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The Role of Music Therapy in NICU Familial Bonding

Katie G. Brinkman

Department of English, Florida State University

ENC 2135: Research, Genre and Context

Issac Vaught

October 6, 2023
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The Role of Music Therapy in NICU Familial Bonding

The neonatal intensive care unit (NICU) is defined by March of Dimes as a “a nursery in

a hospital that provides around-the-clock care to sick or preterm babies” (March of Dimes, n.d.).

Children born prematurely and that require the services of the NICU are faced with countless

physical, emotional and developmental hurdles that often threaten their young lives. During their

time in the hospital these experiences can not only put immense stress on the infant and parents

during the hospitalization but can also bleed into their time outside of the hospital and put strains

on their childhood/adult lives in ways that infants born full term will never know. Thus, there is

often a gap in the care that an infant receives during their time in the NICU as even though they

are receiving vital care that physically provides them with the opportunity for life, there are

added questions as to the social and long-term implications this time in the hospital has on their

well-being. This provides a basis for the use of music therapy within the NICU as its main goal

is to provide preterm infants with the ability to better regulate their emotional as well as physical

state. This poses the additional question; can music therapy be used within the NICU to help

strengthen/impact the bond between a parent and their infant during and after their time in the

NICU?

Trauma and Stress within the NICU

The NICU is a place that is constantly in motion. Over the course of an average NICU

stay, a premature infant “may face…acute states of hyperarousal up to 60 to 100 times as part of

routine procedural care” with a preterm infant’s average number of procedures ranging from

anywhere around 300 to far exceeding 400, depending on the gestational age of the child

(Stewart, 2009). These “states of hyperarousal” are extremely detrimental to an infant as they are

faced with stimulation that their brain has yet to even develop the capabilities to fully process.
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Which can lead to “impaired development of the limbic system [responsible for emotional and

developmental responses] and delayed growth” (Stewart, 2009). Thus, these procedural

interruptions are vital to making a huge positive impact in increasing the survival rates of

neonatal infants they can also cause “profound neurodevlopmental consequences” (Coughlin,

2014) These neurodevlopmental consequences refer to major deficiencies in emotional, and

social development.

A key concern when discussing the stress an infant is faced with during their time in the

NICU is trauma, and its effects on an infant's overall development. While there is still little

known on the long-term impacts of trauma for NICU graduate's experts still broadly know that

early traumatic experiences “may leave a permanent imprint on the structure and mechanisms of

the functioning brain throughout life” (Maroney, 2003). Thus, what an infant experiences during

their time in the NICU can leave life-long impacts on their relationship with coping and the

ability for relaxation, essentially trauma can be defined as a “disruption of rhythm of the self”

(Stewart, 2009). This is why music therapy within the NICU is such a profound form of

treatment, as it addresses these psychological concerns. For example, music therapists can use an

intervention called multi-modal stimulation, which is where a therapist employs qualities of the

senses such as sight, sound, and touch within a musical realm. This form of therapy works

personally with an infant and is primarily used to help preterm infants with their state regulation.

During a session involving multi-modal stimulation, a therapist must pay extremely close

attention to a child’s response to make sure the infant is not becoming too overstimulated by this

music as well as to make sure the infant is finding some solace in the intervention (Knight, et. al.,

2018). Further, from music therapy interventions like the one listed prior it was found Barabara

Menke, et al., that infants who receive these interventions during their time in the hospital can
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achieve NICU developmental milestones at an accelerated pace, roughly two weeks earlier, than

their control counterparts, who received no musical interventions. (Menke, et. al., 2021)

Maternal Mental Health

The experience of having a preterm infant can have huge impacts on almost every aspect

of a mother’s wellbeing. As the infant is faced with enormous hurdles the mother sees these

obstacles and countless more. The emotions of a preemie mother are multi-faceted and vastly

complex as they “include feelings of guilt, helplessness, sadness over the loss of the “perfect”

child” (Shaw & Horshwitz, 2020). Other factors that put a strain on a mother’s mental well-being

include financial worries, and physical displacement (as they are not living in the same place as

their child). These intricate emotions and situations can ultimately culminate in feelings of stress,

anxiety and depression. It has been shown that mothers with children in the neonatal care unit

tend to experience postpartum depression about 27% more often, and post-traumatic stress

disorder about 15% more often, than their non-NICU counterparts (Shaw & Horshwitz, 2020).

Demonstrating that there is significant risk associated with a mother’s mental health when they

have a child earlier than expected that must be admitted to the NICU for care. Ultimately, these

factors highlight that the mental health of maternal figures in the NICU requires added attention

as it has been proven that with the decline of a mother’s mental health is a similar negative

decline in an “infant’s cognitive, behavioral, and socioemotional development” (Palazzi, et. al.,

2021).

A specific music therapy application that can be used to explore maternal mental health is

mother-infant directed singing. This mode of therapy involves exactly what the term implies, as

the therapist listens to the sounds that an infant is making and helps the mother to create music

and personal lyrics that respond directly to the infant. Utilization of this singing allows the
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mother to take a more active role in connecting to their child and can provide a sense of

empowerment and added confidence (Ettenberger & Ardila, 2018). Additionally, it was found

that these songs created within the NICU could serve long-term goals as they can continually be

used after NICU graduation and serve as a “welcome song” that helps to musically signify the

bond between mother and child (Ettenberger & Ardila, 2018). Based on a study of family-

centered music therapy, there was a major decrease in a mother’s stress from the beginning of

infant hospitalization to discharge. However, due to the size of the study and results there was

not significant evidence that suggests this decrease was caused specifically by music therapy.

However, since it has been proven that when infants receive musical care within the NICU, they

have a much higher likelihood of accelerating their developmental pace. Further, since much of

the stress that a mother of a NICU infant faces surrounds the overall health of her infant it could

be reasonable to assume that music therapy applications help at least slightly to improve a

mother’s mental wellbeing (Menke, et. al., 2021).

Paternal Mental Health

Traditionally speaking, childbirth and the initial care for the infant has fallen primarily in

the maternal realm with the father typically being absent in the presence of childbirth. However,

recently there has been a shift towards a stronger paternal presence within the hospital during

and after childbirth. Specifically speaking, within the neonatal intensive care unit there has

especially been a growth in presences as well as a growing concern as to the mental wellbeing of

the father. When one traditionally thinks of the fathers role in a household, they see them as “the

provider”, “the protector”, or “the rock” that holds the family together and shields it from any

form of harm. However, when a parental pair have a child that must be hospitalized within the

NICU this role is highly threatened. For the father this sudden uncertainty can cause,

“overwhelming emotional instability” as they feel strongly that they are falling short on their
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“social role as the family provider” (Mondanaro, et. al., 2016). Since “the general climate of the

NICU is matriarchal by nature” there is a need for further focus on the father’s identity as well as

“understanding the emotional experiences of the fathers” within the NICU (Mondanaro, et. al.,

2016). Music therapy is an extremely well-suited profession/treatment to use in order to bridge

the gap between these two spheres and allow fathers to feel more security and sense of belonging

within the NICU as well as with his newborn child. For example, in an article written by field

experts, John Mondanaro, et. al., they examined three distinct cases where each father was given

the opportunity to interact one on one with their infant. Through positive musical applications it

was found that fathers were able to build a stronger connection to their child as well as able to

“experience himself as vital in a role”, with that role being the father of a child (Mondanaro, et.

al., 2016). Through the use of musical applications, the fathers were able to build back their

sense of the role of “protector”.

Music as a Mode of Communication

One of the most important aspects of life for an infant is the bond they form with their

parents (in this sense the mother and father dyad). For a neonatal child this bond can become

strained and at points almost impossible to form due to countless obstacles that present

themselves both physically and emotionally. While a parent and newborn infant can traditionally

bond through physical touch, comforting sound and their shared experience, infants within the

NICU are often unable to have these bonding experiences due to their fragility and demands of

their care. Further the NICU creates an “environment where uncertainty can manifest in parental

detachment and at times ambivalence about bonding” (Creighton, 2011). Which can pose an

issue to the infants' wellbeing, as it has been proven that for children born prematurely there is an

“increased risk for later problems with parent-infant relationship” (Creighton, 2011). Thus, when
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these parent-infant relationships are fragile so too are the coping and emotional regulatory

abilities of the infant.

Thus, NICU music therapy allows for parents and children to bond deeply through

musical application and in ways that work around the infant’s care. One of the ways in which

music therapy applications can help families within the NICU is simply in the fact that it’s a

change of pace. Music therapy is not a highly common/well-known practice within the general

public let alone the highly specialized care which is the NICU. This means that NICU music

therapy can often be seen as “different”, as it “provide various opportunities for parents to

experience a more normalized interaction with their infant, despite being hospitalized”, thereby

establishing the idea of music therapy as a form of distraction for NICU parents (Ghetti, et. al.,

2021). Through this distraction parents are able to momentarily put aside their stressful mental

state and to fully focus on their newborn. One primary music therapy application utilized for

familial bonding is that of Song of Kin, which is when parents either choose or create a song that

is used to convey a sense of security to their child. Within a study, by Barabara Menke, et al., it

was shown that when parents’ voices are utilized within music therapy it supports infant self-

regulation as well as allows the parents to feel closer to “their child in daily life” (Menke, et al.,

2021). While music therapy aims to draw its conclusions primarily from empirical research,

there are countless personal anecdotes that illustrate the success of music therapy. For instance,

in a research study that utilized parental interviews one of the maternal responses stated that with

music therapy “you get to see how he responds directly to sound and to your voice. And you

form that relationship then.” (Ghetti, et. al., 2021). Highlighting how music therapy applications

can be a strong form of therapy and allow parents to feel connected to their child in ways that

would not be possible without the addition of music. Ultimately this suggests that the practice of
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music therapy within the neonatal care unit can be used to significantly help strengthen the bond

between parents and their infant.

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References

American Music Therapy Association, INC. (2021) Music Therapy and the Neonatal Intensive

Care Unit (NICU) [Fact Sheet].

https://www.musictherapy.org/assets/1/7/FactSheet_Music_Therapy_and_the_Neonatal_I

ntensive_Care_Unit__2021.pdf

This source is a fact sheet that comes directly from the American Music Therapy

Association (AMTA) and was last updated in 2021. The AMTA is a non-profit

organization that is the sole music therapy association operating within the United States,

which advocates for the profession as well as works to ensure that all music therapists are

operating at a board-certified level. This source specifically details a brief overview of

the music therapy profession within the NICU. Within this overview is the description of

various musical applications used specifically in the NICU, as well as various benefits

that are seen often from the practice of music therapy within this field. Thus, this source

relates back to my paper because it provides a baseline from which I can expand my

research, by see all the applications that can take place in this field and various benefits I

have a better understanding of what to look for when researching.

Coughlin, M. E. (R.M.N.) (2014). Transformative Nursing in the NICU : Trauma-Informed Age-

Appropriate Care. Springer Publishing Company.

Creighton, A. (2011). Mother-infant musical interaction and emotional communication: A

literature review. Australian Journal of Music Therapy, 22, 37–56.

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Ettenberger, M., & Ardila, B. M. Y., (2018). Music therapy song writing with mothers of

preterm babies in the Neonatal Intensive Care Unit (NICU) – A mixed-methods pilot

study, The Arts in Psychotherapy, 58, 42-52, https://doi.org/10.1016/j.aip.2018.03.001.

This article was written by Ettenberger and Ardila, two experts in the field of music

therapy with hospital experience and was published in 2018 within the research journal,

The Arts in Psychotherapy. Within this study Ettenberger and Ardila aimed to investigate

the way in which a mothers’ musical interactions with their child impacted their bond as

well as the mother’s mental wellbeing (stress, anxiety, and depression). This source adds

a deeper layer to my research question as it primarily focuses on maternal mental

wellbeing as opposed to mainly focusing on the infant wellbeing, like many of the other

sources selected for this paper. The results from this study showed that music therapy

interactions between mother and infant created a greater mother-infant bond as the

mother had a deeper understanding of subtle communication cues from their child as well

as showing that song writing for the parent could provide an outlet for much of the stress

felt with their infant in the NICU. Thus, providing interesting information into how music

therapy can not only be used to strengthen the bond between mother and infant but

additionally be used to alleviate stress felt in the NICU as well as trauma gained from the

whole experience. This relates to my research question since it provides further insight

into the bond between mother and infant as well as providing a perspective on how stress,

depression and trauma can impact this fragile bond.

Ettenberger, M., Cárdenas, R. C., Parker, M., & Odell-Miller, H., (2017) Family-centred music

therapy with preterm infants and their parents in the Neonatal Intensive Care Unit

(NICU) in Colombia – A mixed-methods study, Nordic Journal of Music Therapy (26:3),

207-234, DOI: 10.1080/08098131.2016.1205650

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This article published in the Nordic Journal of Music Therapy was peer-reviewed and

written by four experts in the field of music therapy who are either associated with

university music therapy programs or are active hospital staff. Within this research study,

Ettenberger, Cárdenas, Parker, and Odell-Miller investigate the impacts music therapy

has on infants as well as their parents when exposed to “family-centred” music therapy

approaches. “Family-centred” meaning that this is one of the first studies to not only

research on the bonding between mother and child but to also consider the experiences

and interactions of the father as well. A key point in this study was the consideration that

since preterm infants have extremely subtle movements it can be very difficult for parents

to truly pick up on the attitudes and feelings of their child. However, the use of music

through therapy allowed for the child to respond more to the sounds and interactions

which in turn allowed the parents a greater degree of bonding than if they didn’t have

access to these musical interactions. Thus throughout the course of this study, it was

found that the use of music therapy applications in a family-centred method (with mother,

father, and child) made it much easier for parents and infant to connect and provides

evidence that this form of intervention could even be beneficial for long-term health

development of the child as well as for the overall bond of the family. Which ties back to

my research question showing that there is evidence music therapy provides a way for

mother and preterm infant to strengthen their bond through these applications.

Ghetti, C. M., Vederhus, B. J., Gaden, T. S., Brenner, A. K., Bieleninik, Ł., Kvestad, I., Assmus,

J., & Gold, C. (2021). Longitudinal Study of Music Therapy’s Effectiveness for

Premature Infants and Their Caregivers (LongSTEP): Feasibility Study With a

Norwegian Cohort. Journal of Music Therapy, 58(2), 201–240.

https://doi.org/10.1093/jmt/thaa023
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In this research study published in 2021 in the Journal of Music Therapy, Ghetti, et al.,

works to determine not only if music therapy affects the bond between parents and

infants but also works to gage how much parents wish to interact with music therapy

applications. Throughout this peer-reviewed study it was found that parents of premature

infants are open to engaging in not only music therapy sessions within the NICU but are

also willing to participate in post-discharge sessions. This provides a basis for the idea

that these music therapy sessions make a huge impact on the lives/experiences of the

parents within the NICU, since they are willing and even want to engage in these sessions

past their time in the NICU. Additionally, it was addressed that the music therapy

application parents most wished to use were those where the parent voice was the “main

means of musical interaction” (Ghetti, et al., 2021). Thus, this article proves that parents

wish to form a strong bond with their child within the NICU and that by using their own

voice music therapy provides an avenue for these parents to engage with their child on a

deep and hopefully long-term basis.

Knight, A. J., LaGasse A. B., & Clair, A. A. (2018). ****Music Therapy: An Introduction to the

Profession. American Music Therapy Association, Inc.

March of Dimes. (n.d.). Neonatal intensive care unit (NICU): Giving your baby the best possible

care. https://www.marchofdimes.org/find-support/topics/nicu

Maroney, D. (2003). Recognizing the Potential Effect of Stress and Trauma on Premature Infants

in the NICU: How are Outcomes Affected?. J Perinatal 23, 679–683.

https://doi.org/10.1038/sj.jp.7211010
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Menke, B. M., Hass, J., Diener, C., & Pöschl, J. (2021). Family-centered music therapy—

Empowering premature infants and their primary caregivers through music: Results of a

pilot study. PLOS ONE, 16(5), 1–18. https://doi.org/10.1371/journal.pone.0250071

This research article titled, “Family-centered music therapy—Empowering premature

infants and their primary caregivers through music: Results of a pilot study”, published in

2021 in the research journal PLOS ONE, a nonprofit journal created to make “rigorous

research accessible without barriers” (PLOS ONE, 2023). This article investigates the

impacts music therapy has on the physical health of premature infants as well as the

mental health of their parents. Throughout the course of this peer-reviewed study it was

found that premature infants benefited from music therapy applications as they hit

various neonatal milestones 11-15 days (about 2 weeks) earlier than their non music

therapy influenced counterparts. Additionally, this study showed that while there was a

decrease in parental stress between the beginning and end of the NICU experience it may

or may not have been caused by music therapy interventions. This article helps add to the

weight of my research question because it provides a varying perspective to my current

proposition as well as shows that others have the same questions as I do as to the long-

term impacts of music therapy on infants in the NICU.

Mondanaro, J., Ettenberger, M., & Park, L., (2016). Mars Rising: Music Therapy and the

Increasing Presence of Fathers in the NICU. Music & Medicine. 8. 96.

10.47513/mmd.v8i3.440.

Palazzi, A., Meschini, R., & Piccinini, C. A. (2021). NICU music therapy effects on maternal

mental health and preterm infant's emotional arousal. Infant Mental Health Journal, (42),

672–689. https://doi.org/10.1002/imhj.21938
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This Brazilian research study published in the Infant Mental Health Journal in 2021

conducted by Palazzi, Meschini, and Piccinini, (all working at universities within the

music therapy departments) dives into the different effects the use of music therapy has

on the health of pre-term infants as well as the effects on numerous aspects of the

mother’s mental health. From this peer-reviewed study it was concluded that the use of

music therapy interventions made a significant difference in the health of pre-term infants

when compared to the control group since it provided “positive stimulation” and

“emotional arousal”. This positive intervention led to numerous positive health trends

such as “decreasing HR, stabilizing SO2, and reducing the length of hospitalization”

(Palazzi et al., 2021). Additionally, this study showed promising results that music

therapy interventions can help improve/protect the mother's mental health and decrease

the impacts and feelings of anxiety, stress, and postnatal depression. The results of this

study provide a basis for future research as it actively discusses how the practice of music

therapy has a large positive impact on the various health's of both mother and preterm

infant. Thus, illustrating how music therapy can improve the living conditions of the pair

and make it so that the bonding between mother and child can be further explored.

Shaw, R. J. & Horwitz, S. (2020). Treatment of Psychological Distress in Parents of Premature

Infants : PTSD in the NICU. American Psychiatric Association Publishing.

Stewart, K. (2009). PATTERNS--A Model for Evaluating Trauma in NICU Music Therapy: Part

2 Treatment Parameters. Music and Medicine. 1. 123-128. 10.1177/1943862109344858.