[Research]
In the Groove: An Evaluation to Explore a Joint Music Therapy and Occupational Therapy Intervention for Children with Acquired Brain Injury
By Karen Twyford & Samantha Watters
Abstract
An acquired brain injury in children disrupts brain development and neural pathways, which may have serious implications on occupational role performance. Assessment and management of children with neurological disorders is complex and treatment requires the engagement of a multidisciplinary team. Increasing evidence indicates that both occupational therapists and music therapists work effectively towards similar goals with children with acquired brain injury. This evaluation investigated the effectiveness of a joint music therapy and occupational therapy group in promoting the development of self-regulation skills in children with an acquired brain injury or neurological condition, as part of a pilot project at a regional paediatric hospital in Australia. Six participants, aged five and half to ten years, were recruited through the acquired brain injury and neurology outpatient service at a regional paediatric hospital. Children underwent occupational therapy assessment and were identified to have sensory processing difficulties that negatively impacted on the child’s occupational roles of "friend" and "student." The intervention group, In the Groove, received seven, weekly, one-hour sessions, held for one hour on a weekly basis. Each session involved a variety of joint music therapy and occupational therapy activities, specifically planned to achieve intervention goals. A range of standardised occupational therapy and music therapy outcome measures were used, as well as non-standardised measures. All children received positive outcomes following intervention for at least one outcome measure. The findings indicate that joint music therapy and occupational therapy intervention may provide children with acquired brain injury and neurological impairment opportunities to develop self-regulation skills.
Keywords: music therapy, occupational therapy, acquired brain injury, sensory processing, group intervention, cognitive rehabilitation
Introduction
People suffering an acquired brain injury (ABI) or a neurological disorder can experience a range of physical and/or psychological symptoms and disabilities, which can have long lasting consequences as a result (Australian Institute of Health and Welfare, 2007; Bradt, Magee, Dileo, Wheeler & McGilloway, 2010; Brain Injury Association of Queensland (BIAQ), 2013; National Children’s Bureau, 2012; The Australian and New Zealand Child Neurology Society, n.d.). The most important difference between an ABI in children and adults is that a child’s brain is still developing (BIAQ, 2013). A brain injury, which is often global rather than isolated, may therefore disrupt brain development and development of neural pathways in children, which can have serious implications for skill development and abilities. Clinical care guidelines recommend that rehabilitation of people with acquired brain injuries is beneficial and should be goal orientated and coordinated (National Clinical Guideline Centre, 2014; Turner-Stokes & Wade, 2004).
Music and Music Therapy within Neuro-rehabilitation
Music as a complex stimulus engages the global network of the brain in order to be processed (Aldridge, 1996; Bower & Shoemark, 2012; Levitin, 2009), and can provide a foundation for recovery (O’Callaghan, 1999). Musical skills are acquired in utero and develop progressively and cumulatively across the lifespan (Gooding & Standley, 2011). Musical exposure and music making therefore has the potential to induce brain plasticity (Altenmüller & Schlaug, 2013; Stegemöller, 2014); act as a mnemonic tool for a variety of cognitive functions including memory, attention and executive functioning (Thaut, 2010), and is effective in facilitating appropriate emotional regulation development (Sena Moore & Hanson-Abromeit, 2015).
Increasing evidence documents the use of music in the hospital setting to reduce stress and anxiety for patients, families and caregivers (Klassen, Liang, Tjosvold, Klassen & Hartling, 2008; Park, 2010; Preti & Welch, 2011; Walworth, Rumana, Nguyen & Jarred, 2008), and to also provide social support (Preti & Welch, 2011). Furthermore, the use of familiar repertoire is important and can be beneficial in improving quality of life indicators such as anxiety (Preti & Welch, 2011; Walworth et al., 2008), and a way to create trust with patients (Steele, 2012). In addition to supporting the goals of the wider professional team, music therapy in the hospital setting can provide emotional support and opportunities for self-expression for paediatric patients and also their families (Edwards, 1999; Edwards & Kennelly, 2004).
There is an increasing body of evidence, including some doctoral studies, which documents the effective outcomes of music therapy within the area of neuro-rehabilitation (Aldridge, 2005; Baker, 2004; Baker, Kennelly & Tamplin, 2005; Bower, 2010; Bradt et al,, 2010, Daveson, 2008; Gilbertson, 2005; Gilbertson & Aldridge, 2008; Kennelly & Brien-Elliot, 2001; Kennelly & Edwards, 1997; O’Kelly, James, Palaniappan, Taborin, Fachner, & Magee, 2013; Rosenfeld & Dun, 1999; Street, Magee, Odell-Miller, Bateman, & Fachner, 2015; Tamplin, 2006; Thaut, 2010). Evidence suggests that music is effective in connecting the physiological, psychological, cognitive and emotional components of physical rehabilitation, which indicates that music therapy has the potential to provide holistic care (Magee, 1999; Weller & Baker, 2011). The temporal organisation inherent in music has the potential to increase organisation and attention (Bower & Shoemark, 2012; Brien-Elliot & Kennelly, 2001; Thaut, 2010). Music therapists use restorative and compensatory approaches to promote functional improvement (Daveson, 2008; Baker & Roth, 2004). Music therapists also use psycho-social-emotional approaches. These approaches involve the use of music to express emotions, change emotions, facilitate socialisation and social-skill development, shape psychological functioning (Daveson, 2008) and promote positive changes in self-concept and wellbeing (Baker, Rickard, Tamplin & Roddy, 2015).
The majority of literature regarding music therapy in neuro-rehabilitation focuses on work with adults, however examples of work with children are increasingly documented (Bower, 2010; Bower & Shoemark, 2009, 2012; Edwards & Kennelly, 2004; Shoemark, Hanson-Abromeit, & Stewart, 2015). As children and adolescents experience periods of rapid developmental change, work with child and adult patients differs, and therefore knowledge of brain development is important for assessment, planning and evaluation purposes (Magee et al., 2011). Music therapy in paediatric settings falls within four main areas including motor skills, behavioural/cognitive skills, speech/language/communication skills, and psychosocial care. Music therapy can promote coping, reduce pain or distress, and promote developmentally appropriate skills (Kennelly & Brien-Elliot, 2001).
Comprehensive guidelines (Kennelly, 2013) exist for music therapists working within different stages of paediatric care and the three phases of neuro-rehabilitation, acute, sub-acute, and chronic phases. A wide range of music therapy techniques is effective when used across these phases (Gilbertson, 2009; Kennelly, 2013).
Occupational Therapy in ABI Rehabilitation
Executive functioning (EF), which includes all aspects of goal directed behaviour (Slomaine & Locasio, 2009), enables people to perceive social cues, interpret social behaviour, control emotional responses and social interactions, adjust social behaviour and develop personal identity, and self-awareness (Ylviskar & Feeney, 2002). There is increasing understanding of the relationship between occupational performance and EF, and that current intervention for EF combines compensatory strategies and metacognitive frameworks (Cramm, Krupa, Missiuna, Lysaght & Parker, 2013).
Cognitive rehabilitation for children with ABI is a relatively new discipline (Kennedy & Turkstra, 2006). There is a paucity of evidenced based literature reviewing cognitive and behavioural rehabilitation for children with EF impairment post ABI (Laatsch et al., 2007; Slomine & Locascio, 2009). Treatment of children and adolescents post ABI should target the development of attention skills and must consider the family as active treatment providers (Laatsch et al., 2007). There is increasing evidence for teaching EF skills, in particular self-monitoring, and that children should be given opportunities to practice new skills within everyday routines (Slomine & Locascio, 2009). Intervention that utilises real world meaningful activities to improve self-awareness of changes that have occurred post injury, can increase occupational performance by enabling individuals to identify difficulties, set goals and adopt effective compensatory activities (Goverover, Johston, Toglia, & Deluca, 2007).
Occupational therapists use cognitive strategies to enhance occupational performance including compensatory techniques that substitute for impaired skills. Strategies may include "modality specific strategies" such as deep pressure and visual, auditory and kinaesthetic cues, "mental strategies" such as repetition and self-verbalisation, and "task modification strategies" including stimuli reduction, organisation, and attention to doing (Toglia, Rodger & Polatajko, 2012). Cognitive strategies can alternatively be grouped into three clusters: performance strategies that support efficacy of performance during an activity (e.g. sensory cues), learning strategies that optimise attention, understanding and memory, and self-regulation strategies that assist individuals to monitor arousal levels, evaluate performance and monitor emotions (Toglia, Rodger, & Polatajko, 2012).
Sensory Processing and ABI
The term self-regulation is used to describe the way in which people handle incoming sensory input (Dunn, 2011), and is conceptualized by occupational therapists in the Sensory Processing Practice model (Case-Smith & O’Brien, 2010). This model has evolved from work by Dr. Jean Ayres who applied neuroscience knowledge to hypothesise that behaviour is the result of sensory integration; whereby children use information from their bodies and the environment to respond to environmental demands, the adaptive response, while placing significant importance on the child’s inner drive i.e. motivation (Case-Smith & O’Brien, 2010; Dunn, 2011). Dunn’s model of sensory processing (SP) (1997) outlines two important concepts; the first being that the nervous system operates under neurological thresholds that are individual to each person. Low thresholds are indicated by quick and frequent responses, whereas a person with slow responses is said to have high thresholds (Dunn, 2011). The second concept outlined in the SP model is a continuum of self-regulation, whereby individuals engage in passive and active behaviours that help them to feel comfortable in a particular environment (Dunn, 2011).
Despite SP forming the basis for EF, there is a scarcity of literature examining the impact of ABI on children’s ability to receive, integrate and respond to sensory information (Galvin, Froude & Imms, 2009). Children with ABI are at risk of specific SP difficulties including hypersensitivity to auditory stimulation, challenges processing visual information and difficulties with multi-sensory processing (Galvin et al. 2009).
Therapeutic Groups
Group work can offer a powerful therapeutic experience that provides motivation, modelling, and peer-to-peer learning and is consistent with the International Classification of Function, Disability and Health for Children and Youth (ICF-CY) (World Health Organization, 2007) recommendations for service delivery (Paustian, 2010). Therapeutic group activities are designed to develop function and occupational performance, and typically involve purposeful activity, practice, socialisation, teaching, and learning (Ward, Neidstadt & Blesedell Crepeau, 1998). To optimise skill transference, therapeutic groups target specific interpersonal skills with individualised therapy goals, opportunities to practice skills within groups, and in natural environments (Dahlberg et al., 2007, Lindeck & Pundole, 2008). The group context creates opportunities to engage in meaningful activities while feeling supported by age related peers who also have ABI (Hickey & Saunders, 2010); however negative social outcomes are common in children with ABI (Yeates et al., 2007). Despite the crucial need to have effective intervention that develops interpersonal skills and enables social participation, there is a lack of research exploring the use of occupational therapy group work to achieve this (Agnihotri et al., 2012). Group work can provide a space for individuals to feel more connected, and achieve a sense of belonging (Richards & Davies, 2002).
Music Therapy and Occupational Therapy in Acquired Brain Injury
Examples of diverse and creative collaborative partnerships between music therapists and other professionals where commonalities or parallels between models are increasingly evident in the literature (Bonny, 1997; Kennelly, Hamilton & Cross, 2001; Summer, 1997; Twyford & Watson, 2008; Wheeler, 2003). Joint work with occupational therapists is documented in the music therapy literature; however only a few examples in the area of neuro-rehabilitation provide detailed description. Millman (2008) described working with an occupational therapist to provide a creative means for a young woman with brain injury to practice developing functional skills. This collaboration provided opportunities to jointly address team goals, including communication, cognition, and physical status.
Rationale
A paucity of literature relating to group work with children with ABI indicated this evaluation was timely. The evaluation described here was undertaken as part of a pilot project, which was possible by a small funding grant made to the Occupational Therapy Department at an Australian regional paediatric hospital. Occupational therapy staff was keen to trial the effectiveness of music therapy as a specialist service for children with ABI and neurological conditions. Initial planning meetings resulted in the decision to implement and evaluate a joint music therapy and occupational therapy group that would be facilitated by the authors, a music therapist and occupational therapist. One other occupational therapist participated in sessions in an observational role and contributed to data collection. Development of In the Groove was guided by the occupational therapy model of practice, Occupational Performance Model (Australia) (OPMA) (Chapparo & Ranka, 1997); and by the defining principles of humanistic perspectives (Bunt & Stige, 2014) and community music therapy practice (Ansdell, 2002; Ruud, 2004; Stige & Aarø, 2014). The therapists sustained clearly defined roles throughout all aspects of planning, intervention and evaluation. A fluid approach to group facilitation roles was maintained through clear and open professional communication.
The purpose of this evaluation was to investigate the effectiveness of a joint music therapy and occupational therapy group for children, ages 5.5-10 years with an ABI, that promoted the development of self-regulation skills, with the aim of improving interpersonal skills required for friendships, and to enable new knowledge acquisition within learning environments, such as the school classroom.
The primary goal of the intervention was for the acquisition of self-regulation skills including the ability to maintain a quiet/alert arousal state conducive to listening to others and attending to tasks, through shared musical experiences and opportunities for creative self-expression. Using the ICF-CY (WHO, 2007), the goal was considered in regards to body functions, activity limitations, and participation. The intervention aimed to address impaired body functions including attention functions (ICF-YC code: b140) and perceptual functions (ICF-CY code: b1550). At an activity and participation level, the overall goal involved listening, focusing attention, directing attention, carrying out daily routines, managing one’s own behaviour, communicating, and general interpersonal interactions (ICF-CY codes: d115, d160, d161, d230, d250, d310 – d349, d710-d729 respectively). It was anticipated that in targeting body functions and activity limitations there would be a related positive effect on participation in ’major life areas’ specifically school education.
Furthermore, we proposed that a collaborative approach would provide staff and service users experiential opportunities to understand and rate music therapy. It was anticipated that effective outcomes might result in future funding opportunities for music therapy for children with ABI and neurological conditions.
Method
Approval was received for the evaluation to be conducted by the ‘Governance, Evidence, Knowledge and Outcomes’ department at the regional hospital.
Participants
The group participants included seven outpatients who met the following inclusion/exclusion criteria. Inclusion criteria comprised: child was between 5.5 and 10 years old; under the hospital’s ABI or neurology team; child has priority goals relating to social participation and/or self-regulation; child is able to follow 2-3 step instructions and has new learning/comprehension skills in order to understand new abstract concepts; and child is available to attend 1-hour group session each week for 7 weeks. Exclusion criteria comprised: child accessing community therapy.
Children had a variety of neurological conditions including encephalitis, astrocytoma, epilepsy, and impairments associated with traumatic brain injury (ataxia, impulsiveness, hemiplegia, and cognitive impairment). Occupational therapy assessment identified that each child had an element of difficulty in SP (poor attention to task, differences in processing of auditory, visual, tactile, and movement sensations). Each child’s weekly progress was recorded against identified Individualised Music Therapy Assessment Profile (IMTAP) domains, and children completed a weekly self-evaluation of their experience.
Additional participants included the children’s parents and occupational therapy staff directly involved.
Recruitment and Informed Consent
Convenience sampling was used to select the most available people within the outpatient service of a regional paediatric hospital (Portney & Watkins, 2009). The participants in the project were children currently receiving outpatient services at the hospital, their parents, and staff from the occupational therapy department involved in the group sessions. Before the intervention commenced, parents of potential participants were sent an information sheet regarding the group In the Groove and data collection methods. This enabled parents to make an informed decision regarding their child’s inclusion in the group and evaluation, and also their own participation in the study. A decision not to be involved in any part of the project did not impact on inclusion in the group.
Outcome Measures
Data was gathered from multiple sources involving a variety of outcome measures including Goal Attainment Scaling (Turner-Stokes, 2009), Individualised Music Therapy Assessment Profile (Baxter et al., 2007), School Function Assessment (Coster, Deeney, Haltimanger & Haley, 1998), Canadian Occupational Performance Measure (Law et al., 1990), child, parent and staff questionnaires, clinical notes, records, video and audio recordings, and observations.
Goal Attainment Scaling (GAS). The GAS (Turner-Stokes, 2009). is a collaborative standardised outcome measure used for patient rehabilitation, whereby patient’s individual goals are rated in relation to specific tasks. GAS is advantageous as it allows for flexibility when recording any type of goal in any area of the International Classification of Function (McDougall & Wright, 2009). GAS has also been found to increase the likelihood that intervention is carried out in varying contexts including home and school (Østensjø, Øien, & Fallang, 2008). GAS goals were formulated in conjunction with parents/carers, and the child’s primary assessing therapist documented the goals and provided written recommendations/home programs based on the group content. Post testing results were agreed upon by observations of the three examining therapists. The three therapists jointly evaluated GAS goals at the conclusion of the intervention period. Therapists individually rated each child’s performance in relation to identified goals using the GAS goal scoring system. Therapists then shared their analysis and agreed on a score for each goal. Statistical analysis of the data was not possible due to a small sample size. Instead, data were collated and graphed to illustrate outcome results and trends for participants.
The Individualised Music Therapy Assessment Profile (IMTAP). The IMTAP (Baxter et al., 2007) is an in-depth assessment protocol developed for use in paediatric and adolescent settings, providing a clear profile of client functioning in specified domains over time. Children’s weekly responses in relation to specific tasks were recorded by the therapists, in a group meeting at the conclusion of each session. Each task was rated on a scale in relation to the frequency in which it was observed within the session i.e. never, rarely, inconsistent, and consistent. Weekly results were entered into a spreadsheet and scored using the IMTAP scoring procedure. This information generated individualised scores for key domains (social, cognitive, emotional, expressive communication, and musicality) that could be graphed to provide an IMTAP profile for each child.
The School Function Assessment (SFA) (Coster, Deeney, Haltimanger & Haley, 1998) is a judgment-based assessment that measures a student’s performance of functional tasks that support their participation in the academic and social aspects of the school program. The SFA was given to each of the participant’s teachers for completion. It was planned that pre and post testing would be undertaken. However, limited post testing was accomplished due to the completion of the school year and inability to contact teachers during school holidays. Pre and post testing of the SFA was completed for child 3 only.
The Canadian Occupational Performance Measure (COPM). The COPM (Law et al., 1990) is a client-centred tool designed to capture the client’s self-perception of performance in relation to everyday living. The COPM was administered by the occupational therapists and completed by each child’s parent pre and post intervention to provide performance and satisfaction scores. Each score is a numerical value rated from 1–10 by the parent/carer with 1 indicating limited performance of an occupation and 10 indicating no difficulties in occupational performance. Statistical analysis of the data was not possible due to a small sample size. Instead, data were collated and graphed to illustrate results and trends for participants.
Children completed the 5-point Likert-type self-evaluation scale each week at the conclusion of the group session. For questions 1-3 children selected a response level from the following choices - not at all, a little, about half, a lot, and always; and for question 4, children selected a response level from: didn’t like, nervous, unsure, happy, and really liked. Each child’s weekly responses were collated to ascertain any observable trends across the period of the programme.
A parent questionnaire, incorporating both Likert-type and open-ended questions, was administered during the final group session. Six parents and one grandparent completed a total of seven questionnaires. Adults selected a response level using a 5-point Likert-type scale, that included strongly disagree, disagree, neither agree or disagree, agree, and strongly agree response choices. An online staff survey incorporating both Likert-type and open-ended questions was implemented at the conclusion of the pilot. A total of three questionnaires were completed by occupational therapists directly involved in the pilot i.e. in a facilitative or referring capacity. Likert-type question responses were collated in both the parent and staff questionnaires. A process of interpretative analysis was used for open-ended questions in both parent and staff questionnaires. This involved transcribing written responses into a spreadsheet; reading responses to identify emerging themes; creating coding categories and coding responses; contextualising themes; and presenting them as findings.
Intervention
The In the Groove group, aimed to develop self-regulation skills and interpersonal skills required for friendships and new knowledge acquisition in learning environments, such as the school classroom.
Children were given opportunities to recognise their own arousal states (over aroused, under aroused, and quiet alert) and were shown strategies to achieve and maintain an optimum arousal state through movement activities, auditory input, and visual prompts. The group process allowed for opportunities for modelling of appropriate behaviour by age related peers and practice of newly acquired self-regulation skills in a busy "classroom like" environment. Music activities were carefully selected and planned to facilitate positive social interactions (initiating conversation, attending to non-verbal cues, cooperating, and listening). Shared music experiences created opportunities for practice of self-regulation and interpersonal skills through a non-threatening medium with the aim of facilitating feelings of success and confidence.
The group was held in the occupational therapy department gym. This large room provided ample space for the group and was suitable for a variety of instrumental and movement activities. Upon arrival, children sat on chairs within the group circle. Prerecorded instrumental music played quietly to provide a sensory focus for group participants. Structured and unstructured activities were loosely planned on a weekly basis in response to children’s observed responses from the previous week. Each session began and finished with the same song/activity, however the remainder of the session was non-linear to respond to group dynamics and perceived need. Original songs were written for the group to incorporate key concepts. Improvised songs were used to motivate, focus, and promote group awareness and cohesion as required. Musical instruments available for group use included a small range of hand held un-tuned percussion, and a large gathering drum. The music therapist used a guitar. Discussion formed an integral part of the group process.
| Activity | Goal |
|---|---|
| Let’s get started - group chant incorporating body percussion | Weekly starter activity to enable each group member to sound within the group. |
| Animal conga – movement activity | Providing creative opportunities whilst promoting ways for children to regulate themselves through gross motor movements |
| Musical Conversations – instrumental activity utislising a large gathering drum and involving 2-3 children at a time | Providing opportunities for children to engage creatively and socially in non-verbal joint music making, and for children to evaluate their own social interactions. |
| Slow me down – group song | Song to promote generalisable calming strategies using deep pressure techniques. |
| In the Groove – group song | Weekly song sung to conclude group and reflect on key group messages. |
At the end of each session children were encouraged to complete a self-report of their experience using the self-evaluation form. Therapists assisted children to complete the forms where necessary. Children left the room with the therapists and met their parents in the foyer. At this time it was possible for therapists to meet briefly with parents to discuss outcomes and progress relevant to the group and also other occupational therapy programmes the child was involved in. Each week parents were given an activity sheet that outlined what the group had involved and tips and suggestions for use at home. Following each session the therapists met to evaluate and record children’s responses for data collection purposes. At this time the therapists discussed priorities for the group and planned the next week’s session. Parents were invited into the final session to share in the children’s work, by way of a short performance.
Findings
The findings are detailed in relation to each outcome measure and include a descriptive analysis to compare both quantitative and qualitative data.
Goal Attainment Scaling (GAS) Goals
All six children received a positive outcome at post testing; see Figure 1 below. Five children had at least one goal that achieved the expected outcome and three children reached somewhat more than their expected outcome for at least one goal. One child achieved much more than the expected outcome for one of their goals. All children improved beyond their baseline but 2 children only improved to somewhat less than their expected outcome for at least one of their goals.
Individualised Music Therapy Assessment Profile (IMTAP)
The following group charts for identified domains (Figure 2–6 below), illustrate general positive trends for most children across all areas. The data provide pictorial progress indicators of each child’s level of functioning in the group situation from the initial evaluation episode (first group session attended by each child, which for one child was in Week 2) to the final evaluation episode (last group session attended by each child – where one child concluded the group in Week 6).
Each IMTAP domain is divided into further sub domains to provide a broader understanding of weekly responses in specific areas, for example the emotional domain consists of fundamental, differentiation/expression, regulation and self-awareness sub-domains.
School Function Assessment
Table 2 details the results from the single case where pre and post testing occurred for the SFA, suggesting a slight improvement in the raw score for "positive interactions." No change was identified in "task behaviour/completion" and "following conventions."
| Pre test raw score | Post test raw score | Result | |
|---|---|---|---|
| Following social conventions | 41 | 42 | No change with standard error = 3 |
| Task behaviour/completion | 59 | 60 | No change with standard error = 3 |
| Positive interaction | 63 | 72 | Slight improvement with standard error =3 |
Canadian Occupational Performance Measure
Figure 8 below illustrates the COPM performance scores obtained at pre and post testing. An average performance score across each individual child’s goals was calculated to obtain a single overall performance score delineated below. It can be seen that 3 children achieved a positive outcome indicating an improvement in occupational performance of their goals. One child stayed the same with no improvement or regression. One child received a reduction in his total performance score indicating reduced occupational performance.
Figure 9 below illustrates the COPM satisfaction scores obtained at pre and post testing. An average satisfaction score across each individual child’s goals was calculated to obtain a single overall satisfaction score delineated below. It can be seen that 4 children achieved a positive outcome indicating an improvement in satisfaction of occupational performance. One child stayed the same with no improvement or regression in parent’s satisfaction of occupational performance.
Children’s Enjoyment and Self-observation Survey
Children’s responses to the weekly survey questions 1–3 were collated to provide both median and mode responses for each question, see Table 3 below.
| Question | Median |
|---|---|
| 1. How much did you enjoy yourself today | Always |
| 2. How well were you able to keep your 'engine' just right? | Always |
| 3. How well could you make friends today? | Always |
Children’s responses to the weekly survey question 4 were collated to provide a median and mode response, see Table 4 below.
| Question | Median |
|---|---|
| 4. How I felt about using music today | Really Liked |
Overall, children’s responses to the self-report questionnaire suggested that the group was a positive experience, which was also supported by staff observations.
Parent Satisfaction Survey
Responses to the parent survey questions 1-8 were collated to provide a group median response for each question (see Table 5 below).
| Question | Group Median |
|---|---|
| 1. My child enjoyed attending the group | Strongly Agree |
| 2. The group met our expectations | Strongly Agree |
| 3. Music enhanced my child's learning of self-regulation and social skills | Agree |
| 4. My child has learnt helpful strategies to help regulate their arousal and attention to task/others | Agree |
| 5. My child has used learned skills and strategies at home and/or in the classroom | Agree |
| 6. The group increased my child’s confidence to use music to express them self | Strongly Agree |
| 7. I have noticed positive changes in my child, as a result of them attending the group | Strongly Agree |
| 8. I was happy with the amount of information sent home, and feedback was adequate | Strongly Agree |
Three main themes were derived from the parent questionnaire using interpretive analysis, which encompasses identifiable outcomes for the children involved, their parents and the hospital department. These themes include the benefits for the children, valuing rehabilitation services at the hospital, and the positive effects of music.
Parents noted that the program provided a number of observable benefits for their children, and grandchildren, and in some cases had a positive generalisable effect on the whole family. Parents indicated that children learned a number of transferable skills that could be used in other settings; including the home and at school and that these skills were functional, effective, and accessible. Additionally, parent comments indicated that the program enabled children to develop greater awareness of self and promoted positive self-esteem.
Parents were happy with the service provided and said they would be keen to see it continue for their own children and also others. Furthermore they noted that the program provided another method of support for them and their child. Parent responses indicated that the program had created a sense of community by providing an opportunity for children with similar needs to come together. This helped parents realise that they and their children were not alone and made them feel less isolated.
Parents provided suggestions, in relation to their own experience, for future group considerations. This included increasing the session time and shortening the number of weeks, or scheduling the group for the afternoon. Parents also expressed an interest in being able to attend more than one session.
Parents noted that the children loved the opportunity to access a music programme, which incorporated singing, instruments and dancing, at the hospital. Parents indicated that music was effective in promoting the skills being learned in the session and had a positive generalisable effect.
Staff integration and Scope Survey
Information gathered from the completed online integration and scope survey that included both quantitative (Likert-type) and open-ended questions is detailed below.
Median responses to the Likert-type questions (Questions 1, 2, and 5) are shown in Table 6 below.
| Question | Group Median |
|---|---|
| 1. The music therapy pilot, part of ABI/Neuro services met my expectations. | Strongly Agree |
| 2. My understanding of music therapy increased as a result of my involvement with the ABI/Neuro pilot. | Strongly Agree |
| 5. Information, communication and liaison as part of the pilot was adequate. | Strongly Agree |
Four themes were derived from the open-ended component of the staff survey and include; benefits for the children involved in the pilot, professional benefits for occupational therapy staff, the value of music and music therapy with this client population, and appraisal and future scope for music therapy services.
Staff indicated that the group sessions provided positive experiences and were highly beneficial for the children involved. Providing a group situation for children to address their needs and goals was deemed valuable, as children usually accessed treatment on an individual basis. Staff indicated that the group provided important and varied learning opportunities for the children, and in particular social interaction. An increase in social skills was evident on a week-to-week basis in the waiting room.
Staff valued the addition of music therapy services to the ABI/neuro outpatient team, stating that it complemented existing services and could target similar goals using different approach. The group provided opportunities for inter-professional collaboration and experiential learning, which led to an increased understanding of music therapy and its potential role with this client group.
Staff recognised music as a useful treatment tool for children in the group setting, providing focus but also motivating and effective for skill and concept acquisition. As an extended treatment option, music provided a specialised medium for expression, where children could explore emotions and feelings in a non-threatening way.
Discussion
Findings suggest that overall the introduction of a joint music therapy and occupational therapy group facilitated the development of self-regulation skills, thereby positively impacting on interpersonal skills required for friendships, and the acquisition of new knowledge within learning environments. A range of positive outcomes for both children and their parents/caregivers on various social domains were identified and discussed below in regards to strengths and limitations of the pilot.
Outcomes for Children
The group situation was identified as being effective in helping the children to develop self-awareness of their arousal levels and how this impacts on behaviour and independence. Where children had previously accessed treatment on an individual basis, the group setting was valuable to enhance standard intervention strategies while addressing their individual goals. The group provided motivating and varied learning opportunities, and a forum to practice skills that could be transferred into other settings, as reported by the parents. It also provided opportunities for social interaction outside of the classroom setting, which differed from individual sessions.
These findings support Paustian’s (2010) statement that groups provide a motivating opportunity for modelling and peer-to-peer learning. The In the Groove group enabled children to meet and interact with other children with similar needs, which was observed by parents and staff as providing a positive experience and assisting with the achievement of therapy goals. Furthermore, the department waiting room proved to be an incidental opportunity to observe positive social interactions being practiced and friendships being formed.
Children appeared to rate their experience of the group highly, however the findings from the children’s survey provided uncertain results. Consequently, the therapists drew an assumption in relation to each child’s capacity to complete the form accurately. One conclusion therapists drew from children’s responses was that in the initial sessions children’s responses were more extreme and not in line with therapist observations. Over the 7 week period it was observed that some children were able to give more consideration to the questionnaire, and give a more accurate responses that reflected observed behaviours. These observations are supported by a study by Chambers and Johnston (2002) in which children completed Likert-type scales. The authors revealed that young children (5–6 years old) respond in an extreme manner when rating their own emotional state, rather than giving graded responses. In addition it was identified that it is difficult to establish the truth of children’s ratings, which suggests that children do not use rating scales appropriately, particularly when responding to their own feelings (Chambers & Johnston, 2002).
Results indicate that the group was effective in meeting 72% of therapy goals documented in Goal Attainment Scaling. By giving the children opportunities to practice these activities in a real life social situation with age related peers it was anticipated that gains would also be made at a participation level with children being able to participate optimally in interpersonal interactions and school education. However, the current evaluation lacked an ecologically valid outcome measure that would measure these gains in participation thus demonstrating generalisability of skills outside of the therapy group.
The COPM guided individual therapy goals and was used to identify changes in the child’s occupational performance and to determine parent/carer satisfaction with this performance. Due to a small sample size, only minor inferences can be drawn from the data. The fact that three of the six children showed an improvement in occupational performance suggests an encouraging outcome. One child’s ‘performance’ score reduced after intervention but this may be explained by the fact that the child lost education assistant funding over the course of the study resulting in poorer performance in occupational roles of friend and student. Changes in satisfaction scores on the COPM were in line with changes in performance scores but with differences in scores showing greater improvements. In one case, the average satisfaction score increased from 4.3 to 8 that may be attributed to the parent/education component of the group; increasing caregiver’s knowledge of SP difficulties, helps to explain behaviour, improve understanding and therefore increase overall satisfaction of occupational performance.
General positive trends were seen for children across all IMTAP domains with the exception of the social domain. A marginal decline in social skills scoring was noted for three of the six children. This may have been attributed to the fact that only IMTAP results from the initial and last sessions were collated, which provided data for a snapshot in time rather than changes across the social domain over time. This is therefore true of all IMTAP domains and suggests that the test/re-test interval of time may have been too small. Furthermore, the IMTAP tool as it was used was not sensitive to small changes. Slovaki (2012) notes that a more detailed IMTAP scoring system may glean finer differences in levels of functioning.
Unfortunately, poor completion of the post-test SFA means that very little value was added to the data. For the sole respondent for post testing, there was no change for following social conventions and task completion with only a slight positive result for positive interaction. It may be that the SFA was not sensitive enough in this situation to measure changes; however this needs to be further explored. Burgess et al. (2006) highlight that there is a pressing need for an ecological test of EF that models real world situations and this will need to be considered in future studies in this area.
Outcomes for Adults
Positive outcomes provided important support for parents, which is a fundamental component of rehabilitation services for children. Sharing of information enabled parents to learn new strategies and take an active role in their child’s rehabilitation, creating opportunities for empowerment. The group created a positive sense of community which parents valued. Weekly sessions brought children with similar needs together. This allowed parents to realise that they and their children were not alone, and to some extent normalised the experience. O’Callaghan, Powell, and Oyebode (2006) revealed that being with others with similar problems assisted in normalising and validating experiences and reduced anxiety for people with moderate to severe traumatic brain injuries. Furthermore, parents extended their own social networks as they interacted with one another in the waiting room on an increasing level as each week passed.
Music and Music Therapy in Rehabilitation Services
Parents welcomed the opportunity to access a music programme at the hospital, and felt music was effective in promoting the skills being learned in the sessions, and had a positive generalisable effect. Music is motivating for children, easy to relate to, fun and non-threatening. As a treatment tool it is an effective medium for self-expression particularly to explore emotions and feelings and effective for skill and concept acquisition, whilst helping provide a focus.
Music therapy as an extended treatment option provides a specialised medium of expression, for children. In the group, the children were motivated by music and enjoyed opportunities to express themselves through a variety of creative activities that incorporated active and receptive musical activities, and movement to music. The focus of the various activities was to promote engagement and participation, whilst imparting valuable and transferable skills.
The experience of weekly, shared music making appeared a positive experience for all children on the whole. A group theme song was sung each week to reinforce core learning and to create a sense of group cohesiveness. Lindeck and Pundole (2008) found that a participation in a shared group song promoted a sense of group identity. Furthermore, different musical activities promoted various forms of social interaction. The children’s engagement and participation in active music making further instilled a sense of community in which, children were observed to feel confident in order to share and interact with one another.
Having the opportunity to perform some of the group songs to the parent group at the final session provided an opportunity to sustain the relationships that had been built and share these with the parent group. This performance also enabled children to validate the skills and growth they had acquired through their participation in the sessions. Baker (2013) noted the importance of sharing songs to reinforce and validate internal changes through the experience of being heard by others.
Combining Services – Outcomes for the Department
Occupational therapy staff valued the addition of music therapy services to the ABI/neurology outpatient team. The combination of music therapy and occupational therapy services was complementary, as both disciplines had similar underlying principles, which enabled goals for each discipline to be incorporated jointly.
Music is typically used within occupational therapy treatment plans with children, however this generally does not involve live music making. Having a music therapist with the skills to focus on one medium appeared advantageous to staff as it meant similar goals could be targeted using a different approach.
Furthermore, staff valued the opportunity for inter-professional collaboration and found it beneficial professionally to work across disciplines. Staff noted that they had developed an increased understanding of music therapy and the role it could play for patients. Staff stated that this learning would be helpful in making appropriate referrals and intervention planning.
The evaluators were particularly interested in examining the occupational performance area of productivity at school and play occupations. The occupational performance components that were thought to be negatively impacting on the children’s roles were sensory-motor, cognition, and psychosocial skills. The OPMA (Chapparo & Ranka, 1997) dictates that occupational roles must be considered in relation to an individual’s environment (economic, political, and physical) and that the core elements of human existence (conscious and unconscious intellect and spirituality) must be considered. Dunn (2011) summarised occupational therapy best practice principles to include, the importance of harnessing individual strengths, family centered practice, and collaborative working with family/carers. Similarly, music therapy models of practice place importance on promoting the health, function, and wellbeing of individuals in a shared musical relationship, which is process focused, needs and strengths based and incorporates client/family-centred and collaborative approaches. It can be seen that the overarching principles that guide intervention for music therapy and occupational therapy are reflective and complementary of each other which enabled occupational therapy and music therapy to work towards similar goals within the group and for therapists to work with a cohesive approach.
Sensory Processing Intervention to address Executive Dysfunction.
Despite limited literature being available that examines the relationship between EF and SP impairment, Galvin et al. (2009) reasons that when applying knowledge of ABI to Dunn’s model of SP (1997), it is important to consider the relationship between the two concepts. In the current study, it was difficult to determine whether occupational performance difficulties were related to EF impairment, SP difficulties or whether indeed, it is possible to separate the two areas; as Galvin et al. (2009) suggested, SP forms the basis for EF. The question is then raised; can standard SP interventions be used to effectively address EF impairments? Similarities between standard cognitive rehabilitation compensatory techniques and standard SP interventions were identified. Of the numerous cognitive strategies listed by Toglia et al. (2012) many are also utilised to address SP difficulties. For example, both interventions can involve teaching self-awareness, modality specific strategies such as employing movement, visual and auditory cues, and the use of rehearsal, reducing sensory stimulation, task simplification, and attention to doing. Despite a small sample size, results indicated a positive trend for improved occupational performance, suggesting that standard SP intervention used in combination with music therapy may be an effective intervention for children with EF caused by ABI.
Future Scope for Music Therapy as part of Acquired Brain Injury Services
The children, parents/caregivers, and staff involved with the pilot valued the introduction of music therapy services to ABI and neurology outpatients. Music therapy is an integral part of rehabilitation services at other regional paediatric hospitals and work undertaken with children with ABI in is regularly documented (Bower, 2010; Bower & Shoemark, 2102; Kennelly, 2013). This suggests that there is adequate scope for further group and individual music therapy services across a variety of caseloads within the ABI/Neurology Department, as indicated by occupational therapy staff. This may include joint group services with a similar format and focus to the current study.
Strengths and Limitations
A number of strengths and limitations were identified in relation to the evaluation. This practical and feasible study demonstrated the effectiveness of both the program and interdisciplinary application of it, and could easily be translated into practice. It indicates a need for research into the effects of joint music therapy and occupational therapy services with this population.
Regarding limitations, the small sample size meant that data collection had constraints. GAS goal post tests would usually be completed jointly with the therapists and family; however on this occasion due to time constraints, only the therapists rated them. Post School Function Assessments were only completed for one child. However the data provide sufficient evidence to support further exploration of this joint intervention for children with ABI with a larger sample.
In relation to the music therapy service, no formal music therapy assessments of children were undertaken prior to the group commencing. This meant that the music therapist had no prior relationship with the children and limited understanding of their needs. Essentially the group sessions offered a form of assessment for each child that could inform future music therapy intervention, as responses and progress were documented through the use of the IMTAP. The outcome measure as it was used in this study was not highly sensitive to small changes, however indications of positive progress for all children were observed across the majority of domains. Future studies using the IMTAP as a progress indicator should address the test/retest interval.
Whilst it would be preferable to include formal clinical assessments as part of the service, the funding available in this instance did not provide scope for this aspect of service delivery, particularly where seven children were involved. It is recommended that future funding applications should stipulate provision for individual assessment services prior to group intervention.
Furthermore, taking time to educate staff to assist their understanding of a new specialist service is important. Occupational therapy staff indicated they had gained valuable experiential understanding of music therapy and this would assist them in making future referrals. However, staff unfamiliar with music therapy expressed the need for prior knowledge, which may have helped in referring children for the group and for planning purposes. Whilst the music therapist spent time with staff in the initial planning meetings, it was not possible to provide an in-depth understanding of music therapy, especially where the practicalities of moving the project forward were important. In the future, it would advantageous to run an informative workshop for staff.
Future planning for groups such as the one described in this study should consider practical issues including parent/child availability and timing of the sessions in relation to the school year. Involving parents in more than one session may also be a possibility, particularly for modelling of techniques and strategies.
Conclusion
This evaluation has evaluated the impact of a joint music therapy and occupational therapy intervention on the development of self-regulation skills of children with ABI and neurological conditions. The study formed an integral part of a pilot project to ascertain the effectiveness of music therapy within the ABI and neurology caseload at a regional paediatric hospital. We found that the joint intervention was effective in the children’s ability to make progress towards maintaining quiet/alert arousal states conducive to listening to others and attending to tasks, and engaging in positive interpersonal relationships. Parents of the children involved felt supported and empowered to implement a range of strategies for parents to play an active role in their child’s rehabilitation. Positive outcomes from this study indicate there is future scope for the continuation of music therapy services, particularly as both service users and staff at the hospital valued it. We propose that further studies to evaluate the effectiveness of group work with children with ABI and neurological conditions are required.
Acknowledgement
The authors would like to acknowledge and thank Bess Fowler, Research and Evaluation Coordinator, for her guidance and contributions. Thanks are also extended to Zoe Massey, Occupational Therapist, who was involved in data collection.
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