Ukm Music Therapy

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practice & research

music activities initiated bystaff within services for peoplewith intellectual disabilityRichard Jackson describes a study undertaken in Ireland that wasdesigned to establish the potential benefits ofmusical activities aimedat people with a learning disability. His description of the findingsconcludes with recommendations for practice and further research

Keywords music therapy creative therapy communcationThese keywords are based on the subjecheadings from the British Nursing IndexThis article has been subject to a doub leblind review.

T he literature on music and musictherapy for people with intellectualdisability is mostly written by musictherapists and psychologists. However, themajority of those who actually initiate musicactivities in intellectual disability servicesin Ireland are nurses and teachers/trainers(Table 1), In this study, a questionnaire wassent to the people initiating music activitiesin Ireland with the aim of finding out whatthey are doing and whether they find musicactivit ies worthwhile. The purpose of theresearch was to compare what the researchparticipants are doing with the literature inorder to make recommendationsfor practice and set direction forfuture research.

Music is defined in theChambers dict ionaryas an art form usinga harmonious, melo-d ious and rhy thmic

form ofnotes. Music therapy is defined as afunctional and scientific application of musicby a trained music therapist to enhance theindividual's social, emotional, educationaland behavioura l development (BerkleeMusic Therapy Department 2003). The useof music in intellectual disability in this studyincorporates listening to music, taking part inplaying percussion instruments, skills trainingand moving to music as a form of exercise,dance training and development of psycho-motor skills.Literature reviewMusic is a medium that can meet people'sneeds for ach ievement , s ign i f icance ,belonging, freedom and fun (Glasser 1989).Music allows expression of self and findingmeaningful, enjoyable com munication w ithothers (Juslin and Sloboda 2001). Musicresearch in the area of intellectual disabilityhas investigated the use of music; as a recreational ac tivity (Cheseldine and

Jeffree 1981) to teach self-help skills, recreation skills

and social skills (Logomarcino et a/ 1984.Duffy and Fuller 1998)

in increasing the capacity of the personwith intellectual disability to interact withpeers and/or staff (Hooper 1992. 2002,

anxiety and stress (Hooper and Linds1990. Durand and Mapstone 1998)

in achieving care plan goals (Oldfi1990, Duffy and Fuller 1998),Much of the research was comple

with small samples and therefore tresu l ts canno t be genera l ised to whole in te l lectual d isabi l i ty populat ibut overall the research affirms the usemusic and music therapy. Some reseaparticipants were able to achieve thepeutic and developmental goals (Aldridet al 1995. Toolman and Coleman 19Hooper 1992. 2002).

List of professions' ' " "o lved inth efearch studyProfession

Registered Ntjrse Intellectua l D isabilityOther nursing qualificationsCare staffMusic therapistMusic teacherTeacherWorkshop or activation managerOther multidisciplinary team memtjerHoli5tic thera pistChapiin

%322


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practice & j^Cheseldineand Jeffree (1981) conduaed

the only study with a large sample (200parents of adolescents with intellectual disa-bility) and shovfed that 90 per cent of thechildren of the participants chose to listen tomusic as their favourite recreational activity.Further analysis found that the parents inter-viewed perceived that their c hildren listenedto music for two reasons: they enjoyed itand because they lacked the relation-ship and psychom otor skills necessaryto take part in other forms of recrea-t ion.

Logomarcino et al (1984) taught fourpeople with moderate intellectual disab ilityto take part in traditional dancing used by

'Music therapy theory suggests tha tmusic engages w ith the min d, bringingawareness of self and others and leadingto positive change'the local community. Two local communitydance teachers were trained to be observersin the study and achieved an inter-raterreliability rating of 96 per cent. The danceteachers confirmed that three participantswere dancing competently as expected withinlocal community dance settings after trainingand taking part in comm unity events. Twostudies used music CDs to teach self-helpand social skills to people with intellectualdisability. Adenigagbe (1994) used musicto teach self-help skills to 20 people withmoderate intellectual disability of whom 14made significant progress. Duffy and Fuller(1998 ) used music to teach social skills to 32children with intellectual disability in fourgroups. They found music to be equallyeffective as games activities in teaching theskills. These three studies show that for theparticipants, social and psychomotor skillswere taught successfully through the use ofmusic, dance and trainin g strategies.

Using improvisationImprovisation is a musical technique used

involves a music therapistplaying an instrumentof his or her choiceand the participantsplaying instruments oftheir choice, usually percussioninstruments. The therapistshapes the music to meettherapeutic goals (Nordoffand Robbins 1983). Four researchstudies with one to five participantsin each used improvisation as part ofthe study and reported that participantsimproved their capacity to Interaa . Hooper(1992, 2002) used music and games activi-ties; Aldridge (1995) used a developmentalapproach to show increased interaction inpart icipants; and Toolman and Coleman(1994) used music therapy techniques toenable participants to resolve emotionalconflict, thus increasing the participant'scapacity to interaa.

How does music work?Theoretical explanations for the effective-

awareness of self and others and leading positive change (Oldfield 1990, Aldridg1995). According to choice theory (Classe1989), thoughts and feelings change duto actions that are satisfying for the persotaking part. This creates an openness in thperson's mind to learn and develop.

Hooper (2002) contributes to this discu


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on I ts posit iveeffect on the mind.

A well-structured activity,wi th a series of pos it ive

actions that the client enjoys, has the effect ofcreating positive behavioural and emotionalchange. A skilled therapist/train er uses themusical environment t o attain therapeutic ordevelopmental goals.The research studyParticipantsServ ices fo r peop le w i th in te l lec tua ldisability in the Republic of Ireland caterfor between ten and 2.000 people withmoderate to profound intellectual disa-bility. The services were created by rel i-gious orders, parent groups and healthboards. In the study described here, theresearcher divided the services into fivegroups. Each group catered for a similarnumber of people with intellectual disa-bility. Six services were picked randomlyfrom each group. This captured 30 percentof all services in the Republic of Irelandfor people with intellectual disability. Oneperson from each service was selected bythe organisation to identify employees whowere involved in initiating music activitieswit h thei r service users. A tota l of 160employees were identif ied from various

SurveyA questionnaire was developed by theresearcher and agreed as approp riate for thetarget population by a music therapist, a dayactivation team leader and a university stat-istician. Questions were based on the studiesused in the literature review and from theresearcher's knowledge of music activities

can'ied out in services for people w ith intel-^ , lectual disab ility in Ireland. Data were

sought on the type of music activities

Music activit ies increasing interactionThe part icipants were clear that muactivities enable people with intellectdisability to interact more effectively wtheir peers and staff members. Participain this study, as well as using singing apercussion instruments, also employ muand movement activities. This is differefrom the music therapists in the literatuAll of the music therapists in the literatencouraged their clients to sing (if ab

'A skilled therap ist/trainer uses the m usical environm ent toattain therapeutic or developmental goals'

initiated, the effect of music on mood, thecapacity of music to increase interaction andthe participants' perception of the effective-ness of the activities. Questions were alsoasked about available music therapy services,and a space was provided for any commentsin order to a ttain some qualitative data.EthicsEthical approval was given formally througha university committee and the ethicscommittee of one large service. A lettergiven to each participant emphasised thatquestionnaires were to be fiiled in only ifthe participant wanted to do so. To maintainconfidentiality, all data were kept locked inthe researcher's office.Data analysisEach question was analysed with SPSS usingdescriptive statistics and Speamian's two -tailedbivariate correlations to establish any possiblerelationship between data. The question thatoffered participants free space to write what-ever they wanted about their music activi-ties underwent qualitative analysis. This wasachieved by using a step-up system developedby Corrazi (cited in Burns and Grove 2001).The researcher and a university statisticiandeveloped the method of analysis.

Results

and play percussion instruments to devetheir capacity to interact. The inclusion in tstudy of music and movement activities, well as instrument activities, could relatethree factors:

they prov ide choice for clients they provide an activity that gives so

exercise and develops psychomoskills

they help participants overcome thinability to play a musical instrumwell. Only 11 participants were comtent in playing a musical instrument

Music and moodThe follow ing is a summary of q uali-tative data from nine participants whowrote about the impact of music on mostates ofthose with intellectual disabili' In music, activity needs are genuinmet so that the entire group experiencpositive emotion from feeling relaxed ahappy or an even greater sense of exciment or fun. Music appears to change mfrustrations - for example, irritability, manxiety, being withdrawn and boredom.music activity brings the person with intlectual disability and the staff taking pinto the mindset necessary to get more oof any one day.'

In this study participants reported tpositive use of music in an everyday cont


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mental, emotional and behavioural changein their clients {Aldridge 1995, Toolman andColeman 1994. Hooper 2002).Participants' perceptionsThirty-five per cent of participants saw musicas being equally effective as other avail-able activities, and 24per cent perceivedmusic as more effective than other activi-ties, Thirty-one per cent of respondents tothis question thought that music reinforcesgoals in clients' care plans. This benefitis also found in the literature: Duffy andFuller (1998) and Hooper (1992, 2002)found music activities and games trainingactivities effective in helping clients learnsocial and in teraa ion skills. Oldfield (1990)and Adenigagbe (1994) used music activi-ties successfully to attain relevant care pla ngoals toclients with moderate to profoundintellectual d isability.

Two groups of participants consistentlyanswered questions in amore positive waythan others. The tw o groups were the peoplewho played amusical instrument well (16per cent ofparticipants) and the group thatused CDs to teach fun ction al and social skillsto people with intellectual disability (13 percent). Both groups are too small for findings

Table 2Musical activity

initiatedRecreationalactivitiesinit iated bypart icipants100% ofparticipantsanswered thisquestionStyles ofmusiclistened to/in i t ia ted dur ingactivities

100% ofparticipantsanswered thisquestion

Musicalinstrumentsused bypart icipantsin init iatedactivities

70 % ofparticipantsresponded to thisquestion

Music andmovemen tactivitiesinit iated bypart icipants.

76 % ofparticipantsresponded to thisquestion

Singingactivitiesinit iated bypart icipants79 % answeredCDs made forpeople wi thintellectualdisabil ity foreducat ion andto providean enjoyableactivity

^ K ^ u s i ^ ^Over half ofparticipants

initiated this activityRelaxation activities

Complementarytherapies and musicMusic for fun, activityusing percussion musicalinstruments and guitar/pianoPopular musicIrish traditional musicClassical m usic

TambourinesShakersDrumsBeils

Singing t o recordedmusicSinging withoutaccompaniment

[iira:viiActual

%

85

5867

766257

56555150

62

57

iiiRuailfpllniiinTLess than half ofparticipants initiated this

activitySpiritual needs activities

Taking part in a concertGiving music lessonsBeing part of an audience

Folk musicRock musicReligious musicNursery rhym es

KeyboardsCymbalsGuitarWoodblocksTriangies

Disco dancingAction songsImprovised danceWheelchair dancingDrama, rTiusicandmovementGames to m usicAerobicsIrish dan cingSinging to percussionaccompanimentSinging wit h piano or guitaraccompanimentSonasTapes to meet trainingneeds of people w ithintellectual disability.Body and voice

Actual%42

231706

40403210

3432201817

4443383226

24211739

332613

08

^ ^ ^ ^ ^ ^Fewer t han 5%of participantsundertook this

activityMUSIC appreciation

Increase v ocabularyexerciseAfrican drumm ing

Improvised soundsReggae musicTraditional musicfromdifferent culturesNew age soundsDrumming soundsMUSIC for massage

Baron (Irish drum)RainmakerXylophoneChime barsAfrican drumsBongosBoom whackersAfrican beltsGourdsIrish waltzesDrumming andmovementSing-along movementHand and foot massagSensory integrationSacred danceGentle exercise

KaraokeMicrophone singing

KnillMusic and dramaSherbornEducational rhythmics


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to be generalised but data could be explainedby the fact that both groups of participantsinvested more of themselves in their initiativeand therefore perceived music as more effec-tive than it actually v^'as. A second possibleexplanation is that they offered a moreskilled musical input or training element tothe musical activity, making it more effectivefor th e service user.Role of the music therapistFour per cent of participants had clientsvwho attended sessions with a music ther-apist. Six per cent reported that their

mu lt idisciplina ry team included a musictherapist and 90 per cent of participantsreported the need for a music therapist. Thisindicates a large gap between perceivedneed and the music therapy service avail-able. Among the comments made by thefew participants who had access to musictherapists were these: 'The music therapysessions were brilliant': and 'Today I stilluse some of the activities learned from themusic therapist to help a client focus theirattention.' One respondent, the parent of achild with profound intellectual disability.

Table 3 Questions relating to participants' perception of theeffectiveness of music activitiesQuestion

How effective are interventionsyou use in assisting a person tochange mood?

In your opinion does musichelp the people you workwit h improve their capacity tointeract w ith others?

How effective is the music inputinitiated in comparison w ithother activities initiated?

Result87% posit ive

+ 1:39%+ 2 :30%+ 3:18%

90 % posi t ive

56 % said that music increasesinteraction with staff and peers24 % said that music increases

interaction with staff only10% said that music increases

interaction wit ii peers oniy

100% answered this question

35%. music is equal to otherinitiated activities

2 4 % : music is more effective thanother activities

31 %: music is effective inreinforcing goals in the person's

care plan10%: music is not as effective as

other activities

82% of the group that used trainingCDs (nine participants) saw music as

Comment87% of participants saw music as apositive way to change m ood

The 56% group used more musicand movem ent activities than the24 % groupThe 24 % group worked more withpeople with severe and p rofoundintellectual disability. This explainswhy this group increased interactionwith staff only

The first and third groups used moremusic and movement activities.The use of music and movementactivities to increase interactionrequires more investigation90 % of the participants see musicas an effective activitySplit file analysis showed that thatthe 24% and 31 % groups weremore positive in their answersto aii the questions. This couldbe because the staff membersthemselves enjoy music m ore thanother ac tivities, or their observationof client responses in music andother activities

Although this group is small it needsto be noted that tiie group offering

wrote: 'I think music therapy changed son's life.'

Music therapists c ontribute a good dealthe literature but their contribution to seices in Ireland is still min im al.DiscussionThe literature describes two approacheshelp people with disability develop commnicat ion, social and psychomotor skiOne is to use music therapy interventio(Toolman and Coleman 1994. Aldrid1995 ); the other is to teach skills throughcombination of music and training aaiviti(Duffy and Fuller 1998). The researcherseach study agree that some participants wintellectual disability make a lot of progreand others only a little.

The staff members in this study usa range of musical instrument activitietraining CDs. and music and movemeactivities (Table 2). Music activities, how evare not a panacea. Music is just one strateto help people with intellectual disabildevelop their overall potential. Hoop(1992, 2002), Duffy and Fuller (1998) a35 per cent of respondents in this stufound music interventions equally effectas other interventions.

The participants overwhelmingly (90 pcent) agreed that their client groups need tservice of a music therapist, A large numbof adults with intellectual disability in Irelahave limited access to a multidisciplinateam (Baman and Mulvany 200 4). Therefoit is not surprising that fewer than 10 per cof participants had access to a music thepist. Increasing the number of multidiscinary members, including music therapisis a major issue for people with intellectdisabilities in the Republic of Ireland.Weaknessesof the studyDe Vaus (2002) perceived superficialityinforma tion as a weakness in survey desigThis study did not have the scope to g


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excluded some teachers and staff on annualleave. This may partly explain the 52 percent response rate.Recommendations forpractice and future researchServices need to consider the employmentof music therapists to initiate therapeuticprogrammes and offer support to staffalready initiating music programmes (33per cent of participants in this study v^antsupport). The participant group that playedan instrument well were more positive intheir ansv^ers to the questions. Staff in itiatin gmusical activities who are given support togain expertise in playing a musical instru-ment will increase the potential for devel-oping improvisational techniques.

There is a need to develop and research

'Music therapists contribute agood deal to the literature buttheir con tribution to services inIreland is still minimal'

services. Specific music and movementmethods should also be researched todetermine their capacity to developpsychomotor and communicat ion

skills.Finally, it will be important to establish

whether music therapy, musical instrumentactivities and music and movement interven-tions have long-term benefits to the person

with intellectual disability.ConclusionThe majority of staff who initiate music

activities for people with intellectual disa-bility in the Republic of Ireland are notmusic therapists or musically trained; theyare nurses, teachers, care staff an d membersof the multidisciplinary team (Table 1). Inspite of this they provide a variety of musicand music and movement activities thathave some observed benefits. These includeincreasing the capacity for the person withdisability to interact, improved mood, andmeeting client care plan goals.

The participants in this study concur withevidence from the literature that, comparedto other strategies, music is equally or moreeffective in enabling people with intellectualdisability to reach desired goals (Table 4).The most positive participants in this studywere those who could play a musical instru-ment well, or who used music as a part of aCD training programme. This requires furtherinvestigation.

The absence of music therapists from thearea of intellectual disability is well noted bythe participants. Services need to considerthis in planning multidisciplinary servicesin the future. Recommendations have beenmade in light of the findings

Richard Jackson MSc Nursing , RN

ReferencesAldridge D, CListorff D, Neugebauer L(1995)A pilot study of music iherapy in the treatmenwith developmental delay. ComplementuryTherapies in Medicine. 3. 197-205.Barren S. Mulvan y F (2004) National IntellectuDisability Database Comminee. HRB. DublinBerklee Music Therapy Department (2003)(Online). Available from http://www.ber'klee.edu/d epartm entV [Last accessed; 1 June 200Burns N, Grove S (2001) Tfie Practice o^NursinBesearcfi. Conduct. Critique and Utilization. 4t hedition . WB Saunders & Company, London.Cheseldine S. Jeffree D (1981) Mentallyhandicapped adolescents: their use of leisure.Joumal of Menta! Deficiency Research. 25. 149-59.De Vaus D (2002 ) Surveys in Social iesearcfi.edition. Routledge, London.Duffy B, Fuller R {1998) Roie of music therapyin social skills development in children wit hmoderate intellectual disability. Journal ofApplied Research in Intellectual Disabilities.77-89.Durand M. Mapstone E (1998) Influenceof 'mood-inducing' music on challengingbehaviour. American journa/ of MentalRetardation. 102. 4, 367-378.Gtasser W (198 9) Control Theory. Harper & RLondon.Hooper J (1992) Developing Interact/en ThrougShared Musical Experiences: A Strategy to Eand Validate the Descriptive Approach. ConferProceedings. Volume 3. British Society of M usiTherapy. London.Hooper J (2002) LJsing music to deve lop peerinteraction: an examination of the response oftwo subjects w ith a learning disability. BritishJournal of Learning Disabilities. 30, 4, 166-1Hooper J, Lindsay B (1990) Music and thementally handicapped - the effect of music onanxiety, British Journal of Music Therapy. 4, 19-26,juslin N, SlobodaJ (2001) Music and Emotfon:Theory and research. Oxford University PressOxford.Logomarcino A eta/ {1984) Leisure-danceinstruction for severely and profoundly retardepersons; teaching and intermediaie-living skillJoorna /of Applied BehaviouraMna/ysis. 17, 1,71-84,Nordoff P Robbins C (1983) Music Therapy Special Education. MMB Publishing, LondonOldfield A (1990) The effects of music therapyon a group of profoundly mentally handicappadults. Journal of Menta! Deficiency Researc1.107-125.


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