Effects of Dyadic Music Therapy Intervention On Parent-Child Interaction in Families With Emotionally Neglected Children: A Rand...

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Effects of Dyadic Music Therapy Intervention on

Parent-Child Interaction in Families with Emotionally
Neglected Children: A Rand....
Article in Journal of music therapy · December 2014

DOI: 10.1093/jmt/thu028
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Journal of Music Therapy, 51(4), 2014, 310–332
doi:10.1093/jmt/thu028
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Effects of a Dyadic Music Therapy

Intervention on Parent-Child Interaction,
Parent Stress, and Parent-Child
Relationship in Families with Emotionally
Neglected Children: A Randomized
Controlled Trial
Downloaded from http://jmt.oxfordjournals.org/ at Appalachian State University on December 15, 2014

Stine L. Jacobsen, PhD
Aalborg University, Denmark
Cathy H. McKinney, PhD

Appalachian State University, USA
Ulla Holck, PhD
Background: Work with families and families at risk within the field of
music therapy have been developing for the last decade. To diminish risk
for unhealthy child development, families with emotionally neglected chil-
dren need help to improve their emotional communication and develop
healthy parent-child interactions. While some researchers have investi-
gated the effect of music therapy on either the parent or the child, no
study has investigated the effect of music therapy on the observed inter-
action between the parent and child within the field of child protection.
Objective: The purpose of this study was to investigate the effect of
a dyadic music therapy intervention on observed parent-child interac-
tion (mutual attunement, nonverbal communication, emotional parental
response), self-reported parenting stress, and self-reported parent-child
relationship in families at risk and families with emotionally neglected
children, ages 5–12 years.
Method: This was a randomized controlled trial study conducted at
a family care center in Denmark. Eighteen parent-child dyads were
The author would like to acknowledge Professor Tony Wigram for his invaluable
contribution and support to the study. Furthermore, the authors give thanks to the
families who participated in the study and staff that assisted with data collection
especially psychologist Mark Self. This study was completed in partial fulfillment
of the degree of Doctor of Philosophy at Doctoral Programme in Music Therapy at
Aalborg University.
Vol. 51, No. 4 311
randomly assigned to receive 10 weekly music therapy sessions with

a credentialed music therapist (n = 9) or treatment as usual (n = 9).
Observational measures for parent-child interaction, self-reported meas-
ures for parenting stress and parent-child relationship were completed at
baseline and 4 months post-baseline assessment.
Results: Results of the study showed that dyads who received music
therapy intervention significantly improved their nonverbal communica-

tion and mutual attunement. Similarly, parents who participated in dyadic
music therapy reported themselves to be significantly less stressed by
the mood of the child and to significantly improve their parent-child rela-
tionship in terms of being better at talking to and understanding their
children than parents who did not receive music therapy. Both groups
significantly improved in terms of increased positive and decreased neg-
ative emotional parental response, parenting stress and stress in general.
There were no significant between group differences in self-perceived
autonomy, attachment, and parental competence.
Conclusions: The dyadic music therapy intervention examined in this
study improved emotional communication between parent and child and
interaction after 6 to 10 sessions and can be considered as a viable treat-
ment alternative or supplement for families at risk and families with emo-
tionally neglected children.
Keywords: at-risk families, emotional neglect, parent-child interaction,
parenting
Helping families to function better by improving emotional com-

munication and parent-child interaction is a difficult and delicate
task. Families with emotionally neglected children, where parents
need to improve how they care for their child, are especially com-
plex and can be ethically challenging. Primary tasks for therapists
working with parents of emotionally neglected children include
empowering parents, increasing their self-esteem, and improving
parental competence particularly in the area of emotional commu-
nication (Wolf & Peregoy, 2003). Learning to communicate emo-
tionally with a child is not easy, especially if the concept is foreign to
the parent, which is often the case with families at risk (Killén, 2010;
Shore & Shore, 2008). Highly stressed parents who have lost their
sense of control are more likely to emotionally neglect and abuse
their children. Moreover, parental stress is often linked with fami-
lies at risk (Barth, 2009; Guterman, Lee, Taylor, & Rathouz, 2009;
312 Journal of Music Therapy
Thomas & Zimmer-Gembeck, 2011). Emotional neglect in this

study is understood as a lack of emotional support from the parent,
which occurs mainly due to different types of immaturity in parents,
and is often based on a lack of support in the parents’ own child-
hood. Emotionally neglecting parents rarely intend to be neglectful
and often their level of emotional insight and emotional communi-
cation skills are poor (Killén, 2010). Emotional neglect can lead to

anxiety, stress, and depression in later life and severe cognitive and
academic deficits, social withdrawal, and limited peer interaction
in childhood (Carpenter, Tyrka, Ross, Khoury, Anderson, & Price,
2009; Elzinga et al., 2011; Young, Lennie, & Minnis, 2011). To stop
the negative transgenerational spiral of neglected children becom-
ing parents of neglected children, therapists and practitioners must
address the core of the matter – improving actual parent-child inter-
actions, diminishing parent stress, and improving the parent-child
relationship – specifically in the area of emotional communication.
Music is a powerful medium for bringing parents and children
together, because music can facilitate play and the communicative
functions of play. Through musical play, interaction can arise natu-
rally and spontaneously. In a carefully guided music therapy setting,
the musical play can allow the parent and the child to replicate early
forms of interaction between infant and parent in an age-appropri-
ate and mutually satisfying way (Edwards, 2011). Musical interac-
tion enhances interplay with turns, imitation, and affect attunement
between the parent and the child (Holck, 2004 2011). Parents’ abil-
ity to match their expression to the child’s expression is essential for
the child’s social and emotional development. In situations where
the early interactions between mother and infant have failed, music
therapy can help restore the vital nonverbal affect attunement
through an improvisational and playful focus (Trolldalen, 1997a).
Using a music therapy approach focused on parent and child inter-
action, it is thus possible to create or recreate the experience of
shared timing, rhythm, pulse, melody, and pitch, all of which are
natural elements of the early attachment process (Davies, 2008;
Drake, 2008; Salkeld, 2008; Trondalen & Skårderud, 2007).
Music therapy can support the development of reciprocity between
parent and child by offering the opportunity to try out different ways
of interaction and being together (Pasiali, 2012). Music is an effective
medium for the parent. Music enables the parent to get in touch with
the child in a new way, in which new interaction models are created
Vol. 51, No. 4 313
and explored through musical activities such as improvisational exer-

cises and singing games (Abad & Williams, 2007; Bull, 2008; Horvat &
O’Neill, 2008; Howden, 2008; Oldfield, 2006a, b). Furthermore, joint
musical activities can contribute to strengthening parent-child interac-
tion, as improvisational interaction and songs create an opportunity
for mutual recognition and understanding of each other’s musical
expression (Trolldalen, 1997a). Recognition consists of affirmation,

listening, acceptance, understanding, and tolerance and involves a
genuine attempt to understand each other. The musical interaction
has therapeutic potential because it takes place on a nonverbal level.
Nonverbal interaction is essential for the child’s emotional devel-
opment and understanding of the world (Stern, 2000). The family
member’s individual musical expression amplifies the individual com-
munication and intentions, which can facilitate good communication
between parent and child. According to Trolldalen (1997b) musical
interactions between parent and child can be understood as a reflec-
tion of the real-life interactions. Positive musical interaction can lead
to strengthened and enhanced parent-child interaction in general.
Using music therapy with emotionally neglected children and
families at risk is developing and carefully designed studies are rare.
Nevertheless, more studies are present within the broad field of music
therapy with families where the child has special needs and can be
used to inform this emerging are of practice. Results from randomized
studies show that music therapy positively affects infants’ and tod-
dlers’ ability to engage in social play. Attachment improves between
parent and child, and parents are more positively and less negatively
engaged in interacting with their child (Thompson, 2012; Walworth,
2009). Results from other systematic studies with families with special
needs children also indicate improvements in parental involvement,
reduced stress in the parent, increased social interaction of the child,
more appropriate demands from parents, and less evasive or avoid-
ant behavior from the child following music therapy (Allgood, 2005;
Müller & Warwick, 1993; Oldfield, 2006b). Sing & Grow is an Australian
program in which children under 5 years of age and their parents par-
ticipate in group musical activities. Several researchers investigating
the effect of Sing & Grow, have found significantly improved parent-
child interaction through improved parental satisfaction, parenting
skills, and the overall development of the child especially in social
skills (Abad, Berthelsen, Bradley, Nicholson, & Williams, 2008; Abad
& Williams, 2007; Nicholson, Berthelsen, Williams, & Abad, 2010;
Williams, Berthelsen, Nicholson, Walker, & Abad, 2012).
The purpose of this study was to investigate the effect of a dyadic

music therapy intervention on observed parent-child interaction
(mutual attunement, nonverbal communication, emotional paren-
tal response), self-reported parenting stress, and self-reported
parent-child relationship in families with emotionally neglected
children and families at risk. A unique feature of the study was
the use of both observational and parent self-report measures, to

potentially provide a more comprehensive evaluation of parent-
child and parent outcomes. The research question was therefore
formulated as follows: Can music therapy treatment with a par-
ent and his/her emotionally neglected child improve parent-child
interactions, diminish parent stress, and improve parent-child
relationship?
Method
Participants
The 18 participating families were recruited to this study from a
residential family care center in a medium-sized city in Denmark
by the family care center staff based on inclusion and exclusion
criteria. A participating family consisted of one child and one
parent also referred to as the dyad. The sample size was based on
dyad availability and almost met the expected 20 dyads within the
2-year data collection period. The care center is described as an
alternative to removing the child from the parents, and all par-
ticipating families were described by the social services as exhibit-
ing signs of severe emotional neglect (e.g., socially dysfunctional,
extensively withdrawn or acting out, falling behind in emotional
and cognitive development). Eligibility criteria for study participa-
tion were as follows: (a) children 5–12 years old inclusive, with no
severe developmental deficits or diagnoses (This child age range
was chosen because studies reporting analysis of effect and assess-
ment of observed parent-child interaction with verbal children are
rare within the field of child protection. When children become
verbal the observed interaction between parent and child becomes
extremely complex and difficult to measure because each family
has a different way of using language. The use of language has indi-
vidual histories and personal narratives. Often interview, psycho-
logical tests, and self-report questionnaires are used for this age
group. However, observed interaction is just as important for verbal
Vol. 51, No. 4 315
children as for nonverbal children when the aim is to improve

emotional communication and healthy parent-child interaction);
(b) parents currently exhibiting signs of severe emotional neglect
(based on report from social services); (c) parents with minor men-
tal concerns such as mild depression and stress were not excluded
from study participation, as this is often part of the problem in such
families; (d) no history of parent or child receiving previous music

therapy treatment; (e) parents receiving other forms of therapy,
such as Parent Management Training (Feldman & Kazdin, 1995),
were excluded from study participation; (f) parents with reported
substance abuse were excluded from study participation.
No participating family had reports of physical abuse. However,
this might not have been known to social services and cannot be
ruled out. All families voluntarily participated in the study and
signed an informed consent statement. The welfare of all children
and adults participating in the study was of utmost importance, and
all participating families were treated with a high degree of respect.
The study was approved by the Human Research Ethics Board at
Aalborg University, Denmark.
Procedure and Music Therapy Approach

A blind randomization procedure assigned one of two music
therapists to each of the 18 participating families. After approval
from staff, the assigned music therapist invited the family to partici-
pate in the study at the beginning of their enrollment in the care
center. A second blind randomization procedure assigned either
the music therapy or treatment as usual condition to each of the
18 participant family dyads, resulting in nine dyads in the dyadic
music therapy treatment condition and nine in the treatment as
usual condition (see Figure 1).
Parent-child dyads in the experimental group and the treatment
as usual group both received treatment as usual at the family care
center, which mainly consisted of psychological and pedagogical
support and guidance. Each family had a pedagogue contact per-
son who gave extensive guidance on how to structure domestic
tasks, how to talk to and affirm their child, how to set age appropri-
ate demands, how to set boundaries, and so on. Each family also
had a few conversations with a psychologist around the general
development of their child and their own well-being as a parent.
Assessed for eligibility (n = 29)
Excluded (n = 11)
Not meeting inclusion criteria (n = 10)
Declined to participate (n = 0)
Other reasons (n = 1)
Enrolled (n = 19)

Randomized (n = 19)
Baseline Measures (n =
19)
Dyadic Music Therapy (n = 10) Treatment as Usual (n = 9)

Received allocated intervention (n = 9) Received allocated intervention (n = 9)
Did not receive allocated intervention
(discharged from family care center) (n = 1)
Post-Treatment Measures (n = 9) Post-Treatment Measures (n = 9)
Figure 1.
CONSORT diagram for trial accrual, intervention delivery, and data collection.
All family dyads underwent two identical, video-recorded Assessment

of Parenting Competences (APC; Jacobsen & McKinney, 2014) ses-
sions approximately one week apart and both trained music thera-
pists were certified APC therapists (Note: APC is further explained
below). The parent completed self-report questionnaires within
the same 2-week period assisted by an authorized psychologist.
Participants in the experimental group received 6 to 10 music
therapy sessions, which took place once a week and lasted around
45–50 min. Out of the nine family dyads in the experimental
group, six received all 10 treatment sessions while two family dyads
only received six and eight treatment sessions respectively because
of cancellations due to child or parent illness. The last family was
referred on in the system due to moving out of the district. Four
months after completing the first APC assessment sessions, partici-
pants in the experimental and treatment as usual groups under-
went the APC assessment sessions again and filled out question-
naires in the same manner as prior to treatment.
Vol. 51, No. 4 317
The music therapy approach for the experimental group was

experience-oriented with a mix of client-centered and therapist-
directed experiences. Client-centered activities were based on the
family dyad’s wishes, expressions, and preferences and therapist-
directed activities were based on initiatives and interaction-based
foci from the therapist. There was an emphasis on a strong working
alliance with the parent, supported by conversations outside the

sessions, where aims and goals were agreed upon between thera-
pist and parent. Changes were followed and much affirmation was
given to the hardworking parent. Depending on the level of resist-
ance and insight into the often-unintended emotional neglect, the
goal or focus was based on the parent’s ability to be clear, to affirm
the child, or to lead more or lead less. For parents with less insight
and more resistance due to immaturity and low level of emotional
insight, the goals were based on the child’s need for structure, affir-
mation, independence, and ability to give room. A focus on the
child’s needs was considered more appropriate for parents who
had difficulties looking at their own possible insufficiencies.
The music therapist functioned both as a role model providing
structure and guidelines and as a facilitator for the parent-child
relation. By showing the parent how to interact appropriately with
the child in the musical activities, as well as all other part of the
session, the parent could observe and model proper and dynamic
interaction with the child. In verbal role modeling, there is often
risk for overshadowing the parent’s relation to the child, but musi-
cal improvisations enabled the music therapist to both model and
facilitate interaction to minimize this risk. Whenever possible, the
initiatives from the family and especially the parent’s initiatives
to interact with the child were enhanced, striving to let the rela-
tion between parent and child unfold. If the parent-child dyad
needed support and guidance, the music therapist would provide
it. When support and guidance was not or no longer needed, the
parent-child dyad was encouraged to interact and relate on their
own, thus helping them to build a stronger bond and develop a
healthy emotional communication (Jacobsen, 2012). Several strat-
egies were enacted to help ensure consistency of treatment deliv-
ery across therapists during the study. Prior to the study, the two
music therapists formulated the main goals, process of choosing
them, interventions, and techniques to be used with enrolled par-
ent-child dyads. During treatment sessions, the two therapists had
joint supervision on a regular basis with a supervisor experienced

in supervising family music therapy.
Measures
Assessment of Parenting Competencies (APC; Jacobsen &
McKinney, 2014). The APC is an observational music therapy
assessment tool measuring parent-child interactions in three

areas: Mutual Attunement between parent and child (i.e., how
well they interact in terms of matching each other), Nonverbal
Communication Skills between parent and child (i.e., how they
interact in terms of clearly communicating nonverbally with each
other), and Emotional Parental Response from parent to the child
(i.e., how the parent responds negatively and positively to the emo-
tional needs of the child). The APC also has a total score; Parent-
Child Interaction in Music. All four APC scores were selected for
measures in the current study. The APC measures are based on
in-depth observational analysis from two 25-min, video recorded
APC music therapy assessment protocol sessions Two sessions are
needed for the family to get familiar with the music therapy setting,
giving them a chance to show their potential strengths, as well as
their weaknesses. Observations from the second session provided
the primary data used to calculate scores. APC scores are based on
frequency of autonomy events in both parent and child musical
behavior; frequency of the gestural and musical turns of both par-
ent and child; and musical, gestural, and verbal parental responses.
The APC scores were developed by comparing observations from
clinical and non-clinical groups of family dyads (Jacobsen, 2012;
Jacobsen & Killén, 2014; Jacobsen & Wigram, 2007). Interrater reli-
ability for the APC scores have been found to range from 0.73 to
0.89 and test-retest reliability from 0.70 to 0.89 with an internal
consistency alpha level of .93. Correlations between APC scores
range from .57 to .91. Validity analyses of APC have demonstrated
its ability to distinguish between different groups of family dyads
establishing the concurrent validity of the tool. Pearson correlation
coefficients computed between APC scores and scores from PSI
and PCRI show low to moderate correlations ranging from 0.26–
0.56 (Jacobsen & McKinney, 2014).
Parenting Stress Index (PSI). The PSI is a clinical and research
parent self-report questionnaire (Abidin, 1995). The instrument
has 101 items that lead to a total parent stress score, three domain
Vol. 51, No. 4 319
scores (Parent Domain, Child Domain, & Total Stress), and 15

subscale scores. The domains measured are stressors related to
child characteristics and parental characteristics. PSI is described
as a screening and diagnostic assessment tool used to identify par-
ent and child systems that are under stress. Furthermore, PSI can
detect whether deviant development of the child is likely to take
place, or if dysfunctional parenting is likely to occur. From PSI the

following five subscales and subdomains were selected as measures
for this study: Competence, Attachment, Parent Domain, Mood,
Child Domain; we also used the Total Stress score. High scores in
Competence indicate problems in multiple aspects of parenting
competencies such as lack of knowledge, unmet expectations of
parenthood, and lack of acceptance from the child’s other parent.
High scores in Attachment suggest that the parent may not feel a
sense of emotional closeness to the child and/or that the parent
might not be able to observe and understand the child’s needs and
feelings accurately. High scores in Parent Domain indicate that the
sources of stress may be related to the dimensions of the parent’s
functioning. Parent domain is a sum of all underlying subscales
for that domain. High scores in Mood are associated with children
whose affective functioning shows evidence of dysfunction to the
parent. High scores in Child Domain indicate children who display
qualities that make it difficult for parents to fulfil their parenting
roles. Child Domain can also be interpreted as a measure of how
much parents perceive their children to cause them stress and is
a sum of all underlying subscales for that domain. High scores of
Total Stress are associated with parent-child systems that are under
stress, and at risk of developing dysfunctional parenting behaviour
or behaviour problems in the child. The Total Stress is a sum of
the Parent Domain and the Child Domain. Alpha reliability coeffi-
cients measuring the internal consistency of the PSI subscales, each
domain, and the total score are reported to be high (0.70–0.95).
Multiple test-retest reliability studies found the temporal stability
of the test to range from 0.55 to 0.96. The PSI has shown signifi-
cant correlations with multiple tests measuring the same construct
(Heinze & Grisso, 1996).
Parent-Child Relationship Inventory (PCRI). PCRI consists
of 78 items that examine how parents view the task of parenting
and how they feel about their children (Gerard, 2005). It identi-
fies specific areas in which problems may occur and covers seven
distinct subscales. The relevant selected subscales from PCRI were

Communication and Autonomy. Low scores in Communication
represent poor parental communication with the child, both in
terms of the parent’s ability to talk to the child and the level of the
parent’s empathy. Low scores in Autonomy indicate a relationship
where the child is unhealthily dependent on the parent, or where
the parent does not encourage a sense of independence in the

child. The coefficient alpha values for the subscales ranges from
0.70–0.88, test-retest reliability ranges from 0.68–0.93 for various
subscales (Heinze & Grisso, 1996).
Design and Analyses

We used a repeated measures with between groups design (spe-
cifically a split-plot factorial or mixed design with randomization
to therapist and then to music therapy or treatment as usual) to
explore effects of music therapy. It is a mixed design because there
were both within and between factors included. The between
groups variable had two levels: experimental group and treatment
as usual group. The within-groups variable was time point with two
levels: pre-treatment and post-treatment. An alpha level of .05 was
used for all statistical tests, except in simple effects analyses where
the alpha level was adjusted for the family-wise error rate, yield-
ing an alpha level of .0375. Where necessary, missing observations
were estimated according to the iterative estimation-minimization
procedure described by Yates (1933, as cited in Kirk, 1982), and
error degrees of freedom were adjusted downward accordingly.
Our analyses did not control for the potential effects of the two
therapists but assumed that the effects were the same.
A Mauchly test computed for each variable assured that the
assumption of sphericity was not violated in any case, and histo-
grams of scores revealed a normal distribution. A Box’s Test com-
puted for each variable measured equality of covariance; for four
variables (Mood, Child Domain, Competence, and Parent Domain
from PSI) the assumption was violated. A nonparametric test of two
related samples was performed, a Wilcoxon signed rank test for the
within-groups measures for these two variables. Effect sizes were
measured by computing Cohen’s d using the average of the stand-
ard deviations from pretreatment and posttreatment and adjusting
for the correlation between the two. For nonparametric analyses,
Vol. 51, No. 4 321
the researchers calculated the relative treatment effect based on

the mean ranks as described by Erceg-Hurn and Mirosevich (2008).
Results
Demographic Variables

An analysis of four demographic variables compared similarities
and differences between the experimental and treatment as usual
groups. Independent samples t-tests showed that the groups were
not statistically different in mean parent age or mean child age (see
Table 1). Chi-square analyses determined that the groups were not
significantly different in terms of parent or child gender (see Table 2).
Dependent Variables
Independent samples t-tests showed no statistically significant
differences between groups prior to treatment in all dependent
variables. Violation of the assumption of homogeneity of variance
was corrected for PSI Mood scores by use of reciprocal transforma-
tion. A descriptive comparison of the mean scores for the experi-
mental and treatment as usual groups in pre and posttreatment
assessment sessions for the two therapists combined revealed that
all changes were in the predicted direction. On average across both
therapists, the families experienced positive improvement in all
significant outcome measures as described below.
Table 1
Means and Standard Deviations for Parent and Child Age by Group
Experimental (n = 9) Control (n = 9)
M SD M SD F df p
Parent age 34.00 6.708 37.44 6.54 1.22 1, 17 .286

Child age 6.78 2.386 8.44 2.56 2.05 1, 17 .172
Table 2
Frequencies and Counts on Gender by Group
Experimental (n = 9) Control (n = 9)
Female Male Female Male X2 p
Child 56.6% 44.4% 56.6% 44.4% 0.00 1.000

Parent 77.8% 22.2% 100% 0% 2.25 .235
Parent-Child Interaction. The ANOVA for Mutual Attunement

score revealed a significant group by time interaction, F(1,
12) = 11.592, p < .005. Analysis of simple effects and an examina-
tion of group means showed that the experimental group experi-
enced a significant increase in Mutual Attunement over time, F(1,
12) = 23.44, p < .001, d = 1.60, whereas the treatment as usual group
showed no significant change, F(1, 12) = 0.24, p = .633 (see Table 3).

The ANOVA for Nonverbal Communication Skills revealed a
significant group by time interaction, F(1, 12) = 9.446, p < .009.
Simple effects analysis and an examination of group means showed
that the experimental group experienced significant increase in
Nonverbal Communication over time, F(1, 12) = 10.46, p < .007,
d = 1.25, whereas the treatment as usual group showed no signifi-
cant change over time, F(1, 12) = 2.5, p = .139 (see Table 3).
The ANOVA for Emotional Parental Response: Negative did not
reveal a significant group by time interaction, F(1, 12) = .154, p
< .702. An examination of main effects showed that both groups
changed significantly over time F(1, 12) = 12.46, p < .004. Means
and standard deviations are presented in Table 3. The ANOVA
for Positive Response scores did not reveal a significant group by
time interaction, F (1, 12) = .352, p < .564. An examination of main
effects and group means showed that both groups increased their
Positive Response scores significantly over time. F(1, 12) = 14.54,
p < .002. Means and standard deviations are presented in Table 3.
The ANOVA for Parent-Child Interaction in Music (Total) scores
revealed a significant group by time interaction, F(1, 12) = 16.675,
p < .002. Simple effects analysis and an examination of group
means showed that the experimental group experienced significant
increase over time, F (1, 12) = 41.45, p < .000, d = 1.77, whereas the
treatment as usual group showed no significant change over time,
F(1,12) = 0.44, p = .519 (see Table 3). Means, standard deviations,
and effect sizes for dependent APC variables of interest are pre-
sented in Table 3.
Parenting Stress. The assumption of homogeneity of variance
was violated for Mood scores from PSI and could not be corrected
by arithmetic transformation of data. Nonparametric Wilcoxon
test showed that the 8 out of 9 families in the experimental group
experienced a decrease (no ties) in Mood score change over time,
Z = -2.56, p < .001, whereas only 1 out of 9 families in the treatment
as usual group experienced a decrease in stressful Mood score over
time (4 ties), Z = -1.36, p > .176, r = .45 (see Table 4).
Vol. 51, No. 4
Table 3
Means, Standard Deviations, and Effect Sizes for APC scores by Group
Pretreatment Posttreatment
Variable Group (n = 9) M SD M SD Cohen’s d
Mutual attunement
Experimental 74.11 9.39 90.59** 11.32 1.60
Treatment as usual 82.93 12.03 84.62** 11.42
Nonverbal communication
Experimental 20.11 5.44 25.11** 3.86 1.25
Emotional parental Response: Negative
Experimental 28.11 2.52 29.78** 1.56 0.67
Emotional parental Response: Positive
Experimental 8.78 3.31 11.67** 2.12 1.20
Parent-child interaction in music
Experimental 131.11 15.10 157.15** 14.71 1.77
**p < .01.

323

The assumption of homogeneity of variance was violated for

Child Domain scores from PSI and could not be corrected by
arithmetic transformation of data. Nonparametric Wilcoxon test
showed that the 9 out of 9 families in the experimental group
experienced a decrease (no ties) in Child Domain score change
over time, Z = -2.67, p < .008, r = .89, whereas 8 out of 9 families
in the treatment as usual group experienced a decrease in Child

Domain score over time (0 ties), Z = - 1.61, p > .108, r = .54 (see
Table 4). Medians, range, and relative effect are shown in Table 4.
The ANOVA for Attachment scores did not reveal any significant
group by time interaction (F(1, 8) = .430, p < .531 and non-signif-
icant main effect, F(1, 8) = .310, p < .593). Means and standard
deviations are presented in Table 5.
Additionally, scores for Total Stress and Parent Domain decreased
significantly for family dyads in both the experimental and the
treatment as usual group over time (see Tables 4 & 5). The assump-
tion of homogeneity of variance was violated for Parent Domain
scores from PSI and could not be corrected by arithmetic transfor-
mation of data. Nonparametric Wilcoxon test showed the 9 out of
9 families in the experimental group experienced a decrease (no
ties) in Parent Domain score change over time Z = -2.666, p < .004,
and 8 out of 9 families in the treatment as usual group experienced
a decrease in Parent Domain score over time (1 tie), Z = - 2.521, p
> .006). Medians and ranges are listed in Table 4. The ANOVA for
Total Stress did not reveal significant interaction between groups
(group x time interaction, F(1, 8) = 3.576, p < .089). An examina-
tion of main effects showed that both groups changed significantly
over time F(1, 8) = 20.53, p < .002. Means and standard deviations
are presented in Table 5.
Parent-Child Relationship. ANOVA for Communication scores
from PCRI revealed a significant group by time interaction, F(1,
8) = 9.595, p = .014. Analysis of simple effects and an examination
of group means showed that the experimental group experienced
significant increase over time, F(1, 8) = 11.48, p < .005, d = 0.82,
whereas the treatment as usual group showed no significant change
over time, F(1, 8) = 0.99, p = .349 (see Table 5). The ANOVA for
Autonomy score did not reveal any significant interaction between
groups (Non-significant group x time interaction, F(1, 8) = .472, p <
.512 and non-significant main effect F(1, 8) = .31, p < .593). Means
and standard deviations are presented in Table 5. Means, standard
Vol. 51, No. 4
Table 4
Median and Range for Mood, Child Domain, Competence, and Parent Domain from the Parenting Stress Index by Groups
Pretreatment (n = 9) Posttreatment (n = 9) Relative treatment effect
Variable group Median Range Median Range ^pi
Mood
Experimental 90.00 25.00 - 96.00 50.00** 1.00 – 97.00 0.55
TAU 98.00 75.00 – 99.00 99.00** 90.00 – 99.00 0.22
Child domain
Experimental 85.33 25.00 – 96.85 71.30** 33.00 – 78.33 0.50
TAU 93.13 65.00 – 99.00 87.50** 72.00 – 97.70 0.44
Competence
Experimental 80.00 35.00 – 99.00 62.50** 15.00 – 98.50 0.28
TAU 98.50 45.00 – 99.00 89.60** 25.00 – 98.20 0.27
Parent domain
Experimental 68.33 16.67 – 99.00 60.00** 8.00 – 97.53 0.50
TAU 92.81 58.33 – 98.38 78.00** 12.86 – 97.74 0.44
Note. * p < 0.05; ** p < 0.01, TAU = Treatment as usual.

325

Table 5
Means and Standards Deviations for Parent-Child Relationship Inventory and Parenting
Stress Index Subscales by Group
Pretreatment Posttreatement Cohen’s
Variable group (n = 9) M SD M SD d
Communication

Experimental 36.77 9.63 43.22* 8.29 0.82
TAU 40.33 10.19 38.448* 9.13
Autonomy
Experimental 43.83 3.25 43.17* 4.49 0.17
TAU 42.50 3.00 44.50* 7.05
Attachment
Experimental 51.17 41.83 47.83* 36.00 0.1
TAU 67.75 38.00 63.25* 41.72
Total Stress
Experimental 72.74 25.70 57.86** 28.97 0.57
TAU 91.31 10.36 77.99** 19.02
* p < 0.05; ** p < 0.01, TAU = Treatment as usual.
deviations and effect sizes for all dependent PSI and PCRI variables
that were analyzed using ANOVA are presented in Table 5.
Discussion
Researchers in this study investigated the effect of music therapy
on parent-child interaction, parent stress, and parent-child relation-
ship in families where the child had experienced emotional neglect.
Music therapy significantly improved parenting competencies and
parent-child interaction in terms of Mutual Attunement between
parent and child, Nonverbal Communication between parent and
child, and the Parent-Child Interaction in Music as measured by APC.
Music therapy significantly improved the parent´s perceived ability to
talk to the child, including increasing the parent’s perceived level of
empathy as measured by the Communication score from the PCRI.
Music therapy also decreased the degree to which the parents per-
ceived their children as stressful (Child Domain) and how stressful
the child’s mood was to the parent as measured by the PSI.
The findings of positive effects of music therapy support earlier
research findings of parents tending to view the child in a more
positive light and parents being able to read the emotional state of
the child more easily following music therapy (Abad et al., 2008;
Vol. 51, No. 4 327
Müller & Warwick, 1993; Oldfield, 2006a; Thompson, 2012; &

Trolldalen, 1997a). The improvement in Mutual Attunement and
Nonverbal Communication also supports earlier research findings
demonstrating that parents and children improved their way of
interacting through music therapy (Abad & Williams, 2007; Larsen,
2011; Oldfield, 2006b; Thompson, 2012; & Trolldalen, 1997a).
Both groups improved significantly in terms of emotional parental

response indicating that parents receiving treatment as usual also
improved their response type toward their child on the same level
that parents receiving dyadic music therapy, although they did not
improve the musical interaction scores, Mutual Attunement, and
Nonverbal Communication significantly over time. One might
wonder whether the improvement in Mutual Attunement and
Nonverbal Communication only were due to getting more familiar
with the music therapy setting, and therefore question a generali-
zation effect to other areas of the daily life of the families. However,
the significant differences between groups in (stressful child)
Mood and (parental) Communication as measured by PCRI and
PSI seem to contradict the idea of a positive generalization effect.
There were no significant differences between groups in terms
of autonomy, (parental) competence, and attachment. The
Autonomy score is meant to pick up a child’s unhealthy depend-
ence on the parent or lack of parental encouragement of inde-
pendence in the child. The absence of between group differences
for this measure indicates that the dyadic music therapy may not
significantly affect these and may not be a relevant outcome meas-
ure for this study. The Competence measure is related to multiple
aspects outside of the direct parent-child interaction such as lack
of parental knowledge, unmet expectations of parenthood, and
lack of equal acceptance from the child’s other parent indicating
that dyadic music therapy may not significantly affect these aspects
or differentiate between groups in treatment outcome. Likewise,
the Attachment score is related to the parent’s sense of emotional
closeness to the child and ability to observe and understand the
child’s needs accurately. No significant difference between groups
might indicate that more sessions are needed for music therapy to
influence these core aspects of parenting significantly more than
treatment as usual.
Whether or not the parent’s perception of how stressful the
child was is related to any change in the child is not clear from this
study. The child improved his or her ability to effectively commu-

nicate with the parent in music therapy and developed a mutual
attunement with the parent as the scores depend on both child
and parent behaviour, but the actual carry-over effect for the child
is not clearly addressed in this study. One might consider evaluat-
ing child feedback as described by Iwaniec (1995) and Crittenden
(2006) by examining different aspects of interaction patterns such

as level of cooperation, passiveness, and resistance. More informa-
tion about the child would also inform the results of the Emotional
Parental Response for parents and produce more in-depth and
valuable information.
Both groups changed significantly over time in terms of how
stressed the parents were due to both the parents’ general func-
tioning and how stressful the parent-child systems were in general.
This indicates that music therapy treatment is as equally effective as
standard treatment protocols and suggests that music therapy can
be a viable alternative or supplement. Furthermore, looking at the
results from the treatment as usual group, there was an unexpected
(non-significant) decrease only in Nonverbal Communication
Score indicating that music therapy might address nonverbal com-
munication issues in more effective ways than a more traditional
approach within the field of child protection.
Limitations
In the study, the researcher was also one of the clinical music
therapists, which increases the possibility of biases of the thera-
pist. Being both a researcher and a clinical music therapist might
have influenced clinical decisions in music therapy for one of the
therapists. However, an examination of the mean scores for the
experimental and treatment as usual groups revealed that family
dyads from both therapists experienced a positive improvement in
all primary dependent variables of the study. There were no signifi-
cant differences between outcomes for family dyads from the two
music therapists.
Out of the nine family dyads, three only received 6–8 music ther-
apy treatment sessions thus making the family dyad less comparable
in terms of “doses” of music therapy. Looking at the results, eight
or six sessions might have been enough for change to take place in
the family dyad, or there might have been significant differences
Vol. 51, No. 4 329
in Emotional Parental Response or/and other measures, if all nine

families had received ten sessions.
Recommendations for Further Research

To validate the positive effect of dyadic music therapy interven-
tions on parenting competencies and parent-child interaction,

research comparing music therapy with a second condition is
needed. Both groups should thus receive treatment as usual and
a second condition. Study replication and larger sample sizes are
necessary to confirm these results. Furthermore, long-term effect,
effect on measures of the child, and effect on younger children is
relevant especially considering the field of child protection.
Exploring the process of treatment within child protection is
also relevant for this developing field. One might examine differ-
ent aspects of improvisation or spontaneous turn-taking/turn-giv-
ing between therapist, parent, and child, or one might explore the
experiences of the families and let their voices be heard. Future
research that focuses on the connection between communicative
musicality and trained musicality would contribute not only to the
field of music therapy but also to related fields of musicology and
musical training.
Summary
In families with children who had experienced emotional neglect,
music therapy had a significant, positive effect on parenting com-
petencies and parent-child interaction, in terms of level of mutual
attunement between parent and child, nonverbal communication,
and parent-child interaction. Music therapy had a significant effect
on the parent´s ability to talk to the child including the parent’s
level of empathy. Music therapy also significantly decreased how
stressful parents perceived their children and in particular, how
stressful the child’s mood was to the parent. Dyadic music therapy
intervention with families at risk can improve the emotional com-
munication between parent and child and interaction after only
6 to 10 sessions and should be considered as a viable alternative
or supplement. Music therapy might address nonverbal commu-
nication issues in more effective ways than traditional approaches
within the field of child protection. As a society, we are obligated to
provide the right kind of care for emotionally neglected children

both to ensure their health but also to stop the negative spiral of
history repeating itself.
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Effects of Dyadic Music Therapy Intervention on

Article in Journal of music therapy · December 2014

Stine Jacobsen Cathy Mckinney

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Effects of a Dyadic Music Therapy

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Cathy H. McKinney, PhD

randomly assigned to receive 10 weekly music therapy sessions with

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Helping families to function better by improving emotional com-

Thomas & Zimmer-Gembeck, 2011). Emotional neglect in this

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and explored through musical activities such as improvisational exer-

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The purpose of this study was to investigate the effect of a dyadic

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children as for nonverbal children when the aim is to improve

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Procedure and Music Therapy Approach

Assessed for eligibility (n = 29)

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Dyadic Music Therapy (n = 10) Treatment as Usual (n = 9)

Post-Treatment Measures (n = 9) Post-Treatment Measures (n = 9)

All family dyads underwent two identical, video-recorded Assessment

The music therapy approach for the experimental group was

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joint supervision on a regular basis with a supervisor experienced

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scores (Parent Domain, Child Domain, & Total Stress), and 15

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distinct subscales. The relevant selected subscales from PCRI were

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Design and Analyses

the researchers calculated the relative treatment effect based on

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Experimental (n = 9) Control (n = 9)

Parent age 34.00 6.708 37.44 6.54 1.22 1, 17 .286

Experimental (n = 9) Control (n = 9)

Female Male Female Male X2 p

Child 56.6% 44.4% 56.6% 44.4% 0.00 1.000

Parent-Child Interaction. The ANOVA for Mutual Attunement

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Variable Group (n = 9) M SD M SD Cohen’s d

**p < .01.

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The assumption of homogeneity of variance was violated for

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Pretreatment (n = 9) Posttreatment (n = 9) Relative treatment effect

Variable group Median Range Median Range ^pi

Note. * p < 0.05; ** p < 0.01, TAU = Treatment as usual.

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Pretreatment Posttreatement Cohen’s

Variable group (n = 9) M SD M SD d

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