ADHD Techniques

Joumal of Music Therapy, XL (4), 2003, 302-3230 2003 by the American Music Therapy Association

A Survey of Music Therapy Methods andTheir Role in the Treatment of EarlyElementary School Children with ADHD

Nancy A. Jackson

Temple University

Attention-Deficit Hyperactivity Disorder (ADHD) has recentlybeen receiving more frequent attention in professional cir-cles and in the press, and some sources would assert that itsoccurrence in the general population is consistently growing.Because music therapists often work with preschool andschool-age children, it is likely that they will increasingly betreating children with a diagnosis of ADHD. However, there islittle in the music therapy literature about music therapytreatment 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 isperceived to be, and the role that music therapy treatmentplays in relation to other forms of treatment. Results of thesurvey indicated that music therapists often utilize a numberof music therapy methods in the treatment of children withADHD. 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 ofdifferent sources, although parents and teachers were indi-cated to be the most frequent referral sources. Most childrenwith ADHD receiving music therapy services also receiveother 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 ofmusic therapy with ADHD are identified.

The author -vishes to express sincere gratitude to Cheryl Dileo, PhD, for guid-ance and encouragement throughout the completion of this projecL

VoL XL, No. 4, Winter 2003

Attention-Deficit Hyperactivity Disorder (ADHD) is a diagnosiswhich creates controversy regarding every aspect of the disorderfrom 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 typicallyseen in other individuals of the same developmental level, andwhich 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 specificdefinition of the disorder, with different sources identifying any-where from two to seven sub-types, each of which suggests differingetiologies (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 lackof agreement in how to define the disorder, but also because manyof the symptoms of ADHD, such as inattention, hyperactivity, im-pulsivity, poor behavioral control, learning difficulties, anxiety, anddisrupted 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-morbidwith ADHD (American Academy of Pediatrics, 2000). Burchamand DeMers (1995) indicated that a comprehensive assessment ofADHD requires information from multiple sources, and must de-termine the extent to which ADHD characteristics are actuallypresent, the extent to which these characteristics can be attributedto some cause other than the disorder, and the extent to which thecharacteristics are interfering in the child's global functioning.However, assessment for ADHD, which generally occurs in theoffices of pediatricians and general family practitioners, is notstandardized, leading to misdiagnoses, which include both over-diagnosis and under-diagnosis (Carey, 1999).

In light of the difficulties present in defining and assessingADHD in children, it comes as no surprise that proper treatment ofthe disorder is also a matter of controversy. In reviewing the litera-ture on ADHD, it is clear that clinicians generally feel that treatmentwith stimulant medication, usually methylphenidate, is by far the

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most efficacious treatment (Johnson, 1988), and historically, it hasbeen 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, thepoor monitoring of patient response to medication, and the lack ofcareful 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 behavioralchange 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 isnot the single or ultimate answer for treating children with ADHD.

Behavioral therapy frequently appears in literature on ADHDeven though numerous studies have shown that behavior therapyinterventions, and self-management strategies in particular, havebeen 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 behavioraltherapy treatment alone, but also found that multimodal treatmentwas not significantly more effective than stimulant treatment alonefor the core symptoms of ADHD (MTA Cooperative Group, 1997).

A notable lack of literature is to be found on other forms oftreatment 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 ofspecific tones embedded in white noise to modulate brainwavefunction, 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), toencourage creative growth (Smitheman-Brown & Church, 1996),and as part of a multimodal approach to address interpersonal andsocial problems associated with ADHD (Henley, 1998).

Likewvise, literature on the use of music therapy to treatADHD issparse at best. Background music has been shown to reduce hyper-activity and other unwanted behaviors for those with attentiondeficits (Cripe, 1986; Pratt, Abel, & Skidmore, 1995). Rock musicwas used in conjunction with a time-out procedure as negative re-

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inforcement for effectively decreasing inappropriate or disruptivebehavior (Wilson, 1976). Montello and Coons (1996) studied theeffects of active versus passive music interventions, and found thatthose with severe attentional deficits might benefit most from lis-tening interventions that do not require the internal structure thatactive 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), andthe 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 thedifferent music therapy approaches that best fit these differingtheories has numerous implications for treatment of children withADHD 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 inchildren, and Morton, Kershner, and Siegel (1990) who demon-strated that music enhances the effect of dichotic listening, whichmay 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, thereappears to be good reason to support further investigation into theways that music might be used to effectively treat children withADHD. More information is needed about how music therapy isbeing used clinically for the treatment of ADHD, however, andthose currently working with these children can best provide thatinformation. Therefore, it was the purpose of this survey to ascer-tain what music therapy methods are being used for children withan ADHD diagnosis, how effective this treatment is perceived to be,and the role that music therapy treatment plays in relation to otherforms of treatment.

Method

Subjects

A sample of board-certified music therapists was randomly se-lected from members of the American Music Therapy Association

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(AMTA) who had identified themselves in the AMTA 2001 annualsurvey as working with populations likely to include early elemen-tary school children. Only practicing, board-certified clinicianswere selected from these categories, with students and others beingexcluded. Using these filters, AMTA identified 1116 music thera-pists who matched the criteria for the study, from which 500 wererandomly 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, wasused 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 andreturn 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 todetermine if the number of responses received was sufficient to beconsidered a representative sample. The responses from the re-turned questionnaires were then compiled into aggregate form foranalysis 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 anoverall return rate of 54%. Of those responses, 98, or 37% of theresponses 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 wvas compiled utilizing the Systat program, and the resultswere 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 theyuse to treat children diagnosed with ADHD. These results areshown in Table 1. Music and movement was the method that mostrespondents indicated they use with this population, followed byinstrumental improvisation, musical play, and group singing, re-

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TABLE I

Music Therafty Methods Usedfor Treating ADHD Children

MIsethod Number of respondecits Pcrcenitage

Music and movement 73 74%Instrumental improvisation 66 67%Musical play 62 63%Group singing 54 55%Instrumental instruction 46 '47%Other creative arts 35 36%Music assisted relaxation 31 32%Vocal improvisation 22 22%Mainstreamed music education 17 17%Orff-Schulwerk 16 16%Nordoff-Robbins 5 5%Vocal instruction 5 5%Other 22 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" byrespondents included song writing, recreational music, educational music activities

for speech and skill development, music and sensory integration, music attentiontraining, hand bell choir, and music and equine-assisted therapy.

spectively. Most respondents indicated that they use two or moremethods, with only 2% indicating only one method.

Goals Addressed by Music Therapy Methods

Subjects were asked to indicate the types of goals they address inmusic therapy for children with ADHD. Behavioral goals were iden-tified by 92 respondents (94%), psychosocial goals were identifiedby 87 respondents (89%), and cognitive goals were identified by 68respondents (69%). Most respondents indicated that they addresstwo or more types of goals, and 81 (83%) ranked the types of goalsaccording 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 themusic therapy methods identified by respondents. Regardless ofmethod employed, behavioral goals were indicated as the type mostaddressed, followed by psychosocial goals; then cognitive goals. |

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TABLE 2

PerceivedEffectiveness of Music Therapy Treatmen forADHD

Treatment outcomes Otier professionals Teachers Parena Children

Number 98 93 82 81 94Percentage 100% 95% 84% 83% 96%Range 3 3 3 2 3Mean 4.1 4.1 4.1 4.1 4.3

Note. Effectiveness ratings represent the respondents' perceptions, and were basedon 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 reportedratings. 'Mean" is the average rating in each category.

Music Therapy TreatmentFarmatsforADHD Children

Subjects were asked to identify the format of their treatment ofADHD children. Forty respondents (41%) indicated that they seethese children in both group and individual formats, followedclosely by 38 respondents (39%) who see children only in a groupformat. Twenty respondents (20%) indicated that they treatADHDchildren individually. The questionnaire did not ask the subjects tospecify the type of setting in which they treat these children, butmany respondents added this information. These settings includededucational, residential, community-based, acute hospital, and psy-chiatric treatment settings.

Perceived Effectiveness of Music Therapy Treatment forADHD

Subjects were asked to rate the effectiveness of music therapytreatment 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 theresponses of the children receiving music therapy (Table 2). Ingeneral, respondents' indicated that music therapy treatment is ef-fective according to their treatment outcomes, and they perceivedthat 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 sortedaccording 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,

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TABLE 3

Treatments Used in Conjunctian with Music TherapyforADHD

7Bpe Number Percentage Percentage of total

Medication 85 91% 87%Psychological services 52 56% 53%Occupational therapy 51 55% 52%Nutrition 27 29% 28%Other creative arts 25 27% 26%Physical therapy 25 27% 26%Speech therapy 5 5% 5%Therapeutic recreation 5 5% 5%Massage 3 3% 3%Chiropractic 1 1% 1%Other 18 19% 18%

Note. Subjects were asked to identify all other treatments being used in conjunctionwith music therapy for ADHD. 'Percentage" is the percentage of respondents whoindicated 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" orbetter (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 inconjunction with other forms of treatment for ADHD, and if so, tospecify what other treatments are used. Of the 98 respondents, 93or 95%, indicated that other treatments were used (Table 3). Mostof these respondents indicated that medication was the most fre-quently used conjunctive treatment, followed by psychological ser-vices and occupational therapy, respectively.

Referral Sourcesfor Music Therapy Treatment of ADHD

Referral sources from which respondents receive music therapyreferrals for children with ADHD are shown in Table 4. Respon-dents indicated that parents and teachers are the most frequentsources of referrals to music therapy for ADHD children, followedclosely by treatment teams. Subjects were also asked if their facilityuses an Individualized Education Plan (IEP), and, if so, if musictherapy is mandated on that form. Twenty-nine respondents (29%)

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TABLE 4

Music Therapy Refermal SoutresforADHD Clhildren

Source Number Perccnuge

Parents 43 44%Teachers 31 32%Treatment team 29 30%IEP 14 14%Physician 13 13%School guidance counselor 13 13%Psychologist or therapist 10 10%Other 36 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 respondentsidentifying 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 IEP-mandatedmusic therapy also come from numerous sources, and not solelyfrom 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 playsin the treatment of ADHD as primary, multidisciplinary, or adjunc-tive. A notable majority of the respondents (71 or 73%) describedmusic therapy's role with this population as multidisciplinary. A fewrespondents also indicated that the role music therapy plays intreatment for these children is case-specific, and may be describedin any of these three ways, dependent upon the setting, the referralsource 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 thesewould be helpful to the study and who chose to include them.These additional comments, which are grouped in categories, arepresented in Table 6. Of all the respondents, 19 or 19%, chose toadd comments to the questionnaire.

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TABLE 5Referral SourcesforIEP-mandated Music Tlherapy

Source Number Percentage

Parents 15 52%IEP 11 38%Teachers 10 34%Treatnent team 9 31%Psychologist 3 10%Physician 3 l 10%Guidance counselor 2 7%Other 12 41%

Note. This table presents the referral sources for those respondents who indicaiedthat music therapy is specifically mandated on the IEP in their facility. Subjects wereasked to identify all sources from which they receive referrals. The total number ofrespondents represented in this table is 29. 'Number" is the number of respondentsidentifying each referral source. "Percentage" is the percentage of the 29 respon-dents represented herein.

Discussion

A random sample of 500 music therapists were surveyed aboutthe treatment of early elementary school children with ADHD, re-sulting in the receipt of 98 questionnaires completed by musictherapists working with this population. Because of the 54% over-all return rate for the quiestionnaire, and because responses werereceived from all regions, of the country, it is not unreasonable toassume that the results provide a generally accurate picture of howmusic therapists are working with this population.

Music Therapy Methods Used with ADHD Children

Respondents identified many different types of music therapymethods they use with ADHD children, and they combined thesemethods in many different groupings, none of which showed anyparticular trends. One would wonder, then, why music and move-ment, instrumental improvisation, musical play, and groupsinging were each identified by more than 50% of the respon-dents. Perhaps there is a shared element or elements that lead totheir more frequent use. Or, perhaps further investigation wouldshow that the frequent use of these methods has more to do withthe age of the child than with the diagnosis. Or again, perhapsthe choice of method has some correspondence with the type ofsetting. For instance, is group singing identified more often be-

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TABLE 6Respondents'Additional Comments About Music Tlherapy and ADHD

Catcgory Commenu

Methods use methods that are multi-sensory (2)use iso-principle-based activities (2)improvisation allows the children to lead and create within

a structureafter a structured group music activity, give music choice

time for children to pick an instrument to play, or pick aselection to listen to

sensory integration is important for younger and lower levelchildren

use group music activities that require attention, turn-taking,and responding to cues

Effectiveness 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 resistanceimproves healthy emotional expressionis related to the "chemistry between the therapist's aproach

and each child," and their ability to 'observe/discerntogether"

"some [children] are overly stimulated by certain types ofmusic and do better with verbal instruction in a quietenvironment"

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 motivatea multidisciplinary approach seems to work best

Elements of music provides structure that helps children 'get organized"therapy provides opportunity for energy release within a structure

"consistency and structure are key elements-contributes to improved sensory integration

Recommendations parents should be involved in sessions so that results canbetter generalize to other settings (2)

assist the child in finding what works best for him/hera qualitative research approach might give more pertinent

informationa theoretical model is needed for formulating and testing

treatment strategiesMiscellaneous success in one setting may lead to referrals from other settings

more formalized training in this area might help musictherapists but none seems to be available

misdiagnosis is commonmultiple 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 aftera 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.

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cause many of these children may be seen in an educational typeof group setting? I

The previously cited literature on ADHD suggests several ele-ments of music itself that may play a part in the choice of methodfor treating ADHD. Among these are the element of movement andits impact on dual hemispheric activation in the brain (Hannaford,1995; Morton et al., 1990), the ability of music to increase memoryfunctions and auditory perception for improved learning (Roskam,1979; Shehan, 1981; Wolfe & Horn, 1993), and the ability of specificsounds or tones to affect brain wave production (Abarbanel, 1995;Furman, 1978; Morton et al., 1990; Plude, 1995; Swingle, 1995). Incomparing the most often identified music therapy methods andthe elementsjust mentioned, one can see that at least some of theseelements 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 singingare likely to often involve movement on both sides of the body andacross midline (dual activation of both hemispheres in the brain).Musical play and group singing are likely to involve the pairing ofmusic and information, while music and movement may pair musicwith an increased awareness of emotion or increased spatial aware-ness (auditory perception and memory). And, of course, all involvethe 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 Methodsfor ADHD

A majority of the respondents indicated that they address morethan one type of goal with the methods that they use to treat chil-dren with ADHD. Perhaps multiple goals are addressed by musictherapy because, regardless of' the type of method used, music isexperienced on multiple levels simultaneously. As a parentheticalexample, a music intervention can have the ability to create anexperience of structure, both through the music itse,lf, and throughthe directives given to the participanL That same intervention mayinvolve learning a music skill that includes the movement of bothsides of the body across midline. It may also provide opportunity fora fulfilling experience of appropriate interaction between the mu-sic, the participant, and all other participants, while anchoring thelearning from that experience in the participant's memorythrough the very movements required by participation. This one

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intervention could address behavioral, psychosocial, and cognitivegoals within a short span of time. It may be that there are fewmodalities that are able to address multiple areas simultaneously.

Referring again to the cited literature, much of the evidence thatsupports the use of music with this population is related to brainfunction and its impact on processing of information and learning.It is interesting, then, that cognitive goals are identified as beingaddressed less often than behavioral or psychosocial goals. Thereare a number of factors that might explain this. First, behavioraland psychosocial improvements are much easier to track and doc-ument in an "objective and measurable" manner than are cognitiveimprovements, since cognitive improvements are likely to developand generalize over a period of time, and often require specific test-ing in order to obtain a measuremenL 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 beingaddressed as often may be that music therapists, in general, do nothave extensive education in neurobiological functioning. This is aspecialized area of knowledge, and perhaps only those therapistswho have a particular interest in this area actually take the time tolearn more about it. This is also an area of science that we knowlittle about in comparison to other areas of physiology. Since evi-dence does show that music encourages cognitive gains, it may bethat many music (therapists address cognitive concerns with thesechildren without realizing that they are doing so. Further explo-ration of music's effect on cognitive functioning could potentiallyprovide important information for the treatment of this population.

The current multidisciplinary nature of treatment may also playa 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, andchief among these is the tendency for the specificity that each dis-cipline brings to the treatment process to be "wvatered dowvn" or di-luted through the process of developing a general plan. Also, be-cause the current standard in healthcare is to provide objective andmeasurable results for the treatment provided, it would not be sur-

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prising to find that multidisciplinary teams may tend to addresseasily observable and measurable goals. As a result, it may be thatmusic 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 whatthey do to fit into the generalized plan. Regardless of the reasonsthat cognitive goals are addressed less often, it may be time for mu-sic therapists to pay closer attention to the cognitive benefits of theinterventions that they provide for these children.

Music TYherapwy Treatment FormatsforADHD Children

Subjects were not asked to specify the settings in which they treatADHD children; this was -a flaw in the questionnaire design. The in-formation on group or individual treatment does not give muchinsight 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. E l l

Some respondents chose to offer information on the setting inwhich they see these children, mentioning both educational andhealth 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 ofhow music therapy can most benefit them.

Perceived Effectiveness of Music Therapy Treatment forADIHD

In general, it appears that music therapists feel that music ther-apy treatment for children with ADHD is effective, and that theyalso perceive others to feel that it is effective, based on feedbackthat they receive from these others. Interestingly, the perception ofeffectiveness was relatively the same regardless of methods used, orthe types of goals being addressed, or the other types of treatmentused in conjunction with music therapy. This consistent perceptionof music therapy's effectiveness in treating ADHD children regard-less of the variables revisits the question posed earlier: Is theresome 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 ofhow the children in treatment feel about the effectiveness of musictherapy was consistently higher than any other group, even their

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own treatment outcomes. The amount of difference in the ratingswas not remarkable,just the consistency of the ratings regardless ofthe variables being examined. A study that described and exploredthe ADHD child's experience of music therapy might be an invalu-able source of information for further defining and developingmusic therapy's approach to treating these children. For example,does the ADHD child feel that music therapy is effective because ithelps him to perform better academically, or because it helps himto 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 fertileground for further research.

Other Treatments Used in Conjunction with Music Therapy forADHD

It is no surprise that medication was indicated as being used inconjunction with music therapy for a large majority of the childrenwith ADHD that respondents treat. The existing literature clearlyidentifies medication as the most widely used form of treatment forADHD despite some controversy over whether it is the best or mostappropriate 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 overallperceived effectiveness including those children who do receiveconjunctive medication treatment. The number of respondents inthis group was small, so no firm conclusions can be drawn from thisstudy, but further investigation in this area is warranted. Perhapsthere 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 musictherapy environment, in which case it might be enlightening toexplore how the positive effects of music therapy generalize toother 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 wvith medication and chil-dren not being treated with medication within the same musictherapy setting.

In looking at the respondents' perceptions of effectiveness formusic therapy treatment of children not receiving medication, it

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seems that the respondents perceived that they and the childrenfeel music therapy is somewhat more effective than do others. Fur-ther studies that would survey other professionals, teachers, andparents about how they perceive the effectiveness of music therapymight be quite helpful, since this study only reflects the respon-dents' perceptions. This might also indicate that generalization toother 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 wasfound that could lead to generalization later in time. Further foun-dational research in the effect of music upon brain functioningmight be extremely important in this case.

Referral Sources forMusic Therapy Treatment of ADHD

There is certainly some meaning in the fact that most referralsfor music therapy for children diagnosed with ADHD come fromthe parents of these children, even when music therapy is mandatedon the child's IEP. Perhaps this suggests that parents really do feelthat music therapy is effective for treating their ADHD children. Orit might suggest that the standard treatments for ADHD are not fullymeeting their children's needs, or that the side effects from medica-tion are unacceptable and parents are seeking alternate treatmentthat 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 therapyfor ADHD children, could also provide important information ifasked 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 aboutthe generalization of skills or behaviors that are being developed inmusic therapy.

The Role of Music Therapy in the Treatment of ADHD Children

Most respondents indicated that the role music therapy plays inthe treatment of ADHD children is multidisciplinary. It seems thata multidisciplinary approach may be the best for this particularpopulation since, by definition, children with ADHD will presentproblems in multiple functional domains and in multiple settings.

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As previously mentioned, when the music therapist works with oth-ers in the treatment of these children, not only will the childrenhave the benefit of multiple approaches in treatment, but the ther-apist will have the opportunity to receive feedback from othersabout how the children are functioning in other settings, such as inthe classroom. The MTA study conducted by the NIMH, which wascited earlier, was an attempt to determine if multiple forms of treat-ment were most effective for children diagnosed with ADHD, butthe sheer size of the project may have hindered the success of itsoutcome as no firm conclusions could be drawn from the results. Amore controlled study involving the comparison of similar facilitiestreating similar populations might provide better results fromwhich conclusions could be drawn. This kind of study would bene-fit all of the professions involved, and could make a real differencein the kinds of treatment children with ADHD receive.

Additional Comments

Respondents made a number of comments related to musictherapy methods used for children with ADHD. Some commentedon 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 feelsright to the child. These comments help in clarifying what thera-pists consider when choosing an approach or method to employ intreatment of these children, and also begin to define some of theelements contained in these methods.

The idea of "freedom within a structure" has not been examinedin the existing music therapy literature as it relates specifically toADHD 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 successfullytreat ADHD children. It would be interesting to see if there is someconnection 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.

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These included comments pertaining to attention, on-task behav-ior, increased self-esteem, increased self-expression, and increasedfrustration 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 togeneralize to settings outside the sessions. One respondent com-mented that a multidisciplinary approach is most effective, and thiscomment may be related to the question of generalization in thatprofessionals working together on a treatment or educational planfor a child should create some continuity of care that should in-crease the likelihood that improvement will be seen in more thanone setting. It also raises the question of who should be involved inthe music therapy session. If parents, teachers, or other people whowork with the child are involved in the music therapy sessions, willthere be better carry-over from one setting into another?

One respondent noted that the relationship between therapistand child is an important element in the effectiveness of musictherapy treatment, stating that it is the ability to "observe/discerntogether" that makes treatment successful. This is somewhat re-lated to those who commented on the iso-principle in terms ofmeeting the child where he is at the moment, but also implies thatthe child himself has some inner wisdom about what he, needs andthe therapist who is sensitive to that wisdom may have more successwith treatment. Studies examining the relationship between musictherapist and the ADHD child might not only bring insight into theprocess of the therapy, but also might be informative in terms ofidentifying those elements of music therapy that most contribute tosuccessful treatment.

Comments from respondents that were directly related to ele-ments of music therapy treatment for ADHD children follow in suitwith the previous comments. Structure and how it is used in themusic therapy session seems to be an important element that canbe approached in different ways. Some comments mention struc-ture in a manner that seems to suggest that it is the therapist's roleto create the structure needed for the child to organize himself,while others seem to suggest that the therapist provides structure asa container in which the child can decipher how he needs to be or-ganized. This is a subtle difference that would have large impact onthe choice of method used in the therapy session. A closer exami-nation of how structure is created and used within the music ther-

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apy session with ADHD children might yield some interesting andrevelatory findings.

Music's ability to improve sensory integration was mentioned bya respondent as an element of music therapy important in thetreatment 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 themost likely culprit in ADHD symptomatology. Multi-sensory inputis easily created with music since it is experienced through hearing,through touch by means of vibrations, through spatial awareness bymeans 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 bedeveloped for the formulation and testing of treatment strategiesfor children with ADHD. The many questions raised by this surveygive credence to the need for such a model, and indeed, that ideawas intrinsic to the development of this study. It also mirrors thestate of treatment for ADHD in general, which seems to be contin-ually searching for the theory that wvill bring forth better results inthe treatment of these children.

A final recommendation made by a respondent was to use quali-tative research methods in order to better understand how musictherapists are treating children with ADHD. Hopefully, this recom-mendation will not go unheeded. Some of the questions arisingfrom this study would benefit from a qualitative research approach,such as: what is the ADHD child's experience of music therapytreatment, 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 literaturereports about the lack of standard assessment for diagnosingADHD, and about co-morbid diagnoses that make assessment andtreatment more difficult. Music therapy may have a role to play inassessment of children with ADHD if better understanding of theeffects of music on these children can be developed. In line withthis was a comment regarding training for music therapists. This re-

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spondent indicated that ADHD is an area in which specializedtraining should be given for music therapists, and noted that verylittle was available, even at national conferences. This may be,again, reflective of the overall controversy surrounding ADHD, itsassessment and treatment. Until some consensus can be reachedabout 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 ofhow music therapists are treating early elementary school childrenwith a diagnosis of ADHD, and of the role music therapy plays inthe overall treatment of these children. It was hoped that this pic-ture would provide music therapists with the information neededto make more purposeful and effective choices for successful treat-ment. It was also hoped that this picture might highlight patternsupon which a theory of music therapy for the treatment of ADHDmight begin to be formed. As is usual with most research, the finalresults raise many new questions. Among these are questions aboutwhat element/s of music therapy is/are most responsible for bring-ing about effective results, about how success in music therapytreatment for ADHD can be generalized to other settings, andabout how music therapy treatment for ADHD compares to treat-ment with medication. Ultimately, it is hoped that these and otherquestions to which this study has given rise will provide impetus formusic therapists to further investigate the influence of music onchildren with ADHD.

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TITLE: A Survey of Music Therapy Methods and Their Role inthe Treatment of Early Elementary School Children withADHD

SOURCE: The Journal of Music Therapy 40 no4 Wint 2003PAGE(S): 302-23

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