Music Therapy

Music therapy was provided by a specialized and certified neonatal music therapist. Music was played after opening one or two doors of the incubator. The distance between incubators was ~1.5–2 m. Doors of the other incubators remained closed. To optimize music therapy for preterm infants, it is suggested that a volume between 45 and 60 decibels (dBs) should be achieved (12 (link)). A sound meter was placed in the incubator to monitor dBs, always providing levels between 40 and 65 dBs. This level of dBs is sufficient for music therapy provided to the individual infant, but too soft for other infants to hear.
The music therapy was aimed at relaxation, to try to minimize effects of pain and stress during NICU stay, by particularly following respiratory patterns in the improvised musical interventions. Before the music therapy sessions commenced, the music therapist consulted parents and nurses to inquire specific information on the infant's behavioral state and medical condition. It was our distinct intention to actively involve parents in the music therapy sessions. Parental expectations were managed through detailed information on the sessions and value of music therapy for their infant. As the risk of overstimulating an infant this age may grow after a short time, the music therapist provided each infant with approximately three sessions per week of roughly 15 min of music therapy. Infants received individually improvised music interventions using the Remo Lullaby Ocean Disc, guitar-arpeggios or voice interventions, based on the “rhythm, breath, and lullaby” method as developed by Loewy (8 (link)).
To prevent overstimulation, we used maximum one instrument (either the Ocean Disc or guitar) and voice in each music therapy session. During the first two to four sessions, the Ocean Disc was the preferred instrument. This musical instrument is a round disc with small metal beads inside, that replicates the “whoosh” -like timbre of the placenta (7 (link)). From the third music therapy session onwards the music therapist collaborated with parents to incorporate song-of-kin (8 (link)). Song-of-kin concerns recomposing parental favorite music into a lullaby for the infant. Parents are stimulated to provide this song-of-kin to their infant to empower them in their role as caregivers. If parents did not provide a song-of-kin, the music therapist used the melody of “Twinkle Twinkle Little Star,” since previous research demonstrated good results of this melody in older childer and this melody is familiar to many parents (7 (link), 8 (link)). We introcuced the guitar with caution, including ~4 consecutive tones in 6/8 patterns, as to prevent possible overstimulation of the infants by overtones.
The music therapist tailored the interventions to the behavioral state of the infant. When an infant was in quiet sleep, the music therapist played calmly and adjusted the tempo of the music to the infant's breathing pattern. In active sleep, quiet wakefulness or active states, the improvisation was adjusted to the muscle tension and breathing pattern of the infant. Playing was personalized to achieve a calm state, mainly by applying guitar or voice. When infants were tense or cried, the music therapist paced with the infant, until a calmer rhythm could be achieved and environmental sounds could be incorporated into the improvisation. In this state, limitation of dynamics, tempo and stimulations from the music were deemed essential. After the sessions, if parents were present, they were provided the opportunity to talk about their experiences and ask questions to the music therapist.

A well-trained and experienced music therapist (HF) formulated individualized, culturally adapted treatment plans based on an initial child–parent assessment, which included assessment of parental needs, musical heritage, culture, context, and parental integration in the therapeutic process. The therapist individually adapted the aims over the course of hospitalization in accordance with the principles of neonatal music therapy and family-integrating care approaches (Haslbeck, 2014 ; Haslbeck and Hugoson, 2017 ; O'Brien K et al., 2018 ). Therapy sessions started immediately following parental consent, two to three times per week in the morning after feeding time. Each CMT intervention lasted approximately 20 min and was directed to the infant at the bedside alone or with the parents in skin-to-skin contact. Each infant received a minimum of eight sessions of CMT, since this is the recommended number of sessions suggested to measure a therapeutic effect (Hanson-Abromeit et al., 2008 ). During the CMT session, the infant was lying in the incubator or in warmers. Mostly, when the infants tolerated touch, the session started with an initial touch, for instance of the head and feet, which was transformed into therapeutic touch to offer contact and to feel and stimulate the breathing rhythm of the infant (Haslbeck, 2014 ; Hanley, 2008 ). After an initial period of observation, the humming was faded in smoothly, starting with some long, calm notes developing over time into a smooth melody in lullaby style. The humming and singing were individually tailored to the breathing rhythm, facial expression, and gesture of the infant. The families’ musical heritage and culture were addressed by integrating musical preferences into the improvisation, for example by incorporating the parents’ favorite song (e.g., folk song of their culture, pop song) in lullaby style (Loewy et al., 2013 ). At the end of the session, the music faded out smoothly, and the therapist cautiously removed her hands.
During therapy with the parents, the humming and singing was provided in the same manner, but the infant was placed on the parent's chest in skin-to-skin contact or, when the infants were older, on the parent's lap. Additionally, a vibro-acoustic monochord2 was used to accompany the singing and to fade the music in and out. This was placed at the elbow of the parents to allow its vibrations to transmit relaxation, particularly to parents still in a post-traumatic state. The parents were invited to relax, to observe their infant, or to sing along with the music therapist and were empowered to hum to their infant in general. If appropriate, the music therapist shared her perceptions of the infant's behavioral state and reactions (e.g., smiling, finger movements, if these occurred) to encourage positive and sensitive parent–infant interactions to empower the parents and parent–infant attachment. Before hospital discharge, the music therapist provided a final consultation and debriefing discussion with the parents, including therapeutic recommendations and offering music consultation for the first year of life (Fig. 1) (Haslbeck et al., 2017 (link)).Fig. 1

Creative Music Therapy with preterm infants and their parents. Responsiveness, communicative musicality, and empowerment via infant-directed humming/ singing and relaxing monochord sounds.

Fig. 1

Specifically, this study attempted to select songs that correspond to three music conditions (Motivating, Relaxing, and M + R) among music that is highly preferred by Korean children and adolescents. Along with the selection of healing music, the overall structural analysis of the song was evaluated by a group consisting of two composers and one professional performer.
The subjects who finally decided to participate in the ADHD music therapy group (n = 18) completed a preference questionnaire consisting of a 5-point Likert Scale, and audio files were sent using a smartphone or email. To minimize the influence of lyrics, genres like pop without lyrics, traditional Korean music, and New Age were selected.
Also, music that matched the participants’ preferences (having been checked as “normal” or “like” by them) was selected [52 (link)].
The music listening used for the music therapy consisted of Motivating, Relaxing, and M + R (a total of three songs were selected: Arirang, Golden Star, White Tower), and were selected through a preference survey. Based on a previous study [53 (link)], the chosen songs were composed in the key of C, D, and G Major, and mainly used major chords, with some minor chords interspersed to create interest in the music [53 (link)].

The ADHD control group children and adolescents continued to receive existing recommended [54 ], drug therapy only. ADHD music therapy group children and adolescents and continued to receive existing recommended [54 ], drug therapy and active music therapy (improvisation) and receptive music therapy (music listening).