towards improving quality of

length of life, the process of

hospitalization and its

associated procedures may

impact the child’s development

significantly.”

Wolfe and Waldon, 2009, p. 24


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How does hospitalization affect the family?

• Normal family routines are disrupted due to unpredictability of the

situation and trying to maintain two homes (Gentile, 1987)

• Lack of privacy

• Family members may be separated

• Emotional distress can cause break down in functioning and conflict

among family members (Gentile, 1987)

• Limited capacity to focus on building and maintaining relationships

within the family (Gentile, 1987)

How does hospitalization affect the caregivers? • Living in emotional distress, including feelings of hopelessness,

depression, fear, frustration, shock, and anxiety

• Grief regarding the loss of hopes and dreams for their child, loss of

normalcy, and even anticipation of long-term disability or death (K.

Nelson, personal communication, 11/8/2018)

• May struggle to find a balance of becoming hypervigilant of the ill

child and treating their child normally (Wolfe & Waldon, 2009)

• May not know how to interact or provide comfort for their child

(Wolfe & Waldon, 2009)

• Constant worry, financial burden, sleep deprivation, and changing

roles create significant stress (Wolfe & Waldon, 2009)

How does hospitalization affect siblings? • Separation from caregivers and family members disrupts relationships

• Lost opportunities for experiences within family may lead to

development regression or delay

• Development of sibling relationships are disrupted, which are often

key in development of personality and identity in children (Knecht et

al., 2015)

• May experience emotions such as loneliness, feeling ignored and

neglected, jealousy, rejection, confusion, and anxiety (Knecht et al.,

2015)

• Emotional distress and family changes may affect academic performance and social interaction

(Knecht et al., 2015)

• Older siblings may feel overburdened with additional responsibilities and lose opportunities for

peer interaction and independence (Knecht et al., 2015)

“My reactions to approaching

hospital stays affect the manner in

which I relate to my family. I

experience a progression of

emotions similar to what occurs

in the grieving process,

beginning with the scheduling of

surgery and ending weeks after

hospital discharge. I deny

upcoming surgical dates until they

are scheduled and resent others

who remind me beforehand. After

denial, I feel angry and powerless.

I try not to really those emotions

to my daughter as I prepare her

for the hospital stay. The routine

of packing, organizing babysitting

services, and scheduling social

appointments after the hospital helps remind me that normal life

will continue. However, the

emotional turmoil caused by the

hospital stay lasts weeks after

discharge. I noticed regressive

behavior in my children and feel

let down at homecoming after

having adapted to the hospital

routine.”

- From Annarita Gentile

(1987) regarding the

hospitalization of her

daughter


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“Family members tend to interact and form relationships like the individual pieces of a

mobile. Each is capable of independent behavior, but each is connected to another, and

together they make the whole family. Any movement or change in a single member

influences and changes the group as a whole.”

Coleman, 2002

Family-Centered Care

Why Families? Families play a key role in not only a child’s development, but also in the process of recovery and coping

with stress. Managing a child’s psychosocial symptoms and needs of the family can lead to improved

well-being and decreased length of stay for the child, and increased satisfaction with care for all involved.

• Families are the most

valuable source of

information and support

• Families are complex

social-emotional

organizations with many

different factors that

contribute to its

functioning (Coleman,

2002)

• Any change to one family

member affects the whole

family (Coleman, 2002)

• Helping parents see their children as normal helps decrease anxiety and enables them to meet the

child’s emotional needs (Anderson et al., 2010)

• Family relationships are significant for child development (Coleman, 2002)

• “Good parent-child relationships promote optimal child outcomes, especially behavior and mood”

(Coleman, 2002)

• Parents and siblings play a key role in fostering positive coping attitudes in the ill child, which

can be significant for treatment compliance, long-term adjustment, and recovery (Blotcky et al.,

1985)

• Positive family communication and functioning are associated with positive psychological

adjustment in both the ill child and in family members (Blotcky et al., 1985)


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Focus on strengths of the family

Dignity and respect

Individual beliefs, values, culture, and coping styles of the family

Communication and collaboration with the family

Understanding and incorporating developmental needs of the child

Empowering families to provide care

Family-Centered Care

Family-Centered care is an approach to health care that recognizes the family as the expert on

the child and includes all family members as care recipients. It is a multi-disciplinary approach that

involves meeting family’s complex needs, including physical, psychological, social and spiritual facets

in order to improve family functioning and the patient’s overall well-being (Dall'Oglio, et al., 2018). By

incorporating the family’s unique culture into the child’s care, the family can play a role in the child’s

psychological well-being and progress even when they are not physically present (Shoemark et al., 2015).

Some of the core elements of Family-Centered Care include:

In a study done by Arabiat et al. (2018), parents' definitions of Family-Centered Care included:

❖ “Being cared for by people as if they were family, with the whole family unit included”

❖ “Family being able to be together”

❖ “Care that is centered on the needs of the family not just the individual”

❖ “Caring for the family not just the patient, being sensitive to how the family is coping”

❖ “Recognizing that individuals are part of a family which is closely connected to their

wellbeing”


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❖Connects people through joint

attention: people experience

music simultaneously

❖Music is a normalized,

comfortable, and familiar

experience

❖Flexible and adaptive to meet

needs in the moment

❖Provides techniques and

resources that can be used

after hospitalization

❖Can provide an alternate form

of communication

(Lindenfelser et al., 2012)

“We have the unique opportunity

to bring people together in a

joyful, supportive experience

where the child can be

themselves and the family can

have meaningful interactions

through the music. Everyone

comes together - drawn to the

music - to play, sing and move.

They turn off the TV and put

down the tablet for a few minutes

and engage. Siblings laugh and

parents relax. I’ve even had

grandparents dance in the

room!”

- Kirsten Nelson, MT-BC (Personal

communication, 11/8/18)

Why Music Therapy?

Music Therapy with Hospitalized

Children and Families

“Music therapy serves as a consistent and predictable period for joy, playfulness, and family bonding in a child’s daily

routine” (Bradt, 2013, p. 481).

Approaches

Common approaches used within Family-Centered Care include:

• Collaborative: music therapists work together with the

health care team to provide care based on needs and

identified by the team in a way that respects the family’s

unique culture and structure (Lindenfelser et al., 2012)

• Biopsychosocial: care of the child is based on a

comprehensive view of the whole child and the interactive

influences of the child’s circumstances, perceptions, and

family interaction (Coleman, 2002)

• Others: humanistic and psychodynamic approaches,

which emphasize internal conflicts, emotional expression,

and mindfulness (K. Powell, personal communication,

11/5/2018)

Goals

Goals are primarily for the hospitalized child, however, music

therapists can address the needs of the whole family while starting

with the child’s needs Some of the common goals referenced in

research and used by pediatric music therapists to address multiple

domains of functioning in the child include:

• Improve communication skills

• Improve use and knowledge of positive coping skills

• Improve leisure skills

• Decrease stress and anxiety

• Promote developmental progress

• Increase self-expression

• Increase family bonding and integration

• Improve self-esteem

• Increase socialization


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Instrumental Improvisation:

Set a small xylophone to a

blues scale and present the

group members with slips of

paper or faces to represent

common feelings, such as

happy or angry. Give each

member an opportunity to

pick a mood from the given

options and improvise on

the xylophone while the MT

play a blue progression on

the guitar. For a fun twist,

have the rest of the group

members guess the mood

that the individual is

playing.

Case Example:

L is an 11-year-old boy who

loves to drum. The MT

visits L on a weekly basis

and plays guitar with him

while he plays an electronic

drum set with his favorite

music. L’s older brother is

often at the hospital with

him and expresses an

interest in playing the

electric guitar. The MT

visits both L and his brother

and models how to play the

electric guitar. After L has

learned how to play some

simple things on the guitar,

the MT brings in a electric

bass to create a “rock band”

for the two brothers to play

together.

EXAMPLES Interventions

Music therapists use a variety of interventions, music, and materials and with children

and their families according to their individualized needs and preferences. Music and

materials should always be developmentally appropriate for the child, and

interventions should provide opportunities for both children and their families to make

choices and be as successful as possible. Provide structure and support within sessions

and interventions while allowing children and their families to have as much control as

possible. (Robb, 2003; K. Nelson, personal communication, 11/8/18; Wolfe &

Waldon, 2009).

Common interventions to use with families include:

• Singing familiar songs preferred by the child and family

• Playing with instruments together

• Instrumental improvisation: Give everyone a turn!

• Songwriting

• Musical games

• Music for recreation, such as learning to play the ukulele

• Music and Movement

• Music listening for relaxation and comfort

• Permanent musical products, such as recording a song written by the child or

recording a mother’s singing voice for her infant

Including Family Members

While family bonding and caregiver interaction is important, it is important to be

sensitive to the needs of the family in the moment. Encourage all family members to

participate but respect their wishes. When family members do choose to participate in

music therapy, facilitate interaction among family members and use tasks that require

active participation and attention. This may aid the family members in “forgetting”

their worry, even for just a few minutes. Strategies may include:

• Utilize turn-taking and imitation of each other to facilitate interaction

• Model positive interactions for family members

• Encourage playfulness, humor, and creativity among all family members

• Use live music as often as possible

• Avoid excessive music therapy jargon when speaking with family members

“Even when parents and family members don’t think they’re participating, they’re

experiencing the music and responding to it”

- Kelli Rae Powell, MT-BC (Personal communication, 11/15/18)


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Resources If you are interested in learning more about music therapy and how it can be used to support

hospitalized children and their families, consider consulting the following resources and

publications for additional information: ● www.musictherapy.org

● www.cbmt.org

● Music Therapy and Pediatric Medicine :A Guide to Skill Development and Clinical

Intervention by Wolfe and Waldon. (2009)

● Music Therapy in Pediatric Healthcare: Research and Evidence-based Practice by Robb

(2003)

Where can you find research about music therapy? The American Music Therapy Association produces two scholarly journals where research in

music therapy is published and shared:

• The Journal of Music Therapy is published by AMTA as a forum for authoritative

articles of current music therapy research and theory. Articles explore the use of music in

the behavioral sciences and include book reviews and guest editorials. An index appears

in issue 4 of each volume (Description from AMTA)

• Music Therapy Perspectives is designed to appeal to a wide readership, both inside and

outside the profession of music therapy. Articles focus on music therapy practice, as well

as academics and administration (Description from AMTA)

Music therapy research can also be found in variety of publications, including psychology,

nursing, music, and medical journals.

Contact Information

Danae Mollenkamp

Music Therapy Intern

Marwood Manor Skilled

Nursing and Rehabilitation

(920)-342-9340

[email protected]

American Music Therapy

Association:

8455 Colesville Road, Suite

1000

Silver Spring, MD 20910

Phone: 301-589-3300

Fax: 301-589-8175

To Verify That A Music

Therapist is Board Certified:

Certification Board for Music

Therapists

506 East Lancaster Avenue,

Suite 102

Downingtown, PA 19335

Phone: 610-269-8900

Fax: 1-610-269-9232

Online Verification available

online at: www.cbmt.org

http://www.cbmt.org/


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Testimonials

❖ “I'm lucky that my daughter's stay was short and a one-time event. Even in her short stay, the music therapy significantly improved her mood (mine too!). She still talks positively about the music therapy session almost a year later. Also, since her session, we have used music to help her learn/concentrate, express her emotions” (Moses, 2015).

❖ “We already do a great deal of music at home with our child, but there was

still something incredibly special about my toddler's ability to connect with a masked stranger through music, when she was absolutely terrified of anyone else. The session offered my child control (she loved telling the music therapist what to play and watching her requests be honored) and helped ease her into a much-needed nap” (Moses, 2015).

❖ “We now try to play more music and are working on improving her singing

skills now that her vocabulary has recovered and improved even more” (Moses, 2015).

❖ “The music therapy was so wonderful for [child]. We have a very musical

family so this made her feel right at home” (Moses, 2015).

❖ ‘‘It’s a way of communicating that she totally gets, it’s a way for us to reach

her” (Lindenfelser et al., 2012).

❖ “Music therapy provided a way for the girls (siblings) to see that L’s just like us, it brought them closer’’ and ‘‘the sessions have been great for her sister to see that it’s about her too” (Lindenfelser et al., 2012).


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’Useful Tips for a Pediatric Music Therapist

❖ “Establish rapport with children and parents through casual conversation”- Wolfe and Waldon,

2009

❖ “Be sensitive to the possible stressful status of the parent; avoid asking excessive questions” -

Wolfe and Waldon (2009)

❖ “Be courteous and ask for parent permission to enter a child’s room; some times are better than

others for initiating interaction” - Wolfe and Waldon (2009)

❖ “Refrain from using excessively complicated jargon with regard to music therapy and its benefits.

The parents know you are there to help the child; appeal to what might interest the child and

encourage him/her to attend. If the child or parent declines, state that you may ‘check back’ on

another day” - Wolfe and Waldon (2009)

❖ “Always encourage parents to accompany their children to music therapy. In some cases, seeing

the music therapist working with hospitalized children serves as a model for meaningful

interaction for parents” - Wolfe and Waldon (2009)

❖ “Empower parents by giving them strategies & resources they can use with their child” – Robb

(2003)

❖ Use live music as often as possible. “Live music, by definition, involves the presence of another

human” and can provide a safe and familiar atmosphere for parents and family members to

interact – Robb (2003)

❖ “Use familiar, age and developmentally appropriate music and materials to introduce normal

childhood activities and create a feeling of comfort and security for children and their families” –

Robb (2003)

❖ Alleviate parental anxiety by providing them with resources and facilitating interaction that

maintain the parent-child bond – Robb (2003)

❖ Caregiver interaction is important, but also realize we don’t see all of the caregiving going on

behind the scenes. We can encourage caregiver interaction, but also have grace and

understanding.”– Kim Arter, MT-BC and mother of frequently hospitalized child

❖ Always keep development in mind and let parents know why you’re doing something by

including in your positive reinforcement to the child- Sarah Woolever, MT-BC


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References

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Understanding of parent-child relationships: A nursing scholarship review series. Part 4:

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