Music Therapy to Promote Prosocial Behaviors in Aggressive Adolescent Boys-A Pilot Study

Music Therapy to Promote Prosocial Behaviors in Aggressive Adolescent Boys-A Pilot Study

Rickson, Daphne J

This pilot study was undertaken to investigate whether music therapy is effective in promoting prosocial behaviors in aggressive adolescent boys who have social, emotional, and learning difficulties. Fifteen subjects (aged 11-15 years), enrolled at a special residential school in New Zealand, were randomly assigned to music therapy treatment groups (n = 6, n = 5), and a waitlist control group (n = 4). Examination of demographic data identified differences between groups for diagnosis (p = .044), with Group 1 all having Attention Deficit Hyperactivity Disorder (ADHD), and for age (p = .027), with Group 2 having a mean age 1.38 years older. Measures included parent and teacher versions of the Developmental Behaviour Checklist (DBC-P & DBC-T) (Einfeld & Tonge, 1994; Einfeld, Tonge, & Parmenter, 1998). While no definite treatment effects could be detected, results suggest that a music therapy program promoting autonomy and creativity may help adolescents to interact more appropriately with others in a residential villa setting, but might a/so lead to a temporary mild increase in disruptive behavior in the classroom. A more highly structured program and smaller group numbers may be advantageous for boys who have ADHD.

This pilot study was undertaken to investigate the hypothesis that music therapy is effective in promoting prosocial behaviors in aggressive adolescent boys, in classroom and residential villa settings. While there appears to be considerable anecdotal evidence pointing to the potential advantage of group music therapy with adolescents, there is an extreme paucity of recent music therapy literature relating to the use of music therapy with adolescents who have social and emotional difficulties.

Children and adolescents who have learning disabilities are thought to exhibit a certain amount of internal arrhythmia or dysrhythmia (Evans, 1986). Those with Attention Deficit Hyperactivity Disorder (ADHD) (APA, 1994) are often unable to inhibit their motor responses to the sights and sounds around them, are not guided by internal instructions, and therefore find it difficult to independently restrict their inappropriate behaviors. Self-control is the precursor to the development of higher ‘executive functions’ and therefore provides a critical foundation for the performance of basic tasks. It has been suggested that rhythm activities can facilitate internal organization (Gaston, 1968), the co-ordination of mind and body (Montello, 1996), and, by providing a sense of internal security, can help with the control of impulses (Bruscia, 1987).

Eidson (1989) examined the effects of a behavioral music therapy treatment program on emotionally handicapped middle school students (N= 25), aged 11-16. Experimental subjects’ scores for classroom behavior were almost twice as stable as scores for control subjects. In the same year Haines compared two active treatments (music vs. verbal) in a small sample of subjects identified by their school systems as emotionally disturbed adolescents, and found no treatment effects over the short term, that is, after six half-hour sessions (Haines, 1989).

In a single case study with an adolescent boy who had a diagnosis of Conduct Disorder, Kivland (1986) documented an increase of prompted positive self-statements following individual music therapy sessions. Similarly, although significance was not achieved, Henderson (1983) found that hospitalized adolescent psychiatric patients in music therapy programs had a trend towards improving more than controls, on measures of self-esteem. Thaut (1989) measured self-perceived changes in states of relaxation, mood/emotion, and thought/insight in psychiatric prisoner-patients before and after music therapy. The three different music therapy techniques used in this study all proved to be successful in changing the prisoner-patients’ self-perceived states of relaxation, mood/emotions, and thoughts about self and one’s own life.

Montello and Goons (1998) set out to evaluate the effects of active rhythm-based versus passive listening-based group music therapy treatment on young adolescents with emotional, learning, and behavioral disorders, using 24 items relating to attention, motivation, and hostility selected from the Child Behavior Checklist Teacher Report Form (CBCL-TRF) (Achenbach, 1991). They found that subjects improved after receiving either the passive or active intervention, particularly on the aggression/hostility scale. They therefore argued for future research to discriminate between externalizing or internalizing behaviors in inclusion criteria. However while in that study overall improvements in the three groups were recorded, Group A increased their score for hostility problems during the treatment (active therapy) phase and returned to baseline during the control (passive therapy) phase, which suggests between group differences. Montello and Coons proposed that the treatment approach might have to be more structured for adolescents who have more fragile ego development.

This pilot study aimed to confirm and add to the research of Montello and Coons by targeting students who have identified externalizing behaviors. Further, the music therapy treatment sessions included active music making as well as listening activities, which are described in more detail later in this paper, and the study utilizes multi-informant data gathering. In summary, it aimed to investigate the hypothesis that music therapy is effective in reducing aggressive behaviors.

Method

Population Sample

The subjects were drawn from a population of 88 adolescent boys who have intellectual, social, and emotional deficits, who were enrolled in a special education residential facility in New Zealand. From students enrolled at the school in April 2001, those who started before May 2000 and after March 2001 (i.e., 49 boys) were excluded to control for historical effects and the likelihood of their leaving before the study was completed. Remaining students (39) were screened for aggressive behaviors using the Child Behaviour Checklist (CBCL) data held by the school for all students. Eighteen students were excluded because of insignificant aggression, and 3 were excluded because they were, or had been previously involved in music therapy programs.

After exclusions, the potential research sample consisted of boys (N= 18) ranging in age from 11 years 6 months to 15 years 3 months (average of 13 years 2 months, and median age of 13 years) with clinically significant measures on the CBCL Aggression/Hostility scale. Twelve of the boys in this study had previous diagnoses of Attention Deficit Disorder (ADD) or Attention Deficit Hyperactivity Disorder (ADHD), four of General Developmental Delay, and oneeach of Head Injury and Depression. Five of the boys with ADD or ADHD had a dual diagnosis including Oppositional Defiant Disorder (ODD) or Conduct Disorder (CD) according to DSMIV criteria (APA, 1994). Half of the boys (n = 9) were taking psychotropic medication, most commonly stimulants. Nine of the boys were of Maori ethnicity (50%) and nine were New Zealand European (50%).

Research Sample

From the initial research sample (N= 18), students were randomly assigned to two music therapy groups (n = 6, n = 6), and one waitlist control group (n=6). One of the boys in the control group was indefinitely suspended shortly before the therapy program began. A second withdrew after attending only 10 minutes of one session and a third was suspended after one music therapy session only, because of severely disruptive and aggressive behavior in the residential villa environment. Fifteen subjects therefore completed music therapy treatment (Group 1, n= 6, Group 2, n= 5, Control Group 3, n = 4). Music therapy treatment was the same for all groups.

Measures

Developmental Behaviour Checklist (UBC). The potential effects of the music therapy program on aggressive behavior were measured using the subscales of disruption and antisocial behavior in the Development Behaviour Checklist (DBC), (Einfeld & Tonge, 1994). Although the Child Behavior Checklist ‘CBCL’ was used for initial inclusion criteria, the more recently developed DBC, which has been derived from the CBCL, was deemed a more appropriate measure for this study as it is normed for children and adolescents who have mild mental retardation. Residential social workers, acting as ‘key workers’ for students in their villa accommodation, scored the parent version. Other subscales measured by the DBC included Self-absorption, Communication Disturbance, and Anxiety. A further category on the parent version relates to autistic-type behaviors, while the teacher version measures social relationships.

Converting scores to percentiles gives information about how normal or abnormal that score is, which is useful for comparison. It needs to be noted that while the Teacher version clinical cutoff point is the 30th percentile, the Parent version is set at the 60th percentile. The DBC was administered to all boys at the end of Terms 1 and 3, 2001, (as a pre and posttest for treatment groups, and a baseline for controls), and again at the end of Term 4, 2001 (as a posttest for controls and follow-up for treatment groups).

Video Analysis. Video data were analyzed to measure within-session change. The process involved writing a thorough description of group activity and each individual subject’s specific behavior in that context, during a 10-minute allocated period. Descriptions were coded according to the quality of each interaction. The video data were analyzed by recording the number of positive or negative ‘events’ that occurred for each individual during the 10-minute data segment. Group totals were then calculated and the data presented as a percentage of total number of events for each session. To assess rater reliability a second rater was employed to view the videotape of one randomly selected individual in each videotaped session.

Statistical Analysis. Because music therapy treatment was the same for all boys, data were pooled for Groups 1 and 2. However, early observations of dissimilarities between these two groups led to additional analysis to determine the extent of the differences between all three groups. DBC data were tested using analysis of variance for repeated measures (ANOVA) to look at treatment effects, consistent difference between groups, and difference in changes between groups over time. Confidence levels were set at 95%.

Music Therapy Treatment

Music therapy intervention consisted of 16 sessions of approximately 30-45 minutes, twice a week, during Term 3, 2001. A waitlisted group of control subjects were offered music therapy intervention of 16 sessions of approximately 30-45 minutes twice a week during Term 4, 2001.

Because the music therapist uses a client-centered humanistic model of psychotherapy as her framework, the program and activities were varied from the initial planning documents according to client responses. Early sessions provided clear structure and control to meet the needs of subjects. However, by session 4 onwards they were gradually invited to take more responsibility for themselves and others and were increasingly given opportunities for choice making and creative expression. A program goal was to use the process of group music to increase students’ awareness of the existence and feelings of self and others. Further, it was intended that by experiencing success through contributing to group activity, recognition of themselves as valuable group members would increase. Finally, the groups were to provide a setting for peer relationships to develop based on respect and trust.

The activities included:

1. Bringing self selected music. During initial sessions, each student was asked to bring favorite music to share and to stimulate discussion (listening-based activity). One student per week would play their chosen piece to the group and then be invited to talk about why they chose that music. Other group members would then be asked individually to make a positive comment about their peer’s choice. Boys were initially instructed not to talk until invited.

2. Personalized song, where boys were asked to greet each other in song and to shake hands with a peer.

3. Active rhythm-based activities where each student was encouraged to support other group members, as well as to ‘solo.’ Engagement was achieved through call and response rhythm games, rhythm ensembles, and creative improvisation using a range of percussion instruments.

4. Opportunities to experience and care for musical instruments, and to share these with group members in appropriate ways. Subjects were encouraged to explore unfamiliar sounds, to listen to the creative sounds of their peers, to ask for and to receive instruments in a respectful manner, to offer, pass and respond to requests for instruments from peers.

5. Group song writing activities in ‘blues’ form, which enabled the group to build on and support each individual student’s small personal contribution to lyrics. The familiar 12-bar blues pattern provided a useful structure for the song writing as this form accommodates short repetitive ideas that can be built on or be ‘resolved’ in the final phrase. The short phrases encouraged boys to take the risk of sharing a simple idea. Further, the blues framework invited echoing of short phrases sung by peers thereby leading to affirmation and support within the group.

Once the subjects were familiar with what each experience entailed, they were encouraged to make their own group decisions regarding which activities they would undertake in a session. However, on occasions when group negotiations were at risk of breaking down, the therapist would intervene with more support and direction. By the completion of the program it was anticipated that students would be more able to attend, to offer a simple appropriate verbal response to a question, to wait for their turn and take a turn when it was offered, to offer a creative idea and accept and work with someone else’s idea. It was also considered likely that they would learn to keep a steady beat and to play instruments with some self-control (e.g., play quietly when requested).

Results

Age of Subjects

While the average age of students in both Group 1 and Group 3 was 12.42 years, the average age for Group 2 was 13.8 years. Analysis of Variance between group tests (ANOVA) revealed statistical differences between groups (p = .027). However repeating the test with Groups 1 and 2 combined revealed no significant differences (p =.299).

Diagnosis

Despite randomization, all six boys in Group 1 had a diagnosis of Attention Deficit Hyperactivity Disorder, whereas in Group 2 only three of five, and in Group 3, one of four had that particular diagnosis. Statistical analysis (Pearson Chi-Square) revealed a significant difference (p = .044) between groups. When the test was repeated with Groups 1 and 2 combined, the difference was nearing significance (p= .077).

Key to Reading Data & Graphs

The DBC measures negative behaviors, and treatment aims to facilitate a decrease in scores over time. A downward trend in the graphs therefore represents an improvement. Groups 1 and 2 had music therapy between Test 1 and Test 2. Waitlist controls, Group 3, had music therapy between Tests 2 and 3. The solid lines on the line graphs, therefore, represent time in treatment, while the dotted lines represent pretreatment for Group 3, and posttreatment period for Groups 1 and 2.

DBC Data as Mean Scores

The mean scores across subscales for the three music therapy groups are shown in Table 1 (Parent Version) and Table 2 (Teacher Version). Apart from a small increase in disruptive behavior subscale for Group 1 and ‘no change’ in Communication Disturbance subscale for Group 3, residential social workers, scoring the parent version, rated all three groups consistently improving during treatment across all six subscales. Teachers, however also rated Group 1 boys as more disruptive during music therapy treatment, and further, noted an increase in Communication Disturbance in Groups 1 and 2, and Anxiety across all three groups. Scores were higher posttreatment on Self Absorbed Subscale for Group 3, and Social Relating Subscales for Groups 2 and 3. The DBC subscales that are of particular relevance to this study are those measuring ‘Disruptive’ and ‘Antisocial’ Behavior.

DBC Disruptive Behaviour Subscales

On the Disruptive subscales (Figure 1), percentile scores recorded by teachers show slight deterioration in classroom behavior for treatment Groups 1 and 2 during the period of the music therapy, while ‘controls’ in Group 3 continued a trend toward improvement which had begun prior to music therapy intervention. Residential social workers who completed the parent version of the DBC also noted a reduction in the disruptive behavior of subjects in Group 3 prior to treatment, which continued when the music therapy program commenced. Contrasting with the teacher view, the residential staff also recorded a reduction of disruptive behaviors for Groups 1 and 2, which levelled off posttreatment.

DEC Antisocial Subscale

Mean scores for the Antisocial Subscale are shown in Figure 2. Teacher version scores for Groups 1 and 2 show a slight increase in antisocial behavior during the music therapy treatment period, while a much sharper ‘improvement’ was noted posttreatment.

Conversely, the parent version scores by residential social workers show a stronger improvement trend for Groups 1 and 2 while in treatment, which levelled off when the music therapy program finished. Despite deterioration prior to treatment, Group 3 also showed a trend for improvement while in therapy, as recorded by both teachers and residential social workers.

Assessment of ‘Disruptive’ and ‘Antisocial’ data using Analysis of Variance (ANOVA) multiple comparisons revealed no statistical differences.

DBC Total Problem Behaviour Scores

Figures 3 and 4 demonstrate mean DBC Total Problem Behavior Scores for Groups 1 and 2, and Group 3 as percentile data. Note that the clinical cut-off for the DBC-T is the 30th percentile, while the DBC-P is set at the 60th percentile. Overall, teachers noted no improvement in the boys during the music therapy period, but for Groups 1 and 2 they recorded a posttreatment improvement. Residential social workers noted improvement for Groups 1 and 2 while in music therapy which levelled off posttreatment, while the improvement in the control period for Group 3 also continued during music therapy treatment. Residential social worker scores show boys improving to below clinical cut-off point.

Aggression Within Sessions

Within session aggression was rarely observed. From a total of 4243 behavioral ‘events’ categorized during video analysis, only 13 were coded as ‘aggressive’.

Nevertheless, evidence from video data and therapist’s session notes indicate that total number of negative behaviors (Impulsive, Uncooperative, Interfering, Aggressive, Inattentive/Restless, and Antisocial/Avoidant) increased around Session 9 for all groups. Further, Groups 1 and 2 did not reduce the total number of negative behaviors they exhibited. On the other hand, despite an overall increase in negative behaviors, predominantly in the impulsivity category, Group 1 boys were more attentive, and were contributing more to group activity. In contrast, while Group 3 also demonstrated more negative behaviors around Session 9, they reduced negative behaviors in subsequent sessions and showed overall improvement in their ‘within session’ interactions, particularly on measures of impulsivity. Differences between the three groups in respect to levels of impulsivity over time were significant (p = .014). Tests for difference in levels of attention also achieved significance (p = .014) on mean scores of 5.470 (Group 1), 6.775 (Group 2), and 7.895 (Group 3). Figure 5 demonstrates the mean number of negative behaviors recorded across four sessions. Note the overall number of negative behaviors exhibited by Group 1 subjects is more than double the number recorded for Groups 2 and 3.

Discussion

A notable feature of the results of this study was the difference between ‘Teacher’ and ‘Parent’ reported change. This adds weight to the evidence in the literature that indicates that agreement between different sources is often minimal. Research suggests that ‘externalizing’ behaviors are more accurately reported by the parent(s) (Rapoport & Ismond, 1996). Children and adolescents do have a tendency to present differently across settings, which this study reinforces.

The results of this study are likely to have been significantly affected by three other factors, namely, the age and diagnostic differences between subjects in each group, and the small sample size. Group outcomes appear to be influenced by major events for individuals.

While the results from the Teacher version of the DBC indicate few consistent trends across subscales, the Parent version recorded consistent improvement across all subscales for treatment (Groups 1 & 2) and waitlist control (Group 3) groups. For the students in this study, it is likely that variations in scores between the two versions of the DBC can be attributed, at least partly, to the level of structure provided in different environments.

A highly structured behavioral approach is employed in the classroom, and the boys are given more direction and supervision. In the residential villa environment the boys naturally have considerably more ‘free’ time, and opportunity to interact with peers without adult direction. The consistent improvement across subscales of the Parent Version DBC recorded by residential villa staff suggests the music therapy program may have contributed positively to the boys’ ability to cooperate with peers in a less structured setting.

However, any such generalization was not so apparent for Group 1 boys, who all had a diagnosis of ADHD. In the classroom setting, teachers noted an increase in disruptive behaviors during the period of music therapy treatment only (see Table 2) and this finding is supported by the results of within session measures. Montello and Coons (1998), using the CBCL-T (Achenbach, 1991), which is a similar measurement tool for teachers, also found that the group which had the highest attentional problems became more disruptive after each active music therapy session. This writer would concur with their suggestion that a highly-structured approach may be more appropriate than encouraging spontaneity and creativity with boys who have ADHD, and that groups be kept small. The impression gained was that boys with ADHD might become overstimulated in a less structured situation.

Although the early music therapy sessions were highly structured, the program had intended to support the boys’ individual growth by gradually encouraging more freedom of choice, spontaneity, and creativity. Increased autonomy meant participants needed to take more individual responsibility for self and for other group members. However, the active nature of the sessions is likely to have resulted in physiological arousal, making transition back to the classroom more difficult for some boys. They possibly remained over-aroused after sessions and in their excitement were less able to cope with formal classroom work. Zillman’s 1991 research into the arousal of aggressive subjects (Cumberbatch & Humphreys, 2000, pp. 404-405) may help to explain some of the ‘deterioration’ recorded by teachers in this study. he found that physical exercise ‘energized’ aggression in a group of subjects who had been previously angered, and argued that similar effects were likely to occur with a wide variety of arousing stimuli such as loud noise and vigorous music.

Improvement Trend, Prior to and Posttreatment

It is possible that the improvement noted for Group 3 following their introduction to the study and signing of permission forms was related to awareness of the special attention being paid to them. It is feasible that the attention and anticipation of an enjoyable experience had some positive effect on their behavior. While behavioral theory would not predict this, as music participation was not contingent on good behavior, the suggestion does fit broadly within a humanistic framework. Being chosen for what might have been perceived to be a ‘special’ study, and discussing and signing information sheets and permission forms, may have facilitated the students’ early recognition of acceptance and unconditional regard from the therapist, resulting in an increase in self-esteem.

Inclusion criteria for the study required boys to have attended the school for at least a term in what may have been a spurious attempt to have them accommodated to the environment and program expectations. A continuous trend for improvement could be expected from the placement of boys into a stable and secure environment with consistent behavioral programs. The residential school environment is in effect an active treatment in itself, and it is difficult to attribute change to any particular program within the school. The teachers did record a general improvement in boys’ behavior post-music-therapy treatment, and while one might consider whether a delayed treatment effect was being observed, it is also conceivable that the music therapy sessions were in fact heightening arousal and contributing to an increase in disruptive behavior in the classroom during the treatment period. These results also imply that it could be advantageous to schedule music therapy programs to finish prior to school break times. At the same time there was no suggestion of any negative long term carryover effect. If the decrease in disruptive and antisocial behaviors recorded by villa staff was replicated in a comparable larger study, then it could be argued that such benefits would outweigh the short-term classroom disturbance. Perhaps, by the time the boys in this study returned home after school, the villa staff were able to observe effects of the music therapy treatment once arousal had settled-for example, the ability of the boys to get along with their peers in a less structured environment.

Treatment and Follow-up Period

The results suggest that apart from an increase in disruptive behaviors for Group 1 and no change in Communication Disturbance for Group 3, residential social workers rated all three groups as consistently improving during treatment across all six subscales. Further, there is a tendency for the improvement to level off or to be lost posttreatment, adding weight to the possibility that the music therapy sessions were having a positive effect on students during the period of participation in the program.

Aggression Within Sessions

For all three groups, within-session aggression was rarely observed and subjects did appear to be developing positive relationships with peers. The overall increase in negative behaviors exhibited by Group 1 seemed to be in part related to their enthusiasm for the music making tasks. They were increasingly being challenged to interact with each other, to negotiate and make group decisions without direct instruction from the music therapist. Groups were at times very busy and noisy as boys choose what the focus of their musical activity might be, and this almost certainly contributed to the higher number of impulsive behaviors displayed by the boys who have ADHD. However, they did not resort to using the aggressive responses that might be anticipated from this population. This suggests that the music therapy group is a positive environment for these adolescent boys, and the motivation to be involved enables them, to a certain extent, to regulate and manage their own behavior. Scores on the Parent version of the DBC, and direct observation of prosocial interactions between subjects in the playground raise the possibility that skills learned in a clinical setting might be transferred to other environments, particularly within a residential school.

While resident, these boys did not have the same difficulties with peer relationships encountered by other ‘mainstream’ pupils, as the boys in this study were all’in the same boat.’ This may have facilitated the development of empathy and friendships within the music therapy setting that could be generalized to villa (i.e., homelike environments). Further study would be required to determine whether any effects could be detected when boys return to their local communities, which is, realistically, where any skills that they have attained are most put to the test.

Summary and Conclusion

This study suggests that a music therapy program might help to increase adolescents’ awareness of the existence and feelings of others and to assist in the development of positive relationships with peers, at least for boys without severe attentional deficits. The trends found in this research suggest that rhythm activities may facilitate internal organization and help with impulse control, in boys who are able to attend to the stimuli. However, the within session observations and outcomes as measured by teachers, also suggest that adolescents who have ADHD may become over aroused in a creative music therapy group setting. This implies that individualized and highly structured treatment might be more effective for this population, which is in keeping with the findings of Montello and Coons (1998).

On the other hand, the additional evidence obtained from the DBC-P provides some support for the premise that music therapy might be effective in improving interpersonal relationships in less structured settings. The consistent ‘improvement’ trend recorded by residential villa staff, raises the possibility that music therapy helps adolescents with aggressive behaviors interact more appropriately with others in a less formal environment, such as a residential villa setting. This in turn suggests that, for this population, some generalization of skills to other environments might be possible. The importance of using multiple informants across settings, and multiple measures, was strongly reinforced by this research. While there are indications that the music therapy program may temporarily lead to some deterioration in classroom behavior for some boys during the period of the music therapy treatment, no carry-over effect was observed.

Although the randomization process did not produce the desired group equivalency, differences between groups and the varying responses of the groups adds weight to what is reported about the influence of ADHD on group processes. On the other hand, differences between groups with respect to age, diagnosis, numbers of participants, and other concurrent treatments raises further questions about which variables could be affecting outcomes.

No significant statistical differences were found; therefore no firm conclusions can be drawn from this study. However, social workers did record consistent improvement trends that are of clinical interest and merit further study. In addition, future study, which takes into account specific diagnoses of subjects, is also warranted.

Future Sludy

The total number of participants, and size of the groups is particularly relevant to the results of this research, as only a large treatment effect could have been identified in a study of this size. Detecting smaller effects would require larger numbers of subjects and, given the limits on the school roll, would inevitably take some years to complete.

When exclusion criteria are applied, the maximum numbers of eligible participants in any such residential settings could be expected to be small. Although this study utilized the maximum number of students who met the criteria for inclusion, the remaining small number of participants (N= 18), was problematic.

A design that utilizes multiple sites would enable greater numbers of participants, and would have the likely advantage of reducing the study period. However, a multisite-study of this type can be confounded by the variability in populations across settings, as well as differences in the way group music therapy treatment is delivered. The alternative design, making use of the same site and measuring change in several groups of participants over time in ‘waves,’ lessens the problems with regard to environmental and treatment delivery consistency, but inevitably takes much longer to complete.

The difficulties associated with the small size of this study could be addressed by a larger study incorporating a cluster design, thereby enabling allocation of subjects to more evenly matched groups. For example, it would have permitted students with ADHD to be randomly assigned across groups. However the current study, and that of Montello and Coons (1998), also suggests that music therapy treatment for students who have ADHD may need groups of smaller size and programs that are highly structured where participants are given less autonomy. This raises two questions. Firstly, do diagnostic differences influence the mode of participation in group therapy? To investigate this would require contrasting groups based, for example, on inclusion and exclusion criteria for ADHD. And secondly, how much does group size matter? Such subsidiary questions would require more complex designs and larger numbers. However, stricter inclusion criteria would limit the generalizability of any findings.

A much larger study would also be required to determine whether the number of therapy sessions provided is a variable that significantly influences outcome. Data from the parent version of the DBC indicated a possible trend toward improvement during treatment, which levelled off when music therapy finished. However, longer-term treatment risks being confounded by multiple other variables. While randomization is the most effective way of addressing this problem a large sample size is still required. Further, it would be important to consider the cost effectiveness of longer-term interventions in any such study.

Marked differences in individual scores provide some indication that group outcomes were influenced by major events for individuals. The consistent trend towards improvement recorded by residential social workers who completed the Parent Report form of the DBC raises the possibility of a Type II error, that is, while the results show no major treatment effect, a modest undetected effect may be present.

A series of single-case studies using a multiple baseline design might be particularly suitable for assessing music therapy outcomes for individual boys, and provide support for the effectiveness of music therapy for this population. The single case allows more indepth study of individual responses, and measurement of within session change.

The variability of multi-informant data found in this work indicates the importance of utilizing a multi-informant approach in future study. The results of this study suggest that subjects’ behavior varied across residential villa and school settings, which allowed a more complex, but fuller, picture of the boys’ overall functioning to emerge.

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Daphne J. Rickson

Halswell Residential College, New Zealand

William G. Watkins

Otago University, New Zealand

Daphne J. Rickson, Halswell Residential College, Christchurch, New Zealand; William G. Watkins, Department of Psychological Medicine, Christchurch School of Medicine & Health Sciences, Otago University, New Zealand.

Daphne Rickson is now at College of Design, Fine Arts & Music, Massey University, Wellington.

Daphne Rickson undertook this study towards the qualification of Master of Health Science (Mental Health), Otago University. William G. Watkins provided supervision and assistance with editing for publication. The authors would like to acknowledge Isobel Stevens, Research Facilitator, Christchurch School of Medicine for assistance with data organization; and Associate Professor Chris Frampton, Biostatistician, Christchurch School of Medicine for statistical analysis.

Correspondence concerning this article should be addressed to Daphne Rickson, Music Therapy Tutor, College of Design, Fine Arts and Music, Massey University, P.O. Box 756, Wellington, New Zealand. E-mail: ricksons@xtra.co.nz

Copyright American Music Therapy Association Winter 2003

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