RESEARCH ARTICLE Open Access
Effects of music therapy in the treatment of
children with delayed speech development results
of a pilot study
Wibke Groß1,2*
, Ulrike Linden2
, Thomas Ostermann3
Abstract
Background: Language development is one of the most significant processes of early childhood development.
Children with delayed speech development are more at risk of acquiring other cognitive, social-emotional, and
school-related problems. Music therapy appears to facilitate speech development in children, even within a short
period of time. The aim of this pilot study is to explore the effects of music therapy in children with delayed
speech development.
Methods: A total of 18 children aged 3.5 to 6 years with delayed speech development took part in this
observational study in which music therapy and no treatment were compared to demonstrate effectiveness.
Individual music therapy was provided on an outpatient basis. An ABAB reversal design with alternations between
music therapy and no treatment with an interval of approximately eight weeks between the blocks was chosen.
Before and after each study period, a speech development test, a non-verbal intelligence test for children, and
music therapy assessment scales were used to evaluate the speech development of the children.
Results: Compared to the baseline, we found a positive development in the study group after receiving music
therapy. Both phonological capacity and the children’s understanding of speech increased under treatment, as well
as their cognitive structures, action patterns, and level of intelligence. Throughout the study period, developmental
age converged with their biological age. Ratings according to the Nordoff-Robbins scales showed clinically
significant changes in the children, namely in the areas of client-therapist relationship and communication.
Conclusions: This study suggests that music therapy may have a measurable effect on the speech development of
children through the treatment’s interactions with fundamental aspects of speech development, including the
ability to form and maintain relationships and prosodic abilities. Thus, music therapy may provide a basic and
supportive therapy for children with delayed speech development. Further studies should be conducted to
investigate the mechanisms of these interactions in greater depth.
Trial registration: The trial is registered in the German clinical trials register; Trial-No.: DRKS00000343
Background
Music therapy is an established form of creative art
therapy. By using music as a specific medium of communication
and expression and adapting it to the individual
resources and abilities of the patient, music therapy
can be beneficial in activating and supporting mental
and psycho-physical recovery. Several systematic reviews
have shown the effects of music therapy in different
clinical and therapeutic settings, such as for the treatment
of psychiatric diseases like schizophrenia or schizophrenia-like
illnesses [1], psychosis [2], neurological
diseases like multiple sclerosis [3], dementia [4], or for
the treatment of anxiety and pain [5].
In addition to these therapeutic fields, music therapy
can also be applied in the treatment of developmentally
delayed children. Already in 1995, Aldridge et al. illustrated
the use of music therapy in children with developmental
delay [6]. In another study, Duffy and Fuller
(2001) found that an 8-week music therapy intervention
* Correspondence: wfeenders@gmx.de
1
Nordoff Robbins Centre of Music Therapy, Ruhrstrasse 70, 58452 Witten,
Germany
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© 2010 Groß et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons
Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in
any medium, provided the original work is properly cited.
in social skills development in moderately disabled children
resulted in an increment in terms of turn-taking,
imitation, and vocalization [7]. Perry (2003) found direct
relationships between the level of communication skills
and elements of musical interaction in children with
severe and multiple disabilities [8]. Finally, Kim et al.
(2008) demonstrated the effects of music therapy on
joint attention behaviours in preschool children with
autism in a randomized controlled study [9].
Developmental delay often accompanies delayed
speech development. Speech development is an important
predictor for later problems, such issues with reading
and spelling, among other learning difficulties.
Gallagher [10] found that “studies of children with language
impairment have reported emotional and behavioural
problems in 50-75% of that population”.
According to Sallat [11], different authors describe children
with delayed speech development as being highly
at risk of other cognitive, social-emotional, and schoolrelated
problems.
However, definitions of speech development disorders
still differ greatly and data on the prevalence of delayed
speech development actually range from 4 to 40% [12].
Grimm et al. [13] detected substantial speech development
disorders in 10% of children between the ages of 4
and 5 in Bielefeld, Germany, and suspected speech
development disorders in 20%. General textbooks quote
the epidemiology of specific speech development disorders
as being between 3 and 5%; however, this is without
a traceable background [14]. According to a study
in Bavaria, 22.5% of tested children showed at least one
problem in various tested areas that required speech
therapy [15].
Although there are considerable epidemiological variations
due to the definition of developmental speech
delay, its prevention is a challenging social issue. In this
respect, it is of vital importance to apply therapies that
are able to support the salutogenetic capacities of the
child with the aim of enhancing his or her speech development
as early as possible.
According to findings of Aldridge [6] and Schumacher
[16], music therapy is an approach that may facilitate
significant advances in speech development and communication
skills, particularly in children with autism.
Additionally, Lathan-Radocy [17] described different
ways and methods of working with speech and language
impaired children by engaging them in music therapy.
Finally, several case studies found positive effects of
music therapy on speech development in children
[18-20].
Based on these findings, this study aims at examining
the effectiveness of music therapy on a child’s verbal
reasoning abilities. Furthermore, we wanted to investigate
whether experiencing musical structures, such as
rhythm or strophic forms, and improvising with a music
therapist could stimulate a child’s ability to understand
sentences, as well as encourage his or her interest in
communicating with others.
Methods
Study design
This observational pilot study was conducted in the
Department of Music Therapy at Herdecke Community
Hospital between 2006 and 2008. We chose an ABAB
reversal design with alternations between music therapy
and no treatment with an interval of approximately
eight weeks between the blocks. Before and after the
music therapy blocks, a speech therapist and a psychologist,
who were both blinded to the conditions and timing,
tested the children using validated speech and
nonverbal developmental tests. The study was approved
and accepted by the ethics commission at the University
Witten/Herdecke (application number: 115/2006) and is
registered in the German clinical trials register (TrialNo.:
DRKS00000343; http://www.drks.de).
Participants and inclusion criteria
All children were recruited via announcements in integrative
and regular nursery schools. Parents contacted
the music therapy department at the hospital by phone
and after the first selection, 39 children aged 3.5 to 6
years, all with German as their native language, were eligible
to participate in the study. Participants had to pass
a medical examination and take a speech test to check
whether they had a specific developmental speech disorder
(ICD-10-Codes: F80.1, F80.2, F83). They also had to
score below 50 out of 100 points in the phonological
short-term memory test for non-words (German: PGN)
and in one other subscale of the applied speech test
SETK 3-5 (see “Test instruments” section for a detailed
description). Children diagnosed with autism or muteness
and/or a speech development disorder due to any
organic causes (e.g. deafness) were excluded, as well as
those children who had previous experience with music
therapy.
As a result, a total of 18 children (6 girls; mean age:
4.3 ± 0.5 years) were selected to participate in the study
(see Figure 1 for the consort diagram of the study).
None of the participants were physically disabled and all
were able to move and act independently.
Parents or guardians provided written informed consent
for their child’s participation in the study before
enrolment of the study. This included a discussion of
the music therapist on the nature and purpose of the
proposed music therapy treatment and its potential risks
and benefits. Parents were also given the opportunity to
ask questions to elicit a better understanding of the
music therapy treatment. Accompanying therapies, like
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speech therapy and early intervention programs, continued
uninterrupted due to ethical considerations.
Setting
Children received music therapy on an out-patient basis
at the Department of Music Therapy at Herdecke Community
Hospital. The participants were brought to
music therapy sessions by their parents, but entered the
music therapy room alone when possible. Single therapy
sessions had a mean duration of 25 minutes and were
provided by a therapist and co-therapist together. To
meet the quality criteria of the hospital, the two music
therapists had to have a master’s degree in music therapy
and sufficient clinical experience (a minimum of
two years) in their field.
Music therapy
This study applied the concept of creative music therapy
based on the Nordoff-Robbins approach [18]. Both patient
and therapist were active in singing and making music
with percussion instruments (i.e. bells, drums, pentatonic
tone bars, shakers, reed horns, and lyres) and a piano.
Figure 1 Consort diagram of the selection process
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Songs specifically composed for playtime and that dealt
with the child’s interests, such as hide-and-seek songs or
songs about animals, completed the therapeutic spectrum.
Individual themes and musical developments thus
emerged for each individual child; some wanted to sing
and dance, others wanted to be sung to, and some wanted
to play an instrument on their own. According to this
individualized approach, the improvised music was
oriented at the musical and vocal expressions of the child
and therefore played the central role of the therapy.
Test instruments
SETK 3-5
The speech development test for children aged three to
five years (SETK 3-5) is the first standardized German
language test to examine speech abilities in children of
this age group with an immediate correlation between
linguistic and auditory memory performance. With
Cronbach’s alpha values between 0.62 and 0.89 and an
inter-rater reliability of 90.1%, the test yields a “reliable
and valid description of receptive and productive speech
abilities in children” [21] and covers three areas of
speech development, divided into three categories with
five subtests:
1. Children’s understanding of speech (subtest
“understanding sentences"; abbrev.: VS)
2. Speech production (subtest “generation of morphological
rules"; abbrev.: MR)
3. Memory of speech, with a focus on abilities of
speech processing, not on qualities of pronunciation
(subtest “phonological memory for non-words";
abbrev.: PGN; subtest “memory for sentences";
abbrev.: SG, and subtest “memory for word
sequences"; abbrev.: GW)
SON-R
The SON-R 2 1/2 - 7 is an individual intelligence test
which does not require the use of spoken or written language
[22]. It is especially suited for children with problems
in the area of language and verbal
communication and is comprised of six subtests of
about 15 items that address the dimensions activity patterns
and cognitive structures.
Activity patterns include the scales “categories
(abstract thinking, organizing principles)”, “analogies
(abstract thinking)” and “situations (concrete thinking)”.
The scales “mosaics (spatial comprehension)”, “puzzles
(concrete thinking)”, and “drawing structures (spatial
comprehension)” represent the dimensions of the child’s
mental structure. Norm tables for monthly age groups
enable the transformation of raw subtest scores into
normalized standard scores. The total test results are
represented as IQ scores and reference ages. IQ scores
between 89 and 110 are average, 79 to 88 are below
average, 68 to 78 are borderline, and IQ values below 67
indicate an intellectual deficit.
With a Cronbach’s alpha value of 0.90 and a testretest
reliability of r = 0.79 for the overall IQ score, the
reliability of the test is sufficient.
All psychometric tests were conducted by speech
therapists and a psychologist blinded to the conditions
and timing.
Music therapy assessment scales
All sessions were videotaped for analysis and consecutively
assessed in detail after each session independently
by the therapist and co-therapist. Nordoff-Robbins
assessment scales were used to evaluate developments in
music therapy for the first and last session of each
music therapy block respectively. Scale I assessed the
“child-therapist relationship in musical activity” (CTR)
and Scale II assessed “musical communicative ability”
(MCA); both were measured on a 10-point scale where
0 denotes lowest values and 10 denotes highest values
in the respective categories. Inter-rater reliability values
showed high agreement rates within the range of one
point of 82% in Nordoff-Robbins therapists ratings [18].
Statistical analysis
Data were analyzed using intention-to-treat analysis
(ITT). Missing values were imputed using the method
of last observation carried forward with the following
rules: a missing value before a block of music therapy or
no treatment was replaced with the corresponding presession
value. A missing value after a session was
replaced with the according pre-session value.
The Friedman test was used to analyze the effect of
music therapy over the course of time and the Wilcoxon
rank-sum test was used for baseline comparisons (T0)
and final measurements after the last therapeutic session
(T4). We judged p £ 0.05 as significant and p between
0.05 and 0.1 as a trend. To quantify the outcome we
also calculated effect sizes for all scales between T0 and
T4. According to Cohen [23], effect size values between
0.2 and 0.5 are indicative of a small effect; values
between 0.5 and 0.8 denote a medium effect and values
greater than 0.8 indicate a large effect size.
Results
SETK
Mean SETK scores yielded the following results: “phonological
memory for non-words” (PGN) and “understanding
sentences” (VS) revealed distinct upward
trends, whereby increases were more pronounced during
periods with music therapy. These two parameters
showed mostly parallel development. These two subtests
PGN and VS showed a particularly steeper increase
after music therapy blocks (T0-T1/T2-T3) compared to
waiting periods (T1-T2/T3-T4). “Memory for sentences”
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(SG) also improved distinctively, starting from a very
low level. A second boost was registered after the second
waiting period (see Table 1).
“Generation of morphological rules” (MR) also increased
after music therapy blocks while decreasing during waiting
periods. “Memory for word sequences” (GW) was the
hardest factor to assess. It was measured in different units
compared to the rest of the parameters and in addition it
is only measured in children aged four and older, so that
the number of test results gained in this instance is far
smaller. All general developments (T0-T4) for the five
subtests of the speech test SETK revealed a definite
increase. Over the entire study period (T0-T4), parameters
PGN and VS showed statistically significant results (p <
0.001), which suggest that music therapy may have an
effect on the development of phonological memory and
understanding sentences. Phonological memory (PGN)
indicated statistically significant results during the first
waiting period (T1-T2 p = 0,008) and also after the second
block of music therapy (T2-T3 p = 0,001; see Table 1).
SON-R
The three parameters of SON-R (cognitive structures
(DS), action patterns (HS), and IQ increased significantly
in the study course (DS p = 0,001; HS p < 0,001;
IQ p < 0,001). The parameter of cognitive structures
(DS) showed higher mean scores compared to activity
patterns (HS) at time T0. It is interesting to note that
DS and HS differed by several points at first (T0, T1)
but later converged after the first interval (T2) to almost
identical levels. The scores diverged again after the second
music therapy intervention (T3), although this time
on a higher level. The scores finally converged after the
second interval (T4) (see Table 1).
Difference between age and biological age
Analysis of reference age revealed that the developmental
age of the children in the course of music therapy
interventions converged more and more towards their
biological age. The difference was reduced from
approximately one year at baseline to seven months at
the end of therapy. Moreover, the variance in their
developmental age increased meaning that some of the
children corresponded with their biological age at the
end of the study, while other children demonstrated a
development approaching their biological age. The complete
development over the course of time is shown in
Figure 2.
Nordoff-Robbins Scales
Ratings according to the Nordoff-Robbins scales showed
distinctly significant changes. Both parameters CTR for
child-therapist relation and MCA for musical communicative
ability increased after the first music therapy
block (T2), then subsequently decreased (T3), and then
finally reached the previously achieved higher level after
the second music therapy block (T4). MCA showed a
slightly higher increase (Figure 3).
Compliance
The compliance of the children was a major problem in
the developmental tests, particularly in completing the
SETK-questionnaire. While the SON-R was well
accepted by the children and Nordoff-Robbins items
were scored by the therapist, completing the SETK with
the children was difficult, yielding to incomplete items
in the SETK subscales (between 14% (VS-Scale) and
36% (GW-Scale) of the items). However, the imputation
of missing values reduced these rates to a mean level of
10% remaining incomplete items.
Discussion
This study is the first to provide valid information about
the effects of music therapy in children with developmental
speech delay. It was found that music therapy
had an effect on fundamental qualities of speech
Table 1 Changes in the course of time and overall effect sizes in SETK subscales and SON-R outcome measures
T0 Mean ± Sd T1 Mean ± Sd T2 Mean ± Sd T3 Mean ± Sd T4 Mean ± Sd Fried-man-Test Wilcoxon-Test
(T1-T4)
Effectsize
(T1-T4)
SETK
PGN 37.4 ± 10.2 40.0 ± 11.0 41.5 ± 14.4 44.7 ± 16.3 47.0 ± 14.5 <0.0005 0.002 0.45
VS 37.4 ± 9.37 41.9 ± 12.7 43.7 ± 15.4 47.0 ± 16.3 48.2 ± 16.1 0.001 0.001 0.39
SG 30.4 ± 11.4 36.9 ± 12.4 35.2 ± 14.3 36.9 ± 13.5 39.9 ± 22.1 0.076 0.028 0.61
MR 40.8 ± 12.6 42.6 ± 10.7 41.6 ± 15.2 47.9 ± 17.6 46.9 ± 16.5 0.116 0.054 0.19
GW 3.0 ± 0.7 2.9 ± 1.3 3.1 ± 1.2 3.1 ± 1.1 3.2 ± 1.1 0.077 0.480 0.03
SON-R (ref-age)
HS 3.2 ± 1.0 3.6 ± 1.0 4.0 ± 1.0 4.0 ± 1.2 4.2 ± 1.2 <0.0005 <0.0005 0.61
DS 3.5 ± 1.2 3.8 ± 1.3 4.0 ± 1.0 4.3 ± 1.2 4.3 ± 1.3 <0.0005 0.002 0.31
IQ 3.3 ± 1.1 3.7 ± 1.1 3.9 ± 1.0 4.1 ± 1.2 4.3 ± 1.3 <0.0005 <0.0005 0.57
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Figure 2 Difference of developmental age (age IQ) to biological age over the study period. Error bars denote the 95% confidence interval
Figure 3 Development of Nordoff-Robbins rating over the study period
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development and resulted in significant improvements
in phonological memory and the children’s understanding
of sentences. Furthermore, a positive shift in the
memory of sentences and generation of morphological
rules was observed. In particular, the difference between
the developmental age and biological age of the children
decreased significantly. These results were accompanied
by a clinically significant effect of music therapy on the
child-therapist relationship and musical communicative
ability, as measured by the Nordoff-Robbins scales.
Initial effect
Empirical observations frequently described the phenomena
of an “initial effect” of music therapy on speech
development (i.e. that music therapy seemed to stimulate
the speech development of developmentally delayed
children even after a few music therapy sessions). In
accordance with these findings, results from this pilot
study illustrate which aspects of speech development are
influenced specifically by music therapy and show to
what extent an initial effect may be detected. Results
show improvements in the development of speech and
cognitive abilities even after the first block of music
therapy treatment. Children may benefit specifically in
the areas of relationship and communication as shown
by the rating according to the Nordoff-Robbins scales.
It is assumed that a newly acquired ability, such as a
basal social experience, has an initial effect on the
further development of the sense of self-perception and
the perception of others. Furthermore, it influences selfawareness
and emotional mood. This ‘snow ball effect’
could possibly explain the relatively fast positive development
of the participants. Since communication is a
basic human need, it can be further assumed that the
provided individual communication model ‘music therapy’
was simply claimed by the participants after a successful
introduction and was also maintained.
Speech Development
The changes in phonological memory (PGN) and the
understanding of sentences (VS) increased significantly
with a parallel slope. Test results suggest that music
therapy interventions may initially provide a boost in
the development of these skills. Abilities covered by the
subscale PGN are obviously related to prosodic abilities
[24]. We believe that the improvements occur because
music therapy addresses listening, perception, processing,
and the memorizing of sounds and musical structures.
This corresponds to a study by Jungblut et al.
[25], who reported positive improvements in speech
development in patients with aphasia due to music therapy.
Here, prosody was one of the parameters showing
substantial progress. This corresponds with the theoretical
considerations of Grimm [24], who regards prosody
as a defining aspect of speech processing and language
acquisition.
The improvement in the VS subscale is underlined by
the empirical observations we made in the study. In the
beginning, most of the children we worked with had difficulty
focusing their attention with hand-eye-coordination
and the concentration on a joint activity with the
therapist. During music therapy sessions, most of the
children enhanced their concentration and were increasingly
able to direct their eyes and concentration to a
joint activity with the therapist and to playing an instrument.
The improvement in the Nordoff-Robbins scales
especially underlines these observations. Children benefit
specifically in the areas of forming relationships and
enhancing their communication skills. Parents, speech
therapists, and teachers reported that the children
started to communicate more frequently and started to
have more social contacts. According to a deeper single
case analysis of two children in our study, we found that
one important element in achieving linguistic understanding
is the ability to relate to another person [26].
Moreover, Grimm [24] describes three areas of so-called
anticipatory abilities that are essential even in infants for
acquiring speech: social cognition, perception, and cognition.
These include the abilities to direct attention to
objects and events, to differentiate between them, and to
remember the differences. In addition, he determined
that constructing a common point of focus has proved
to be especially important in acquiring language skills.
The scores measured for SG also show a distinct
increase over the study period. This may be explained
through the inherent experience of structure and perspective
in the process of active music making with the
therapist. Studies of infants’ abilities to perceive speech
found that infants prefer well-structured speech patterns
to less well-structured ones [24]. Perception and grasp
of structures seem to be important skills for acquiring
speech. Form and general structure of a sentence must
be understood in order to grasp the entire meaning.
These qualities are exercised and targeted all the time
when making music. They may be shortened or
expanded step by step and thus be adapted to the individual
making the music and his or her abilities.
It is interesting to note that the parameter “generation
of morphological rules” shows improvements after
music therapy blocks. This parameter, quite unrelated to
music at first sight, seems to address recognition and
understanding of structures, which is continuously practised
in active music-making. Deficits in generation of
morphological rules are considered as particularly distinct
and obstinate. Music therapy may give support to
the development of this ability.
Rhythmic-prosodic abilities seem to be central for
acquiring language. Again, Grimm describes that
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children with developmental speech delay frequently display
considerable difficulties in the rhythmic-prosodic
area. An impaired ability to grasp the totality of prosodic
structures means that larger parts of the working
memory must be relied upon, thus limiting the amount
of working memory available for the understanding and
processing of language. Training a child’s reproduction
capabilities of phonologic (and therefore also of prosodic)
structures could provide significant support in the
child’s development of language abilities [24].
Aldridge [27] emphasized the importance of rhythmic
structures and abilities for infantile development:
“rhythm plays a central co-ordinating role in the organization
of human perception and action, and for the
developmentally delayed child, a controlled - yet flexible
- rhythmic structure found in musical playing seems to
be an island of stability from which new initiatives can
take place.” According to Trevarthen & Aiken [28],
music therapy from a neuropsychological point of view
may support human communication skills that are organized
rhythmically in accordance with neurological processes.
Thus, active, creative music therapy works
immediately with the contact and communication
between the improvising participants. In such a setting,
the integration of several senses, like hearing or seeing,
motor abilities, and emotion, is of vital importance [29]
because both verbal communication and joint musical
improvisation require a meaningful integration of these
senses. Thus, music therapy may offer a specific space
to test and develop various senses on a level appropriate
to the child’s individual abilities and speed.
From a music therapy perspective, Neugebauer [20]
relates the steps of language development to musical
qualities and concludes that music therapy works on
those musical qualities and speech development can
thus be enhanced. These findings are underlined by
Papousek’s research on infants [30]. She analyzed
mother-infant interaction and its relation to musical
parameters, even if the use of the musical metaphors
has to be taken into account critically [29]. This might
be an explanation of why music therapy can be effective
in children with communication disorders. The therapeutic
processes that took place in our study have been
described comprehensively in the case report of two
patients [26].
Cognitive Development
The non-verbal development test SON-R produced
encouraging results. The SON-IQ of the entire group
rose significantly and the difference between developmental
age and biological age of the children decreased
significantly. Even here our study showed an initial
effect. For a majority of children it may be assumed that
their intelligence potential had not been fully exploited
prior to the study. In music therapy we see many children
who seem to have no experience whatsoever with
symbolism, imagining fantasy stories, or playing with
sounds. At first these children seem to soak up our imaginative-musical
proposals before they start to develop
and share their own creative potential. Music therapy
thus seems to evoke and reveal unused potential. During
music therapy, children seemed to access their potential
and were even able to adapt it to another setting such
as in the test situation. This corresponded to a detailed
analysis by Rittelmeyer [31], who emphasized the impact
of creative abilities in the neurological, cognitive, and
emotional development of children.
An analysis of the two subtests for cognitive structures
and action patterns is also of interest. At first, the two
scales diverge, converge closely after the first waiting
period in order to diverge again, and approach each
other on a significantly higher level at the end of the
study (see Figure 2). Cognitive structures are the first
subtests to advance. Action patterns keep up with the
development during the waiting period. Again an initial
effect of music therapy can be assumed in this case. It is
remarkable that action patterns converge to the similar
level with cognitive structures. Cognitive structures and
action patterns are nearly integrated at that point. A
child cannot do much with certain cognitive abilities
without knowing how to use them actively. An integration
of thinking and doing appears to be indispensable
for the meaningful use of cognitive abilities. Music therapy
may therefore provide an important contribution to
the promotion of integrated thinking and doing and
may reveal a child’s hidden potentials.
Limitations
Although the large effect sizes in the present study point
to a potential impact of music therapy, the small number
of participants in the study should be mentioned as
an important limiting factor. The discussion of whether
observational studies tend to overestimate the effects of
a therapy compared to the results of controlled clinical
trials is still vital [32] and the call for randomized controlled
trials (RCTs) has already reached the borders of
music therapy [33]. Due to organizational and structural
aspects we abstained from carrying out a RCT in this
case. However, other researchers recommend more naturalistic,
observational studies of patients in psychotherapy
[34] and, with regards to external evidence, our
findings give an impression of the real world effectiveness
of music therapy. In order to verify the test results,
further studies with a higher number of participants
should be conducted to underline and specify the effects
found in this setting [35,36].
As there is no control group or a specific control condition
we are of course aware that the changes observed
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here might not be attributed to the music therapy
applied. It could, for instance, simply be the intervention
itself associated with a high amount of care giving or the
attention given to the kids. A further point is that the
children might have improved their behaviour simply in
response to the fact that they were being studied. This
is also known as the Hawthorne effect [37]. In his study
on the effects of background music on quality of sleep
in elementary school children, Tan also suggested, that
children might be responding to music therapy treatment
due to their awareness of participation [38].
Also, unblinding might be a potential source of bias.
According to a study of Noseworthy et al., blinded outcome
evaluators do assess outcomes less optimistically
than unblinded evaluators [39]. Thus, we tried to avoid
unblinding of the external evaluators in our study. Consequently,
they were not introduced in the therapeutic
strategy at any time of the study to rule out that they
would for example focus on a special subcategory of the
psychological tests like phonologic memory. However as
the evaluators in the case of the speech and intelligence
tests directly interacted with the children and did see
them five times within the course of the study, unblinding
can not be ruled out.
Due to financial limitations, it was not possible for
external therapists to conduct therapeutic music therapy
ratings. Although the findings on inter-rater reliability
in [18] give sufficient assurance on the reliability of the
Nordoff-Robbins rating, an external rating would have
probably been of higher internal validity with a more
objective character.
Considering these limitations, our results should be
interpreted with care.
Underlying working principles
Until now, working principles of music therapy have
mostly been examined using qualitative research.
Although single case studies tried to identify possible
modes of action in music therapy in speech development,
we are still not able to isolate elements of music
therapy as the driving therapeutic force. The only aspect
that is for certain is that a mutually created musical dialogue
improves the child’s perception of him or herself
and of the person who is sharing the experience. As a
result, according to [27] the “activity of listening, in a
structured musical improvisational context, without the
lexical demands of language” may improve the cognitive,
gestural, emotional, and relational development of the
child.
Neuro-physiological approaches might underline these
results but, due to limited resources, they have only
been marginally applied in music therapy research.
Additionally, it is questionable whether neuro-physiological
approaches would be able to show development in
areas such as social communication and self-consciousness,
which are essential preconditions for language
acquisition.
In addition, some important parameters for the development
of language skills are not covered by the test
parameters. Vital information was provided by the additional
qualitative data collected from parents and testers.
Most of the children started to use their language with
increasing confidence; social skills improved and children
were motivated to communicate more intensively.
Although these data often did not correlate with the test
results, these findings seem to be evidence of very
important parameters that cannot be checked by the
speech test and development tests alone. The NordoffRobbins
scales, however, do reflect these aspects.
Conclusions
Music therapy according to this study may have a beneficial
effect on speech development. It does not seem to
influence individual isolated aspects of speech development
but might address and integrate many different
aspects in a comprehensive way that are important for
speech development, including relationship abilities and
prosodic abilities. It might be supposed that music therapy
interacts with very fundamental aspects of speech
development and has measurable effects even after a
short period of time. Therefore, music therapy may provide
a very fundamental, basic, and supportive therapy
for children with developmental speech delay.
Acknowledgements
We are grateful to the foundation Aktion Mensch for their generous support
of this study.
Our thanks go to Dr. B. Irion, Dr. B. Berger and Dr. M. Mousers, who helped
organize the study at the Herdecke Community Hospital, and Dr. K Boehm
and Katie Renaud, who cross-checked the manuscript.
We also thank the following foundations whose support enabled us to
evaluate and publish the results of the study: Gerhard-Kienle-Stiftung,
Herdecke; Andreas und Emilie Olmstedt-Stiftung, Witten; Werner Richardund
Dr. Carl Dörken-Stiftung, Herdecke; Stiftung Musik HILFT by NordoffRobbins,
Berlin and the Verein zur Förderung der Nordoff/RobbinsMusiktherapie
e.V., Herdecke.
Author details
1
Nordoff Robbins Centre of Music Therapy, Ruhrstrasse 70, 58452 Witten,
Germany. 2
Department of Music Therapy, Community Hospital Herdecke,
Gerhard-Kienle-Weg 4, 58313 Herdecke, Germany. 3
Center of Integrative
Medicine, University of Witten/Herdecke, Gerhard-Kienle-Weg 4, 58313
Herdecke, Germany.
Authors’ contributions
WF carried out the study, participated in the evaluation of data, and helped
draft the manuscript. UL conceived of the study and carried out the study,
participated in evaluation of data, and helped draft the manuscript. TO
participated in the design of the study, performed the statistical analysis,
and wrote the final version of the manuscript. All authors read and
approved the final manuscript.
Competing interests
The authors declare that they have no competing interests.
Groß et al. BMC Complementary and Alternative Medicine 2010, 10:39
http://www.biomedcentral.com/1472-6882/10/39
Page 9 of 10
Received: 7 October 2009 Accepted: 21 July 2010
Published: 21 July 2010
References
1. Gold C, Voracek M, Wigram T: Effects of music therapy for children and
adolescents with psychopathology: a meta-analysis. J Child Psychol
Psychiatry 2004, 45(6):1054-63.
2. Silverman MJ: The influence of music on the symptoms of psychosis: a
meta-analysis. J Music Ther 2003, 40(1):27-40.
3. Ostermann T, Schmid W: Music therapy in the treatment of multiple
sclerosis: a comprehensive literature review. Expert Rev Neurother 2006,
6(4):469-77.
4. Schmitt B, Frölich L: Creative therapy options for patients with dementia–
a systematic review. Fortschr Neurol Psychiatr 2007, 75(12):699-707.
5. Nilsson U: The anxiety- and pain-reducing effects of music interventions:
a systematic review. AORN J 2008, 87(4):780-807.
6. Aldridge D, Gustorff D, Neugebauer L: A pilot study of music therapy in
the treatment of children with developmental delay. Complementary
Therapies in Medicine 1995, 3:197-205.
7. Duffy B, Fuller R: Role of Music Therapy in Social Skills Development in
Children with Moderate Intellectual Disability. Journal of Applied Research
in Intellectual Disabilities 2000, 13(2):77-89.
8. Rainey Perry MM: Relating improvisational music therapy with severely
and multiply disabled children to communication development. J Music
Ther 2003, 40(3):227-46.
9. Kim J, Wigram T, Gold C: The effects of improvisational music therapy on
joint attention behaviors in autistic children: a randomized controlled
study. J Autism Dev Disord 2008, 38(9):1758-66.
10. Gallagher TM: Interrelationships among childrens language, behavior,
and emotional problems. Topics in language disorders 1999, 19(2):1-15.
11. Sallat S: Musikalische Fähigkeiten im Fokus von Sprachentwicklung und
Sprachentwicklungsstörungen Idstein: Schulz-Kirchner-Verlag 2008.
12. Weber B: Auditive Wahrnehmung und Sprachentwicklung. Master Thesis
University of Innsbruck 2004 [http://www.hss-Innsbruck.at/Auditive%
20Wahrnehmung%20und%20Sprachentwicklung.pdf].
13. Grimm H, Aktas M, Jungmann T, Peglow S, Stahn D, Wolter E:
Sprachscreening im Vorschulalter: Wie viele Kinder brauchen tatsächlich
eine Sprachförderung? Frühförderung interdisziplinär 2004, 3:108-117.
14. Möller HJ, Laux G, Deister A: Psychiatrie und Psychotherapie Stuttgart:
Thieme Verlag 2005.
15. Deutsche Gesellschaft für Sprachheilpädagogik e.V. Landesgrupe
Thüringen. [http://www.dgs-ev.de/thueringen/Fachliches/
studie_zur_erfassung_von_kindern.htm].
16. Schumacher K, Calvet-Cruppa C: Musiktherapie als Weg zum
Spracherwerb. Musiktherapeutische Umschau 1999, 20:216-221.
17. Lathan-Radocy WB: Pediatric Music Therapy Springfield: Charlie C. Thomas
Publishers Ltd 2002.
18. Mahoney JF: Interrater Agreement on the Nordoff-Robbins Evaluation
Scale I: Client-Therapist Relationship in Musical Activity. Music and
Medicine 2010, 2(1):23-28.
19. Bruscia KE: Case Studies in Music Therapy Philadelphia: Barcelona Publishers
1996.
20. Neugebauer L: The importance of music therapy for encouraging latent
potential in developmentally challenged children. Music Therapy Today
2005, VI(3):430-455[http://www.musictherapyworld.net].
21. Grimm H, Aktas M, Frevert S: SETK 3-5 Sprachentwicklungstest für drei- bis
fünfjährige Kinder. Diagnose von Sprachverarbeitungsfähigkeiten und auditiven
Gedächtnisleistungen Göttingen: Hogrefe-Verlag 2001.
22. Tellegen PJ, Laros JA, Petermann F: SON-R 2 1/2 - 7. Nonverbaler
Intelligenztest Göttingen: Hogreve-Verlag 2002.
23. Cohen J: Statistical power analysis for the behavioral sciences New York:
Academic Press, 2 1988.
24. Grimm H: Störungen der Sprachentwicklung: Grundlagen - Ursachen Diagnose
- Intervention - Prävention. Göttingen: Hogrefe-Verlag 2003.
25. Jungblut M, Aldridge D: Musik als Brücke zur Sprache - die
musiktherapeutische Behandlungsmethode SIPARI bei
Langzeitaphasikern. Neurologische Rehabilitation 2004, 10(2):69-78.
26. Linden U, Feenders W, Meusers M, Ostermann T: Musiktherapie bei
Kindern mit Sprachentwicklungsverzögerung-Zwei Einzelfallstudien aus
einer Pilotstudie. Musiktherapeutische Umschau 2008, 29(4):227-240.
27. Aldridge D: Music Therapy and it’s Implications for Child-Development.
Curare 1996, 9:357-362.
28. Trevarthen C, Aitken KJ: Brain development, infant communication, and
empathy disorders: Intrinsic factors in child mental health. Development
and Psychopathology 1994, 6:597-633.
29. Schwaiblmair F: Infant research and music therapy - The significance of
musical characteristics in early mother-child interaction for music
therapy. Music Therapy Today (online) 2005, 6(1):48-59 [http://
musictherapyworld.net].
30. Papousek M: Intuitive Parenting: a hidden source of musical stimulation
in infancy. Musical Beginnings. Origins and Development of Musical
CompetenceDeliege I, Sloboda J 1996.
31. Rittelmeyer Ch: Kindheit in Bedrängnis. Zwischen Kulturindustrie und
technokratischer Bildungsreform Stuttgart: Verlag W. Kohlhammer 2007.
32. Concato J, Shah N, Horwitz RI: Randomized, controlled trials,
observational studies, and the hierarchy of research designs. N Engl J
Med 2000, 342:1887-1892.
33. Edwards J: Can music therapy in medical contexts ever be evidencedbased?
Music Therapy Today (online) 2004, 5:4 [http://www.
musictherapyworld.net].
34. Perry JC, Banon E, Ianni F: Effectiveness of Psychotherapy for Personality
Disorders. Am J Psychiatry 1999, 156:1312-1321.
35. Aldridge D, Pietroni P: Research trials in general practice: towards a focus
on clinical practice. Fam Pract 1987, 4(4):311-5.
36. Aldridge D: Guidelines for clinical research in complementary medicine. J
Altern Complement Med 2000, 6(3):245-51.
37. Whitehurst GJ, Falco FL, Lonigan CJ, Fischel JE, DeBaryshe BD, ValdezMenchaca
MC, Caulfield M: Accelerating language development through
picture book reading. Developmental Psychology 1988, 24(4):552-559.
38. Tan LP: The effects of background music on quality of sleep in
elementary school children. J Music Ther 2004, 41(2):128-50.
39. Noseworthy JH, Ebers GC, Vandervoort MK, Farquhar RE, Yetisir E, Roberts R:
The impact of blinding on the results of a randomized, placebocontrolled
multiple sclerosis clinical trial. Neurology 1994, 44:16-20.
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Cite this article as: Groß et al.: Effects of music therapy in the treatment
of children with delayed speech development - results of a pilot study.
BMC Complementary and Alternative Medicine 2010 10:39.
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