CREATING EVIDENCE BASED POLICIES REGARDING MUSIC THERAPY PROVISION

CREATING EVIDENCE BASED POLICIES REGARDING MUSIC THERAPY PROVISION Órla Casey, Head of Music Therapy Matthew Gunn, Head of Service Cambridgeshire Music Cambridgeshire County Council, UK Dr. Helen Odell-Miller Deputy Head of Department of Music and Performing Arts Professor of Music Therapy Anglia Ruskin University, Cambridge, UK October 2011 This report is copyright in its entirety to Cambridgeshire Music on behalf of the contributors and authors. Permission should be sought to reproduce or distribute the research carried out prior to use from cm@cambridgeshire.gov.uk

CONTENTS 1. Context 2. Background to the Profession and music therapy in Cambridgeshire with Cambridgeshire Music 3. Response to document statements and detailing of evidence bases relating to music therapy 3.1 Robust Evidence 3.1.1 Normal mainstream work evidence 3.1.2 Early Intervention evidence 3.1.3 PMLD work in mainstream evidence 3.1.4 Disadvantaged children evidence 3.1.5 Autism evidence 3.1.6 Life-limited/life-threatened, bereavement evidence 3.2 Criteria applied in decision making regarding funding 3.3 Equality of funding for all therapeutic services 3.4 The LA is of the view. 3.5 Is music therapy a True form of therapy 3.6 Special Schools 3.7 Discharge processes 4. Challenges to outcome requests for music therapists and other professionals 5. Conclusion 6. Bibliography and References 7. Appendix 1. START team statement 2. History of Music Therapy with Cambridgeshire Music 2

1. Context This paper is written in response to a statement produced by the Student Assessment and Resource Team, Cambridgeshire County Council, (START), UK in which the author questions the value of music therapy intervention with students in the school system in Cambridgeshire relating this to a lack of sufficient evidence to support outcomes (Appendix 1). There is no robust evidence to identify which form of music therapy is effective for which needs and what the outcomes would be for an identified cohort of children. There is little, if any, qualitative evidence that music therapy is successful in facilitating educational goals. It is believed by the authors of this paper that this statement is informing policy and decision making about music therapy provision by START at Cambridgeshire County Council. This document will challenge the call for robust evidence and detail a wealth of robust evidence relating to the role of music therapy in supporting education. It is suggested that the lack of robust evidence is in fact related to the START statement for a lack of detail and reference to support the document. It is acknowledged that there is a need for further evidence work regarding music therapy with children in mainstream schools towards more rigorous based outcomes. Current standardised research models across the disciplines relating to child health and education may not be sufficient to identify outcomes from music therapy as they do not always take into account the role of music as therapy, a creative arts intervention in facilitating skills in comparison to other environments. However, robust evidence both case focussed and more formally presented exists and is presented below, concerning music therapy for children in schools and related environments. This paper will address the need for clarification of some of the statements in the aforementioned document and also show that contrary to this statement, there is indeed a wealth of evidence available to support outcomes for students with emotional, social and health needs within the education system. These students are supported by music therapy intervention both in the UK and on an international basis. This paper will offer examples from worldwide research studies by music therapists both on an individual basis and music therapists in conjunction with local authorities, education institutions and the NHS Scotland that document outcomes of music therapy work in supporting access to learning and improved outcomes for students. It will also draw from outcomes detailed in two recent book publications about the use of music therapy and the arts in education, one which was edited by members of the Cambridgeshire County Music Therapy Service. In order to offer a context to the work I will firstly offer a background to the music therapy profession and to music therapy work in Cambridgeshire County by Cambridgeshire Music music therapists. Secondly I will offer examples of music therapy evidence base across a wide spectrum of need of students as part of addressing the START statement. Finally I will outline some of the issues involved in standardising an evidence base which are currently being addressed across professions. 3

2. Background to the profession The World Federation of Music Therapy defines Music Therapy thus: Music Therapy is the use of music and/or musical elements (sound, rhythm, melody and harmony) by a qualified music therapist with a client or group, in a process designated to facilitate and promote communication, relationship, learning, mobilisation [sic] and other relevant therapeutic objectives, in order to meet physical, emotional, mental, social and cognitive needs. Music therapy aims to develop potentials and/or restore functions of the individual so that he or she can achieve better intra- and inter-personal integration and, consequently, a better quality of life through prevention, rehabilitation or treatment. Music Therapy is a relatively small profession having been established as a profession over the past 50 years. Basic training is at Masters level, and there is a higher percentage of music therapists holding PhD qualifications, or studying for PhD s in relation to numbers of practising therapists, than in the other Allied Health Professions (Physiotherapy, Occupational Therapy for example). There are seven training courses in the UK and over 700 music therapists working in the country. Music Therapists must be legally registered by the Health Professions Council since 2003. Evidence from bodies such as the General Medical Council, Royal College Occupational Therapists, Royal College of Psychiatrists, Royal College of Nursing was required for the profession to be initially registered by the Council for Professions Supplementary to Medicine (CPSM) in 1997, and this led subsequently to the professional registration under the HPC. Music therapy is currently recognised in central government documents which attest to its efficacy. Quotes from Promoting Research in Nursing and Allied Health Professions and Meeting the Challenge documents state that Arts Therapists have an important role to play in services for children and adults with learning difficulties, improving mental health services and in services for older people. Arts therapists also have an important contribution to make to palliative care and cancer services p13 Around half of the music therapists working in the UK work with children and the vast majority of music therapy work with children takes place in schools. A county music therapy service was established in Cambridgeshire in 1995 in partnership with Anglia Polytechnic (now Anglia Ruskin University) and Cambridgeshire County Council. The Cambridgeshire Music, Music Therapy team has been in existence since then and now operates one of the biggest music therapy services in the country delivering 189 hours of music therapy per week to vulnerable children in 37 schools, units attached to schools, special schools, units attached to schools and children s centres across the county. See appendix 2 for more information. 4

3. Response to document statements and detailing of evidence bases relating to music therapy This section will address in further detail the statements of the document produced by START outlining inaccuracies and questions arising. The first point will be followed by outline of evidence bases before addressing further statements(p11). 1. "There is no robust evidence to identify which form of music therapy is effective for which needs to identify what the outcomes would be for an identified cohort of children..." a. It is unclear as to the meaning of the word robust in this statement. Is the author referring to a particular type of evidence and is this evidence relevant to a creative arts intervention? b. To the extent that there is a gap in the system relating to sharing the outcomes for an identified cohort of children, this is in part the fault of annual review processes and poor use of agreed systems. There is plenty of evidence to show what outcomes could be expected from certain music therapy intervention Clearly, however, if annual reviews are looking for specific outcomes then there should be clear definition from the START team about a) what those outcomes are b) requirements regarding specific review of the progress made against those outcomes c) the measurement scales to be used This gap is not the fault of the music therapist and easily correctable in process. However, it raises the question of how outcomes are being set and results being ratified and communicated for other provision. 3.1.1 Evidence Bases for music therapy work with children and adolescents in mainstream school a) Literature Reviews 1a) Sample evidence found by this author included two literature reviews, a joint research project and a current study relating to music therapy as an early intervention with at risk adolescents. A systematic literature review (Carr 2009) was commissioned by the Music Therapy Charity UK in 2008 to identify needs for research in this area and out of which the Youth at Risk project developed was and funded (see 2 below). It cites over 60 articles of music therapy work with children in a mainstream setting. Normal mainstream children were the main subject of such work within the schools followed by work done to integrate children with special educational needs. (Carr, 2009). 2a) McIntyre s (2007) literature review is internationally based and addresses the question Is music therapy effective with BD/ED adolescents? 5

Conclusions Articles cite the effectiveness of music therapy with students experiencing lack of self esteem and self concept (Henderson, 1983,; Johnson, 1981; Kivland, 1986; Friedlander, 1994) high levels of anxiety (Cooke, 1969; Alvin, 1975; Ricci, 1993; Hendricks et al., 1999) difficulties with self-control, thinking, responding appropriately and social interaction (Stratton, 1989, Friedlander, 1994) lack of emotional awareness and responsiveness (Wasserman 1972) problems of impulsivity and self-regulation (Layman et al. (2002) Additonal music therapy outcomes included assisting internal organisation and co-ordination of the mind and body. (Gaston, 1968; Montello 1996) demonstration of more immediate differences in group dynamics than those participating in verbal therapy alone. (Gaston, 1968; Montello 1996) high motivation to participate in music therapy groups. Appropriate social behaviours emerged and were learned as the group tried to work together toward a common goal of musical experience and performance (Haines ((1989) in McIntyre, J. (2007)) work with depression, loss, bereavement - depressed adolescents listening to music experienced a significant decrease in stress hormone (cortisol) levels, and most adolescents shifted toward left frontal EEG activation (associated with positive affect) Field, et al (1998) Adolescence, 33(129), 109-116 significant improvement on the Aggression/ Hostility scale of Achenbach s Teacher s Report Form, suggesting that group music therapy can facilitate self-expression and provide a channel for transforming frustration, anger, and aggression into the experience of creativity and self-mastery (Montello, L.M., & Coons, E.E. (1998). 2. Joint Research Project A joint research project about the creation, delivery and evaluation of a music therapy research service within four schools across the borough designed and co-evaluated by Dr. Ulrich Von Hecker, School of Psychology, Cardiff University. 46 children with SEBD were the target group for the project. A minimum of six sessions were offered to each student with pre and post therapy assessments. Conclusion Feedback from head teachers and staff members provided reassuring evidence that music therapy contributed in a very positive and successful manner in helping children with SEBD. Key partnerships and relationships between the Behaviour Support Service, Bridgend County Borough Council, the schools and their staff, the music therapist and the project s lead body at Musicatwork also contributed to the success of the project. 6

I see an agency such as Musicatwork (a county music therapy service) as fulfilling a very timely need to co-ordinate activities in the education sector with developments in the music therapy domain, and to link these with the resources that psychology as an academic discipline provides to society. Dr. Ulrich Von Hecker, School of Psychology, Cardiff University www.cf.ac.uk 3.1.2 Early Intervention with at risk students - current research Derrington writes in three separate articles of her experiences working with clients in centre attached to a mainstream school. On the whole, students in the Centre are very troubled young people who have experienced failure in the educational system. The majority of music therapy referrals indicated that the students learning was being affected by severe emotional difficulties, either as a result of one-off trauma or from ongoing emotional stress. (Tomlinson, Derrington and Oldfield, (2011) p196). Conclusion Derrington s experience is that these students are highly motivated to attend and engage with music therapy. She is currently conducting a major research project investigating early intervention outcomes to support The effectiveness of music therapy for young people at risk of underachieving or exclusion at Cottenham Village College, Cambridge. This is co-funded to the tune of 150,000 by the Music Therapy Charity and the Institute of Education as part of their Youth At Risk project. 3.1.3 Children in mainstream with PMLD Evidence includes a literature review and sample evidence of work with one client group with Retts Syndrome a. Literature Review - McFerran, K, et al. (2009) A systematic and rigorous analysis of literature describing music therapy with children and young people who have intellectual, physical and learning disabilities. It identifies standard approaches to music therapy treatment for this population differentiating between individuals whose disabilities are more and less profound. It highlights a tendency towards the blended use of active methods of music intervention in practice and a reliance on case studies and case series as frameworks for research. Conclusion Music Therapy can facilitate developmental changes within a relational context. Aims for people with mild or moderate learning impairments often relate to work towards behavioural, social and learning outcomes consistent with their capacity. Aims for people with multiple disabilities often tend towards more basic communication outcomes and physical achievements. Music Therapists do not focus on a prescriptive approach but rather focus on the needs of the individual who exists in the context of his/her disability. b. Cochavit, (2002) Cochavit details outcomes of work towards Enhancing communication in girls with Rett Syndrome through songs in music therapy as part of her thesis submitted for degree of philosophy, Aalborg University. 7

Abstract - One of the main areas of affected functioning for females with Rett syndrome is a severe impairment of receptive and expressive communication, and as a result educational intervention in this area is considered to be of utmost importance. Females with Rett syndrome have been observed as very responsive to music and, used therapeutically by trained practitioners, this intervention has been shown to promote and motivate their desire to interact and communicate with their surroundings. The study was set up as a multiple probe design. Music Therapy Results showed that can Girls with Rett syndrome are able to make intentional choices Girls with Rett syndrome reduce response time over time ie. quicker response Girls with Rett syndrome are able to learn and to sustain learning over time Girls with Rett syndrome reveal consistent preferences through choices Girls with Rett syndrome demonstrate emotional and communicative behaviours be translated into understandable messages by attentive caregivers and therapists. As a result of this study the participants expanded their communication skills into other areas of daily living. These included: picture symbols during interactive storytelling, during mealtime, computer games in the classrooms as well as with their caregivers at home. (p45) The present research revealed hidden abilities and skills in a population perceived as noneducable until not long ago. (p45) 3.1.4 Disadvantaged children Mosca, L. et al (2005) write of work with three hundred three- year-old children in a territory of 13 towns on the Sorrento peninsula over a period of eight months (October-May 2003). The music therapy project was part of a bigger project called "Da città a feli-città", sponsored by Regione Campania, that included various interventions like: bringing young people together, possibilities to support disadvantaged children, possibilities to help families with education, and, finally, a project to encourage children to read stories. The music therapy project was presented as a possibility to develop the children's expressive and creative needs, to give them the opportunity to experiment, and then to transform, the educational contents in new expressive forms. Music therapy proposals had the following aims: to develop skills to discern various musical timbres; to extend creative abilities through musical improvisation; to facilitate children's relationships; to prevent hyperactivity Results Students experimented alternative communication possibilities, based on emotional and creative levels, and then applied these new possibilities to verbal communication. The use of musical language increased their emotional background; their participation became more spontaneous and more creative and this became evident when they began to suggest new forms of musical play with the group. Attention levels and their frustration at resìstance levels were very high, and these results were very important for the teachers and their job, because the children were more concentrated on school activities. 8

This work was also useful in so far as it offered the Sanitary Institution some suggestions how to cope with some childrens' dysfunctional behaviour. In some cases it increased the chance to define a clinical diagnosis. Thanks to the music therapy project, the teachers had an opportunity to perceive the children's skills and their communicative potentials in a more creative way and to apply this new vision of their students to normal school activities that became more fluid and free. 3.1.5 Autism The use of music therapy as a positive intervention with people with autism is well documented. a. Music Therapy as supporting assessment for diagnosis and treatment for autism. Dr. Tony Wigram (2002) publishes a comprehensive study detailing evidence available documenting work with children with autism both quantitative and qualitative including work to support diagnosis which is acceptable to wider institutions such as the DOH. The author also points out that in the case of children with autism and other developmental, physical and learning disorders, healthcare needs that are typically met by music therapists are defined from the agreed, prevailing characteristics of children with clear diagnoses under DSM IV and ICD10 classifications. Research outline Music Therapy intervention was assessed over 20 sessions using qualitative and quantitative techniques to assess psychological, musical, psychoanalytic and existential relationships which include interpersonal and intermusical relationships. Dr. Wigram s approach assumes that no minimum level of cognition is needed for music therapy in relation to that needed for alternative interventions eg. TEACHH or LOVAS. Conclusions Outcomes evidence that music therapy contributed significantly to a more balanced description of strengths and weaknesses not identified in SLT cognition tests which then informed learning planning. RCTS It is generally agreed that as music therapy is based on active and improvisational music making that RCT s are not suitable for assessment. However his literature review found findings from RCTs and Experimental Studies that music therapy supported; Better pragmatic skills development when using music with children on the autistic spectrum. Significant changes occur in hand-eye co-ordination, non-verbal and verbal communication due to music therapy intervention Pre and post test criteria found significant improvement in the experimental group, compared with the control group, in musical ability, communication skills and self perception. In relation to pre-adolescents with EBD the most significant change was found in aggression/hostility. Group music therapy can facilitate a process of self-exploration in emotionally disturbed/learning disabled adolescents and provide a channel for transforming frustration, anger and aggression into the experience of creativity and self-mastery. 9

Case study outcomes include Increased tolerance and attention, progress in interpersonal relationships, reduction of rigidity and aggression and a tested increase in developed intelligence over the 6 months of therapy which was measured as a 10-month improvement in mental age. P21 Improvement in social behaviour A significant decrease in autistic flapping and rocking, with increase in appropriate participation during the music session. Results strongly suggest the efficacy of improvisational music therapy in increasing autistic children s communicative behaviour. Dr. Helen Odell-Miller writing in response to this paper suggests that this article demonstrates that music therapy is an effective treatment for ASD and should be a priority for any service responsible for people with this disorder. b. Comparison between ADOS and MTDA systems for children with autism shows that music therapy offers additional information to normal diagnostic tools. Dr. Amelia Oldfield (2006) in collaboration with her professional clinical team at the Child Development Centre in Cambridge outlines a study comparing systems of diagnosis including the Autistic Diagnostic Observation (ADOS) and her Music Therapy Diagnostic Assessment (MTDA). Outcomes Music therapy tests seem particularly good at showing how well children can communicate nonverbally even if they appear not to be communicative through spoken language. p26 c. Trevarthen. C., Robarts, J. et al (1998), Music Therapy with Children with Autism Music therapy is included in a seminal book Children with Autism. Diagnosis and Interventions to Meet their Needs. Jacqueline Robarts, Research Fellow in Music Therapy, City University London and Senior Music Therapist and Clinical Tutor at the Nordoff-Robbins Music Therapy Centre, London writes of music therapy work with children with autism in relation to diagnosis, intervention and how psychotherapy can inform thinking and education of children with students with autism. 3.1.6 Life-limited/life-threatened children in school and pre and post bereavement work a. Work with life limited children Casey (2011) writes of Music Therapists work in almost all of the children s hospices in the UK to support children with life threatening illnesses including children with cancer, degenerative conditions and those with complex medical needs. Many of these children miss considerable amounts of time in school due to medical needs. Hospice music therapists work with these children across different settings whether that be hospital, home recuperation or in school to support integration and well-being of the child wherever they are and also to support transition between settings for these children. Cambridgeshire Music, music therapists work with the EOTAS team to provide music therapy to children who are absent from school due to illness. 10

The paper is a case study description of two teenagers with life threatening illnesses who spend considerable amounts of time out of school due to medical needs. The chapter outlines differences in presentation of the teenagers between hospital, home and school settings and the role of music therapy in helping to integrate the wellbeing of the whole child and support transition across the different settings. b. McFerran, K. et al (2008), action research into how music therapy can be used in schools to promote health coping with grief and loss Outcomes Students addressed grief and had positive outcomes after initially using music therapy to explore and gain some control in their lives. Difficulties were acknowledged in involving students fully in the action research as many were not ready to be considered researchers. However the therapeutic process was observed by the therapist. c. Skewes, K. (2001), conducted a phenomenological study into the experience of group music therapy for six bereaved adolescents as part of a PHD dissertation at the University of Melbourne, Australia. Outcomes Common themes were identified and the importance of being able to share common experience was identified as important to the teenagers. I would now like to address other aspects of the statement from START. 3.3 "The LA is of the view that in the absence of appropriate data it will not fund music therapy of individual children." The question arises as to the methodology used to research and compile this data. It has been shown above that indeed there is a wealth of appropriate data available from a variety of sources. Within the START statement document there is an absence of supporting references or a reading list. Futhermore, at no time in the process of reviewing research did the researcher contact either the Head of Music Therapy at Cambridgeshire Music or the Head of Music Therapy at Anglia Ruskin University, the two people most likely to be able to provide access to local information and research about data. Nationally the British Association of Music Therapists was not contacted. It is argued that rather than there being a lack of robust evidence to support music therapy outcomes that the lack of robust evidence in fact relates to the statement document itself. 3.4 "Any use of musical interventions would be the responsibility of the school to fund". This and the earlier sentences seems to suggest that music is identified here as a specific form of therapy that is now treated differently to other therapies. If the council wishes to limit its provision of financial support for therapeutic activity in schools then all potential therapies should be equally reviewed and similar statements of intent or otherwise produced based on the research outcomes. Otherwise this could not be seen as an equitable application of policy decision making across all supportive therapies whether via health, educational psychologists or education based therapists. 11

3.5 Therefore the Local Authority (LA) is of the view that for children with developmental disorders and learning difficulties it is appropriate for mainstream schools to source advice from specialists for Special Education Needs (SEN) and/or disabilities. This sentence is unclear in the context of a statement about music therapy. This would be expected in any situation for such a child in any school. Music Therapists liaise and work closely with SEN specialists to both source advice and also to offer information to support statementing, diagnosis and information about the child. Eg. Wigram (2002) case study about Joel regarding the role of music therapy in offering additional information about the child which had not been identified by other professional assessment processes. 3.6. "Should children require music as a "true form" of therapy..." The meaning of this statement is unclear. The term true form of therapy is not a recognised term. Is the suggestion that music as a therapy is any less effective than another therapy or that the therapy provided in the past has not been "true" music therapy? Music Therapists are recognised health professionals who are qualified to masters degree level. Music Therapy intervention, similar to verbal therapies, is based on theories of psychoanalysis, object relations, child development, attachment theory etc.. Music therapists are not educators and development of musical skills is not a goal of music therapy. Interventions promote musical engagement towards improved social, emotional and communication wellbeing. Music Therapy practice and procedures as acknowledged by the Health Professions Council guide referrers through an identified referral, intervention and discharge system. All music therapy work involves an assessment process out of which review and recommendations are made for further work (if appropriate) with each student. Ongoing reports are provided for annual reviews and multi-disciplinary meetings and at discharge. It is acknowledged that there can be confusion amongst other health professionals and support services at times as to the aims of music therapy. The musical experience of many people has been in field of music education without any exposure to music as a therapeutic medium and the tendency can be to confuse music therapy with educational outcomes. The Cambridgeshire Music Music Therapy service engages in ongoing training and information sessions with professionals to address this. Further information is available from www.cambridgeshiremusic.org.uk; www.bamt.org 3.7 "Special Schools would remain responsible for ensuring that they have the right mix of additional therapies (art, play aromatherapy, music) to meet the needs of their children and young people. It is unreasonable to align creative arts therapies with complementary therapies such as aromatherapy as there is no comparison. It is true that interventions for children with additional needs prioritise therapies such as speech, occupational, physio therapies. However the holistic development of the child must be taken into account. Children with additional needs also experience difficulty with emotional and social development and not least in mainstream schools. The medium of music therapy offers a particular dimension in its ability to motivate and engage some of the most isolated children in the educational system towards development, integration and inclusion. Vicky Karkou (2009) attests to this in her recent book Arts Therapies in Schools, Research and Practice suggesting that In most school environments, addressing social or emotional needs is seen as a way of supporting learning ie. developing skills and achieving cognitive outcomes. (p14) 12

She continues Education remains the setting where children at risk of developing mental health problems can have their initial contact with responsible adults and qualified professionals. Through this contact, difficulties can be identified early and can be addressed before it becomes necessary to resort to the aid of specialized services outside the school environment. In all cases it is possible that arts therapists can play a valuable role. (p13) 3.8 "NB - Where music therapy remains detailed in an existing statement the LA will fund until such time as the statement is amended and music therapy removed" Whilst this does not directly relate to the policy aspect under discussion it is important to note current feedback from schools, parents, therapists and Cambridgeshire Music, Music Therapists that current decisions in relation to review and discharge processes are problematic on an ongoing basis: a. Lack of communication in sufficient time for a correct therapeutic ending process to be completed, with potential adverse consequences for the child b. Reasons being given for changes not always based on recognised criteria ie. psychological need and reference incorrectly music learning and therapeutic music definitions c. Communication processes agreed with the START team are not being used in a timely and efficient way, potentially costing the START team additional funding under contractual arrangements with the Music Therapy Service. 13

4. Current work addressing needs to standardise evidence based practice by music therapists It is acknowledged that there is a lack of rigorous research quantifying the benefits of music therapy as reducing barriers to learning and detailing observable changes in behaviour that meets the demands of evidence-based practice (McFerran and Stephenson 2006, 2009). For example, the nature of music therapy work does not fit easily into RCT trials due to the requirement to respond flexibly to client relationship and interaction as part of creative therapeutic work. The small number of RCT studies available are used within an applied behavioural approach which is the dominant approach in the USA. However this does not always take into account process and relationship, which are major factors in European models of music therapy. A recent literature review by Pethybridge (2010) described seven rating scales used by music therapists to inform their work. These aim to measure the client-therapist relationship and musical communicativeness (Nordoff & Robbins 1977, 2007), analysis of musical improvisations with reference to sensorimotor, perceptual, cognitive, emotional, and interpersonal skills (Bruscia 1987), gross motor, fine motor, oral motor, sensory, receptive communication/auditory perception, expressive communication, cognitive, social, emotional and musicality (Baxter et al. 2007), musical interaction (Pavlicevic 1999), the quality of relationships (Schumaker and Calvert-Kruppa 1999, 2007) and the musical progress of children with profound needs evaluating reactive, proactive and interactive responses (Ockelford 2008). Difficulties acknowledged by music therapists with some scales are ensuring objectivity, that standards are not always measurable and that clearer definitions are needed to ensure agreement from therapists working from contrasting theoretical backgrounds. Other difficulties relate to the time involved in using these systems as therapists time is dedicated to delivering clinical work and also that music therapists are not trained in research. Difficulties relating these scales as creative and processed based interventions to standardised scales used with children in other professions are noted. Some research studies rely on tools from other professions measuring behaviours pre and post therapy rather than musical observables (Gold, Voracek & Wigram 2004). Tools used by music therapists have included Visual Analogue Mood Scale, Psychology Observation scales for autism, the Affective Communication Scale, a Speech and Language Therapy tool, a Multi-Disciplinary behaviour inventory the 'Good Profile', an assessment graph used in Pre-school units in Gwynedd and Mon, Sounds of Intent (Ockelford 2008), HoNOSCA (Health of the Nation Outcome Scales for Children and Adolescents), which is often a routine measurement in Child and Adolescent Mental Health services and various autism rating scales e.g. GARS (Gillian Autism Rating Scale). Whilst offering higher rates of reliability and validity tools from other professions may not encapsulate the professional identity of the music therapist or the musical data. The difficulty is therefore finding a tool that meets the rigorous demands of evidence based practice and yet accounts for the flexibility of the creative processes in music therapy (Wigram 1999a). Dr. Amelia Oldfield (1993) published a study of methods used to review clients progress. She noted that an essential part of current evidence does not often address the difference music makes to facilitate the achievement of skills in comparison to other environments, which she considered essential. 14

For example, the literature describing music therapy work with people with disabilities is a small but consistent body of work. It focuses mostly on young people with moderate to severe levels of disability. There is a high level of agreement in the field both in terms of treatment interventions and research designs. Although there are some suggestions about future research that are in line with expectations of evidence-based practice, this does not detract from the valuable contribution of the existing body of research investigations. Music Therapy stands firm on a fifty-year tradition of practice in the field of disabilities. Music plays a powerful role in facilitating communication with this group of people and also providing a highly motivating context in which to establish relationships and maintain physical and behavioural achievements. People with disabilities and their families frequently advocate for more music therapy services and this support is based on a practice grounded in standardized treatment and outcome expectations. There is agreement in the music therapy profession that music therapy measures need to stand alongside other evidence based practices. Currently case series designs are accepted within the evidence base hierarchy (Wigram, 2002). It seems that the best approaches to outcomes are approaches that use case study designs alongside video analysis which allow for documentation of musical observables. There are currently many studies using these approaches. Research is ongoing eg. the Youth at Risk study between the Music Therapy Charity and the Institute of Education, Northern Ireland Music Therapy Trust, Coram, Cambridgeshire Music using Early Years outcomes and currently launching a pilot evaluation system for students in school etc.. 15

5. Summary and conclusion This paper has shown that contrary to the statement by START, that there is a wide range of research work available attesting to the value of music therapy in mainstream schools with many different client groups. The breadth of evidence includes work with children with EBD, bereavement, trauma, refugees, looked after children and reflects work on an international basis. The role of music therapy in services for children young people is acknowledged in central government documents which attest to its efficacy. Collaborative research work between music therapists and state bodies eg. between the Music Therapy Charity and the Institute of Education, NHS Education for Scotland Paediatric and the Advanced Practice Succession Planning Development Pathways, Bridgend Borough Council and Musicatwork (music therapy service) attest to the efficacy of music therapy work as noted and reported by a wide range of professionals. Music Therapy work is published and presented not only in music therapy journals but also journals related to education and health eg. Educational Action Research, British Journal of Music Education, Music Educators Journal, Journal of Child Psychology and Psychiatry, Counselling and Psychotherapy Journal, Social work with groups, The Arts in Psychotherapy. The Government Research Report also calls for more funding for Allied Health Professions Research (p26). Ongoing research into standardising outcomes is occurring however this does not detract from the valuable contribution of the existing body of research investigations. Music Therapy offers a particular approach and intervention which is unique in how it can engage students and in what it can offer to students in relation to other psychological interventions. I would like to conclude this paper with some final quotes from other professionals about music therapy. Sandra Wilson (1991) sees music therapy as an adjunct to education where children with learning disabilities resulting from physical, psychological or emotional problems can develop socially, emotionally, cognitively and physically... Music therapy in an educational setting contributes significantly to an individual s learning capacity and just as importantly in their motivation to learn. (in McIntyre J. 2007) Dr. Fatima Janjua MD MSc FRCPCH PhD, Consultant Community Paediatrician writes of her experience of music therapy in relation to clinical work at the child development centre and in relation to multidisciplinary work. In this book Amelia (Dr. Amelia Oldfield, 2006) clearly demonstrates the power of music not only in drawing the attention and interest of even the most withdrawn children but also in promoting awareness of the other and laying down some basic rules of interaction. When dealing with severe social communication problems this breakthough is essential and should be happening as early as possible in the intervention process. The effectiveness of music therapy in encouraging communication and the fact that this happens mostly in a relaxed and enjoyable context where there is no testing of the child s ability makes it particularly suited to become one of the first services to be involved immediately after diagnosis. In a multi disciplinary team these initial gains in music therapy could be built upon and extended by other support workers. I have no doubts that among all other therapies music therapy is best placed to initiate the process of encouraging parents and to achieve their co-operation from the very beginning. This would certainly have repercussions on the work of other therapists. 16

Paul Carolan, Headteacher, Birtenshaw School writes of his experience of music therapy In every session I observed I saw moments both moving and profound - children with multiple barriers to learning and living listening intently and making real attempts to communicate... In terms of addressing the triad of impairments autism presents, I find music therapy inspirational and transformative. It is a powerfully effective tool within a total communication environment. Kathryn Nall, Former Head of Music Therapy writes of her experience of working with and leading the Cambridge County Council Music Therapy service; Music therapists as registered Health Professionals have good reason to be part of these interventions and assessment processes. Music Therapy has a place within Children and Young People s Services in Cambridgeshire (CYPS) and it is essential that we continue to be part of the process of identifying, assessing and meeting children s needs. (KN (2011) p217) In the forward to a recent book Music Therapy in Schools Dr. Frankie Williams, School Inspector states that It has taken 40 years to build up this essential resource of music therapy in schools, local authorities and the health service, and it can take a few minutes to demolish this in a government or a council meeting. All those taking these decisions should read this book first. (Dr. Frankie Williams, (2011), p11) 17

MUSIC THERAPY IN MAINSTREAM EDUCATION LITERATURE Akombo, D.O. (2001) Reporting on music therapy in Kenya. Voices: A world forum for music therapy 1 (1). Retrieved March 10, 2008, from http://www.voices.no/mainissues/mitext11akombo.html Allen, J. (2007) Both sides of the wall: A review of the ongoing music therapy intervention undertaken in primary schools located in high profile interface areas of Belfast. In Trauma: Current thinking and practice in music therapy; conference abstracts. Anglia Ruskin University, Cambridge 23-24 November, 2007. Cambridge: Anglia Ruskin University Association of Professional Music therapists (APMT)(2007) Music Therapy in the U.K. Poster presented at 7th European Music Therapy Congress in Eindhoven, The Netherlands 15th - 19th August 2007 Baker, F. & Jones, C. (2005) Holding a steady beat: The effects of a music therapy program on stabilising behaviours of newly arrived refugee students. British journal of music therapy 19 (2): 67-74 Brooks, D.M. (1989) Music therapy enhances treatment with adolescents. Music Therapy Perspectives 6: 37-39 Brotons, M. (2001) Music therapy in the school system in Spain: A pilot project. Bulletin of the Council for Research in Music Education 148:19-30. Buchanan, J. (2000) The effects of music therapy interventions in short-term music therapy with teens at risk: an opportunity for self-expression in a group setting. Canadian Journal of Music Therapy 7 (1): 39-50 Bunker, M. & Ryan, S. (2004) Miss, I ain t doin none of that talkin stuff. Counselling and Psychotherapy Journal 15 (1) Retrieved on March 10, 2008 from http://www.therapytoday.net/archive/feb2004/cover_feature2.htm Bunt, L. (2003) Music Therapy with children: A complementary service to music education? British journal of music education 20 (2): 179-195. Butterton, M. (1993) Music in the pastoral care of emotionally disturbed children. Journal of British Music Therapy 7 (2): 12-20 Camilleri, V.A. (2007) Healing the Inner City child: Creative arts therapies with at-risk youth. London: Jessica Kingsley Publishers Carr, C., and Wigram, T., (2009), Music Therapy with children and adolescents in mainstream schools: a systematic review, British Journal of Music Therapy, Vol 23, no.1. Chester, K.K., Holmberg, T.K., Lawrence, M.P. & Thurmond, L.L. (1999) A program-based consultative music therapy model for public schools. Music Therapy Perspectives 17: 82-91 Darnley-Smith, R. & Patey, H.M. (2003) Music Therapy. London: Sage Publications 18

Department for Children, Schools and Families (DCSF) (2008). Pupil absence in schools in England, including pupil characteristics 2006-7. London: DCSF Department for Children, Schools and Families (DCSF) (2007a) The Children s Plan. London: Department for Children, Schools and Families Department for Children, Schools and Families (DCSF) (2007b) Guidance for schools on developing emotional health and wellbeing. London: Department for Children, Schools and Families Department for Education and Skills (2005a) Higher standards, better schools for all. London: Department for Education and Skills Department for Education and Skills (2005b) Excellence and enjoyment: social and emotional aspects of learning. London: Department for Education and Skills Derrington, P., (current study) The effectiveness of music therapy for young people at risk of underachieving or exclusion, Cottenham Village College, Cambridge. Major Doctoral Research Project investigating music therapy in early intervention outcomes to support at risk students. 150,000 invested. Music Therapy Charity, UK and Institute of Education. Derrington, P. in Tomlinson, J., Derrington, P., Oldfield, A., (2011), (eds.) Music Therapy in Schools - Working with Children of All Ages in Mainstream and Special Education, Jessica Kingsley Publishers, London Derrington, P. (2010) The Sweet Escape: Hearing Impaired students in a mainstream secondary school get out of lessons to go to music therapy. Unpublished paper to the Anglia Ruskin University conference: The Music of Music Therapy Derrington, P. (2005) Teenagers and songwriting: Supporting students in a mainstream secondary school. In Baker, F. & Wigram, T. (Eds.) Songwriting: Methods, Techniques and clinical applications for music therapy clinicians, educators and students. London: Jessica Kingsley Publishers Diamond, K. (2007) Music as a CODA to Troubles related trauma. In Trauma: Current thinking and practice in music therapy; conference abstracts. Anglia Ruskin University, Cambridge 23-24 November 2007 Cambridge: Anglia Ruskin University Dixon, M. (2002) Music and human rights. In Sutton, J.P. (Ed.) Music, music therapy and trauma: International perspectives. London: Jessica Kingsley Publishers. Drake, T. (2008) Music Therapy at Coram: Research into practice. London: Coram. Retrieved on 31st July 2008 from https://www.coram.org.uk/attachment.php?binary=83e8f7f1f620888a44e734da0c5d952b/coram% 20Music%20Therapy%20Research%20Summary.pdf Duerkson, G.L. & Darrow, A.A. (1991) Music class for the at-risk: A music therapist s perspective. Music Educators Journal 78 (3): 46-49 D Ulisse, M, Ferrara, C. Walter, D. & Valentina, M. (2001) Music therapy and integration: application within schools. Paper presented at the 5 th European Music Therapy Congress. Naples, Italy. Eidson, C.E. (1989) The effect of behavioural music therapy on the generalization of interpersonal skills from sessions to the classroom by emotionally handicapped middle school students. Journal 19

of music therapy 26 (4): 206-221. Elefant, C., (2002), Enhancing communication in girls with Rett Syndrome through songs in music therapy, Thesis submitted for the degree of doctor of philosophy, Aalborg University Institute of music and music therapy. Ely, E.M. & McMahon, M.A. (1990) Integration where does it begin? A creative arts perspective. Australian journal of music therapy 1: 36-44. Estelle, C.J. (1990) Contrasting creativity and alienation in adolescent experience. The arts in psychotherapy 17: 109-115. Facchini, D. (2001) Music Therapy in the Educational System a course of experiences and emotions. Paper presented at the 5 th European Music Therapy Congress, Naples, Italy. Field, T., Martinez, A., Nawrocki, T., Pickens, J., Fox N.A., & Schanberg, S. (1998) Music shifts frontal EEG in depressed adolescents. Adolescence, 33(129), 109-116. Gilbertson, S. & Aldridge, D. (2003) Strategies for searching electronic databases. Music Therapy Today (online) Volume 4 (4) Sept. 2003 Gold, C., Wigram, T. & Berger, E. (2001) The development of a research design to assess the effects of individual music therapy with mentally ill children and adolescents. Nordic Journal of music therapy 10 (1): 17-29 Gold, C., Voracek, M. & Wigram, T. (2004) Effects of music therapy for children and adolescents with psychopathology: a meta-analysis. Journal of Child Psychology and Psychiatry 45 (6): 1054 1063. Goolsby, T.M., Frary, R.B. & Rogers, M.M. (1974) Observational techniques in determination of the effects of background music upon verbalisations of disadvantaged Kindergarten children. Journal of Music Therapy, 11: 21-32. Haines, J.H. (1989) The effects of music therapy on the self-esteem of emotionally disturbed adolescents. Music Therapy 8 (1): 78-97 Hilliard, R.E. (2007) The effects of Orff-based music therapy and social work groups on childhood grief symptoms and behaviours. Journal of Music Therapy, 44 (2): 123-138. Hippel, N. & Laabs, F. (2006) [music therapy in school a new field for music therapists?]. Musik Therapeutische Umschau 27 (3): 280-289. HM Government (2003) Every Child Matters. London: Department for Education and Skills Home Office (2006) The respect action plan. London: Home Office Howden, S. (2008) Music Therapy with Traumatised Children and their Families in Mainstream Primary Schools: A case Study with a Six-year-old girl and her Mother. In A. Oldfield and C Flower (eds) Music Therapy with Children and their Families. London: Jessica Kingsley Publishers. Hunt, M. (2005) Action research and music therapy: Group music therapy with young refugees in a school community. Voices: A world forum for music therapy 5 (2). Retrieved March 10, 2008, from http://www.voices.no/mainissues/mi40005000184.html Jenkins, C. (2006) Music Therapy with adolescents with emotional and behavioural difficulties: A flexible approach. PGDip Dissertation. London: Guildhall School of Music and Drama. 20

Jellison, J.A. & Gainer, E.W. (1995) Into the mainstream: a case study of a child s participation in music education and music therapy. Journal of Music Therapy 32 (4): 228-247 Karkou, V. (ed.), (2009) Arts Therapies in Schools, Research and Practice, Jessica Kingsley, London Kartz, B. (2000) Grenzen. Heilpädagogische Musiktherapie an einer Schule fűr Erziehungshilfe. Thesis submitted for diploma in Music Therapy Enschede: Conservatory, Saxion Hogeschool Kennedy, R. & Scott, A. (2005) A pilot study: The effects of music therapy interventions on middle school students ESL skills. Journal of Music Therapy 12 (4): 244-261 Kids Company (2008). Kids Company Learning from vulnerable children: How to care better Retrieved 31 July, 2008, from http://kidsco.org.uk/ Kim, S., Kverno, K., Lee, E.M., Park, J.H., Lee, H.H. & Kim, H.L. (2006) Development of a music group psychotherapy intervention for the primary prevention of adjustment difficulties in Korean adolescent girls. Journal of child and adolescent psychiatric nursing 19 (3): 103-111 Kivland, M.J. (1986) The use of music to increase self-esteem in a conduct disordered adolescent. Journal of Music Therapy 23 (1): 25-29 Koch-Temming, H. (1999) [From treating illness to insuring health; music therapy in the integrated kindergarten]. Musik Therapeutische Umschau 20 (1): 5-13 Kok, M. (2006) [new paths for music therapy in music schools; cooperation with schools of general education]. Musik Therapeutische Umschau 27 (3): 269-274 Krout, R.E. & Mason M. (1988). Information sharing: Using computer and electronic music resources in clinical music therapy with behaviourally disordered students 12 to 18 years old. Music Therapy Perspectives 5: 114-118 Laiho, S. (2005) The psychological goals for engaging in music in adolescence. Music Therapy Today (online) 4 (4) Retrieved March 10, 2008 from http:www.musictherapytoday.com Laiho, S. (2004) The psychological functions of music in adolescence. Nordic Journal of Music Therapy 13 (1): 47-63 Mahns, W. (2002) The psychodynamic function of music in analytical music therapy with children. In Eschen, J.T. (Ed.) Analytical Music Therapy. London: Jessica Kingsley Publishers Mahns, W. (1996) Individual music therapy in the Integrative Primary School in Hamburg Ten sessions with a slow learning girl. In Pedersen, I.N. & Bonde, L.O. (Eds.) Music Therapy in Multi- Disciplinary Teams. Aalborg: Universitetsforlag. McFerran, K, Lee, Ju-Young, Steele, M, Bialocerkowski, A (2009) A descriptive review of the literature (1990-2006) Addressing Music Therapy with People who have Disabilities, Musica Humana, Vol1, No.1 45-80 McFerran, K. & Hunt, M. (2008) Learning from experiences in action: music in schools to promote health coping with grief and loss. Educational Action Research 16 (1): 43-54 McFerran-Skewes, K. (2003) Using songs with groups of teenagers: How does it work? Social work with groups 27 (2/3): 143-157 21

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Appendix 1 Music Therapy Statement There is no robust evidence to identify which form of music therapy is effective for which needs and what the outcomes would be for an identified cohort of children. There is little, if any, qualitative evidence that music therapy is successful in facilitating educational goals. The LA is of the view that in the absence of appropriate data it will not fund music therapy of individual children. Any use of musical interventions would be the responsibility of the school to fund. Therefore the Local Authority (LA) is of the view that for children with developmental disorders and learning difficulties it is appropriate for mainstream schools to source advice from specialists for Special Education Needs (SEN) and/or disabilities. Should children require music as a true form of therapy this should be provided by health as it does for SAL needs, motor difficulties etc. Special Schools would remain responsible for ensuring that they have the right mix of additional therapies (art, play aromatherapy, music) to meet the needs of their children and young people. NB Where music therapy remains detailed in an existing statement the LA will fund until such time as the statement is amended and music therapy removed. Cambridgeshire County Council START Team, June 2011. 25

Appendix 2. 3. History of Music Therapy with Cambridgeshire Music Around half of the music therapists working in the UK work with children and the vast majority of music therapy work with children takes place in schools. A county music therapy service was established in Cambridgeshire in 1995 in partnership with Anglia Polytechnic (now Anglia Ruskin University) and Cambridgeshire County Council. The Cambridgeshire Music, Music Therapy team has been in existence since then and now operates one of the biggest music therapy services in the country delivering 189 hours of music therapy per week to vulnerable children in 37 schools, units attached to schools and children s centres across the county. Music Therapy work in Cambridgeshire initially occurred in special schools beginning with three music therapists employed in a variety of special schools across the county. It quickly expanded to include all of the special schools in Cambridge and some in the wider Cambridgeshire county - Spring Common, Samuel Pepys, Meadowgate School, Wisbech etc. The experience has been that although money in schools is always restricted that schools are very positive about music therapy and that generally music therapy hours increase the longer a therapist works there. Participation in Ofsted inspections has also impacted on development of music therapy work with positive feedback within schools reports. In more recent years music therapy continues to be part of the Ofsted process but has not been included in the written report from inspectors as the primary focus is now on evaluation systems and assessing teaching and learning. (Jo Storey (2011) p215) Mainstream work Work in mainstream schools developed over time and has continued to grow in particularly with normal students (work with refugees, mainstream children with emotional and/or behavioural problems, children deemed at risk, bereaved children and deprived children) but also work to support integration of children with special educational needs. Gradually music therapy was recognised as a legitimate therapeutic support intervention in schools helping to fulfil requirements of the government s agenda Every Child Matters (DfES 2003). Many more children with special needs are now being supported in mainstream schools both primary and secondary. As part of this scheme there has been an emphasis on providing creative therapeutic interventions for those with special needs. Through liaision with services such as student assessment and access to learning and inclusion music therapy was incorporated into the Cambridgeshire County Council resource panel funding scheme. Many schools in deprived areas have nurseries or childcare facilities and cater for the needs of parents and siblings as well as those of the children. Music Therapy work in these areas means that music therapists are supporting more children and families than ever before and in a wider range of settings. Music therapy has been engaged to support children with additional needs and as a result music therapy work has grown in special schools, mainstream and secondary schools, nurseries and children s centres. The Cambridgeshire Music Service has continued to grow and a report by the Federation of Music Services in 2010 highlighted the importance of the current music therapy service to schools 14 music therapists deliver 189 hours of music therapy a week this represents a significant contribution to vulnerable children and young people (in Cambridgeshire). (Federation of Music Services Smith 2010 p5) Dr Amelia Oldfield in her introduction to the recent Music Therapy in Schools book (2011) relays the importance of finding a way to support music therapy The chapters in this book take us forward to the 21 st century and underline the importance and breadth of music therapy for children and young people in a range of educational [and health] settings. Music Therapy is now an extremely important intervention with children. 26