Journal of Music Therapy, Volume 40, Number 4, Winter 2003

Transcription

ISSN 0022-2917
JOURNAL. OF
MUSIC THERAPY
Winter 2003
Vol. XL No. 4
EDITOR
JAYNE M. STANDLEY
The Florida State University
ASSOCIATE EDITOR
BUSINESS MANAGER
SUZANNE RITA BYRNES
Kansas City. MO
ANDREA FARBMAN
AMTA National Office
EDITORIAL COMMITTEE
KENNETH S. AIGEN
Nordoff-Robbins Center at New York
University
MARY E. BOYLE
State University of New York at New Paltz
WARREN BRODSKY
Ben-Gurion University of the Negev
DARLENE M. BROOKS
Temple University
MELISSA BROTONS
Generalitat de Catalunya
KENNETH E. BRUSCIA
Temple University
JANE W. CASSIDY
Louisiana State University
MICHAEL D. CASSITY
Drury University
NICKI S. COHEN
Texas Woman's University
CYNTHIA M. COLWELL
University of Kansas
ALICE-ANN DARROW
WILLIAM B. DAVIS
Colorado State University
ANTHONY DECUIR
Loyola University
SHANNON K. DE L'ETOILE
University of Miami
WAYNE E. COINS
Kansas State University
MICHELE A. GREGOIRE
Flagler College
DIANNE GREGORY
ROBERT GROENE
University of Missouri-Kansas City
NANCY A. HADSELL
Texas Woman's University
MICHELLE J. HAIRSTON
East Carolina University
SUZANNE B.HANSER
Berkiee College of Music
CAROLYN KENNY
University of California
CAROL PRICKETT
University of Alabama
ALAN L. SOLOMON
State University of New York at Potsdam
This paper meets the requirements of ANSI/NISO Z39.48-1992 (Permanence of Paper).
Journal of
music therapy
CONTENTS
Vol. XL No. 4
Winter 2003
ARTICLES
Sheri L. Robb 266
Daphne J. Rickson
William G. Watkins
283
Music Interventions and Group
Participation Skills of Preschoolers with
Visual Impairments: Raising Questions
about Music, Arousal, and Attention
Music Therapy to Promote Prosocial
Behaviors in Aggressive Adolescent
Boys—A Pilot Study
Nancy A. Jackson 302 A Survey of Music Therapy Methods
and Their Role in the Treatment of Early
Elementary School Children with ADHD
Simon K. Gilbertson 324 Searching PubMed/MEDLINE, Ingenta,
David Aldridge
and the Music Therapy World Journal
Index for Articles Published in the
Journal of Music Therapy
345
Index to Volume XL (2003)
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Journal of Music TTierapy, XL (4), 2003, 266-282
© 2003 by the American Music Therapy Association
Music Interventions and Group
Participation Skills of Preschoolers with
Visual Impairments: Raising Questions
about Music, Arousal, and Attention
Sheri L. Robb, PhD, MT-BC
University of Missouri-Kansas City
The purposes of this pilot study were two-fold: First, to doc
ument and compare attentive behavior during music and
play-based group instructional sessions and second, to doc
ument and compare 4 group participation behaviors during
music and play-based sessions. The 4 group participation
behaviors included facing a central speaker, following one
step directions, manipulating objects according to their func
tion, and remaining seated. Six of the 12 children enrolled
completed the study, with all participants enrolled in an early
intervention program due to visual impairments. Study par
ticipants were between the ages of 4 and 6 years inclusively.
Children participated in 4, 30-minute instructional sessions.
Two instructional sessions were music-based and two were
play-based with the 4 sessions equally distributed across a
2-week period. An ABBA design was used to control for
possible order effects. Each session was videotaped to facil
itate collection of behavioral data. Statistical analysis of these
data revealed that attentive behavior was significantly higher
during music based-sessions (i(5) = 5.81; p = .002). Mean
scores for the remaining group participation behaviors were
higher in the music condition, but these differences were not
statistically significant. Discussion regarding differential out
comes among participants, as well as an exploration of theo
ries related to music, arousal, and attention are discussed in
an effort to guide future research.
The author would like to thank Barbara Gunderman and Suzi Kilbride, teachers
at the Children's Center for the Visually Impaired (CCVI), as well as the staff, stu
dents, and families at CCVI for their participation and support of this project.
Vol. XL, No. 4, Winter 2003
267
Social skills used by children and adults are learned incidentally
through observation and modeling. In fact, 85% of what sighted in
dividuals learn is learned through the eyes (Children's Center for
the Visually Impaired, 2000). In contrast, interpreting expressive
gestures, comprehending words and phrases that are heavy with vi
sual imagery, and reading other nonverbal cues can be difficult for
persons with visual impairments. As young children, sighted indi
viduals acquire social skills through interactions with their peers.
Mere physical integration, however, does not result in interaction
and acquisition of important social skills for children with visual
impairments. Social skills' training for children with visual impair
ments requires careful manipulation of the environment and the
use of specific intervention strategies. Most social skill research has
involved school-age children in integrated environments, with an
even higher frequency of research with adolescents and adults. De
spite the lack of research with young visually impaired children, the
professional literature emphasizes the importance of early inter
vention for social skills development (Best, 1992; Erwin, 1993;
Loumiet & Levak, 1993, O'Donnell & Livingston, 1991; Parsons,
1986; Raver & Drash, 1988; Rogow, 1999; Sacks, Kekelis, & GaylordRoss, 1992; Workman, 1986).
Structuring opportunities for preschoolers with visual impair
ments to participate in small group activities affords them the
chance to practice group interaction skills. A prerequisite for
group participation is the ability to attend to central activities for a
sustained period. Sighted children use their vision to maintain fo
cused and sustained attention. Children with vision impairments
must concentrate on an activity primarily through listening. Given
that a child with impaired vision must rely on auditory and tactile
cues, sitting in a traditional group environment can be challeng
ing. Sustained and focused attention can also be difficult when
there are auditory distractions in the environment (Best, 1995; Ro
gow, 1984; Warren, 1994). If the group instructional environment
is too confusing or uninteresting, the child may look inward for
stimulation. Best (1995) indicates that the task of listening can be
made easier if the relevant sounds of an activity stand out from a
plain background.
It is important to remember that attention is a mediating
process. Sustained attention is an important prerequisite to learn
ing, but children must also exercise selective attention which re
268
quires that the child learn to identify which stimuli warrant atten
tion and direct their attention accordingly. As children's attention
becomes more organized, they are better able to learn and more
effectively encode information. Music is an auditory and vibrotac
tile medium that therapists use to enhance children's attention; ad
ditionally, music has effectively been used to structure acquisition
and rehearsal of socialization skills (Gfeller, 1999; Jellison, 2000;
Thaut, 1999).
Researchers have documented the effective use of music to en
hance children's attentiveness, especially when interventions and
instruction involve the use of participatory activities (Forsyth, 1977;
Madsen & Alley, 1979; Sims, 1986; Standley & Hughes, 1996).
Preschool children, in a study by Standley and Hughes (1996),
demonstrated a high level of attentive behavior during music therapy
sessions. Children in this study were able to sustain attentive on
task behavior for approximately 97% of the session's duration. Ad
ditionally, children experienced a high level of success, responding
correctly to teacher directed tasks with greater than 90% accuracy.
Music has also been used as a structure to elicit specific social
behaviors from children, creating an environment where children
can learn and practice important social skills (Gunsburg, 1988;
Hughes, Robbins, McKenzie,& Robb, 1990; Humpal, 1991; Stand
ley & Hughes, 1996). Gunsburg (1988) developed a technique, Im
provised Musical Play (IMP), to sustain the duration of preschool
children's play. Using this technique, the author was able to sustain
children's episodes of play and promote interaction between chil
dren with and without disabilities. In 1991, Humpal developed an
integrated music program to increase social interactions among
children with disabilities and their typical peers. Through age
appropriate interactive music activities, the author used a series of
systematic prompts to encourage interaction and provide a milieu
for practicing these skills. Outcomes revealed an increase in initi
ated social interactions from the pre to postintervention period.
A common thread among these music therapy programs is the
systematic manipulation of the music environment. In these stud
ies, music therapists manipulated the learning environment in sev
eral ways. First, the music was systematically manipulated to solicit
an identified behavior and structure the desired response. Second,
age-appropriate and interactive music activities were used to pro
mote children's participation. Finally, the therapist designed inter
269
ventions to afford children multiple opportunities to practice the
identified skill or behavior. Educators and researchers in the fields
of early intervention and visual impairment have documented the
need for structured interventions to promote the acquisition of so
cial skills. The aforementioned studies support the efficacy of music
therapy interventions to address the development of social skills.
Music therapy studies cited in this review of literature involved
preschool-age children with varying disabilities. To date, research
specific to early intervention with visually impaired children is lim
ited. A comprehensive review of music therapy literature for blind
and severely visually impaired persons, conducted by Codding
(2000), provides summative information for 27 data-based research
studies and 17 case studies. Of the 27 data-based research studies,
only 3 studies involved children under the age of 6. Topics investi
gated in these studies included differences in the use of music
related language by blind and sighted students (Flowers, 1999), an
examination of sound levels in the learning environment (Graham
& Eraser, 1992), and music to promote orientation and mobility
skills (Vise, 1972).
The need for additional music therapy research in early inter
vention, specific to children with visual impairments is evident.
Additionally, Standley and Hughes (1996) called for further re
search to contrast music therapy curricular substance with other in
structional activities. Although this study does not contrast cur
ricular content, it does compare the efficacy of music-based and
nonmusic based instruction to sustain attentive behavior and in
turn engage children in the rehearsal of identified skills. Specifi
cally, this study (a) documents and compares student's attentive be
havior during music and nonmusic small group activities and (b)
documents and compares students' ability to independently exe
cute specific group participation skills during music and nonmusic
small group activities.
Method
Study Design
The investigator used a within subjects repeated measures de
sign, allowing subjects to act as their own controls. This design was
necessary and served as a viable alternative to randomly assigned
groups given the small sample size, range of ages, and heteroge
neous nature of children's visual impairments—with several chil
270
dren having multiple disabilities. Children, whose parents provided
informed consent, participated in four 30-minute instructional ses
sions. Instructional sessions occurred over 4 days; two instructional
sessions were music-based and two were play-based. Each session
was videotaped to facilitate the collection of behavioral data. An
ABBA design was used to control for possible order effects.
Participants
This study solicited the participation of 12 children enrolled in
two preschool classrooms at an early intervention program for chil
dren with visual impairments. Of the 12 children enrolled, 6 com
pleted all four sessions. Children were between the ages of 4 and 6
years inclusive and each child had been diagnosed with a visual im
pairment (see Table 1). Prior to their participation in the study,
parents were informed of the study's purposes and interventions.
Measurements
Based on a review of related literature, the investigator identified
five group participation skills that are important for the success of
children with visual impairments in the classroom environment
(Loumiet & Levak, 1993). These skills included attentive behavior,
following one-step directions, remaining seated, facing a speaker
(i.e., orienting one's body to the central speaker or central ac
tivity), and functional object manipulation.
Observational measures. The researcher videotaped each instruc
tional session to facilitate the collection of behavioral data. A time
sampling data collection method, with 10-second observe/5-second
record intervals, was used to evaluate participant's attentive behav
ior, as well as frequency and level of independence in executing
specific group participation skills. Attentive behavior was measured
using the Student On-Task Observation Form (Madsen & Madsen,
1983). Attentive behavior was defined as verbal and motor behavior
that conforms to rules for group participation (i.e., remaining
seated, keeping hands to self) and remaining engaged in and ori
ented toward the central learning activity (i.e., listening during ver
bal directives, playing instruments at appropriate time, moving
body as requested, etc.).
Performance on the remaining four group participation skills,
following one-step directions, remaining seated, facing the central
speaker, and functional object manipulation, was measured using a
271
TABLE i
Student Demographics
Participant
Age
Gender
PI
6 yrs. 2 mo.
P2
6 yrs. 6 mo. Female
P3
4 yrs. 5 mo.
Male
P4
P5
P6
6 yrs. 3 mo.
5 yrs. 10 mo.
6 yrs. 4 mo.
Male
Male
Male
Male
Visual impairment
Cortical Visual Impairment
Blind; one prosthetic eye
Bi-lateral Retinoblastoma
Nystagmus
Nystagmus
Additional disabilities
Cerebral Palsy
Hydrocephalus
Autis tic-like
tendencies
None Documented
Cerebral Palsy
None Documented
Traumatic Brain
Injury
time sampling data form designed by the author (see Table 2).
This data form was designed to measure four independent molec
ular behaviors, which are defined as single observable behaviors.
These behaviors were not used to make conclusions about unob
servable constructs; therefore, content and construct validity were
not an issue. Criterion validity for a low inference molecular mea
sure is a measure of observer accuracy; therefore, reliability served
to ensure criterion validity for this coding form. Criterion validity
was based on the degree of agreement between observers when
making independent observations of the same behavior (Pelle
grini, 1996; Suen & Ary, 1989).
Using sample videotapes, two observers blind to the purpose of
the study were trained in time-sampling procedures. Training con
tinued until intraobserver reliability reached a minimum criterion
of .85 for both coding forms. Reliability was computed using an in
dex of concordance (sum of agreements -r sum of agreements + dis
agreements). To ensure consistency between both observers, inter
observer reliability checks were conducted on 20% of all session
material coded. Twenty percent of the total observations, there
fore, were subjected to evaluation by both observers. Reliability be
tween the coded scores of the observers were computed using an
index of concordance and remained at a minimum criterion of .85.
Procedures
The investigator designed two 30-minute small group instruc
tional sessions. One session was music-based and involved singing,
instrument play, and movement. The other session was nonmusic
272
TABLE 2
Observational Coding Form—Specified Group Participation Behaviors
Participant's Initials:
Group Participation Coding Form
Tape Number:
Coder's Name:
0:10
Child facing the
central speaker,
activity, or person
he/she is inter
acting with during
the interval
(Code Majority)
0:15
0:25
0:30
0:40
0:45
0:55
1:00
+
+
+
+
-
-
-

Followed one-step
directions
+
VP
PP
VP
PP
VP
PP
VP
PP
Manipulated
materials according
to their function
(Code Majority)
+
VP
PP
—
VP
VP
VP
PP
PP
PP
+
+
+
+
-
-
-

Seated
(Must occur for
duration)
+ = behavior occurred as an independent response.
- = behavior did not occur.
VP = child required verbal prompting to execute the skill.
PP = child required physical prompting or full physical assistance to execute the skill.
based and involved the use of structured games and interactive sto
ries. Each instructional session was designed to have similar con
tent, the primary exception being the presence or absence of mu
sic. For example, in the music-based session a song was used to
communicate what each child should do sequentially when using a
social greeting. The song also structured rehearsal of this skill. In
the nonmusic, play-based session, similar information was dissemi
nated verbally and greetings practiced in a game format.
Children in two classrooms participated in the proposed study.
Each classroom experienced four instructional sessions. Two ses
sions were music-based and two were play-based. The study used a
within subjects repeated measures design to compare participant's
attentive behavior and ability to independently execute the four
specified socialization skills during these two conditions. On days 1
273
and 4, participants experienced the play-based instructional ses
sion. On days 2 and 3, participants experienced the music-based in
structional session.
No-music, play-based-sessions. On days 1 and 4, the investigator ar
rived at the classroom 10-minutes before the instructional session
to set up two video cameras and arrange materials for the session.
The investigator began the session with the following statement,
"Today, we will be playing some games together." The investigator
then proceeded to implement the no-music, play-based protocol.
At the conclusion of the session, the investigator collected all ma
terials and video equipment.
Music-based sessions. On days 2 and 3, the investigator arrived at
the classroom 10-minutes before the instructional session to set up
two video cameras and arrange materials for the session. The in
vestigator began the session with the following statement, "Today,
we will be making some music together." The investigator then pro
ceeded to implement the music-based protocol. At the conclusion
of the session, the investigator collected all materials and video
equipment.
Results
Mean scores and standard deviations for each behavioral cate
gory are summarized in Table 3. Descriptive and graphic analyses
of these data revealed higher mean scores for all behavioral mea
sures during the music condition.
A paired samples t-test was computed to compare attentive be
havior scores during music and play-based instructional sessions.
Outcomes from the t-test indicated that attentive behavior was sig
nificantly higher during music-based sessions than during play
based sessions (t(5) = 5.81, p = .002). Statistical analyses of group
participation skills including, facing a central speaker, following di
rections, manipulating objects according to function, and remain
ing seated were not found to be significantly different during each
condition (Table 4).
A majority of the participants, five of the six enrolled, demon
strated equal or improved performance on all measures during
music-based sessions. Post hoc analysis of individual participant
scores indicated that three students with multiple disabilities (PI,
P2, & P4) demonstrated higher mean difference scores than their
peers (P3, P5, & P6) on several measures during the music condi
274
TABLE 3
Means and Standard Deviations by Group and Variable
Condition/variable
Face/Play
Face/Music
Directions/Play
Directions/Music
Manipulation/Play
Manipulation/Music
Seat/Play
Seat/Music
Attn. Beh./Play
Attn. Beh. /Music
M
SI)
63.50
83.70
63.83
75.83
68.30
84.90
86.00
91.75
69.50
86.83
33.79
18.35
29.83
17.61
N
5*
5
6
6
5*
5*
4**
4
6
6
36.59
14.77
9.77
8.87
20.05
16.97
*P4 was not coded on this skill area due to physical limitations. **P4 & PI were not
coded on this skill due to physical limitations.
tion (see Figures 1-6). Although all participants demonstrated
gains in the area of attentive behavior, Participants 1, 2, and 4
demonstrated some dramatic changes in their performance in the
areas effacing a central speaker, following one-step directions, ma
nipulating objects according to their function, and remaining
seated.
Participant 1 demonstrated dramatic differences in his mean
scores for facing a central speaker (M= 91.0; 45.0), following one
step directions (M= 68.0; 39.0), manipulating objects according to
their function (M= 62.0; 12.0), as well as attentive behavior (M =
96.0; 73.0) with the music condition producing optimal outcomes
(see Figure 1). An examination of means scores for Participant 2
also revealed notable differences in performance in the areas of
facing a central speaker (M= 56.0; 16.0), following one-step direcTABLE 4
Paired Samples t-test by Condition and Dependent Variable
Paired sample
Face speaker/Play - Music
Directions/ Play - Music
Manipulation/Play Music
Seated/Play - Music
Attn. beh./Play Music
M
-20.20
-12.00
-16.60
-5.75
-17.33
SD
SKM
20.98
14.73
25.75
6.54
2.98
9.38
6.01
11.52
3.27
2.98
*statistically significant p<.001; «(5) =-5.8l,p= .002.
t
-2.15
-2.00
-1.44
-16.15
-5.81
•tf
4
5
4
3
5
p (2-tailed)
.098
.103
.223
.177
.002*
275
Directions
Manipulate
Behavioral Category
FIGURE i.
Mean scores: Participant 1.
tions (M = 56.0; 34.0), manipulating objects according to their
function (M= 85.0; 51.0), and attentive behavior (M= 58.0; 41.0;
see Figure 2). Participant 4 also demonstrated notable gains in fol
lowing one step directions (M= 63.0; 39.0; see Figure 4).
Participants 3, 5, and 6 had less notable gains in these areas with
Participant 3 demonstrating diminished performance during the
Directions
Manipulation
Behavioral Category
FIGURE 2.
276
Facing Speaker
Manipulation
Behavioral Category
FlGURH 3.
music conditions for manipulating objects according to function
and following one-step directions (see Figures 3, 5, and 6). Inter
estingly, Participants 1, 2, and 4 had disabilities in addition to their
visual impairment including cerebral palsy and autistic-like ten
dencies; whereas Participants 3 and 5 did not have any docu
mented secondary disabilities.
Behavioral Category
FlGURK 4.
277
Manipulation
Behavioral Category
FlGURK 5.
Discussion
In this study, music functioned to significantly increase attentive
behavior in a group instructional setting. Attentive behavior was
denned as the student exercising impulse control by remaining
seated and maintaining their personal space, as well as engaging in
Manipulation
Behavioral Category
FIGURE 6.
Mean scores: Participant (5.
278
activities as specified by the group leader. Attending or attentive
behavior is considered a necessary prerequisite skill for learning
and success in the mainstream classroom environment, but per
haps of equal or greater importance will be the visually impaired
student's ability to exercise selective attention in the learning envi
ronment (Best, 1992; Loumiet & Levak, 1993).
Although attention as a construct was not directly measured in
this study, these preliminary outcomes raise questions about how
music functioned to solicit increased attentive behaviors in these
participants. Perhaps even more intriguing are the differential out
comes for students with only vision impairments when compared
with outcomes for students with multiple disabilities. In order to
fully explore hypotheses regarding these outcomes, it is important
to consider research literature in the areas of attention, arousal,
and music perception. An exploration of these areas will serve to
develop follow-up studies that more directly examine questions re
garding the use of music to affect arousal and attention in children
with vision impairments.
Attention is a complex construct that cannot be explained or de
fined by a single dimension. Plude and colleagues (1994) point to
three dimensions of attention that have been distinguished through
empirical research including arousal, capacity, and selectivity. Music
may have functioned in this study to increase attentive behavior by
soliciting optimal levels of arousal in the participants. Arousal is de
fined as momentary excitation or alertness in the information pro
cessing system (Plude, Enns, & Brodeur, 1994), and is an important
mediator for attentive behavior; therefore, arousal should be con
sidered when examining outcomes from this initial study.
In his discussion surrounding neuropsychological processes in
music perception, Thaut (2002) notes that psychophysiological re
search has demonstrated that centers in the brain responsible for
controlling hedonic responses and fluctuations in arousal overlap
in the limbic system. These same centers of the brain are also acti
vated when processing music stimuli. Given that processing of mu
sic stimuli occur in the same centers of the brain associated with
emotion, arousal, and pleasure, it would appear reasonable to con
sider that in this study, music may have functioned to induce opti
mal levels of arousal in participants. In their review of literature,
Husain and colleagues (2002) cite numerous studies that have es
tablished the impact of music on arousal. Additionally, research lit
279
erature has documented the influence of arousal on performance,
with optimal performance occurring during intermediate levels of
arousal and low and very high levels of arousal resulting in dimin
ished performance—otherwise referred to as Yerkes-Dodson law
(Beh & Hirst, 1999; Hallman, Price, & Katsarou, 2002; Yerkes &
Dodson, 1908; Yoon, 1997; Yoon, May,& Hasher, 2000).
Husain and colleagues (2002) propose an arousal-mood hypoth
esis that suggests that listening to music affects arousal and mood,
which in turn influences performance on a variety of cognitive
tasks. In their study, Husain and colleagues (2002) demonstrated
that manipulations in musical tempo affected arousal but not
mood in the listener; however, manipulations of mode affected
mood but not arousal. Additionally, the authors found that perfor
mance on a spatial task was enhanced when listeners were moder
ately aroused and in a pleasant mood state. Given that music can
directly impact arousal, with optimal levels of arousal increasing
performance on certain cognitive tasks, it would appear prudent to
conduct additional studies that examine the relationship between
arousal and changes in attentive behavior to determine if arousal
was the mediating variable responsible for significant changes in at
tentive behavior observed in these study participants. Another im
portant consideration that may point to the role of arousal were be
havioral scores for "facing a central speaker". These data indicate
that participants were able to more effectively orient themselves to
the central stimulus during the music condition. This type of overt
orientation to an external stimulus is referred to as "orienting" and
represents a more basic component task of selective attention
(Pludeetal., 1994).
The ability to exercise selective attention is of monumental im
portance for children with visual impairments, as they must filter
out extraneous and competing stimuli in order to attend and process
information embedded in a central learning task. It would appear in
this study that participants were able to physically orient to a central
stimulus more readily in the music condition; however, confirmation
that participants were orienting cognitively and effectively filtering
information cannot be determined from this study.
The attentional task of "orienting" involves the filtering of only
one type of information—spatial information (Plude et al., 1994).
Behavioral data from this study indicate that all participants suc
cessfully oriented their body position more effectively to a central
280
music stimulus over a play based stimulus. The attentional task of
"filtering"; however, refers to the processing of certain attributes of
an object or stimulus to the exclusion of other attributes. Addi
tional studies that directly examine filtering as a component of se
lective attention would be a valuable contribution, given that filter
ing sensory information can be especially challenging for children
with visual impairments.
In summary, these initial outcomes indicate that music had a pos
itive influence on these study participants' ability to demonstrate at
tentive behavior in a group instructional environment. These out
comes also appear to be congruent with theories concerning
relationships among music, arousal, and attention; however, addi
tional studies that directly examine how music functions to influ
ence visually impaired students' levels of arousal and performance
on selective attentional tasks, as well as vigilance tasks in a controlled
experimental environment will be necessary before any conclusions
can be drawn about the efficacy of music to sustain attention and fa
cilitate selective attention in children with visual impairments.
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Children's Center for the Visually Impaired. (2000). Opening new doors [Brochure].
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Journal of Music Therapy, XL (4), 2003, 283-301
Music Therapy to Promote Prosocial
Behaviors in Aggressive Adolescent
Boys—A Pilot Study
Daphne J. Rickson
Halswell Residential College, New Zealand
William G. Watkins
Otago University, New Zealand
This pilot study was undertaken to investigate whether music
therapy is effective in promoting prosocial behaviors in ag
gressive adolescent boys who have social, emotional, and
learning difficulties. Fifteen subjects (aged 11-15 years), en
rolled at a special residential school in New Zealand, were
randomly assigned to music therapy treatment groups (r\ - 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 in
cluded 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
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 Univer
sity, Wellington.
Daphne Rickson undertook this study towards the qualification of Master of
Health Science (Mental Health), Otago University. William G. Watkins provided su
pervision and assistance with editing for publication. The authors would like to ac
knowledge Isobel Stevens, Research Facilitator, Christchurch School of Medicine for
assistance with data organization; and Associate Professor Chris Frampton, Biostatis
tician, Christchurch School of Medicine for statistical analysis.
Correspondence concerning this article should be addressed to Daphne Rick
son, Music Therapy Tutor, College of Design, Fine Arts and Music, Massey Univer
sity, P.O. Box 756, Wellington, New Zealand. E-mail: [email protected]
284
others in a residential villa setting, but might also lead to a
temporary mild increase in disruptive behavior in the class
room. 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 ag
gressive adolescent boys, in classroom and residential villa settings.
While there appears to be considerable anecdotal evidence point
ing to the potential advantage of group music therapy with adoles
cents, there is an extreme paucity of recent music therapy litera
ture 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 dys
rhythmia (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 in
dependently 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 se
curity, can help with the control of impulses (Bruscia, 1987).
Eidson (1989) examined the effects of a behavioral music ther
apy 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 con
trol subjects. In the same year Haines compared two active treat
ments (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 diagno
sis of Conduct Disorder, Kivland (1986) documented an increase of
prompted positive self-statements following individual music ther
apy sessions. Similarly, although significance was not achieved,
Henderson (1983) found that hospitalized adolescent psychiatric
285
patients in music therapy programs had a trend towards improving
more than controls, on measures of self-esteem. Thaut (1989) mea
sured self-perceived changes in states of relaxation, mood/emo
tion, and thought/insight in psychiatric prisoner-patients before
and after music therapy. The three different music therapy tech
niques used in this study all proved to be successful in changing the
prisoner-patients' self-perceived states of relaxation, mood/emo
tions, and thoughts about self and one's own life.
Montello and Coons (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 be
havioral 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 inter
vention, particularly on the aggression/hostility scale. They there
fore argued for future research to discriminate between external
izing 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 dur
ing 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 treat
ment 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 ex
ternalizing behaviors. Further, the music therapy treatment ses
sions 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 re
ducing 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
286
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 At
tention Deficit Disorder (ADD) or Attention Deficit Hyperactivity
Disorder (ADHD), four of General Developmental Delay, and one
each of Head Injury and Depression. Five of the boys with ADD or
ADHD had a dual diagnosis including Oppositional Defiant Disor
der (ODD) or Conduct Disorder (CD) according to DSMIV criteria
(APA, 1994). Half of the boys (n= 9) were taking psychotropic med
ication, 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 ran
domly 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 be
gan. A second withdrew after attending only 10 minutes of one ses
sion and a third was suspended after one music therapy session
only, because of severely disruptive and aggressive behavior in the res
idential villa environment. Fifteen subjects therefore completed mu
sic 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 (DEC). The potential effects of
the music therapy program on aggressive behavior were measured
using the subscales of disruption and antisocial behavior in the De
velopment Behaviour Checklist (DEC), (Einfeld & Tonge, 1994).
Although the Child Behavior Checklist 'CBCL' was used for initial
287
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, act
ing 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 Anxi
ety. 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 pre
sented as a percentage of total number of events for each session. To
assess rater reliability a second rater was employed to view the video
tape 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 ad
ditional analysis to determine the extent of the differences be
tween all three groups. DBC data were tested using analysis of vari
ance 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 approxi
mately 30-45 minutes, twice a week, during Term 3, 2001. A wait
288
listed group of control subjects were offered music therapy inter
vention 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 activi
ties were varied from the initial planning documents according to
client responses. Early sessions provided clear structure and con
trol to meet the needs of subjects. However, by session 4 onwards
they were gradually invited to take more responsibility for them
selves 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 ac
tivity, recognition of themselves as valuable group members would
increase. Finally, the groups were to provide a setting for peer rela
tionships to develop based on respect and trust.
The activities included:
1. Bringing self selected music. During initial sessions, each stu
dent 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 encour
aged to support other group members, as well as to 'solo.' En
gagement 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 lis
ten to the creative sounds of their peers, to ask for and to re
ceive instruments in a respectful manner, to offer, pass and re
spond to requests for instruments from peers.
289
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 pat
tern 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 encour
aged 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 en
tailed, they were encouraged to make their own group decisions re
garding which activities they would undertake in a session. How
ever, 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 ap
propriate 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. Analy
sis 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
(£=.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 diag
nosis. Statistical analysis (Pearson Chi-Square) revealed a signifi
cant difference (p = .044) between groups. When the test was re
peated with Groups 1 and 2 combined, the difference was nearing
significance (p = .077).
290
TABLE i
Raw Data far DEC Parent Version
Subscale
Disruptive
(Dis)
Self-absorbed
(SA)
Communication
disturbance
(CD)
Anxiety
(Anx)
Autistic R.
(AR)
Antisocial
(And)
Group
Baseline
Music
Follow-up
i
21.000
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
23.400
26.250
7.000
6.200
7.500
5.333
4.200
3.500
8.333
6.000
9.000
5.000
5.000
5.250
2.667
3.000
1.750
22.000
16.400
20.333
17.800
5.333
3.000
6.833
4.600
3.500
2.000
3.333
2.800
6.500
3.400
7.167
4.400
2.833
3.400
3.000
4.200
1.833
2.200
2.167
2.000
Baseline 2
Music
20.250
17.500
3.750
2.500
1.500
1.500
5.750
4.750
4.750
3.250
2.000
1.000
Key to Reading Data & Graphs
The DBC measures negative behaviors, and treatment aims to fa
cilitate 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 dot
ted 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 sub
scale 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 treat
ment across all six subscales. Teachers, however also rated Group 1
boys as more disruptive during music therapy treatment, and further,
291
TABLE 2
Raw Datafor DEC Teacher Version
Subscale
Disruptive
(Dis)
Group
Baseline
Music
Follow-up
1
12.333
14.400
13.250
3.333
2.600
1.500
1.333
2.800
0.500
3.833
2.400
2.250
3.667
1.800
3.250
0.833
2.400
0.500
15.167
12.600
7.833
15.200
2.667
2.400
1.500
4.200
1.833
3.400
0.667
3.400
4.333
2.600
2.000
5.800
2.167
3.200
1.000
4.000
1.333
2.000
0.333
1.400
2
3
Self-absorbed
(SA)
Communication
disturbance
(CD)
Anxiety
. (Anx)
Social relatmg
(SR)
Antisocial
(Anti)
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
Baseline 2
Music
12.250
10.750
1.250
1.500
1.250
.500
2.500
2.750
4.250
5.250
1.500
0.500
noted an increase in Communication Disturbance in Groups 1 and
2, and Anxiety across all three groups. Scores were higher post
treatment on Self Absorbed Subscale for Group 3, and Social Re
lating Subscales for Groups 2 and 3. The DEC subscales that are of
particular relevance to this study are those measuring 'Disruptive'
and 'Antisocial' Behavior.
DEC Disruptive Behaviour Subscales
On the Disruptive subscales (Figure 1), percentile scores re
corded by teachers show slight deterioration in classroom behavior
for treatment Groups 1 and 2 during the period of the music ther
apy, while 'controls' in Group 3 continued a trend toward im
provement which had begun prior to music therapy intervention.
Residential social workers who completed the parent version of the
DEC 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 behav
iors for Groups 1 and 2, which levelled off posttreatment.
292
DISRUPTIVE BEHAVIOUR SUBSCALE.
TEACHER VERSION
DISRUPTIVE BEHAVIOUR SUBSCALE,
PARENT VERSION
T1
TESTS OVER TIME
T2
T3
TESTS OVER TIME
FIGURE i.
Disruptive subscales, teacher and parent versions.
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 work
ers show a stronger improvement trend for Groups 1 and 2 while in
treatment, which levelled off when the music therapy program fin
ished. 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.
ANTISOCIAL S U B S C A L E . TEACHER
ANTISOCIAL SUBSCALE. PARENT
VERSION
VERSION
TESTS OVER TIME
TESTS OVER TIME
T2
FIGURE 2.
Antisocial subscales, teacher and parent versions.
T3
293
Groups One & Two - Total Scores
as Percentile Data -Teacher
Version
Group Three, Total Scores as
Percentile Data - Teacher Version
100
R
60
E] Baseline
80 .
60
=5=
40
——
d Music
Therapy
Q Post Music
Therapy
20
A
0
1
rj Baseline
40
Q Music
Therapy
20
0 .
FIGURE 3.
Total scores for DEC, Teacher Version.
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. Resi
dential 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.
Group Three, Total Scores as
Percentile Data - ParentVersion
Groups One & Two. Total Scores
as Percentile Data - Parent Version
o Baseline
90
0 Baseline
80
> ;
40
20
Therapy
v
QPostMT
20
FIGURE 4.
Total scores for DBC, Parent Version.
'
Therapy
294
Mean Number of Negative Events
FIGURE 5.
Mean number of negative behaviors recorded within sessions.
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 nega
tive behaviors they exhibited. On the other hand, despite an over
all 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 demon
strated more negative behaviors around Session 9, they reduced
negative behaviors in subsequent sessions and showed overall im
provement 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
(/>= .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 nega
tive behaviors recorded across four sessions. Note the overall num
ber 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
295
to the evidence in the literature that indicates that agreement be
tween different sources is often minimal. Research suggests that
'externalizing' behaviors are more accurately reported by the par
ent(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 af
fected by three other factors, namely, the age and diagnostic dif
ferences between subjects in each group, and the small sample size.
Group outcomes appear to be influenced by major events for indi
viduals.
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 ver
sions 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 consid
erably 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 pe
riod 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 disrup
tive after each active music therapy session. This writer would con
cur 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 impres
sion gained was that boys with ADHD might become overstimu
lated in a less structured situation.
296
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 re
mained over-aroused after sessions and in their excitement were
less able to cope with formal classroom work. Zillman's 1991 re
search 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 expe
rience had some positive effect on their behavior. While behavioral
theory would not predict this, as music participation was not con
tingent 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 infor
mation sheets and permission forms, may have facilitated the stu
dents' 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 at
tempt to have them accommodated to the environment and pro
gram expectations. A continuous trend for improvement could be
expected from the placement of boys into a stable and secure envi
ronment 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'
297
behavior post-music-therapy treatment, and while one might con
sider whether a delayed treatment effect was being observed, it is
also conceivable that the music therapy sessions were in fact height
ening arousal and contributing to an increase in disruptive behav
ior 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 class
room disturbance. Perhaps, by the time the boys in this study re
turned home after school, the villa staff were able to observe effects
of the music therapy treatment once arousal had settled—for ex
ample, 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 be
haviors for Group 1 and no change in Communication Distur
bance 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 mu
sic 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 ob
served and subjects did appear to be developing positive relation
ships with peers. The overall increase in negative behaviors exhib
ited by Group 1 seemed to be in part related to their enthusiasm
for the music making tasks. They were increasingly being chal
lenged 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 popu
298
lation. This suggests that the music therapy group is a positive en
vironment for these adolescent boys, and the motivation to be in
volved enables them, to a certain extent, to regulate and manage
their own behavior. Scores on the Parent version of the DEC, and
direct observation of prosocial interactions between subjects in the
playground raise the possibility that skills learned in a clinical set
ting 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., home
like environments). Further study would be required to determine
whether any effects could be detected when boys return to their lo
cal 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 fa
cilitate internal organization and help with impulse control, in
boys who are able to attend to the stimuli. However, the within ses
sion observations and outcomes as measured by teachers, also sug
gest that adolescents who have ADHD may become over aroused in
a creative music therapy group setting. This implies that individu
alized 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 appro
priately with others in a less formal environment, such as a resi
dential villa setting. This in turn suggests that, for this population,
299
some generalization of skills to other environments might be pos
sible. 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 de
sired group equivalency, differences between groups and the vary
ing 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 clin
ical interest and merit further study. In addition, future study,
which takes into account specific diagnoses of subjects, is also war
ranted.
Future Study
The total number of participants, and size of the groups is par
ticularly relevant to the results of this research, as only a large treat
ment effect could have been identified in a study of this size. De
tecting 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 ex
pected to be small. Although this study utilized the maximum num
ber 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 num
bers of participants, and would have the likely advantage of reduc
ing 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 deliv
ered. The alternative design, making use of the same site and mea
suring change in several groups of participants over time in 'waves,'
300
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 ran
domly assigned across groups. However the current study, and that
of Montello and Coons (1998), also suggests that music therapy treat
ment 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 differ
ences influence the mode of participation in group therapy? To in
vestigate 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 re
quire 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. How
ever, 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. Fur
ther, 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 individu
als. The consistent trend towards improvement recorded by resi
dential social workers who completed the Parent Report form of
the DBC raises the possibility of a Type II error, that is, while the re
sults 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 in
depth study of individual responses, and measurement of within
session change.
301
The variability of multi-informant data found in this work indi
cates the importance of utilizing a multi-informant approach in fu
ture 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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Developmental Psychiatry, Monash, Clayton, VIC 3168, Australia.
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Haines,J. H. (1989). The effects of music therapy on the self-esteem of emotionally
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Montello, L. M., & Coons, E. E. (1998). Effects of active versus passive group music
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Journal of Music Therapy, XL (4), 2003,302-323
A Survey of Music Therapy Methods and
Their Role in the Treatment of Early
Elementary School Children with ADHD
Nancy A. Jackson
Temple University
Attention-Deficit Hyperactivity Disorder (ADHD) has recently
been receiving more frequent attention in professional cir
cles and in the press, and some sources would assert that its
occurrence in the general population is consistently growing.
Because music therapists often work with preschool and
school-age children, it is likely that they will increasingly be
treating children with a diagnosis of ADHD. However, there is
little in the music therapy literature about music therapy
treatment for ADHD. The purpose of this survey was to as
certain what music therapy methods are being used for chil
dren with an ADHD diagnosis, how effective this treatment is
perceived to be, and the role that music therapy treatment
plays in relation to other forms of treatment. Results of the
survey indicated that music therapists often utilize a number
of music therapy methods in the treatment of children with
ADHD. They often address multiple types of goals, and treat
ment outcome is generally perceived to be favorable. Refer
rals for music therapy services are received from a number of
different sources, although parents and teachers were indi
cated to be the most frequent referral sources. Most children
with ADHD receiving music therapy services also receive
other forms of treatment, with an overwhelming majority re
ceiving medication. The implications of these results are dis
cussed, and areas for continuing research into the use of
music therapy with ADHD are identified.
The author wishes to express sincere gratitude to Cheryl Dileo, PhD, for guid
ance and encouragement throughout the completion of this project.
303
Attention-Deficit Hyperactivity Disorder (ADHD) is a diagnosis
which creates controversy regarding every aspect of the disorder
from definition to treatment. Most sources agree on its basic de
scription: a disorder characterized by a pattern of inattentiveness,
often with hyperactivity, and sometimes with concurrent impulsiv
ity, which is of a persistent nature, is more severe than is typically
seen in other individuals of the same developmental level, and
which causes subsequent difficulties in learning, behavior manage
ment, interpersonal relationships, and socialization (American Acad
emy of Pediatrics, 2000; American Psychiatric Association, 2000). Be
yond this description, there is very little agreement on a specific
definition of the disorder, with different sources identifying any
where from two to seven sub-types, each of which suggests differing
etiologies (Amen, 2001; American Psychiatric Association, 2000; Au
gust & Garfinkle, 1989; Marshall, Hynd, Handwerk, & Hall, 1997).
Assessment of ADHD is complicated not only because of the lack
of agreement in how to define the disorder, but also because many
of the symptoms of ADHD, such as inattention, hyperactivity, im
pulsivity, poor behavioral control, learning difficulties, anxiety, and
disrupted social interactions, are also symptoms of other disorders,
such as learning disorders (Hannaford, 1995), mood disorders
(American Academy of Pediatrics, 2000), or conditions such as al
lergies, stress, or malnutrition (Tobias, 1995). To further compli
cate the matter, these other disorders are commonly co-morbid
with ADHD (American Academy of Pediatrics, 2000). Burcham
and DeMers (1995) indicated that a comprehensive assessment of
ADHD requires information from multiple sources, and must de
termine the extent to which ADHD characteristics are actually
present, the extent to which these characteristics can be attributed
to some cause other than the disorder, and the extent to which the
characteristics are interfering in the child's global functioning.
However, assessment for ADHD, which generally occurs in the
offices of pediatricians and general family practitioners, is not
standardized, leading to misdiagnoses, which include both over
diagnosis and under-diagnosis (Carey, 1999).
In light of the difficulties present in defining and assessing
ADHD in children, it comes as no surprise that proper treatment of
the disorder is also a matter of controversy. In reviewing the litera
ture on ADHD, it is clear that clinicians generally feel that treatment
with stimulant medication, usually methylphenidate, is by far the
304
most efficacious treatment (Johnson, 1988), and historically, it has
been the primary intervention for this population (Dupaul, Barkley,
& McMurray, 1991). However, Volkmar, Hoder, and Cohen (1985)
discuss how the lack of careful and comprehensive assessment, the
poor monitoring of patient response to medication, and the lack of
careful consideration of the risks associated with stimulant medica
tions can lead to the inappropriate use of stimulant therapy. Addi
tionally, improved academic performance and long-term behavioral
change have not been convincingly demonstrated in follow-up stud
ies on stimulant treatment for ADHD (Barkley & Cunningham,
1978; Johnson, 1988). This suggests that medication treatment is
not the single or ultimate answer for treating children with ADHD.
Behavioral therapy frequently appears in literature on ADHD
even though numerous studies have shown that behavior therapy
interventions, and self-management strategies in particular, have
been largely ineffective with the ADHD population (Abikoff,
1985). The Multimodal Treatment Study of Children with Atten
tion Deficit/Hyperactivity Disorder (MTA) overseen by the Na
tional Institute for Mental Health (NIMH) demonstrated that mul
timodal treatment for ADHD was more effective than behavioral
therapy treatment alone, but also found that multimodal treatment
was not significantly more effective than stimulant treatment alone
for the core symptoms of ADHD (MTA Cooperative Group, 1997).
A notable lack of literature is to be found on other forms of
treatment for ADHD. Some studies have addressed nutritional con
cerns related to ADHD (Haslam, Dalby, & Rademaker, 1984; Wen
der & Solanto, 1991). More recently, neurotherapeutics, the use of
specific tones embedded in white noise to modulate brainwave
function, has been espoused as a hopeful new treatment (Abar
banel, 1995; Plude, 1995; Swingle, 1995). Art therapy has also ad
dressed ADHD including the use of art therapy to assess the effec
tiveness of medication treatment (Epperson & Valum, 1992), to
encourage creative growth (Smitheman-Brown & Church, 1996),
and as part of a multimodal approach to address interpersonal and
social problems associated with ADHD (Henley, 1998).
Likewise, literature on the use of music therapy to treat ADHD is
sparse at best. Background music has been shown to reduce hyper
activity and other unwanted behaviors for those with attention
deficits (Gripe, 1986; Pratt, Abel, & Skidmore, 1995). Rock music
was used in conjunction with a time-out procedure as negative re
305
inforcement for effectively decreasing inappropriate or disruptive
behavior (Wilson, 1976). Montello and Coons (1996) studied the
effects of active versus passive music interventions, and found that
those with severe attentional deficits might benefit most from lis
tening interventions that do not require the internal structure that
active interventions require.
The use of music to assist in learning has also received some at
tention in the literature, including the use of music paired with vi
sual cues to increase information retention (Shehan, 1981), and
the use of music to improve auditory perception and language
skills in learning disabled children (Roskam, 1979). Gfeller's
(1984) exploration of three theories of learning disability and the
different music therapy approaches that best fit these differing
theories has numerous implications for treatment of children with
ADHD since learning disabilities seem to be either part of, or co
morbid with, ADHD. Also of interest are studies of the effect of mu
sic and sound on neurological functioning, such as Furman (1978),
who studied the effect of music on alpha brain wave production in
children, and Morton, Kershner, and Siegel (1990) who demon
strated that music enhances the effect of dichotic listening, which
may result in increased short-term memory, decreased distractibil
ity and an enhancement of information processing.
Considering the potential of music to impact upon brain func
tion, attention, activity level, social behavior, and learning, there
appears to be good reason to support further investigation into the
ways that music might be used to effectively treat children with
ADHD. More information is needed about how music therapy is
being used clinically for the treatment of ADHD, however, and
those currently working with these children can best provide that
information. Therefore, it was the purpose of this survey to ascer
tain what music therapy methods are being used for children with
an ADHD diagnosis, how effective this treatment is perceived to be,
and the role that music therapy treatment plays in relation to other
forms of treatment.
Method
Subjects
A sample of board-certified music therapists was randomly se
lected from members of the American Music Therapy Association
306
(AMTA) who had identified themselves in the AMTA 2001 annual
survey as working with populations likely to include early elemen
tary school children. Only practicing, board-certified clinicians
were selected from these categories, with students and others being
excluded. Using these filters, AMTA identified 1116 music thera
pists who matched the criteria for the study, from which 500 were
randomly selected by the researcher to receive the questionnaire.
Design and Procedure
An experimenter-designed questionnaire, which was first sub
mitted to a group of professional music therapists for feedback, was
used to survey subjects. The questionnaire, along with a cover let
ter that indicated the purpose of the study, elicited informed con
sent, and provided necessary information for the completion and
return of the questionnaire, was submitted to the Institutional Re
view Board of Temple University for approval prior to administra
tion. Those subjects who did not work with the identified popula
tion were requested to indicate so and return the questionnaire to
determine if the number of responses received was sufficient to be
considered a representative sample. The responses from the re
turned questionnaires were then compiled into aggregate form for
analysis using SPSS Systat 6.0 statistical software.
Results
Of the 500 questionnaires sent, a total of 268 responses were re
ceived from music therapists residing in 43 states, constituting an
overall return rate of 54%. Of those responses, 98, or 37% of the
responses received, were from music therapists in 36 states who in
dicated that they currently work with early elementary school chil
dren diagnosed with ADHD. The data from these 98 survey re
sponses was compiled utilizing the Systat program, and the results
were derived from basic statistical computations and from compar
isons of various groupings and sortings of this data.
Music Therapy Methods Used with ADHD Children
Subjects were asked to identify the method or methods that they
use to treat children diagnosed with ADHD. These results are
shown in Table 1. Music and movement was the method that most
respondents indicated they use with this population, followed by
instrumental improvisation, musical play, and group singing, re
307
TABLE i
Music Therapy Methods Used for Treating ADHD Children
Method
Number of respondents
Percentage
Music and movement
Instrumental improvisation
Musical play
Group singing
Instrumental instruction
Other creative arts
Music assisted relaxation
Vocal improvisation
Mainstreamed music education
Orff-Schulwerk
Nordoff-Robbins
Vocal instruction
Other
73
66
62
54
46
35
31
22
17
16
5
5
22
74%
67%
63%
55%
47%
36%
32%
22%
17%
16%
5%
5%
22%
Note. Subjects were asked to indicate all the methods they use to address this popu
lation. Biofeedback was a method offered on the questionnaire, but which no re
spondent selected. Therefore, it has been deleted from this and subsequent tables.
"Percentage" is the percentage of all respondents. Methods identified as "Other" by
respondents included song writing, recreational music, educational music activities
for speech and skill development, music and sensory integration, music attention
training, hand bell choir, and music and equine-assisted therapy.
spectively. Most respondents indicated that they use two or more
methods, with only 2% indicating only one method.
Goals Addressed by Music Therapy Methods
Subjects were asked to indicate the types of goals they address in
music therapy for children with ADHD. Behavioral goals were iden
tified by 92 respondents (94%), psychosocial goals were identified
by 87 respondents (89%), and cognitive goals were identified by 68
respondents (69%). Most respondents indicated that they address
two or more types of goals, and 81 (83%) ranked the types of goals
according to the frequency with which they address them. Again,
behavioral goals were identified as being addressed most fre
quently, followed by psychosocial goals and then cognitive goals.
The types of goals addressed were also examined in relation to the
music therapy methods identified by respondents. Regardless of
method employed, behavioral goals were indicated as the type most
addressed, followed by psychosocial goals, then cognitive goals.
308
TABLE 2
Perceived Effectiveness of Music Therapy Treatment for ADHD
Treatment outcomes
Number
Percentage
Range
Mean
98
100%
3
4.1
Other professionals
93
95%
3
4.1
Teachers
82
84%
3
4.1
Parents
81
83%
Children
94
96%
2
3
4.1
4.3
Note. Effectiveness ratings represent the respondents' perceptions, and were based
on a scale of 1-5; 1 = not effective. 3 = somewhat effective. 5 = very effective. "Num
ber" is the number of respondents. "Percentage" is the percentage of all respon
dents. "Range" is the difference between the minimum and the maximum reported
ratings. "Mean" is the average rating in each category.
Music Therapy Treatment Formats for ADHD Children
Subjects were asked to identify the format of their treatment of
ADHD children. Forty respondents (41%) indicated that they see
these children in both group and individual formats, followed
closely by 38 respondents (39%) who see children only in a group
format. Twenty respondents (20%) indicated that they treat ADHD
children individually. The questionnaire did not ask the subjects to
specify the type of setting in which they treat these children, but
many respondents added this information. These settings included
educational, residential, community-based, acute hospital, and psy
chiatric treatment settings.
Perceived Effectiveness
of Music Therapy Treatment for ADHD
Subjects were asked to rate the effectiveness of music therapy
treatment for children with ADHD based on their treatment out
comes, and on their perception of the responses of other profes
sionals, the responses of teachers, the responses of parents, and the
responses of the children receiving music therapy (Table 2). In
general, respondents' indicated that music therapy treatment is ef
fective according to their treatment outcomes, and they perceived
that others also feel music therapy is an effective treatment.
To ascertain if the perceived effectiveness of music therapy treat
ment varied according to the type of music therapy method em
ployed or to the type of goal(s) addressed, responses were sorted
according to method and to type of goal, and the effectiveness ac
cording to respondents' treatment outcomes was examined for each.
Regardless of the methods employed or the types of goals addressed,
309
TABLE 3
Treatments Used in Conjunction with Music Therapy for ADHD
Type
Medication
Psychological services
Occupational therapy
Nutrition
Other creative arts
Physical therapy
Speech therapy
Therapeutic recreation
Massage
Chiropractic
Other
Number
Percentage
Percentage of total
85
52
51
91%
87%
53%
52%
28%
26%
26%
27
25
25
5
5
3
1
18
56%
55%
29%
27%
27%
5%
5%
5%
5%
3%
1%
19%
3%
1%
18%
Note. Subjects were asked to identify all other treatments being used in conjunction
with music therapy for ADHD. "Percentage" is the percentage of respondents who
indicated that conjunctive treatments are used. "Percentage of Total" is the per
centage of all respondents. Treatments identified as "Other" by respondents in
cluded speech therapy, therapeutic recreation, rehabilitation services, anger man
agement training, residential milieu programs, hippotherapy, cranio-sacral therapy,
and weighted vests.
the vast majority of respondents rated effectiveness as "effective" or
better (4 or 5 on the rating scale, with 5 being very effective).
Other Treatments Used in Conjunction with Music Therapy for ADHD
Subjects were asked to indicate if music therapy is provided in
conjunction with other forms of treatment for ADHD, and if so, to
specify what other treatments are used. Of the 98 respondents, 93
or 95%, indicated that other treatments were used (Table 3). Most
of these respondents indicated that medication was the most fre
quently used conjunctive treatment, followed by psychological ser
vices and occupational therapy, respectively.
Referral Sources for Music Therapy Treatment of ADHD
Referral sources from which respondents receive music therapy
referrals for children with ADHD are shown in Table 4. Respon
dents indicated that parents and teachers are the most frequent
sources of referrals to music therapy for ADHD children, followed
closely by treatment teams. Subjects were also asked if their facility
uses an Individualized Education Plan (IEP), and, if so, if music
therapy is mandated on that form. Twenty-nine respondents (29%)
310
TABLE 4
Music Therapy Referral Sources for ADHD Children
Source
Number
Percentage
Parents
Teachers
Treatment team
IEP
Physician
School guidance counselor
Psychologist or therapist
Other
43
31
29
14
13
13
10
36
44%
32%
30%
14%
13%
13%
10%
37%
Note. Subjects were asked to identify all sources from which they receive music ther
apy referrals for children with ADHD. "Number" is the number of respondents
identifying each referral source. "Percentage" is the percentage of all respondents.
Referral sources identified as "Other" by respondents included social workers, pri
vate music teachers, special education directors, Department of Developmental Dis
abilities case managers, nurses, DSS workers, other creative arts therapists, occupa
tional therapists, and speech therapists.
indicated that music therapy was mandated on the IEP in their fa
cility. Their responses indicated that referrals for lEP-mandated
music therapy also come from numerous sources, and not solely
from the IEP process. These referral sources are shown in Table 5.
The Role of Music Therapy in Treatment of ADHD Children
Subjects were asked to describe the role that music therapy plays
in the treatment of ADHD as primary, multidisciplinary, or adjunc
tive. A notable majority of the respondents (71 or 73%) described
music therapy's role with this population as multidisciplinary. A few
respondents also indicated that the role music therapy plays in
treatment for these children is case-specific, and may be described
in any of these three ways, dependent upon the setting, the referral
source and the needs of the child.
Additional Comments
A space was provided at the end of the questionnaire for addi
tional information or comments for those subjects who felt these
would be helpful to the study and who chose to include them.
These additional comments, which are grouped in categories, are
presented in Table 6. Of all the respondents, 19 or 19%, chose to
add comments to the questionnaire.
311
TABLE 5
Referral Sourcesfor lEP-mandated Music Therapy
Source
Number
Percentage
Parents
IEP
Teachers
Treatment team
Psychologist
Physician
Guidance counselor
Other
15
11
10
9
3
3
2
12
52%
38%
34%
31%
10%
10%
7%
41%
Note. This table presents the referral sources for those respondents who indicated
that music therapy is specifically mandated on the IEP in their facility. Subjects were
asked to identify all sources from which they receive referrals. The total number of
respondents represented in this table is 29. "Number" is the number of respondents
identifying each referral source. "Percentage" is the percentage of the 29 respon
dents represented herein.
Discussion
A random sample of 500 music therapists were surveyed about
the treatment of early elementary school children with ADHD, re
sulting in the receipt of 98 questionnaires completed by music
therapists working with this population. Because of the 54% over
all return rate for the questionnaire, and because responses were
received from all regions of the country, it is not unreasonable to
assume that the results provide a generally accurate picture of how
music therapists are working with this population.
Music Therapy Methods Used with ADHD Children
Respondents identified many different types of music therapy
methods they use with ADHD children, and they combined these
methods in many different groupings, none of which showed any
particular trends. One would wonder, then, why music and move
ment, instrumental improvisation, musical play, and group
singing were each identified by more than 50% of the respon
dents. Perhaps there is a shared element or elements that lead to
their more frequent use. Or, perhaps further investigation would
show that the frequent use of these methods has more to do with
the age of the child than with the diagnosis. Or again, perhaps
the choice of method has some correspondence with the type of
setting. For instance, is group singing identified more often be
312
TABLE 6
Respondents'Additional Comments About Music Therapy and ADHD
Category
Methods
Effectiveness
Elements of music
therapy
Recommendations
Miscellaneous
Comments
use methods that are multi-sensory (2)
use iso-principle-based activities (2)
improvisation allows the children to lead and create within
a structure
after a structured group music activity, give music choice
time for children to pick an instrument to play, or pick a
selection to listen to
sensory integration is important for younger and lower level
children
use group music activities that require attention, turn-taking,
and responding to cues
encourages on-task behavior (3)
interventions are effective during sessions, but little or no
generalized response is noted outside of sessions (2)
increases attention span, positive behaviors, and self
esteem (2)
decreases frustration and resistance
improves healthy emotional expression
is related to the "chemistry between the therapist's aproach
and each child," and their ability to "observe/discern
together"
"some [children] are overly stimulated by certain types of
music and do better with verbal instruction in a quiet
environment"
especially effective with medication
"music therapy is the one group they sit through and stay
focused"
group music is effective because of its demands and its
ability to motivate
a multidisciplinary approach seems to work best
provides structure that helps children "get organized"
provides opportunity for energy release within a structure
"consistency and structure are key elements"
contributes to improved sensory integration
parents should be involved in sessions so that results can
better generalize to other settings (2)
assist the child in finding what works best for him/her
a qualitative research approach might give more pertinent
information
a theoretical model is needed for formulating and testing
treatment strategies
success in one setting may lead to referrals from other settings
more formalized training in this area might help music
therapists but none seems to be available
misdiagnosis is common
multiple diagnoses are common
Note, This table represents additional comments added to the questionnaire by re
spondents. Some comments are paraphrased to fit into the chart format. Those com
ments that are not paraphrased are in quotation marks.A number in parentheses after
a comment indicates that more than one respondent added this comment to the ques
tionnaire, and identifies the specific number of respondents who made that comment.
313
cause many of these children may be seen in an educational type
of group setting?
The previously cited literature on ADHD suggests several ele
ments of music itself that may play a part in the choice of method
for treating ADHD. Among these are the element of movement and
its impact on dual hemispheric activation in the brain (Hannaford,
1995; Morton et al., 1990), the ability of music to increase memory
functions and auditory perception for improved learning (Roskam,
1979; Shehan, 1981; Wolfe & Horn, 1993), and the ability of specific
sounds or tones to affect brain wave production (Abarbanel, 1995;
Furman, 1978; Morton et al., 1990; Plude, 1995; Swingle, 1995). In
comparing the most often identified music therapy methods and
the elements just mentioned, one can see that at least some of these
elements are part of each of the methods. Music and movement, in
strumental improvisation, musical play, and group singing all in
volve some sort of physical movement, and all except group singing
are likely to often involve movement on both sides of the body and
across midline (dual activation of both hemispheres in the brain).
Musical play and group singing are likely to involve the pairing of
music and information, while music and movement may pair music
with an increased awareness of emotion or increased spatial aware
ness (auditory perception and memory). And, of course, all involve
the use of sound and tones (potential brainwave modulation).
Clearly, further investigation is needed in each of these areas to bet
ter understand how music can be effective for these children.
Goals Addressed by Music Therapy Methods for ADHD
A majority of the respondents indicated that they address more
than one type of goal with the methods that they use to treat chil
dren with ADHD. Perhaps multiple goals are addressed by music
therapy because, regardless of the type of method used, music is
experienced on multiple levels simultaneously. As a parenthetical
example, a music intervention can have the ability to create an
experience of structure, both through the music itself, and through
the directives given to the participant. That same intervention may
involve learning a music skill that includes the movement of both
sides of the body across midline. It may also provide opportunity for
a fulfilling experience of appropriate interaction between the mu
sic, the participant, and all other participants, while anchoring the
learning from that experience in the participant's memory
through the very movements required by participation. This one
314
intervention could address behavioral, psychosocial, and cognitive
goals within a short span of time. It may be that there are few
modalities that are able to address multiple areas simultaneously.
Referring again to the cited literature, much of the evidence that
supports the use of music with this population is related to brain
function and its impact on processing of information and learning.
It is interesting, then, that cognitive goals are identified as being
addressed less often than behavioral or psychosocial goals. There
are a number of factors that might explain this. First, behavioral
and psychosocial improvements are much easier to track and doc
ument in an "objective and measurable" manner than are cognitive
improvements, since cognitive improvements are likely to develop
and generalize over a period of time, and often require specific test
ing in order to obtain a measurement. For example, it is easy to ob
serve and measure on-task behavior or appropriate self-expression,
while observing and measuring brain activity, such as dual hemi
spheric activation and its long-term results, is quite difficult.
Another reason that cognitive goals were not identified as being
addressed as often may be that music therapists, in general, do not
have extensive education in neurobiological functioning. This is a
specialized area of knowledge, and perhaps only those therapists
who have a particular interest in this area actually take the time to
learn more about it. This is also an area of science that we know
little about in comparison to other areas of physiology. Since evi
dence does show that music encourages cognitive gains, it may be
that many music therapists address cognitive concerns with these
children without realizing that they are doing so. Further explo
ration of music's effect on cognitive functioning could potentially
provide important information for the treatment of this population.
The current multidisciplinary nature of treatment may also play
a role in the types of goals that music therapists are addressing.
Multidisciplinary teams certainly have their advantages: better as
sessment, more complete evaluation of treatment based on func
tioning in multiple areas, better continuity of care, and so on. Mul
tidisciplinary teams also have their disadvantages, however, and
chief among these is the tendency for the specificity that each dis
cipline brings to the treatment process to be "watered down" or di
luted through the process of developing a general plan. Also, be
cause the current standard in healthcare is to provide objective and
measurable results for the treatment provided, it would not be sur
315
prising to find that multidisciplinary teams may tend to address
easily observable and measurable goals. As a result, it may be that
music therapists follow the more generalized plan of the multidis
ciplinary team. Or, it may be that they are addressing cognitive ar
eas in their treatment, but they adjust the way they describe what
they do to fit into the generalized plan. Regardless of the reasons
that cognitive goals are addressed less often, it may be time for mu
sic therapists to pay closer attention to the cognitive benefits of the
interventions that they provide for these children.
Music Therapy Treatment Formats for ADHD Children
Subjects were not asked to specify the settings in which they treat
ADHD children; this was a flaw in the questionnaire design. The in
formation on group or individual treatment does not give much
insight into treatment of these children without corresponding in
formation about the setting in which the treatment takes place.
The format could be a function, of the setting, or it could give in
formation independent of the setting.
Some respondents chose to offer information on the setting in
which they see these children, mentioning both educational and
health care settings. This is reflective of the prevalence of this di
agnosis in the general population, and suggests that music thera
pists need to be aware of the specific needs of these children and of
how music therapy can most benefit them.
Perceived Effectiveness of Music Therapy Treatment for ADHD
In general, it appears that music therapists feel that music ther
apy treatment for children with ADHD is effective, and that they
also perceive others to feel that it is effective, based on feedback
that they receive from these others. Interestingly, the perception of
effectiveness was relatively the same regardless of methods used, or
the types of goals being addressed, or the other types of treatment
used in conjunction with music therapy. This consistent perception
of music therapy's effectiveness in treating ADHD children regard
less of the variables revisits the question posed earlier: Is there
some element or elements of music itself which lead to the effec
tiveness of music therapy treatment for these children?
Another interesting result is that the respondents' perceptions of
how the children in treatment feel about the effectiveness of music
therapy was consistently higher than any other group, even their
316
own treatment outcomes. The amount of difference in the ratings
was not remarkable, just the consistency of the ratings regardless of
the variables being examined. A study that described and explored
the ADHD child's experience of music therapy might be an invalu
able source of information for further defining and developing
music therapy's approach to treating these children. For example,
does the ADHD child feel that music therapy is effective because it
helps him to perform better academically, or because it helps him
to feel better and more confident about himself, or because it pro
vides him an opportunity to release excess energy through creativ
ity and self-expression? Each scenario suggests the use of a differ
ent music therapy approach. Again, these questions provide fertile
ground for further research.
Other Treatments Used in Conjunction with Music Therapy for ADHD
It is no surprise that medication was indicated as being used in
conjunction with music therapy for a large majority of the children
with ADHD that respondents treat. The existing literature clearly
identifies medication as the most widely used form of treatment for
ADHD despite some controversy over whether it is the best or most
appropriate treatment in all cases. Those respondents who indi
cated that medication was not used conjunctively with music ther
apy for the children they treat, however, rated the perceived effec
tiveness of music therapy treatment about the same as the overall
perceived effectiveness including those children who do receive
conjunctive medication treatment. The number of respondents in
this group was small, so no firm conclusions can be drawn from this
study, but further investigation in this area is warranted. Perhaps
there is something that music therapy can address with these chil
dren upon which medication has no impact. Or perhaps the effec
tiveness of music therapy may have to do with the actual music
therapy environment, in which case it might be enlightening to
explore how the positive effects of music therapy generalize to
other settings as compared with how the positive effects of medica
tion generalize. Also of interest would be to closely study the dif
ferences between children being treated with medication and chil
dren not being treated with medication within the same music
therapy setting.
In looking at the respondents' perceptions of effectiveness for
music therapy treatment of children not receiving medication, it
317
seems that the respondents perceived that they and the children
feel music therapy is somewhat more effective than do others. Fur
ther studies that,would survey other professionals, teachers, and
parents about how they perceive the effectiveness of music therapy
might be quite helpful, since this study only reflects the respon
dents' perceptions. This might also indicate that generalization to
other settings is a topic for careful study. If music therapy interven
tions are effective within the confines of the session, but those ef
fects are not generalized to other settings, then is music therapy ac
tually effective? The answer might be yes if a cumulative effect was
found that could lead to generalization later in time. Further foun
dational research in the effect of music upon brain functioning
might be extremely important in this case.
Referral Sources for Music Therapy Treatment of ADHD
There is certainly some meaning in the fact that most referrals
for music therapy for children diagnosed with ADHD come from
the parents of these children, even when music therapy is mandated
on the child's IEP. Perhaps this suggests that parents really do feel
that music therapy is effective for treating their ADHD children. Or
it might suggest that the standard treatments for ADHD are not fully
meeting their children's needs, or that the side effects from medica
tion are unacceptable and parents are seeking alternate treatment
that will be effective. Again, a survey of the parents of these chil
dren would provide needed information about why they seek mu
sic therapy as a treatment, and how effective they find it to be.
Teachers, who make the second most referrals to music therapy
for ADHD children, could also provide important information if
asked the same questions. Additionally, teachers could provide in
formation about the effects of music therapy on the scholastic per
formance of these children, as well as providing feedback about
the generalization of skills or behaviors that are being developed in
music therapy.
The Role of Music Therapy in the Treatment of ADHD Children
Most respondents indicated that the role music therapy plays in
the treatment of ADHD children is multidisciplinary. It seems that
a multidisciplinary approach may be the best for this particular
population since, by definition, children with ADHD will present
problems in multiple functional domains and in multiple settings.
318
As previously mentioned, when the music therapist works with oth
ers in the treatment of these children, not only will the children
have the benefit of multiple approaches in treatment, but the ther
apist will have the opportunity to receive feedback from others
about how the children are functioning in other settings, such as in
the classroom. The MTA study conducted by the NIMH, which was
cited earlier, was an attempt to determine if multiple forms of treat
ment were most effective for children diagnosed with ADHD, but
the sheer size of the project may have hindered the success of its
outcome as no firm conclusions could be drawn from the results. A
more controlled study involving the comparison of similar facilities
treating similar populations might provide better results from
which conclusions could be drawn. This kind of study would bene
fit all of the professions involved, and could make a real difference
in the kinds of treatment children with ADHD receive.
Additional Comments
Respondents made a number of comments related to music
therapy methods used for children with ADHD. Some commented
on the use of multi-sensory interventions or sensory integration.
Others commented on various ways of providing structure, or pro
viding freedom within a structure. And, importantly, some men
tioned the iso-principle, or the necessity of matching what feels
right to the child. These comments help in clarifying what thera
pists consider when choosing an approach or method to employ in
treatment of these children, and also begin to define some of the
elements contained in these methods.
The idea of "freedom within a structure" has not been examined
in the existing music therapy literature as it relates specifically to
ADHD children, but which might be deserving of more attention.
Comments made by respondents implied that they combine the el
ement of freedom with the element of structure to successfully
treat ADHD children. It would be interesting to see if there is some
connection between exposure to this type of experience and de
velopment of the child's ability to internally structure himself. If so,
this might impact heavily upon the ADHD symptom of impulsivity,
a symptom that not only is disruptive to the child and his environ
ment, but that also can be potentially dangerous.
Numerous comments related to the effectiveness of music ther
apy treatment for ADHD children were made by respondents.
319
These included comments pertaining to attention, on-task behav
ior, increased self-esteem, increased self-expression, and increased
frustration tolerance, all of which the respondents felt were en
couraged and supported by music therapy. Some respondents in
dicated, however, that these improved behaviors do not seem to
generalize to settings outside the sessions. One respondent com
mented that a multidisciplinary approach is most effective, and this
comment may be related to the question of generalization in that
professionals working together on a treatment or educational plan
for a child should create some continuity of care that should in
crease the likelihood that improvement will be seen in more than
one setting. It also raises the question of who should be involved in
the music therapy session. If parents, teachers, or other people who
work with the child are involved in the music therapy sessions, will
there be better carry-over from one setting into another?
One respondent noted that the relationship between therapist
and child is an important element in the effectiveness of music
therapy treatment, stating that it is the ability to "observe/discern
together" that makes treatment successful. This is somewhat re
lated to those who commented on the iso-principle in terms of
meeting the child where he is at the moment, but also implies that
the child himself has some inner wisdom about what he needs and
the therapist who is sensitive to that wisdom may have more success
with treatment. Studies examining the relationship between music
therapist and the ADHD child might not only bring insight into the
process of the therapy, but also might be informative in terms of
identifying those elements of music therapy that most contribute to
successful treatment.
Comments from respondents that were directly related to ele
ments of music therapy treatment for ADHD children follow in suit
with the previous comments. Structure and how it is used in the
music therapy session seems to be an important element that can
be approached in different ways. Some comments mention struc
ture in a manner that seems to suggest that it is the therapist's role
to create the structure needed for the child to organize himself,
while others seem to suggest that the therapist provides structure as
a container in which the child can decipher how he needs to be or
ganized. This is a subtle difference that would have large impact on
the choice of method used in the therapy session. A closer exami
nation of how structure is created and used within the music ther
320
apy session with ADHD children might yield some interesting and
revelatory findings.
Music's ability to improve sensory integration was mentioned by
a respondent as an element of music therapy important in the
treatment of children with ADHD. This is an area that merits fur
ther investigation as it is very closely related to the cognitive pro
cessing problems that some like Hannaford (1995) theorize is the
most likely culprit in ADHD symptomatology. Multi-sensory input
is easily created with music since it is experienced through hearing,
through touch by means of vibrations, through spatial awareness by
means of rhythm and movement, and through sense memory,
which can easily be activated with music. The manner in which mu
sic as sensory input is used, however, may be extremely important.
One respondent noted that some ADHD children can become over
stimulated by music, and do best when in a quiet environment.
A recommendation was made that a theory of music therapy be
developed for the formulation and testing of treatment strategies
for children with ADHD. The many questions raised by this survey
give credence to the need for such a model, and indeed, that idea
was intrinsic to the development of this study. It also mirrors the
state of treatment for ADHD in general, which seems to be contin
ually searching for the theory that will bring forth better results in
the treatment of these children.
A final recommendation made by a respondent was to use quali
tative research methods in order to better understand how music
therapists are treating children with ADHD. Hopefully, this recom
mendation will not go unheeded. Some of the questions arising
from this study would benefit from a qualitative research approach,
such as: what is the ADHD child's experience of music therapy
treatment, and, what is the importance of the therapist/client rela
tionship in the treatment of children with ADHD?
A last miscellaneous category of comments by respondents in
cluded comments about misdiagnosis and multiple diagnoses.
These comments are reflective of what the cited related literature
reports about the lack of standard assessment for diagnosing
ADHD, and about co-morbid diagnoses that make assessment and
treatment more difficult. Music therapy may have a role to play in
assessment of children with ADHD if better understanding of the
effects of music on these children can be developed. In line with
this was a comment regarding training for music therapists. This re
321
spondent indicated that ADHD is an area in which specialized
training should be given for music therapists, and noted that very
little was available, even at national conferences. This may be,
again, reflective of the overall controversy surrounding ADHD, its
assessment and treatment. Until some consensus can be reached
about what ADHD is and how it should be diagnosed and treated,
training in this area will probably be sparse at best.
Conclusion
The purpose of this study was to develop a general picture of
how music therapists are treating early elementary school children
with a diagnosis of ADHD, and of the role music therapy plays in
the overall treatment of these children. It was hoped that this pic
ture would provide music therapists with the information needed
to make more purposeful and effective choices for successful treat
ment. It was also hoped that this picture might highlight patterns
upon which a theory of music therapy for the treatment of ADHD
might begin to be formed. As is usual with most research, the final
results raise many new questions. Among these are questions about
what element/s of music therapy is/are most responsible for bring
ing about effective results, about how success in music therapy
treatment for ADHD can be generalized to other settings, and
about how music therapy treatment for ADHD compares to treat
ment with medication. Ultimately, it is hoped that these and other
questions to which this study has given rise will provide impetus for
music therapists to further investigate the influence of music on
children with ADHD.
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Swingle, P. G. (1995-2001). Subthreshold 10-Hz sound suppresses EEC theta: Clin
ical application for the potentiation of neurotherapeutic treatment of ADD/
ADHD. Journal of Neurotherapy, 2, [Online]. Available: http://www.snr-jnt.org/
JournalNT/JNT(2-l)3.html
Tobias, B. (1995). ADHD look-alikes: Other reasons children flit, squirm, distract and just
space out. Lake Forest, California: Smart! Productions.
Volkmar, F. R., Hoder, E. L., & Cohen, D.J. (1985). Inappropriate uses of stimulant
medications. Clinical Pediatrics, 24, 127-130.
Wender, E. H., & Solanto, M. V. (1991). Effects of sugar on aggressive and inatten
tive behavior in children with attention deficit disorder with hyperactivity and
normal children. Pediatrics, 88, 960-966.
Wilson, C. V. (1976). The use of rock music as a reward in behavior therapy with
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Wolfe, D. E., & Horn, C. (1993). Use of melodies as structural prompts for learning
and retention of sequential verbal information by preschool students.Journal
Journal of Music Therapy, XL (4), 2003, 324-344
Searching PubMed/MEDLINE, Ingenta,
and the Music Therapy World Journal
Index for Articles Published in the Journal
of Music Therapy
Simon K. Gilbertson, BMus, Dip. MT, Dip). MTh
David Aldridge, BEd, BPhil, PhD
University Witten Herdecke
The purpose of this study was to carry out a comparison be
tween references to articles published in the Journal of Music
Therapy before December 2002 identified through searching
PubMed/MEDLINE, the Ingenta database and those actually
published in the journal. To carry out this comparison we
have created a new database, called the Music Therapy World
Journal Index, which includes complete indexes of selected
music therapy journals. All articles published in the Journal of
Music Therapy since its commencement in 1964 are refer
enced in this database. We found a large number of articles
that are not identified by searching PubMed/MEDLINE. There
is an under-representation of both the amount of articles
published in this journal and in the range of areas for clinical
application and research in music therapy. The Ingenta data
base is comprehensive but limited in its coverage of the early
years. To carry out a comprehensive research of the litera
ture, it is necessary to consult an expert database, such as
the Music Therapy World Journal Index, that guarantees an
unequivocal level of completeness.
MEDLINEis a database of bibliographical references to journal
articles produced by the US National Library of Medicine
(http://www.nlm.nih.gov) and contains indices of articles pub
lished since 1966 in approximately 4,500 selected journals. The
Please direct communications to Prof. David Aldridge, Chair for Qualitative Re
search in Medicine, Institute for Music Therapy, University Witten Herdecke,
Alfred-Herrhausen-Str. 50, D-58448 GERMANY, Ph: 02302/926-780, FAX 02302/
926-783, [email protected].
325
journals cover "the fields of medicine, nursing, dentistry, veteri
nary medicine, the health care system, the preclinical sciences, and
some other areas of the life sciences" (MEDLARS, 2001). The jour
nal indices are also produced in printed form as Index Medicus.
MEDLINE is also available on CD-Rom.
It has been possible to search the MEDLINE database online, via
Internet, since 1971. The U.S. National Center for Biotechnology
Information has developed an additional service called PubMed
that provides free access to MEDLINE (http://www.ncbi.nlm.nih.
gov/pubmed/). Access to MEDLINE is also provided by commer
cial organizations and the use of these services requires a fixed-fee.
To the present day the PubMed/MEDLINE database has included
indexes of only one music therapy journal, the Journal of Music
Therapy. No other music therapy journal has been considered to
fulfil the criteria for inclusion in PubMed/MEDLINE by the Na
tional Library of Medicine.
When searching for literature it is important to be able to rely on
comprehensive databases. We need to know if all articles published
in the journal are referenced in the database. Otherwise relevant
literature may not be identified, and we will not be able to judge
the efficiency of our search strategy. More significantly, if we are
not informed about existing relevant material, the value and rele
vance of both our clinical and research endeavors is jeopardized. A
comprehensive search of the literature is also the foundation of a
structured review. We must, therefore, be fully informed about how
comprehensive a database is and how accurate the contents are.
There have been various assessments of the coverage and com
prehensiveness of the MEDLINE database. Dickersin, Scherer, and
Lefebvre (1994) found only 77% of all known trials in a search of
MEDLINE for randomized controlled trials in the area of ophthal
mology. The Cochrane Collaboration (Clarke & Oxman, 2001)
stated that "only 30-80% of all known published randomized con
trolled trials are identifiable using MEDLINE (depending on the
area or specific question)" (p. 28). Greenhalgh (2001) emphasizes
the situation in which "according to one estimate, 40% of material
which should be listed by MEDLINE can, in reality, only be accessed
by looking through all the journals again, by hand" (p. 34). It is of
interest to assess PubMed/MEDLINE in the light of music therapy
literature. Our suspicion of missing references developed during
early stages of our Structured Review Project.
326
We have carried out a large number of searches of PubMed/
MEDLINE as a part of our Structured Review Project that began in
April 2002. During initial searches we became aware that many ref
erences to articles published in the Journal of Music Therapy were
not appearing in the search results. During a preliminary search,
the first article we searched for, "Hanser, S. B., Larson, S. C., and
O'Connell, A. S. (1983). "The Effect of Music on Relaxation of Ex
pectant Mothers During Labor"/Music Ther, 20, (2), 50-58", could
not be found in PubMed/MEDLINE using diverse search strategies.
At this point we decided to investigate into the causes for missing
references. To implement that investigation, we had to compile a
database of our own from known material.
We have created a new electronic database called the Music
Therapy World Journal Index (MTWJI). The MTWJI contains biblio
graphic references to every article published in selected music
therapy journals. These references refer to a broad range of con
tents; experimental studies, clinical studies and reports, theoreti
cal musings and anecdotal information. The database covers the
AustralianJournal of Music Therapy, BritishJournal of Music Therapy,
Journal of Music Therapy, Music Therapy, Music Therapy Perspectives,
Musiktherapeutische Umshau, New Zealand Society of Music Therapy
AnnualJournal, Nordic Journal of Music Therapy, Music Therapy To
day, and Voices. No limits of inclusion have been applied based on
the date of publication. All issues of the journals published before
the end of 2002 have been indexed and included in this database
(see Table 1). It is possible to access the MTWJI viz Internet at
www.musictherapyworld.net. Regular updates of the database are
planned to maintain comprehensiveness.
This new database guarantees that all articles published in the in
cludedjournals can be identified using a database, which is reliable
and comprehensive. The database is a benchmark from which we
can assess other databases and a resource for researchers and prac
titioners.
Method
We have indexed all issues of the Journal of Music Therapy pub
lished since 1964 in the MTWJI electronic database. With the exis
tence of this new database, it is possible to carry out various com
parisons of the references identified by PubMed/MEDLINE and
Ingenta, and those actually published in the Journal of Music Therapy,
327
TABLE i
Scope of Coverage of Music Therapy Journals Indexed in the Music Therapy World Journal
Index
Journal name
Scope
AustralianJournal of Music Therapy
BritishJournal of Music Therapy
CanadianJournal of Music Therapy
Latin-AmericanJournal of Music Therapy
Music Therapy
Music Therapy Perspectives
1990-2002 (complete)
In preparation
In preparation
Musiktherapeutische Umschau (German language)
New Zealand Society of Music Therapy AnnualJournal
NordicJournal of Music Therapy
Music Therapy Today
Voices
1987—2002 (complete)
efficiently. In this paper we limit our all our comparisons of refer
ences to articles published up to December 2002 though the
MTW/Iis being constantly updated to cover articles published in
the most recent issue.
Searching the Databases for References to Articles Published in the Journal
of Music Therapy
After preparing the MTWJI, the following task was to search
PubMed/MEDLINE for references to articles published in the Jour
nal of Music Therapy. The search strategy included two search pro
cedures. The first search procedure was limited to searching the
'journal tide' (ta) data tag. This tag commands the search program
to search only the data fields containing information about the
journal name, the journal name abbreviation, and the Interna
tional Standard Serial Number (ISSN) of each of the references.
The terms used in the first search were the full journal name Jour
nal of Music Therapy, the PubMed/ MEDLINE journal name abbrevi
ation "J Music Ther", and the ISSN of the journal, "0022-2917."
This procedure is necessary to be certain that we receive only ref
erences to material published by the Journal of Music Therapy, and
not references in which the phrase 'Journal of Music Therapy' is
used in the title or in the abstract text.
The second search procedure was not limited, and searched for
the same terms in all fields of the database. This was done using the
328
' [all fields]' proximity command. This second search was used to
be certain that relevant references were not missed due to errors in
the entry of data into the wrong data fields stored in the PubMed/
MEDLINE database.
The exact search strings used were:
Search 1: "Journal of Music Therapy"[ta] OR "J Music Ther"[ta]
OR "0022-2917" [ta]
Search 2: "Journal of Music Therapy" [all fields] OR "J Music
Ther"[all fields] OR "0022-2917" [all fields]
Searches were repeated on March 03, 2003, April 30, 2003, and
May 12, 2003 using the PubMed/MEDLINE access: http://www.ncbi.
nlm.nih.gov/PubMed/. In this paper we refer to the results of the
searches of PubMed/MEDLINE carried out on Monday 12.05.2003.
Through carrying out the searches on a Monday we could be cer
tain to avoid any unnecessary disturbances of function related to
the update processes of the PubMed/MEDLINE database. These up
date processes are usually performed on Tuesdays or Wednesdays.
Both search procedures of the strategy retrieved 138 references.
The references were imported into a local bibliographic database
created using the EndNote™ bibliographic software from Thom
son ISI ResearchSoft. A separate database was created for the re
sults of each search. Though both searches retrieved the same
number of references, the references were compared in order to
be certain whether the references retrieved were identical, and
both searches were.
The American Music Therapy Association recommends search
ing for articles published in the Journal of Music Therapy (http://
www.musictherapy.org/research.html) via the Ingenta database
(www.ingenta.com). As {he Journal of Music Therapy is an official or
gan of the American Music Therapy Association, which recom
mends the use of the Ingenta database, then we expect that the con
tents of the Ingenta database to reflect the contents of the Journal of
Music Therapy. We repeated the search strategy used with
PubMed/ MEDLINE with the Ingenta database to judge whether the
Ingenta database can provide a better alternative to PubMed/MEDLINE, and whether it does in fact reflect the complete contents of
the journal. The searches were carried out on May 15, 2003 and the
results were imported into an Endnote™ bibliographic database.
329
We initially investigated the comprehensiveness and accuracy of
the references identified in the PubMed/ MEDLINE and Ingenta
databases. Both the PubMed/MEDLINE and the Ingenta database
limit the coverage of the JMT based on the date of publication.
Though the Journal of Music Therapy has been published since 1964,
no articles published in this journal before 1977 are referenced in
the PubMed/MEDLINE database. The Ingenta database includes ref
erences only the articles published since 1988. In our initial com
parisons we applied the date of publication limits to the MTWJI
originating from PubMed/MEDLINE and Ingenta databases. Refer
ences identified in the complete PubMed/MEDLINE database have
been compared with references to the Journal of Music Therapy in
the MTWJI between 1977-2002 and the Ingenta search results were
compared to only the 1988-2002 section of the MTWJI. With this
strategy it is possible to assess the accuracy of the databases.
For the purposes of clarity, we provide information about limits
used during search procedures in brackets following the name of
the database throughout this paper. In our comparison of the
PubMed/ MEDLINE, Ingenta and MTWJI databases we have used the
MTWJI (1977-2002) or MTWJI (1988-2002) sections of the data
base. Where only the database name appears (PubMed/MEDLINE,
Ingenta, MTWJI) no limits have been applied and we are referring
to the complete contents of the databases.
After assessing the coverage of the PubMed/ MEDLINE and In
genta databases we investigated the effects of excluded or inaccu
rate references on the representation of certain areas of music
therapy. We searched for both general and specific terms com
monly used in music therapy literature. The general terms we used
for these searches were, 'effect,' 'child,' 'adult,' 'assessment,' 're
search,' 'adolescent,' 'training,' 'survey,' 'treatment,' 'technique,'
'test,' 'review,' 'trial,' and 'psychotherapy.' The more specific terms
used were 'relaxation,' 'singing,' 'dementia,' 'alzheimer's,' 'disabil
ity,' 'anxiety,' 'handicap,' 'vibrotactile,' 'stress,' 'rhythm,' 'improvisa
tion,' 'song,' 'pain,' 'infant,' 'guided imagery,' 'autism,' 'cerebral,'
'palliative,' 'NICU' (Neonatal Intensive Care Unit), and 'aphasia.'
We used both the singular and plural form of terms in our search
strategy where this is applicable. The search was restricted to terms
appearing in the article titles, as there are differences in the ab
stracts and keywords of the PubMed/MEDLINE data and MTWJI. It
is not the aim of this strategy to identify all articles that are related
330
to the topic area. Moreover, it is our intention to demonstrate the
extent of missing literature when simply using terms used in the
titles of the articles.
If we intend to pursue research into publications in the Journal
of Music Therapy, it is unusual that we would freely choose to apply
limits to the date of publication. In the case of a systematic review,
meta-analysis or any other comprehensive literature review, it is
methodologically unsound to apply any limits based on date of
publication. This is a form of database bias (Egger & Smith, 1998).
Bias refers, here, to a variety of reasons why material is not in
cluded in a literature review.
The MTWJI includes bibliographic references to all articles pub
lished in the Journal of Music Therapy since its beginnings in 1964 up
to the most recent issue. To make the effect of the limit of publica
tion date upon the representation of the selected subject areas
transparent, we finally compared the results of searching in the
PubMed/ MEDLINE, Ingenta, and the MTWJI databases for our cho
sen general and specific terms in the titles of Journal of Music Ther
apy articles published before December 2002.
Results
Comparison o/PubMed/MEDLINE and the Music Therapy World
Journal Index (1977-2002)
We initially compared the references identified by PubMed/ MEDLINE and the MTWJI. We consulted data published by Codding
(1987) to confirm the comprehensiveness of the MTW//between
1977 and 1985. The number of references identified by Codding
(1987) and the MTWJI are identical. There is a dramatic difference
however between the number of references identified by
PubMed/MEDLINE and the two other sources (see Figure 1).
When viewing this comparison at a year-by-year perspective the
extent of missing references becomes more transparent (see Figure
2). There is a very large number of articles not identified by the
PubMed/MEDLINE search. PubMed/MEDLINE did not retrieve ref
erences for the years 1988, 1990, and 1993-1997 at all. Only since
1998 are all published articles identified.
Searching PubMed/MEDLINE identified only 54 of the 341 arti
cles published in the Journal of Music Therapy between 1977 and
1997. Expressed in other terms, 84% of journal material cannot be
331
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i
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1
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30
j
I
1
f
"
R«nge of Years
*
19771979
I
ss
i
S
I
1
I
1
1980- 19831982 1985
54
7
49
HMTWJI (1977-2002)
54
49
16
55
15
55
1!
I
K
I
S
1
1
IIi
D Codding (1987)
• PubMed/MEDLINE
1
T—
|
I
•i
i
1
I
y
3
|
f
i"
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|
1
1986-
1989-
1988
1991
8
50
1
e
v^
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1
I
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1
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|
2001
19921994
1995-
-
-
-
-

6
2
0
50
34
47
42
44
50
34
1997
19982000
2002
FIGURE i.
A comparison of the numbers of references to articles published in the JMT
between 1977-2002 identified by Codding (Codding, 1987). PubMed/MEDLINE
(complete), and MTWJI (1977-2002).
identified using this database. This has repercussions on research
strategies where PubMed/MEDLINE reviews are cited.
If we assume that the PubMed/MEDLINE database, as a readily
available and cost free resource for searching literature, is an accu
rate source of music therapy citations, then we are mistaken. Indi
viduals, or institutions, making decisions based on the results of
PubMed/MEDLINE searches will be misled in their decision-making.
The dramatic extent of these results led us to seek explanations for
the missing references with the producers of PubMed/MEDLINE,
the National Library of Medicine.
The National Library of Medicine (NLM) produces a database
that documents the contents of PubMed/MEDLINE. This database
is called LOCATORplus (http://locatorplus.gov/). The Journal of
Music Therapy was first published in 1964 and it is stated in the
LOCATORplus that the NLM owns copies of all issues published
since 1977 Volume 1 Issue 1 (see Figure 3). This could misleadingly
create the impression that all issues have been indexed and can be
identified when searching PubMed/MEDLINE.
It is only when we view the 'Details' page of the entry that it is
CO
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ro
20
18
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o
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i
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• PubMed/MEDLINE
a MTWJI (1977-2002)
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77 1978 979 1980 1981 198 2 198 3 198.i 1985 1985 198 7 1988 1989 1990 199 1 1992 1993 1994 1995 1996 1997 1998 1999 2000|2001 2002
3
1
3
7
7
7
2
5
3
2
6
0
0
0
0
0
16 17
17
18
16
3
0
3
0
2
18
16
15 18
17 19 18
18
19
15 18 17
17
18
16
18 13 16 13 14
15
14 15
15
16 17
Q
o
FIGURE 2.
A year-by-year comparison of the results of searching for articles published in the/MTbefore 2002 in PubMed/MEDLINE (complete)
and the Music Therapy World Journal Index ( 1977-2002).
c
CO
o'
333
Journal of music therapy.
Authors): National Association for Music Therapy.
Title Abbreviation: J Music Ther
Titie: Journal of music therapy.
Description: v. illus.
Publication Date(s): v 1-Mar. 1964-
Publisher: Lawrence. Kan , National Assn. for Music Therapy.
Supersedes: Bulletin of NAMT
ISSN: 0022-2917
NLM Unique ID: 0014162
Other ID Numbers: (DNLM)J30560000(s)
(OCoLC)02308498
Location: General Collection
CaU Number: Wl JO776
NLM Owns: v. 1, no. 1 (1964)--
Status: Not Available v. 39. no. 4 Winter 2002 c. 1 Due on 07/12/2003
PubMed/MEDLINE
FIGURE 3.
holdings of the Journal of Music Therapy shown in the NLM
LOCATORplus.
possible to see the index profile of the Journal of Music Therapy (see
Figure 4). The index profile is described in the LOCATORplus data
base as follows:
•
•
Index medicus v37nl, spring 2000
MEDLINE v!4nln4, winter 1977-v29n4, winter 1992;v37nl,
spring 2000
• PubMed v!4nln4, winter 1977-v29n4, winter 1992;v37nl, spring
2000
• Hospital literature index v!4n4, winter 1977-v29n4, winter 1992
• Psychological abstracts
From this profile we can see that the contents of the Journal of Mu
sic Therapywere not indexed in PubMed/MEDLINE between Volume
29 Number 4 1992 and Volume 37 Number 1 2000. To be certain
about the indexing policies applied to the Journal of Music Therapy,
we have contacted the National Library of Medicine. Through this
communication, it has been possible to gain a clearer impression of
the situation of indexing policy.
334
Journal of music therapy.
Authors): National Association for Music Therapy
Title Abbreviation: J Music Ther
Title: Journal of music therapy.
Publication Date(s): v. 1-Mar 1964-
Publisher: Lawrence, Kan, National Assn. for Music Therapy.
Supersedes: Bulletin of NAMT
Description: v. iflus.
Language: eng
Frequency: Quarterly
ISSN: 0022-2917
Journal Title Code: IZV
Indexed In: Index medicus v?7nl,spring 2000
MEDLINEvl4nln4.winter 1977-v29n4,winter 1992; v37nl,spring 2000-
PubMed vl4nln4,wmter 1977-v29n4.winter 1992; v37nl,spring 2000-
Hospital literature index vl4n4,winter 1977-v29n4,winter 1992
Psychological abstracts
MESH Subjects: Music Therapy
Periodicals
NLM Unique ID: 0014162
Other ID Numbers: (DNLM)J30560000(s)
(OCoLC)02308498
FIGURE 4.
A view of the 'Details' page of the LOCATORplus entry for the Journal of Music Therapy.
The Journal of Music Therapy was selectively indexed between
1977 and 1992 for a database called the Hospital Literature Index.
The American Hospital Association (AHA), in cooperation with
the National Library for Medicine, produced this index that was
later integrated into PubMed/MEDLINE. The AHA indexers se
lected only "articles that in some way touched on health care ser
vices, staffing and personnel, hospitals, or the like" (M Marcetich,
personal communication, March 3 2003) from the Journal of Music
Therapy. Only 54 articles published between 1977 and 1992 were in
cluded in the index. There was no indexing of the Journal of Music
Therapy between 1992 and 2000. The journal was accepted for in
dexing in PubMed/MEDLINE in 2000, and Volume 37 Number 1 was
the first to be indexed completely. There has been no selection
process since 2000, and all articles published after 2000 are indexed.
In addition to the missing references due to indexing policies,
there are some references that may not be found due to errors
335
TABLE 2
A Comparison of the Number of References toJMT Articles Published Before 2002 Using
General Terms in the Title Identified in tfjeMTWJI (1977-2002) and PubMed/MEDLINE
(complete) Databases
Term searched in title
effect/effects
child/ children
adult/adults
research
training
assessment/ assessment
survey/surveys
adolescent/adolescents
treatment/ treatments
technique/ techniques
test/ tests
review/ reviews
trial/trials
psychotherapy
M7"W77 identified
references (1977-2002)
PubMed identified
references
134
47
36
8
25
21
17
16
16
13
11
7
4
3
1
0
7
9
6
3
9
5
5
2
2
2
0
0
stored in the database. The year of publication of Volume 35 Num
ber 1 and 2 has been incorrectly entered in the PubMed/MEDLINE
database. The entries read '1999' and not as '1998'. This leads to a
curious situation whereby PubMed retrieves eight references more
than were actually published in 1999 and there are eight missing
references from 1998.
There is a dramatic amount of articles not identified by PubMed/
MEDLINE (see Table 2). The under-representation of key elements
of the music therapy literature is particularly obvious if we consider
the amount of research material missing from the PubMed/MEDLINE
results. If we search for article titles that use the terms 'effect," 're
search,' 'assessment,' 'survey,' and 'review' there is a sum of 131,
from 190 articles, that are not identified. When searching for the
terms 'child,' and 'adult,' there is also a deficit; PubMed/MEDLINE
does not identify 57 of 72 references, in which the term 'child' or
'adult' appears in the title. After searching for general terms in the
titles of articles, we continued to investigate references using more
specific terms in the titles. Once again, there is a large amount of
the literature not identified by PubMed/MEDLINE (see Table 3).
Seven of the terms searched—'handicap,' 'vibrotactile,' 'pain,'
'cerebral,' 'palliative,' 'NICU,' 'aphasia'—were not identified at all by
336
TABLE 3
Specific Terms in the Title Identified in (AeMTWJI (1977-2002) andPubMed/MEDLINE
(complete) Databases
MTWJJ identified
references (1977-2002)
relaxation
singing
dementia/ dementias
alzheimer's
disability/disabilities
anxiety
handicap/handicapped
vibro tactile
stress
rhythm/rhythms
improvisation
song/songs
pain
infant/infants
guided imagery
autism
cerebral
palliative
NICU (Neonatal Intensive Care Unit)
aphasia
19
12
12
12
12
11
10
8
7
6
6
5
5
5
4
3
2
1
1
1
PubMed identified
references
4
3.
4
3
5
2
0
0
4
1
2
2
0
2
2
1
0
0
0
0
PubMed/MEDLTNE. PubMed/MEDLINE identified 25% or less of the
tides using the terms 'dementia' or 'Alzheimer.' PubMed/MEDLINE
does not identify the complete material published between 1977
and 2002 for any one of the terms searched.
A Comparison of the Ingenta Database and the Music Therapy World
Journal Index (1988-2002)
The archives of the Ingenta database are stated to cover the range
Volume 25 1988 to Volume 39 2002 of the Journal of Music Therapy.
As the Journal of Music Therapy was first published in 1964 there is
an information gap between what has appeared in print and what
is indexed in the database. Between 1964 and 1988 there were 422
articles published in the Journal of Music Therapy that are missing. A
search for the ISSN 0022-2917 (JMT) identified 233 references in
Ingenta, as did a search using the complete journal name. To be cer
tain about the contents of these references, we compared each of
the references with our MTWJournal Index (1988-2002).
337
TABLE 4
A Comparison of the Number of References to JMT Articles Published Before 2002 Using
General Terms in the Title Identified in the MTWJI (1988-2002) and Ingenta (complete)
Databases
effect/effects
child/children
adult/ adults
assessment/ assessments
research
adolescent/ adolescents
training
survey/surveys
technique/techniques
test/ tests
review/ reviews
trial/trials
psychotherapy
MT\Vjl identified references
( 1988-2002)
Ingenta identified
references (existing
identified references)
86
27
19
9
86
25
16
8
7
7
6
3
5
5
5
4
4
3
3
1
0
4
4
4
3
4(3)
1
0
For the period 1988 Volume 25 to 2002 Volume 39, 233 refer
ences were found in Ingenta. In this period, 234 articles (not book
reviews or editorials) were published in the Journal of Music Therapy.
The references begin unexpectedly with Volume 25 No. 3. Volume
25 numbers 1 and 2 are completely missing from the database.
More surprising is the complete omission of Volume 25 Issue 4
(listed as Gunsberg, 1988; Gfeller & Baumann, 1988; James, 1988;
Hughes, Robbins, & King, 1988).
All four articles in the 1989 Volume 26 number 4 issue, occur as
double entries (listed as Davis & Thaut, 1989; Pearsall, 1989,
Burleson, Center, & Reeves, 1989; Eidson, 1989). Of these double
entries one surname appears with different spellings (Persall &
Pearsall). Even more disturbing is the appearance of references to
the same four articles published in 1989, a year later in 1990. The
author Pearsall, alias Persall, appears this time as Pearsal.
The correct citation of authors is questionable. Ruth V. Brittin
does not appear as co-author in the article titled 'Aesthetic re
sponse to music: Musicians versus nonmusicians' in 1993 Volume
30 No. 3, pp. 174-191 (Madsen, Byrnes, Capperella-Sheldon, &
Brittin, 1993). The order of authors' names has been altered so
that the article appears under the name Capperella-Sheldon and
338
TABLE 5
A Comparison of the Number of References (oJMT Articles Published Before 2002 Using
Specific Terms in the Title Identified in the MTWJI (1988-2002) and Ingenta (complete)
Databases
MTW/I identified
references
(1988-2002)
relaxation
singing
dementia/dementias
alzheimer's
anxiety
vibrotactile
stress
rhythm/ rhythms
improvisation
song/songs
pain
infant/infants
guided imagery
autism
cerebral
palliative
NICU (Neonatal Intensive Care Unit)
aphasia
10
11
Ingenta identified
12(10)
10
12
13(12)
12
10
12
10
9
11(9)
4(2)
2
8
4
3
0
5
1
3
4
2
0
1
1
1
8
4
2
0
5
1
3
2
2
0
1
1
1
not Madsen. Pavlicevic, Trevarthen, and Duncan, 1994 appears as
Paclicevic in Volume 31 No. 2. O'Callaghan, 1996 appears as
Ocallaghan in Volume 33 No. 2. Four of the published editorials
and guest editorials have been included in the index of articles
(Flowers, 1995; Forinash & Lee, 1998; Price, 1995; Standley, 1995).
Although there are a large number of terms in titles identified by
Ingenta, there are articles that are not identified (see Table 4). The
tides including the terms 'child,' 'adult,' 'assessment' and 'survey'
were not comprehensively identified. Because of the aforemen
tioned duplicate references, the term 'review' identifies more arti
cles than have been actually published. The number of those ref
erences identified that actually exist is shown in brackets in the
table (see Table 4).
When searching for more specific terms there are some terms that
are completely identified in the references stored in the Ingenta data
base (see Table 5). These terms include 'dementia,' 'alzheimer's,'
'anxiety' and 'vibrotactile.' Ingenta identifies some terms in tides
339
TABLE 6
General Terms in the Title Identified in the MTWJI (complete), Ingenta (complete) and
PubMed/MEDLINE (complete) Databases
Terms searched in title
effect/effects
child/children
research
adult/ adults
training
adolescent/adolescents
survey/surveys
technique/techniques
test/ tests
psychotherapy
review/ reviews
trial/trials
M'I'WJI identified
references
156
83
31
30
24
21
19
16
12
7
6
3
1
Ingenta identified
PubMed
identified
references
86
25
36
8
9
8
16
7
4
5
7
6
4
5
9
5
4
3
0
4(3)
1
2
2
0
2
0
more times than exist in reality (actual results are shown in brackets
in the table). These over-represented terms are 'relaxation,' 'de
mentia,' 'anxiety' and 'handicap.' Specific terms are more compre
hensively identified in the Ingenta database than PubMed/MEDLINE.
It is possible to identify a larger amount of articles published in
the Journal of Music Therapy by searching the Ingenta database than by
searching PubMed/MEDLINE. But there are some parts of the mate
rial published between 1988 and 2002 that cannot be identified by
searching Ingenta. Articles published in the Journal of Music Therapy
before 1988 cannot be identified by searching the Ingenta database.
The MTWJI: A Database Without Limits to Publication Date
Through applying limits to publication dates, the Ingenta and
PubMed/MEDLINE database prohibit the identification of a large
amount of the material published in the Journal of Music Therapy
(see Table 6). For the terms 'research' and 'treatment,' 'adoles
cent,' and 'survey' PubMed/MEDLINE identifies more of the arti
cles than Ingenta.
A graphic illustration of the differences between the numbers of
articles identified when searching for general terms that appear in
titles makes clear the effect of the missing references in the Ingenta
and the PubMed/MEDLINE databases when compared to the com
340
• MTWJI
Identified
references
Dlngenta
Wemffled
references
FIGURE 5.
A comparison of the number of references to JMT articles published before 2002
using general terms in the title identified in the MTWJI (complete), Ingenta
(complete) and PubMed/MEDLINE (complete) databases.
plete index of all articles published in the Journal of Music Therapy
stored in the MTWJI (see Figure 5). If we search for the term 'psy
chotherapy,' in either Ingenta or PubMed/MEDLINE, we will simply
not find the six references that are published in the Journal of Mu
sic Therapy due to the indexing policies (indicated order: Douglass
& Wagner, 1965; Boenheim, 1966; Butler, 1966; Boenheim, 1967;
Boenheim, 1968; Bonny & Pahnke, 1972). Similarly, terms that
have been commonly used in titles throughout the publication
period of the Journal, such as 'effect,' 'child,' 'adult,' 'research,' 'as
sessment,' 'training,' 'survey,' and 'treatment' are grossly under
represented by both Ingenta and PubMed/MEDLINE databases.
We carried out a comparison of the results of searching the three
databases using more specific terms (see Table 7). As we read ear
341
TABLE 7
A Comparison of the Number of References to JMT Articles Published Before 2002 Using
Specific Terms in the Title Identified in the MTWJI (1988-2002), Ingenta (complete) and
PubMed/MEDLINE (complete) Databases
Term searched in tide
relaxation
singing
anxiety
alzheimer's
dementia/ dementi as
song/songs
vibro tactile
rhythm/rhythms
stress
infant/infants
pain
guided imagery
improvisation
autism
cerebral
palliative
NICU (Neonatal Intensive
Care Unit)
aphasia
MTWfl identified
references
19
16
14
14
13
12
12
11
8
7
Ingenta identified
PubMed.
identified
references
12(10)
4
3
10
10
11(9)
12
13(12)
5
4(2)
8
2
6
6
5
4
3
3
3
1
1
4
3
1
1
2
0
5
2
3
4
2
0
0
1
4
2
0
2
2
2
1
0
1
1
0
0
0
1
0
Her, Ingenta identifies the use of more specific terms in the titles
compared with PubMed/MEDLINE. Ingenta applies a limit to publi
cations appearing in the journal since 1988. If we look for the term
'vibrotactile,' it is identified by the Ingenta database on eight occa
sions. PubMed/MEDLINE does not identify this term at all. A
scrutiny of the publication dates for these eight articles shows that
the term was used in paper titles in 1989, 1990, twice in 1991, and
again in 1992,1994,1996 and 1997. We assume that the topic was of
interest during this period and persons responsible for indexing
were aware of its value.
Discussion
Evidence for the benefit of therapeutic effect, through systematic
reviews, meta-analyses, or qualitative meta-synthesis is a developing
field of research. After formulatinga research question, the first
342
step is to carry out searches of electronic databases. The underpin
ning of our research is built from the results obtained from these
searches. Whereby systematic searches for literature should include
searches of many various databases, hand searches of journals, and
searches of reference lists, these processes may only be possible
within the context of larger research projects. If we are to encour
age research, then we need to support all potential researchers
with adequate resources, particularly those with limited access to
institutional resources. One of these sources of support will be a
comprehensive database.
The results of database searches determine the quality of a study
and influence any preliminary hypotheses or the generation of
working ideas. As the Journal of Music Therapy is the only music
therapy journal indexed in the PubMed/MEDLINE database, and only
approximately 20% of the articles published in the Journal of Music
Therapy are represented, then the results of studies that rely on this
database will be compromised. Some areas are not identified at all. In
genta is well represented but limited in time and therefore cannot be
used to identify all articles published in the Journal of Music Therapy.
Indexing, according to title words, is a matter of policy and de
pendent upon concepts popular at the time, the awareness of the
indexer and editorial decisions made by the compiling agency. If
we wish to scrutinize databases, then our searches will only be as
good as the indexing policy of the database compilers and the com
prehensiveness of the data. Schneider (1968) discussed, in an arti
cle published in the Journal of Music Therapy, the role professional
literature plays in both the development of a profession and in de
termining the image of the profession. In this article, not indexed
by the PubMed/MEDLINE or Ingenta databases, he stated, "the
amount, type, and quality of such literature, not only serves as an
in-service media for the membership group, but it also creates, as
official documents, an image of the group to its members, and to
members of allied disciplines" (p. 3). The secondary documenta
tion of articles in bibliographic databases must be comprehensive
as it affects the perception of the profession to which it belongs. An
awareness of the existence of published material for potential read
ers is of importance both for the development of the profession
and accuracy of the image of the profession perceived by others.
The 'right to treat' in health care delivery is ever-increasingly de
termined by evidence gained from published research. Unless we
343
have accurate data sources of published material, our work will be
under-represented, and inaccurate. We need, therefore, a sound
comprehensive database for music therapy research. By creating the
new Music Therapy World Journal Index we aim to combat the under
representation of music therapy literature by providing a compre
hensive resource of references from all journal sources. This is an
international service, free of user access costs, intended to support
researchers and clinicians interested in furthering the evidential
support for music therapy. We are currently working with other
music therapy journals to index their material. The process of in
dexing the CanadianJournal of Music Therapy and the Latin-American
Journal of Music Therapy is in preparation. We need urgently to in
clude foreign language material as other journals begin to develop.
In this paper we have compared the contents of the PubMed/
MEDLINE and Ingenta database with the Music Therapy World Journal
Index. We hope that this current article is successfully indexed in
the PubMed/MEDLINE and Ingenta databases by appearing in this
journal. If this is the case, then there will be a chance that users of
the database may see that there is more to the Journal of Music Ther
apy, and indeed the profession of music therapy, than meets the
eye—in PubMed/MEDLINE and Ingenta at any rate.
References
Boenheim, C. (1966). Music and group psychotherapy. Journal of Music Therapy, 3,
49-52.
Boenheim, C. (1967). The importance of creativity in contemporary psychother
apy. Journal of Music Therapy, 4, 3—6.
Boenheim, C. (1968). The position of music and art therapy in contemporary psy
chotherapy. Journal of Music Therapy, 5, 85—87
Bonny, H. L., & Pahnke, W. N. (1972). The use of music in psychedelic (LSD) psy
chotherapy. Journal of Music Therapy, 9, 64-67.
Burleson, S. J., Center, D. B., & Reeves, H. (1989). The effect of background music
on task performance in psychotic children.Journal of Music Therapy, 26, 198-205.
Butler, B. (1966). Music group psychotherapy. Journal of Music Therapy, 3, 53-56.
Clarke, M., & Oxman, A. (Eds.). (2001). Cochraine miiewer's handbook 4.1.5 [updated
April 2002] (4.1.5 ed. Vol. 2). Oxford: Update Software. Updated quarterly.
Codding, P. A. (1987). A content analysis of the Journal of Music Therapy, 1977-85.
Davis, W. B., & Thaut, M. H. (1989). The influence of preferred relaxing music on
measures of state anxiety, relaxation, and physiological responses. Journal of Mu
sic Therapy, 26, 168-187.
Dickersin, K., Scherer, R., & Lefebvre, C. (1994). Systematic reviews: Identifying rel
evant studies for systematic reviews. BritishJournal of Medicine, 309, 1286-1291.
344
Douglass, D. R., & Wagner, M. K. (1965). A program for the activity therapists in
group psychotherapy. Journal of Music Therapy, 2, 56-60.
Egger, M., & Smith, G. D. (1998). Meta-analysis bias in location and selection of
studies. EM], 316, 61-66.
Eidson, C. E. J. (1989). The effect of behavioral music therapy on the generaliza
tion of interpersonal skills from sessions to the classroom by emotionally handi
capped middle school students. Journal of Music Therapy, 26, 206-221.
Flowers, P.J. (1995). Guest Editorial. Journal of Music Therapy, 32, 206.
Forinash, J., & Lee, C. (1998). Guest Editorial. Journal of Music Therapy, 35, 142.
Gfeller, K., & Baumann, A. A. (1988). Assessment procedures for music therapy
with hearing impaired children: Language development. Journal of Music Ther
apy, 25, 192-205.
Greenhalgh, T. (2001). How to read a paper: The basics of evidence based medicine. Lon
don: BMJ Books.
.
Gunsberg, A. (1988). Improvised musical play: A strategy for fostering social play
between developmentally delayed and nondelayed preschool children. Journal
Hanser, S. B., Larson, S. C., & O'Connell, A. S. (1983). The effect of music on re
laxation of expectant mothers during labor.Journal of Music Therapy, 20, 50-58.
Hughes, J. E., Robbins, B. J., & King, R. J. (1988). A survey or perception and atti
tudes of exceptional student educators toward music therapy services in a
county-wide school district. Journal of Music Therapy, 25, 216-222.
James, M. R. (1988). Music therapy values clarification:A positive influence on per
ceived locus of control. Journal of Music Therapy, 25, 206-215.
Madsen, C. K., Byrnes, S. R., Capperella-Sheldon, D. A., & Brittin, R. V. (1993). Aes
thetic response to music: Musicians versus nonmusicians./ourna/ of Music Ther
apy, 30, 174-191.
MEDLARS. (2001). Introduction to web-based Searching: Using PubMed, the NLM
Gateway and ClinicalTrials.gov. Retrieved October 10, 2001, from: http://www.
nlm.nih.gov/pubs/web_based.html
O'Callaghan, C. C. (1996). Lyrical themes in songs written by palliative care pa
tients. Journal of Music Therapy, 33, 74-92.
Pavlicevic, M., Trevarthen, C., & Duncan,J. (1994). Improvisational music therapy
and the rehabilitation of persons suffering from chronic schizophrenia. Journal
Pearsall, E. R. (1989). Differences in listening comprehension with tonal and atonal
background music. Journal of Music Therapy, 26, 188-197.
Price, H. E. (1995). Guest Editorial. Journal of Music Therapy, 32, 134.
Schneider, E. M. (1968). Professional literature: Creator of an image.Journal of Mu
sic Therapy, 5, 3-5.
Standley.J. M. (1995). Editorial. Journal of Music Therapy, 32, 64.
345
INDEX TO VOLUME XL (2003)
The number in parentheses indicates the issue in which the arti
cle will be found; the final number indicates the page.
Aldrige, D. See Gilbertson, S. K.
Brooks, D. A history of music therapy journal articles published in the English lan
guage, 40(2), 151.
Brotons, M., & Marti, P. Music therapy with Alzheimer's patients and their family
caregivers: A pilot project, 40(2), 138.
Cevasco, A. M., & Grant, R. E. Comparison of different methods for eliciting exercise
to-music for clients with Alzheimer's disease, 40(1), 41.
Christ, A. See Gfeller, K.
Glair, A. A. See Hamburg, J.
Davis, W. B. Ira Maximilian Altshuler: Psychiatrist and Pioneer Music Therapist,
40(3), 247.
DeLoach Walworth, D. The effect of preferred music genre selection versus pre
ferred song selection on experimentally induced anxiety levels, 40(1), 2.
Geringer.J. M. See Johnson, C. M.
Gfeller, K., Christ, A., Knutson, J., Witt, S., & Mehr, M. The effects of familiarity and
complexity on appraisal of complex songs by cochlear implant recipients and
normal hearing adults, 40(2), 78.
Gilbertson, S. K., & Aldrige, D. Searching PubMed/MEDLINE, Ingenta, and the Mu
sic Therapy World Journal Index for articles published in the Journal of Music Ther
apy, 40(4), 324.
Grant, R. E. See Cevasco, A. M.
Hamburg, J., & Clair, A. A. The effects of a movement with music program on mea
sures of balance and gait speed in healthy older adults, 40(3), 212.
Hideki, T. See Iwaki, T.
Hilliard, R. E. The effects of music therapy on the quality of life of people diagnosed
with terminal cancer, 40(2), 113.
Hirokawa, E., & Ohira, H. The effects of music listening after a stressful task on im
mune functions, neuroendocrine responses, and emotional states in college
students, 40(3), 189.
Hori, T. See Iwaki, T.
Iwaki, T., Hideki, T, & Hori, T. The effects of preferred familiar music on falling
asleep, 40(1), 15.
Jackson, N. A. A survey of music therapy methods and their role in the treatment of
early elementary school children with ADHD, 40(4), 302.
Johnson, C. M., Geringer.J. M., & Stewart, E. E. A description analysis of Internet in
formation regarding music therapy. 40(3), 178.
Knutson, J. See Gfeller, K.
Marti, P. See Brotons, M.
Mehr, M. See Gfeller, K.
Ohira, H. See Hirokawa.
Pargman, D. See Wininger, S. R.
346
Perry, M. M. Rainey. Relating improvisational music therapy with severely and mul
tiply disabled children to communication development, 40(3), 227.
Rickson, D. J., & Watkins, W. G. Music therapy to promote prosocial behaviors in ag
gressive adolescent boys: A pilot study, 40(4), 283.
Robb, S. Music interventions and group participaton skills of preschoolers with vis
ual impairments: Raising questions about music, arousal, and attention, 40(4),
266.
Silverman, M. J. The influence of music on the symptoms of psychosis: A meta
analysis, 40(1), 27.
Stewart, E. E. See Johnson, C. M.
Watkins, W. G. See Rickson, D. J.
Wininger, S. R., & Pargman, D. Assessment of factors associated with exercise enjoy
ment, 40(1), 57.
Witt, S. See Gfeller, K.
RESEARCH PUBLICATION/PRESENTATION CODE OF ETHICS1
Research Publication/Presentation Code of Ethics
1. Multiple submissions—An author must not submit the same manuscript for simultane
ous consideration by two or more journals. If a manuscript is rejected by one journal, an
author may then submit it to another journal.
2. Duplicate publication—An author must not submit a manuscript published in whole or in
substantial part in another journal or published work. Exceptions may be made for previous
publication (a) in a periodical with limited circulation or availability (e.g., a government
agency report) or (b) in an abstracted form (e.g., convention proceedings). Any prior publi
cation should be noted and referenced in the manuscript, and the author must inform the
editor of the existence of any similar manuscripts that have already been published or ac
cepted for publication or that may be submitted for concurrent consideration to the journal
or elsewhere.
3. Piecemeal publication—Investigators who engage in systematic programs of research re
port their results from time to time as significant portions of their programs are completed.
This is both legitimate and inevitable in research programs that are on very large scales or
of several years' duration. In contrast to this kind of publication, articles are received in
which a single investigation has been broken up into separate manuscripts submitted seri
atim. Authors are obligated to present work parsimoniously and as completely as possible.
Data that can be meaningfully combined within a single publication should be presented to
gether. Authors who wish to divide reports of studies into more than one article must inform
the editor.
4. Authorship—Authorship is reserved to those who make major contributions to the re
search. Credit is assigned to those who have contributed to a publication in proportion to
their professional contributions. Major contributions of a professional character made by
several persons to a common project are recognized by joint authorship, with the individual
who made the principal contribution listed first. Minor contributions of a professional char
acter and extensive clerical or similar assistance may be acknowledged in endnotes or in
an introductory statement. Acknowledgement through specific citations is made for un
published as well as published material that has directly influenced the research or writing.
Persons who compile and edit material of others for publication publish the material in the
name of the originating group if appropriate, with their own names appearing as chairper
son or editor. All contributors are to be acknowledged and named.
5. Copyright—Once an article is accepted, an author transfers literary rights on the published
article to the publishing organization (e.g., MENC) so that the author and the association are
protected from misuse of copyright material. An article will not be published until the au
thor's sinned copyright transfer has been received by the national office of the publishing
organization. Contributors are responsible for obtaining copyright clearance on illustrations,
figures, or lengthy quotes used in their manuscripts that have been published elsewhere.
6. Conference presentation—Papers submitted for presentation via any format (i.e., posters,
paper-reading sessions) should not have been presented at another major conference. If
the data have been presented in whole or substantive part in any forum, in print, or at pre
vious research sessions, a statement specifying particulars of the above must be included
with the submission.
NOTE: Any violation of the Code of Ethics will result in immediate rejection of the manu
script/paper, without further consideration.
1
This version of the Code of Ethics was adopted in Nov. 1998. The material is based on the
following sources: American Psychological Association. (1994). Publications Manual (4th ed.).
Washington, DC and "Ethical Principles of Psychologists." (1981). American Psychologist, 36,
633-638.
±L±i;l±l±
Be nwpy AHCatton. Mss
r
INFORMATION TO CONTRIBUTORS
Manuscripts should be addressed to Editor, JOURNAL OF
MUSIC THERAPY, Center for Music Research, The Florida State
University, Tallahassee, Florida 32306-1180. Five copies of the
manuscript must be submitted and must conform with the most
recent style requirements set forth in the PUBLICATIONS MANUAL (5th ed.) for the American Psychological Association (APA).
For historical or philosophical papers, Chicago (Turabian) style is
also acceptable. An abstract of 150-200 words should accom
pany the manuscript.
Since manuscripts are sent out anonymously for editorial review,
the author's name and affiliations should appear only on a sep
arate page. Authors are also requested to remove all identifying
personal data from submitted articles
Manuscripts will be acknowledged upon receipt by the Editor
and will not be returned. Contributors can usually expect a deci
sion concerning the acceptability of a manuscript for publication
within 2-3 months after receipt. Accepted articles will ordinarily
appear in print within 12 months after acceptance.

Journal of Music Therapy, Volume 40, Number 4, Winter 2003

Transcription

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