MUSIC THERAPY AND EMOTIONALLY DISTURBED CHILDREN’S

SOCIAL-EMOTIONAL DEVELOPMENT

A Master’s Project

Presented to

The Faculty of the Kalmanovitz School of Education

Saint Mary’s College of California

In Partial Fulfillment

Of the Requirements for the Degree

Master of Arts

By

Simone Miranda

Spring, 2022
© 2022 by Simone Miranda

All Rights Reserved

This master’s project, written under the direction of the candidate’s master’s project advisory

committee and approved by members of the committee, has been presented to and accepted by

the faculty of the Kalmanovitz School of Education, in partial fulfillment of the requirements for

the Master of Arts degree.

______________________________________________________ ____________

Candidate: Simone Miranda Date

Master’s Project Advisory Committee:

______________________________________________________ ____________

Chair: Dr. Laura Heid, Ph.D. Date

______________________________________________________ ____________

Reader: Jodi Courick, Ph. D. Date

______________________________________________________ ____________

Department Chair: Date

______________________________________________________ ____________

Dean: Dr. Carol Ann Gittens, Ph.D. Date

 Abstract

Music Therapy and Emotionally Disturbed Children’s Social-Emotional Development

By

Simone Miranda

With a Specialization in Marriage & Family Therapy

Saint Mary’s College of California, 2022

Laura Heid, Ph. D., Chair

The purpose of this project is to propose an eight-week, school-based music therapy group for

fourth and fifth grade children with emotional disturbance. Children with emotional disturbance

experience challenges in social-emotional areas of development that affect regular functioning

throughout their lifetime. The proposed intervention is a music therapy group grounded in

education-oriented music therapy. The use of this intervention will provide psychoeducation to

children around music, emotional expression and regulation, support peer and adult relationships,

provide a safe space to explore their experiences as well as opportunities to be in community

while playing music. It will also introduce the concept of identity and the intersectionalities that

make it up. The group approach aims to support social-emotional growth and an understanding

of self through music.

 Dedication

I dedicate this master’s project to my Thompson and Miranda family. Everything I have

become and worked for is because of your unconditional love and support. Most importantly, I

dedicate this project to my parents Eddie and Kelley Miranda; from the bottom of my heart thank

you for everything you have instilled in me, being my backbone, and your sacrifices. I will

forever be grateful for your examples of hard-work and perseverance. I love you. To my siblings,

Chase, Natalie, and Tyce, thank you for being my forever cheerleaders and making dark days a

lot lighter. I’m grateful to have siblings that are there for me through everything. To my nieces

and nephews, thank you for being my motivation to further my education and give back to the

younger generation. Lastly, to my crew, thank you for being the best group of friends anyone

could ask for. Your loyalty and support is unmatched.

I would also like to acknowledge my professors and cohort; Thank you for your

inspiration and encouragement. It has been a privilege to learn from you all. Thank you to the

additional educators in my life who have pushed me to my fullest potential. Lastly, I would like

to acknowledge those who have influenced my love for music.

“I love music because it makes you feel. It makes you reminisce and appreciate things

from the past, present, and future. Helps face the vulnerabilities and what is being buried down.

Music gives you a voice when you don’t even know what it means to have one. I love music

because it’s a form of connection…through language and generations. It’s always there.”

(Simone Miranda, December 17, 2021).

 Table of Contents

Chapter Page

1. Introduction …………………………………………………………………….1

Background of the Problem ……………………………………………2

Symptoms of Emotional Disturbance ………………………….3

Factors Contributing to Emotional Disturbance ……………….4

Consequences of Emotional Disturbance ………………………7

Treatment for Emotional Disturbance ………………………….9

Statement of the Problem ………………………………………………9

Purpose and Significance of the Project ………………………………10

An Overview of Music Therapy ………………………………………11

Historical Context ……………………………………………..11

Description of Music Therapy ………………………………...13

How Music Therapy …………………………………………..14

Results of Using Music Therapy ………………………………15

Summary ………………………………………………………………16

Definition of Terms: ……………………………………………………17

2. Literature Review ………………………………………………………………19

Characteristics/Behaviors of Children with Emotional Disturbance …..19

Factors that Contribute to Emotional Disturbance …………………….23

Negative Outcomes for Children with Emotional Disturbance ………..28

Therapeutic Interventions Implemented with Children with ED ………33

Music Therapy …………………………………………………………39

Ways MT Supports Social-Emotional Development in Children with ED …40

Summary ……………………………………………………………………..46
 3. Application …………………………………………………………………..48

Setting and Structure …………………………………………………49

Selection of Group Members ………………………………………..49

Program Approach …………………………………………………..50

Week 1: Rapport Building and Group Agreements …………51

Week 2: Emotions and Music Session 1 …………………….54

Week 3: Emotion(al) Expression and Music Session 2 ……..57

Week 4: Identity and Music Session 1 ………………………61

Week 5: Music and Identity Session 2 ………………………64

Week 6: Friends Session 1 …………………………………..66

Week 7: Friends and Music Session 2 ………………………69

Week 8: Termination ………………………………………..71

Summary ……………………………………………………………73

4. Discussion ………………………………………………………………….74

Strengths ……………………………………………………………74

Limitations …………………………………………………………75

Considerations for Counselors ……………………………………..76

Recommendations …………………………………………………77

Conclusion …………………………………………………………78

References …………………………………………………………………………80

Appendices ………………………………………………………………………..88

A. Informed Consent …………………………………………………………88

B. Survey Questionnaire ……………………………………………………..89
C. Cool Down Post-it ………………………………………………………..90
D. “Why Do We Lose Control of Our Emotions?” ………………………….91
E. Cool Down Choice Poster ………………………………………………..92
F. Structure of Cool Down Break …………………………………………..93
G. “Emotions for Kids” ……………………………………………………..94
H. Body Template …………………………………………………………..95
I. Powerpoint Slides on Emotions …………………………………………96
J. Forte and Piano Powerpoint Slides ………………………….…………..97
K. Emotion Strips ………………………………………………………….100
L. Identity Flower Hand-Out ………………………………………………101
M. “Feelings Thermometer” Check-In ……………………………………..102
N. “Identity Explained for Children” Video ……………………………….103
O. “Mixed Me!” Read Aloud ………………………………………………104
P. Music and Identity Lesson ………………………………………………105
Q. “Soundtrack of my Life” Hand-Out ……………………………………..107
R. Friendship Video ………………………………………………………...108
S. “Recipe for Friendship” Example ……………………………………….109
T. “Lean on Me” Lyrics …………………………………………………….110
U. Main Ideas Hand-Out ……………………………………………………111
V. Evaluation Form …………………………………………………………112
 Introduction

More than 335,000 children nationwide are considered to be emotionally disturbed

(Samuels, 2018). Layman et al. (2002) referred to emotional disturbance as a “diverse group of

diagnoses including behavior disorders, schizophrenia, affective disorders (mania and

depression), autism, and anxiety and attachment disorders'' (p. 164). Children with emotional

disturbance are unidentified and underserved in most spaces (e.g. schools, healthcare, criminal

justice system) (Kauffman, Mock, & Simpson, 2007, p. 44). According to Samuels (2018),

nationwide, 6% of children with any kind of disability (e.g. learning, speech impairment,

processing) are classified as having an emotional disturbance; however, the numbers do not

represent this specific population. Some children who present the features of an emotional

disturbance are not properly identified due to misdiagnosis, and as a result, are unidentified for

appropriate support (e.g. individual education plan, 504 plan, behavior plan, treatment plan)

(Samuels, 2018). Children with emotional disturbances represent a group that faces the most

challenges in spaces such as academia, and they are often unidentified until adolescence, when

interventions are more difficult to provide (Samuels, 2018).

Due to a disruption in social-emotional development, emotionally disturbed children

acquire internalized and externalized behaviors that interrupt effective development to function

in prosocial environments (Malik & Marwaha, 2020). Internalized behaviors reflect a child’s

emotional or psychological state and can include anxiety (e.g., uncontrollable overthinking,

feeling irritable, trouble concentrating), depression (e.g., feelings of sadness or hopelessness, loss

of interest or pleasure in activities), withdrawal, or somatic complaints (Liu, Chen, & Lewis,

2011); while externalized behaviors are problem behaviors that are directed toward the external

environment (e.g., defiance, physical aggression, stealing, and destruction of property) (Liu,

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2004). Social-emotional development involves “the ability to identify and understand one’s own

feelings, to comprehend emotional states in others, to manage strong emotions and their

expression, to regulate one’s own behavior, to develop empathy for others, and to establish and

maintain relationships” (National Scientific Council on the Developing Child, 2004, para. 2).

Early diagnosis of emotional disturbance in childhood regarding externalizing behaviors has

been associated with a significantly higher prognosis for serious mental disorders later in

pre-adolescence, adolescence, and adult stages (Bongers, Koot, Van Der Ende, & Verhulst, 2004;

Mesman, Bongers, & Koot, 2001).

Children with emotional disturbance (ED) are at high-risk to face challenges with their

social-emotional development and to acquire further struggles with self-regulation, interaction

with their peers and interpersonal relationships, self-esteem, and academic achievement (Sausser

& Waller, 2006). According to the American Association for Employment in Education (2001),

special education and emotional disorders are the areas with the highest demand for support in

the United States. Unfortunately, many children with emotional disturbance are stigmatized as

“troubled children” due to their internalized and externalized behaviors (Kauffman, Mock, &

Simpson, 2007, p. 45). As a result of interfering stimuli, such as impulsive reactions in minor

situations, there is a need to apply hands-on learning experiences to motivate and support the

social-emotional development of these children (Sausser & Waller, 2006).

Background of the Problem

Children who are emotionally disturbed confront intense emotions that can be

overwhelming to regulate in over stimulated spaces. The epidemiology of emotional disturbance

is complex and may be rooted in: attachment disruption, which refers to insecure attachment or

separation from primary attachment figure that negatively affects making emotional connections

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with others (Bowlby, 1984); trauma, which is an emotional response to a terrible event such as

physical, emotional, or sexual abuse; neglect; or witnessing domestic violence (Wasmer-Nanne

& Vandenberg, 2013); reactive classroom management, which is the way in which teachers (and

other adults) react to misbehavior (Chen, Lewis, & Liu, 2011); or improper support in place,

(i.e., lack of resources to provide specific services, untrained staff in place, lack of consistency)

(Kauffman, Mock, & Simpson, 2007). According to Lane, Gresham, and O’Shaghnessy (2002),

efforts in understanding emotional disorders have increased in identification and assessment;

however, several challenges still exist that require prompt attention and support (pp. 507-521).

While there are treatment approaches in place, such as Cognitive Behavioral Therapy (CBT) and

behavior management, these approaches focus on shaping the behavior for the child to act in

accordance with what is considered “normal” in the environment, instead of focusing initially on

cognitive distortions, or how external factors impact the child’s social-emotional development

(Halder & Mahato, 2019). Children with emotional disturbance face various challenges and

consequences that might contribute to larger systemic issues like, the school-to-prison pipeline

later in adolescence and adulthood (Wagner et al., 2005); such issues will be discussed further in

the chapter. This section will address the following: Symptoms of Emotional Disturbance,

Factors Contributing to Emotional Disturbance, Consequences of Emotional Disturbance, and

Treatment for Children with Emotional Disturbance.

Symptoms of Emotional Disturbance

A significant factor that contributes to poor outcomes in social-emotional development

with children who are emotionally disturbed is the failure to identify symptoms of emotional

disturbance early on in order to introduce appropriate interventions (Mitchell et al., 2019).

Children with emotional disturbance exhibit a complex mix of behavioral, social-emotional,

3
educational, and/or medical/neurological difficulties. Mclaughlin et. al. (2009) conducted a study

2 years post Hurricane Katrina, and the results indicated that in the first 3 to 6 months after the

hurricane, more than 50% of the children who had been exposed to the disaster exhibited

symptoms of posttraumatic stress disorder (PTSD), disruptive behaviors, or other manifestations

of psychological distress (p. 1069) .

Emotional disturbance is described by the Individuals with Disability Education Act

(IDEA, 2017) as, “a condition exhibiting one or more of the following characteristics over a long

period of time and to a marked degree that adversely affects a child’s educational performance”

(300.8 [c] [4]). There are five criteria that serve as characteristics of emotional disturbance.

According to the IDEA (2017) the five criteria are as follows: (a) an inability to learn that cannot

be explained by intellectual, sensory, or health factors, (b) an inability to build or maintain

satisfactory interpersonal relationships with peers and teachers, (c) inappropriate types of

behavior or feelings under normal circumstances, (d) a general pervasive mood of unhappiness

or depression, and (e) a tendency to develop physical symptoms or fears associated with personal

or school problems. The characteristics described within the criteria are manifested through

internalized or externalized behaviors (“problem behaviors''). Such behaviors interrupt the

experience, expression, and management of emotions and the ability to establish positive and

rewarding relationships with others (Cohen et. al., 2005).

Factors Contributing to Emotional Disturbance

Children who have experienced one or more traumatic events are at high risk for

developing emotional disturbances (EDs). The National Survey of Children’s Health (NSCH,

2016) identified 46% of the nation’s youth ages 17 and under who had experienced at least one

trauma; the relationship between trauma and emotional disturbance will be further explained

4
within this section. Children who are emotionally disturbed are stigmatized in spaces such as

academia because of their deficiency in social-emotional regulation in over-stimulating

experiences, which is then expressed through internalized and externalized behaviors (Kauffman,

Mock, & Simpson, 2007, p. 45). Mclaughlin et al. (2009) identified that people in academia or in

places of power have high expectations in terms of “normative behavior” and a lack of

culturally sensitive approaches to understand the social-emotional needs of children who are

emotionally disturbed. Reactive teaching styles and frequent changes in environment or

treatment plans, are a few of the factors that could contribute to the interruption of effective

development for this vulnerable population (Lee et al., 2013, p. 157).

Biologically, the emotional brain is frequently reactive in the emotionally disturbed child.

According to Van Der Kolk (2015), the reptilian brain and limbic system, also known as the

emotional brain, is activated when intense emotions activate the limbic system, specifically in an

area called the amygdala. The amygdala’s function is to warn the body of forthcoming danger

and activate the body’s stress response. When trauma occurs and influences emotional

disturbance in children through images, sounds, or thoughts related to their experience, the

amygdala automatically reacts with panic (Van Der Kolk, 2015). As a result, the panic triggers

intense stress hormones and nerve impulses that increase blood pressure, heart rate, and oxygen

intake, which eventually stimulates externalized or internalized behaviors (Van Der Kolk, 2015).

The effects of the stress hormones can affect memory, decrease attention, and increase irritability.

Additionally, when a child is unable to recover from a situation, the body is triggered to defend

itself, which causes dysregulation and makes them feel agitated and provoked (Van Der Kolk,

2015). When the emotional brain is triggered, it is more susceptible to impulsive thoughts and

feelings without warning, leaving rational capacities to be delayed long after the danger or threat

5
is gone.

Research has identified that attachment style is also an important contributing factor to

undeveloped social-emotional skills. On an attachment level, mastering the skill of

self-regulation depends on how secure early interactions with caregivers were (Van Der Kolk,

2015). If the adult is more responsive to the child, then the attachment is deeper, and the child is

more likely to develop healthy self-esteem and positive ways of responding to people around

them. Van Der Kolk (2015) explained that through secure attachment, children can learn how

other people have feelings and thoughts that are both similar to and different from theirs.

Therefore, both child and caregiver are emotionally attuned to one another, and the child

understands situations when they need help. On the other hand, if attachment is disorganized and

emotional communication is disrupted, children begin to feel unsafe and have trouble regulating

their moods and emotional responses as they get older (Van Der Kolk, 2015). As a result,

children tend to be more aggressive or disengaged, which creates a high reaction in stress

hormones. Caregivers who are still working through their own trauma or stresses might also be

too emotionally unstable to offer much comfort and protection, and to be attuned to their child’s

needs (Van Der Kolk, 2015).

Furthermore, children from low socioeconomic status (SES) are associated with higher

levels of emotional and behavioral difficulties (Decarlo Santiago, Stump, & Wadsworth, 2011).

Sanchez et al. (2017) implied that economic stress and exposure to violence, alongside ongoing

discrimination have been associated with increased internalizing and externalizing symptoms,

further insinuating the need for “interventions to develop effective coping strategies” (pp. 15-24).

Being exposed to poverty during childhood appeared to have an impact that was detrimental on

childhood social and cognitive ability than experiencing poverty later in life (Duncan et al.,

6
1998, as cited in Hosokawa & Katsura, 2018, p. 3). Compared to children from high SES

backgrounds, children with low SES were two to three times more likely to develop mental

health problems because of everyday stressors that impacted their development (Reiss et al.,

2019). Along with low SES, a shortage of appropriate support such as mental health

services/resources, is also a contributing factor for emotional disturbance in young children.

According to Shapiro et al. (1999), many adults reported a lack of training and access to

supportive resources to effectively educate and behaviorally manage children with emotional

disturbance. Many children who are emotionally disturbed and have undeveloped

social-emotional skills are pathologized by some institutionalized environments, teachers, or

other adults and, as a result, are treated as a “problem” in the environment, rather than the

environment being considered an issue for the child (Kauffman, Mock, & Simpson, 2007).

Environments that are overstimulating, or classrooms with poor classroom management might

influence further disruptions in the emotionally disturbed child’s social-emotional development

(Kayıkçı, 2009). For example, poor classroom management portrays the temperament of the

teacher; if a teacher is dismissing certain “problem” behavior, or reacting negatively, rather than

using it as a teaching moment, then the child misses out on learning how to regulate their

emotions (Kayıkçı, 2009). Emotionally disturbed children who do not receive the necessary

support to encourage healthy development continue to face struggles throughout adolescence and

adulthood (Costello, Angold, & Keeler, 1999).

Consequences of Emotional Disturbance

Due to overwhelming symptoms, such as aggressive impulsivity, short attention spans,

difficulty concentrating, withdrawal, or an inability to manage uncontrollable emotions and

behaviors related to emotional disturbance, children may not achieve the social and cognitive

7
breakthroughs typical to their chronological age (Paul, 1984). As a consequence,

social-emotional development, along with psychosocial development, are threatened and might

cause children to isolate and form unhealthy relationships with others (Choi, Lee, & Lee, 2010).

According to Yau and Fachner (2021), when children do not have the tools or skills to

self-regulate, they show much more behavioral/emotional problems in their social contexts and

they acquire low self-image (pp. 529-546).

According to Wagner, Cameto, and Newman (2003), about 58% of children with

emotional disturbance are arrested 3 to 5 years out of high school; as a consequence, the

school-to-prison pipeline increases and the population continues to be served unjustly. Lee et al.

(2013) reported that emotional disturbance and inadequate social-emotional development

influenced lower self-esteem, an increase in grade detainment, at risk drop-out rates, and a higher

likelihood of receiving school suspensions (Lee et al., 2013). Additionally, Forness et al. (2012)

explained that a critical consequence in the lack of provision of services to this population of

children is that the prevalence is underestimated or underreported; thus, so many children are not

getting services. For that reason, many children with emotional disturbance are underserved and

their social-emotional development continues to be vulnerable. Furthermore, children with

emotional disturbance are significantly maladjusted to the social-emotional expectations within

various environments (Forness et al., 2012). For example, according to Forness et al. (2012),

general education (K-12) administrators are likely to view a child’s lack of involvement in

certain instructional activities as a learning problem rather than as a “potential symptom of

depression and anxiety” (p. 14). As a result, there is a lack of referrals and/or limited access to

appropriate resources, as well as services (Bussing, Mason, Bell, Porter, & Garvan, 2010).

8
Treatment for Emotional Disturbance

The approach commonly used to support social-emotional development of children with

emotional disorders is cognitive behavior therapy (CBT) or behavior management (American

Academy of Pediatrics, 2021). According to the American Psychological Association (2021),

“CBT is based, in part, on faulty or unhelpful ways of thinking” (para. 4). While CBT and

behavior management involve efforts to change behavioral patterns and have been shown to be

effective, according to Guadiano (2008), the approaches are determined by physical process

alone and fail to address the concerns of the “‘whole’” patient (p. 3). The sole focus is to change

behavior, rather than understanding the context of the behavior or focusing on social-emotional

development to better support the change in emotions or behavior (Guadiano, 2008). Approaches

such as cognitive behavioral therapy and behavioral management, while helpful, provide support

in behavioral problems; however, they do not consider cultural aspects or experiences within the

child’s realm that can be reintegrated to regulate effective social-emotional development (Levy

et. al., 2021). Additionally, there is rarely any consideration of familial and cultural influences

within the therapeutic formulation for a case (Levy et. al., 2021). Further research still needs to

be done specific to CBT and behavior management and children with emotional disturbances.

Statement of the Problem

A child who meets one or more of the five characteristics of emotional disturbance is

considered emotionally disturbed according to the IDEA (2017). Emotional disturbance can be

caused by a traumatic experience and can also include diagnoses of emotional/behavior

disorders, anxiety, schizophrenia, attachment, depression, mania, and emotional issues associated

with autism. Children with emotional disturbance are one of the most underserved populations,

and they have challenges with social-emotional skills, which they express through externalized

9
and internalized behaviors. Factors that can contribute to emotional disturbance and unhealthy

social-emotional development have been identified: insecure attachment, reactive teaching

styles, and improper support in place. A deficiency in social-emotional development involving

children with emotional disturbance has consequences correlated with the school-to-prison

pipeline, an increase in emotional and behavioral challenges within their environment, low

self-image, an increase in being held back a grade, and limited access to appropriate resources or

services (Bussing, Mason, Bell, Porter, & Garvan, 2010; Lee et al., 2013). An inability to build

and maintain positive relationships is an additional consequence of undeveloped

social-emotional skills in children with emotional disturbance. A few studies have been

conducted on the beneficial approaches and treatment of CBT and behavior management with

emotionally disturbed children and their social-emotional development; however, many of them

neutralize behavior in order for the child to conform to the expected environment. In other

words, the focus of such treatments is to make behavior ineffective or harmless by an opposite

force or effect, so the child aligns with the standards that are appropriate in institutionalized

spaces; rather than initially focusing on ways to make cognitive errors, or irrational thinking

patterns, ineffective (neutralized) to support a shift in behavioral or emotional development.

Purpose and Significance of the Project

The purpose of this project is to identify how music therapy can be utilized as an

approach to reconceptualize social-emotional development with children who are emotionally

disturbed, as well as how to integrate cultural values and experiences in their treatment.

Meaning, how can music therapy be used as an approach to form a new perception of

social-emotional development in a different way, for emotionally disturbed children? The

modality of Education-oriented Music Therapy (EoMT) (Chong & Kim, 2010) will be depicted

10
as a significant treatment technique for supporting social-emotional needs of children with

emotional disturbance. A hypothetical case study will be presented using music therapy to treat a

group of children with emotional disturbance.

The significance of this project is to improve support for children with emotional

disturbance through the use of music therapy and provide more inclusive techniques, such as

active and passive music approaches, to strengthen social-emotional development. The project

will provide beneficial information to increase support and awareness for emotionally disturbed

children. Additionally, it will include information for music therapy approaches to encourage

self-regulation, healthy emotional expression, group cohesiveness, positive self-image, and

interpersonal relationships. The use of music therapy might be a well-rounded treatment

approach to improve support for the social-emotional development of this vulnerable population.

An Overview of Music Therapy

While there are common techniques and coping strategies to assist children with

emotional disturbance, there are therapeutic interventions, such as music therapy, to help

children self-regulate, set and understand boundaries, and express themselves through the art of

music. Music therapy involves the use of music interventions to accomplish individualized goals

within the therapeutic relationship (American Music Therapy Association, 2005, para. 1). This

section will discuss the following: Influential People and Historical Context of Music Therapy,

Description of Music Therapy, How Music Therapy Works, and The Results of Using Music

Therapy.

Historical Context and Influential People

Music therapy has been around for centuries and has a variety of influential people who

paved the way for music therapy to be used in clinical and educational settings (American Music

11
Therapy Association, 2005). During World Wars I and II, community musicians went to

Veterans’ (VA) hospitals around the country to play for veterans suffering both physical and

emotional trauma from the wars (American Music Therapy Association, 2005). The physical and

emotional responses to music from the patients led medical professionals to request musicians

for VA hospitals. As a result, music therapy became more recognized. Many of the earliest

innovators of music therapy understood that music was a significant method for healing affected

emotional and behavioral interactions, as well as increasing self-esteem. The earliest writings on

the therapeutic value of music were published by Edwin Atlee and Samuel Mathews in the

1800s, and they discussed the influence of music in the cure of diseases (American Music

Therapy Association, 2005). In the 1940s, music therapy began to move towards an

organizational and educational perspective (American Music Therapy Association, 2005). The

development of music therapy programs began with Michigan State College and the formation of

the National Association for Music Therapy (NAMT), because of the need for musicians to be

trained before working in hospital settings in the 1950s (American Music Therapy Association,

2005). The 1950s marked the start of music therapy as a profession with a focus on the

development of training programs and the establishment of the basic structures of the profession

(Beyers, 2016, p. 16). Clinical work focused on working with individuals with intellectual

disabilities, while theoretical developments were being discovered in the United Kingdom,

Germany, Austria, and Switzerland (Beyers, 2016, p. 18).

By the 1960s, deinstitutionalization was an influential movement in Western society and

had a significant effect on the profession due to the early development of music therapy being

essentially for government paid positions in large residential facilities (Beyers, 2016, p. 21).

During the 1960s, clinical practice developed an interest in behavioral psychology, as well as a

12
model that represented a culturally specific way of practice (Beyers, 2016, p. 21). In the 1970s,

clinicians desired ways to improve referrals to music therapy and encouraged other professions

to recognize music therapy as a form of therapy instead of recreation (Lord, 1971). The interest

in the development of music therapy assessments was also encouraged. The 1980s brought new

areas of development within music therapy that included advocacy work with the government

and growing attention on job creations, the concepts of ethics, and the integration of technology

into clinical work (Beyers, 2016, p. 43). Into the 1990s, music therapy as a profession had

become more established throughout the world. Music therapists expanded their services to

trauma survivors, the homeless, domestic violence survivors, and individuals with eating

disorders (Beyers, 2016, p. 62). In the United States, pressure increased to support services with

empirical evidence as music therapy became more recognized. In the beginning of the 21st

century, an explosion of diverse thought and clinical work dominated the music therapy

profession (Beyers, 2016, p. 81). Today, music therapy’s growth is shaped by society's needs and

continues to be influenced by evidence-based practice (Beyers, 2016, p. 96).

Description of Music Therapy

In order to better support emotionally disturbed children, the study of how the brain

functions with music and exploring techniques and strategies involving music therapy can be

used as a therapeutic strategy to improve social-emotional development. Research and clinical

evidence have suggested that music therapy can assist children in reaching their Individual

Education Plan (IEP) goals (Yinger, 2018). Music therapy is an evidence-based practice with the

use of music interventions to meet goals within a therapeutic relationship to address physical,

emotional, cognitive, and social needs of individuals (American Music Therapy Association,

2005). The music therapists’ intention is to determine which music therapy approaches are

13
effective in the reconstruction, maintenance, and improvement in mental and physical health

(American Music Therapy Association, 2005). Music therapy involves the use of active and

passive therapy, where instruments can be played during sessions (active) or music may be

listened to (passive) to reflect on tone, lyrics, or emotion in a musical piece (Montello & Coons,

1998). Sessions involve the client using instruments and their voice to explore the world of

sound, while the therapist supports the clients’ response through improvised music (American

Music Therapy Association, 2005).

The various types of music therapy include: Guided Imagery and Music (Beyers, 2016, p.

39); Nordoff-Robbins Music Therapy (Beyers, 2016, p.40); Free Improvisation Therapy (Beyers,

2016, p. 19); Neurological Music Therapy (Thaut, 2005, p. 126); Resource-Oriented Music

Therapy (Schwabe, 2005, p. 50); Education-Oriented Music Therapy (Chong & Kim, 2010, p.

193) ; and Community Music Therapy (Pavlicevic et al., 2012).

How Music Therapy Works

Jansen, Scherder, and Uhlig (2018) reported that music induces complex

cognitive-emotional processes; interacts with brain areas that modulate mood and stress; and

enhances contact, coordination, and cooperation with others. According to Sharkey (2019),

during sessions, the music therapist attempts to form a bond with their client in order to enhance

well-being and improve confidence, communication skills, awareness, and attention (para. 3).

The goal of the music therapist is to reach a “‘moment of change’” where the therapist can

strengthen their connection with their client to influence positive development (Sharkey, 2019,

para. 9). Music interventions are utilized to attain either individual or group goals; particularly,

the music alone and the way the music is used are customized to meet distinct nonmusical

objectives (Yinger, 2018, p. 2). Yinger (2018) expressed that in music therapy, both the music

14
and the therapeutic relationship with the music therapist are essential to attaining treatment goals

(p. 2). According to Nilsson (2008), with more activation, music acts as a distractor, focusing the

clients’ attention away from negative stimuli to something pleasant and encouraging (p. 781).

From a neurological perspective, listening to music that is pleasurable activates neural areas

associated with the release of dopamine (Blood & Zatorre, 2001, as cited in Yinger, 2018, p. 17).

This implies that music not only leads to feelings of gratification, but also supports human

behavior that is motivating and involved in the function of learning and memory, as a result of its

connection with dopamine.

Results of Using Music Therapy

Musical engagement provides various opportunities for children to explore interests, react

to numerous stimuli, and demonstrate developmental skills that adults can model (Yang, 2016).

In other words, according to Yang (2016), music supports the concept of “matching,” which

involves adult-child interactions where adults adjust their behaviors according to children’s

developmental levels, interests, and behavior styles (p. 34). By acting out songs expressively,

singing with expression, or playing instruments with rhythmic or dynamic changes, parents,

children, and other adults can adapt to one another in a positive way. According to Levitin

(2006), the emotions experienced in response to music involve structures rooted in the primitive,

reptilian regions of the cerebellum and the amygdala, which is the core of emotional processing

in the cortex (p. 87). Through music, children can process their own emotions and understand

how to express their emotions in a healthy demeanor.

Music, whether played or listened to, can influence emotional expression through the

frontal cortex and language development through the cerebral cortex, by use of tone, sound, or

repetition of songs (Levitin, 2006, p. 109). The memory pathways in the brain begin to improve

15
and enhance the pathways for melodic memory, where the brain then translates it into language

(Collins, 2014, p. 5). Rhythm, which is a strong, regular, repeated pattern of sound or movement,

supports the synchronization of physiological functions such as heart rate, blood pressure, and

breathing, so that individuals learn how to be in harmony with themselves (Coons & Montello,

1998, pp. 51-52).

Review Questions

This project is designed to address the following questions:

1. What are the characteristics/behaviors of children with emotional disturbance?

2. What factors contribute to emotional disturbance?

3. What are the negative outcomes for children with emotional disturbance?

4. What therapeutic interventions have been implemented with children with

emotional disturbance?

5. What is music therapy?

6. In what ways does music therapy support social-emotional development in

children with emotional disturbance?

Summary

As a result of undeveloped social-emotional skills, emotionally disturbed children acquire

internalized and externalized behaviors. There are children who display the symptoms of

emotional disturbance, but are misidentified for appropriate support, increasing risk for further

challenges with development (Samuels, 2018). Children who present at least one or more of the

five characteristics within the IDEA’s criteria are considered to be emotionally disturbed. This

leaves a large percentage of children who are either overdiagnosed or misdiagnosed. Children

with emotional disturbance face challenges with self-regulation and have a difficult time

16
managing uncontrollable emotions. As a result, emotionally disturbed children might not

progress towards the social and cognitive development appropriate for their consecutive age. Not

only is social-emotional development threatened, but also psychosocial development which

might cause children to isolate, or form unhealthy coping habits. Music therapy was described,

and it was posited that it could serve as a valuable approach for improving emotionally disturbed

children’s social-emotional development.

Chapter II will review the research that has been conducted on emotionally disturbed

children’s social-emotional development. Treatment and treatment plans that have been used

with this population will be reviewed, and music therapy will be further described. Additionally,

Chapter II will analyze research studies conducted with music therapy and the

reconceptualization of social-emotional skills with emotionally disturbed children. Lastly, it will

acknowledge the benefits music therapy could provide for this population. Chapter III will

provide a creative and intricate description of music therapy treatment for emotionally disturbed

children. Chapter IV will examine the strengths and limitations of this project utilizing music

therapy as an approach, considerations for therapists and adults who support this population, and

recommendations for further research.

Definition of Terms

Active Music Therapy: Participating in singing, music composition, and instrument playing

(Coons & Montello, 1998).

Emotional Disturbance: “An inability to learn that cannot be explained by intellectual, sensory,

or health factors; an inability to maintain satisfactory interpersonal relationships; inappropriate

types of behaviors or feelings under “normal” circumstances; a general pervasive mood of

unhappiness or depression; a tendency to develop physical symptoms or fears associated with

17
personal or school problems” (IDEA, 2017, 300.8 [c] [4]).

Externalized Behaviors: Problem behaviors that are directed toward the external environment

(e.g., physical aggression, disobeying rules, cheating, stealing, and destruction of property) (Liu,

2004).

Internalizing Behaviors: Reflect a child’s emotional or psychological state and include

depressive disorders, anxiety disorders, withdrawal, or somatic complaints (Liu, Chen, & Lewis,

2011).

Music Therapy: “Music Therapy is an established health profession in which music is used

within a therapeutic relationship to address physical, emotional, cognitive, and social needs of

individuals” (American Music Therapy Association, 2005, para. 1).

Passive Music Therapy: Listening to live or recorded music (Coons & Montello, 1998).

Social-Emotional Development: “The ability to identify and understand one’s own feelings, to

comprehend emotional states in others, to manage strong emotions and their expression, to

regulate one’s own behavior, to develop empathy for others, and to establish and maintain

relationships” (National Scientific Council on the Developing Child, 2004, para. 2).

Trauma: An emotional response to a terrible event like physical, emotional, or sexual abuse,

neglect; or witnessing domestic violence (Vandenberg, 2013; Wasmer-Nanne, 2003).

18
 Chapter II

Review of the Literature

Children with emotional disturbance (ED) are challenged with complex disruptions in

their development that continue into adolescence and adulthood. Theoretical orientations

commonly used with this population include CBT and behavior management; while such

techniques have been shown useful, they lack a holistic perspective of the child (Halder &

Mahato, 2019). Therefore, further therapeutic interventions implemented with this population

will be discussed in this chapter. Music Therapy provides a creative medium that captures the

whole client while integrating essential treatment approaches for the client to practice

self-regulation skills and healthy forms of expression, as well as to set fundamental foundations

to support social-emotional development. Researchers have studied children with ED and the use

of music therapy and have found that music therapy is an evidence-based practice that addresses

emotional and social needs of individuals (American Music Therapy Association, 2005) .

Chapter II will cover the following topics: The characteristics/behaviors of children with

Emotional Disturbance, Factors that contribute to Emotional Disturbance, The Negative

Outcomes for Children with Emotional Disturbance, Therapeutic Interventions Implemented

With Children with Emotional Disturbance, Music Therapy, and Ways Music Therapy Supports

Social-Emotional Development in Children with Emotional Disturbance.

The Characteristics/Behaviors of Children with Emotional Disturbance

Understanding the characteristics, behaviors, and experiences of children with ED is

critical to serving them well (Wagner et al., 2005). Findings on this topic, both past and current,

generally confirm that children with ED exhibit maladaptive characteristics to a greater extent

than children without ED (Cullinan et al., 2003). In a study conducted by Cullinan et al. (2003),

19
the characteristics of children with ED and without ED were compared (pp. 99-101). Participants

were 884 elementary school-aged students in U.S. public schools; there were 336 students with

ED and 548 students without ED [or any other education disability]. Of the students with ED, 62

identified as girls and 274 identified as boys; of the students without ED, 260 identified as girls

and 288 identified as boys. Students involved in the study were African-American and

European-American. The procedure involved educators rating children with ED and without ED

using the Scales for Assessing Emotional Disturbance (SAED), which was designed to

operationalize the five quality characteristics of ED (Cullinan et al., 2003). Results indicated that

children with ED were higher in the following categories: inability to learn, relationship

problems, inappropriate behavior, feelings of unhappiness or depression, and physical symptoms

or fears (Cullinan et al., 2003). European American students with ED demonstrated relationship

problems and feelings of unhappiness or depression to a greater extent than the

African-Americans, while girls with ED exhibited more physical characteristics or fears than

boys (Cullinan et al., 2003). Cullinan et al. (2003) specified that social maladjustment in

preadolescent children with ED tends to present at high levels of antisocial behaviors (p. 101).

A significant limitation of this research is the need for more research on the ED

characteristics of more ethnicities (Cullinan et al., 2003). According to the authors, the U.S.

Department of Education collected data on a variety of variables about children with disabilities;

however, the agency needed to take action to obtain and present more detailed information

involving cross-tabulations of age, gender, race or ethnicity, and other important descriptive

variables about U.S. children with ED (Cullinan et al., 2003). Additionally, considering the

measurement limitations, variables could have been measured by other methods, such as

interviewing, target behavior recording, and objective personality testing (Cullinan, 2002).

20
Additional forms of rating scales and other raters, such as parents and children, could have also

been included in the study (Cullinan et al., 2003). Furthermore, in comparing studies involving

participants identified as children with ED, there is often ambiguity with how similar the

participants are across studies (Cullinan et al., 2003).

Wagner et al. (2005) conducted a study on the demographic characteristics of children

with ED and their households, along with their functional characteristics that provided context

for their ongoing school experiences (p. 79). The purpose of the article was to describe the

complex factors that assist in explaining the academic and social challenges children with ED

encounter in the school environment (Wagner et al., 2005). According to Wagner et al. (2005),

the education system is the only child-serving institution mandated to serve children (and youth)

with ED (p. 79). Considering children and household characteristics of ED, children with ED are

more likely than the general population to have several demographic characteristics that are

correlated with poor outcomes (Wagner et al., 2005). The Special Education Elementary

Longitudinal Study (SEELS) and the National Longitudinal Transition Study-2 (NLTS2) were

drawn to generalize all children with disabilities, including ED, who were in particular age

ranges and receiving special education services when the study began (Wagner et al., 2005).

SEELS consisted of children receiving special education who were 6 through 12 years of

age, and NLTS2 consisted of youth ages 13 through 16 years who were receiving special

education services (Wagner et al., 2005). Most of the measurement items that generated the data

reported were surveys or interview questions; parents responded to 11 items regarding their

children’s social interactions, 9 of which were drawn from the Social Skills Rating System

(SSRS) (Wagner et al., 2005). A second scale, measuring functional cognitive skills, was

composed of responses that provided an overall assessment by parents of the abilities of their

21
children with ED to manage everyday functions that require the cognitive ability to read, count,

and calculate (Wagner et al., 2005).

Results of the study indicated that across the school-age range, more than three-fourths of

children and youth classified with ED were boys; in both SEELS (ages 6-12) and NLTS2 (ages

13-16), African-Americans represented a significantly larger percentage of children and youth

with ED than was found in the general population; and children and youth classified with ED

were significantly more likely to live in households with several risk factors for poor outcomes

(Wagner et al., 2005). Furthermore, results specified that one-third of elementary and middle

school children classified with ED lived in a single-parent household; one-fourth of both age

groups classified with ED lived in households whose head was unemployed; and both age groups

of children with ED were more likely than their peers to live in a household that had the added

stress of another member who has a disability (Wagner et al., 2005). In regards to Functional

Characteristics of Children with ED in the research article (e.g., the life domains: the cognitive,

social, and communication skills of children and youth), the wide range of problems that

contribute disabling conditions as reported by parents of children with ED, included anxiety,

bipolar and Tourette’s disorders, depression, Obsessive-Compulsive Disorder (OCD),

oppositional behaviors, and psychosis (Wagner et al., 2005). Almost two-thirds of both

elementary and middle school children classified with ED were reported by parents to have

Attention-Deficit/Hyperactivity Disorder (ADHD) (Wagner et al., 2005). According to parents,

elementary and middle school children with ED had consistent and significantly lower social

skills, as well as in the subareas of self-control, assertion, and cooperation skills, on all measures

than their peers with other disabilities (Wagner et al., 2005). Furthermore, Wagner et al. (2005)

22
stipulated that 10.6% of elementary and middle school children with ED were reported by their

parents to have low functional cognitive skills (p. 85).

Factors that Contribute to Emotional Disturbance

Considering factors that contribute to emotional disturbance, it has been documented that

children from low-income families were more likely to suffer from chronic illnesses, mental

health problems, and disabilities than their privileged counterparts (Brooks-Gunn & Duncan,

1998; Brooks-Gunn, Duncan, & Klebanov, 1994). Studies have examined the effects of

neighborhood and family poverty on the home environment and discovered that neighborhood

poverty was associated with a poorer physical home environment and less maternal/(paternal)

warmth, factors that adversely affect children’s mental health (Klebanov et al., 1994). Gyamfi

(2004) conducted a study that examined the associations between poverty status, receipt of

public assistance, service use, and children’s mental health (p. 1129). She reviewed important

factors such as, the impact of welfare reform on children’s mental health and the effects of

low-income status on service use (Gyamfi, 2004). In regard to the impact of welfare reform on

children’s mental health, the federal welfare legislation, recognized as the Personal

Responsibility and Work Opportunity Reconciliation Act of 1996 (PRWORA), was the most

significant change in welfare policy the United States had initiated in decades, attributable to the

fact that it ended the federal guarantee of cash assistance to needy families (Gyamfi, 2004). The

PRWORA of 1996 was a comprehensive bipartisan welfare reform plan that dramatically

changed the nation’s welfare system into one that required work in exchange for time-limited

assistance (U.S. Department of Health and Human Services, 1996). According to Gyamfi (2004)

the federal entitlement to childcare assistance was no longer available, meaning placements such

as daycare or after-school programs for children with emotional and behavioral problems became

23
more difficult to access (p. 1131). Additionally, the eligibility requirements to participate in

Supplemental Security Income (SSI) had changed in legislation and significantly reduced

eligibility for children with mental-health needs, as children must present a higher level of

severity to qualify (p. 1131). Meaning, families with children with emotional disturbance may

not receive the assistance put in place, because the severity of their child’s emotional disturbance

was not serious enough to qualify for extra support such as child care subsidy. For example,

according to the Social Security Administration (SSA) (2021), symptoms/diagnosis must have

lasted, or be expected to last, at least 1 year or result in death. Additionally, a state agency makes

the disability decision; they will also ask for information from medical and school sources, and

other people familiar with the child’s conditions (Social Security Administration, 2021).

In regard to the effects of low-income status on service use, Gyamfi (2004) stated that

despite poorer health, children from low-income families were less likely to receive health care

services than children from more affluent families (p. 1131). The lack of consistency may be due

to less access to primary care or Medicaid, or the severity of the condition (Gyamfi, 2004). In

other words, resources put in place for children with mental health needs such as emotional

disturbance, could be hard to access for families because of the lack of acknowledgement by

health insurance in regard to the severity of mental health needs. As stated previously, the

purpose of Gyamfi’s (2004) study was to determine the effects of poverty level and receipt of

public assistance on child emotional/behavioral factors and service use among children with

mental-health needs (p. 1132). Data was obtained from the child and family outcome study

component of the National Evaluation of the Comprehensive Community Mental Health

Services for Children and their Families Program; the total sample of 9493 children was

primarily male (68%) around the age of 12, and 55% Caucasian (Gyamfi, 2004). About 65%

24
reported annual incomes at or below the poverty level (U.S. Department of Health and Human

Services, 2004). To examine the impact of low-income status and receipt of public assistance for

children’s mental-health outcomes, functional impairment and emotional/behavioral problems

were the two clinical variables that were examined (Gyamfi, 2004).

Logistic regression analyses were conducted to determine the association between

poverty status, receipt of public assistance, and child behavioral problems, while four separate

analyses were run to determine the effect of poverty status on children’s social and emotional

problems (Gyamfi, 2004). The results indicated that there were no significant associations

between poverty status and internalizing, externalizing, or total behavior problems, along with

child functioning (Gyamfi, 2004). However, according to Gyamfi (2004), significant associations

were found in the child’s age, race/ethnicity, caregiver education, Medicaid receipt, child and

family risk factors, and number of services received (p. 1134). Families with income below the

poverty threshold tended to have older children, to be non-white, to have caregivers with fewer

years of education, to receive Medicaid and Temporary Assitance for Needy Families (TANF)

benefits, to have fewer child risk factors, but more family risk factors, such as history of

domestic violence, mental illness, and substance abuse in the family (Gyamfi, 2004). Such

factors can play a role in contributing to emotional disturbance and affect the development of

children through their adolescence and adult years (Gyamfi, 2004).

Copeland et al. (2007) examined the developmental epidemiology of potential trauma and

posttraumatic stress (PTS) in a longitudinal community sample of children in 11 counties in

western North Carolina. A sample population of 1,420 children ages 9, 11, and 13 years at intake

were followed up annually through the age of 16 years old (Copeland et al., 2007). The authors

based their analyses on (a) psychiatric disorders, (b) potentially traumatic events and associated

25
PTS symptoms, and (c) risk factors (Copeland et al., 2007). Copeland et al. (2007) assessed the

areas using the Child and Adolescent Psychiatric Assessment (CAPA) (p. 578). Children were

interviewed as close as possible to their 9th, 11th, and 13th birthday, as well as annually until 16

years old, either at home or in a location convenient for them (Copeland et al., 2007). Parent(s)

and child were interviewed separately by the Department of Social Services staff (Copeland et

al., 2007).

According to Copeland et al. (2007), about 40% of children with any trauma history had

at least one other mood, anxiety, or disruptive behavioral/emotional diagnosis (p. 580). To test

the predictors of PTS symptoms in the presence of a traumatic event, the authors set four sets of

variables, which were entered into a model: (a) sex and current developmental period (ages 9-13

[childhood] versus 14-16 years [adolescence]); (b) previous emotional and behavioral disorders

(e.g., anxiety disorders, depressive disorders, and disruptive behavior disorders); (c) previous

negative events; and (d) previous environmental, family, and parental risk factors (Copeland et

al., 2007). Results indicated that previous environmental adversity, such as coming from an

impoverished or neglectful home, predicted further symptoms for internalized and externalized

behaviors between ages 14-16 years old (Copeland et al., 2007). The model suggested that age,

prior anxiety, and previous trauma were important considerations of trauma response and

emotional disturbance in the next year (Copeland et al., 2007). Copeland et al. (2007) indicated

that children exposed to trauma had almost double the rates of psychiatric disorders (e.g., any

anxiety, depression, and behavioral diagnosis) of those not exposed (p. 581). Additionally, higher

levels of PTS-related symptoms were associated with higher levels of psychiatric disorders with

rates of 52.6% and 59.5% for painful recall and subclinical PTSD (i.e., no recognizable clinical

findings) (Copeland et al., 2007). Co-occurrence was highest for affective disorders and lower

26
for substance use and disruptive behavior disorders (Copeland et al., 2007). Risk factors that

were speculated to influence trauma exposure were previous environmental adversity, parenting

problems, and history of depressive disorders. The authors identified that children displaying

PTS symptoms in response to trauma exposure were more likely to be older, to have a history of

exposure to trauma, as well as anxiety, and to come from an adverse family environment

(Copeland et al., 2007). Furthermore, higher levels of trauma were related to higher levels of

psychopathology, as well as maladaptive impairments in social-emotional development .

Limitations were not further discussed in the study.

Graves et al. (2007) examined factors associated with mental health and the juvenile

justice involvement among children with severe emotional disturbance. Previous research using

community samples had indicated that almost 46%-88% of children involved with the juvenile

system were diagnosed with a severe emotional disturbance (Lyons et al., 2001). Within Graves

et al. (2007) research, they examined the following factors: demographics (i.e., age, ethnicity);

person-level (i.e., anxious and/or depressed); family-level (i.e., number of transitions in living

situations); and school-level factors associated with being involved in the mental health and

juvenile justice systems (i.e., dual involvement). A total of 1,168 children participated in the

study. The study focused on European American and African American clinically-referred

children between the ages of 11 to 17 years; all children had at least one clinical diagnosis

(Graves et al., 2007). Graves et al. (2007) reported that children were referred to their local

community mental health program from a variety of sources (i.e., caregivers, child-serving

agencies), and trained evaluators conducted in-home interviews lasting 2 hours for caregivers

and 2 hours for children (p. 153).

27
 The measures utilized for this study included: a Demographic Information Questionnaire

(DIQ) that consisted of a 37-item caregiver reported questionnaire that measured child and

family characteristics (e.g., age, race, ethnicity, risk factors, family structure); The Child

Behavior Checklist (CBCL) and Youth Self Report (YSR), which measured person-level factors;

the Caregiver Strain Questionnaire (CGSQ) to assess family-level factors; and the Child and

Adolescent Functional Assessment Scale (CAFAS) to measure school-level factors (Graves et

al., 2007). The results indicated that among the 1,168 participants, 545 disclosed that, in addition

to being involved in the mental health system, they also were involved with the juvenile justice

system, while 623 were not involved. According to Graves et al. (2007), tests indicated that

among these children, girls had significantly higher levels of impairment compared to boys,

suggesting that the mental health status among girls involved in the juvenile system is more

severe than the mental health status of boys in the system. The findings also illuminated that,

children who were older and had had more transitions in their living situations were more likely

to face challenges with their mental health due to instability and lack of caregiving (Graves et al.,

2007). In regard to person-level factors, the results indicated more peer rejection and isolation

rather than social problems, which were more related to deviant peer association (Graves et al.,

2007). Lastly, levels of school functioning were not related to an increased likelihood of

becoming dually involved in both systems. Graves et al. (2007) suggested that future research

would benefit from looking into the possible influences of ethnicity, SES, and system policies in

relation to the mental health of children and the juvenile justice system (p. 163).

The Negative Outcomes for Children with Emotional Disturbance

Siperstein et al. (2011) conducted a study over a 2-year period where 86 children were

drawn from the following three subgroups: children with ED receiving special education in

28
low-income schools, children with ED receiving special education services in high-income

schools, and children not receiving special education services but who were considered high risk

for ED (p. 172). Participants with ED were from elementary schools in the Boston area (public

schools were not included in the study) and consisted of 61 elementary-age students receiving

special education services for ED (35 students with ED from 8 low-income elementary schools,

and 26 students with ED from 12 high-income schools), along with 25 students at risk for ED not

receiving special education services, from one of the 8 low-income schools (Siperstein et al.,

2011). According to Siperstein et al. (2011), general education teachers in participating schools

were asked to identify at-risk students in their classrooms by distinguishing the most externalized

and internalized behaviors in the classroom (p. 175). Outcome measures included reading and

math achievement, as well as ratings of behavioral progress. Measures of academic achievement

consisted of two math subtests and two reading subtests of the Woodcock Johnson III; teachers

rated students behavior using the Social Skills Rating System-Teacher Version and the Critical

Events Index to indicate the frequency of problem behaviors (Siperstein et al., 2011).

The results of the study indicated that children in the low-income schools receiving

special education for ED were significantly behind children from the other two sub-groups in

academics and pro-social behavior, and the scores did not significantly change over the year

(Siperstein et al., 2011). Children at risk for ED in low-income schools were to some degree

below children with ED in high-income schools for academic achievement; these children also

did not make any statistically significant gains in academic achievement over the course of the

year (Siperstein et al., 2011). Ultimately, children with, or at risk for, emotional disturbance did

not appear to show any noticeable progress over a year’s time (not including the high-income

schools) (Siperstein et al., 2011). Furthermore, for students with ED receiving special education,

29
Siperstein et al. (2011) found substantial differences by school income in placement patterns and

related services; students with ED in low-income schools were served in separate settings (e.g.,

special day class instead of included in the mainstream classroom), while students with ED in

high-income schools were mostly served in full or limited inclusion programs (p. 180).

Siperstein et al. (2011) also established a relationship between school context and related

services in that students with ED in low-income schools received less counseling, social skills

training, speech therapy, and occupational therapy than students with ED in high-income schools

(p. 180). Lastly, students with ED in low-income schools also received more discipline in regard

to behavior, than their counterparts (Siperstein et al., 2011).

Bradley et al. (2008) conducted a meta-analysis regarding the identification of children

with emotional and behavioral disorders (EBDs). The article discusses services that children with

EBD receive and their outcomes (Bradley et al., 2008). The authors examined the Special

Education Elementary Longitudinal Study (SEELS), the National Longitudinal Study-2

(NLTS2), and the National Adolescent and Child Treatment Study (NACTS) by Wagner et al.

(2005), Blackorby et al. (2003), and Walker and Tullis (2004). The literature review presented a

comprehensive picture of issues relevant to students with emotional and behavioral disorders

(EBD) (Bradley et al., 2008). The SEELS study focused on students with EBD as they moved

from elementary to middle school, while the NLTS and NLTS2 studies focused on high school

students with EBD as they transitioned into early adulthood (Bradley et al., 2008). Bradley et al.

(2008) stated that the review attempted to highlight the need for a comprehensive and focused

effort tailored toward improving outcomes for children with EBD (p. 5). Data from the NLTS2

and the SEELS showed that students with EBD experienced negative disciplinary and behavioral

outcomes twice as often as other students (Bradley et al., 2008). The SEELS data also showed

30
that children with emotional disturbances had a dramatic increase overtime (33%) in disciplinary

trouble at school (i.e., suspension, expulsion), being fired from a job, or being arrested

(Blackorby et al., 2003; Wagner et al., 2005). According to Bradley et al. (2008), data from the

NLST-2 and NACTS indicated that post-school outcomes for students with EBD have been

concerning; many students have challenges developing the behavioral and social skills to adjust

to adult life (p. 13). Such difficulties to develop social-emotional skills were suggested to

contribute to students’ difficulties in employment, postsecondary education, personal

relationships, and their high rate of involvement with the justice system (Bradley et al., 2008).

Socially, the NACTS study found sizable deficits in social and adaptive behavior in its

sample, specifically low levels of social interaction and disconnection from the community

among students with EBD (Wagner et al., 2005). The NACTS study by Wagner et al. (2005) also

found that two-thirds of the sample had some type of contact with law enforcement, and 43%

had been arrested at least once. Additionally, research by Walker and Tullis (2004) identified that

the consequences of these outcomes had a widespread impact that posed significant costs both

personally and economically (Walker & Tullis, 2004, as cited in Bradley et al., 2008). Bradley et

al. (2008) suggested that there is a continued need for data that will further support the

emotionally disturbed population (p. 19). The results of the longitudinal studies demonstrated a

limitation in the services that have been provided to students with EBD and indicated a

continued need to improve such services (e.g., mental health services, financial support) (Bradley

et al., 2008).

Wagner and Newman (2012) considered the changes in the longitudinal transition

outcomes of youth with emotional disturbances, which they conducted in 1990, 2005, and 2009

(p. 199). The authors provided two perspectives on the transition outcomes using data from the

31
National Longitudinal Transition Study (NLTS) and the National Longitudinal Transition

Study-2 (NLTS2) (Wagner & Newman, 2012). The first perspective compared two cohorts of

youth ages 18-21 who had been out of high school up to 4 years (1990 and 2005) and their rates

of high school completion, post-secondary education enrollment, employment, independent

living, and criminal justice involvement (Wagner & Newman, 2012). The second perspective

provided similar information from the final wave of NLTS2 data collection (2009), when the

same participants were ages 21-25 (Wagner & Newman, 2012). Results indicated that a higher

increase of students with ED had serious academic deficiencies, and one-third of high school

completers did not receive a regular diploma, but a certificate of completion, GED, or “other

nonstandard school-leaving document” (Wagner & Newman, 2012). By 2009, 53% of young

adults with ED had been enrolled in postsecondary education at some time and still represented a

significantly lower rate of enrollment than in the general population of same-age youth (Wagner

& Newman, 2012). In regard to independent living there was no significant difference for youth

in 1990 and 2005; the rate of independent living was higher among adults with ED who had been

out of high school up to 8 years in 2009 (Wagner & Newman, 2012). However, there was a large

increase in the percentage of youth with ED who were reported to have been arrested between

1990 and 2005 from about 36% to 60.7% (Wagner & Newman, 2012). Furthermore, Wagner and

Newman (2012) indicated that among young adults with ED in 2009, 60.5% had been arrested,

and 44.2% had been on probation or parole (p. 205). Lastly, employment rates had declined in

2005 since 1990, falling significantly below the general population rate, while young adults with

ED out of high school up to 8 years showed employment instability (Wagner & Newman, 2012).

32
Therapeutic Interventions Implemented with Children with Emotional Disturbance

Sinha and Kumar (2010) conducted a study to evaluate the usefulness of

Mindfulness-based Cognitive Behavior Therapy (MCBT) for the treatment of emotional

problems in a sample of adolescents affected by HIV/AIDS, yet to be diagnosed with ED who

expressed internalized and externalized behaviors that impaired social functioning (p. 19).

Twelve children ages 13-16 years (7 male and 5 female), living with HIV positive parents, were

the participants of a 12-week intervention (Sinha & Kumar, 2010). At baseline and

post-treatment, assessments were conducted with the help of self-report and teacher-report

measures (Sinha & Kumar, 2010). In order to demonstrate the efficacy of MCBT, Sinha and

Kumar (2010) focused on: Internalizing problems, measured by Youth Self-Report (YSR);

Depression, measured by Children’s Depression Inventory (CDI); Anxiety, measured by Revised

Children’s Manifest Anxiety Scale (RCMAS); Hopelessness, measured by Hopelessness Scale

for Children (HSC); Social and interpersonal competence, measured by Interpersonal

Competence Scale (ICS-T); and Perceived academic stress, measured by Scale for Assessing

Academic Stress (SAAS) (p. 21).

The procedure of the study included a baseline assessment, completed in two sessions,

where all 12 subjects were assessed individually by clinical psychologists (Sinha & Kumar,

2010). Participants were kept in two groups according to gender, and 12 sessions of Mindfulness

Cognitive Behavior Therapy (MCBT) were held in group settings once a week, each session

lasting for 85 minutes (Sinha & Kumar, 2010). According to Sinha and Kumar (2010), the first

20 minutes were for mindfulness practice, and the remaining time was used for CBT intervention

with 5--minute breaks between each intervention (p. 23). Mindfulness practice included

discussion on the power of mind and awareness of how powerful the mind can be, the practice of

33
meditation guided by the trainer, and mindfulness exercises for self-awareness and self-control.

The CBT intervention followed Beck's model (Sinha & Kumar, 2010). Post therapy assessment

was completed after the termination of therapy (Sinha & Kumar, 2010).

The results indicated that more than 80% experienced a clinically significant decrease in

their emotional problems after therapy (91% to 83% ), as well as a significant reduction in the

‘T’ scores: Pre-therapy T scores of 64.80, to post-therapy T scores of 58.0, of the Children’s

Depression Inventory (CDI) scales (Sinha & Kumar, 2010). At the beginning of the study,

participants reported more social and psychological symptom profiles of anxiety as compared to

physiological symptoms; post-therapy scores later indicated significant reduction in anxiety

symptoms (Sinha & Kumar, 2010). In each of the remaining categories that were assessed in the

study--Hopelessness, Perceived Academic Stress, and Social & Interpersonal Competence--

there were significant differences between pre- and post- scores in that participants indicated

improvement in academic performance, enhanced social affiliation, and reduction in

hopelessness and internalization of emotional feelings (Sinha & Kumar, 2010). There was no

further discussion of limitations and strengths of the study.

Benner et al. (2010) conducted research on the impact of intensive positive behavioral

supports on the behavioral functioning of students with emotional disturbance. The two purposes

of the pre-post naturalistic research design were the following: (a) Investigate the impact of

Positive Behavioral Intervention and Supports (PBIS) on the behavioral functioning of students

with ED served in classroom settings (b) and to examine the extent to which teacher fidelity of

PBIS implementation influenced student changes in behavioral functioning over the school year

(Benner et al., 2010). Measures used in this research included the Child Behavior Checklist-

Teacher’s Report Form (CBC-TRF) to measure the behavioral functioning (e.g., difficulty

34
following direction, disturbing other pupils, and disrupting class discipline) of participants, and a

modified version of the Teacher Knowledge and Skills Survey (TKSS) to ascertain fidelity of

PBIS implementation (Benner et al., 2010). Participants included 37 public school students (29

males and 8 females) receiving special education services for ED in an urban northwestern city,

between the ages of 7 to 16 years, as well as eight teachers (Benner et al., 2010). Benner et al.

(2010) reported that at the beginning of the study, all participating teachers had been

implementing PBIS for at least 2 years (p. 87).

In regard to the study’s procedure, all eight ED teachers (e.g., Special Education teachers

responsible for the instruction of all subjects) received 20 2-hour training sessions in Positive

Behavioral Intervention and Support (Benner et al., 2010). Training began with positive

classroom management interventions, including the teaching of behavioral expectations and

replacement behaviors (Benner et al., 2010). Training also included assessing functions of

behavior, developing positive behavior intervention plans precisely linked to the functions of

behavior, identifying and implementing research-based practices in the area of PBIS, and

designing data collection procedures to inform instructional decisions (Benner et al., 2010).

Results of the first finding stipulated that PBIS was correlated with the behavioral functioning of

students with ED in that statistically significant reductions were found in the pre- and post-test

scores of students on the Teacher Report Form (TRF) symptom scores of thought problems,

attention problems, and aggression (Benner et al., 2010). Furthermore, there were significant

reductions in the number of students who met the standard for clinically notable internalizing and

externalizing behavior problems, and total behavior problems were found in acting, thinking,

feeling (Benner et al., 2010). Benner et al. (2010) reported that such data indicated that PBIS

appeared to play an essential role in improving the behavioral functioning of students with ED

35
(p. 94). Results of the second finding suggested that teacher fidelity to the structure and process

of PBIS played a significant role in reducing problem behaviors (Benner et al., 2010). Such

findings demonstrated that the professional development activities were able to successfully

build the capacity of teachers, which resulted in improved children behavior outcomes (Benner et

al., 2010). However, Benner et al. (2010) reported that shortages of well-prepared teachers made

professional development crucial (U.S. Department of Education, 2002, as cited in Brenner et al.,

2010).

Benner et al. (2010) reported that the study had several limitations beginning with the

research design (p. 95). It was suggested that future researchers should use higher quality designs

that include regression, discontinuity, or randomized experimental designs (Benner et al., 2010).

Additionally, the participants in the study did not demographically represent the general

population, along with the mean participant age (13.2 years), which was an overrepresentation of

older students (Benner et al., 2010). Furthermore, the study should have incorporated other

measures of student behavior, including self-assessment, parent-assessment, and observation

(Benner et al., 2010). Benner et al. (2010) also reported implications for the challenge of moving

PBIS to practice (p. 95). The authors referenced Cook et al. (2003) in regard to the services, that

if not used with adequate amounts of treatment (e.g., amount to achieve a desired therapeutic

effect), then approaches could be delivered ineffectively or counterproductively (as cited in

Benner et al., 2010).

In a wait-list control study conducted by Swain et al. (2019), they examined the response

to group CBT in terms of individual-level change in young children with Autism Spectrum

Disorder (ASD) (p. 1). The study measured ASD characteristics using the Social Responsiveness

Scale second edition (SRS-2); Negative affect measures where parents reported on their child’s

36
negative affect using the Liability/Negativity (LN) subscale of the Emotion Regulation Checklist

(ERC); Confidence in managing anger/anxiety where parents completed four questions on a

10-point Likert scale to assess confidence in their ability to manage their child’s anger/anxiety;

Cognitive functioning using the Kaufman Brief Intelligence Test second edition (KBIT-2); and

Treatment evaluation where parents completed a questionnaire on their perceived satisfaction

and usefulness of the treatment and its components after participating in the Stress and Anger

Management Program (STAMP) (Swain et al., 2019). Participants included 18 children (16 boys;

2 girls) between the ages of 5 and 7 years with high functioning ASD, and at least one parent of

each child. The children were not language impaired and were able to tolerate a group setting

(Swain et al., 2019).

Parents completed the SRS-2 prior to treatment and the ERC, confidence scales, and

Behavioral Monitoring Sheets before and after treatment (Swain et al., 2019). Both children and

parents participated in nine hour-long, separate, weekly group sessions led by trained master’s or

doctoral level clinicians (Swain et al., 2019). Swain et al. (2019) reported that each child group

session included stories, interactive lessons, and singing, with session components focusing on a

specific topic that offered strategies to understand and better manage anger/anxiety (p. 6). Parent

group sessions consisted of clinicians holding discussions on session material (e.g., treatment

goals, coping skills, behavior management), home assignments (e.g., behavior chart, personal

goals, journal writing) and issues around applying treatment strategies to other settings (e.g.,

school, supermarket, group settings) (Swain et al., 2019). A child was classified as a “treatment

responder” if they met at least two of the following four criteria: (a) statistically significant

post-treatment decrease in Liability/Negativity (LN) applying the RCI (Reliable Change Index);

(b) greater than 20% decrease in average intensity of outbursts; (c) greater than 20% decrease in

37
frequency of outbursts; or (d) greater than 20% decrease in average duration of outbursts (Swain

et al., 2019).

Results indicated that 12 child participants were classified as treatment responders; nine

of the treatment responders were classified based on a reliable change in RCI and significant

decreases in at least one behavioral monitoring measure (Swain et al., 2019). However, three

treatment responders did not show a significant change in LN but demonstrated a 20% or greater

decrease in at least two behavioral monitoring measures (Swain et al., 2019). Swain et al. (2019)

expressed that within the group of eight parents who endorsed significant decreases in intensity

of their child’s emotional outbursts, five also reported a reduction in episode duration (p. 7).

Parents in the study also observed an increase in changes in their own emotional regulation and

patience, and they identified ways to bridge the gap between the therapy room and the classroom

(Swain et al., 2019). There were specific difficulties with generalization of skills, little indication

of occasional use of the coping strategies by the child, and responses that the program should

have been more tailored to each child’s individual needs (Swain et al., 2019). While almost 70%

of the children responded to treatment, the authors also observed substantial room for

improvement (Swain et al., 2019). Results relied solely on parent-reported information, which

again limited generalizability outcomes (Swain et al., 2019). Swain et al. (2019) concluded that a

better understanding of the parents and children who responded best to treatment would increase

the knowledge of who could benefit from this treatment in a clinical setting, and how it could be

modified for other potential subgroups (p. 9).

38
Music Therapy

Research and clinical evidence have suggested that music therapy can assist children in

reaching their Individualized Education Plan (IEP) goals (Yinger, 2018). In order to better

support emotionally disturbed children, the study of how the brain functions with music and

exploring techniques and strategies involving music therapy can be used as a therapeutic strategy

to improve social-emotional development (Yinger, 2018). Music therapy is an evidence-based

practice with the use of music interventions to meet goals within a therapeutic relationship to

address physical, emotional, cognitive, and social needs of individuals (American Music Therapy

Association, 2005). The music therapists’ intention is to determine which music therapy

approaches are effective in the reconstruction, maintenance, and improvement in mental and

physical health (American Music Therapy Association, 2005). Music therapy involves the use of

active and passive therapy, where instruments can be played during sessions (active) or music

may be listened to (passive) to reflect on tone, lyrics, or emotion in a musical piece (Coons &

Montello, 1998). Sessions involve the client using instruments and their voice to explore the

world of sound, while the therapist supports the clients’ response through improvised music

(American Music Therapy Association, 2005).

The various types of music therapy include: Guided Imagery and Music: the purposeful

use of prepared music by a therapist to evoke sensory and emotional responses in the listener

(Beyers, 2016, p. 39); Nordoff-Robbins Music Therapy: based on the belief that everyone

possesses a sensitivity to music that can be implemented for personal growth (Beyers, 2016,

p.40); Free Improvisation Therapy: free use of music, using instruments and voice to

maintain/improve health (Beyers, 2016, p. 19); Neurological Music Therapy: based on the

scientific knowledge of music perception and the effects of the treatment on nonmusical brain

39
and behavior functions (Thaut, 2005, p. 126); Resource-Oriented Music Therapy: emphasizes the

development and stimulation of individual’s strengths rather than the reduction of symptoms

(Schwabe, 2005, p. 50); Education-Oriented Music Therapy: the use of music activities to foster

the development of motor, communication, cognitive, and social abilities (Chong & Kim, 2010,

p. 193) ; and Community Music Therapy: an approach to working musically with people in

context (e.g., acknowledging the social and cultural factors of their health) (Pavlicevic, 2012;

Stige, 2010).

Ways Music Therapy Supports Social-Emotional Development in Children with Emotional

Disturbance

Chong and Kim (2010) examined how an after-school Education-oriented Music Therapy

(EoMT) program can impact children’s emotional and behavioral problems as well as academic

competency. A 16-week music therapy program using music activities and interventions to

promote academic, social, and emotional skills was implemented with this study (Chong & Kim,

2010). Gresham and Elliott's (1990) Social Skills Rating System (SSRS) was also utilized to

measure social skills, academic competency, and problem behavior (Chong & Kim, 2010). To

identify change in such areas, the SSRS was administered before and after the EoMT program to

assess students’ problem behaviors and interpersonal skills (Chong & Kim, 2010). The study

took place over 6 months (16 weeks), with sessions occurring twice a week and lasting 50

minutes each (Chong & Kim, 2010). A total of 89 elementary students who were identified as

having social and emotional problem behaviors by the SSRS and from 13 different schools, who

did not have any prior music instruction were selected to participate in the study (Chong & Kim,

2010). According to Chong and Kim (2010) participants were placed into three groups of four to

six students by grade: grades 1 and 2 were combined into one group, as well as grades 3 and 4,

40
and grades 5 and 6 were in one group (p. 191). Eight music therapists provided sessions for all of

the participants and met on a weekly basis to discuss the appropriateness of music interventions

for meeting the established therapeutic and educational goals (Chong & Kim, 2010).

Education-oriented Music Therapy (EoMT) was developed to initially address children’s

social and emotional problems, and then to reinforce learning skills essential in musical tasks and

transfer such skills to non-musical or academic subject matter (Chong & Kim, 2010). Each

session plan articulated educational goals and therapeutic goals with a rationale of why the

presented intervention and musical material would meet such goals (Chong & Kim, 2010). The

structure of each session included an opening activity that invited participants to the musical

experience and established a common ground for the main activity, a main activity where music

therapists and students engaged in sequenced musical activities targeting non-musical goals; and

a closing activity that included participants sharing musical challenges and a sense of

achievement in the activity that could be transferred to other non-musical tasks (Chong & Kim,

2010). Chong & Kim (2010) reported that the main activities of sessions were formulated to

utilize cognitive skills to understand the musical process and playing, and at the same time get in

touch with the emotional and social aspects of the intervention (p.193). With each session plan,

music therapists made appropriate adaptations and extensions to accommodate individual

differences within each group (Chong & Kim, 2010).

Results indicated that EoMT was effective in enhancing social skills and bringing about

appropriate behavioral changes (Chong & Kim, 2010). There were also increased changes in the

students’ assertiveness, self-control, and level of cooperation, due to the various roles and

interactions facilitated by the music activities, which supported positive changes in the ways

students worked together to achieve common goals related to music-making (Chong & Kim,

41
2010). Furthermore, results suggested that students who exhibited externalized behavior

problems were able to reduce acting-out behaviors through musical experience, and students

with internalized behavior problems were able to express themselves more outwardly (Chong &

Kim, 2010). Music therapists also indicated that students who had externalized behaviors had an

increase in musical participation, proposing that their impulsive energy was channeled into

purposeful musical behavior, such as percussive playing and singing, while students who had

internalized behaviors learned to be more expressive (Chong & Kim, 2010). On the other hand,

results indicated that there was no visible positive change in academic competence, perhaps due

to the possibility of the implementation period being too short (Chong & Kim, 2010). Therapists

also reported that assisting with academic support was out of their scope and implementing

educational support would have supported academic competency for the students (Chong &

Kim, 2010).

Porter et al. (2017) examined the efficacy of Free Improvisation in clinical practice. Two

hundred and fifty-one child and parent dyads from six Child and Adolescent Mental Health

Service community care facilities in Northern Ireland were randomized to 12 weekly sessions of

community music therapy plus regular therapy (Porter et al., 2017). Follow-up occurred at 13

weeks and 26 weeks (Porter et al., 2017). Child participants were between 8-16 years old with

social-emotional, behavioral, and developmental difficulties; about 41% of participants were

from single-parent families, and 32% were from families where neither parent was employed

(Porter et al., 2017). Measures implemented in this study were communicative and interactional

skills, as measured by parental and self-reporting of the Social Skills Improvement System

Rating Scales (SSIS) at week 13 (Porter et al., 2017). The secondary outcomes included

communicative and interactional skills at week 26, self-esteem, and depressive symptoms were

42
measured using the Center for Epidemiological Studies Depression Scale for Children

(CES-DC), social functioning measured using the Child Behavior Checklist (CBC), and family

functioning assessed using the Family Assessment Device completed by the parent (Porter et al.,

2017).

Participants were randomly assigned to the control group, which received regular therapy

only (“usual care” group), and consisted of psychiatric counseling and/or medication (the dose

and frequency deemed as appropriate). In addition to usual care, patients assigned to the

experimental group received the Alvin model of Free Improvisation (Porter et al., 2017). Porter

et al. (2017) explained that improvisation encourages individuals to create music and sound

freely through voice, instrument, or movement, while receiving support and encouragement

specifically to suit their needs as assessed by their therapist (p. 587). Instruments used in this

study consisted of the guitar, xylophone, keyboard, and drums, and patients had the opportunity

to make personalized CDs (Porter et al., 2017). Sessions were delivered individually,

face-to-face, in a private room for 12 weeks and lasted 30 minutes (Porter et al., 2017).

Participants also received three assessment sessions before treatment objectives were discussed

and established with the music therapist (Porter et al., 2017). After discussion, all music therapy

sessions were led by the participant who was invited to choose an instrument to express how they

were feeling that day and the previous week; each session ended with a verbal or musical

reflection on the session and a plan made for the following week (Porter et al., 2017).

Results indicated a small but clinically significant effect for improved communication

and interaction skills for participants aged 13 and over in the intervention group as compared to

the control group (Porter et al, 2017). At week 13, self-esteem was significantly improved, and

depression scores were significantly lower in the intervention group when compared to the usual

43
care group therapy only group (Porter et al., 2017). At week 26, social functioning was also

significantly improved in the intervention group and a slight improvement in family functioning

as well (Porter et al., 2017).

Limitations of this study included short session times. Porter et al. (2017) reported that if

session times were longer there might have been a higher increase in both primary and secondary

outcomes (p. 591). Additionally, results indicated a need for further studies targeted at specific

disorders (Porter et al., 2017). Lastly, outcome measures were all based solely on parent and

patient reports, while other outcomes such as behavioral observations were by a clinician. More

observations would have helped strengthen the study (Porter et al., 2017).

Levy et al. (2021) examined the effects of a community-based intervention implementing

a hip hop framework with youth who had experienced trauma. Hip hop interventions have been

found by several clinicians to be valuable in increasing individual engagement, fostering a

deeper understanding of experiences, and supporting clients’ communication and interpersonal

skills (Travis & Deepak, 2011, as cited in Levy et al., 2021). This research brought about hip hop

and spoken word therapy (HHSWT), an approach to counseling where students engage in

previously validated counseling interventions through the process of writing, recording, and

performing hip hop music (Levy, 2012). Interviews were conducted with willing participants and

used to measure and collect data for the study (Levy at al., 2021). According to Levy et al.

(2021), the interview guide was developed by the first author to prompt discussion around

participant experiences, including perceptions of what they learned in the program, as well as

what they identified as important to them (p. 7). Interviews ranged from 10-30 minutes and were

conducted by the first and second authors, and then transcribed verbatim (Levy et al., 2021).

Participants were youth at the Boys & Girls Club who displayed internalized and externalized

44
behaviors. However, there was no further information regarding geographic location or age of

participants, but the number of participants ranged from 6 to 12 in each session (Levy et al.,

2021).

Once a week, for 10 weeks, participants engaged in one, 90-minute session that explored

one of the topics suggested by the participants (e.g., the struggles in life) (Levy et al., 2021).

Discussions between participants lead to the development or realization of experiences that they

perceived as difficult or needing to get through (Levy et al., 2021). The topics chosen and the

songs implemented to represent them were utilized to guide choreography and lyric writing in

sessions (Levy et al., 2021). Every week the session began with 5-minute check-ins, where

participants discussed likes and dislikes from the prior sessions and what they wanted to discuss

that day (Levy et al., 2021). In the first part of the session, participants were given 15-20 minutes

to watch a music video that group facilitators selected based on the comparison between the

video content and the identified session topic (Levy et al., 2021). Afterward, participants were

given the space for reflection on the weekly theme and their own lives (Levy et al., 2021).

Participants were then divided into a lyric writing group and a dance group with the same

instrumentals, then asked to create specific dance movements and/or lyrics that represented the

weekly topic (Levy et al., 2021). Within the lyric group, participants worked closely with the

principal investigator (PI), while the dance group worked with two graduate assistants (GA);

both asked their group follow-up questions regarding underlying thoughts and emotions that

included further exploration (Levy et al., 2021). The last 5-10 minutes of each group were

brought together for a group close-out and provided the space for participants to process their

group experiences by discussing the process with other group members or participating in

self-reflection through writing in journals (Levy et al., 2021). Levy et al. (2021) left space for

45
each group to share their work with the rest of the group and tell their peers what the verse or

movement was about, which opened up further discussion (p. 6).

Results identified that participants developed social or emotional skills with the HHSWT

program, and the authors suggested that participants experienced improved confidence, stepped

outside of their comfort zone, and had the ability to process difficult emotions verbally with

others (Levy et al., 2021). Additionally, results indicated that participants were able to share and

learn from others and value that the space was safe and judgment free, while feeling pride in

their community (Levy et al., 2021). Participants expressed learning new skills they did not

possess before, which influenced improvement in self-confidence, along with managing

challenging tasks within a group (Levy et al., 2021). Furthermore, participants expressed the

ability to process difficult topics in a verbal way, as well as forming healthy relationships with

others and managing conflict-ridden situations (Levy et la., 2021). In general, the study indicated

that hip hop elements supported participants in disclosing emotions, and identifying deeper

emotional self-awareness (Levy et al., 2021).

Summary

Chapter II provided a thorough look at research findings on the characteristics of children

with emotional disturbance. Understanding the characteristics and behaviors of children with ED

is critical to serving them well (Wagner et al., 2005). Furthermore, factors that contribute to

emotional disturbance included poverty and trauma in childhood ( Copeland et al., 2007;

Gyamfi, 2004). As a result, the negative outcomes of children with emotional disturbance are at

high-risk for academic challenges, negative disciplinary and behavioral outcomes, as well as

involvement with law enforcement (Wagner & Newman, 2012). Common therapeutic

interventions implemented with children with emotional disturbance include, mindfulness-based

46
CBT and Positive Behavioral Intervention and Supports (PBIS) (Benner et al., 2010; Sinha &

Kumar, 2010). The chapter also described the theoretical orientation of music therapy. The

American Music Therapy Association (2005) was referenced to identify how music therapy is an

evidence-based practice with the use of music interventions to meet goals within a therapeutic

relationship to address physical, emotional, cognitive, and social needs of individuals. The use of

Education-oriented Music Therapy (EoMT) was implemented to describe the ways in which

music therapy supported social-emotional development with children with emotional

disturbances (Chong & Kim, 2010). Porter et al. (2017) also implemented free improvisation, the

use of instruments and voice, to examine the efficacy of music therapy in clinical practice with

emotionally disturbed children. Lastly, the use of Hip-Hop and Spoken Word Therapy (HHSWT)

was examined to identify the effects of a community-based intervention with youth who had

experienced trauma, and results indicated that participants developed deeper social-emotional

skills, as well as improved confidence (Levy et al., 2021).

Chapter III will describe a hypothetical case study of a group of four to six children in

upper elementary grades, with emotional disturbance undergoing Music Therapy treatment.

Chapter IV will identify the strengths and limitations of this project, further therapeutic

considerations for treating clients with ED, and recommendations for future research.

47
 Chapter III

Application

Chapter I presented the symptoms, contributing factors, consequences, and definitions

associated with children with emotional disturbance. Included was the treatment commonly used

with emotionally disturbed children, which is Cognitive Behavioral Therapy (CBT).

Furthermore, it provided information on the use of music therapy and how it has been

implemented to support vulnerable populations such as children with emotional disturbance.

Chapter II reviewed the literature on the characteristics and behaviors, as well as the

negative outcomes, of children with emotional disturbance. Researchers found that children with

emotional disturbance have greater challenges with peer interactions, an inability to learn,

display inappropriate behavior, and have feelings of depression (Cullinan et al., 2003). Research

outcomes for this population have identified that they are at high risk for incarceration (Wagner

& Newman, 2012). Children with emotional disturbance are more likely to have higher

disciplinary trouble in school than their peers (i.e., suspension, expulsion) (Blackorby et al.,

2003; Wagner et al., 2005). Chapter II also described the implementation of music therapy and

its potential benefits in supporting emotionally disturbed children’s social-emotional needs.

This chapter will characterize a therapeutic, psychoeducational group called, “Sweet

Emotion”, for fourth and fifth grade students with emotional disturbance who either have an

Individual Education Plan (IEP) or students without an IEP who have serious externalized and

internalized behaviors. The intervention is grounded in active and passive music therapy and will

be guided by Education-oriented Music Therapy (EoMT) (Chong & Kim, 2010). Incorporated in

this chapter are the setting and structure of the group, the selection of group members, the

program approach, and a detailed 8-week program application.

48
Setting and Structure

This therapy group will take place in a school setting such as a classroom or enclosed

space necessary for the group. The classroom will need a projector and a whiteboard. There will

also need sufficient space for movement. In the classroom, there will be a circular rug with

musical designs and bean bag chairs for group members to sit in. Around the rug, bean bag

chairs will be spaced between members to keep from physical distraction from one another (e.g.,

touching, kicking). To avoid altercations, bean bag chairs will be the same color.

Boys and girls ages 9-11, or in the 4th and 5th grades, will be piloted for this counseling

project. A credentialed music therapist will facilitate the group. There will be no more than eight

students in a group. The group will be 8 weeks long with 50-minute sessions each week, along

with individual check-ins once a week prior to group sessions. Each session will begin with a

group check-in and review of group agreements; a lesson to encourage thinking and expression;

an activity to support relational skills; and a debrief of the group session. Following the initial

session, there will be two sessions on each theme. Session one will provide psychoeducation

regarding the overall theme to familiarize students with the appropriate language to express

themselves, and the second session will continue to implement what was learned the week prior

with psychoeducation on music and the implementation of music therapy interventions. To

support consistency and trust, the group will be closed, and no new members will be admitted

after the initial group session.

Selection of Group Members

The selection process of the group members will first involve a consultation between the

counselor and teachers who have students with emotional disturbance on an IEP, as well as

emotionally disturbed students who do not qualify for an IEP, but display a high level of

49
externalized and internalized behaviors. Prior to the consent form being sent home for the

selected students, the counselor will call the parent(s)/guardian(s) to inform them that a consent

form will be sent home to sign (Appendix A). After obtaining parental consent, the counselor

will hold a brief meeting with recommended students and present what the group is about. The

counselor will explain that the group is for 4th and 5th graders to understand their emotions and

experiences, gain a better understanding of themselves, and form healthy relationships through

the art of music. The counselor will also explain the benefits of music. Following the

presentation, students can express interest in the group by completing a 3-question survey

(Appendix B). The survey will establish students' awareness of what the group is about, their

interest in the group, and their reasons for wanting to participate. Surveys will be collected and

reviewed with the teachers of the students who completed the survey. Teachers will be included

in the screening process with the counselor in order to identify which students would most

benefit from the group. Once students have been chosen, the counselor will meet individually

with chosen students and review their survey together to establish rapport and gain further

understanding of their interest in the group. Informed consent will be reviewed for the student to

understand the important information of the group. The names of the students who were not

accepted in the group will be in a waiting list control group.

Program Approach

This “Sweet Emotion” music therapy group is designed for children (4th and 5th graders)

with emotional disturbance to help them understand their emotions and experiences, gain a better

understanding of themselves, and form healthy relationships through the art of music. The

environment of the group and selected interventions are utilized to promote rapport building and

trust within the group, as well as to promote pro-social skills. Students will also learn how to use

50
music for healthy coping strategies and taking better control of their emotions, as the emotional

brain, specifically in the amygdala and cerebellum, become activated when music is played

(Levy, 2005). The activation leads to the connection to emotions and physical movement in the

body that can move with the sound of the music. Furthermore, the group will include cultural

considerations for the use of music and ways in which indigenous people have used music for

healing and discovering their identity.

Week 1: Rapport Building and Group Agreements

In the initial group session, students will have the opportunity to create a sense of

community through establishing group norms and rapport building activities. Additionally, the

initial session will set the tone for building trust and empathy between the students and

counselor. Every week at the beginning of each session, the students will be given an agenda

regarding the overall structure of how the group session will be held. At check-ins the counselor

can assess students’ feelings and discuss if a “cool down” choice may be needed during the

session. To assess, the counselor will have students check-in by answering the check-in question

of the day at the beginning of each session. The counselor will give students a post-it note sized

paper at the beginning of the session that says “Cool Down” with two blank spaces at the bottom

for students to write their number choice for their break, the post-it note can be seen as a “ticket”

for students (Appendix C). As the group is starting, soft instrumental relaxation music will be

played to make the space inviting and comfortable.

● INTRODUCTION (10 minutes): The counselor will introduce herself and introduce the

overall structure/itinerary of the initial group session: introduction, establishing group

norms, check-in, lesson, rapport building activity, and close-out. This will be the overall

structure for the duration of the 8 weeks that this group will meet. The counselor will

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then ask students to share their name and what grade they are in. After each student shares their

name, the counselor will introduce the check-in process at the beginning of the following

sessions.

● RAPPORT BUILDING ACTIVITY (5-8 minutes): The counselor will then follow up with a

rapport building activity and will invite the students to engage with one another. Each student

will have the opportunity to take turns sharing with their partner.

● The counselor will encourage students to pair up. During this activity, the soft

instrumental relaxation music will play lightly in the background to create the ambiance.

● Students will be prompted to build rapport by answering the following question that will

be written on the whiteboard, “What would your walk-up song be today and why?”

● The counselor will ask students to share one another’s name and their walk-up song. The

student who is being shared on will have the opportunity to elaborate on their walk-up

song and why they chose it.

● ESTABLISHING GROUP NORMS (10 minutes): The counselor will then engage the group

to begin establishing group norms, which will create boundaries surrounding the overall function

of the group and create a sense of community. Group norms will be written on poster sized paper

and displayed at the beginning of each session. After creating group norms, students will sign the

bottom of the poster to acknowledge the norms that were created. The counselor will explain that

at the beginning of each session one group norm will be chosen to focus on during the session.

● To provide structure for establishing group norms, the counselor will give two-three

examples of group norms (e.g., Treat others how you would want to be treated, One voice

at a time, Respect your neighbors) and explain that group norms are important in shaping

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 the way we interact with each other as well as, supporting the group in creating a safe

space.

● The counselor will explain that the group will have space to share a group norm and will

prompt students to raise their hand if they choose to share. The counselor will discuss the

group norms that are shared by the group and write them on the poster.

● The counselor will then discuss the concept and use of a “safe word”. A “safe word” will

be defined to the group as a discreet way to notify or confirm with the counselor that the

student is beginning to feel dysregulated, and, therefore, needs to access and utilize a

“cool down” card. The “safe word” will remain the same word throughout the 8 weeks of

group therapy. The counselor will then prompt the group to identify a word they all agree

to be neutral and inclusive.

● LESSON (20 minutes): The counselor will provide the group psychoeducation regarding

emotional dysregulation and strategies to self-regulate. The counselor will play a short YouTube

video about losing control of emotions (Appendix D). The counselor will then discuss 3-6

pre-selected “cool down” options students can choose from. The counselor will provide options

on a poster (Appendix E). The counselor will then refer to the protocol in how students can

access a cool down break and provide visuals through a powerpoint slide (Appendix F).

How to Access Cool Down Break:

● If students choose to pick a “cool down” choice, they can choose a number from the

poster that will have a strategy to use (e.g., hug/squeeze a pillow, sit with a weighted

blanket on lap, trace a shape and take a breath, 10 jumping jacks with the group, if others

want to join in) . Students can give counselor “cool down” paper when they feel the break

is needed.

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 ● Students will be asked to check-in with the counselor throughout the group if a “cool

down” is needed.

● CLOSE OUT (5-10 minutes): This activity is intended to regulate students before their

transition back to class and is implemented as a mindfulness practice.

● Before explaining the close out activity, the counselor will play the soft instrumental

acoustic beats/music to set a relaxing tone for the end of the group session. The counselor

will ask students to draw/color with provided arts and crafts, on an 8x11 blank piece of

paper and draw an abstract art on what they learned or felt from this initial session, which

will then be placed on a bigger poster board and stored by the counselor once the session

has concluded. The poster will be implemented throughout sessions and used at the very

last session to visually reflect with the group.

Week 2: Emotions and Music Session 1

The purpose of this session will be for students to learn how to be aware of their

emotions and identify where emotions are felt in their bodies. A video will be implemented for

visuals, and students will have the opportunity to practice identifying emotions by completing a

worksheet to assist in visualizing where emotions are felt and experienced throughout the body.

Soft instrumental music will be quietly played as background music during the activity to set a

calm ambiance within the setting. The session will continue to support rapport building and

group cohesion. Therapeutic space will then be provided and held in the event students choose to

share their experiences with their peers. Lastly, as the session comes to a close, students will be

encouraged to be mindful throughout the week of their newfound awareness of any emotions that

they may experience within their bodies.

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● INTRODUCTION (5 minutes): As the group comes in the room, the counselor will be

playing the students playlist based on the activity in the initial session to make the space

inviting. The counselor will stop the music, welcome the students to the second session,

and reintroduce herself and the purpose of the group. The counselor will also ask students

to share their name again before transitioning to the structure of the session. The structure

will be as followed: Review of group norms, check-in, lesson, activity, and wrap-up of

the session.

● GROUP NORMS (5 minutes): Before transitioning to the check-in, the counselor will

display the group norms that the group collaboratively created in the previous session.

The counselor will briefly review the importance of group norms and highlight how the

group worked as a community to form them. The counselor will remind the group that

they will go over the group norms each session before the group begins. Furthermore, the

counselor will prompt the group to think of a group norm they want to focus on for this

session and facilitate discussion if necessary.

○ To highlight which norm the group wants to focus on for the session, the

counselor will use an arrow to point to the chosen group norm.

○ The counselor will make sure the group is in agreement with the chosen group

norm and remind the group about the use of the “safe word” before transitioning.

● CHECK-IN (10 minutes): At the beginning of the check-in, the counselor will briefly

review the structure of a cool down break if students need one and show the powerpoint

slide(s) of how to access a break before students share (Appendix F). The cool down

poster will be displayed for students to refer to throughout the group (Appendix E). The

counselor will then follow up with the check-in for the session: “Rose and Thorn”. The

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 counselor will give an example and ask students to share their positive moments of the

week (rose) and parts of their week the students felt did not go well (thorn). For example,

the rose of the week is having an extra recess, and the thorn is forgetting to do a

homework assignment.

● LESSON (15 minutes) : The counselor will provide the group psychoeducation regarding

where in our bodies we feel strong emotions. The counselor will review psychoeducation

of the brain and emotions from the video in the previous session. The counselor will

transition to watching a 4 minute and 52 second video on Youtube about names of

emotions and then use the video to teach the group where the emotions can be felt in their

body (Appendix G).

○ The counselor will use the video as an interactive way to teach the students how

to be mindful in identifying their emotions.

○ The counselor will pause the video and provide structure for the group in

identifying their emotions in their bodies. For example, the counselor will give an

example of how happiness is felt in their cheeks, or anger is felt in their chest, and

then point to where they feel the emotion.

○ The counselor will prompt the students to point to where named emotions are felt.

The counselor will also use the video to assist students in identifying and giving

examples of feeling sad, happy, or angry. The counselor will encourage discussion

among the group members.

● ACTIVITY (10-15 minutes): The counselor will provide students with a body template

worksheet and coloring supplies (Appendix H). The counselor will display a powerpoint

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 with 4-5 pictures of emotions and ask students to color where on their template they feel

the shown emotion in their body (Appendix I).

○ While students are coloring, soft instrumental music will be played in the

background.

○ Debrief: The counselor will leave 10 to 15 minutes open for students, if they

choose, to openly process with the group if they identify with the theme of the

session, “Emotions”.

■ If the students do not volunteer to share in the process discussion, the

counselor will then attempt to engage the students by asking questions in

relation to the theme of the session:

● When was a time you remember feeling excited?

● What scares you?

● What do you love to do?

● Where do you feel anger in your body?

● CLOSE-OUT (5 minutes): The counselor will provide students their own folders to use

during sessions to keep their papers in and collect them as students are leaving the group.

To close the session, the counselor will do one final check in with the group. The

counselor will briefly review psychoeducation on understanding where we feel our

emotions. And lastly, the counselor will encourage students to be mindful of any

emotions they experience within their bodies, throughout the coming week.

Week 3: Emotion(al) Expression and Music Session 2

The purpose of this session will be to form a feelings circle where students will have the

opportunity to discuss their feelings and express their emotions. The counselor will implement

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music therapy interventions such as, reflective listening and free improvisation with instruments.

Visuals such as powerpoint slide(s) and videos will also be implemented throughout the session.

Students will learn how emotions sound by listening to the loud and soft volume of instrumental

music and be able to express emotions through playing instruments. The session will continue to

support rapport building and group cohesion, therapeutic space will then be provided and held in

the event students choose to share their experiences with their peers. To close, the students will

have the opportunity to reflect on the lesson through art and draw what they felt was important to

learn from the session.

● INTRODUCTION (5 minutes): As the group is entering the room, the counselor will play

a song from the group playlist. The counselor will pause the music when the group is

situated and welcome the group to the third session. The counselor will remind the group

that there are five sessions left. The counselor will briefly summarize the previous session

of identifying emotions to remind the group of what was covered in the previous session

before transitioning to the group norms.

● GROUP NORMS (5 minutes): The counselor will remind the group that they will go over

the group norms each session before the group begins. Furthermore, the counselor will

prompt the group to think of a group norm they want to focus on for this session and

facilitate discussion if necessary. Refer to session two for structure of group norms.

● CHECK-IN (5 minutes): The counselor will continue to review the structure of a cool

down break before students check-in (Appendix F). The cool down poster will be

displayed for students to refer to throughout the group (Appendix E). The counselor will

begin the check-in by asking how the group did with being mindful of their emotions

within their bodies during the week. The counselor will prompt the students to name

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 feelings and identify where in their bodies they experienced the feeling. The counselor

will follow-up with a check-in regarding how students feel in the current session by

displaying the body template on the projector (Appendix H). The counselor will ask

students how they are feeling in the present moment and prompt students to identify

where they feel the feeling in their body. The students will write their name on a sticky

note and either draw the face of their feeling, or write a feeling word to stick on the body

template.

● LESSON (15 minutes): The counselor will provide psychoeducation on emotional

expression and facilitate discussion between the group regarding what it is like to express

their feelings. The counselor will introduce the lesson by providing psychoeducation

about the volume of music, known as forte and piano, and how it relates to how our

emotions are expressed. The counselor will introduce the musical terms forte and piano

on a powerpoint slide to provide visuals as well as define them (Appendix J). The

counselor will explain that just like volume controls how loud or soft music is played, our

emotions control how big or small we express them. The counselor will prompt students

to observe the sounds of an instrumental music clip from youtube (Appendix J) with loud

and soft volumes of sound for 50 seconds. Additionally, the counselor will prompt

students to observe their feelings while listening to the music. The counselor will begin

the discussion after the music clip and encourage students to share what sounds they

heard in the music and hold space for discussion.

Questions for discussion will also be provided on the powerpoint slides for

students to visually see and then answer within the group (Appendix J):

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 ○ What feelings did you notice in your body when you listened to the music get

loud and soft?

○ When was the last time you noticed your emotions get “loud”? Was there

anything you did to “soften” your emotions?

○ What is it like to share your feelings? Are there times where you don’t feel like

sharing your emotions? Why or not?

● ACTIVITY (10 minutes): The counselor will put 8 folded pieces of paper in the middle

of the circle for students to pick from. On these strips of paper will be different emotions

(e.g., happy, sad, angry, surprised, scared, excited, annoyed, and worried) that the

students will either act out or draw on the white board when they are called on to show

what the emotion looks like and where they feel it (Appendix K). The counselor will

prompt students to think about the sound the emotion makes and allow them the choice to

choose one instrument to play the emotion.

○ The counselor will implement active music therapy with the intervention of free

improvisation and students will have the choice of picking between three

instruments to play (small drum, xylophone, mini keyboard piano) to express the

emotion they picked.

○ The counselor will model by naming an emotion (e.g., silly) and draw a picture of

what the emotion “silly” looks like on the white board. The counselor will give

one example of where she feels silly in her body. Following, the counselor will

pick the xylophone and say, “This is what silly sounds like to me” and play the

sound. *The counselor would play a jumpy beat to represent the emotion. The

counselor will provide a visual structure of the activity on the powerpoint

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 (Appendix J). The counselor will also provide structure by calling on students for

them to share their emotions and the instrument/music to demonstrate the sound

of the feeling.

■ Structure of activity:

■ Students will choose an emotion from the center of the circle and name it,

and either act out or draw the emotion on the white board.

■ Students will point to where they feel the emotion in their body, and then

choose their instrument.

■ Students will use the prompt, “This is what __________ sounds like to

me”.

○ Debrief: The counselor will leave 5 to 10 minutes open for students, if they

choose, to openly process with the group if they identify with the theme of the

session, “emotional expression” before transitioning to the close-out

● CLOSE-OUT (5 minutes): To close the session, the counselor will briefly review

psychoeducation on emotional expression. The counselor will express that we can use our

cool down choices to help with our emotions. The Counselor will end by asking students

to share what it feels like to express their emotions with instruments.

Week 4: Identity and Music Session 1

The purpose of this session will be to learn about the meaning of identity and the qualities

of our identity. A video will be shown (Pike, n.d.) to break-down the characteristics of identity

for the students to understand. Furthermore, the counselor will introduce an “Identity Flower”

(Appendix L) and display it for students to visualize. Students will listen to and watch a story

about a boy with different identities (Diggs, 2015) and work collectively as a group to describe

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his qualities on the “Identity Flower” displayed. Lastly, the students will have the opportunity to

complete their own “Identity Flowers” and share an aspect of their identity that is of importance

to them. Songs from the students’ playlist will be quietly played as background music during the

activity to create an enjoyable ambiance within the setting. The music played softly in the

background is a music therapy intervention called passive music therapy implemented to assist

relaxation or receptive listening.

● INTRODUCTION (5 minutes): The counselor will play the group’s playlist as students

are coming into the room. Before sitting down the counselor will pause the music and

join the circle to welcome the group. The counselor will remind and express that there are

4 sessions left of the group. The counselor will briefly explain what was covered in the

previous session and introduce that the topic of this session will be about their own

identity (5 minutes).

● GROUP NORMS (5 minutes): Before transitioning to the check-in, the counselor will

display the group norms that the group collaboratively created in the initial session. The

counselor will briefly review the importance of group norms and highlight how the group

worked as a community to form them. Refer to session two for further structure of group

norms.

● CHECK-IN (5 minutes): The counselor will continue to review the structure for a cool

down break and bring attention to the poster (Appendix E). The counselor will transition

to the check-in and display a visual of a feelings thermometer numbered from 1 to 5

(Appendix M), with 1 being happy and 5 being out of control. The counselor will ask

students to show a number with their fingers to express how they are feeling at the

beginning of the session.

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● LESSON (10 minutes): The lesson for this session will be interactive. The counselor will

introduce the word “Identity” and write its definition on the white board for students to

see. The counselor will define identity as the qualities, beliefs, expressions, appearance

and values that make us who we are. The counselor will ask students to discuss what they

think the word means. The counselor will write the students’ meanings and definitions on

the white board. After a brief discussion about the word identity, the counselor will play a

2 minute and 58 second Youtube video, referred to above, about what makes up our

identity (Pike, n.d.) (Appendix N). The counselor will then explain that understanding our

identity helps us recognize our strengths and makes us unique. The counselor will use the

video to introduce an identity flower (Appendix L) and go over the identities on each

petal. The counselor will ask students if they have any questions about the identities on

the flower.

● ACTIVITY (15 minutes): To transition, students will listen to and watch a story on

Youtube called “Mixed Me” (Diggs, 2015) (Appendix O). Students will be prompted to

observe the character's identity throughout the story. The counselor will project the

identity flower and facilitate discussion between the group in identifying the character's

identity based on what they observed in the video. The counselor will again inquire about

the students' identities and provide an identity flower to each student. Students can draw

or write their qualities on the petals. Music from the students’ playlist will be quietly

played in the background as students decorate their flowers. The students will have the

opportunity to share their flower and share a part of their identity flower that is special to

them.

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 ● CLOSE-OUT (10 minutes): To transition to the end of the session the counselor will

briefly review the theme of identity that was covered in the session. The counselor will

ask the students to name a song that relates to their identity at the close of the group.

Lastly, the counselor will hand out the students’ folders for them to put their identity

flowers in and hand it back to the counselor as they transition back to class.

Week 5: Music and Identity Session 2

The purpose of this session is to continue exploring the meaning of identity. The students

will have the opportunity to further discuss what identity means to them. The counselor will

provide the group psychoeducation regarding how music shapes our identities through a brief

powerpoint. Passive music therapy will be implemented, where music will be played before the

session begins and during the activity portion of the session. Students will be able to write down

their own personal playlists with soundtracks of their songs they connect to and decorate an

individual CD case. While CDs are no longer used, the activity is implemented for students to

visually create an “album cover” (that can fit into the CD case) that they feel connects with their

identities. Additionally, the songs the students include on their soundtrack list are implemented

as a representation of who they are and also as a reference for students to utilize when the group

is over. Lastly, the counselor will facilitate an “I am” affirmation and have students share a

special part about themselves.

● INTRODUCTION (5 minutes): To welcome students into the session, the counselor will

continue to play a song from the students playlist to begin the group. The counselor will

be transparent and share that there are three more sessions of the group left. The

counselor will review the topic of identity from the prior session and have the students

recall and share what was shared in the previous session.

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● GROUP NORMS (5 minutes): Before transitioning to the check-in, the counselor will

display the group norms that the group collaboratively created in the previous session.

The counselor will prompt the group to think of a group norm they want to focus on for

this session. Refer to session two for further structure.

● CHECK-IN (5 minutes): The counselor will review the option for a cool down break

(Appendix C) and bring attention to the cool down poster, reminding students of the

structure in case they need a break (Appendix E). The check-in question will be written

on the white board, asking students how they felt when they listened to the song being

played at the start of the group.

● LESSON (15 minutes): To begin the lesson, the counselor will place cut out letters from

the word “Identity” that are mixed up in the center of the circle. The counselor will

facilitate the group in working with one another to unscramble the word and identify

what the word is. When the group unscrambles the word, the counselor will bring the

group back together and provide psychoeducation on the way music influences our

identities. The counselor will display a powerpoint with 3 brief slides for students to refer

to on the significance of music and its influence on identity (Appendix P).

○ Slides for Powerpoint:

○ Music is an important way to present our identities. When music is listened to, it

brings up memories which helps us create and make sense of who we are.

○ Music is a way for us to express how we feel, where we come from, and allows

us to present ourselves in the way we choose.

○ The music we listen to connects us to different areas of our identities that we

relate to as well as helps us understand others identities.

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 ● ACTIVITY (15 minutes): The counselor will hand out a worksheet titled “The

Soundtracks of My Life” (Appendix Q) where students will get to create their own

personal playlist of songs that they feel connected to. The worksheet will have five

spaces for students to write down their songs. To assist students in spelling and writing,

the counselor will write the names of students' songs on the white board for them to copy.

After students have filled out their hand-out, the counselor will give each student their

own CD case that they can slide their soundtrack into. The students will be able to

decorate the front of the CD case with provided arts and crafts. To wrap-up the activity,

students will be able to share the songs they added onto their soundtrack. While the

students are completing the activity, the counselor will play the group playlist to create a

fun ambiance. The students will be able to take home their CD cases.

● CLOSE-OUT (5 minutes): The counselor will summarize what was done in the session to

transition to the close of the session. . To close the session, the counselor will ask each

student to complete the phrase “I am ___________” and share 1 special thing/positive

quality about themselves.

Week 6: F.r.i.e.n.d.s. Session 1

The purpose of this session will be to identify the qualities of a good and bad friend.

Group cohesion and discussion will be encouraged. Music from the students playlist will play at

the beginning of the session and lightly during the activity of the session to create an engaging

environment. A video from YouTube about a llama and a penguin will be implemented for

students to later reflect on in the discussion (Appendix R). Students will work with one another

in a supportive peer building activity. Lastly, students will engage in positive talk with one

another to close the session.

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● INTRODUCTION (5 minutes): The counselor will continue to play the students’ playlist

of songs as they come to the group. At the start of the session, the counselor will

welcome the group to the sixth session and express that there are two more sessions left.

Furthermore, the counselor will briefly review the topics the group has covered thus far.

The counselor will then introduce the topic of the session- Friendship.

● GROUP NORMS (5 minutes): Before transitioning to the check-in, the counselor will

display the group norms that the group collaboratively created in the initial session. The

counselor will prompt the group to think of a group norm they want to focus on for this

session and facilitate discussion if necessary.

● CHECK-IN (5 minutes): The counselor will be consistent in showing the procedures for a

cool down break if students feel the need (Appendix F), as well as display the cool down

choices for students to refer to (Appendix E). To get an idea of how the group is feeling

about the termination session, the counselor will briefly check-in about how the group is

feeling by using the feelings thermometer (Appendix M). The counselor will leave space

for students to further discuss their feelings if needed.

● LESSON (15 minutes): The counselor will begin the lesson by reviewing the previous

session on identity. The counselor will express to the group that when they recognize and

accept their unique qualities of their identity, it can make it easier for them to recognize

qualities in others. The counselor will prompt students to think of someone they consider

a friend and ask students to share what qualities make this person a friend. As students

are responding, the counselor will write them down on the white board. On the other side

of the board, the counselor will ask students what makes someone a “bad” friend and

write down those qualities. The counselor will then show a humorous two minute and

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 thirty-five second video for students to observe regarding friendship (Appendix R). The

counselor will prompt students to look for the qualities of a good friend and a bad friend

in the video.

The counselor will hold a small discussion on what the students recognized about

friendship in the video. The counselor can use the following questions to prompt

further discussion:

○ How do you know when somebody is your friend?

○ What is a song that you and your friend enjoy listening to and why?

○ What makes you a good friend?

○ What is a song you can think of that describes your friend?

○ Have you had a disagreement with your friend? How did you handle it?

● ACTIVITY (15 minutes): “Friendship Soup” - The counselor will review the qualities

that the students shared of what makes a good friend. The counselor will prompt students

to find a partner and create a recipe for friendship. The counselor will show an example

to the group to refer to if needed (Appendix S). Supplies for coloring will be provided as

well as small poster sized paper for the pairs. During the activity, the counselor will softly

play songs that involve friendship (i.e., “Count on Me” by Bruno Mars, “You've got a

Friend in Me” by Randy Newman, “You’re my Best Friend” by Queen, etc.). When

students are done with their poster, the group can do a brief “Friendship Walk-Around” to

look at other pairs' recipes that they came up with. If time permits, then the counselor will

leave space open for students, if they choose, to openly process with the group.

● CLOSE-OUT (5 minutes): To close this session, the counselor will have a small ball that

the students will pass to one another. The counselor will prompt students to name one

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 person in the group and give them a compliment, passing the ball to the named student

afterwards, and continuing the pattern until each person has had a turn.

Week 7: F.r.i.e.n.d.s. and Music Session 2

In a theory called the music marker, it is suggested that music is relevant to the structure

of peer groups and plays a role in friendship formation (Franken et al., 2017). The purpose of this

session will be for students to be in community with one another while listening and playing

music to support and strengthen peer relationships. The theme of friendship will be incorporated

and students will engage in passive (receptive listening) and active (singing, dancing, playing

instruments) music therapy. The counselor will provide visualizations for the group to refer to

and play a reggae pop song for students to listen to, as well as play or sing along with.

● INTRODUCTION (5 minutes): The counselor will welcome the group and remind them

that this is the second to last group. The counselor will name the topics of emotions and

emotional expression, identity, and friendship that have been covered thus far.

● GROUP NORMS (5 minutes): The counselor will display the group norms that the group

collaboratively created in the initial session. Refer to session two for further structure.

● CHECK-IN (5 minutes): The counselor will briefly refer to the “Cool Down” poster

(Appendix E). For the check-in the counselor will ask students how they are feeling about

the end of the group. The counselor will leave space for students to express themselves.

● LESSON (15 minutes): To transition, the counselor will reintroduce the topic of

friendship and briefly assess what the group recalls about the prior session. As the

counselor is validating the students' responses, they will write it down on the whiteboard.

The counselor will explain that music is a way for us to connect with people around us

whether it is played or listened to. The counselor will hand out the lyrics to the song Lean

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 on Me (Appendix T) and ask the students to follow along as the music plays. The

counselor will play the song Lean on Me by UB40 as it is an upbeat tempo and more

engaging for the students to move along with.When the song is done, the counselor will

write a few questions on the board (refer further down for questions), and ask students to

pair and share with one another. As students are in their pairs, the counselor will play soft

instrumental music quietly in the background to create a calm ambiance. The counselor

will bring the group back together for a bigger group discussion and encourage students

to share what they discussed in their groups.

Questions/Topics to cover for the group discussion:

○ Reflect on the lyrics: e.g. What do you think it means to “swallow your pride”?

○ What do you think this song means?

○ Who is someone you lean on when things get hard?

○ What is one way you help your friends when they are sad or hurt?

● ACTIVITY (10-12 minutes): After the discussion, the counselor will briefly demonstrate

how to play a beat on a floor tom drum and then give each pair of students one children’s

style floor tom drum and one drumstick to play with one another as a group. The

counselor will briefly go over the proper way to use a drum stick (i.e., appropriate ways

to play a drum with a drumstick). The counselor will play a beat that will go with the

song and play with the students so the group can match the rhythm of the song. When the

music starts, students will be encouraged to sing along with the song as they play. The

counselor will project the lyrics of the song on the projector for students to look at while

they play (Appendix T).

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 The counselor will write the following prompts on the board for the students to be

mindful of as they play and hold further discussion:

○ Who is someone you think of when you listen to the song?

○ How does your body feel playing music together?

○ How does your body feel, when the beat of the drum is played as a group?

● CLOSE-OUT (5 minutes): To close the session, the counselor will hand out an 8 x 11

piece of paper for students to draw/write their experience on. The counselor will refer to

the prompts on the board and ask students to draw or write what came up for them.

Coloring and writing supplies will be provided for students. Students will also share their

drawings and impressions of the session.

Week 8: Termination

The final session is focused on closing the group and reflecting on the experiences of

being in the group. The counselor will review the topics that were covered during sessions and

recognize the work the students have done in the group. Students will have the chance to express

what the group meant to them and what they learned about music. Students will also be able to

decorate a wooden musical note to take home with them and be in community with another while

listening to their preferred music. Lastly, the counselor will hand out a brief “End of Group”

questionnaire (Appendix V) for students to fill-out and close the group with a prompt for

students to share their favorite parts of being in the group.

● INTRODUCTION (5 minutes): The counselor will welcome the group to the final

session of the group. The counselor will also acknowledge the growth the students have

developed since the beginning of the group.

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● GROUP NORMS (5 minutes): To keep consistency in the final session, the counselor

will continue to include students in choosing the group norms and recognizing the

collaboration in creating their group norms.

● CHECK-IN (5 minutes): The counselor will still review the choices for a cool down

break (Appendix E) in the final session and review the structure of how to access a break

(Appendix F). For the check-in, the counselor will ask students to name a song that

represents how they are feeling. Students will have space to give one reason they chose

the song (5 minutes).

● REVIEW OF LESSONS (15 minutes): The counselor will briefly review the topics of

emotions, identity, and friendship and the way music influences these areas in our lives.

The counselor will hand out the students folders for them to take as resources to refer to

while at school or at home. The counselor will also provide a handout of the main points

of the group and include it in the students folders (Appendix U). The counselor will hold

a small discussion with the students about their experience in the group and any

takeaways that may have left an impression on them.

● ACTIVITY (15 minutes): For the activity, the counselor will give each student a

keychain sized, wooden musical note for students to decorate with empowering words. A

rectangle table will be placed in the middle of the rug for students to gather around and

arts and crafts will be placed in the middle of the table. The students will be able to

request appropriate songs they would like to be played as they decorate. The counselor

will provide snacks and encourage students to mingle with one another.

● CLOSE-OUT (5 minutes): Before closing the group, students will fill out a brief “End of

Group” questionnaire form (Appendix V) which the counselor will read to them. The

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 counselor will collect the evaluations and close the last session by asking students to

share their favorite part of the group.

Summary

Sweet Emotion is an intervention to be used at the fourth and fifth grade level with

students who are emotionally disturbed. It encourages healthy expression and understanding of

feelings, identity exploration/self-esteem building, and strengthening friendships/peer

relationships. Children with emotional disturbance struggle in various areas that affect their

interactions with themselves and others. Music is a medium that connects individuals to their

feelings and fosters an understanding of how to express their emotions. Music in the group

environment is fitting for children with emotional disturbance to understand their emotions in a

fun integrative way as well as form relationships by creating music with one another. Throughout

the 8-week group the participants have the opportunity to create community, understand their

sense of self, and acknowledge how music can be used as a tool for self-regulation.

Chapter IV will include the strengths and limitations of this intervention, and the

implications for educators and counselors will be discussed. Lastly, suggestions for additional

research will be provided.

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 Chapter IV

Discussion

Chapter I introduced the symptoms, factors, consequences, and common treatment for

children with emotional disturbance, as well as the overview of music therapy. Chapter II

examined a review of the literature in regards to the characteristics/behaviors of children with

emotional disturbance; the factors that contribute to emotional disturbance; the negative

outcomes for children with emotional disturbance; therapeutic interventions implemented with

children with emotional disturbance; music therapy; and ways music therapy supports

social-emotional development in children with emotional disturbance. Chapter III suggested an

8-week, school based psychoeducational music therapy group called Sweet Emotion for 4th and

5th grade boys and girls with emotional disturbance. Chapter IV proposes the strengths and

limitations of Sweet Emotion. Lastly, it discusses the considerations for counselors and

recommendations for future research.

Strengths of the Project

This project is suggested to further support the social-emotional development for children

with emotional disturbance. A significant strength is that the early intervention involving music

therapy activities are interactive and hands-on. In Chapter II, research presented that musical

engagement contributes a variety of opportunities for children to explore interests, connect with

their emotions, and demonstrate positive interactions with others (Yang, 2016). The music

therapy interventions implemented in this project give children with emotional disturbance the

opportunity to feel and hear their experiences, as well as the experiences of their peers, through

playing instruments and receptively listening to music. Music gives individuals the opportunity

to freely express themselves and gives a voice to those who may not have one. By providing

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psychoeducation around emotions/emotional expression, identity, and peer relationships with the

intervention of music, children with emotional disturbance may learn more awareness of

themselves and others around them.

Another strength of this project is the information from chapters I and II that was

provided in regarding the factors that contribute to emotional disturbance. This project gives

context to the way trauma and attachment contribute to emotional disturbance, as well as how the

body is dysregulated through traumatic experiences. The therapeutic group provides

psychoeducation on why our bodies lose control and gives children the language to understand

what they are experiencing. Furthermore, a strength of this project is that children can be in

community with one another in a school-based intervention. By holding the group in a school

setting, more students have access to counseling services and children are still able to see one

another outside of the group.

The last significant strength is that parents are involved and aware of the purpose of the

group to support their child. Parents are given the counselors contact information on the consent

form and can communicate if needed. At the end of the 8 weeks, the students will also be able to

keep their folder of the work they accomplished in the group which parents can keep if they feel

the need to implement what was focused on at home. The resource hand-out provided on the last

session of the group is also a strength for families to refer to after the music therapy group.

Limitations of the Project

A notable limitation of this project is the duration of the group. It would be more

impactful to have additional sessions on emotions, identity, and peer relationships than just two

sessions for each topic that is implemented. Furthermore, the duration of the session time, 50

minutes, seemed limited with the different avenues of social-emotional interventions that can be

75
applied for children with emotional disturbance. Research presented by Porter et al. (2017)

suggested that longer session times with music therapy groups could have increased the

outcomes in areas such as prosocial peer interactions, communication, and emotional expression.

With this group being in a school setting, there is a limitation in prolonging the session time.

There is also a limitation in scheduling an appropriate time where all 8 students can come

to the group. With some students being in different grades, as well as classes, there can be a

challenge in scheduling which part of the school day the group can be held. Teachers schedules

would also have to be considered, along with considering the work students may have to

make-up while they are in group.

An additional limitation of this project is the process of receiving consent. Children in 4th

and 5th grade are required to receive consent from their parent(s)/guardian(s) to participate in a

therapeutic group. Receiving consent and getting in contact with some parents can pose a

challenge if parents are working or do not communicate with the school, slowing down the

screening process for selected students. For some cultures, therapy and mental health are

stigmatized and, therefore, poses a limitation on parents giving consent for their children to

participate.

Considerations for Counselors

The counselor will be working with children with emotional disturbance and will need to

be aware of sociocultural context to support further growth in the therapeutic group environment.

The way in which individual behaviors of children with emotional disturbance present

themselves is important to acknowledge so the counselor can understand the social-emotional

needs of the child and how to appropriately support them in their development. As mentioned in

previous chapters, in spaces of power such as academia, adults hold high expectations in terms of

76
“normative behavior” and lack culturally sensitive approaches to understanding the

social-emotional needs of children with emotional disturbance (Mclaughlin et al., 2009). It is

necessary for counselors to acknowledge the developmental stage that group members are at and

the challenges facing this population. It is important to understand how group members perceive

themselves in the world they live in and for the counselor to acknowledge their own privilege

when working with this population, as well as be aware of their countertransference.

The counselor who will facilitate the group will also need to be aware of musical terms

and the way in which music supports social-emotional growth. When implemented appropriately,

music therapy is beneficial for pain control; reducing anxiety; stress; anger, and agitation; and

improving mood states (Choi, Lee, & Lee, 2010). Furthermore, the counselor must be aware of

the intersectionalities of the members of the group to effectively build rapport and create a safe

space. There is the likelihood that the group would need to be adjusted to accommodate different

behaviors (e.g., elopement, physical aggression, shut-down).

This intervention is directed towards the needs of a population that often is dismissed or

reprimanded harshly, because of norm expectations by people in authority. Children with

emotional disturbance have the potential to make connections with others with the appropriate

support. Furthermore, children with emotional disturbance struggle with expressing themselves

and do not seek help easily. Therefore, it is essential for counselors to hold unconditional

positive regard for the group members.

Recommendations for Future Research

There is a lot of research on children with emotional disturbance, as well as research on

music therapy. However, there is not much research on using music therapy with children with

77
emotional disturbance. Future research is needed on the influence and advantages of a music

therapy group for children with emotional disturbance.

Another recommendation for future research would be with elementary-aged children

with emotional disturbance and the impact Covid has on their social-emotional development.

The pandemic affected many children and created a social-emotional gap when children returned

to school. Further research would support closing the gap and implementing additional resources

to improve the support for children with emotional disturbance.

Furthermore, there is a need for research to be more inclusive of children with emotional

disturbance who are from multicultural backgrounds. Additional research on various ethnic

backgrounds and the norms within these cultures would involve cultural competence in how

symptoms and behaviors present themselves in different cultures. Understanding the cultural

norms would be supportive in holding mental health conversations with multicultural families

and including them in treatment for their child.

Conclusion

This counseling intervention presented an 8-week music therapy group for 4th and 5th

grade children with emotional disturbance. Children with emotional disturbance experience

several challenges within their social-emotional development that affects the way they express

themselves and interact with others. The group, Sweet Emotion, is a counseling group rooted in

education-oriented music therapy and provides psychoeducation around emotional regulation,

emotions and emotional expression, identity, and peer relationships. A safe space will be

provided for children to explore their experiences and build community with others in the group.

It will also address the way behavior is expressed and provide space for the children to reflect on

how their emotions serve them and how they do not. Through music, Sweet Emotion will help

78
children with emotional disturbance connect with themselves and externalize the meaning of

their experiences through music to support healthy understanding and expression of the self.

79
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87
Appendix A

Consent Form

88
 Appendix B

Survey Questionnaire

89
 Appendix C

Post-it “Cool Down” Ticket

90
 Appendix D

“Why Do We Lose Control of Our Emotions?” Video

“Why Do We Lose Control of Our Emotions?” Video

https://www.youtube.com/watch?v=3bKuoH8CkFc

91
 Appendix E

“Cool Down” Poster

92
 Appendix F

Powerpoint Slide with Structure of Cool Down Break

93
 Appendix G

Emotions for Kids - Happiness, Sadness, Fear, Anger, Disgust and Surprise Video

Emotions for Kids - Happiness, Sadness, Fear, Anger, Disgust and Surprise Video

https://www.youtube.com/results?search_query=Emotions+for+Kids+-+Happiness%2C+Sadness

%2C+Fear%2C+Anger%2C+Disgust+and+Surprise

94
 Appendix H

Body Template

Body Template

https://www.templateroller.com/template/1493322/human-body-template.html

95
 Appendix I

Powerpoint Slide of Happy, Sad, Mad, Surprised, and Scared Emotions.

96
 Appendix J

Powerpoint Slides Forte and Piano

97
98
99
 Appendix K

Emotion Strips for Activity

100
 Appendix L

Identity Flower Handout

https://www.glsen.org/sites/default/files/Identity-Flowers-Lesson-Plan.pdf

101
 Appendix M

Feelings Thermometer

https://www.teacherspayteachers.com/Product/5-point-feelings-scale-3620536?gclid=CjwKCAj
wyryUBhBSEiwAGN5OCDGa0SOhNE5BAEvlBETG-F1X-_gDUeZYX0rGR4elfkt3KzmSP--P
AhoCtwAQAvD_BwE

102
 Appendix N

“Identity Explained for Children” Video

“Identity Explained for Children” Video

https://www.youtube.com/watch?v=eRzRAh2M2Ao&t=110s

103
 Appendix O

“Mixed Me!” Video

“Mixed Me” Video

https://www.youtube.com/watch?v=rhwAQ3OHZpw

104
 Appendix P

Powerpoint of Music and Identity

105
106
 Appendix Q

“Soundtrack of My Life” Handout

107
 Appendix R

Video on Friendship

Video on Friendship

https://www.youtube.com/watch?v=t4Q_B0fIrJE

108
 Appendix S

Example of Recipe for Friendship

https://pin.it/2L1cFx0

109
 Appendix T

Lyrics to Lean on Me

110
 Appendix U

Handout of Main Ideas

111
 Appendix V

End of Group Questionnaire

112
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