©
2003 Psychiatric Times. All rights reserved.
Music Therapy With Emotionally
Disturbed Children
by David L. Hussey, Ph.D., and Deborah Layman, M.M., MT-BC
Psychiatric Times 
June 2003 Vol. XX
Issue 6
Music therapy is defined as "the prescribed use of music by a qualified
person to effect positive changes in the psychological, physical,
cognitive, or social functioning of individuals with health or educational
problems" (American Music Therapy Association, 2003). While music therapy
is closely aligned with the behavioral sciences, it is distinct in that it
bridges art with science. Two publications by Elio Frattaroli, M.D.,
(2002, 2001) illustrate the dilemma faced by modern psychiatry in trying
to understand mental illness, not only in the science of neurological
processes but also in the art of skillful healing relationships.
Music therapists are skillful practitioners who orchestrate their
talents to help soothe a wide variety of painful human conditions. While
many psychiatrists are aware of the uses of music therapy for the
treatment of autism, substance abuse, Alzheimer's disease and pain, far
fewer are aware of the exciting work that's being done with children who
have serious emotional disturbances.
Children with such disturbances have diagnosable mental health
disorders and extreme functional impairment that limit or interfere with
the ability to function in the family, school and/or community (Stroul and
Friedman, 1994). Conservative estimates from epidemiological studies
suggest that 8% to 12% of students ages 6 to 21 suffer from a significant
disability, and approximately 8%, roughly 470,000 of this population, are
identified through their schools as being emotionally disturbed (U.S.
Department of Education, 2001).
A review of the music therapy literature delineates at least three
broad domains of functioning where music therapy has been successfully
utilized in the treatment of emotionally disturbed children: affect
regulation, communication and social/behavioral dysfunction. Assessment
and intervention in each of these domains requires strong grounding in
developmental theory, a key component in the training of music therapists.
Early on, music therapy was identified as an intervention to treat
impairments in affective functioning, including reducing levels of anxiety
(Cooke, 1969), and as a tool to improve emotional responsiveness
(Wasserman, 1972). Music therapy has been well-suited to help improve
communication deficits and stimulate nonverbal communication. Numerous
positive outcomes in improving social functioning, social awareness and
cooperation (Werbner, 1966), and decreasing disruptive behaviors (Hong et
al., 1998) have been reported. One of the major contemporary applications
for music therapy is working with children who have serious emotional
disturbances and high degrees of impulsivity and limited ability to
self-regulate (Layman et al., 2002).
Some of the modalities and techniques used in the treatment of
emotionally disturbed children include live music production (e.g.,
playing instruments and/or singing), improvisation, guided imagery (e.g.,
pairing of visualization with music), creative songwriting and lyric
analysis. After a careful assessment of the child's needs and
capabilities, music therapists formulate individualized treatment plans
that include goals and measurable objectives. Music therapists reinforce
and shape targeted behaviors, while dynamically exploring underlying
feelings and issues. Music therapists who work on multidisciplinary
treatment teams often concentrate on a specific subset of treatment goals
or objectives most appropriate for music therapy intervention. These
techniques are applied in a variety of community treatment settings, as
well as in hospitals, residential treatment centers and partial
hospitalization programs. Therapy sessions with children typically last
from 30 to 60 minutes and may be structured to include individual, family
and group formats.
Rationale for Music Therapy
An advantage of music therapy is that it is an inherently
nonthreatening and inviting medium. It offers a child a safe haven from
which to explore feelings, behaviors and issues ranging from self-esteem
to severe emotional dysregulation. Music therapy techniques can be
designed to address more complex issues such as grief, abandonment or
deeply conflicted emotions. As a medium, music therapy has enormous range
and scope in targeting multiple clinical needs across the gamut of
childhood developmental stages. It can set the occasion for a child to
establish a meaningful relationship with an adult through musical play and
interaction. Music therapy can also facilitate the development of
prosocial skills, trust and feelings of positive attachment.
Developmentally, almost all children respond to music. This greatly
assists in laying a strong foundation for engaging in deeper therapeutic
work. Children's natural interest in music is enhanced by the fact that
they are occupied in stimulating motor and auditory activities more
associated with play or fun than work or therapy. The careful and
repetitious orchestration of such multisensory experiences, in the context
of a skillful and nurturing relationship, has a remarkable range of
clinical benefits.
Music Therapy Applications
The mental health care and child welfare fields are searching for
effective therapies that can be utilized with victimized children,
especially those who have comorbid disorders. The most heavily researched
psychiatric sequelae of victimization is posttraumatic stress disorder,
and its most frequently studied treatment is cognitive-behavioral therapy.
A concerning gap in the treatment literature is that many emotionally
disturbed children suffer from cognitive deficits and developmental
disabilities. Research indicates that the average IQ of child welfare
populations undergoing intensive mental health treatment is in the low- to
mid-80s (Hussey and Guo, 2002). Such intellectual and
information-processing deficits render cognitive and verbal therapies less
effective for these children than for children with higher IQs.
Fortunately, music therapy is ideally suited to help fill this gap, and
researchers are beginning to formally investigate its application. A
common dynamic that child therapists encounter is the reluctance of
traumatized children to engage in direct therapeutic work. Often, it is
particularly difficult for children with low IQs to verbally express
traumatic events, especially if the trauma occurred early in life when
verbal skills were still emerging (Robb, 1999). Because of this, indirect
and nonverbal forms of communication such as music can be highly effective
avenues for treating victimized children.
Music has the potential to bypass the defensive operations of the
higher cortical functions of the brain and move directly to the limbic
system where emotions are processed. Music is also thought to stimulate
right-brain functioning, which is associated with imagination and
feelings, especially feelings of sadness (Montello, 1999). Research has
found that early trauma affects the developing nervous system, causing
chronic states of over-arousal in traumatized children. Music is an ideal
way to help these children self-regulate and soothe as it creates a middle
ground between over-arousal and numbness and helps the child to experience
a state of stability (Montello, 1999). The immediate success that children
experience in the music therapy setting can provide a boost to self-esteem
and create a successful, nonthreatening environment in which the therapist
can help the child to decrease symptoms of arousal or disinhibition.
The robust conceptual framework of music therapy affords tremendous
flexibility and range of application. Music provides a curative mechanism
for abused children to use symbols (e.g., sounds) to externalize their
internal world and process overwhelming emotional material from a safer
distance. This externalization process can serve as a vehicle of gradual
exposure, whereby children naturally, and at their own pace, encounter,
organize and better manage their dysregulated affects and anxieties.
Music therapy is also a powerful tool for helping children in foster
care (Layman et al., 2002), particularly as they negotiate issues related
to attachment and loss. While most of these children have been placed in
foster care due to abuse or neglect, many have also experienced multiple
early significant disruptions in their primary caregiver relationships.
Such disruptions severely impair children's capacities to form trusting
relationships and can lead to the development of a spectrum of
attachment-disordered behaviors. Music therapy has been utilized to
promote the establishment of trust and the development of reciprocal
interactions (Hong et al., 1998). Music improvisation, for example,
provides children with a nonverbal way to connect with the music therapist
as a means of establishing a safe, therapeutic relationship.
Creativity is required by the music therapist in order to adapt the
broad range of treatment techniques to the individualized needs and
presentations of the child. As children practice and gradually acquire new
relational and behavioral skills, they are helped to transfer these skills
to other relationships, such as adoptive parents or foster caregivers,
that are outside the music therapy context and into their natural
environments.
Case Example
"Sarah" was a 9-year-old African-American female with a history of
sexual abuse, neglect and abandonment. The focus of her music therapy
treatment addressed self-regulation and prosocial skill development. Music
therapy sessions included improvisation, lyric analysis, live music
production and songwriting. The structure of the sessions was
activity-based and included use of visual aids to create a concrete and
multisensory process.
The "Feelings Faces" improvisation activity used with Sarah explores
musical expression of feeling states to encourage development of a
feelings vocabulary. Pictures of actual people, each with a different
affect (e.g., happy, sad, mad, scared), were first viewed and discussed.
Then, Sarah and the music therapist took turns selecting a "feelings face"
and improvising music on the piano that matched that feeling state. Each
took turns guessing what feeling was being musically expressed. Sarah
played loudly and aggressively to portray a mad feeling and softly to
portray a sad feeling. The therapist encouraged Sarah to discuss and
process circumstances and events in her life that contributed to these
different feeling states.
"Helping Hands" is a more advanced lyric analysis activity that helped
Sarah decrease her aggressive behavior and increase prosocial behavior.
Printed lyric sheets of the song "Hands" by the recording artist Jewel
were distributed, along with blank sheets of paper. Sarah was encouraged
to follow the lyrics and actively listen to the meaning of the song. The
recording was then played a second time (at a lower dynamic level), and
Sarah was directed to trace around each of her hands on the blank sheets
of paper. She was then asked to write or draw on each finger of her left
hand one way in which she could use her hands to help others (e.g.,
handshake, kind touch, wave hello, help with chores). She was asked to
write or draw on each finger of her right hand one way in which hands
could be used to hurt others (e.g., hit, push, grab). Sarah and the
therapist examined ways to use hands to help others and how to avoid using
hands for hurtful behaviors. Sarah's foster mother used a sticker token
economy to reinforce the times when Sarah used her hands in helpful ways.
Future Directions
As the evidence supporting the utility and effectiveness of music
therapy continues to accumulate, stronger research designs are needed to
directly compare music therapy with other child therapies. The rigor of
this type of testing is at the core of the evidence-based practice
movement. In addition, the next generation of music therapists will
pioneer the integration of music with multimedia treatment methods and
computer-assisted technologies. These emerging technological capacities
will provide new and innovative instruments for music therapists to use in
modern psychiatry's struggle to "heal the soul in the age of the brain."
Dr. Hussey is assistant professor in the department of justice
studies at Kent State University and faculty associate at the
Institute for the Study and Prevention of Violence.
Ms. Layman is a music therapist at Beech Brook Campus in
Cleveland.
References
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Frattaroli E (2001), Healing the Soul in the Age of the Brain: Becoming
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Frattaroli E (2002), Healing the Soul in the Age of the Brain: Why
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