Music therapy for young children with acquired communication impairments: An international survey of clinical practices

ABSTRACT

Introduction

Acquired communication impairments (ACIs) can significantly hinder the development and functioning of language and communication in children, impeding their social interactions and self-expression. Music therapy is emerging as a favourable practice in supporting children with ACIs; however, a deeper understanding of the clinical practices of music therapists with this population is required to advance service provision.

Method

This study employed an online cross-sectional descriptive survey to investigate current approaches, clinical interventions, and outcome measures used by music therapists working with young children with ACIs to address language- and communication-oriented goals. Fifty-four music therapists across ten countries completed a 16-item online questionnaire. Descriptive statistics and conventional content analysis were used to analyse the data.

Results

Respondents demonstrated a notable preference for humanistic and integrative approaches in their clinical practice. Among the diverse range of interventions employed by music therapists, song singing, vocal improvisation, and music and play emerged as the most effective techniques for supporting individuals with ACIs in achieving their communication goals. Additionally, collaborative endeavours with speech and language therapists were considered the most impactful approach to intervention. Respondents also sought alternative non-standardised evaluation methods, driven by a scarcity of suitable measures, to evaluate the effectiveness of their work.

Discussion

There exists a high degree of heterogeneity in clinical practices amongst music therapists working with children with ACIs, reflecting diverse backgrounds and approaches. The absence of clear trends or dominant approaches emphasises the necessity for further research to establish evidence-based practices for this population.

KEYWORDS:

• Music therapy
• acquired communication impairments
• paediatrics
• clinical practice
• survey

Introduction

Language development between the ages of 2 and 6 is a critical period of growth and acquisition. During this time, children make significant strides in their language skills, including vocabulary expansion, grammar development, and the ability to engage in meaningful conversation (Saxton, 2017). A prominent mechanism that fuels vocabulary growth during this period is fast mapping. Through this process children rapidly absorb and integrate new words into their lexicon, acquiring an average of two to three new words per day (Owens, 2019). Receptive vocabulary expands exponentially during this preschool period, growing from around 200 words to over 10,000 words, and expressive vocabulary typically reaches 2,000 words or more (Saxton, 2017; Shipley & McAfee, 2021). As children advance their narrative skills, they develop causal chains to connect events or actions in a cause-and-effect relationship (Owens, 2019). Furthermore, they undergo grammatical development, becoming proficient in using past and future tenses and demonstrating appropriate grammar usage in most instances (Shipley & McAfee, 2021). As children actively engage in conversations and interactions with others, they continue to strengthen and refine their communication skills. They unceasingly enhance the foundational structures of communication, which include active listening, turn-taking, and the ability to interpret non-verbal cues (Buckley, 2003).

Acquired communication impairments (ACIs) are disturbances in speech-language function that result from some form of cerebral insult after language acquisition has already commenced (Hécaen, 1976). The cerebral insult can result from a variety of aetiologies, including traumatic brain injury, cerebrovascular accidents, brain haemorrhage, tumour, and infection. While adult and paediatric ACIs closely resemble one another, it is important to remember that children, depending on their age, are either beginning to develop or are still developing speech and language concurrent with damage to the central nervous system (Murdoch, 2011). In children, a brain lesion could interfere with the aspects of language that are already developed or disrupt the acquisition of those that have not fully emerged yet (Gilardone et al., 2022). Consequently, the combination of acquired neurological damage and child development complicates the translatability of adult research to the paediatric population (Murdoch, 2011). Aphasia, dysarthria, apraxia, and cognitive communication impairments are among the chief alternations in communication that are caused by neurological damage.

Aphasia is a linguistic processing disorder that compromises the brain’s ability to formulate and/or interpret words and sentences (Hora et al., 2014). Acquired childhood aphasia follows damage to the neural language network and, similarly to the adult population, aetiology can vary. Murdoch (2011) and O’Hare (2016) note that childhood aphasia is predominantly non-fluent, with its major features being mutism and lack of spontaneous speech. However, O’Hare (2016) also acknowledges the possibility of paraphasia, preservation, and circumlocution occurring. Dysarthria is a motor speech disorder in which the muscles that are used to produce speech are damaged or paralysed (Hora et al., 2014). Children with dysarthria commonly experience shallow irregular breathing which creates difficulties in generating sufficient breath to support speech production. Paediatric dysarthria often leads to the low-pitched, breathy or harsh voices, nasalised speech, and poor pronunciation (Pennington et al., 2016). Acquired apraxia of speech is a motor speech disorder and is defined as the inability to articulate sounds necessary for successful speech or language production (Beathard & Krout, 2008; Cohen, 1992). There is a dearth in the literature surrounding the nature and occurrence of acquired apraxia of speech in children (Murdoch, 2011). As in adults, it is reported that apraxia frequently co-occurs with acquired aphasia and/or dysarthria. Murdoch (2011) suggests that one potential reason for the limited attention given to acquired apraxia of speech in the literature is that the condition appears to resolve quickly. In children, acquired apraxia of speech is characterised primarily by inaccuracies in articulation and secondarily by alterations in prosody (Murdoch, 2011). Cognitive communication impairments are characterised by difficulties with listening, speaking, reading, writing, conversing, or interacting socially that stem from underlying cognitive impairments in attention, memory, organisation, information processing, problem-solving, or executive functions (Cermak et al., 2019; Turkstra et al., 2015). For young children with cognitive communication impairments, there is a notable risk of experiencing delays in vocabulary acquisition which may contribute to impairments in reading and auditory comprehension (Turkstra et al., 2015).

The complex interplay of ACIs highlights the diverse challenges faced by children in their language development, underscoring the importance of comprehensive assessment and intervention strategies. Children with ACIs often require intensive interdisciplinary neurorehabilitation involving speech and language therapy and occupational therapy to facilitate the relearning and development of changed or lost abilities as a result of their injury (Murdoch, 2011). As an example, when addressing paediatric dysarthria, speech and language therapy intervention often employs traditional drill exercises of the tongue and lips to increase the rate, strength, range, or co-ordination of the musculature supporting articulation (Morgan & Vogel, 2008).

Music and language exhibit common characteristics, employing elements such as pitch, rhythm, and tempo to convey meaning and evoke emotional responses (Besson & Schön, 2001). Furthermore, music is a social activity that works at both pre-verbal and verbal levels. It acts as a potent means of communication that is readily accessible long before the acquisition of expressive language, making it an effective medium for relearning and enhancing communication skills as well as fostering social interaction (Bunt & Stige, 2014). In light of this, music therapy becomes increasingly relevant in supporting young children with ACIs; however, the body of literature surrounding the use and clinical practice of music therapy with this population remains limited. A selection of case study reports offer valuable insight into clinical practices and shed light on the impact of music therapy when working with children with ACIs.

Bower and Shoemark (2009) illustrate the effectiveness of collaborative music therapy and speech and language therapy in supporting a 10-year-old boy with an acquired neurogenic communication disorder. Through therapeutic song singing, drumming interventions, and vocal improvisation exercises, collaboration between the disciplines improved the clarity and intelligibility of the boy’s speech as well as fostering his ability to engage in meaningful interaction. More specifically, case vignettes by Kennelly and Brien-Elliott (2001) and Kennelly et al. (2001) also describe the use of combined music therapy and speech and language therapy to address dysarthria rehabilitation. The collaborative sessions included breathing exercises focusing on sustained vowel sounds and melodic variation exercises in major and minor tonalities to target the areas of articulation, pitch, and volume control. To encourage active participation, the sessions incorporated familiar songs played at a slow tempo. The tempo was gradually increased as articulation and breath control improved to develop a faster rate of speech. Additionally, both case studies highlighted the emotional support provided by music therapy intervention, aiding the children in adapting to the hospital environment. Conversely, Cohen (1988) employed song singing at a tempo of 80 beats per minute with an 18-year-old experiencing dysarthria and an excessively fast rate of speech, leading to a significant decrease in speech production.

Only one case study has been identified that discusses music therapy intervention for children with ACIs during the formative pre-schooler stage, which encompasses ages 2–6. Kennelly et al. (2001) present a joint music therapy and speech and language therapy intervention, focused on aphasia rehabilitation in a three-year-old girl. Her communication difficulties encompassed delayed language development, severe word-finding difficulties, offering inappropriate responses to questions, and experiencing challenges in following directions. Familiar songs were used to elicit one-word utterances at the end of a phrase through anticipatory cues in the music, and the elements of music were explored and manipulated to encourage vocalisations. By the end of this joint therapeutic intervention, the child could successfully verbalise their preferred song choice, sing entire songs, and follow directions related to instrumental play. While the highlighted case studies draw attention to a collaborative approach involving speech and language therapy, there remains a limited scope of information and literature regarding the application of music therapy with paediatric ACIs.

Study aims

Given the extremely limited research and evidence regarding the role of music therapy for children with ACIs, the aim of this study was to gather information regarding current approaches, clinical interventions, and outcome measures being used by music therapists in their work with children, aged 2–6, to address language- and communication-oriented goals. The objective was to target music therapists currently working with this population to document the body of knowledge that exists in clinical practice but is not necessarily published. The following research questions were established:

• What music therapy approaches and clinical models are currently being used with children, aged 2–6, with ACIs?

• What clinical interventions do music therapists find most effective in addressing language- and communication-oriented goals with this population?

• How are music therapists evaluating the impact of their work on language and communication in children, aged 2–6, with ACIs?

Methodology

Research design

An online cross-sectional descriptive survey design was adopted for this study in order to generate a robust description of music therapy practices used with young children with ACIs. This design was employed to facilitate a comprehensive exploration of the multifaceted landscape while also enhancing generalisability to the entire population as a direct result of being able to gather larger amounts of data (Curtis, 2016). Cross-sectional descriptive surveys offer valuable insights into the status of phenomena at a fixed point in time, offering a snapshot of prevailing trends (Andres, 2012).

Participant recruitment

When recruiting participants for this study, a purposive sampling method was employed. This method allows researchers to glean knowledge from individuals who have particular expertise and experience “that is valuable to the research process” (Bowling, 2014, p. 209). As with other non-probability sampling techniques, purposive sampling has been criticised for being prone to sampling bias. However, given the purpose of this study, this limitation was of minor concern to the researchers.

The inclusion criteria stipulated that participants be professional music therapists currently working with children, aged 2–6, with ACIs. No restriction was imposed on participants based on their length of experience. As the survey instrument was in the English language, participants were excluded from this study if they were unable to submit their responses in English.

The recruitment process involved identifying music therapists who met the specified inclusion criteria, with invitations extended to clinicians currently employed at paediatric rehabilitation hospitals and research centres. Moreover, researchers actively involved in paediatric acquired brain injury research were also invited to participate. Potential participants and facilities were contacted by the research team, issuing invitation letters and information leaflets.

Data collection

A 16-item questionnaire was constructed by the research team with five areas of inquiry: (a) professional background, (b) music therapy clinical practice, (c) music therapy interventions, (d) outcome measures, and (e) case vignette. See Table 1 for the survey content and accompanying rationale for each of the five areas of inquiry.

Table 1. The survey content and accompanying rationale for each of the five areas of inquiry

Section	Question	Rationale	Origin
Professional Background	(1) number of years as a qualified music therapist	To better understand the level of expertise and experience of the participants.	Johnson and Heiderscheit (2018), Kern and Tague (2017), Knott et al. (2020)
	(2) number of years working as a music therapist with children, aged 2–6, with ACIs	To better understand the level of expertise and experience of the participants.	Johnson and Heiderscheit (2018)
Music Therapy Clinical Practice	(3) clinical approach used	To identify the overarching philosophy that informs practitioners’ interventions. While there exists potential for integration and overlap between approaches, respondents are encouraged to reflect on the primary lens through which they approach their work.	Johnson and Heiderscheit (2018) Further informed by Edwards (2017), Moore and Lagasse (2018), Wheeler (2015)
	(4) clinical model applied	To gain insight into the perceived effectiveness of different models for achieving language and communication goals. Allowing multiple answers recognises the reality of music therapy practice, where therapists may draw from a toolbox of clinical models and techniques depending on the child’s individual needs.	New question – outside the scope of referenced research Further informed by Edwards (2017), Moore and Lagasse (2018), Wheeler (2015)
	(5) frequency of sessions per week	To understand how often therapists deem intervention to be necessary with this population to reach target goals.	Johnson and Heiderscheit (2018)
	(6) capacity in which music therapy is offered	To capture the diverse ways in which music therapy is delivered to this population.	Johnson and Heiderscheit (2018), Kern and Tague (2017)
	(7) capacity found most impactful	To gain insight into the perceived effectiveness of different programme types in achieving target goals.	Kern and Tague (2017)
	(8) length of music therapy sessions	To identify average duration of sessions.	Johnson and Heiderscheit (2018), Kern and Tague (2017)
Music Therapy Interventions	(9) effectiveness of music therapy interventions in addressing speech and language goals	To gain insight into the perceived effectiveness of various music therapy interventions for language and communication goals.	Johnson and Heiderscheit (2018), Kern and Tague (2017), Knott et al. (2020)
	(10) joint therapeutic interventions employed	To identify joint therapeutic interventions	New question – outside the scope of referenced research
Outcome Measures	(11) use of standardised outcome measures	To assess the integration of standardised outcome measures into clinical practice, and if so, to identify which specific measures are being used.	Knott et al. (2020)
	(12) use of non-standardised outcome measures	To assess whether non-standardised outcome measures are integrated into clinical practice.	New question – outside the scope of referenced research
	(13) identifying non-standardised outcome measures used	To identify which non-standardised measures are being used.	New question – outside the scope of referenced research
	(14) additional methods used to evaluate clinical programmes	To gather a comprehensive view of any additional assessment practices.	New question – outside the scope of referenced research
Case Vignette	(15) provision of case vignette	To determine if participants wish to share a case vignette.	New question – outside the scope of referenced research
	(16) case vignette details	To gather a holistic understanding of music therapy in the context of young children with ACIs	New question – outside the scope of referenced research

Informed by prior survey studies (Johnson & Heiderscheit, 2018; Kern & Tague, 2017; Knott et al., 2020), survey questions included a combination of nominal, rank order, and open-ended response options. To acknowledge the wide variety of music therapy practices and trends worldwide, semi-closed question formats were incorporated, including the option “Other (Please Specify.)” in six of the nominal questions. The option “Unsure” was included in two nominal questions regarding the participants’ music therapy approach. By explicitly offering an unsure option, it indicated to respondents that it was acceptable to say that they did not have the information with which to answer the question and in turn minimised guessing (Krosnick & Presser, 2010). Open-ended response questions were utilised to solicit detailed descriptions of music therapy interventions, outcome measures, and an example of participants’ clinical work. Participants were required to answer 12 questions and the remaining 4 questions were optional.

The survey was hosted on Qualtrics, an online survey tool, and was made available to the participants for 8 weeks from 16 January to 13 March 2023. The estimated time to complete the survey was 10–15 minutes. A full copy of the survey instrument is available as online supplemental material (see Supplemental Online Material 1).

Ethical considerations

Ethical approval was sought and obtained through the Research Ethics Committee at the University of Limerick. The online survey included a cover page outlining participant information and consent. Participants who did not agree to the terms in the consent form were disqualified from completing the survey. Furthermore, participants were made aware that the point of withdrawal was at the point of submission. As data collection was anonymous, participants were not able to withdraw their information after this time.

Data analysis

Categorical and numerical data, which were collected from participants’ responses to closed and semi-closed questions, were analysed in Qualtrics using descriptive statistical analysis. This process entails using mathematical methods to ascertain distribution frequencies, aggregate totals, and averages (Meadows, 2016). Subsequently, the research team conducted a comprehensive review to ensure accuracy.

Responses to open-ended questions on music therapy interventions and outcome measures yielded definitive exclusive clusters, converted to post hoc categories for descriptive statistical analysis, complemented by illustrative examples.

Qualitative data gathered through the case vignettes was analysed using conventional content analysis as outlined by Shava et al. (2021). This cyclical method involved identifying and categorising recurring patterns and themes that are derived directly and inductively from the data. A conventional approach to qualitative content analysis is appropriate when a study aims to describe a phenomenon where existing literature is limited, as it enables researchers to immerse themselves in the data and uncover new insights (Hsieh & Shannon, 2005; Kondracki et al., 2002). The authors independently reviewed the data before collaboratively developing themes and discussing findings in order to minimise bias, thus augmenting the credibility of the results. However, the optional provision of the case vignettes led to an inherent imbalance in the qualitative and quantitative data. This imbalance limited the scope for triangulation and integration of findings, necessitating only cautious interpretation.

Measures of rigour and quality

Two senior music therapists with extensive clinical experience in the areas of paediatric ACIs served as experts to review a preliminary draft of the questionnaire. Their feedback highlighted some issues with the user interface and the need for further amendments regarding the clarity and intention of some questions.

Content validity testing was employed to assess the accuracy of the survey and ensure its items effectively represent the intended construct it aims to measure. Content validity is defined as the extent to which an instrument adequately evaluates all aspects of the research domain of interest when attempting to measure phenomena (Wynd et al., 2003). It is recommended to conduct content validity testing on a new survey instrument to ensure that it includes all essential items and eliminates undesirable items to a particular construct domain (Taherdoost, 2016; Wynd et al., 2003).

The most widely used method for measuring content validity is the content validity index (CVI) which is based on expert ratings of relevance using a four-item scale (Polit et al., 2007). The first two items of the scale, not relevant (score 1) and needs major revisions (score 2), are considered “content invalid” while the remaining two items, needs minor revisions (score 3) and are relevant to the aims of the research (score 4), are considered “content valid” (Lynn, 1986; Polit et al., 2007; Wynd et al., 2003). To calculate a CVI value, the number of experts giving a rating of either 3 or 4 is divided by the total number of experts. Items that are below the acceptable level of relevance are eliminated (Polit et al., 2007). Eight experts were invited to review the survey subjectively. This process was carried out for every item of the survey, ensuring the survey questions reflected the aims of the study and that key related subjects were not excluded.

There are no defined guidelines that indicate what an acceptable CVI should be. Davis (1992) states that for new instruments, investigators should seek 80% or better agreement among expert reviewers. Therefore, an item was deemed content valid and accepted for this study if a CVI of 0.8 was obtained. The CVI was calculated for each item of the survey (i.e. the number of 3 or 4 ratings divided by the number of experts, in this case 8). Each item scored 1.0 or 0.875; no items scored below 0.8. It can be concluded from this analysis that there was a strong agreement amongst the reviewers that the content of the survey was valid.

Results

The survey was completed over an 8-week period from 16 January to 13 March 2023. A total of 54 participants across 10 countries completed the survey. In addition to the following presentation of the main results, supplemental online material is available, providing further details on professional background, session format, and an overview of the case vignettes (see Supplemental Online Material 2).

Professional background

The number of years respondents worked as a music therapist ranged from 8 months to 36 years; most had between 1 and 5 years (n = 16, 29.6%) and 11 to 20 years (n = 16, 26.6%) of work experience. Based on 52 responses, the majority of music therapists indicated that they had been working with children with ACIs between 1 and 5 years (n = 18, 34.6%).

Music therapy clinical practice

When working with children with ACIs, clinicians mainly reported applying a humanistic, person-centred approach (n = 25, 46.3%) or an integrative (eclectic) approach (n = 17, 31.5%) to inform their clinical practice. Of the 17 respondents that reported utilising an integrative approach, 12 unique combinations were identified. Three clinicians (5.6%) stated they utilised a humanistic and developmental approach, and two respondents (3.7%) shared that they adapted their clinical approach depending on the context and immediate needs of the child.

Survey respondents were presented with seven music therapy clinical models and asked to select all models they have applied when working with a child with an ACI towards language- and communication-oriented goals. Clinicians indicated using Neurologic Music Therapy (n = 40, 74.1%), Behavioural Music Therapy (n = 17, 31.5%), Nordoff-Robbins Music Therapy (n = 14, 25.9%), and Resource-Oriented Music Therapy (n = 14, 25.9%). Table 2 outlines the wide variety of clinical approaches and models used by clinicians when working with this population.

Table 2. Clinical approaches and models

Question	Count	%
Clinical Approach
Humanistic	25	46.3
Integrative	17	31.5
Developmental	8	14.8
Cognitive-Behavioural	3	5.6
Psychodynamic	1	1.9
Clinical Model
Neurologic Music Therapy	40	74.1
Behavioural Music Therapy	17	31.5
Nordoff-Robbins Music Therapy	14	25.9
Resource-Oriented Music Therapy	14	25.9
Other (Please specify.)	9	16.7
Community Music Therapy	7	13
Analytical Music Therapy	4	7.4
Unsure	2	3.7
Guided Imagery and Music	1	1.9

In the question pertaining to clinical models, respondents were permitted to select multiple response options. Consequently, the total number of responses for this question exceeds the sample size, N = 54.

Session format

Music therapists shared that they primarily work with the same child once per week (n = 29, 53.7%), followed by twice per week (n = 14, 25.9%). A smaller number of therapists reported seeing the same client three times per week (n = 8, 14.8), four times per week (n = 1, 1.9%), or five times per week (n = 2, 3.7%). The mean frequency was 1.76 times per week. Sessions were reported to range from 20 to 60 minutes in duration.

All participants (n = 54, 100%) reported that they offered individual music therapy programmes to children with ACIs. Respondents also indicated offering joint music therapy and speech and language therapy programmes (n = 39, 72.2%), joint music therapy and occupational therapy programmes (n = 23, 42.6%), group music therapy programmes (n = 20, 37%), and telehealth music therapy programmes (n = 4, 7.4%). A small percentage of respondents (n = 3, 5.6%) listed additional programmes under the response option “Other”; these included group joint music therapy and speech and language therapy programmes, joint music therapy and physiotherapy programmes, and joint music therapy and parent programmes.

Thirty-two music therapists ranked joint music therapy and speech and language therapy programmes as the most impactful medium to address language- and communication-oriented goals with children with ACIs (59.2%). Individual music therapy programmes were deemed most impactful by 17 respondents (31.9%), and group music therapy programmes were considered most impactful by 3 respondents (5.6%). Two respondents (3.7%) selected “Other”, further elaborating that it was dependant on the needs of the client. The most predominant choice was telehealth music therapy programmes, selected as a fifth priority by 35 respondents. See Table 3.

Table 3. Most impactful session orientation

Session Orientation	Priority						Sum
	1st	2nd	3rd	4th	5th	6th
Individual Music Therapy Programmes	17	31	3	2	0	0	53
Group Music Therapy Programmes	3	4	17	23	3	0	50
Joint Music Therapy and Speech and Language Therapy Programmes	32	12	4	2	1	0	51
Joint Music Therapy and Occupational Therapy Programmes	0	5	25	12	3	1	46
Telehealth (Online) Music Therapy Programmes	0	1	0	6	35	1	43
Other (Please specify.)	2	0	0	0	1	0	3

N = 54. Participants were asked to rank each orientation 1–6, where 1 is the most impactful and 6 is the least impactful.

Music therapy interventions

Table 4 illustrates the music therapy interventions found most effective by clinicians in addressing language- and communication-oriented goals when working with children, aged 2–6, with ACIs. Notably, only three respondents indicated using Neurologic Music Therapy interventions under the response option “Other”.

Table 4. Music therapy interventions

Music Therapy Interventions	Count	%
Song Singing	50	92.6
Vocal Improvisation	34	63
Music and Play	31	57.4
Instrumental Improvisation	24	44.4
Music combined with Visual Media	21	38.9
Story Song Creation	21	38.9
Augmentative and Alterative Communication	19	35.2
Music and Movement	16	30
Songwriting/Composition	9	16.7
Other (Please specify.)	6	11.1
Music Listening	5	9.3
Conducting Music	4	7.4
Song Discussion	3	5.6
Computer-based Music Activities	2	3.7
Music and Art	1	1.9
Lyric Analysis	0	0

Respondents were allowed to select a maximum of five interventions. Consequently, the number of responses for this question exceeds the sample size, N = 54. Other response options include: Neurologic Music Therapy Speech and Language Techniques, Breathing Exercises, Using Wind Instruments to Support Sustained Exhalation, Singing and Sign Language.

Twenty-two music therapy practitioners provided details on additional joint therapeutic interventions used in sessions with children, aged 2–6, with ACIs. Among the responses, participants highlighted collaborative efforts with speech and language therapy (n = 15, 68.2%), occupational therapy (n = 4, 18.2%), physiotherapy (n = 2, 9,1%), and neuropsychology (n = 1, 4.5%). Respondents described how music therapy provides a motivating quality that promotes adherence to therapeutic activities. They shared experiences of collaborating with speech and language therapists, incorporating target sounds and words into familiar songs, utilising music to reinforce speech exercises, assisting in the exploration of augmentative and alternative communication (AAC) devices, and contributing musical interactions during standardised speech assessments. One respondent shared that “sessions tend to be music therapy led” and remarked that music is used as a stimulus that is often adapted to achieve specific speech or communication goals. Participants also described collaborating with occupational therapists, using music to explore potential AAC devices and promoting a developing awareness through musical play.

Outcome measures

The majority of respondents (n = 48, 88.9%) indicated that they did not use standardised outcome measures to assess the impact of music therapy intervention on language and communication in their work with children, aged 2–6, with ACIs. However, a small number of participants (n = 6, 11.1%) answered in the affirmative. These respondents used a range of standardised outcome measures, including the Dysarthria Impact Profile (DIP), Diagnostic Evaluation of Articulation and Phonology (DEAP), Goldman-Fristoe Test of Articulation (GFTA), Pediatric Evaluation of Disability Inventory (PEDI), and Weschsler Abbreviated Scale of Intelligence (WASI).

When asked if they utilised non-standardised outcome measures to evaluate the effectiveness of their work, 46 respondents (85.2%) replied “Yes”, while the remaining participants (n = 8, 14.8%) responded “No”. Those who answered “Yes” were then asked to specify which non-standardised outcomes measures they used to evaluate their work. Out of the 46 respondents, the methods commonly used by music therapists included observation (n = 43, 93.5%), video recording (n = 21, 45.7%), using their own or developmental screening tool (n = 18, 39.1%), audio recording (n = 13, 28.3%), a modified standardised outcome measure (n = 11, 23.9%), and other methods (n = 6, 13%).

Nineteen music therapists offered further information on methods used to evaluate the outcomes of music therapy intervention on language and communication in children, aged 2–6, with ACIs. Eight respondents (42.1%) highlighted how they used observation and feedback from parents, grandparents, and other family members to assess progress. Additionally, collaboration with other therapists (n = 7, 36.8%) and the wider rehabilitation team (n = 4, 21.1%) was also a common method used for evaluating progress.

Case vignette

Only four music therapists chose to provide a brief case vignette detailing their work with a child with an ACI (7.4%). From these vignettes, three major themes emerged in analysis, as presented below.

Enhancing communication skills

Across the case studies, music therapy is noted as being effective in improving communication skills. In the case study of Maria, who had dysarthria, music therapy “was successful in supporting controlled breathing, improving articulation, and regulating rate of speech”. In the cases of Julie and Lucy, collaborative music therapy and speech and language therapy was used to promote vocalisation and phrase completion through familiar song, visual cues, and instrumental improvisation. Similarly, Ryan’s music therapist reported an improvement in his ability to verbally recall single-step commands.

Collaboration

Interdisciplinary collaboration was present within three of the case studies. In the cases of Julie and Lucy, collaboration between music therapy and speech and language therapy assisted in facilitating a comprehensive treatment plan that targeted each child’s specific communication needs. In the case study of Ryan, collaborative music therapy and occupational therapy provided initial support in his pre-speech exercises, including enhancing his ability to sustain attention and “developing his proprioceptive understanding of his voice”. Following reassessment, it was concluded that Ryan would benefit more from participating in collaborative music therapy and speech and language therapy in order to further advance his speech acquisition and language development.

Diverse practices

Although the case vignettes share similarities, they serve to highlight the diverse array of diagnoses and communication difficulties that fall under the umbrella of ACIs. Consequently, a variety of approaches and interventions are employed to address specific communication areas, such as expressive output, breath control, sustained phonation, or sustained attention.

Discussion

Variability within clinical practice

There is a high degree of heterogeneity in the results presented. This diversity may be indicative of the lack of consensus or standardisation in the field of music therapy and paediatric ACIs. This heterogeneity does not necessarily signify uncertainty but rather reflects the varied backgrounds and approaches of the music therapists who participated in the survey. Among the 17 respondents who reported using an integrative approach to music therapy, 12 unique combinations of approaches were identified, indicating that clinicians draw from a myriad of theoretical perspectives when working with children, aged 2–6, who have ACIs. Additionally, the wide range of clinical models used emphasises the diversity present in music therapy clinical practice. This heterogeneity reflects the eclectic and client-led nature of music therapy, tailoring treatment to the individual needs of each child and the primacy within the profession for clinicians to be flexible and adaptable in their approach (Edwards, 2017). As one respondent stated, “my clinical approach incorporates a variety of theoretical approaches and is dynamic and responsive depending on the needs and context of the child”.

The survey findings indicate that clinicians primarily applied a humanistic, person-centred approach to inform their clinical practice, while neurologic music therapy (NMT) was reported as the most favourable clinical model. This could be interpreted as a potential incongruity between the values of a humanistic, person-centred approach, which emphasises the individual’s unique experiences, and the underpinning principles of a neuroscience-informed approach, which may be perceived as authoritarian as it is grounded in addressing the client’s presenting disease and disability, potentially diminishing the client’s agency (Moore & Lagasse, 2018). Furthermore, while 40 respondents reported adopting an NMT model in their clinical practice, only three respondents reported using specific NMT interventions such as melodic intonation therapy and vocal intonation therapy as effective methods for addressing language- and communication-oriented goals. This disparity might indicate a variance in the extent to which clinicians adhere to specific NMT interventions. Some clinicians might selectively integrate principles or concepts from NMT into their interventions without embracing the full array of associated techniques. Alternatively, some respondents may have chosen NMT due to their familiarity with the approach but may not use it in their clinical practice with children who have ACIs. It is also worth considering that the absence of predefined NMT options among the intervention response choices may have influenced the low selection of these specific interventions. Wheeler (2015) acknowledges that many music therapists incorporate elements of various approaches and models in their work, whereas others follow a particular orientation. However, the interplay between these distinct models and approaches can create challenges in maintaining a consistent therapeutic framework as the theoretical orientation serves as the foundation upon which clinicians construct their practices, influencing the choice and implementation of clinical intervention (Johnson & Heiderscheit, 2018).

The broad spectrum of approaches and models used by music therapists when working with children with ACIs may be reflective of the diverse presentations that fall under this diagnostic umbrella. However, it is also possible that the array of clinical practices and lack of clear trends or dominant approaches indicate a need for greater understanding and education among clinicians to ensure that they are equipped to provide effective and tailored support to this population in their language and communication needs. This raises the question of whether there is a need to formalise and standardise music therapy as a profession, or if its strength lies in its inherent flexibility and adaptability. More research is needed to establish evidenced-based practices for music therapy in this area.

Interdisciplinary strength

The results indicate that collaboration between music therapists and professionals from other disciplines, particularly speech and language therapy and occupational therapy, is common and considered impactful for addressing language- and communication-oriented goals with children with ACIs. The results revealed that 72.2% of the respondents reported offering joint music therapy and speech and language therapy programmes, while 59.2% of surveyed music therapists ranked this collaborative approach as the most effective method for achieving these goals. The case vignettes offered by respondents further highlight how collaboration between music therapy and speech and language therapy assisted in facilitating a comprehensive treatment plan that targeted each child’s specific communication needs. This collaborative relationship has been extensively reported in previous case studies (Bower & Shoemark, 2009; Kennelly & Brien-Elliott, 2001; Kennelly et al., 2001), and these results reinforce that collaboration between these disciplines is perceived to be effective in improving language and communication skills in children with ACIs. Although this study did not explore the reasons behind the perceived effectiveness of collaboration over music therapy alone, it is reasonable to speculate that the integration of various therapeutic disciplines offers a more comprehensive treatment approach. Speech and language therapy, for instance, can provide specific techniques and strategies for enhancing language and communication skills, while music therapy can improve motivation and engagement, promote social interaction, and provide opportunities for self-expression. By combining these two therapies, clinicians can offer a holistic approach within a creative environment that not only targets specific language and communication goals but also fosters growth and development.

Shifting the focus

While we know which music therapy interventions were deemed most effective by clinicians in addressing language- and communication-oriented goals when working with children with ACIs, this survey did not identify the specifics of how these interventions are used or what specific communication goals they target. The case vignettes provided some insights into the application of music therapy for enhancing communication skills; however, these vignettes present only a few examples, including using song singing to elicit vocalisations through anticipatory cues, vocal improvisation to promote prolonged phonation, and instrumental improvisation to support the foundations of pre-verbal communication such as turn-taking, choice-making, and sustained attention. Song singing can be an effective method to target vocabulary building, pronunciation, and intonation but may not be the most effective in addressing cognitive-communication impairments. For instance, difficulties with sustaining attention, executive function, or sentence construction and comprehension may not be adequately addressed through song singing alone. Perhaps when treating ACIs it may be more advantageous to focus on the symptoms rather than solely relying on the diagnosis itself. For example, as well as considering how music therapy can address apraxia, it would be beneficial to explore how music therapy can address specific issues like slow or effortful speech as well as inconsistent stress and intonation. Shifting the focus to these symptoms could prove valuable in terms of session planning and preparation, ultimately resulting in more impactful and successful programmes.

Evaluating music therapy programmes

It appears that the majority of surveyed music therapists do not use standardised outcome measures to evaluate the effectiveness of music therapy intervention on language and communication in children aged 2–6 with ACIs. Only a small percentage (11.1%) reported using such measures, and a broad range of assessment tools were offered by the survey respondents. The suitability of these tools to measure changes in language and communication in this population depends on several factors, including the nature and severity of the child’s communication impairment and their developmental level. For instance, the Diagnostic Evaluation of Articulation and Phonology (DEAP) and the Goldman-Fristoe Test of Articulation (GFTA) are primarily intended to evaluate a child’s articulation and phonology abilities, making them appropriate for children with speech sound disorders but not necessarily for assessing other aspects of communication like language comprehension and production. Furthermore, the Dysarthria Impact Profile (DIP) evaluates the impact of dysarthria and is potentially inappropriate for children with other acquired communication impairments. Given the complex and diverse range of symptoms associated with these impairments, it is challenging (and perhaps impractical) to capture all aspects of a child’s language profile using a single assessment tool. Language development during this period is complex and varied and would require the use of a range of tools to obtain a comprehensive understanding of a child’s communication abilities. Further inquiry with speech therapists regarding their assessments of this population, and an investigation into whether these assessments are more standardised or present similar challenges, is highly recommended. Furthermore, conducting an exploration of how these assessment practices align with those of music therapy will yield valuable insights.

The survey results indicate a clear preference for non-standardised outcome measures, including observation, video recording, and using developmental screening tools. However, the survey failed to capture important contextual information about how these measures are used and implemented to measure change. This lack of information may limit the usefulness of the survey results. Non-standardised outcome measures may be more accessible to music therapists who may not have the necessary specialised training to use standardised tools effectively. Non-standardised measures can offer greater flexibility in terms of their administration and interpretation, which can be particularly useful in clinical settings where standardised tools may not be practical or feasible. The previously published case studies about paediatric ACIs use observational methods to evaluate the impact of their work and make no reference to standardised assessment tools or outcome measures. This may be because these existing standardised measures are not always appropriate in the complex clinical contexts in which these impairments occur (Bower & Shoemark, 2009; Kennelly & Brien-Elliott, 2001; Kennelly et al., 2001). Conversely, it is worth noting that while non-standardised measures can provide valuable information, they may not be as valid or reliable as standardised outcome measures. Therefore, the use of both standardised and non-standardised measures may be more beneficial for a comprehensive evaluation of music therapy intervention.

Study limitations and directions for future research

The relatively small sample size of this survey deserves consideration. Due to the specific nature of the clinical population being studied within a small profession, it was not feasible to obtain a large survey population. It is important to acknowledge that the small sample size may not be fully representative of music therapists working in the studied setting, and it is possible that there is bias in that those who chose to reply were therapists with positive experiences of successfully working with this client group. Only four participants contributed case vignettes that informed the development of the themes arising from the conventional content analysis. Consequently, it is crucial to interpret these findings with care, as they may not fully capture the breadth of experiences and practices within the larger group of respondents.

While the survey instrument underwent pilot testing and content validity testing to enhance its quality, it is important to acknowledge that the survey’s design may have inadvertently influenced participants’ responses by presenting a predetermined set of response options. Nonetheless, participants were given the opportunity to offer their own perspectives by utilising the “Other” response option. Despite its wide distribution, the survey results are restricted to respondents from only 10 countries. This limited geographical representation may constrain the generalisability of the findings, particularly considering that some countries had only one respondent. Furthermore, the survey tool was developed and distributed solely in English, which may have posed language comprehension difficulties for some participants, potentially leading to hesitancy in completing the study or misunderstanding some of the questions. Future research should explore the use of the survey tool in multiple languages to ensure a more inclusive and comprehensive examination of the phenomenon.

The survey also relied on self-reported data from music therapists, which could introduce bias or inaccuracies in the responses. For example, music therapists may have selectively chosen to report case studies that were particularly successful, rather than providing a more representative sample of their work with children with ACIs. Despite these limitations, the study still provides valuable insight into the clinical practice of music therapists with children with ACIs, aged 2–6, and is the largest study of its kind to date.

It is recommended that future research should seek to understand specific music therapy clinical models further and their effectiveness in supporting language and communication in children aged 2–6 with ACIs. This will enable the identification of the most effective approach that will yield the best outcomes for these children. Furthermore, it may be worthwhile to conduct this survey again in the future to assess whether the perspectives and clinical practices of music therapists have evolved as the field of music therapy continues to grow and develop within this context.

Conclusion

This study provides valuable insights into the current landscape of music therapy practices for children, aged 2–6, with ACIs. It offers important information about music therapy approaches, clinical interventions, and outcome measures used with this population when working towards language- and communication-oriented goals. The results reveal a lack of standardisation in this field and highlight the diversity within clinical practices. Consequently, further research is necessary to establish evidence-based practices. Nevertheless, it is important to acknowledge the strengths of the profession, which lie in its inherent flexibility and adaptability. These qualities allow for tailored heterogeneous programmes, particularly necessary in acute rehabilitation settings, providing respite from the clinical environment which is especially beneficial for young children undergoing intensive rehabilitative intervention.

Acknowledgements

The authors would like to acknowledge the experts involved in the reviewing and content validity testing of the survey instrument.

Disclosure statement

Hilary Moss is associate editor of the Nordic Journal of Music Therapy. To avoid conflict of interest, Hilary Moss was fully masked to the editorial process including peer review and editorial decisions and had no access to records of this manuscript. No other potential conflict of interest was reported by the authors.

Supplementary material

Supplemental data for this article can be accessed online at https://doi.org/10.1080/08098131.2024.2329898.

Additional information

Funding

No funding was received for this study.

Notes on contributors

James Burns

James Burns is Music Therapist at Children’s Health Ireland at Temple Street, Dublin and PhD Candidate at the University of Limerick.

Rebecca O’Connor

Rebecca O’Connor is Senior Music Therapist and Creative Arts Therapy Service Lead at the National Rehabilitation Hospital, Dublin.

Hilary Moss

Hilary Moss is Associate Professor of Music Therapy at the University of Limerick.