- Open Access
Effects of music therapy as an alternative treatment on depression in children and adolescents with ADHD by activating serotonin and improving stress coping ability
BMC Complementary Medicine and Therapies volume 23, Article number: 73 (2023)
The objective of this study was to determine the effect of music therapy as an alternative treatment on depression in children and adolescents with attention-deficit hyperactivity disorder (ADHD) by activating serotonin (5-HT) and improving stress coping ability.
This study is designed based on randomization method. A total of 36 subjects participated in the experiment, consisting of an ADHD control group (n = 18) and ADHD music therapy group (n = 18). The ADHD control group received standard care, while the ADHD music therapy group received music therapy and standard care. The ADHD music therapy group received both active music therapy (improvisation) and receptive music therapy (music listening) for 50 minutes, twice a week, for 3 months: a total of 24 times. From a neurophysiological perspective, changes in depression and stress were tracked by measuring 5-HT secretion, cortisol expression, blood pressure (BP), heart rate (HR), and CDI and DHQ psychological scales.
The ADHD music therapy group’s 5-HT secretion increased (p < 0.001), whereas cortisol expression (p < 0.001), BP (p < 0.001) and HR (p < 0.001) decreased. The CDI and DHQ psychological scales also showed positive changes (p < 0.01 and p < 0.001, respectively). However, the ADHD Con G’s (who did not receive music therapy) 5-HT secretion did not increase, whereas cortisol expression, BP, and HR did not decrease. In addition, the CDI and DHQ psychological scales did not display positive changes.
In conclusion, the application of music therapy as an alternative treatment for ADHD children and adolescents showed positive neurophysiological and psychological effects. Therefore, this study would like to propose a new alternative to medicine for preventing and treating depression through various uses of music therapy.
Attention-deficit hyperactivity disorder (ADHD) is characterized by the presence of attention deficit, hyperactivity, and impulsivity as major symptoms, along with characteristics overlapping with other psychiatric disorders such as anxiety, depression, defiant disorder, and learning disability [1,2,3]. Compared with adolescents without ADHD, adolescents with ADHD show functional impairments across several areas (e.g., social, family, and academic fields) and experience reduced quality of life . This, as a result, suggests that most adolescents and children with ADHD are more likely to develop depression [5,6,7].
From a physiological point of view, ADHD patients with depression show lower blood levels of serotonin (5-HT) than those without depression, suggesting that chronic reduction in the availability of 5-HT is associated with clinical manifestations of ADHD . It is known that 5-HT can interact with the dopamine system to mediate the impulsive behavior. It is related to various behaviors such as impulsivity, inhibition, and attention . In addition, 5-HT activity in the frontal-frontal circuitry is associated with the pathophysiological mechanism of ADHD. It is closely related to the secretion of 5-HT from serotonin neurons located in the central nervous system [10,11,12]. Depletion of 5-HT can lead to a lack of emotional control, resulting in depression . Therefore, selective serotonin reuptake inhibitor (SSRI), a drug that regulates 5-HT, is considered a treatment of choice for ADHD treatment.
The environmental factors of depression in children and adolescents are mainly related to stress levels, and hormone cortisol is involved in controlling the level of stress . Acute stress can trigger the release of adrenocorticotropin from the pituitary gland, which can stimulate the adrenal gland and release glucocorticoid (mainly human cortisol) into the bloodstream . Therefore, high stress level led to high level of cortisol and at the same time causes various problems such as growth and immunity problems [16, 17].
Overall, children and adolescents with ADHD have high levels of stress but less 5-HT secretion than ordinary children  They are more likely to suffer from depression when they grow into adults [6, 18,19,20]. ADHD with depression as a coexisting disorder can be seen as a more serious situation than general ADHD [21, 22]. This is because accompanying depression can cause negative effects and risks on the patient’s social performance such as family problems, reduced opportunities for occupational activities, and increased likelihood of crime [23, 24].
Children and adolescents have much greater emotional and physical flexibility than adults. Thus, if appropriate treatment is performed children and adolescents with ADHD before they develop adult depression, the therapeutic effect can be much higher.
However, in reality, medical treatment for depression in ADHD mostly uses drugs. This is a symptomatic treatment that only temporarily suppresses symptoms. It has many limitations and problems because of the risk of side effects due to chemical drug treatment. There is an absolute need for a sustainable treatment that is safer with a lasting effect.
Music therapy is one of various nonpharmacological treatments. Numerous prior studies have already reported that music therapy performed by credentialed therapists can improve cognitive and sensory movements of depressed patients an restore self-esteem by establishing positive self-awareness [25, 26].
The purpose and approach of this study are designed in this context. The basic principle is described as follows. Children and adolescents with ADHD respond more sensitively to the unpredictability of daily life and experience more tension and stress than ordinary children and adolescents. When music therapy is applied, the subject of treatment projects his or her tension and anxiety into the musical structure. Through the process of developing harmonious music balance and chord, introjection of stable emotions is made [27,28,29]. As the emotional response gradually shifts from a tense fast tempo and dissonance to a slow tempo and consonance, unpleasant emotions are converted into pleasant emotions following the tempo and chord of the music [30, 31].
In addition, music therapy needs subjects to directly participate, such as improvisation and positive self-expression, which can not only further enhance the therapeutic effect, but also can alleviate depression by improving their ability to cope with stress. In particular, during the selection process of music used in music therapy, auditory stimulus factors such as tempo, chord, tone, and contrast effect of emotion should be considered.
The principle of operation is explained in detail as follows. Music therapy can produce substantial physiological changes. It can activate the physical therapeutic effect by generating a limbic response using musical sound . The brain’s limbic system is closely related to respiratory rate, blood pressure, and heart rate. Applications of the auditory stimuli can relieve psychological stress experiences and depression .
Above all, negative emotions, and experiences such as depression as well as the ability to cope with the resulting stress should be considered. It is also a very important treatment goal in terms of social protection of children and adolescents with ADHD. Coping Skill refers to the ability to balance the secretion of hormones and neurotransmitters with the operation of the body immune system [34,35,36]. This adjustment process is also specifically related to 5-HT . Related previous studies have confirmed that auditory stimulation using melody can directly affect monoamine activity in nucleus acumens. Furthermore, it has been found that auditory stimulation can activate the secretion of serotonin [38, 39]. Yet to date, ADHD is a neurodevelopmental disorder with an estimated worldwide prevalence of 3 to 7% in childhood and adolescence [40,41,42], and 3% in adulthood [43, 44], Prior studies lacked systematic investigation on the practice of music therapy for preventing depression as a major coexisting disease in children and adolescents with ADHD.
Thus, the study attempts to quantitatively analyze effects of music therapy as an alternative treatment on depression in children and adolescents with ADHD based on changes in neurophysiological indicators of 5-HT and cortisol, systolic blood pressure (SBP), diastolic blood pressure (DBP), heart rate (HR), and psychological scale as psychological indicators (Scheme 1 and Scheme 2). Based on verified research results, we intend to confirm the possibility of continuous application and utilization of music therapy as an alternative to medicine for preventing and treating depression in children and adolescents with ADHD.
The study was conducted near Chungcheong-do, Republic of Korea. Participants were recruited by posting a recruitment notice at the General Welfare Center located in Republic of Korea. This study is designed based on randomization method.
The study was conducted near Chungcheong-do, Republic of Korea. Participants were recruited by posting a recruitment notice at the General welfare center located Chungcheong-do in Republic of Korea. There were four prerequisites for being selected as a subject for the experiment: (1) Children and adolescents must meet ADHD diagnostic criteria . (2) Patients aged 7 to 8 must be diagnosed with ADHD (at a university hospital located near Chungcheong-do, Republic of Korea) and complaining of depression (with CDI Scale results at 22 pts. or higher) (3) ADHD children and adolescents must have obtained parents’ consent to participate in this study (4) ADHD children and adolescents must not have had any prior experience with music therapy.
Exclusion criteria are as follows: (1) ADHD children and adolescents who have experienced music therapy (2) ADHD children and adolescents with physical disabilities (3) Children and adolescents with ADHD with communication and self-report disorder. (4) Children and adolescents in the ADHD music therapy group who have participated in music therapy programs fewer than 3 times (5) ADHD children and adolescents who have experienced side effects and adverse reactions during study.
A total of 60 subjects were included in the design criteria for randomization in this study. They were divided into an ADHD control group (n = 30) and an ADHD music therapy group (n = 30) each on a 1:1 basis. (Fig. 1). By substituting a 0.05 confidence interval, a study power of 0.80, and effect size of 0.89 based on a previous study  using the G-power 126.96.36.199 program, a sample size of 42 people (ADHD control group 21/ADHD music therapy group n = 21) was calculated (Fig. 1). However, 18 ADHD control group subjects and 18 ADHD music therapy group subjects were finally selected due to the limitations of continuous therapy, COVID-19, and distance (Fig. 1). The ADHD control group received standard care, while ADHD the music therapy group received standard care and active music therapy (improvisation) and receptive music therapy (music listening) and completed statistical analysis after follow-up (2 months). The study flowchart is summarized in (Fig. 1).
Randomization and blinding
The principal Investigator selected the subjects by reviewing the selection and exclusion criteria among ADHD children and youth participants. Random assignments were made using random number table generated by the Excel program to generate a random list with 2 groups and 60 samples.
The registered subjects were equally assigned to the ADHD Control group or ADHD music therapy group assigned by the random number table in the order of registration. This study is a music therapy intervention study. Therefore, the principal investigator of the ADHD children and youth participants, music therapists, and research will not be blinded by the assigned treatment. However, data statisticians will be blinded to group allocation. In order to protect the study subjects as much as possible, alphabet letters replaced their names.
ADHD control group: standard care, ADHD music therapy group: standard care and active music therapy (improvisation) and receptive music therapy (music listening).
Music therapy intervention
Music therapy, an alternative to medication, was conducted for 3 months (24 sessions in total) twice a week (Tuesday and Friday) from 2:00 PM to 3:00 PM each time. During this period, music therapy was conducted for 50 minutes for the ADHD music therapy group. Music therapy was conducted as follows step1: 8 min, step2: 12 min, and step3: 30 min (total 50 min). The music therapy program referred to [30, 31, 45,46,47, 49,50,51] previous studies to restore psychological and neurobiological functions to relieve depression and stress according to the purpose of this study. In addition, the researcher reconstructed it appropriately for the subject, including both receptive (listening to music) and active music therapy (Improvisation) interventions, and it was conducted in three stages after verifying the validity of three music therapy experts (Scheme 1). Application of music therapy was conducted by three certified music therapists who had extensive clinical therapy experience.
Music therapy was conducted in a stable and comfortable treatment room without noise, maintaining room temperature of 20 ~ 22 °C to get the most precise measurements. In the music therapy room, a piano for improvisation and a variety of rhythmic instruments that are easy to use to improvise without any special skills were placed.
When listening to auditory stimulus music, the subjects closed the door and sat in a comfortable position on the chair. And they closed eyes and listened to music, recalling positive images and words according to the therapist’s guidance. 3 steps of activity were conducted by using positive image and word that are visualized during listening to auditory stimulus music. 3 music therapists guided subjects to visualize positive images and words while they were listening to music.
Also, the therapists recorded specific changes in the subject’s behavior and attitude. After finishing each session of therapy, they qualitatively classified emotions expressed based on positive self-expression.
After music therapy, a song file for music appreciation was transmitted to ADHD Music therapy Group so that the song could be enjoyed at home. During the 3 months / 24 sessions of music therapy, music appreciation was practiced in daily life for 5 days a week when treatment was not performed, and it was intended to increase the effectiveness of the treatment in connection with the home.
Music preference survey
Specifically, this study attempted to select songs that correspond to three music conditions (Motivating, Relaxing, and M + R) among music that is highly preferred by Korean children and adolescents. Along with the selection of healing music, the overall structural analysis of the song was evaluated by a group consisting of two composers and one professional performer.
The subjects who finally decided to participate in the ADHD music therapy group (n = 18) completed a preference questionnaire consisting of a 5-point Likert Scale, and audio files were sent using a smartphone or email. To minimize the influence of lyrics, genres like pop without lyrics, traditional Korean music, and New Age were selected.
Also, music that matched the participants’ preferences (having been checked as “normal” or “like” by them) was selected .
The music listening used for the music therapy consisted of Motivating, Relaxing, and M + R (a total of three songs were selected: Arirang, Golden Star, White Tower), and were selected through a preference survey. Based on a previous study , the chosen songs were composed in the key of C, D, and G Major, and mainly used major chords, with some minor chords interspersed to create interest in the music .
The ADHD control group children and adolescents continued to receive existing recommended , drug therapy only. ADHD music therapy group children and adolescents and continued to receive existing recommended , drug therapy and active music therapy (improvisation) and receptive music therapy (music listening).
Blood samples were collected from antecubital veins of subjects according to the guidelines of the Clinical and Laboratory Standards Institute to identify changes in serum markers immediately before and after music therapy. Blood samples were transferred to SST tubes and immediately centrifuged at 3000 rpm for 10 minutes at 4 °C. The serum was subsequently removed and stored in 1 ml aliquots at − 80 °C until analysis (Scheme 2).
Analysis of 5-HT and cortisol levels
To determine 5-HT level, a high-pressure liquid chromatography (HPLC) method (Serotonin Kit, Recipe, Germany) with an Alliauce Waters 465 HPLC (Waters, USA) was used. Cortisol level was determined using a CORTISOL RIA CT (AMP, Germany) with a γ-counter COBRA 5010 QUANTUM (PACKARD, USA).
Measurement equipment for SBP, DBP and HR
SBP, DBP, and HR were measured using an automatic blood pressure monitor (OMRON, HEM-7210, Japan). SBP, DBP, and HR was measured one time per minute for a total three times immediately before and after music therapy. The average value was then calculated and used. All statistical analyses such as paired-test, unpaired-test, and analysis to verify music therapy follow-up effects were conducted using a commercial software (SPSS for Windows, version 21.0; SPSS Inc., Chicago, IL, USA). Results are expressed as average ± standard deviation. Significance level was set at p < 0.05 (Scheme 2).
Psychological measurement usage inventory
Children’s depression inventory (CDI)
Children’s Depression Inventory employed Kovacs’s CDI; M Kovacs  infant depression inventory, which modified Back’s Depression inventory for use in age range of 7 to 17 years old. Depression inventory consisted of a total of 27 questions. Based on answers to each question, the status of depression was diagnosed by combining each score from 0 to 2. If the combined score was in the score range of 22 to 25, it indicated a somewhat depressed condition. If the combined score was in the score range of 26 to 28, it indicated a in quite depressed condition. If combined score was above 29, it indicated a harsh depressed condition .
Daily hassles questionnaire (DHQ)
Daily stress was assessed with a 16-item questionnaire. The Daily stress questionnaire was based on Daily Hassles Questionnaire by RT Rowlison and RD Felner , and revised by MH Han and AJ Yoo , for students in Republic of Korea.
Measurement of daily stress consists of eight questionnaires of parent’s factors, seven questionnaires of family environmental factors, seven questionnaires of friend’s factors, seven questionnaires related to study, and seven questionnaires related to teacher and school. Likert inventory has a full score of 4, with higher score indicating higher daily stress level perceived .
The internal consensus level (Cronbach’s) of each factor was 0.85 for parent-related stress, 0.83 for home environment-related stress, 0.89 for friend-related stress, 0.83 for academic-related stress, and 0.77 for stress related to teachers and school life.
This study has been approved by the Institutional Review Board on Human Subjects Research and Ethics Committees, Soonchunhyang University, Cheonan, Korea (Approval No. 1040875-202012-BR-095, 1040875-202009-BR-075 and 1040875-202104-BR-030). All subjects and their parent or legal guardian were thoroughly briefed on the purpose of the study, experimental procedures, and potential risks. Participants were children and adolescents between the ages of 9–15. Before the study was undergone, informed consent/assent to participate in the study was obtained from the participant’s parents or legal guardians of all the children and adolescents who took part in the study in the form of a statement in a manuscript. All procedures complied with the 2013 Helsinki Declaration of the World Medical Association.
Technical statistics as a method of statistical analysis was conducted using paired-test, unpaired-test, and analysis to verify effects of music therapy during follow-up using a commercial computer software (SPSS for Windows, version 21.0; SPSS Inc., Chicago, IL, USA). Data are expressed was average ± standard deviation. Significance level was set at p < 0.05.
With the participation of three music therapists, pre-interviews were conducted with 60 people who were recruited through the recruitment notice for music therapy research. Recruitment commenced in 2021 and was completed in 2022. A statistical analysis was performed at follow-up (2 months later). In this study, 60 participants were recruited and underwent both the target selection criteria and the exclusion criteria. Subsequently, subjects who did not participate in all sessions due to conflicting work schedules and experimental schedules were excluded from the study. Therefore, among the 60 subjects, a total of 36 subjects, 18 in the ADHD control group and 18 in the music therapy group, were classified as subjects who met the criteria for selection as subjects for research. The physical features of all subjects are shown in Table 1. This study clearly explained study purpose, process, method, and possible side effects in detail to parents, legal representatives, ADHD children, and adolescents. Also, parents’ and legal representative’s consent was obtained after they had been fully informed about the overall study process. During the study no abnormal reactions or side effects were found in any of the participants.
The results of the analysis of the serotonin expression level of the ADHD music therapy group (ADHD MT G) that had music therapy showed a statistically significant increase after, as compared to before, they had music therapy (before: ADHD MT G: 28.20 ± 20.70 ng/ml vs. after: 39.50 ± 27.40 ng/ml p < 0.001, Fig. 2). However, the 5-HT analysis of the ADHD control group (ADHD Con G), who didn’t receive music therapy, showed that serotonin expression levels had not significantly increased after, as compared to before (before: 28.75 ± 20.03 ng/ml vs. after: 29.63 ± 20.29 ng/ml, Fig. 2). Prior to music therapy being applied, there was no significant difference in serotonin expression levels between the ADHD MT G and the ADHD Con G (before: ADHD MT G: 28.20 ± 20.70 ng/ml vs. ADHD Con G: 28.75 ± 20.03 ng/ml, Fig. 2). However, results of the analysis of the 5-HT expression levels after the ADHD MT G had music therapy showed that 5-HT expression was statistically significantly higher in the ADHD MT G than in the ADHD Con G (ADHD MT G: 39.50 ± 27.40 ng/ml vs. ADHD Con G: 29.63 ± 20.29 ng/ml, p < 0.05, Fig. 2).
The ADHD music therapy group (ADHD MT G) showed statistically significantly lower cortisol levels after the music therapy (before: 12.52 ± 4.40 ng/ml after g/dL vs. after: 11.06 ± 4.20 g/dL, p < 0.001, Fig. 3). However, the analysis of the ADHD control group (ADHD Con G), who did not receive music therapy, showed that cortisol level expression had not significantly decreased after, as compared to before (before:12.77 ± 4.29 g/dL vs. after: 12.46 ± 4.51 g/dL, Fig. 3). Prior to music therapy being given, there was no significant difference in cortisol expression levels between the ADHD MT G and the ADHD Con G (ADHD MT G: 12.52 ± 4.40 g/dL vs. ADHD Con G: 12.77 ± 4.29 g/dL, Fig. 3). However, results of the analysis of the cortisol expression levels of the ADHD MT G after receiving music therapy showed that cortisol expression was statistically significantly lower in the ADHD MT G than in the ADHD Con G (ADHD MT G: 11.06 ± 4.20 g/dL vs. ADHD Con G: 12.46 ± 4.51 g/dL, p < 0.05, Fig. 3).
SBP, DBP, and HR
The ADHD music therapy group (ADHD MT G) showed statistically significantly lower SBP, DBP, and HR levels after the music therapy (all p < 0.001, Table 2). However, analysis of the ADHD control group (ADHD Con G), who did not receive music therapy, showed that SBP, DBP, and HR levels were not significantly lower after, as compared to before (Table 2). Prior to music therapy being administered, there was no significant difference in SBP, DBP, and HR levels between the ADHD MT G and the ADHD Con G (Table 2). However, results of the analysis of the SBP, DBP, and HR levels after music therapy was given to the ADHD MT G showed that the SBP, DBP, and HR levels were all statistically significantly lower in the ADHD MT G than in the ADHD Con G (all p < 0.05, Table 2).
Psychological scale analysis
The ADHD music therapy group (ADHD MT G) showed statistically significantly lower CDI depression scores after the music therapy (p < 0.01, Table 3 and Fig. 4). However, the ADHD control group (ADHD Con G), who did not receive music therapy, had CDI depression scores that were not significantly lower after, as compared to before (Table 3 and Fig. 4). Prior to music therapy being applied, there was no significant difference in CDI depression scores between the ADHD MT G and the ADHD Con G (Table 3 and Fig. 4). However, results of the analysis of the CDI depression scores of the ADHD MT G after receiving music therapy showed that the CDI depression scores were statistically significantly lower in the ADHD MT G than in the ADHD Con G (p < 0.01, Table 3 and Fig. 4).
The ADHD music therapy group (ADHD MT G) showed statistically significantly lower DHQ stress scale scores after the music therapy (p < 0.001, Table 3 and Fig. 5). However, the DHQ stress scale scores of the ADHD control group (ADHD Con G), who did not have music therapy, were statistically significantly not lower after, as compared to before (Table 3 and Fig. 5). Prior to music therapy being applied, there was no significant difference in the DHQ stress scale scores between the ADHD MT G and the ADHD Con G (Table 3 and Fig. 5). However, results of the analysis of the DHQ stress scale scores of the ADHD MT group after receiving music therapy showed that the DHQ stress scale scores were statistically significantly lower in the ADHD MT G than in the ADHD Con G (p < 0.01, Table 3 and Fig. 5).
This study was conducted to verify the effectiveness of music therapy as an alternative treatment for improving depression in children and adolescents with ADHD by serotonin activation and stress coping ability improvement. To this end, this study compared and analyzed neurophysiological and psychological parameters before and after music therapy for children and adolescents with ADHD by measuring 5-HT, cortisol, SBP, DBP, HR, and psychological scale (CDI, DHQ) (Scheme 2). For the music therapy treatment, resonance frequency breathing [45, 46], was applied as the first step. The second step involved using musical elements such as chords, tempo, tonality, and contrast effects of emotions  to enable the listening to have auditory stimulation elements. When applying the two-stage treatment, the goal was to activate depression-related 5-HT and decrease stress-related cortisol. The measurement results of 5-HT and cortisol in relation to the second step of the treatment are as follows: Prior to music therapy being applied, there was no significant difference in serotonin expression levels between the ADHD MT G and the ADHD Con G. However, results of the analysis of the 5-HT expression levels of the ADHD MT G after receiving music therapy showed that 5-HT expression was statistically significantly higher in the ADHD MT G than in the ADHD Con G (Fig. 2). The ADHD MT G showed statistically significantly lower cortisol levels after the music therapy: however, the cortisol levels of the ADHD Con G had not significantly decreased after, as compared to before (Fig. 3). The research plan was based on previous studies which showed correlations between musical stimuli and lowered depression and stress [46, 61]. Actual measurement results also showed positive changes in neurophysiology and psychology after treatment using music therapy. This is consistent with the results of a previous study conducted by [26, 28, 33, 61] suggesting that emotions and neurophysiological factors such as blood pressure, heart rate, hormones, and body temperature are closely related . It can be seen that music therapy can directly cause neurophysiological changes in the human body and prove the possibility of switching in a positive direction. In addition, the ADHD MT G showed as a result of measurement, it was confirmed that 5-HT activation and cortisol reduction resulted in positive results in subsequent depression scale (CDI) test and related stress scale (DHQ) test (Table 3). It was confirmed that the neurophysiological effect of music therapy was interconnected with the psychological effect.
In the last step, after improvisation and positive self-expression activities were performed as post-activity, ADHD music therapy group showed statistically significantly lower SBP, DBP, and HR levels after the music therapy. In addition, as a result of measuring the psychological scale, it was confirmed that the score of the stress scale (DHQ) test of the ADHD MT G was decreased significantly after treatment than that before music therapy. Since those with ADHD are more likely to suffer from emotional disorders such as depression [63, 64], music therapy can be interpreted in a very encouraging direction in that it not only relieves ADHD children and adolescents’ depression, but also strengthens their ability to cope with problems. When overall analysis results are summarized, application points that can extend music therapy to the treatment process of depression and stress in ADHD children and youth groups can be summarized as follows. First, music therapy can be a non-pharmaceutical alternative treatment for depression and stress of ADHD. In fact, previous studies have consistently indicated that it is necessary to combine continuous and non-pharmaceutical treatments in order to reduce side effects of pharmacological treatment and increase the effectiveness of treatment for these diseases [2, 65]. Music therapy used in the present study has an advantage in that it has convenient accessibility during continuous treatment. Children and adolescents in the ADHD music therapy group In order to proceed with a music therapy, it was designed to transmit sound source files for listening to auditory music at home and allow them to observe their heart rates using home blood pressure and heart rate monitoring machines , which are recommended for ADHD children and adolescents after listening to music. This is an attempt to increase the treatment effect by linking music therapy to daily life. This music therapy configuration minimizes the need for space and cost for treatment. It can be applied more easily than other non-pharmacological treatments. Second, music therapy is an effective treatment method for developing the ability to cope with stress in children and adolescents with ADHD. In particular as social, and psychological stress increases due to the COVID-19 , treatment measures and their necessity are further emphasized [66, 68, 69]. The music therapy constructed and devised in this study is also very effective in this case. Music therapy has the advantage that it can be accessed from anywhere without any spatial constraints and that the treatment cost is low. In addition, music therapy can be conveniently used even under unexpected circumstances, such as a global pandemic. On the other hand, existing studies on music therapy for children and adolescents with ADHD have been focused on improving their academic ability [70, 71] or on the improvement of impulsivity and attention based on cognitive therapy [72,73,74,75,76]. On the contrary, this study has a major difference in that it focused on depression as the most fundamental emotional underlying disease and sought musical therapy as a solution to this.
In particular, the study quantified 5-HT and cortisol expression based on neurophysiological treatment effects, presented indicators on changes in SBP, DBP, and HR, and verified psychological treatment effects through psychological scale verification (CDI, DHQ). Therefore, it is expected that the applicable proposal of Scheme 2, an alternative model of alternative medicine, will be used in various ways for ADHD children and adolescents.
This study suggested the use of scientific clinical evidence in the form of physiological indicators as an alternative to depression and stress, which are emotional symptoms of ADHD. It is necessary to conduct a follow-up study on data analysis that can confirm the point of subject’s recovery when music therapy is applied to subjects suffering from depression and stress.
In conclusion, the application of music therapy as an alternative treatment for depression in ADHD children and adolescents showed positive neurophysiological and psychological effects. This study intends to present a new alternative of medicine towards preventing and treating depression of ADHD through a neurophysiological and psychological approach. Indicators of the confirmed results meet the need for continuous application and the added value of use. Additionally, it is expected that music therapy will contribute to the establishment and spread of clinical foundations through active use in the medical field.
Availability of data and materials
All data generated or analyzed during this study are included in this published article. The raw data supporting the conclusion of this article will be made available by the authors, without undue reservation. The dataset supporting the conclusions of this article can be made available from the corresponding author on reasonable request.
Thapar A, Cooper M. Attention deficit hyperactivity disorder. Lancet. 2016;387(10024):1240–50.
Posner J, Polanczyk GV, Sonuga-Barke E. Attention-deficit hyperactivity disorder. Lancet. 2020;395(10222):450–62.
Kautzky A, Vanicek T, Philippe C, Kranz GS, Wadsak W, Mitterhauser M, et al. Machine learning classification of ADHD and HC by multimodal serotonergic data. Transl Psychiatry. 2020;10(1):104.
Bussing R, Mason DM, Bell L, Porter P, Garvan C. Adolescent outcomes of childhood attention-deficit/hyperactivity disorder in a diverse community sample. J Am Acad Child Adolesc Psychiatry. 2010;49(6):595–605.
Purper-Ouakil D, Ramoz N, Lepagnol-Bestel AM, Gorwood P, Simonneau M. Neurobiology of attention deficit/hyperactivity disorder. Pediatr Res. 2011;69(5 Pt 2):69r–76r.
Meinzer MC, Pettit JW, Waxmonsky JG, Gnagy E, Molina BS, Pelham WE. Does childhood attention-deficit/hyperactivity disorder (ADHD) predict levels of depressive symptoms during emerging adulthood? J Abnorm Child Psychol. 2016;44(4):787–97.
Shapero BG, Gibb BE, Archibald A, Wilens TE, Fava M, Hirshfeld-Becker DR. Risk factors for depression in adolescents with ADHD: the impact of cognitive biases and stress. J Atten Disord. 2021;25(3):340–54.
Wang LJ, Yu YH, Fu ML, Yeh WT, Hsu JL, Yang YH, et al. Attention deficit-hyperactivity disorder is associated with allergic symptoms and low levels of hemoglobin and serotonin. Sci Rep. 2018;8(1):10229.
Hou YW, Xiong P, Gu X, Huang X, Wang M, Wu J. Association of Serotonin Receptors with attention deficit hyperactivity disorder: a systematic review and Meta-analysis. Curr Med Sci. 2018;38(3):538–51.
Kanen JW, Arntz FE, Yellowlees R, Cardinal RN, Price A, Christmas DM, et al. Serotonin depletion amplifies distinct human social emotions as a function of individual differences in personality. Transl Psychiatry. 2021;11(1):81.
Zepf FD, Gaber TJ, Baurmann D, Bubenzer S, Konrad K, Herpertz-Dahlmann B, et al. Serotonergic neurotransmission and lapses of attention in children and adolescents with attention deficit hyperactivity disorder: availability of tryptophan influences attentional performance. Int J Neuropsychopharmacol. 2010;13(7):933–41.
Nautiyal KM, Tanaka KF, Barr MM, Tritschler L, Le Dantec Y, David DJ, et al. Distinct circuits underlie the effects of 5-HT1B receptors on aggression and impulsivity. Neuron. 2015;86(3):813–26.
Curatolo P, D'Agati E, Moavero R. The neurobiological basis of ADHD. Ital J Pediatr. 2010;36(1):79.
Engert V, Smallwood J, Singer T. Mind your thoughts: associations between self-generated thoughts and stress-induced and baseline levels of cortisol and alpha-amylase. Biol Psychol. 2014;103:283–91.
Oyola MG, Handa RJ. Hypothalamic-pituitary-adrenal and hypothalamic-pituitary-gonadal axes: sex differences in regulation of stress responsivity. Stress. 2017;20(5):476–94.
Ooishi Y, Mukai H, Watanabe K, Kawato S, Kashino M. Increase in salivary oxytocin and decrease in salivary cortisol after listening to relaxing slow-tempo and exciting fast-tempo music. PLoS One. 2017;12(12):e0189075.
Wuttke-Linnemann A, Nater UM, Ehlert U, Ditzen B. Publisher correction: sex-specific effects of music listening on Couples' stress in everyday life. Sci Rep. 2020;10(1):1630.
Biederman J, Ball SW, Monuteaux MC, Mick E, Spencer TJ, Mc CM, et al. New insights into the comorbidity between ADHD and major depression in adolescent and young adult females. J Am Acad Child Adolesc Psychiatry. 2008;47(4):426–34.
Roy A, Oldehinkel AJ, Verhulst FC, Ormel J, Hartman CA. Anxiety and disruptive behavior mediate pathways from attention-deficit/hyperactivity disorder to depression. J Clin Psychiatry. 2014;75(2):e108–13.
Yoshimasu K, Barbaresi WJ, Colligan RC, Voigt RG, Killian JM, Weaver AL, et al. Adults with persistent ADHD: gender and psychiatric comorbidities-a population-based longitudinal study. J Atten Disord. 2018;22(6):535–46.
Faraone SV, Larsson H. Genetics of attention deficit hyperactivity disorder. Mol Psychiatry. 2019;24(4):562–75.
Luo Y, Weibman D, Halperin JM, Li X. A review of heterogeneity in attention deficit/hyperactivity disorder (ADHD). Front Hum Neurosci. 2019;13:42.
Chen MH, Pan TL, Hsu JW, Huang KL, Su TP, Li CT, et al. Attention-deficit hyperactivity disorder comorbidity and antidepressant resistance among patients with major depression: a nationwide longitudinal study. Eur Neuropsychopharmacol. 2016;26(11):1760–7.
Young S, Asherson P, Lloyd T, Absoud M, Arif M, Colley WA, et al. Failure of healthcare provision for attention-deficit/hyperactivity disorder in the United Kingdom: a consensus statement. Front Psychiatry. 2021;12:649399.
Conrad C. Music for healing: from magic to medicine. Lancet. 2010;376(9757):1980–1.
Tang Q, Huang Z, Zhou H, Ye P. Effects of music therapy on depression: a meta-analysis of randomized controlled trials. PLoS One. 2020;15(11):e0240862.
Masataka N, Perlovsky L. Cognitive interference can be mitigated by consonant music and facilitated by dissonant music. Sci Rep. 2028;2013:3.
Schaal NK, Brückner J, Wolf OT, Ruckhäberle E, Fehm T, Hepp P. The effects of a music intervention during port catheter placement on anxiety and stress. Sci Rep. 2021;11(1):5807.
Koelsch S, Bashevkin T, Kristensen J, Tvedt J, Jentschke S. Heroic music stimulates empowering thoughts during mind-wandering. Sci Rep. 2019;9(1):10317.
Schellenberg EG, Corrigall KA, Ladinig O, Huron D. Changing the tune: listeners like music that expresses a contrasting emotion. Front Psychol. 2012;3:574.
Cheng TH, Tsai CG. Female Listeners' autonomic responses to dramatic shifts between loud and soft music/sound passages: a study of heavy metal songs. Front Psychol. 2016;7:182.
Koelsch S. Brain correlates of music-evoked emotions. Nat Rev Neurosci. 2014;15(3):170–80.
de Witte M, Spruit A, van Hooren S, Moonen X, Stams GJ. Effects of music interventions on stress-related outcomes: a systematic review and two meta-analyses. Health Psychol Rev. 2020;14(2):294–324.
Fuhrmann D, Knoll LJ, Blakemore SJ. Adolescence as a sensitive period of brain development. Trends Cogn Sci. 2015;19(10):558–66.
Pascual-Leone A, Amedi A, Fregni F, Merabet LB. The plastic human brain cortex. Annu Rev Neurosci. 2005;28:377–401.
Cousijn J, Luijten M, Feldstein Ewing SW. Adolescent resilience to addiction: a social plasticity hypothesis. Lancet Child Adolesc Health. 2018;2(1):69–78.
Altenmüller E, Schlaug G. Apollo's gift: new aspects of neurologic music therapy. Prog Brain Res. 2015;217:237–52.
Moraes MM, Rabelo PCR, Pinto VA, Pires W, Wanner SP, Szawka RE, et al. Auditory stimulation by exposure to melodic music increases dopamine and serotonin activities in rat forebrain areas linked to reward and motor control. Neurosci Lett. 2018;673:73–8.
Feduccia AA, Duvauchelle CL. Auditory stimuli enhance MDMA-conditioned reward and MDMA-induced nucleus accumbens dopamine, serotonin and locomotor responses. Brain Res Bull. 2008;77(4):189–96.
Du Rietz E, Brikell I, Butwicka A, Leone M, Chang Z, Cortese S, et al. Mapping phenotypic and aetiological associations between ADHD and physical conditions in adulthood in Sweden: a genetically informed register study. Lancet Psychiatry. 2021;8(9):774–83.
Polanczyk G, de Lima MS, Horta BL, Biederman J, Rohde LA. The worldwide prevalence of ADHD: a systematic review and metaregression analysis. Am J Psychiatry. 2007;164(6):942–8.
Polanczyk GV, Salum GA, Sugaya LS, Caye A, Rohde LA. Annual research review: a meta-analysis of the worldwide prevalence of mental disorders in children and adolescents. J Child Psychol Psychiatry. 2015;56(3):345–65.
Fayyad J, Sampson NA, Hwang I, Adamowski T, Aguilar-Gaxiola S, Al-Hamzawi A, et al. The descriptive epidemiology of DSM-IV adult ADHD in the World Health Organization world mental health surveys. Atten Defic Hyperact Disord. 2017;9(1):47–65.
Dobrosavljevic M, Solares C, Cortese S, Andershed H, Larsson H. Prevalence of attention-deficit/hyperactivity disorder in older adults: a systematic review and meta-analysis. Neurosci Biobehav Rev. 2020;118:282–9.
Brown RP, Gerbarg PL, Muench F. Breathing practices for treatment of psychiatric and stress-related medical conditions. Psychiatr Clin North Am. 2013;36(1):121–40.
Erkkilä J, Brabant O, Hartmann M, Mavrolampados A, Ala-Ruona E, Snape N, et al. Music therapy for depression enhanced with listening homework and slow paced breathing: a randomised controlled trial. Front Psychol. 2021;12:613821.
Herff SA, Cecchetti G, Taruffi L, Déguernel K. Music influences vividness and content of imagined journeys in a directed visual imagery task. Sci Rep. 2021;11(1):15990.
Ribeiro MK, Alcântara-Silva TR, Oliveira J, Paula TC, Dutra JB, Pedrino GR, et al. Music therapy intervention in cardiac autonomic modulation, anxiety, and depression in mothers of preterms: randomized controlled trial. BMC Psychol. 2018;6(1):1–10.
Zimmermann MB, Diers K, Strunz L, Scherbaum N, Mette C. Listening to Mozart improves current mood in adult ADHD - a randomized controlled pilot study. Front Psychol. 2019;10:1104.
Porter S, McConnell T, McLaughlin K, Lynn F, Cardwell C, Braiden HJ, et al. Music therapy for children and adolescents with behavioural and emotional problems: a randomised controlled trial. J Child Psychol Psychiatry. 2017;58(5):586–94.
Windle E, Hickling LM, Jayacodi S, Carr C. The experiences of patients in the synchrony group music therapy trial for long-term depression. Arts Psychother. 2020;67:101580.
Yeo H, Nam HW, Lee J. The effect of listening to SMT music made using musical expectancy violations on brain concentration and activation. Chin J Phys. 2021;64(3):159.
Daengruan P, Chairat R, Jenraumjit R, Chinwong D, Oon-Arom A, Klaphajone J, et al. Effectiveness of receptive music therapy with imbedded 10 Hz binaural beats compared with standard Care for Patients with major depressive disorder: a randomized controlled trial. Complement Ther Med. 2021;61:102765.
Young JL, Goodman DW. Adult attention-deficit/hyperactivity disorder diagnosis, management, and treatment in the DSM-5 era. Prim Care Companion CNS Disord. 2016;18(6):26599.
Kovacs M. The Children's depression, inventory (CDI). Psychopharmacol Bull. 1985;21(4):995–8.
Stumper A, Olino TM, Abramson LY, Alloy LB. A factor analysis and test of longitudinal measurement invariance of the Children's depression inventory (CDI) across adolescence. J Psychopathol Behav Assess. 2019;41(4):692–8.
Rowlison RT, Felner RD. Major life events, hassles, and adaptation in adolescence: confounding in the conceptualization and measurement of life stress and adjustment revisited. J Pers Soc Psychol. 1988;55(3):432–44.
Han MH, Yoo AJ. Development of daily hassles scale for children in Korea. J Korean Home Econ Assoc. 1995;33(4):49–64.
Park J, Kwon YD, Park H, Yu SE, Noh JW. Health-promoting behavior and influencing factors in Young north Korean refugees (NKRs) living in South Korea. J Immigr Minor Health. 2018;20(6):1355–61.
Du BD, Du BE. Clinical calorimetry: tenth paper a formula to estimate the approximate surface area if height and weight be known. Arch Intern Med. 1916;XVII(6_2):863–71.
Ribeiro MKA, Alcântara-Silva TRM, Oliveira JCM, Paula TC, Dutra JBR, Pedrino GR, et al. Music therapy intervention in cardiac autonomic modulation, anxiety, and depression in mothers of preterms: randomized controlled trial. BMC Psychology. 2018;6(1):57.
Grabowski K, Rynkiewicz A, Lassalle A, Baron-Cohen S, Schuller B, Cummins N, et al. Emotional expression in psychiatric conditions: new technology for clinicians. Psychiatry Clin Neurosci. 2019;73(2):50–62.
Babinski DE, Neely KA, Ba DM, Liu G. Depression and suicidal behavior in young adult men and women with ADHD: evidence from claims data. J Clin Psychiatry. 2020;81(6):22578.
Powell V, Riglin L, Hammerton G, Eyre O, Martin J, Anney R, et al. What explains the link between childhood ADHD and adolescent depression? Investigating the role of peer relationships and academic attainment. Eur Child Adolesc Psychiatry. 2020;29(11):1581–91.
Owens EB, Zalecki C, Gillette P, Hinshaw SP. Girls with childhood ADHD as adults: cross-domain outcomes by diagnostic persistence. J Consult Clin Psychol. 2017;85(7):723–36.
Cortese S, Asherson P, Sonuga-Barke E, Banaschewski T, Brandeis D, Buitelaar J, et al. ADHD management during the COVID-19 pandemic: guidance from the European ADHD guidelines group. Lancet Child Adolesc Health. 2020;4(6):412–4.
Zhang J, Shuai L, Yu H, Wang Z, Qiu M, Lu L, et al. Acute stress, behavioural symptoms and mood states among school-age children with attention-deficit/hyperactive disorder during the COVID-19 outbreak. Asian J Psychiatr. 2020;51:102077.
Mastnak W. Psychopathological problems related to the COVID-19 pandemic and possible prevention with music therapy. Acta Paediatr. 2020;109(8):1516–8.
Torous J, Wykes T. Opportunities from the coronavirus disease 2019 pandemic for transforming psychiatric care with Telehealth. JAMA Psychiatry. 2020;77(12):1205–6.
Serrallach B, Groß C, Bernhofs V, Engelmann D, Benner J, Gündert N, et al. Neural biomarkers for dyslexia, ADHD, and ADD in the auditory cortex of children. Front Neurosci. 2016;10:324.
Waschbusch DA, Craig R, Pelham WE Jr, King S. Self-handicapping prior to academic-oriented tasks in children with attention deficit/hyperactivity disorder (ADHD): medication effects and comparisons with controls. J Abnorm Child Psychol. 2007;35(2):275–86.
Lopez PL, Torrente FM, Ciapponi A, Lischinsky AG, Cetkovich-Bakmas M, Rojas JI, et al. Cognitive-behavioural interventions for attention deficit hyperactivity disorder (ADHD) in adults. Cochrane Database Syst Rev. 2018;3(3):Cd010840.
Dursun P, Fidan U, Karayagiz S. Probable role of listening therapy in the management of ADHD symptoms: three case studies. Curr Psychol. 2021;40(9):4219–34.
Carrer LR. Music and sound in time processing of children with ADHD. Front Psychiatry. 2015;6:127.
Kollins SH, DeLoss DJ, Cañadas E, Lutz J, Findling RL, Keefe RSE, et al. A novel digital intervention for actively reducing severity of paediatric ADHD (STARS-ADHD): a randomised controlled trial. Lancet Digit Health. 2020;2(4):e168–78.
Mawjee K, Woltering S, Tannock R. Working memory training in post-secondary students with ADHD: a randomized controlled study. PLoS One. 2015;10(9):e0137173.
We extend our thank to the subjects whose participation made this study possible.
This work was supported by Soonchunhyang University Research Fund and a grant (BK21 Four) of the Basic Science Research Program through the National Research Foundation (NRF) funded by the Ministry of Education, Republic of Korea.
Ethics approval and consent to participate
This study has been approved by the Institutional Review Board on Human Subjects Research and Ethics Committees, Soonchunhyang University, Cheonan, Republic of Korea (Approval No. 1040875-202012-BR-095, 1040875–202009-BR-075 and 1040875–202104-BR-030). All subjects and their parents or legal guardians were thoroughly briefed on the purpose of the study, experimental procedures, and potential risks. Participants were children and adolescents between the ages of 9–15. Before the study was undergone, informed consent/assent to participate in the study was obtained from the participant’s parents or legal guardians of all the children and adolescents who took part in the study in the form of a statement in a manuscript. This study clearly states that the informed consent of participants (their parent or legal guardian in the case of children under 16) was obtained. All procedures complied with the 2013 Helsinki Declaration of the World Medical Association.
Consent for publication
The authors declare that they have no competing interests.
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Rights and permissions
Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.
About this article
Cite this article
Park, JI., Lee, IH., Lee, SJ. et al. Effects of music therapy as an alternative treatment on depression in children and adolescents with ADHD by activating serotonin and improving stress coping ability. BMC Complement Med Ther 23, 73 (2023). https://doi.org/10.1186/s12906-022-03832-6
- Children and adolescents with ADHD
- Music therapy
- Serotonin (5-HT)
- Ability to address stress