Evaluation of a Music Therapy Social Skills Development Program for Youth with Limited Resources

Evaluation of a Music Therapy Social Skills Development Program for Youth with Limited Resources Abstract Background Children living in low-resource communities are at risk for poorer socio-emotional development and academic performance. Emerging evidence supports use of group music therapy experiences to support social development through community afterschool programming. Objective To examine the potential benefit of a music therapy social skills development program to improve social skills and academic performance of school-aged children with limited resources in an afterschool program. Method We used a single-group pre/post-test design, and recruited 20 students (11 females, 9 males), ages 5 to 11 years, from an afterschool program. The music therapy social skills program consisted of eight 50-minute sessions, and we measured social competence and antisocial behavior using the Home & Community Social Behavioral Scale (HCSBS; Merrell & Caldarella, 2008), and social skills, problem behaviors, and academic competence using the Social Skills Improvement System (SSIS; Gresham & Elliot, 2008a, 2008b). Results Only students who attended a minimum of six sessions (N = 14) were included in data analysis. Results showed no significant change in individual HBSC subscale scores; however, the total number of low-performance/high-risk skills significantly decreased. SSIS teacher results indicated significant improvement in communication, significant decrease of hyperactivity, autistic behavioral tendencies and overall problem behaviors, and marginal decreases in internalization. Parent ratings mirrored, in part, those of the teacher. Conclusions Results indicated that music therapy has the potential of being an effective intervention for promoting social competence of school-aged children with limited resources, particularly in the areas of communication and low-performance/high-risk behaviors. Teaching skills through song lyrics and improvisation emerged as salient interventions. The US Department of Health and Human Services has identified the promotion of social and emotional well-being in children as a national priority (Administration for Children and Families, 2012). To promote well-being in children, Lippman, Moore, and McIntosh (2011) developed a strengths-based approach that focuses on increasing the child’s individual resources (i.e., competencies, skills, behaviors, personal qualities) as well as social relationships that would support adaptive developmental outcomes across the life span. Specifically, they identified social development and behavior as a categorical construct that is essential to the development of a child’s well-being. Moreover, they recognized participation in arts-based activities as supporting children’s cognitive development. In this study, we (a board-certified music therapist and an experimental psychologist) designed and tested an intervention to promote social competence of school-aged children with limited resources that place them at risk for developmental problems. For this study, we defined children with limited resources as those who may experience any combination of risks (factors that increase the possibility of negative outcomes) and vulnerabilities (factors that act as catalysts in the presence of adversity or risk and lead to maladaptive outcomes).1 Exposure to risks and vulnerabilities creates a scarcity situation that may affect socio-emotional development. Socio-emotional competence is composed of a variety of skills that involve individual action and interaction within situational-cultural contexts (Andrews, 2006; Rose-Krasnor, 1997). Therefore, several contextual factors (such as community violence or low socioeconomic status) combined with family factors (such as inter-partner conflict, distress, poor parenting, or lack of social supports) place youth at high risk for deficits in their social-emotional development and related outcomes (Lippman et al., 2011). In particular, socio-emotional competence, which includes the ability to use one’s individual skills and knowledge to navigate different environments, adapt to expectations, and interact with others (Winner, 2008), can be an important predictor for educational and socially adaptive outcomes and is directly linked to behavioral and academic performance outcomes for students. For example, Izard and colleagues (2001) found that a lack of emotion knowledge mediated the relationship between verbal ability and academic competence. Furthermore, based on a comprehensive literature review including 34 meta-analyses, Wang, Haertel, and Walberg (1993) concluded that affective and social factors had more of an impact on academic achievement than peer influences, family influences, or direct academic instruction. Social skills are an important component of social competence. Children experiencing situational and contextual risk factors may require systematic instruction to help them gain social skills and behaviors needed to develop adaptive social relationships (Andrews, 2006). According to Durlak and colleagues (2011), such instruction must use a systematic process that targets specific skills using sequential activities that include hands-on experiential components. Outcomes from this type of instruction have included improvements in socio-emotional skills, reductions in externalized and internalized problem behaviors, and improvement in academic performance (Durlak et al., 2011). Furthermore, Shernoff (2010) found that afterschool programming that promotes students’ active engagement might be an important factor in predicting social competence and positive academic outcomes. Durlak and Weissberg (2007) conducted a review of afterschool programs for the Center for Academic, Social, and Emotional Learning (CASEL) and concluded that children attending afterschool programs that incorporate evidence-based curricula focused on building social/emotional competence show significant improvements in feelings and attitudes, decreases in behavioral problems, and improvements in school grades and overcall academic achievement. The aforementioned results are relevant to the current study because we measured social competence, antisocial behavior, behavioral problems, and academic competence. In addition, we used existing evidence-based curricula to inform development of the social skills music therapy program Social Skills Improvement System Intervention (SSIS™; Elliott & Gresham, 2008a) and Skillstreaming the Elementary School Child (McGinnis, 2005). Music therapy clinicians often serve children and youth who experience threats to their overall adaptation resulting from exposure to social, economic, or cultural stressors. In a survey of music therapy practice with youth identified as high risk, Clark and colleagues (2013) found that the most frequently addressed goals included self-expression and coping skills. Additional goals included self-esteem, social skills, and behavior management. Although there are multiple reports describing clinical interventions for youth with limited resources (e.g., Camilleri, 2007, Clements-Cortès, 2013; Cobbett, 2009; Fouche & Torrance, 2005; Quintanilla, 2008; Smith, 2012a, 2012b; Snow & D’Amico, 2010), there has been limited empirical examination of programmatic outcomes. In the current music therapy literature, a majority of research examining social skills development has focused on children and adolescents with developmental delays. Findings indicated improvement in eye gaze, joint attention, and learning specific social behaviors or routines (c.f., Brownell, 2002; Kalas, 2012, Kern, Wolery, & Aldridge, 2007; Kim, Wigram, & Gold, 2008; LaGasse, 2014). Moreover, some music therapy researchers have addressed the development of social and problem-solving skills of young children. Staum (1993) and Ulfarsdottir and Erwin (1999) derived ideas from a curriculum called I Can Problem Solve (Shure, 1993, 2001), originally designed for high-functioning children with autism. Findings from both studies, however, were inconclusive due to methodological design issues. Finally, researchers targeting development of social skills and overall well-being with adolescents found improvements in communication skills, attitudes toward learning, and relationships with peers (Derrington, 2012; Porter et al., 2017). Although the results of the studies referenced above offer information about development of social skills, only three studies have examined the use of music for social skills development in at-risk children in afterschool programs (Chong & Kim, 2010; Gooding, 2011; Heiskell, 2010). Heiskell (2010) designed an educative music therapy curriculum to develop math and social competence skills in high school students. The program was structured to provide students with opportunities to learn and exercise the targeted skills by learning and performing songs as a rock band. Sessions were conducted at a high school during group guitar classes and at a local afterschool program. Participating students self-reported an increase in their academic and social performance following completion of the 10-week program. Gooding (2011) administered a five-session social skills training curriculum across three different settings: a school, a residential setting, and an inner-city afterschool program. She measured effectiveness by using a researcher-constructed observation measure of social skills and the Home and Community Social Behavioral Scale (HCSBS; Merrell & Caldarella, 2008). Participants included 45 children aged 6–17 years. The curriculum included active music experiences such as movement to music, improvisation, and music performance. The music therapist implementing the program used cognitive behavioral strategies and problem-solving to model appropriate social skills and interactions. Participants in the school setting and the afterschool setting self-reported improved social functioning. Case-manager ratings in the residential treatment setting using the HCSBS indicated significant improvement in antisocial behaviors. Behavioral observations during sessions using the researcher-constructed form indicated increased on task behaviors during sessions across all three settings. These results are a preliminary indicator that music-based curricula targeting social skills may improve functioning. Working with elementary school-aged children, Chong and Kim (2010) recruited 89 participants from 13 different schools. Teachers referred participants to music therapy if they exhibited behavioral or social problems, but had no formal diagnosis. They labeled their intervention Education-oriented Music Therapy (EoMT) because social, emotional, and academic outcomes were addressed by focusing on learning musical concepts such as recognizing differences between musical tones (height, intensity), sound groupings, and meter. They also introduced musical performance elements such as relaying or imitating musical phrases. Moreover, they introduced how to identify or portray emotion in music and practiced impulse control and emotional coping strategies through songwriting. Participants received music therapy twice a week for a total of 16 weeks. Chong and Kim (2010) used an earlier version of the Social Skills Improvement System (SSIS; Gresham & Elliot, 2008a, 2008b) as pre/post-test and found a significant improvement in social skills and problematic behaviors, but no improvement in academic competence. These three studies (Chong & Kim, 2010; Gooding, 2011; Heiskell, 2010) provide evidence supporting the use of group music therapy experiences for children experiencing multiple threats to their socio-emotional development and positive adaptation; however, additional research is needed to examine the use of group music therapy for social competence training with elementary school-aged children living in low resource communities. To address this gap in existing research, we designed a music therapy social skills development program for this population. Program participation was not intended as a “fix” for existing issues. Rather, our intent was to provide a proactive intervention to support development of social competencies (e.g., taking turns in conversations, polite manners, paying attention to others, asking for help, or doing your part in a group), and healthy behaviors (e.g., doing the right thing, getting along with others, or paying attention to your work). We directly targeted social competencies and healthy behaviors during music therapy sessions. However, we expected indirect benefits in academic performance. Thus, one of our measures screened for individual strengths and low-performance/high-risk skills (Home & Community Social Behavioral Scale [HCSBS]; Merrell & Calderella, 2008), and the other yielded information about social skills, problem behaviors, and academic competence (Social Skills Improvement System [SSIS]; Gresham & Elliot, 2008a, 2008b). Since we collaborated closely with the afterschool teacher, we also aimed to identify her perceptions about the music therapy program. Specific research questions that guided our study were as follows: 1. Will the number of low-performance/high-risk skills, as measured by the HCBS, identified at baseline decrease following participation in the music therapy social skills development program? 2. What is the effect of participation in the music therapy social skills development program (as measured by the HCBS) on social competence and antisocial behavior? 3. What is the effect of participation in the music therapy social skills development program (as measured by the SSIS) on social skills, problem behaviors, and academic competence? 4. What are the afterschool teacher’s perceptions about the music therapy social skills development program and the responses of participants to the program? Method Setting The setting was an afterschool program delivered in a common space/leasing office area at a public-housing apartment complex in a large metropolitan city. The afterschool program was managed by a nonprofit community agency. Families living in the apartment complex were participating in a five-year self-sufficiency program. Eligibility criteria for the self-sufficiency program included low-income or disabilities. Families were evaluated by case managers who determined specific needs, established long-term goals, and referred families for services such as remedial education, substance abuse counseling, training in money and household management, parenting skills classes, transportation, and childcare (Charlotte Housing Authority, 2017). Thus, because of the study setting, all participants in this study were exposed to various social, economic, or cultural stressors. Research Design We used a single-group pre/post-test design to examine improvements in social skills, problem behaviors, and academic performance resulting from participation in the music therapy social skills development program. Use of a more rigorous control group design was not possible due to the programmatic structure of the afterschool program. The research team consistent of: (a) the first author, who is a music therapy educator and a board-certified music therapist with 15 years’ experience; (b) the second author, who is a psychology educator; and (c) three undergraduate sophomore music therapy students and one undergraduate psychology student. The sophomore students had one year of clinical experience working at a university-based on-campus clinic and one semester (approximately 10 sessions) of co-leading therapy groups at early intervention settings. The first author designed the music therapy program and served as the primary therapist delivering the sessions. The second author conducted the data analysis and teacher interview. The first author led music experiences during each session. The three music therapy students assisted the first author during music therapy sessions by gathering materials, and leading some of the therapeutic experiences during the session. Students rehearsed therapeutic music experiences under the supervision of the first author prior to scheduled sessions with study participants. Their involvement in the treatment process gradually increased as the sessions progressed and they became familiar with the setting and the participants. The music therapy students also performed data entry. The psychology student conducted data entry and transcribed the teacher interview. All students involved in the research team completed training required by the Research Ethics Board and signed confidentiality agreements. Procedure During a regularly scheduled afterschool program community meeting, the afterschool teacher and second author provided information about the study, answered questions, and obtained signed informed consent from interested parents. Consenting parents were then given copies of the baseline (pre-test) assessments for completion at home. During the week prior to the first music therapy session, the teacher and her assistant visited parents in their apartments to collect the assessment forms and receive informed consent from parents who were unable to attend the first informational meeting. The afterschool teacher also completed baseline (pre-test) measures on each participating child one week prior to the first study session. Following pre-test data collection, participants received eight weekly music therapy sessions delivered in a group setting. The size of the group ranged from 8 to 21 students. It is important to note that seven students enrolled in the afterschool program while the study was ongoing. Those students participated in weekly music therapy sessions because the program was offered as part of regular afterschool programming; however, no data were collected on these students. Each session had a duration of 50 minutes, and the eight sessions were delivered across a period of 10 weeks. The teacher and parents completed post-test assessments within two weeks of program completion, and the second author conducted the teacher interview three weeks following program conclusion. Participants All 20 participants (11 females, 9 males), ages 5 to 11 years, enrolled in the afterschool program at the beginning of this study were recruited to participate. Each week, all students attending the afterschool program verbally assented to participate in music therapy. During implementation of the music therapy social skills development program, five students withdrew from the afterschool program because their families moved out of the apartment complex. Thus, the study attrition rate (number of lost participants divided by total number of participants) was 25%. Students who withdrew were not included in the data analysis. Moreover, one student was excluded because he attended fewer than six sessions—only students who attended a minimum of six sessions were included in the data analysis. Overall session attendance rate was 74.67%. The remaining number of participants (N = 14) constituted the sample size included in the data analysis. All participants were typically developing, based on verbal reports by the afterschool teacher, and did not have a diagnosed disability. The Queens University of Charlotte Research Ethics Review Committee approved this study, and all parents provided written informed consent for their child’s participation. Measures Home and Community Social Behavioral Scale (HCSBS;Merrell & Calderella, 2008). The HCSBS is a 64-item screening tool of social functioning levels yielding scores of social competence and antisocial behavior. The HCSBS is a robust measure designed to assess the common social competencies and problems seen in children and takes only 10 minutes to complete. The standardized norms are consistent with other child behavior scales. Higher social competence scores (includes peer relations, self-management/compliance, and a total social competence score) indicate better adjustment. Higher antisocial behavior scores (includes defiant/disruptive, antisocial/aggressive, and a total antisocial behavior score) indicate greater levels of social behavior problems. Reliability measures are all quite strong for both dimensions (.82–.97). Validity assessments are also strong (.62–.81). The full-time afterschool teacher completed this scale. The administration manual includes cut-off scores for all the subscales identifying each child’s social functioning level. The total score for social competence, and each of its subscales, has four social functioning levels: high functioning, average, at risk, and high risk. The total score for antisocial behavior, and each of its subscales, has three social functioning levels: average, at risk, and high risk. Only the afterschool teacher completed this measure. Social Skills Improvement System (SSIS;Gresham & Elliot, 2008a, 2008b). This rating scale yields information about a child’s social skills, problem behaviors, and academic competence. The social skills subscale provides assessment of communication, cooperation, assertion, responsibility, empathy, engagement, and self-control. The problem behavior subscale surveys behaviors that inhibit or prevent development of social skills focusing on externalizing, bullying, hyperactivity/inattention, internalizing, and autism spectrum behavioral tendencies. Academic competence is a separate subscale focusing on student motivation, reading and math skills, parental support, and overall cognitive functioning. The academic subscale, capturing parental or teacher perceptions of competence, was included as a way to capture the relationship between academic performance and social competence (Gresham & Elliot, 2008b). Reliability is high (.86–.92), as is validity. The SSIS is normed on a large national sample and yields two global scores for social and behavioral competence. This measure provided a more detailed assessment of social skills, problem behaviors, and academic performance, pre and post intervention. The administration manual includes cut-off scores for all the subscales identifying each child’s functioning level. Both parents and the afterschool teacher completed this scale. Teacher Interview. The second author conducted a semi-structured interview three weeks post intervention to examine the teacher’s perceptions about the music therapy program and responses of the children to the intervention. Sample questions included: What factors or circumstances do you think contributed or affected the delivery of the program? What did you like best about the program? How would you improve the program? In your opinion, what are the most important outcomes or benefits that have resulted from the music therapy program? A teacher assistant, who only worked part-time and did not observe music therapy, did not participate in this interview. The Music Therapy Social Skills Development Program The first author designed an eight-session Music Therapy Social Skills Development Program targeting improvement of social skills and reduction of problem behaviors. Readers will find a list of all the social skills and problem behaviors targeted during sessions, including descriptions of therapeutic music experiences, in Table 1. Similar to other researchers (Staum, 1993; Ulfarsdottir & Erwin, 1999), the first author incorporated materials and emphasized sequential skills outlined in the following documented intervention guide programs: the Social Skills Improvement System Intervention (SSIS™; Elliott & Gresham, 2008a), and Skillstreaming the Elementary School Child (McGinnis, 2005). In addition, the first author used scores from the HCBS to guide session content (i.e., identification of specific social skills and problem behaviors that needed attention). Specifically, based on recommendations outlined in the HCSBS user’s guide (Merrell & Caldarella, 2008), the first author identified low-performance/high-risk skills, and looked for trends and individual areas of growth. Table 1 Music Therapy Social Skills Development Program–Therapeutic Interventions Outline Interventions Targeting Social Skills Specific Skill Description of Intervention(s) Taking turns in conversations. (Unit 1, SSIS; Gresham & Elliot, 2008a). Skill steps and instructions embedded in lyrics of original song created by the first author. Saying “please” and “thank you.” (Unit 2, SSIS; Gresham & Elliot, 2008a). Chants about good manners. Role-play during sessions. Beginning a conversation. (Skill 16. McGinnis, 2005). Ending conversations. (Skill 17. McGinnis, 2005). Original song created by first author that contained the steps for each skill in the lyrics. Practiced beginning and ending musical conversations during improvisation. Paying attention to others. (Unit 3, SSIS; Gresham & Elliot, 2008a). Listening to others. (Skill 55; McGinnis, 2005). Structured drumming games and improvisation using various instruments. Taking turns modeling musical patterns for others to repeat in the group. Improvisation using various instruments. Incorporation of adapted Orff-Schulwerk music education techniques (i.e., pentatonic song, body percussion sections, and assigning instruments and specific parts for each child in the group, alternated singing songs or chants with assigned instrumental parts and improvising in an ABA format). Following directions. (Unit 4, SSIS; Gresham & Elliot, 2008a). Creating a thunderstorm sound-story. Playing silly musical games that involve following a leader. Performing songs using bell chimes. Asking for help. (Unit 7, SSIS; Gresham & Elliot, 2008a). Original lyrics adapted to fit into the song Help by the Beatles. Doing your part in a group. (Unit 11, SSIS; Gresham & Elliot, 2008a). Structured drumming games and improvisation using various instruments. Activities encouraging group collaboration using props such as the stretch rope or the parachute. Introducing yourself to others. (Unit 16, SSIS; Gresham & Elliot, 2008a). Chanting and practicing introductions while drumming. Accepting no. (Skill 54; McGinnis, 2005). Skill 55. Skill 55. Refusing a request/Saying no. (Skill 55; McGinnis, 2005). Playing yes and no game (MT says yes and the students respond the opposite no while matching facial affect and intensity of voice; similarly, if MT says no, the students say yes). Role-play requesting instruments and coping by making a different selection when the answer is no. Practicing saying no when wanting to continue playing a particular instrument. Knowing your feelings. (Skill 26; McGinnis, 2005). Chanted about feeling mad. Using a visual of a volcano to write different scenarios that elicit the feeling mad. Additional songs and chants about different feelings (e.g., Stop and think song, Angry bear/happy bear). Interventions Targeting Problem Behaviors Specific Skill Description of Intervention(s) Paying attention to your work. (Unit 5, SSIS; Gresham & Elliot, 2008a). Learning short songs and playing accompaniment with Orff instrumentation. Practicing playing parts without getting distracted (vocal ostinators, rhythmic ostinatos). Ignore Song–original song developed by the first author that included the steps for this skill in the lyrics. Do the right thing (Unit 5, SSIS; Gresham & Elliot, 2008a). Sing along and song discussion. Song used: Do the Right Thing, by Ages and Ages, included in the Album Divisionary. Created rap verse for song about different actions that represent the right thing to do in different scenarios. Getting along with others. (Unit 15, SSIS; Gresham & Elliot, 2008a). Making compromises. (Unit 17, SSIS; Gresham & Elliot, 2008a). Defined the word compromise and caring. Proceeded with music-assisted relaxation using compromise and caring as focus words during inhale and exhale. Negotiated which instruments each child would play by making requests, asking to share, finding an alternative instrument when first choice was not available. Interventions Targeting Social Skills Specific Skill Description of Intervention(s) Taking turns in conversations. (Unit 1, SSIS; Gresham & Elliot, 2008a). Skill steps and instructions embedded in lyrics of original song created by the first author. Saying “please” and “thank you.” (Unit 2, SSIS; Gresham & Elliot, 2008a). Chants about good manners. Role-play during sessions. Beginning a conversation. (Skill 16. McGinnis, 2005). Ending conversations. (Skill 17. McGinnis, 2005). Original song created by first author that contained the steps for each skill in the lyrics. Practiced beginning and ending musical conversations during improvisation. Paying attention to others. (Unit 3, SSIS; Gresham & Elliot, 2008a). Listening to others. (Skill 55; McGinnis, 2005). Structured drumming games and improvisation using various instruments. Taking turns modeling musical patterns for others to repeat in the group. Improvisation using various instruments. Incorporation of adapted Orff-Schulwerk music education techniques (i.e., pentatonic song, body percussion sections, and assigning instruments and specific parts for each child in the group, alternated singing songs or chants with assigned instrumental parts and improvising in an ABA format). Following directions. (Unit 4, SSIS; Gresham & Elliot, 2008a). Creating a thunderstorm sound-story. Playing silly musical games that involve following a leader. Performing songs using bell chimes. Asking for help. (Unit 7, SSIS; Gresham & Elliot, 2008a). Original lyrics adapted to fit into the song Help by the Beatles. Doing your part in a group. (Unit 11, SSIS; Gresham & Elliot, 2008a). Structured drumming games and improvisation using various instruments. Activities encouraging group collaboration using props such as the stretch rope or the parachute. Introducing yourself to others. (Unit 16, SSIS; Gresham & Elliot, 2008a). Chanting and practicing introductions while drumming. Accepting no. (Skill 54; McGinnis, 2005). Skill 55. Skill 55. Refusing a request/Saying no. (Skill 55; McGinnis, 2005). Playing yes and no game (MT says yes and the students respond the opposite no while matching facial affect and intensity of voice; similarly, if MT says no, the students say yes). Role-play requesting instruments and coping by making a different selection when the answer is no. Practicing saying no when wanting to continue playing a particular instrument. Knowing your feelings. (Skill 26; McGinnis, 2005). Chanted about feeling mad. Using a visual of a volcano to write different scenarios that elicit the feeling mad. Additional songs and chants about different feelings (e.g., Stop and think song, Angry bear/happy bear). Interventions Targeting Problem Behaviors Specific Skill Description of Intervention(s) Paying attention to your work. (Unit 5, SSIS; Gresham & Elliot, 2008a). Learning short songs and playing accompaniment with Orff instrumentation. Practicing playing parts without getting distracted (vocal ostinators, rhythmic ostinatos). Ignore Song–original song developed by the first author that included the steps for this skill in the lyrics. Do the right thing (Unit 5, SSIS; Gresham & Elliot, 2008a). Sing along and song discussion. Song used: Do the Right Thing, by Ages and Ages, included in the Album Divisionary. Created rap verse for song about different actions that represent the right thing to do in different scenarios. Getting along with others. (Unit 15, SSIS; Gresham & Elliot, 2008a). Making compromises. (Unit 17, SSIS; Gresham & Elliot, 2008a). Defined the word compromise and caring. Proceeded with music-assisted relaxation using compromise and caring as focus words during inhale and exhale. Negotiated which instruments each child would play by making requests, asking to share, finding an alternative instrument when first choice was not available. View Large Table 1 Music Therapy Social Skills Development Program–Therapeutic Interventions Outline Interventions Targeting Social Skills Specific Skill Description of Intervention(s) Taking turns in conversations. (Unit 1, SSIS; Gresham & Elliot, 2008a). Skill steps and instructions embedded in lyrics of original song created by the first author. Saying “please” and “thank you.” (Unit 2, SSIS; Gresham & Elliot, 2008a). Chants about good manners. Role-play during sessions. Beginning a conversation. (Skill 16. McGinnis, 2005). Ending conversations. (Skill 17. McGinnis, 2005). Original song created by first author that contained the steps for each skill in the lyrics. Practiced beginning and ending musical conversations during improvisation. Paying attention to others. (Unit 3, SSIS; Gresham & Elliot, 2008a). Listening to others. (Skill 55; McGinnis, 2005). Structured drumming games and improvisation using various instruments. Taking turns modeling musical patterns for others to repeat in the group. Improvisation using various instruments. Incorporation of adapted Orff-Schulwerk music education techniques (i.e., pentatonic song, body percussion sections, and assigning instruments and specific parts for each child in the group, alternated singing songs or chants with assigned instrumental parts and improvising in an ABA format). Following directions. (Unit 4, SSIS; Gresham & Elliot, 2008a). Creating a thunderstorm sound-story. Playing silly musical games that involve following a leader. Performing songs using bell chimes. Asking for help. (Unit 7, SSIS; Gresham & Elliot, 2008a). Original lyrics adapted to fit into the song Help by the Beatles. Doing your part in a group. (Unit 11, SSIS; Gresham & Elliot, 2008a). Structured drumming games and improvisation using various instruments. Activities encouraging group collaboration using props such as the stretch rope or the parachute. Introducing yourself to others. (Unit 16, SSIS; Gresham & Elliot, 2008a). Chanting and practicing introductions while drumming. Accepting no. (Skill 54; McGinnis, 2005). Skill 55. Skill 55. Refusing a request/Saying no. (Skill 55; McGinnis, 2005). Playing yes and no game (MT says yes and the students respond the opposite no while matching facial affect and intensity of voice; similarly, if MT says no, the students say yes). Role-play requesting instruments and coping by making a different selection when the answer is no. Practicing saying no when wanting to continue playing a particular instrument. Knowing your feelings. (Skill 26; McGinnis, 2005). Chanted about feeling mad. Using a visual of a volcano to write different scenarios that elicit the feeling mad. Additional songs and chants about different feelings (e.g., Stop and think song, Angry bear/happy bear). Interventions Targeting Problem Behaviors Specific Skill Description of Intervention(s) Paying attention to your work. (Unit 5, SSIS; Gresham & Elliot, 2008a). Learning short songs and playing accompaniment with Orff instrumentation. Practicing playing parts without getting distracted (vocal ostinators, rhythmic ostinatos). Ignore Song–original song developed by the first author that included the steps for this skill in the lyrics. Do the right thing (Unit 5, SSIS; Gresham & Elliot, 2008a). Sing along and song discussion. Song used: Do the Right Thing, by Ages and Ages, included in the Album Divisionary. Created rap verse for song about different actions that represent the right thing to do in different scenarios. Getting along with others. (Unit 15, SSIS; Gresham & Elliot, 2008a). Making compromises. (Unit 17, SSIS; Gresham & Elliot, 2008a). Defined the word compromise and caring. Proceeded with music-assisted relaxation using compromise and caring as focus words during inhale and exhale. Negotiated which instruments each child would play by making requests, asking to share, finding an alternative instrument when first choice was not available. Interventions Targeting Social Skills Specific Skill Description of Intervention(s) Taking turns in conversations. (Unit 1, SSIS; Gresham & Elliot, 2008a). Skill steps and instructions embedded in lyrics of original song created by the first author. Saying “please” and “thank you.” (Unit 2, SSIS; Gresham & Elliot, 2008a). Chants about good manners. Role-play during sessions. Beginning a conversation. (Skill 16. McGinnis, 2005). Ending conversations. (Skill 17. McGinnis, 2005). Original song created by first author that contained the steps for each skill in the lyrics. Practiced beginning and ending musical conversations during improvisation. Paying attention to others. (Unit 3, SSIS; Gresham & Elliot, 2008a). Listening to others. (Skill 55; McGinnis, 2005). Structured drumming games and improvisation using various instruments. Taking turns modeling musical patterns for others to repeat in the group. Improvisation using various instruments. Incorporation of adapted Orff-Schulwerk music education techniques (i.e., pentatonic song, body percussion sections, and assigning instruments and specific parts for each child in the group, alternated singing songs or chants with assigned instrumental parts and improvising in an ABA format). Following directions. (Unit 4, SSIS; Gresham & Elliot, 2008a). Creating a thunderstorm sound-story. Playing silly musical games that involve following a leader. Performing songs using bell chimes. Asking for help. (Unit 7, SSIS; Gresham & Elliot, 2008a). Original lyrics adapted to fit into the song Help by the Beatles. Doing your part in a group. (Unit 11, SSIS; Gresham & Elliot, 2008a). Structured drumming games and improvisation using various instruments. Activities encouraging group collaboration using props such as the stretch rope or the parachute. Introducing yourself to others. (Unit 16, SSIS; Gresham & Elliot, 2008a). Chanting and practicing introductions while drumming. Accepting no. (Skill 54; McGinnis, 2005). Skill 55. Skill 55. Refusing a request/Saying no. (Skill 55; McGinnis, 2005). Playing yes and no game (MT says yes and the students respond the opposite no while matching facial affect and intensity of voice; similarly, if MT says no, the students say yes). Role-play requesting instruments and coping by making a different selection when the answer is no. Practicing saying no when wanting to continue playing a particular instrument. Knowing your feelings. (Skill 26; McGinnis, 2005). Chanted about feeling mad. Using a visual of a volcano to write different scenarios that elicit the feeling mad. Additional songs and chants about different feelings (e.g., Stop and think song, Angry bear/happy bear). Interventions Targeting Problem Behaviors Specific Skill Description of Intervention(s) Paying attention to your work. (Unit 5, SSIS; Gresham & Elliot, 2008a). Learning short songs and playing accompaniment with Orff instrumentation. Practicing playing parts without getting distracted (vocal ostinators, rhythmic ostinatos). Ignore Song–original song developed by the first author that included the steps for this skill in the lyrics. Do the right thing (Unit 5, SSIS; Gresham & Elliot, 2008a). Sing along and song discussion. Song used: Do the Right Thing, by Ages and Ages, included in the Album Divisionary. Created rap verse for song about different actions that represent the right thing to do in different scenarios. Getting along with others. (Unit 15, SSIS; Gresham & Elliot, 2008a). Making compromises. (Unit 17, SSIS; Gresham & Elliot, 2008a). Defined the word compromise and caring. Proceeded with music-assisted relaxation using compromise and caring as focus words during inhale and exhale. Negotiated which instruments each child would play by making requests, asking to share, finding an alternative instrument when first choice was not available. View Large The first author designed the intervention so that one therapist could deliver the music therapy social skills development program. However, in this study we used a clinical team, consisting of the first author and three music therapy undergraduate students, to provide the intervention. The first author developed and scripted session plans, and student music therapy assistants participated in 60-minute weekly supervision to discuss treatment implementation, brainstorm and contribute ideas to session planning, simulate and practice each of the therapeutic music experiences, and exchange feedback with the first author. The weekly supervision served as both training and monitoring of session delivery. The music therapy students received college credit for their work on the study, which counted toward the clinical training requirements for their degree. The music therapy sessions consisted of several experiences (both active and receptive), such as movement to music, active music-making, Orff-based musical exercises, improvisation, songwriting, role-play, music performance, and music-assisted relaxation. Using structured improvisation (we used Beer, 2001, as a conceptual model) and Orff-based activities, which were adapted from music education resources, allowed the clinical team to engage each child in an appropriate and flexible manner. An Orff-based approach has been used by other researchers to engage children in low-income families (c.f., Young-Bae & Ji-Eun, 2013). Older children were given harder musical tasks or group-leading roles. The variety of experiences was purposeful and designed to sustain engagement, interest, and attention over the 50-minute session. The therapy sessions had a beginning, middle, and end format. At the beginning of the session, the children and therapist reviewed/practiced previously learned skills, new skills were introduced in the middle of the session, and sessions ended with a closing song. The first author prepared a weekly newsletter that each parent in the afterschool program received. The newsletter included information about the skills targeted during music therapy, and contained step-by-step flashcards with instructions on how to reinforce some of the skills at home. The afterschool teacher also received the same information and flashcards to implement during the afterschool program. The teacher reviewed the flashcards with the students during the week and posted them on the classroom bulletin board. Providing information and assigning a skill to practice was similar to the approach used by Gooding (2011). In order to monitor the number of sessions that each participant received (i.e., dose), we maintained an attendance log. Based on this information, only participants who received a minimum of six sessions (approximately two-thirds of the “treatment”) were included in the data analysis. Data Analyses The second author used SPSS (Version 23) for all quantitative analyses. Paired t-tests were conducted separately on teacher and parent responses for SSIS and HCBS subscale scores. The HBSC has two dimensions (social competence and antisocial behavior). Each dimension has two subscales and a total score. Thus, six items were analyzed together as a set. The SSIS has two dimensions: social skills total score and seven subscales, for a total of eight items grouped together; problem behavior total score and five subscales, for a total of six items grouped together. Academic competence was analyzed separately. Parent scores were analyzed separately from teacher scores. Given the independence of the dimensions as indicated in the manuals, this grouping of analyses seemed justified. Bonferroni corrections were calculated for each set of multiple t-tests. All p-values reported reflect the adjustment for multiple comparisons. Cohen’s d was used to calculate effect size using Morris and DeShon’s (2002) equation 8 to correct for dependence of means. Reliability across raters for scales with two or more raters was assessed according to the test manuals. Final scores were arrived at through discussion for the few cases where there was initial disagreement. Following recommendations outlined in the HCSBS user’s guide (Merrell & Caldarella, 2008), the authors conducted a visual qualitative inspection of the ratings of individual items on the HCSBS scale looking for areas of concern, trends among identified items of need, or individual areas of growth. Specifically, individual items receiving ratings of 1 or 2 on the social competence subscale and 4 or 5 on the antisocial behavior subscale were highlighted as low-performance/high-risk skills. Subsequently, the frequency of students exhibiting low performance/high risk for each individual item was tabulated (see Table 2) and the information was used to develop the music therapy session plans. A paired t-test was used to compare the average number of individual items of concern participants exhibited pre and post the implementation of the music therapy social skills development program. Table 2 Individual Items Rated as Low-Performance/High-Risk Skills on the HCSBS Scale Social competence items identified as concerns Pre Post S3 Completes chores without being reminded 6 4 S28 Notices and compliments accomplishments of others 5 1 S14 Completes chores and assigned tasks on time 5 3 S4 Offers to help peers when needed 3 2 S19 Interacts with a wide variety of peers 3 0 S7 Remains calm when problems arise 3 1 S8 Listens to and carries out directions from parents or supervisors 0 2 S10 Asks appropriately for clarification of instructions 2 0 S11 Has skills or abilities that are admired by peers 2 0 S23 Responds appropriately when corrected by parents or supervisors 2 0 S24 Controls temper when angry 2 0 S26 Has good leadership skills 2 1 S32 Is looked up to or respected by peers 2 0 S23 Responds appropriately when corrected by parents or supervisors 2 0 S12 Is accepting of peers 2 0 S5 Participates effectively in family or group activities 0 1 S2 Makes appropriate transitions btw different activities 1 0 S6 Understands problems and needs of peers 1 1 S15 Will give in or compromise with peers when appropriate 1 2 S17 Behaves appropriately at school 1 0 S18 Asks for help in an appropriate manner 1 0 S21 Is good at initiating or joining conversations with peers 1 0 S22 Is sensitive to the feelings of others 1 1 S27 Adjusts to different behavioral expectations across settings 1 1 S31 Shows self-control 1 0 Total 50 20 Antisocial behavior items identified as concerns Pre Post A1 Blames others for his or her problems 3 3 A7 Teases and makes fun of others 3 1 A3 Is defiant to parents or supervisors 2 2 A8 Disrespectful or sassy 2 1 A22 Argues or quarrels with peers 2 1 A20 Insults peers 2 1 A9 Easily provoked or has a short fuse 1 1 A6 Is dishonest and tells lies 1 1 Antisocial behavior items identified as concerns Pre Post A17 Threatens others or is verbally aggressive 1 1 A24 Bothers and annoys others 1 1 A25 Gets into trouble at school or in the community 1 0 A29 Is cruel to other persons or animals 1 0 A23 Difficult to control 1 0 A27 Boasts and brags 1 0 A4 Cheats on school work or in games 1 0 A30 Acts impulsively without thinking 0 1 A2 Takes things that are not his or hers 0 1 A21 Whines and complains 0 2 A11 Acts as if he or she is better than others 0 1 A28 Is not dependable 0 1 Total 24 21 Social competence items identified as concerns Pre Post S3 Completes chores without being reminded 6 4 S28 Notices and compliments accomplishments of others 5 1 S14 Completes chores and assigned tasks on time 5 3 S4 Offers to help peers when needed 3 2 S19 Interacts with a wide variety of peers 3 0 S7 Remains calm when problems arise 3 1 S8 Listens to and carries out directions from parents or supervisors 0 2 S10 Asks appropriately for clarification of instructions 2 0 S11 Has skills or abilities that are admired by peers 2 0 S23 Responds appropriately when corrected by parents or supervisors 2 0 S24 Controls temper when angry 2 0 S26 Has good leadership skills 2 1 S32 Is looked up to or respected by peers 2 0 S23 Responds appropriately when corrected by parents or supervisors 2 0 S12 Is accepting of peers 2 0 S5 Participates effectively in family or group activities 0 1 S2 Makes appropriate transitions btw different activities 1 0 S6 Understands problems and needs of peers 1 1 S15 Will give in or compromise with peers when appropriate 1 2 S17 Behaves appropriately at school 1 0 S18 Asks for help in an appropriate manner 1 0 S21 Is good at initiating or joining conversations with peers 1 0 S22 Is sensitive to the feelings of others 1 1 S27 Adjusts to different behavioral expectations across settings 1 1 S31 Shows self-control 1 0 Total 50 20 Antisocial behavior items identified as concerns Pre Post A1 Blames others for his or her problems 3 3 A7 Teases and makes fun of others 3 1 A3 Is defiant to parents or supervisors 2 2 A8 Disrespectful or sassy 2 1 A22 Argues or quarrels with peers 2 1 A20 Insults peers 2 1 A9 Easily provoked or has a short fuse 1 1 A6 Is dishonest and tells lies 1 1 Antisocial behavior items identified as concerns Pre Post A17 Threatens others or is verbally aggressive 1 1 A24 Bothers and annoys others 1 1 A25 Gets into trouble at school or in the community 1 0 A29 Is cruel to other persons or animals 1 0 A23 Difficult to control 1 0 A27 Boasts and brags 1 0 A4 Cheats on school work or in games 1 0 A30 Acts impulsively without thinking 0 1 A2 Takes things that are not his or hers 0 1 A21 Whines and complains 0 2 A11 Acts as if he or she is better than others 0 1 A28 Is not dependable 0 1 Total 24 21 Scores represent the number of participants exhibiting each item at low performance/high risk. View Large Table 2 Individual Items Rated as Low-Performance/High-Risk Skills on the HCSBS Scale Social competence items identified as concerns Pre Post S3 Completes chores without being reminded 6 4 S28 Notices and compliments accomplishments of others 5 1 S14 Completes chores and assigned tasks on time 5 3 S4 Offers to help peers when needed 3 2 S19 Interacts with a wide variety of peers 3 0 S7 Remains calm when problems arise 3 1 S8 Listens to and carries out directions from parents or supervisors 0 2 S10 Asks appropriately for clarification of instructions 2 0 S11 Has skills or abilities that are admired by peers 2 0 S23 Responds appropriately when corrected by parents or supervisors 2 0 S24 Controls temper when angry 2 0 S26 Has good leadership skills 2 1 S32 Is looked up to or respected by peers 2 0 S23 Responds appropriately when corrected by parents or supervisors 2 0 S12 Is accepting of peers 2 0 S5 Participates effectively in family or group activities 0 1 S2 Makes appropriate transitions btw different activities 1 0 S6 Understands problems and needs of peers 1 1 S15 Will give in or compromise with peers when appropriate 1 2 S17 Behaves appropriately at school 1 0 S18 Asks for help in an appropriate manner 1 0 S21 Is good at initiating or joining conversations with peers 1 0 S22 Is sensitive to the feelings of others 1 1 S27 Adjusts to different behavioral expectations across settings 1 1 S31 Shows self-control 1 0 Total 50 20 Antisocial behavior items identified as concerns Pre Post A1 Blames others for his or her problems 3 3 A7 Teases and makes fun of others 3 1 A3 Is defiant to parents or supervisors 2 2 A8 Disrespectful or sassy 2 1 A22 Argues or quarrels with peers 2 1 A20 Insults peers 2 1 A9 Easily provoked or has a short fuse 1 1 A6 Is dishonest and tells lies 1 1 Antisocial behavior items identified as concerns Pre Post A17 Threatens others or is verbally aggressive 1 1 A24 Bothers and annoys others 1 1 A25 Gets into trouble at school or in the community 1 0 A29 Is cruel to other persons or animals 1 0 A23 Difficult to control 1 0 A27 Boasts and brags 1 0 A4 Cheats on school work or in games 1 0 A30 Acts impulsively without thinking 0 1 A2 Takes things that are not his or hers 0 1 A21 Whines and complains 0 2 A11 Acts as if he or she is better than others 0 1 A28 Is not dependable 0 1 Total 24 21 Social competence items identified as concerns Pre Post S3 Completes chores without being reminded 6 4 S28 Notices and compliments accomplishments of others 5 1 S14 Completes chores and assigned tasks on time 5 3 S4 Offers to help peers when needed 3 2 S19 Interacts with a wide variety of peers 3 0 S7 Remains calm when problems arise 3 1 S8 Listens to and carries out directions from parents or supervisors 0 2 S10 Asks appropriately for clarification of instructions 2 0 S11 Has skills or abilities that are admired by peers 2 0 S23 Responds appropriately when corrected by parents or supervisors 2 0 S24 Controls temper when angry 2 0 S26 Has good leadership skills 2 1 S32 Is looked up to or respected by peers 2 0 S23 Responds appropriately when corrected by parents or supervisors 2 0 S12 Is accepting of peers 2 0 S5 Participates effectively in family or group activities 0 1 S2 Makes appropriate transitions btw different activities 1 0 S6 Understands problems and needs of peers 1 1 S15 Will give in or compromise with peers when appropriate 1 2 S17 Behaves appropriately at school 1 0 S18 Asks for help in an appropriate manner 1 0 S21 Is good at initiating or joining conversations with peers 1 0 S22 Is sensitive to the feelings of others 1 1 S27 Adjusts to different behavioral expectations across settings 1 1 S31 Shows self-control 1 0 Total 50 20 Antisocial behavior items identified as concerns Pre Post A1 Blames others for his or her problems 3 3 A7 Teases and makes fun of others 3 1 A3 Is defiant to parents or supervisors 2 2 A8 Disrespectful or sassy 2 1 A22 Argues or quarrels with peers 2 1 A20 Insults peers 2 1 A9 Easily provoked or has a short fuse 1 1 A6 Is dishonest and tells lies 1 1 Antisocial behavior items identified as concerns Pre Post A17 Threatens others or is verbally aggressive 1 1 A24 Bothers and annoys others 1 1 A25 Gets into trouble at school or in the community 1 0 A29 Is cruel to other persons or animals 1 0 A23 Difficult to control 1 0 A27 Boasts and brags 1 0 A4 Cheats on school work or in games 1 0 A30 Acts impulsively without thinking 0 1 A2 Takes things that are not his or hers 0 1 A21 Whines and complains 0 2 A11 Acts as if he or she is better than others 0 1 A28 Is not dependable 0 1 Total 24 21 Scores represent the number of participants exhibiting each item at low performance/high risk. View Large The first author listened to the audio recording and read the transcript from the teacher interview. She then conducted a thematic analysis in order to identify themes without being bound to a specific theoretical orientation (c.f., Braun & Clarke, 2006). The analysis focused on synthesizing a semantic description of the teacher’s perception of the music therapy social skills program. Results Teacher Ratings HBSC. Results showed no significant changes on any individual HBSC subscale pre-post comparisons (all ps > .1). However, the average number of behaviors in which children were classified as low performance/high risk on the HCBS decreased significantly from pre- (M = 2.0, SD = 1.50) to post-test (M = .8, SD = 1.08; t (24) = 2.54, p < .001, d = .918). The frequency distribution of individual items on the HCSBS scale identified as an area of low performance/high risk pre and post the implementation of the music therapy social skills development program is included in Table 2. SSIS. The SSIS teacher results indicated significant improvement in one specific social skill subscale score, communication (pre M = 13.61, SD = 4.37; post M =16.31, SD = 3.38; t (12) = –3.19, p = .007, d = .933). Significant decreases were seen in overall problem behaviors (pre M = 7.23, SD = 10.37; post M =1.23, SD = .72; t (12) = 2.13, p = .05, d = .787). Regarding specific problem behaviors, significant decreases were seen in hyperactivity/inattentiveness (pre M = 7.54, SD = 3.15; post M =5.38, SD = 2.60; t (12) = 3.18, p = .008, d = .903), and autistic tendencies (pre M = 8.54, SD = 4.87; post M = 4.38, SD = 3.25; t (12) = 3.28, p = .007, d = .957), and marginal decreases in internalizing behaviors (pre M = 4.00, SD = 2.04; post M =2.07, SD = 2.2; t (12) = 2.85, p = .015, d = .806). An unexpected finding was teacher ratings showing a significant decrease in academic competence from pre- to post-test (pre M = 10.38, SD = 6.64; post M = 5.61, SD = 2.81; t (10) = 2.79, p = .017, d = .97). Parent Ratings Parents completed pre and post ratings on the SSIS scale. Only 11 of the 14 children who attended 6 or more sessions had complete pre and post parent rating data. The analyses were conducted on the scores for these 11 children. SSIS parent scores revealed no significant differences in subscales. Although not significant, increases in communication scores were seen, similar to those observed in teacher ratings. Significant decreases were again seen in overall problem behaviors (pre M = 4.18, SD = 4.28; post M =1.18, SD = .75; t (10) = 2.29, p = .045, d = .85), Regarding specific problem behavior subscales, significant decreases were seen only in internalizing behaviors (pre M = 4.45, SD = 2.58; post M =2.45, SD = 2.25; t (10) = 2.21, p = .05, d = .67). Finally, parent ratings of overall academic competence were consistent with the teacher ratings. Parents rated their children as significantly decreasing in overall academic competence from pre to post session (pre M = 10.64, SD = 6.02; post M = 5.73 SD = 3.07; t (10) = 2.96, p = .014, d = 1.0). Table 3 includes pre and post means, (SD), Cohen1s D, and adjusted p-values for all measures. Table 3 Descriptive Data for Paired t-Test Analyses Pre-test Post-test M SD M SD Adjusted p* Cohen’s d HBSC  Peer Relations 63.71 13.62 65.14 12.81 NS --  Self-Management 55.14 12.24 58.14 11.74 NS --  Total Social 118.86 24.17 124.00 23.17 NS --  Defiant/Disruptive 35.29 13.47 32.71 11.83 NS --  Aggressive/Antisocial 36.86 15.52 33.07 12.14 NS --  Antisocial Total 72.14 28.72 65.79 23.16 NS -- SSIS–Teacher  Communication 13.61 4.37 16.31 3.38 .007 .933  Cooperation 11.69 4.25 11.85 3.05 NS --  Assertion 14.23 1.88 15.23 1.74 NS --  Responsibility 12.23 3.85 11.53 4.18 NS --  Empathy 11.38 4.27 12.00 3.70 NS --  Engagement 14.54 3.43 16.15 2.97 NS --  Self-Confidence 11.61 6.02 12.23 5.18 NS --  Social Skills Total 89.31 23.59 95.31 21.27 NS --  Externalizing 10.77 5.26 9.31 5.27 NS --  Bullying 3.38 3.15 3.31 3.42 NS --  Hyperactivity 7.54 3.15 5.38 2.60 .008 .903  Internalizing 4.00 2.04 2.08 2.25 .015 .806  Autism 8.54 4.87 4.38 3.25 .007 .957  Problem Behaviors 7.23 10.37 1.23 .725 .05 .787  Academic Competence 10.38 6.64 5.61 2.81 .017 .97 SSIS–Parent  Communication 14.00 4.33 15.83 3.71 NS --  Cooperation 12.64 4.06 12.00 3.28 NS --  Assertion 14.00 1.95 15.09 1.81 NS --  Responsibility 12.91 3.56 11.73 4.41 NS --  Empathy 11.91 4.18 11.82 3.99 NS --  Engagement 14.00 3.25 15.83 3.21 NS --  Self-Confidence 11.91 6.46 12.18 5.67 NS --  Social Skills Total 90.82 25.16 95.09 23.27 NS --  Externalizing 10.00 5.14 9.0 5.64 NS --  Bullying 3.64 4.13 3.45 3.56 NS --  Hyperactivity 7.73 3.41 5.27 2.69 NS --  Internalizing 4.45 2.58 2.45 2.25 .05 .67  Autism 7.36 3.93 4.54 3.53 NS --  Problem Behaviors 4.18 4.28 1.18 .75 .045 .85  Academic Competence 10.64 6.02 5.73 3.07 .014 1.0 Pre-test Post-test M SD M SD Adjusted p* Cohen’s d HBSC  Peer Relations 63.71 13.62 65.14 12.81 NS --  Self-Management 55.14 12.24 58.14 11.74 NS --  Total Social 118.86 24.17 124.00 23.17 NS --  Defiant/Disruptive 35.29 13.47 32.71 11.83 NS --  Aggressive/Antisocial 36.86 15.52 33.07 12.14 NS --  Antisocial Total 72.14 28.72 65.79 23.16 NS -- SSIS–Teacher  Communication 13.61 4.37 16.31 3.38 .007 .933  Cooperation 11.69 4.25 11.85 3.05 NS --  Assertion 14.23 1.88 15.23 1.74 NS --  Responsibility 12.23 3.85 11.53 4.18 NS --  Empathy 11.38 4.27 12.00 3.70 NS --  Engagement 14.54 3.43 16.15 2.97 NS --  Self-Confidence 11.61 6.02 12.23 5.18 NS --  Social Skills Total 89.31 23.59 95.31 21.27 NS --  Externalizing 10.77 5.26 9.31 5.27 NS --  Bullying 3.38 3.15 3.31 3.42 NS --  Hyperactivity 7.54 3.15 5.38 2.60 .008 .903  Internalizing 4.00 2.04 2.08 2.25 .015 .806  Autism 8.54 4.87 4.38 3.25 .007 .957  Problem Behaviors 7.23 10.37 1.23 .725 .05 .787  Academic Competence 10.38 6.64 5.61 2.81 .017 .97 SSIS–Parent  Communication 14.00 4.33 15.83 3.71 NS --  Cooperation 12.64 4.06 12.00 3.28 NS --  Assertion 14.00 1.95 15.09 1.81 NS --  Responsibility 12.91 3.56 11.73 4.41 NS --  Empathy 11.91 4.18 11.82 3.99 NS --  Engagement 14.00 3.25 15.83 3.21 NS --  Self-Confidence 11.91 6.46 12.18 5.67 NS --  Social Skills Total 90.82 25.16 95.09 23.27 NS --  Externalizing 10.00 5.14 9.0 5.64 NS --  Bullying 3.64 4.13 3.45 3.56 NS --  Hyperactivity 7.73 3.41 5.27 2.69 NS --  Internalizing 4.45 2.58 2.45 2.25 .05 .67  Autism 7.36 3.93 4.54 3.53 NS --  Problem Behaviors 4.18 4.28 1.18 .75 .045 .85  Academic Competence 10.64 6.02 5.73 3.07 .014 1.0 All p-values reflect an adjustment for multiple comparisons using Bonferroni corrections. View Large Table 3 Descriptive Data for Paired t-Test Analyses Pre-test Post-test M SD M SD Adjusted p* Cohen’s d HBSC  Peer Relations 63.71 13.62 65.14 12.81 NS --  Self-Management 55.14 12.24 58.14 11.74 NS --  Total Social 118.86 24.17 124.00 23.17 NS --  Defiant/Disruptive 35.29 13.47 32.71 11.83 NS --  Aggressive/Antisocial 36.86 15.52 33.07 12.14 NS --  Antisocial Total 72.14 28.72 65.79 23.16 NS -- SSIS–Teacher  Communication 13.61 4.37 16.31 3.38 .007 .933  Cooperation 11.69 4.25 11.85 3.05 NS --  Assertion 14.23 1.88 15.23 1.74 NS --  Responsibility 12.23 3.85 11.53 4.18 NS --  Empathy 11.38 4.27 12.00 3.70 NS --  Engagement 14.54 3.43 16.15 2.97 NS --  Self-Confidence 11.61 6.02 12.23 5.18 NS --  Social Skills Total 89.31 23.59 95.31 21.27 NS --  Externalizing 10.77 5.26 9.31 5.27 NS --  Bullying 3.38 3.15 3.31 3.42 NS --  Hyperactivity 7.54 3.15 5.38 2.60 .008 .903  Internalizing 4.00 2.04 2.08 2.25 .015 .806  Autism 8.54 4.87 4.38 3.25 .007 .957  Problem Behaviors 7.23 10.37 1.23 .725 .05 .787  Academic Competence 10.38 6.64 5.61 2.81 .017 .97 SSIS–Parent  Communication 14.00 4.33 15.83 3.71 NS --  Cooperation 12.64 4.06 12.00 3.28 NS --  Assertion 14.00 1.95 15.09 1.81 NS --  Responsibility 12.91 3.56 11.73 4.41 NS --  Empathy 11.91 4.18 11.82 3.99 NS --  Engagement 14.00 3.25 15.83 3.21 NS --  Self-Confidence 11.91 6.46 12.18 5.67 NS --  Social Skills Total 90.82 25.16 95.09 23.27 NS --  Externalizing 10.00 5.14 9.0 5.64 NS --  Bullying 3.64 4.13 3.45 3.56 NS --  Hyperactivity 7.73 3.41 5.27 2.69 NS --  Internalizing 4.45 2.58 2.45 2.25 .05 .67  Autism 7.36 3.93 4.54 3.53 NS --  Problem Behaviors 4.18 4.28 1.18 .75 .045 .85  Academic Competence 10.64 6.02 5.73 3.07 .014 1.0 Pre-test Post-test M SD M SD Adjusted p* Cohen’s d HBSC  Peer Relations 63.71 13.62 65.14 12.81 NS --  Self-Management 55.14 12.24 58.14 11.74 NS --  Total Social 118.86 24.17 124.00 23.17 NS --  Defiant/Disruptive 35.29 13.47 32.71 11.83 NS --  Aggressive/Antisocial 36.86 15.52 33.07 12.14 NS --  Antisocial Total 72.14 28.72 65.79 23.16 NS -- SSIS–Teacher  Communication 13.61 4.37 16.31 3.38 .007 .933  Cooperation 11.69 4.25 11.85 3.05 NS --  Assertion 14.23 1.88 15.23 1.74 NS --  Responsibility 12.23 3.85 11.53 4.18 NS --  Empathy 11.38 4.27 12.00 3.70 NS --  Engagement 14.54 3.43 16.15 2.97 NS --  Self-Confidence 11.61 6.02 12.23 5.18 NS --  Social Skills Total 89.31 23.59 95.31 21.27 NS --  Externalizing 10.77 5.26 9.31 5.27 NS --  Bullying 3.38 3.15 3.31 3.42 NS --  Hyperactivity 7.54 3.15 5.38 2.60 .008 .903  Internalizing 4.00 2.04 2.08 2.25 .015 .806  Autism 8.54 4.87 4.38 3.25 .007 .957  Problem Behaviors 7.23 10.37 1.23 .725 .05 .787  Academic Competence 10.38 6.64 5.61 2.81 .017 .97 SSIS–Parent  Communication 14.00 4.33 15.83 3.71 NS --  Cooperation 12.64 4.06 12.00 3.28 NS --  Assertion 14.00 1.95 15.09 1.81 NS --  Responsibility 12.91 3.56 11.73 4.41 NS --  Empathy 11.91 4.18 11.82 3.99 NS --  Engagement 14.00 3.25 15.83 3.21 NS --  Self-Confidence 11.91 6.46 12.18 5.67 NS --  Social Skills Total 90.82 25.16 95.09 23.27 NS --  Externalizing 10.00 5.14 9.0 5.64 NS --  Bullying 3.64 4.13 3.45 3.56 NS --  Hyperactivity 7.73 3.41 5.27 2.69 NS --  Internalizing 4.45 2.58 2.45 2.25 .05 .67  Autism 7.36 3.93 4.54 3.53 NS --  Problem Behaviors 4.18 4.28 1.18 .75 .045 .85  Academic Competence 10.64 6.02 5.73 3.07 .014 1.0 All p-values reflect an adjustment for multiple comparisons using Bonferroni corrections. View Large Teacher Interview The teacher reported that exposing the children to playing, touching, and hearing multiple instruments “they’ve never seen before” was the most intriguing aspect of the therapy sessions. The hands-on component of both singing and playing instruments served to maintain the engagement of children. Maintaining engagement was a key issue since this was an afterschool program and the younger children in particular were tired. The length of sessions seemed ideal in maintaining attention. Regarding musical instruments used in sessions, the teacher would have preferred, when bringing instruments that the children had not seen before, that there be one instrument for each child to explore. She shared that she used a teaching approach of empowering the older children to assist during the afterschool program. She reported that pulling older children aside, informing them about the music therapy session plan in advance, and enlisting their help would have perhaps promoted older child engagement in sessions. The teacher reported hearing the children singing snippets of the songs introduced during music therapy sessions throughout the day. The teacher used the newsletters as ways to communicate information about what the children learned in music therapy with their parents. She also reported using the information as a way to reinforce targeted social skills throughout the week. In particular, she implemented a problem-solving dialogue to resolve a conflict between two children in the classroom. She stated, “This program gave the children a new approach to how to handle conflict. It also taught my assistant and myself how to apply what we have learned as well and then reinforce it. I did this by re-examining the worksheets as needed.” Overall, the teacher seemed optimistic about the experience and eager to see it employed in the future. Discussion Through this study, we sought to develop and evaluate a music therapy social skills development program for youth with limited resources. Here, we discuss findings related to the effect of the music therapy program on social competence, antisocial behavior, and total number of low-performance/high-risk skills (as measured by the HCBS), and social skills, problem behaviors, and academic competence (as measured by the SSIS). We also report indirect benefits on academic achievement and the teacher’s perceptions about the program and student responses. In general, the music therapy program was feasible to implement, as indicated by the 100% parental consent and child assent for participation, and a 75% retention rate. Collaboration and support from the afterschool teacher and her part-time assistant played a key role in achieving high recruitment and retention. Attrition was the result of family circumstances and changes in housing, and not due to a lack of interest in or decision to discontinue the music therapy program. Our findings are consistent with other studies in which children in afterschool programs receiving music therapy showed improvements in social competence (Chong & Kim, 2010; Gooding, 2011), children from families with low income showed improvements in self-expression, self-efficacy, and social skills (Young-Bae & Ji-Eun, 2013), and children with various psychopathologies affecting social skills self-reported improvements in communication and interactions (Porter et al., 2017). Participation in this eight-session program appears to have reduced the average number of low-performance/high-risk behaviors. On the HBSC, none of the participants scored as having a specific area as an identified strength. As indicated in Table 2, the frequency of individual low performance/high risk (in areas such as complete chores without being reminded, notices and compliments accomplishments of others, completes chores and assigned tasks on time, offers to help peers when needed) was reduced. This outcome is important when considering that some of the group participants were siblings or cousins (as reported by the teacher). Sibling and peer influences may have bidirectional effects in risky behaviors (c.f., Whiteman, Jensen, & McHale, 2017). Thus, interventions that reduce frequency of low-performance/high-risk skills, particularly in a close-knit group of children, may reinforce shaping each other’s positive socialization outcomes. Porter and colleagues’ (2017) music therapy intervention involved one-on-one individual sessions using free improvisation. In contrast, the therapeutic music experiences we designed for music therapy sessions were similar to Gooding (2011), due to the emphasis we placed on active participation through improvisation, movement, and playing various instruments. Like Gooding, we also implemented cognitive behavioral techniques in modeling or redirecting behaviors during the sessions. In addition, several of our therapeutic music experiences were similar to those implemented by Chong and Kim (2010) because we also focused on performing musical parts, matching musical play to various meters, imitating or initiating musical phrases, and performing various roles in improvisational musical plays (i.e., holding rhythms, performing rhythm or melodic pattern variations). However, some of our therapeutic music experiences were more prescriptive than those used by Chong and Kim because of our reliance on social skills curricula and tailoring experiences to the specific needs of the participants. A possible explanation for the positive trends observed in this study may be that active music-making can help children focus and sustain attention (Gold, Voracek, & Wigram, 2004; Pasiali, LaGasse, & Penn, 2014) and thus learn new information/skills during music therapy sessions. The prescriptive nature and structured delivery of our program may also explain the significant improvement in communication (a construct measured on the SSIS social skills subscale), the significant decrease in hyperactivity, autistic behavioral tendencies, and overall problem behaviors, and marginal decreases in internalization reported by the teacher. The therapeutic music experiences targeted a specific set of skills and introduced them using a step-by-step process. Consistent across teacher and parent were increases in communication and engagement, and overall decreases in problem behaviors. Our findings parallel those of Porter et al. (2017) but also raise important questions about the type of intervention/programming. Even though Porter and colleagues noticed improvement in communication and interaction skills (as measured using a child self-report version and a guardian SSIS scale), those improvements were significant for participants older than 13. Thus, further research is warranted to determine if younger participants may benefit more from structured interventions whereas adolescents may benefit more from unstructured free improvisation. The Porter study findings also raise questions about treatment dose and delivery since significant benefits were measured at week 13 but not sustained at week 26. It is possible that intervention effects at the child level are not sustained without systemic supports provided for other socialization agents involved in a child’s life (peers, teachers, parents). Although academic performance was not directly targeted by our intervention, we hypothesized that it might improve as an indirect result of improvements in the areas targeted in our programming. As such, we were surprised by our finding that academic competence ratings actually decreased following the intervention despite observed improvements in communication and interaction. This outcome parallels the findings of Chong and Kim (2010), who also noticed improvements in social skills, a decrease in problem behaviors, as well as a decrease in academic competence. A possible explanation is that the afterschool program was partially funded through a literacy-based grant, and that with the end of the academic year approaching, the teacher may have been more focused on achieving academic outcomes and that focus may have affected the post ratings. Another possible explanation is that more difficult academic material was introduced at the end of the school year, and this may have contributed to perceptions of poorer academic performance. Regardless, both teacher and parent ratings indicated a perceived decrease in academic competence, and this is something that warrants further investigation. Facility constraints (i.e., all students participating in sessions) did not allow the research team to divide students into age groups. In contrast, Chong and Kim (2010) were able to divide participants into small groups by grade level (grades 1 & 2 in one group, grades 2 & 3 in one group, etc.), allowing the therapists to tailor intervention content based on developmental level. In our study, by working to address the social development needs across a wide range of development in a large group may have lessened the effect of our program. While working with a large group may not explain the decrease in academic performance, it can shed light on why academic improvement may not have been impacted. The teacher interview data is helpful in identifying what worked, and what can be adjusted to improve the music therapy social skills development program. As indicated by the teacher’s comments, the children memorized snippets of songs containing information pertinent to the development of social skills. Both the teacher and the children in the program consistently referred to the information and materials explored during the music therapy session. Using songs as vehicles for delivering information, a salient element of the music therapy program, seemed to be an effective way of reinforcing skills targeted through the program. The teacher reported that the children sang portions of the songs throughout the week and that repetition may have played a role in committing skills and concepts to memory. The newsletters, visuals, and informational material provided by the researchers allowed the teacher to reinforce the skills introduced during music therapy sessions throughout the week, and in communicating with parents about what the children were learning. This inclusive nature of our programming, encouraging involvement of multiple socialization agents (parent/guardian and teacher), may also explain notable changes in areas of low performance/high risk, improvements in communication, and a decrease in problem behaviors. In other words, providing materials and engaging the teacher in reviewing and reinforcing the targeted skills likely played a role in learning and generalization of skills in the afterschool classroom, and represents an attribute of the program that warrants further examination and development. Pairing music therapy programming in this setting (where families are living in poverty, and the afterschool program was under-resourced at the time of this study) was a positive and beneficial resource to the teacher. Regarding the implementation of the music therapy social skills development program, due to limited resources, there was only one large room available for this afterschool program. On a daily basis, 8–21 children participated. All services and activities took place in that large room. Program planning was challenging because of the wide range in developmental levels of children in the group. Maintaining attention and active engagement involved planning smooth and quick transitions between tasks, constantly monitoring and reinforcing participation, and differentiating instruction. As other researchers recommended (e.g., Gold et al., 2004), adopting an eclectic and flexible style, alternating between structured and improvised activities, was central in differentiating instruction to match the developmental level of each student in the group. Finally, rhythmic and pattern synchronization during active music-making emerged as a salient feature during the music therapy sessions. In planning our approach to active music-making, we referenced the continuum developed by Beer (2011) to gradually increase the complexity of improvisational experiences. Also, some of the principles we employed parallel those described by Geretsegger et al. (2015) and included various cues (verbal, nonverbal, musical, physical) to prompt synchronization and sustain musical interactions. Moreover, we scaffolded musical interactions by repeating material, gradually introducing new instruments, and increasing the complexity of musical tasks. For our participants, it was easier to achieve sharing sounds and synchronizing to the same underlying pulse during structured active music-making (e.g., repeating musical patterns, playing assigned instrumental parts). However, when asking children to simply improvise, that synchronization dissolved and each child was focused on playing their instrument without any outward effort to make musical contact with other members of the group. By session 6, we observed an improvement in ability to sustain synchronization to the same musical pulse. This shift may reflect an increased mutuality in the way each child was participating in the music experience. Researchers explored the notion that music improvisation is a pathway for improving social awareness and attention through active listening (c.f., Geretsegger et al., 2015), and based on our clinical observations it warrants further investigation with the population in this study. Limitations and Future Research A number of limitations should be considered when interpreting results of this study. The fact that the first author included students (non-credentialed MT-BCs) as members of the clinical team delivering the intervention is a limitation. Even though they were directly supervised and rehearsed interventions prior to implementation, their skill level may have influenced outcomes. Noteworthy is that during supervision we addressed both therapeutic skills and development of therapeutic relationships, an important factor identified as a predictor of positive outcomes (c.f., Lambert & Barley, 2001). Furthermore, use of a single-group, pre/post-test design cannot rule out any confounding variables and validity threats. For example, we cannot conclude that our music therapy social skills development program brought forth the observed change in participants. Change could have occurred because the teacher was verbally reinforcing the skills we addressed during sessions, or simply as a result of maturation effects. Moreover, statistical regression cannot be ruled out since none of the participants scored as having specific areas of strength during the pre-test assessment and there are several areas of low performance/high risk reported by the teacher. Another limitation was that the teachers and parents, with their full knowledge of the program, completed all measures. Specifically, the teacher who completed the ratings was present during the music therapy sessions. The consistency of findings across teacher and parent ratings, however, lends strength to the results. Although not identical, similarities across teacher and parent ratings lend strength to the results. Finally, there were no follow-up measures to show sustainability of the effect of the Music Therapy Social Skills Development Program. Long-term assessment is always difficult but crucial to determine the strength of interventions focused on behavior change. In summary, the results indicate benefits in reducing low-performance/high-risk skills, reducing problem behaviors such as hyperactivity and autistic behavioral tendencies, and improving communication. The next step would be implementation of the social skills development program in a multisite study using comparison groups. Overall, more research on the use of music therapy as a proactive intervention to support the development of individual social competencies in children living in environments with low resources is warranted. The authors would like to express their appreciation for: (a) the families, students, and teachers at YWCA, Charlotte, NC; (b) Dr. Nyaka Niilampti for her input and support of this project; and (c) the psychology and music therapy students who served as research assistants. 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For permissions, please e-mail: journals.permissions@oup.com This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices) http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Journal of Music Therapy Oxford University Press

Evaluation of a Music Therapy Social Skills Development Program for Youth with Limited Resources

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Abstract

Abstract Background Children living in low-resource communities are at risk for poorer socio-emotional development and academic performance. Emerging evidence supports use of group music therapy experiences to support social development through community afterschool programming. Objective To examine the potential benefit of a music therapy social skills development program to improve social skills and academic performance of school-aged children with limited resources in an afterschool program. Method We used a single-group pre/post-test design, and recruited 20 students (11 females, 9 males), ages 5 to 11 years, from an afterschool program. The music therapy social skills program consisted of eight 50-minute sessions, and we measured social competence and antisocial behavior using the Home & Community Social Behavioral Scale (HCSBS; Merrell & Caldarella, 2008), and social skills, problem behaviors, and academic competence using the Social Skills Improvement System (SSIS; Gresham & Elliot, 2008a, 2008b). Results Only students who attended a minimum of six sessions (N = 14) were included in data analysis. Results showed no significant change in individual HBSC subscale scores; however, the total number of low-performance/high-risk skills significantly decreased. SSIS teacher results indicated significant improvement in communication, significant decrease of hyperactivity, autistic behavioral tendencies and overall problem behaviors, and marginal decreases in internalization. Parent ratings mirrored, in part, those of the teacher. Conclusions Results indicated that music therapy has the potential of being an effective intervention for promoting social competence of school-aged children with limited resources, particularly in the areas of communication and low-performance/high-risk behaviors. Teaching skills through song lyrics and improvisation emerged as salient interventions. The US Department of Health and Human Services has identified the promotion of social and emotional well-being in children as a national priority (Administration for Children and Families, 2012). To promote well-being in children, Lippman, Moore, and McIntosh (2011) developed a strengths-based approach that focuses on increasing the child’s individual resources (i.e., competencies, skills, behaviors, personal qualities) as well as social relationships that would support adaptive developmental outcomes across the life span. Specifically, they identified social development and behavior as a categorical construct that is essential to the development of a child’s well-being. Moreover, they recognized participation in arts-based activities as supporting children’s cognitive development. In this study, we (a board-certified music therapist and an experimental psychologist) designed and tested an intervention to promote social competence of school-aged children with limited resources that place them at risk for developmental problems. For this study, we defined children with limited resources as those who may experience any combination of risks (factors that increase the possibility of negative outcomes) and vulnerabilities (factors that act as catalysts in the presence of adversity or risk and lead to maladaptive outcomes).1 Exposure to risks and vulnerabilities creates a scarcity situation that may affect socio-emotional development. Socio-emotional competence is composed of a variety of skills that involve individual action and interaction within situational-cultural contexts (Andrews, 2006; Rose-Krasnor, 1997). Therefore, several contextual factors (such as community violence or low socioeconomic status) combined with family factors (such as inter-partner conflict, distress, poor parenting, or lack of social supports) place youth at high risk for deficits in their social-emotional development and related outcomes (Lippman et al., 2011). In particular, socio-emotional competence, which includes the ability to use one’s individual skills and knowledge to navigate different environments, adapt to expectations, and interact with others (Winner, 2008), can be an important predictor for educational and socially adaptive outcomes and is directly linked to behavioral and academic performance outcomes for students. For example, Izard and colleagues (2001) found that a lack of emotion knowledge mediated the relationship between verbal ability and academic competence. Furthermore, based on a comprehensive literature review including 34 meta-analyses, Wang, Haertel, and Walberg (1993) concluded that affective and social factors had more of an impact on academic achievement than peer influences, family influences, or direct academic instruction. Social skills are an important component of social competence. Children experiencing situational and contextual risk factors may require systematic instruction to help them gain social skills and behaviors needed to develop adaptive social relationships (Andrews, 2006). According to Durlak and colleagues (2011), such instruction must use a systematic process that targets specific skills using sequential activities that include hands-on experiential components. Outcomes from this type of instruction have included improvements in socio-emotional skills, reductions in externalized and internalized problem behaviors, and improvement in academic performance (Durlak et al., 2011). Furthermore, Shernoff (2010) found that afterschool programming that promotes students’ active engagement might be an important factor in predicting social competence and positive academic outcomes. Durlak and Weissberg (2007) conducted a review of afterschool programs for the Center for Academic, Social, and Emotional Learning (CASEL) and concluded that children attending afterschool programs that incorporate evidence-based curricula focused on building social/emotional competence show significant improvements in feelings and attitudes, decreases in behavioral problems, and improvements in school grades and overcall academic achievement. The aforementioned results are relevant to the current study because we measured social competence, antisocial behavior, behavioral problems, and academic competence. In addition, we used existing evidence-based curricula to inform development of the social skills music therapy program Social Skills Improvement System Intervention (SSIS™; Elliott & Gresham, 2008a) and Skillstreaming the Elementary School Child (McGinnis, 2005). Music therapy clinicians often serve children and youth who experience threats to their overall adaptation resulting from exposure to social, economic, or cultural stressors. In a survey of music therapy practice with youth identified as high risk, Clark and colleagues (2013) found that the most frequently addressed goals included self-expression and coping skills. Additional goals included self-esteem, social skills, and behavior management. Although there are multiple reports describing clinical interventions for youth with limited resources (e.g., Camilleri, 2007, Clements-Cortès, 2013; Cobbett, 2009; Fouche & Torrance, 2005; Quintanilla, 2008; Smith, 2012a, 2012b; Snow & D’Amico, 2010), there has been limited empirical examination of programmatic outcomes. In the current music therapy literature, a majority of research examining social skills development has focused on children and adolescents with developmental delays. Findings indicated improvement in eye gaze, joint attention, and learning specific social behaviors or routines (c.f., Brownell, 2002; Kalas, 2012, Kern, Wolery, & Aldridge, 2007; Kim, Wigram, & Gold, 2008; LaGasse, 2014). Moreover, some music therapy researchers have addressed the development of social and problem-solving skills of young children. Staum (1993) and Ulfarsdottir and Erwin (1999) derived ideas from a curriculum called I Can Problem Solve (Shure, 1993, 2001), originally designed for high-functioning children with autism. Findings from both studies, however, were inconclusive due to methodological design issues. Finally, researchers targeting development of social skills and overall well-being with adolescents found improvements in communication skills, attitudes toward learning, and relationships with peers (Derrington, 2012; Porter et al., 2017). Although the results of the studies referenced above offer information about development of social skills, only three studies have examined the use of music for social skills development in at-risk children in afterschool programs (Chong & Kim, 2010; Gooding, 2011; Heiskell, 2010). Heiskell (2010) designed an educative music therapy curriculum to develop math and social competence skills in high school students. The program was structured to provide students with opportunities to learn and exercise the targeted skills by learning and performing songs as a rock band. Sessions were conducted at a high school during group guitar classes and at a local afterschool program. Participating students self-reported an increase in their academic and social performance following completion of the 10-week program. Gooding (2011) administered a five-session social skills training curriculum across three different settings: a school, a residential setting, and an inner-city afterschool program. She measured effectiveness by using a researcher-constructed observation measure of social skills and the Home and Community Social Behavioral Scale (HCSBS; Merrell & Caldarella, 2008). Participants included 45 children aged 6–17 years. The curriculum included active music experiences such as movement to music, improvisation, and music performance. The music therapist implementing the program used cognitive behavioral strategies and problem-solving to model appropriate social skills and interactions. Participants in the school setting and the afterschool setting self-reported improved social functioning. Case-manager ratings in the residential treatment setting using the HCSBS indicated significant improvement in antisocial behaviors. Behavioral observations during sessions using the researcher-constructed form indicated increased on task behaviors during sessions across all three settings. These results are a preliminary indicator that music-based curricula targeting social skills may improve functioning. Working with elementary school-aged children, Chong and Kim (2010) recruited 89 participants from 13 different schools. Teachers referred participants to music therapy if they exhibited behavioral or social problems, but had no formal diagnosis. They labeled their intervention Education-oriented Music Therapy (EoMT) because social, emotional, and academic outcomes were addressed by focusing on learning musical concepts such as recognizing differences between musical tones (height, intensity), sound groupings, and meter. They also introduced musical performance elements such as relaying or imitating musical phrases. Moreover, they introduced how to identify or portray emotion in music and practiced impulse control and emotional coping strategies through songwriting. Participants received music therapy twice a week for a total of 16 weeks. Chong and Kim (2010) used an earlier version of the Social Skills Improvement System (SSIS; Gresham & Elliot, 2008a, 2008b) as pre/post-test and found a significant improvement in social skills and problematic behaviors, but no improvement in academic competence. These three studies (Chong & Kim, 2010; Gooding, 2011; Heiskell, 2010) provide evidence supporting the use of group music therapy experiences for children experiencing multiple threats to their socio-emotional development and positive adaptation; however, additional research is needed to examine the use of group music therapy for social competence training with elementary school-aged children living in low resource communities. To address this gap in existing research, we designed a music therapy social skills development program for this population. Program participation was not intended as a “fix” for existing issues. Rather, our intent was to provide a proactive intervention to support development of social competencies (e.g., taking turns in conversations, polite manners, paying attention to others, asking for help, or doing your part in a group), and healthy behaviors (e.g., doing the right thing, getting along with others, or paying attention to your work). We directly targeted social competencies and healthy behaviors during music therapy sessions. However, we expected indirect benefits in academic performance. Thus, one of our measures screened for individual strengths and low-performance/high-risk skills (Home & Community Social Behavioral Scale [HCSBS]; Merrell & Calderella, 2008), and the other yielded information about social skills, problem behaviors, and academic competence (Social Skills Improvement System [SSIS]; Gresham & Elliot, 2008a, 2008b). Since we collaborated closely with the afterschool teacher, we also aimed to identify her perceptions about the music therapy program. Specific research questions that guided our study were as follows: 1. Will the number of low-performance/high-risk skills, as measured by the HCBS, identified at baseline decrease following participation in the music therapy social skills development program? 2. What is the effect of participation in the music therapy social skills development program (as measured by the HCBS) on social competence and antisocial behavior? 3. What is the effect of participation in the music therapy social skills development program (as measured by the SSIS) on social skills, problem behaviors, and academic competence? 4. What are the afterschool teacher’s perceptions about the music therapy social skills development program and the responses of participants to the program? Method Setting The setting was an afterschool program delivered in a common space/leasing office area at a public-housing apartment complex in a large metropolitan city. The afterschool program was managed by a nonprofit community agency. Families living in the apartment complex were participating in a five-year self-sufficiency program. Eligibility criteria for the self-sufficiency program included low-income or disabilities. Families were evaluated by case managers who determined specific needs, established long-term goals, and referred families for services such as remedial education, substance abuse counseling, training in money and household management, parenting skills classes, transportation, and childcare (Charlotte Housing Authority, 2017). Thus, because of the study setting, all participants in this study were exposed to various social, economic, or cultural stressors. Research Design We used a single-group pre/post-test design to examine improvements in social skills, problem behaviors, and academic performance resulting from participation in the music therapy social skills development program. Use of a more rigorous control group design was not possible due to the programmatic structure of the afterschool program. The research team consistent of: (a) the first author, who is a music therapy educator and a board-certified music therapist with 15 years’ experience; (b) the second author, who is a psychology educator; and (c) three undergraduate sophomore music therapy students and one undergraduate psychology student. The sophomore students had one year of clinical experience working at a university-based on-campus clinic and one semester (approximately 10 sessions) of co-leading therapy groups at early intervention settings. The first author designed the music therapy program and served as the primary therapist delivering the sessions. The second author conducted the data analysis and teacher interview. The first author led music experiences during each session. The three music therapy students assisted the first author during music therapy sessions by gathering materials, and leading some of the therapeutic experiences during the session. Students rehearsed therapeutic music experiences under the supervision of the first author prior to scheduled sessions with study participants. Their involvement in the treatment process gradually increased as the sessions progressed and they became familiar with the setting and the participants. The music therapy students also performed data entry. The psychology student conducted data entry and transcribed the teacher interview. All students involved in the research team completed training required by the Research Ethics Board and signed confidentiality agreements. Procedure During a regularly scheduled afterschool program community meeting, the afterschool teacher and second author provided information about the study, answered questions, and obtained signed informed consent from interested parents. Consenting parents were then given copies of the baseline (pre-test) assessments for completion at home. During the week prior to the first music therapy session, the teacher and her assistant visited parents in their apartments to collect the assessment forms and receive informed consent from parents who were unable to attend the first informational meeting. The afterschool teacher also completed baseline (pre-test) measures on each participating child one week prior to the first study session. Following pre-test data collection, participants received eight weekly music therapy sessions delivered in a group setting. The size of the group ranged from 8 to 21 students. It is important to note that seven students enrolled in the afterschool program while the study was ongoing. Those students participated in weekly music therapy sessions because the program was offered as part of regular afterschool programming; however, no data were collected on these students. Each session had a duration of 50 minutes, and the eight sessions were delivered across a period of 10 weeks. The teacher and parents completed post-test assessments within two weeks of program completion, and the second author conducted the teacher interview three weeks following program conclusion. Participants All 20 participants (11 females, 9 males), ages 5 to 11 years, enrolled in the afterschool program at the beginning of this study were recruited to participate. Each week, all students attending the afterschool program verbally assented to participate in music therapy. During implementation of the music therapy social skills development program, five students withdrew from the afterschool program because their families moved out of the apartment complex. Thus, the study attrition rate (number of lost participants divided by total number of participants) was 25%. Students who withdrew were not included in the data analysis. Moreover, one student was excluded because he attended fewer than six sessions—only students who attended a minimum of six sessions were included in the data analysis. Overall session attendance rate was 74.67%. The remaining number of participants (N = 14) constituted the sample size included in the data analysis. All participants were typically developing, based on verbal reports by the afterschool teacher, and did not have a diagnosed disability. The Queens University of Charlotte Research Ethics Review Committee approved this study, and all parents provided written informed consent for their child’s participation. Measures Home and Community Social Behavioral Scale (HCSBS;Merrell & Calderella, 2008). The HCSBS is a 64-item screening tool of social functioning levels yielding scores of social competence and antisocial behavior. The HCSBS is a robust measure designed to assess the common social competencies and problems seen in children and takes only 10 minutes to complete. The standardized norms are consistent with other child behavior scales. Higher social competence scores (includes peer relations, self-management/compliance, and a total social competence score) indicate better adjustment. Higher antisocial behavior scores (includes defiant/disruptive, antisocial/aggressive, and a total antisocial behavior score) indicate greater levels of social behavior problems. Reliability measures are all quite strong for both dimensions (.82–.97). Validity assessments are also strong (.62–.81). The full-time afterschool teacher completed this scale. The administration manual includes cut-off scores for all the subscales identifying each child’s social functioning level. The total score for social competence, and each of its subscales, has four social functioning levels: high functioning, average, at risk, and high risk. The total score for antisocial behavior, and each of its subscales, has three social functioning levels: average, at risk, and high risk. Only the afterschool teacher completed this measure. Social Skills Improvement System (SSIS;Gresham & Elliot, 2008a, 2008b). This rating scale yields information about a child’s social skills, problem behaviors, and academic competence. The social skills subscale provides assessment of communication, cooperation, assertion, responsibility, empathy, engagement, and self-control. The problem behavior subscale surveys behaviors that inhibit or prevent development of social skills focusing on externalizing, bullying, hyperactivity/inattention, internalizing, and autism spectrum behavioral tendencies. Academic competence is a separate subscale focusing on student motivation, reading and math skills, parental support, and overall cognitive functioning. The academic subscale, capturing parental or teacher perceptions of competence, was included as a way to capture the relationship between academic performance and social competence (Gresham & Elliot, 2008b). Reliability is high (.86–.92), as is validity. The SSIS is normed on a large national sample and yields two global scores for social and behavioral competence. This measure provided a more detailed assessment of social skills, problem behaviors, and academic performance, pre and post intervention. The administration manual includes cut-off scores for all the subscales identifying each child’s functioning level. Both parents and the afterschool teacher completed this scale. Teacher Interview. The second author conducted a semi-structured interview three weeks post intervention to examine the teacher’s perceptions about the music therapy program and responses of the children to the intervention. Sample questions included: What factors or circumstances do you think contributed or affected the delivery of the program? What did you like best about the program? How would you improve the program? In your opinion, what are the most important outcomes or benefits that have resulted from the music therapy program? A teacher assistant, who only worked part-time and did not observe music therapy, did not participate in this interview. The Music Therapy Social Skills Development Program The first author designed an eight-session Music Therapy Social Skills Development Program targeting improvement of social skills and reduction of problem behaviors. Readers will find a list of all the social skills and problem behaviors targeted during sessions, including descriptions of therapeutic music experiences, in Table 1. Similar to other researchers (Staum, 1993; Ulfarsdottir & Erwin, 1999), the first author incorporated materials and emphasized sequential skills outlined in the following documented intervention guide programs: the Social Skills Improvement System Intervention (SSIS™; Elliott & Gresham, 2008a), and Skillstreaming the Elementary School Child (McGinnis, 2005). In addition, the first author used scores from the HCBS to guide session content (i.e., identification of specific social skills and problem behaviors that needed attention). Specifically, based on recommendations outlined in the HCSBS user’s guide (Merrell & Caldarella, 2008), the first author identified low-performance/high-risk skills, and looked for trends and individual areas of growth. Table 1 Music Therapy Social Skills Development Program–Therapeutic Interventions Outline Interventions Targeting Social Skills Specific Skill Description of Intervention(s) Taking turns in conversations. (Unit 1, SSIS; Gresham & Elliot, 2008a). Skill steps and instructions embedded in lyrics of original song created by the first author. Saying “please” and “thank you.” (Unit 2, SSIS; Gresham & Elliot, 2008a). Chants about good manners. Role-play during sessions. Beginning a conversation. (Skill 16. McGinnis, 2005). Ending conversations. (Skill 17. McGinnis, 2005). Original song created by first author that contained the steps for each skill in the lyrics. Practiced beginning and ending musical conversations during improvisation. Paying attention to others. (Unit 3, SSIS; Gresham & Elliot, 2008a). Listening to others. (Skill 55; McGinnis, 2005). Structured drumming games and improvisation using various instruments. Taking turns modeling musical patterns for others to repeat in the group. Improvisation using various instruments. Incorporation of adapted Orff-Schulwerk music education techniques (i.e., pentatonic song, body percussion sections, and assigning instruments and specific parts for each child in the group, alternated singing songs or chants with assigned instrumental parts and improvising in an ABA format). Following directions. (Unit 4, SSIS; Gresham & Elliot, 2008a). Creating a thunderstorm sound-story. Playing silly musical games that involve following a leader. Performing songs using bell chimes. Asking for help. (Unit 7, SSIS; Gresham & Elliot, 2008a). Original lyrics adapted to fit into the song Help by the Beatles. Doing your part in a group. (Unit 11, SSIS; Gresham & Elliot, 2008a). Structured drumming games and improvisation using various instruments. Activities encouraging group collaboration using props such as the stretch rope or the parachute. Introducing yourself to others. (Unit 16, SSIS; Gresham & Elliot, 2008a). Chanting and practicing introductions while drumming. Accepting no. (Skill 54; McGinnis, 2005). Skill 55. Skill 55. Refusing a request/Saying no. (Skill 55; McGinnis, 2005). Playing yes and no game (MT says yes and the students respond the opposite no while matching facial affect and intensity of voice; similarly, if MT says no, the students say yes). Role-play requesting instruments and coping by making a different selection when the answer is no. Practicing saying no when wanting to continue playing a particular instrument. Knowing your feelings. (Skill 26; McGinnis, 2005). Chanted about feeling mad. Using a visual of a volcano to write different scenarios that elicit the feeling mad. Additional songs and chants about different feelings (e.g., Stop and think song, Angry bear/happy bear). Interventions Targeting Problem Behaviors Specific Skill Description of Intervention(s) Paying attention to your work. (Unit 5, SSIS; Gresham & Elliot, 2008a). Learning short songs and playing accompaniment with Orff instrumentation. Practicing playing parts without getting distracted (vocal ostinators, rhythmic ostinatos). Ignore Song–original song developed by the first author that included the steps for this skill in the lyrics. Do the right thing (Unit 5, SSIS; Gresham & Elliot, 2008a). Sing along and song discussion. Song used: Do the Right Thing, by Ages and Ages, included in the Album Divisionary. Created rap verse for song about different actions that represent the right thing to do in different scenarios. Getting along with others. (Unit 15, SSIS; Gresham & Elliot, 2008a). Making compromises. (Unit 17, SSIS; Gresham & Elliot, 2008a). Defined the word compromise and caring. Proceeded with music-assisted relaxation using compromise and caring as focus words during inhale and exhale. Negotiated which instruments each child would play by making requests, asking to share, finding an alternative instrument when first choice was not available. Interventions Targeting Social Skills Specific Skill Description of Intervention(s) Taking turns in conversations. (Unit 1, SSIS; Gresham & Elliot, 2008a). Skill steps and instructions embedded in lyrics of original song created by the first author. Saying “please” and “thank you.” (Unit 2, SSIS; Gresham & Elliot, 2008a). Chants about good manners. Role-play during sessions. Beginning a conversation. (Skill 16. McGinnis, 2005). Ending conversations. (Skill 17. McGinnis, 2005). Original song created by first author that contained the steps for each skill in the lyrics. Practiced beginning and ending musical conversations during improvisation. Paying attention to others. (Unit 3, SSIS; Gresham & Elliot, 2008a). Listening to others. (Skill 55; McGinnis, 2005). Structured drumming games and improvisation using various instruments. Taking turns modeling musical patterns for others to repeat in the group. Improvisation using various instruments. Incorporation of adapted Orff-Schulwerk music education techniques (i.e., pentatonic song, body percussion sections, and assigning instruments and specific parts for each child in the group, alternated singing songs or chants with assigned instrumental parts and improvising in an ABA format). Following directions. (Unit 4, SSIS; Gresham & Elliot, 2008a). Creating a thunderstorm sound-story. Playing silly musical games that involve following a leader. Performing songs using bell chimes. Asking for help. (Unit 7, SSIS; Gresham & Elliot, 2008a). Original lyrics adapted to fit into the song Help by the Beatles. Doing your part in a group. (Unit 11, SSIS; Gresham & Elliot, 2008a). Structured drumming games and improvisation using various instruments. Activities encouraging group collaboration using props such as the stretch rope or the parachute. Introducing yourself to others. (Unit 16, SSIS; Gresham & Elliot, 2008a). Chanting and practicing introductions while drumming. Accepting no. (Skill 54; McGinnis, 2005). Skill 55. Skill 55. Refusing a request/Saying no. (Skill 55; McGinnis, 2005). Playing yes and no game (MT says yes and the students respond the opposite no while matching facial affect and intensity of voice; similarly, if MT says no, the students say yes). Role-play requesting instruments and coping by making a different selection when the answer is no. Practicing saying no when wanting to continue playing a particular instrument. Knowing your feelings. (Skill 26; McGinnis, 2005). Chanted about feeling mad. Using a visual of a volcano to write different scenarios that elicit the feeling mad. Additional songs and chants about different feelings (e.g., Stop and think song, Angry bear/happy bear). Interventions Targeting Problem Behaviors Specific Skill Description of Intervention(s) Paying attention to your work. (Unit 5, SSIS; Gresham & Elliot, 2008a). Learning short songs and playing accompaniment with Orff instrumentation. Practicing playing parts without getting distracted (vocal ostinators, rhythmic ostinatos). Ignore Song–original song developed by the first author that included the steps for this skill in the lyrics. Do the right thing (Unit 5, SSIS; Gresham & Elliot, 2008a). Sing along and song discussion. Song used: Do the Right Thing, by Ages and Ages, included in the Album Divisionary. Created rap verse for song about different actions that represent the right thing to do in different scenarios. Getting along with others. (Unit 15, SSIS; Gresham & Elliot, 2008a). Making compromises. (Unit 17, SSIS; Gresham & Elliot, 2008a). Defined the word compromise and caring. Proceeded with music-assisted relaxation using compromise and caring as focus words during inhale and exhale. Negotiated which instruments each child would play by making requests, asking to share, finding an alternative instrument when first choice was not available. View Large Table 1 Music Therapy Social Skills Development Program–Therapeutic Interventions Outline Interventions Targeting Social Skills Specific Skill Description of Intervention(s) Taking turns in conversations. (Unit 1, SSIS; Gresham & Elliot, 2008a). Skill steps and instructions embedded in lyrics of original song created by the first author. Saying “please” and “thank you.” (Unit 2, SSIS; Gresham & Elliot, 2008a). Chants about good manners. Role-play during sessions. Beginning a conversation. (Skill 16. McGinnis, 2005). Ending conversations. (Skill 17. McGinnis, 2005). Original song created by first author that contained the steps for each skill in the lyrics. Practiced beginning and ending musical conversations during improvisation. Paying attention to others. (Unit 3, SSIS; Gresham & Elliot, 2008a). Listening to others. (Skill 55; McGinnis, 2005). Structured drumming games and improvisation using various instruments. Taking turns modeling musical patterns for others to repeat in the group. Improvisation using various instruments. Incorporation of adapted Orff-Schulwerk music education techniques (i.e., pentatonic song, body percussion sections, and assigning instruments and specific parts for each child in the group, alternated singing songs or chants with assigned instrumental parts and improvising in an ABA format). Following directions. (Unit 4, SSIS; Gresham & Elliot, 2008a). Creating a thunderstorm sound-story. Playing silly musical games that involve following a leader. Performing songs using bell chimes. Asking for help. (Unit 7, SSIS; Gresham & Elliot, 2008a). Original lyrics adapted to fit into the song Help by the Beatles. Doing your part in a group. (Unit 11, SSIS; Gresham & Elliot, 2008a). Structured drumming games and improvisation using various instruments. Activities encouraging group collaboration using props such as the stretch rope or the parachute. Introducing yourself to others. (Unit 16, SSIS; Gresham & Elliot, 2008a). Chanting and practicing introductions while drumming. Accepting no. (Skill 54; McGinnis, 2005). Skill 55. Skill 55. Refusing a request/Saying no. (Skill 55; McGinnis, 2005). Playing yes and no game (MT says yes and the students respond the opposite no while matching facial affect and intensity of voice; similarly, if MT says no, the students say yes). Role-play requesting instruments and coping by making a different selection when the answer is no. Practicing saying no when wanting to continue playing a particular instrument. Knowing your feelings. (Skill 26; McGinnis, 2005). Chanted about feeling mad. Using a visual of a volcano to write different scenarios that elicit the feeling mad. Additional songs and chants about different feelings (e.g., Stop and think song, Angry bear/happy bear). Interventions Targeting Problem Behaviors Specific Skill Description of Intervention(s) Paying attention to your work. (Unit 5, SSIS; Gresham & Elliot, 2008a). Learning short songs and playing accompaniment with Orff instrumentation. Practicing playing parts without getting distracted (vocal ostinators, rhythmic ostinatos). Ignore Song–original song developed by the first author that included the steps for this skill in the lyrics. Do the right thing (Unit 5, SSIS; Gresham & Elliot, 2008a). Sing along and song discussion. Song used: Do the Right Thing, by Ages and Ages, included in the Album Divisionary. Created rap verse for song about different actions that represent the right thing to do in different scenarios. Getting along with others. (Unit 15, SSIS; Gresham & Elliot, 2008a). Making compromises. (Unit 17, SSIS; Gresham & Elliot, 2008a). Defined the word compromise and caring. Proceeded with music-assisted relaxation using compromise and caring as focus words during inhale and exhale. Negotiated which instruments each child would play by making requests, asking to share, finding an alternative instrument when first choice was not available. Interventions Targeting Social Skills Specific Skill Description of Intervention(s) Taking turns in conversations. (Unit 1, SSIS; Gresham & Elliot, 2008a). Skill steps and instructions embedded in lyrics of original song created by the first author. Saying “please” and “thank you.” (Unit 2, SSIS; Gresham & Elliot, 2008a). Chants about good manners. Role-play during sessions. Beginning a conversation. (Skill 16. McGinnis, 2005). Ending conversations. (Skill 17. McGinnis, 2005). Original song created by first author that contained the steps for each skill in the lyrics. Practiced beginning and ending musical conversations during improvisation. Paying attention to others. (Unit 3, SSIS; Gresham & Elliot, 2008a). Listening to others. (Skill 55; McGinnis, 2005). Structured drumming games and improvisation using various instruments. Taking turns modeling musical patterns for others to repeat in the group. Improvisation using various instruments. Incorporation of adapted Orff-Schulwerk music education techniques (i.e., pentatonic song, body percussion sections, and assigning instruments and specific parts for each child in the group, alternated singing songs or chants with assigned instrumental parts and improvising in an ABA format). Following directions. (Unit 4, SSIS; Gresham & Elliot, 2008a). Creating a thunderstorm sound-story. Playing silly musical games that involve following a leader. Performing songs using bell chimes. Asking for help. (Unit 7, SSIS; Gresham & Elliot, 2008a). Original lyrics adapted to fit into the song Help by the Beatles. Doing your part in a group. (Unit 11, SSIS; Gresham & Elliot, 2008a). Structured drumming games and improvisation using various instruments. Activities encouraging group collaboration using props such as the stretch rope or the parachute. Introducing yourself to others. (Unit 16, SSIS; Gresham & Elliot, 2008a). Chanting and practicing introductions while drumming. Accepting no. (Skill 54; McGinnis, 2005). Skill 55. Skill 55. Refusing a request/Saying no. (Skill 55; McGinnis, 2005). Playing yes and no game (MT says yes and the students respond the opposite no while matching facial affect and intensity of voice; similarly, if MT says no, the students say yes). Role-play requesting instruments and coping by making a different selection when the answer is no. Practicing saying no when wanting to continue playing a particular instrument. Knowing your feelings. (Skill 26; McGinnis, 2005). Chanted about feeling mad. Using a visual of a volcano to write different scenarios that elicit the feeling mad. Additional songs and chants about different feelings (e.g., Stop and think song, Angry bear/happy bear). Interventions Targeting Problem Behaviors Specific Skill Description of Intervention(s) Paying attention to your work. (Unit 5, SSIS; Gresham & Elliot, 2008a). Learning short songs and playing accompaniment with Orff instrumentation. Practicing playing parts without getting distracted (vocal ostinators, rhythmic ostinatos). Ignore Song–original song developed by the first author that included the steps for this skill in the lyrics. Do the right thing (Unit 5, SSIS; Gresham & Elliot, 2008a). Sing along and song discussion. Song used: Do the Right Thing, by Ages and Ages, included in the Album Divisionary. Created rap verse for song about different actions that represent the right thing to do in different scenarios. Getting along with others. (Unit 15, SSIS; Gresham & Elliot, 2008a). Making compromises. (Unit 17, SSIS; Gresham & Elliot, 2008a). Defined the word compromise and caring. Proceeded with music-assisted relaxation using compromise and caring as focus words during inhale and exhale. Negotiated which instruments each child would play by making requests, asking to share, finding an alternative instrument when first choice was not available. View Large The first author designed the intervention so that one therapist could deliver the music therapy social skills development program. However, in this study we used a clinical team, consisting of the first author and three music therapy undergraduate students, to provide the intervention. The first author developed and scripted session plans, and student music therapy assistants participated in 60-minute weekly supervision to discuss treatment implementation, brainstorm and contribute ideas to session planning, simulate and practice each of the therapeutic music experiences, and exchange feedback with the first author. The weekly supervision served as both training and monitoring of session delivery. The music therapy students received college credit for their work on the study, which counted toward the clinical training requirements for their degree. The music therapy sessions consisted of several experiences (both active and receptive), such as movement to music, active music-making, Orff-based musical exercises, improvisation, songwriting, role-play, music performance, and music-assisted relaxation. Using structured improvisation (we used Beer, 2001, as a conceptual model) and Orff-based activities, which were adapted from music education resources, allowed the clinical team to engage each child in an appropriate and flexible manner. An Orff-based approach has been used by other researchers to engage children in low-income families (c.f., Young-Bae & Ji-Eun, 2013). Older children were given harder musical tasks or group-leading roles. The variety of experiences was purposeful and designed to sustain engagement, interest, and attention over the 50-minute session. The therapy sessions had a beginning, middle, and end format. At the beginning of the session, the children and therapist reviewed/practiced previously learned skills, new skills were introduced in the middle of the session, and sessions ended with a closing song. The first author prepared a weekly newsletter that each parent in the afterschool program received. The newsletter included information about the skills targeted during music therapy, and contained step-by-step flashcards with instructions on how to reinforce some of the skills at home. The afterschool teacher also received the same information and flashcards to implement during the afterschool program. The teacher reviewed the flashcards with the students during the week and posted them on the classroom bulletin board. Providing information and assigning a skill to practice was similar to the approach used by Gooding (2011). In order to monitor the number of sessions that each participant received (i.e., dose), we maintained an attendance log. Based on this information, only participants who received a minimum of six sessions (approximately two-thirds of the “treatment”) were included in the data analysis. Data Analyses The second author used SPSS (Version 23) for all quantitative analyses. Paired t-tests were conducted separately on teacher and parent responses for SSIS and HCBS subscale scores. The HBSC has two dimensions (social competence and antisocial behavior). Each dimension has two subscales and a total score. Thus, six items were analyzed together as a set. The SSIS has two dimensions: social skills total score and seven subscales, for a total of eight items grouped together; problem behavior total score and five subscales, for a total of six items grouped together. Academic competence was analyzed separately. Parent scores were analyzed separately from teacher scores. Given the independence of the dimensions as indicated in the manuals, this grouping of analyses seemed justified. Bonferroni corrections were calculated for each set of multiple t-tests. All p-values reported reflect the adjustment for multiple comparisons. Cohen’s d was used to calculate effect size using Morris and DeShon’s (2002) equation 8 to correct for dependence of means. Reliability across raters for scales with two or more raters was assessed according to the test manuals. Final scores were arrived at through discussion for the few cases where there was initial disagreement. Following recommendations outlined in the HCSBS user’s guide (Merrell & Caldarella, 2008), the authors conducted a visual qualitative inspection of the ratings of individual items on the HCSBS scale looking for areas of concern, trends among identified items of need, or individual areas of growth. Specifically, individual items receiving ratings of 1 or 2 on the social competence subscale and 4 or 5 on the antisocial behavior subscale were highlighted as low-performance/high-risk skills. Subsequently, the frequency of students exhibiting low performance/high risk for each individual item was tabulated (see Table 2) and the information was used to develop the music therapy session plans. A paired t-test was used to compare the average number of individual items of concern participants exhibited pre and post the implementation of the music therapy social skills development program. Table 2 Individual Items Rated as Low-Performance/High-Risk Skills on the HCSBS Scale Social competence items identified as concerns Pre Post S3 Completes chores without being reminded 6 4 S28 Notices and compliments accomplishments of others 5 1 S14 Completes chores and assigned tasks on time 5 3 S4 Offers to help peers when needed 3 2 S19 Interacts with a wide variety of peers 3 0 S7 Remains calm when problems arise 3 1 S8 Listens to and carries out directions from parents or supervisors 0 2 S10 Asks appropriately for clarification of instructions 2 0 S11 Has skills or abilities that are admired by peers 2 0 S23 Responds appropriately when corrected by parents or supervisors 2 0 S24 Controls temper when angry 2 0 S26 Has good leadership skills 2 1 S32 Is looked up to or respected by peers 2 0 S23 Responds appropriately when corrected by parents or supervisors 2 0 S12 Is accepting of peers 2 0 S5 Participates effectively in family or group activities 0 1 S2 Makes appropriate transitions btw different activities 1 0 S6 Understands problems and needs of peers 1 1 S15 Will give in or compromise with peers when appropriate 1 2 S17 Behaves appropriately at school 1 0 S18 Asks for help in an appropriate manner 1 0 S21 Is good at initiating or joining conversations with peers 1 0 S22 Is sensitive to the feelings of others 1 1 S27 Adjusts to different behavioral expectations across settings 1 1 S31 Shows self-control 1 0 Total 50 20 Antisocial behavior items identified as concerns Pre Post A1 Blames others for his or her problems 3 3 A7 Teases and makes fun of others 3 1 A3 Is defiant to parents or supervisors 2 2 A8 Disrespectful or sassy 2 1 A22 Argues or quarrels with peers 2 1 A20 Insults peers 2 1 A9 Easily provoked or has a short fuse 1 1 A6 Is dishonest and tells lies 1 1 Antisocial behavior items identified as concerns Pre Post A17 Threatens others or is verbally aggressive 1 1 A24 Bothers and annoys others 1 1 A25 Gets into trouble at school or in the community 1 0 A29 Is cruel to other persons or animals 1 0 A23 Difficult to control 1 0 A27 Boasts and brags 1 0 A4 Cheats on school work or in games 1 0 A30 Acts impulsively without thinking 0 1 A2 Takes things that are not his or hers 0 1 A21 Whines and complains 0 2 A11 Acts as if he or she is better than others 0 1 A28 Is not dependable 0 1 Total 24 21 Social competence items identified as concerns Pre Post S3 Completes chores without being reminded 6 4 S28 Notices and compliments accomplishments of others 5 1 S14 Completes chores and assigned tasks on time 5 3 S4 Offers to help peers when needed 3 2 S19 Interacts with a wide variety of peers 3 0 S7 Remains calm when problems arise 3 1 S8 Listens to and carries out directions from parents or supervisors 0 2 S10 Asks appropriately for clarification of instructions 2 0 S11 Has skills or abilities that are admired by peers 2 0 S23 Responds appropriately when corrected by parents or supervisors 2 0 S24 Controls temper when angry 2 0 S26 Has good leadership skills 2 1 S32 Is looked up to or respected by peers 2 0 S23 Responds appropriately when corrected by parents or supervisors 2 0 S12 Is accepting of peers 2 0 S5 Participates effectively in family or group activities 0 1 S2 Makes appropriate transitions btw different activities 1 0 S6 Understands problems and needs of peers 1 1 S15 Will give in or compromise with peers when appropriate 1 2 S17 Behaves appropriately at school 1 0 S18 Asks for help in an appropriate manner 1 0 S21 Is good at initiating or joining conversations with peers 1 0 S22 Is sensitive to the feelings of others 1 1 S27 Adjusts to different behavioral expectations across settings 1 1 S31 Shows self-control 1 0 Total 50 20 Antisocial behavior items identified as concerns Pre Post A1 Blames others for his or her problems 3 3 A7 Teases and makes fun of others 3 1 A3 Is defiant to parents or supervisors 2 2 A8 Disrespectful or sassy 2 1 A22 Argues or quarrels with peers 2 1 A20 Insults peers 2 1 A9 Easily provoked or has a short fuse 1 1 A6 Is dishonest and tells lies 1 1 Antisocial behavior items identified as concerns Pre Post A17 Threatens others or is verbally aggressive 1 1 A24 Bothers and annoys others 1 1 A25 Gets into trouble at school or in the community 1 0 A29 Is cruel to other persons or animals 1 0 A23 Difficult to control 1 0 A27 Boasts and brags 1 0 A4 Cheats on school work or in games 1 0 A30 Acts impulsively without thinking 0 1 A2 Takes things that are not his or hers 0 1 A21 Whines and complains 0 2 A11 Acts as if he or she is better than others 0 1 A28 Is not dependable 0 1 Total 24 21 Scores represent the number of participants exhibiting each item at low performance/high risk. View Large Table 2 Individual Items Rated as Low-Performance/High-Risk Skills on the HCSBS Scale Social competence items identified as concerns Pre Post S3 Completes chores without being reminded 6 4 S28 Notices and compliments accomplishments of others 5 1 S14 Completes chores and assigned tasks on time 5 3 S4 Offers to help peers when needed 3 2 S19 Interacts with a wide variety of peers 3 0 S7 Remains calm when problems arise 3 1 S8 Listens to and carries out directions from parents or supervisors 0 2 S10 Asks appropriately for clarification of instructions 2 0 S11 Has skills or abilities that are admired by peers 2 0 S23 Responds appropriately when corrected by parents or supervisors 2 0 S24 Controls temper when angry 2 0 S26 Has good leadership skills 2 1 S32 Is looked up to or respected by peers 2 0 S23 Responds appropriately when corrected by parents or supervisors 2 0 S12 Is accepting of peers 2 0 S5 Participates effectively in family or group activities 0 1 S2 Makes appropriate transitions btw different activities 1 0 S6 Understands problems and needs of peers 1 1 S15 Will give in or compromise with peers when appropriate 1 2 S17 Behaves appropriately at school 1 0 S18 Asks for help in an appropriate manner 1 0 S21 Is good at initiating or joining conversations with peers 1 0 S22 Is sensitive to the feelings of others 1 1 S27 Adjusts to different behavioral expectations across settings 1 1 S31 Shows self-control 1 0 Total 50 20 Antisocial behavior items identified as concerns Pre Post A1 Blames others for his or her problems 3 3 A7 Teases and makes fun of others 3 1 A3 Is defiant to parents or supervisors 2 2 A8 Disrespectful or sassy 2 1 A22 Argues or quarrels with peers 2 1 A20 Insults peers 2 1 A9 Easily provoked or has a short fuse 1 1 A6 Is dishonest and tells lies 1 1 Antisocial behavior items identified as concerns Pre Post A17 Threatens others or is verbally aggressive 1 1 A24 Bothers and annoys others 1 1 A25 Gets into trouble at school or in the community 1 0 A29 Is cruel to other persons or animals 1 0 A23 Difficult to control 1 0 A27 Boasts and brags 1 0 A4 Cheats on school work or in games 1 0 A30 Acts impulsively without thinking 0 1 A2 Takes things that are not his or hers 0 1 A21 Whines and complains 0 2 A11 Acts as if he or she is better than others 0 1 A28 Is not dependable 0 1 Total 24 21 Social competence items identified as concerns Pre Post S3 Completes chores without being reminded 6 4 S28 Notices and compliments accomplishments of others 5 1 S14 Completes chores and assigned tasks on time 5 3 S4 Offers to help peers when needed 3 2 S19 Interacts with a wide variety of peers 3 0 S7 Remains calm when problems arise 3 1 S8 Listens to and carries out directions from parents or supervisors 0 2 S10 Asks appropriately for clarification of instructions 2 0 S11 Has skills or abilities that are admired by peers 2 0 S23 Responds appropriately when corrected by parents or supervisors 2 0 S24 Controls temper when angry 2 0 S26 Has good leadership skills 2 1 S32 Is looked up to or respected by peers 2 0 S23 Responds appropriately when corrected by parents or supervisors 2 0 S12 Is accepting of peers 2 0 S5 Participates effectively in family or group activities 0 1 S2 Makes appropriate transitions btw different activities 1 0 S6 Understands problems and needs of peers 1 1 S15 Will give in or compromise with peers when appropriate 1 2 S17 Behaves appropriately at school 1 0 S18 Asks for help in an appropriate manner 1 0 S21 Is good at initiating or joining conversations with peers 1 0 S22 Is sensitive to the feelings of others 1 1 S27 Adjusts to different behavioral expectations across settings 1 1 S31 Shows self-control 1 0 Total 50 20 Antisocial behavior items identified as concerns Pre Post A1 Blames others for his or her problems 3 3 A7 Teases and makes fun of others 3 1 A3 Is defiant to parents or supervisors 2 2 A8 Disrespectful or sassy 2 1 A22 Argues or quarrels with peers 2 1 A20 Insults peers 2 1 A9 Easily provoked or has a short fuse 1 1 A6 Is dishonest and tells lies 1 1 Antisocial behavior items identified as concerns Pre Post A17 Threatens others or is verbally aggressive 1 1 A24 Bothers and annoys others 1 1 A25 Gets into trouble at school or in the community 1 0 A29 Is cruel to other persons or animals 1 0 A23 Difficult to control 1 0 A27 Boasts and brags 1 0 A4 Cheats on school work or in games 1 0 A30 Acts impulsively without thinking 0 1 A2 Takes things that are not his or hers 0 1 A21 Whines and complains 0 2 A11 Acts as if he or she is better than others 0 1 A28 Is not dependable 0 1 Total 24 21 Scores represent the number of participants exhibiting each item at low performance/high risk. View Large The first author listened to the audio recording and read the transcript from the teacher interview. She then conducted a thematic analysis in order to identify themes without being bound to a specific theoretical orientation (c.f., Braun & Clarke, 2006). The analysis focused on synthesizing a semantic description of the teacher’s perception of the music therapy social skills program. Results Teacher Ratings HBSC. Results showed no significant changes on any individual HBSC subscale pre-post comparisons (all ps > .1). However, the average number of behaviors in which children were classified as low performance/high risk on the HCBS decreased significantly from pre- (M = 2.0, SD = 1.50) to post-test (M = .8, SD = 1.08; t (24) = 2.54, p < .001, d = .918). The frequency distribution of individual items on the HCSBS scale identified as an area of low performance/high risk pre and post the implementation of the music therapy social skills development program is included in Table 2. SSIS. The SSIS teacher results indicated significant improvement in one specific social skill subscale score, communication (pre M = 13.61, SD = 4.37; post M =16.31, SD = 3.38; t (12) = –3.19, p = .007, d = .933). Significant decreases were seen in overall problem behaviors (pre M = 7.23, SD = 10.37; post M =1.23, SD = .72; t (12) = 2.13, p = .05, d = .787). Regarding specific problem behaviors, significant decreases were seen in hyperactivity/inattentiveness (pre M = 7.54, SD = 3.15; post M =5.38, SD = 2.60; t (12) = 3.18, p = .008, d = .903), and autistic tendencies (pre M = 8.54, SD = 4.87; post M = 4.38, SD = 3.25; t (12) = 3.28, p = .007, d = .957), and marginal decreases in internalizing behaviors (pre M = 4.00, SD = 2.04; post M =2.07, SD = 2.2; t (12) = 2.85, p = .015, d = .806). An unexpected finding was teacher ratings showing a significant decrease in academic competence from pre- to post-test (pre M = 10.38, SD = 6.64; post M = 5.61, SD = 2.81; t (10) = 2.79, p = .017, d = .97). Parent Ratings Parents completed pre and post ratings on the SSIS scale. Only 11 of the 14 children who attended 6 or more sessions had complete pre and post parent rating data. The analyses were conducted on the scores for these 11 children. SSIS parent scores revealed no significant differences in subscales. Although not significant, increases in communication scores were seen, similar to those observed in teacher ratings. Significant decreases were again seen in overall problem behaviors (pre M = 4.18, SD = 4.28; post M =1.18, SD = .75; t (10) = 2.29, p = .045, d = .85), Regarding specific problem behavior subscales, significant decreases were seen only in internalizing behaviors (pre M = 4.45, SD = 2.58; post M =2.45, SD = 2.25; t (10) = 2.21, p = .05, d = .67). Finally, parent ratings of overall academic competence were consistent with the teacher ratings. Parents rated their children as significantly decreasing in overall academic competence from pre to post session (pre M = 10.64, SD = 6.02; post M = 5.73 SD = 3.07; t (10) = 2.96, p = .014, d = 1.0). Table 3 includes pre and post means, (SD), Cohen1s D, and adjusted p-values for all measures. Table 3 Descriptive Data for Paired t-Test Analyses Pre-test Post-test M SD M SD Adjusted p* Cohen’s d HBSC  Peer Relations 63.71 13.62 65.14 12.81 NS --  Self-Management 55.14 12.24 58.14 11.74 NS --  Total Social 118.86 24.17 124.00 23.17 NS --  Defiant/Disruptive 35.29 13.47 32.71 11.83 NS --  Aggressive/Antisocial 36.86 15.52 33.07 12.14 NS --  Antisocial Total 72.14 28.72 65.79 23.16 NS -- SSIS–Teacher  Communication 13.61 4.37 16.31 3.38 .007 .933  Cooperation 11.69 4.25 11.85 3.05 NS --  Assertion 14.23 1.88 15.23 1.74 NS --  Responsibility 12.23 3.85 11.53 4.18 NS --  Empathy 11.38 4.27 12.00 3.70 NS --  Engagement 14.54 3.43 16.15 2.97 NS --  Self-Confidence 11.61 6.02 12.23 5.18 NS --  Social Skills Total 89.31 23.59 95.31 21.27 NS --  Externalizing 10.77 5.26 9.31 5.27 NS --  Bullying 3.38 3.15 3.31 3.42 NS --  Hyperactivity 7.54 3.15 5.38 2.60 .008 .903  Internalizing 4.00 2.04 2.08 2.25 .015 .806  Autism 8.54 4.87 4.38 3.25 .007 .957  Problem Behaviors 7.23 10.37 1.23 .725 .05 .787  Academic Competence 10.38 6.64 5.61 2.81 .017 .97 SSIS–Parent  Communication 14.00 4.33 15.83 3.71 NS --  Cooperation 12.64 4.06 12.00 3.28 NS --  Assertion 14.00 1.95 15.09 1.81 NS --  Responsibility 12.91 3.56 11.73 4.41 NS --  Empathy 11.91 4.18 11.82 3.99 NS --  Engagement 14.00 3.25 15.83 3.21 NS --  Self-Confidence 11.91 6.46 12.18 5.67 NS --  Social Skills Total 90.82 25.16 95.09 23.27 NS --  Externalizing 10.00 5.14 9.0 5.64 NS --  Bullying 3.64 4.13 3.45 3.56 NS --  Hyperactivity 7.73 3.41 5.27 2.69 NS --  Internalizing 4.45 2.58 2.45 2.25 .05 .67  Autism 7.36 3.93 4.54 3.53 NS --  Problem Behaviors 4.18 4.28 1.18 .75 .045 .85  Academic Competence 10.64 6.02 5.73 3.07 .014 1.0 Pre-test Post-test M SD M SD Adjusted p* Cohen’s d HBSC  Peer Relations 63.71 13.62 65.14 12.81 NS --  Self-Management 55.14 12.24 58.14 11.74 NS --  Total Social 118.86 24.17 124.00 23.17 NS --  Defiant/Disruptive 35.29 13.47 32.71 11.83 NS --  Aggressive/Antisocial 36.86 15.52 33.07 12.14 NS --  Antisocial Total 72.14 28.72 65.79 23.16 NS -- SSIS–Teacher  Communication 13.61 4.37 16.31 3.38 .007 .933  Cooperation 11.69 4.25 11.85 3.05 NS --  Assertion 14.23 1.88 15.23 1.74 NS --  Responsibility 12.23 3.85 11.53 4.18 NS --  Empathy 11.38 4.27 12.00 3.70 NS --  Engagement 14.54 3.43 16.15 2.97 NS --  Self-Confidence 11.61 6.02 12.23 5.18 NS --  Social Skills Total 89.31 23.59 95.31 21.27 NS --  Externalizing 10.77 5.26 9.31 5.27 NS --  Bullying 3.38 3.15 3.31 3.42 NS --  Hyperactivity 7.54 3.15 5.38 2.60 .008 .903  Internalizing 4.00 2.04 2.08 2.25 .015 .806  Autism 8.54 4.87 4.38 3.25 .007 .957  Problem Behaviors 7.23 10.37 1.23 .725 .05 .787  Academic Competence 10.38 6.64 5.61 2.81 .017 .97 SSIS–Parent  Communication 14.00 4.33 15.83 3.71 NS --  Cooperation 12.64 4.06 12.00 3.28 NS --  Assertion 14.00 1.95 15.09 1.81 NS --  Responsibility 12.91 3.56 11.73 4.41 NS --  Empathy 11.91 4.18 11.82 3.99 NS --  Engagement 14.00 3.25 15.83 3.21 NS --  Self-Confidence 11.91 6.46 12.18 5.67 NS --  Social Skills Total 90.82 25.16 95.09 23.27 NS --  Externalizing 10.00 5.14 9.0 5.64 NS --  Bullying 3.64 4.13 3.45 3.56 NS --  Hyperactivity 7.73 3.41 5.27 2.69 NS --  Internalizing 4.45 2.58 2.45 2.25 .05 .67  Autism 7.36 3.93 4.54 3.53 NS --  Problem Behaviors 4.18 4.28 1.18 .75 .045 .85  Academic Competence 10.64 6.02 5.73 3.07 .014 1.0 All p-values reflect an adjustment for multiple comparisons using Bonferroni corrections. View Large Table 3 Descriptive Data for Paired t-Test Analyses Pre-test Post-test M SD M SD Adjusted p* Cohen’s d HBSC  Peer Relations 63.71 13.62 65.14 12.81 NS --  Self-Management 55.14 12.24 58.14 11.74 NS --  Total Social 118.86 24.17 124.00 23.17 NS --  Defiant/Disruptive 35.29 13.47 32.71 11.83 NS --  Aggressive/Antisocial 36.86 15.52 33.07 12.14 NS --  Antisocial Total 72.14 28.72 65.79 23.16 NS -- SSIS–Teacher  Communication 13.61 4.37 16.31 3.38 .007 .933  Cooperation 11.69 4.25 11.85 3.05 NS --  Assertion 14.23 1.88 15.23 1.74 NS --  Responsibility 12.23 3.85 11.53 4.18 NS --  Empathy 11.38 4.27 12.00 3.70 NS --  Engagement 14.54 3.43 16.15 2.97 NS --  Self-Confidence 11.61 6.02 12.23 5.18 NS --  Social Skills Total 89.31 23.59 95.31 21.27 NS --  Externalizing 10.77 5.26 9.31 5.27 NS --  Bullying 3.38 3.15 3.31 3.42 NS --  Hyperactivity 7.54 3.15 5.38 2.60 .008 .903  Internalizing 4.00 2.04 2.08 2.25 .015 .806  Autism 8.54 4.87 4.38 3.25 .007 .957  Problem Behaviors 7.23 10.37 1.23 .725 .05 .787  Academic Competence 10.38 6.64 5.61 2.81 .017 .97 SSIS–Parent  Communication 14.00 4.33 15.83 3.71 NS --  Cooperation 12.64 4.06 12.00 3.28 NS --  Assertion 14.00 1.95 15.09 1.81 NS --  Responsibility 12.91 3.56 11.73 4.41 NS --  Empathy 11.91 4.18 11.82 3.99 NS --  Engagement 14.00 3.25 15.83 3.21 NS --  Self-Confidence 11.91 6.46 12.18 5.67 NS --  Social Skills Total 90.82 25.16 95.09 23.27 NS --  Externalizing 10.00 5.14 9.0 5.64 NS --  Bullying 3.64 4.13 3.45 3.56 NS --  Hyperactivity 7.73 3.41 5.27 2.69 NS --  Internalizing 4.45 2.58 2.45 2.25 .05 .67  Autism 7.36 3.93 4.54 3.53 NS --  Problem Behaviors 4.18 4.28 1.18 .75 .045 .85  Academic Competence 10.64 6.02 5.73 3.07 .014 1.0 Pre-test Post-test M SD M SD Adjusted p* Cohen’s d HBSC  Peer Relations 63.71 13.62 65.14 12.81 NS --  Self-Management 55.14 12.24 58.14 11.74 NS --  Total Social 118.86 24.17 124.00 23.17 NS --  Defiant/Disruptive 35.29 13.47 32.71 11.83 NS --  Aggressive/Antisocial 36.86 15.52 33.07 12.14 NS --  Antisocial Total 72.14 28.72 65.79 23.16 NS -- SSIS–Teacher  Communication 13.61 4.37 16.31 3.38 .007 .933  Cooperation 11.69 4.25 11.85 3.05 NS --  Assertion 14.23 1.88 15.23 1.74 NS --  Responsibility 12.23 3.85 11.53 4.18 NS --  Empathy 11.38 4.27 12.00 3.70 NS --  Engagement 14.54 3.43 16.15 2.97 NS --  Self-Confidence 11.61 6.02 12.23 5.18 NS --  Social Skills Total 89.31 23.59 95.31 21.27 NS --  Externalizing 10.77 5.26 9.31 5.27 NS --  Bullying 3.38 3.15 3.31 3.42 NS --  Hyperactivity 7.54 3.15 5.38 2.60 .008 .903  Internalizing 4.00 2.04 2.08 2.25 .015 .806  Autism 8.54 4.87 4.38 3.25 .007 .957  Problem Behaviors 7.23 10.37 1.23 .725 .05 .787  Academic Competence 10.38 6.64 5.61 2.81 .017 .97 SSIS–Parent  Communication 14.00 4.33 15.83 3.71 NS --  Cooperation 12.64 4.06 12.00 3.28 NS --  Assertion 14.00 1.95 15.09 1.81 NS --  Responsibility 12.91 3.56 11.73 4.41 NS --  Empathy 11.91 4.18 11.82 3.99 NS --  Engagement 14.00 3.25 15.83 3.21 NS --  Self-Confidence 11.91 6.46 12.18 5.67 NS --  Social Skills Total 90.82 25.16 95.09 23.27 NS --  Externalizing 10.00 5.14 9.0 5.64 NS --  Bullying 3.64 4.13 3.45 3.56 NS --  Hyperactivity 7.73 3.41 5.27 2.69 NS --  Internalizing 4.45 2.58 2.45 2.25 .05 .67  Autism 7.36 3.93 4.54 3.53 NS --  Problem Behaviors 4.18 4.28 1.18 .75 .045 .85  Academic Competence 10.64 6.02 5.73 3.07 .014 1.0 All p-values reflect an adjustment for multiple comparisons using Bonferroni corrections. View Large Teacher Interview The teacher reported that exposing the children to playing, touching, and hearing multiple instruments “they’ve never seen before” was the most intriguing aspect of the therapy sessions. The hands-on component of both singing and playing instruments served to maintain the engagement of children. Maintaining engagement was a key issue since this was an afterschool program and the younger children in particular were tired. The length of sessions seemed ideal in maintaining attention. Regarding musical instruments used in sessions, the teacher would have preferred, when bringing instruments that the children had not seen before, that there be one instrument for each child to explore. She shared that she used a teaching approach of empowering the older children to assist during the afterschool program. She reported that pulling older children aside, informing them about the music therapy session plan in advance, and enlisting their help would have perhaps promoted older child engagement in sessions. The teacher reported hearing the children singing snippets of the songs introduced during music therapy sessions throughout the day. The teacher used the newsletters as ways to communicate information about what the children learned in music therapy with their parents. She also reported using the information as a way to reinforce targeted social skills throughout the week. In particular, she implemented a problem-solving dialogue to resolve a conflict between two children in the classroom. She stated, “This program gave the children a new approach to how to handle conflict. It also taught my assistant and myself how to apply what we have learned as well and then reinforce it. I did this by re-examining the worksheets as needed.” Overall, the teacher seemed optimistic about the experience and eager to see it employed in the future. Discussion Through this study, we sought to develop and evaluate a music therapy social skills development program for youth with limited resources. Here, we discuss findings related to the effect of the music therapy program on social competence, antisocial behavior, and total number of low-performance/high-risk skills (as measured by the HCBS), and social skills, problem behaviors, and academic competence (as measured by the SSIS). We also report indirect benefits on academic achievement and the teacher’s perceptions about the program and student responses. In general, the music therapy program was feasible to implement, as indicated by the 100% parental consent and child assent for participation, and a 75% retention rate. Collaboration and support from the afterschool teacher and her part-time assistant played a key role in achieving high recruitment and retention. Attrition was the result of family circumstances and changes in housing, and not due to a lack of interest in or decision to discontinue the music therapy program. Our findings are consistent with other studies in which children in afterschool programs receiving music therapy showed improvements in social competence (Chong & Kim, 2010; Gooding, 2011), children from families with low income showed improvements in self-expression, self-efficacy, and social skills (Young-Bae & Ji-Eun, 2013), and children with various psychopathologies affecting social skills self-reported improvements in communication and interactions (Porter et al., 2017). Participation in this eight-session program appears to have reduced the average number of low-performance/high-risk behaviors. On the HBSC, none of the participants scored as having a specific area as an identified strength. As indicated in Table 2, the frequency of individual low performance/high risk (in areas such as complete chores without being reminded, notices and compliments accomplishments of others, completes chores and assigned tasks on time, offers to help peers when needed) was reduced. This outcome is important when considering that some of the group participants were siblings or cousins (as reported by the teacher). Sibling and peer influences may have bidirectional effects in risky behaviors (c.f., Whiteman, Jensen, & McHale, 2017). Thus, interventions that reduce frequency of low-performance/high-risk skills, particularly in a close-knit group of children, may reinforce shaping each other’s positive socialization outcomes. Porter and colleagues’ (2017) music therapy intervention involved one-on-one individual sessions using free improvisation. In contrast, the therapeutic music experiences we designed for music therapy sessions were similar to Gooding (2011), due to the emphasis we placed on active participation through improvisation, movement, and playing various instruments. Like Gooding, we also implemented cognitive behavioral techniques in modeling or redirecting behaviors during the sessions. In addition, several of our therapeutic music experiences were similar to those implemented by Chong and Kim (2010) because we also focused on performing musical parts, matching musical play to various meters, imitating or initiating musical phrases, and performing various roles in improvisational musical plays (i.e., holding rhythms, performing rhythm or melodic pattern variations). However, some of our therapeutic music experiences were more prescriptive than those used by Chong and Kim because of our reliance on social skills curricula and tailoring experiences to the specific needs of the participants. A possible explanation for the positive trends observed in this study may be that active music-making can help children focus and sustain attention (Gold, Voracek, & Wigram, 2004; Pasiali, LaGasse, & Penn, 2014) and thus learn new information/skills during music therapy sessions. The prescriptive nature and structured delivery of our program may also explain the significant improvement in communication (a construct measured on the SSIS social skills subscale), the significant decrease in hyperactivity, autistic behavioral tendencies, and overall problem behaviors, and marginal decreases in internalization reported by the teacher. The therapeutic music experiences targeted a specific set of skills and introduced them using a step-by-step process. Consistent across teacher and parent were increases in communication and engagement, and overall decreases in problem behaviors. Our findings parallel those of Porter et al. (2017) but also raise important questions about the type of intervention/programming. Even though Porter and colleagues noticed improvement in communication and interaction skills (as measured using a child self-report version and a guardian SSIS scale), those improvements were significant for participants older than 13. Thus, further research is warranted to determine if younger participants may benefit more from structured interventions whereas adolescents may benefit more from unstructured free improvisation. The Porter study findings also raise questions about treatment dose and delivery since significant benefits were measured at week 13 but not sustained at week 26. It is possible that intervention effects at the child level are not sustained without systemic supports provided for other socialization agents involved in a child’s life (peers, teachers, parents). Although academic performance was not directly targeted by our intervention, we hypothesized that it might improve as an indirect result of improvements in the areas targeted in our programming. As such, we were surprised by our finding that academic competence ratings actually decreased following the intervention despite observed improvements in communication and interaction. This outcome parallels the findings of Chong and Kim (2010), who also noticed improvements in social skills, a decrease in problem behaviors, as well as a decrease in academic competence. A possible explanation is that the afterschool program was partially funded through a literacy-based grant, and that with the end of the academic year approaching, the teacher may have been more focused on achieving academic outcomes and that focus may have affected the post ratings. Another possible explanation is that more difficult academic material was introduced at the end of the school year, and this may have contributed to perceptions of poorer academic performance. Regardless, both teacher and parent ratings indicated a perceived decrease in academic competence, and this is something that warrants further investigation. Facility constraints (i.e., all students participating in sessions) did not allow the research team to divide students into age groups. In contrast, Chong and Kim (2010) were able to divide participants into small groups by grade level (grades 1 & 2 in one group, grades 2 & 3 in one group, etc.), allowing the therapists to tailor intervention content based on developmental level. In our study, by working to address the social development needs across a wide range of development in a large group may have lessened the effect of our program. While working with a large group may not explain the decrease in academic performance, it can shed light on why academic improvement may not have been impacted. The teacher interview data is helpful in identifying what worked, and what can be adjusted to improve the music therapy social skills development program. As indicated by the teacher’s comments, the children memorized snippets of songs containing information pertinent to the development of social skills. Both the teacher and the children in the program consistently referred to the information and materials explored during the music therapy session. Using songs as vehicles for delivering information, a salient element of the music therapy program, seemed to be an effective way of reinforcing skills targeted through the program. The teacher reported that the children sang portions of the songs throughout the week and that repetition may have played a role in committing skills and concepts to memory. The newsletters, visuals, and informational material provided by the researchers allowed the teacher to reinforce the skills introduced during music therapy sessions throughout the week, and in communicating with parents about what the children were learning. This inclusive nature of our programming, encouraging involvement of multiple socialization agents (parent/guardian and teacher), may also explain notable changes in areas of low performance/high risk, improvements in communication, and a decrease in problem behaviors. In other words, providing materials and engaging the teacher in reviewing and reinforcing the targeted skills likely played a role in learning and generalization of skills in the afterschool classroom, and represents an attribute of the program that warrants further examination and development. Pairing music therapy programming in this setting (where families are living in poverty, and the afterschool program was under-resourced at the time of this study) was a positive and beneficial resource to the teacher. Regarding the implementation of the music therapy social skills development program, due to limited resources, there was only one large room available for this afterschool program. On a daily basis, 8–21 children participated. All services and activities took place in that large room. Program planning was challenging because of the wide range in developmental levels of children in the group. Maintaining attention and active engagement involved planning smooth and quick transitions between tasks, constantly monitoring and reinforcing participation, and differentiating instruction. As other researchers recommended (e.g., Gold et al., 2004), adopting an eclectic and flexible style, alternating between structured and improvised activities, was central in differentiating instruction to match the developmental level of each student in the group. Finally, rhythmic and pattern synchronization during active music-making emerged as a salient feature during the music therapy sessions. In planning our approach to active music-making, we referenced the continuum developed by Beer (2011) to gradually increase the complexity of improvisational experiences. Also, some of the principles we employed parallel those described by Geretsegger et al. (2015) and included various cues (verbal, nonverbal, musical, physical) to prompt synchronization and sustain musical interactions. Moreover, we scaffolded musical interactions by repeating material, gradually introducing new instruments, and increasing the complexity of musical tasks. For our participants, it was easier to achieve sharing sounds and synchronizing to the same underlying pulse during structured active music-making (e.g., repeating musical patterns, playing assigned instrumental parts). However, when asking children to simply improvise, that synchronization dissolved and each child was focused on playing their instrument without any outward effort to make musical contact with other members of the group. By session 6, we observed an improvement in ability to sustain synchronization to the same musical pulse. This shift may reflect an increased mutuality in the way each child was participating in the music experience. Researchers explored the notion that music improvisation is a pathway for improving social awareness and attention through active listening (c.f., Geretsegger et al., 2015), and based on our clinical observations it warrants further investigation with the population in this study. Limitations and Future Research A number of limitations should be considered when interpreting results of this study. The fact that the first author included students (non-credentialed MT-BCs) as members of the clinical team delivering the intervention is a limitation. Even though they were directly supervised and rehearsed interventions prior to implementation, their skill level may have influenced outcomes. Noteworthy is that during supervision we addressed both therapeutic skills and development of therapeutic relationships, an important factor identified as a predictor of positive outcomes (c.f., Lambert & Barley, 2001). Furthermore, use of a single-group, pre/post-test design cannot rule out any confounding variables and validity threats. For example, we cannot conclude that our music therapy social skills development program brought forth the observed change in participants. Change could have occurred because the teacher was verbally reinforcing the skills we addressed during sessions, or simply as a result of maturation effects. Moreover, statistical regression cannot be ruled out since none of the participants scored as having specific areas of strength during the pre-test assessment and there are several areas of low performance/high risk reported by the teacher. Another limitation was that the teachers and parents, with their full knowledge of the program, completed all measures. Specifically, the teacher who completed the ratings was present during the music therapy sessions. The consistency of findings across teacher and parent ratings, however, lends strength to the results. Although not identical, similarities across teacher and parent ratings lend strength to the results. Finally, there were no follow-up measures to show sustainability of the effect of the Music Therapy Social Skills Development Program. Long-term assessment is always difficult but crucial to determine the strength of interventions focused on behavior change. In summary, the results indicate benefits in reducing low-performance/high-risk skills, reducing problem behaviors such as hyperactivity and autistic behavioral tendencies, and improving communication. The next step would be implementation of the social skills development program in a multisite study using comparison groups. Overall, more research on the use of music therapy as a proactive intervention to support the development of individual social competencies in children living in environments with low resources is warranted. The authors would like to express their appreciation for: (a) the families, students, and teachers at YWCA, Charlotte, NC; (b) Dr. Nyaka Niilampti for her input and support of this project; and (c) the psychology and music therapy students who served as research assistants. 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Journal of Music TherapyOxford University Press

Published: May 21, 2018

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