Music Therapy With Children With Attachment Disorder

Music therapy began to develop as a profession around the time of World War I. Medical professionals noticed that when music was played during surgery less anesthesia was needed. Music was also used in rehabilitation: for example, playing a wind instrument for respiratory rehabilitation. Since that time music therapy has grown as a profession. Music therapy can be utilized in hospitals, schools, nursing homes and a wide variety of other facilities which promote physical, emotional, and mental development. Music therapy can be a powerful tool when working with children with severe emotional disturbances (SED). Music therapy can bridge the gaps in emotional, developmental and relationship skills. This article will explain some techniques that are used with children with SED and give a short vignette about a child diagnosed with an attachment disorder. Complex therapy cases challenge clinicians and compel them to create effective interventions to reach SED children. A music therapist has the option of utilizing any music related activity to design interventions to address treatment goals. The field of music therapy has refined interventions over the last 45 years. Within the field, universities teach a standard repertoire of activities, which are used in practice and in research. For the purposes of this article, these activities have been categorized into 5 general descriptions: live music production, improvisation, lyric analysis, skill building and self-comforting activities. These categories are not all encompassing of the interventions used by music therapists, but provide a general introduction. Live music production includes a broad range of activities which might include singing, making up a drum pattern as the therapist plays the child's favorite song on the piano, or exploring the interesting sounds one can create on a keyboard. It is music for the sake of making music. A desired response from this activity is access to feelings. A therapist might observe a child's pride in his or her skills, or fear when the child hears spooky music. Another outcome is the spontaneous enjoyment of the aesthetics of live music. Improvisation is a specialized type of live music. Some children will show a natural talent for this or the therapist can teach it. The response the therapist is looking for is identification and expression of a selected feeling. The non-verbal aspect of this intervention is valuable for children with limited verbal skills or those who incurred abuse at a preverbal stage. Often when children are defended and do not like to rely on verbal processing this method can accurately represent the intensity of their feelings.

Lyric analysis relies on the text component of music. A therapist may choose to use popular songs or children's songs. Because of his or her musical training, a therapist can also write a song for a specific child to convey a concept or message. A music therapist also has a variety of songwriting techniques to allow the child to successfully write his or her own song. The content of the song may describe relevant issues which the child is working on. It may also be a way to explore what is absent from the child's life. For example, the loss of a parent, or not seeing siblings. Skill building is not music lessons but adapting educational approaches to bridge developmental delays and enhance self-esteem. Part of the training of a music therapist is to make it possible for anyone to create music. This could be something as simple as pushing the piano key with the red sticker followed by the blue sticker, but the child is making music and the therapist makes it sound "like a real song." The child is allowed to explore a preferred instrument and begin to get some skills under his or her belt. Children with SED have missed so many normalizing activities necessary for developing skills that it is crucial to address this in order to impact arrested development. Finally, self-comforting activities are related to relaxation and receiving comfort from music. Everyone uses music for specific purposes and this is one of the benefits of music which requires no prescription and has no side effects. Endorphins, the pleasure producing chemicals released by the brain, can be produced when listening to music. The ability to receive comfort from music can also, hopefully, lay the groundwork for accepting comfort from human caretakers. Beech Brook is a multi-service agency in Cleveland, Ohio, which provides mental health services for children and families, including outpatient therapy, residential and day treatment, foster care and adoption, and family preservation. The agency uses individual music therapy as a primary therapeutic modality. The following vignette will briefly highlight a prototypical case, describing background history, presenting symptoms, salient treatment themes, and responses to their individualized music therapy approaches. Katy's mother had a criminal record of assault and robbery, a history of alcohol and intravenous drug abuse, and multiple suicide attempts resulting in psychiatric hospitalizations. Police charged her mother and stepfather with physical abuse, sexual abuse, educational neglect and abandonment of their children. Katy and her four siblings entered the social service system after their mother abandoned them.

Katy's behavior had been so unmanageable that she had been in ten different placements by the age of six, with diagnoses of post traumatic stress disorder, separation anxiety, and conduct disorder. Presenting behaviors at the time of her admission to residential treatment included extreme aggression, suicide attempts, sexual acting out, and compulsive lying. Katy also displayed other, more subtle behaviors indicative of attachment disorder, including being highly manipulative, having difficulty trusting others, and rejecting nurturing relationships. Team members thought that these symptoms emanated from her abuse history and subsequent out-of-home placements. The music therapist was asked to address relationship skills. Katy initially used live music performance and improvisation. She developed a relationship to the music but not the therapist. She would use only parallel interaction, not reciprocal during music production. Later in music therapy she distanced herself further from the therapist, but continued to relate her inner self through pop lyrics. Her choice of music reflected powerfully sad core themes that she was unable to verbally relate to the therapist. Had she been in traditional talk therapy, she might not have continued -- but through the projective techniques of music therapy, he was still able to communicate. When improvisation is used with children with attachment disorder, it often serves as a metaphor for their internal relationship capacity. The therapist can gauge the level of a child's ability to relate by the quality of the child's musical involvement (rejecting, independent, parallel or reciprocal), and observe its change over time. Most important, the interdependent and communicative nature of the intervention calls for risk-taking by a child who has learned to avoid intimacy with significant adult figures. Through the practice of risk-taking and developing a new, positive perception of relationships, the child's ability to form healthier future relationships can improve. Interestingly, live music allows a child with attachment disorder to be the "star," and then sets the stage to explore their tendency to be charming and superficially engaging in relationships and thereby avoid intimacy. Because of their avoidance of direct questioning, text or lyrics can be a telling projective tool. Self-comforting activities are also important for this subgroup of children with SED due to their lack of essential early childhood nurturing. Developing a capacity to receive comfort through music lays the groundwork for accepting nurturing and affection from a human caretaker.

Other areas that may or may not be present in a child with an attachment disorder can be addressed with music therapy. It is not uncommon for this subgroup of children to have developmental delays or aggressive behaviors. Such a child can learn songs to develop a feeling vocabulary. Next the child is encouraged to pair instruments with feeling states. With support, the child then connects feelings to life events. The final goal is to allow the child to select a medium to express a feeling, then modulate or change the feeling state, and finally move from a negative to a positive feeling state. Live music making delineates clear limits for behavioral expectations. When a child can execute tasks independently, this indicates increased ability to internalize structure. More sophisticated tasks require more control over impulses. Skill building allows the child to reprocess their negative experiences in a way that promotes a healthier identity. The text of songs may contain lyrics that describe situations that mirror or contrast with the child's violent and abusive relationships. These lyrics offer opportunities for the child to compare violence with healthy, nonviolent relationships and responses. Writing lyrics that describe traumatic experiences allows discharge of feelings in a less threatening manner, thereby gaining a sense of mastery over them. Extremely aggressive youngsters who have histories of maladaptive behaviors often come from environments that did not model healthy problem-solving strategies. These are just a few examples of how music therapy can be used to address common issues seen in children with attachment disorder. Further research and knowledge is needed on how to more effectively treat children with attachment disorder through expressive mediums such as music therapy