Strengthening families: a role for music therapy in contributing to family centred care.

Abad, Vicky ; Edwards, Jane

Abstract

Sing & Grow is a music therapy programme funded by the Australian Commonwealth Government and presented in partnership with Playgroup Queensland and The University of Queensland, initially for a two-year period, but now with funding assured to 2007. The programme is a family based intervention for families with children aged birth to three years that uses music to strengthen parent-child relationships through increasing interactions and assisting parents to bond with their children, and to extend the repertory of parenting skills in relating to children through interactive play. This benefited the participants by engaging young children in developmentally stimulating activities while reinforcing to parents the importance of their active participation in assisting a child to meet developmental milestones. This paper reports the theoretical basis for this project, its implementation in the community sector, and issues in identifying the outcomes to date, including the use of attendance figures to support the value of the programme. The processes in this music therapy programme are indicated through the case vignettes presented.

Key Words: music and parenting; music therapy; music and early childhood; music and attachment

Introduction

Sing & Grow is music therapy programme presented within a family centred model, funded by the Australian Commonwealth Government and presented in partnership with Playgroup Queensland and The University of Queensland. The bid to offer the two-year, fully funded programme was proposed by the School of Music staff at The University of Queensland, who initiated and wrote the bid in response to a call from the Federal Government for new initiatives to promote family well being (1). The project provides Queensland families with children aged from birth to three years the opportunity to participate in a series of ten weekly music therapy sessions. This opportunity serves as an early intervention strategy to families in communities identified as at risk of marginalisation as a result of their socio-economic circumstances, including low income, single parenthood, young parenthood, drug and alcohol addiction, living with a disability, and being a member of a cultural minority.

Literature review

Families at Risk

Research has indicated that families identified as at-risk of marginalisation may experience circumstances that impact on their ability to bond and interact with their children (Kelly, Buehlman, & Caldwell, 2000; Morton & Brown, 1998). This in turn potentially impacts on future development, as the child's early life experiences and social environment have been linked to their later development (Field et al., 2000; Kelly, Buehlman, & Caldwell, 2000). These early experiences of interaction may also affect how the child interacts with others as an adult, including their own children, potentially contributing to a cycle of deprivation (Bradley, Cupples, & Irvine, 2002; Morton & Brown, 1998; Ramey et al., 2000). It is therefore important to ensure that a child's early life experiences include provision for a loving, safe, and supportive environment, as well as an environment in which the capacity for attachment and close bonding between parent and child is available and realised (Carr, 200 1; Stern, 1985).

The quality of family relationships, and the personal, social, and economic resources of the family, impact and entwine for individual physical, social, emotional, cognitive, and language development (Sanders, 1999). Negative, inconsistent parental behaviour and high levels of family adversity are associated with the emergence of problems in early childhood, and persistence of these problems to school age (Campbell, 1995; Shaw, Vondra, Dowdell-Hommerding, Keenan, & Dunn, 1994). In addition, while child maltreatment knows no economic and social boundaries, parental poverty is reported to be a risk factor for physical abuse. It is reported, however, not to be a risk factor for any greater incidence of emotional abuse than occurs in the general population (Jones & McCurdy, 1992).

As research has shown, infant development can be hampered by a number of parental factors including the presence of maternal depression, (O'Connor, Heron, Golding, Beveridge, & Glover, 2002), parental age at the birth of the child, and a family history of psychiatric disorder (Sidebotham, Golding, & The ALSPAC Study team, 2001). "Family intervention" is a process that targets family interaction patterns assumed to contribute to the development and maintenance of disturbances in the child's functioning (Sanders & Markie-Dadds, 1996). By addressing these issues at the level of "family" rather than the individual child, as may occur in Early Intervention, it is proposed that long term benefits occur for the children attending the programme with their parent(s), as well as any subsequent children, born later into the strengthened family system (Dale, 1996).

Music and Parent-Child Relationships

Music has long been associated with parent-child interactions and bonding, as seen in the millennia old culturally shared tradition of singing lullabies and rocking/moving to communicate with and soothe babies (Papousek, 1996). The act of singing is one of the earliest and most common forms of musical interaction shared between a parent and child (Oldfield, 1995; Papousek, 1996). Music is an inviting and fun activity that most children and infants enjoy, and most parents can relate to (Abad & Edwards, 2002), as it is "uniquely engaging" (Shoemark, 1996, p. 12). It can therefore be used to combine the parent and child in a programme that addresses the unique needs of both within the one group setting (Abad & Edwards, 2002; Shoemark, 1996).

Music used with families in an interactive way within a group setting can support participants in developing skills that enhance parent-child relationships (Abad, 2002; Oldfield, 1995, 1999; Oldfield & Bunce, 2001; Shoemark, 1996; Vlismas & Bowes, 1999). Using music to engage a parent and child to help enhance the skills and behaviours required for close, supportive relationships could therefore be seen as an extension of phenomena that are already present in regular social interaction within family life (Oldfield & Bunce, 2001).

Music Therapy and Parent-Child Programmes

While there is some literature pertaining to parent-child programmes in music therapy and related fields, the area is generally under reported and researched. Oldfield and Bunce (2003) stated that short-term music therapy work with mothers and young children is an unusual area for music therapists to work in. One reason for this may be that funding has traditionally been provided in music therapy for treatment rather than prevention, however music therapy work with parents and children to help prevent issues that may arise from social disadvantage is an emerging clinical area (Abad & Edwards, 2002; Oldfield & Bunce, 20D1).

Lyons (2000) described a family-centred social work group with women and children aged from birth to three years who were identified as marginalised. The group programme used music to help parents and children team and grow in a safe, developmentally stimulating group environment that fostered parent-child interaction and reduced isolation. Music provided a way to meet the different needs of the parents and children within the child-centred programme that was offered, and was identified by group members as the highlight of each week.

Shoemark (1996) conducted a family-centred music therapy programme within a playgroup setting with children diagnosed with conditions that may lead to developmental delay. The purpose of this programme was to nurture creative expression and enjoyment in family members and help build mothers' confidence in creating any kind of music. Evaluation indicated that music was able to support families in developing skills to enhance their relationships. In formal and informal feedback, staff acknowledged the engaging quality of a music programme provided by a qualified music therapist.

Oldfield & Bunce (2001) reported on a mother and toddler group that aimed to help families who were experiencing difficulties with parenting. It was noted that many of the mothers involved had not experienced good parenting themselves. This music programme provided support for parents to interact with their children in positive and spontaneous ways. The music interaction was able to create a warm, simple interaction between a mother and her child and allow them to have fun together through music making.

Oldfield & Bunce (2003) conducted an investigation to study the impact of short-term music therapy programmes with mothers and young children in two clinical settings and one control setting. The overall aim of the music therapy groups was to help mothers who were experiencing difficulties in the parenting of their young children by engaging in playful musical interactions with their children, and through reflecting on this process after the sessions to help mothers gain new insights and more confidence in their parenting abilities. Results showed that levels of engagement and interactions were high in nearly all of the sessions conducted. These results indicated that music therapy treatment was able to engage mothers and their children in positive activities in play and music therapy sessions.

Music sessions offered to parents and children in a "family centred" approach can provide opportunities for learning new skills, strengthening interpersonal bonds, and developing creative strengths in both parents and infants.

Method

Establishment

The first 6 months of Sing & Grow focused on developing materials for use in the groups, including traditional and original song material, establishing a referral system, and developing resources such as the CD to be given to each participating family. The CD contained 20 children's songs used in the Sing & Grow program. These consisted of well-known nursery songs, action and movement songs such as Twinkle, Twinkle Little Star, and a number of original songs written by Australian music therapists. These songs were specifically composed to address concept comprehension skills, listening skills, body part awareness, movement activities and other developmental tasks. Quiet lullaby songs were placed at the end of the CD, to encourage parents and children to sit together and share a quiet time. These songs may also be used to help children sleep or relax.

During this early development period, Sing & Grow was promoted extensively within the community sector; mainly through conducting a total of 30 in-services to approximately 200 people from community organisations that support young parents, young women in crisis, women who have experienced domestic violence, parents and children with disabilities, and families who were indigenous or non-English speaking, or with low incomes. Also, child-health clinics that support families with new babies in the identified regions were targeted. It was important that strong links were established in the community with organisations that could make appropriate referrals to the programme and then also provide ongoing support to the families who participated.

Implementation

A trial programme was conducted at a community centre that had an established playgroup with the support of Playgroup Queensland staff. On completion, the session plan, goals, and objectives were modified, and documentation and evaluation protocols were established. Sing & Grow was then introduced into the community sector in collaboration with various organisations that had shown an interest during the in-service phase. The sessions were conducted by the Director, or another Registered Music Therapist, who was contracted to Sing & Grow as a session leader.

Session Plan

Sing & Grow aimed to strengthen parent-child relationships through increasing interactions and assisting parents to bond with their children, within a structured and therapeutic environment that was fun, non threatening, and responsive to the needs of both the parent and child. Specifically, face-to-face interactions, hand-over-hand facilitation, and coactive use of instruments were used to increase interactions and play during sessions. A range of interactive, nurturing, stimulating, and developmental music activities provided the framework for parents to interact and play with their children. Such activities further benefited the participants by engaging young children in developmentally stimulating activities while reinforcing to parents the importance of their active participation in assisting a child to meet developmental milestones. The programme was structured to promote modelling, peer learning, and facilitated learning for the parents involved through encouragement of their skills and strengths.

In order for this potential to be met, parents were actively encouraged to sit on the floor in circle formation with their child sitting in their lap or close by, and participate in each section of the session. Sessions generally followed a structured format that included a hello song, action and nursery songs, movement songs and games, instrumental play, quiet music, and then a goodbye song.

Evaluation

Information on the demographics of participating families and their use of music in the family home was collected by the music therapy session leader at the beginning of each new programme as the funding body required this information. Musical interests and preferences were incorporated into each programme to ensure personal tastes and needs were being addressed and was used to later compare if use of music in the home had changed over the ten-weeks. Parents were asked to complete a questionnaire in weeks five and ten to ascertain their perception on the benefits of participation in the programme. Parents were asked (a) if they found the programme tin and useful, (b) if they had learnt new ways to use music with their child at home since participating in the programme, (c) if the way they used music at home had changed, (d) if they felt more comfortable singing and using music since participating in the programme, (e) if they would participate in another Sing & Grow, and (f) how they would improve sessions.

The session leaders kept weekly notes based on their observations of parent and child participation in relation to the goal areas of the programme. These notes, and the questionaries and verbal feedback from parents and the collaborating organisations, were used to complete a descriptive evaluation of each ten-week programme.

Results

Attendance

Attendance figures show that a total of 467 families were referred to Sing & Grow in the first two years. During the planning phase of Sing & Grow based on similar projects (2) it was estimated that 50% of families referred would follow through and attend at least one session, and that 33% of these families would attend a programme consistently. Attendance records showed that 92% (n=426) of the families referred attended at least one session, and 53% of the 426 families attended at least half the sessions they were offered in the ten-week programme. After two years, 557 infants and toddlers have participated in the programme.

Thirty-four groups were conducted with people identified as having social needs and/or parenting issues. These included young parents, young women in crisis accommodation, women who had experienced domestic violence and/or abuse, families and parents who had been identified as having difficulty bonding and/or interacting with their child, and families with low incomes. Eight programmes were conducted with families with a disability, including parents who were deaf who had hearing children, and women who had been diagnosed with learning difficulties. One programme directly offered to an indigenous community was conducted, but indigenous participants were also involved in other programmes.

Observed Changes

Weekly documentation collated and compared to the descriptive data collected at week one indicated that goal areas were met with participants. Parent-child interactions were observed to increase over the course of each ten-week programme. This was observed in face-to-face interactions, hand-over-hand facilitation in instrumental play and action songs, and facilitation in movement and dance activities. Parents reported that they were more aware of how music could be used to increase parent-child interactions and encourage child development. Children were observed to generally participate more frequently and actively in activities that encouraged cognitive, physical, and social growth and development. Supporting age appropriate language development was also a focus of many of the programs.

Parent Questionnaire

Parental responses to a questionnaire indicated that all families who completed the form rated participating in the group as "fun" or "very fun". This suggests the participants found the program enjoyable and useful. Ninety-three per cent of participants reported that they learned new ways to use music at home. Ninety per cent of respondents indicated that the way they used music at home had changed since participation in Sing & Grow. Some indicated they were now playing more live music in the home. In addition, some reported increasing their repertoire of children's songs. It was also reported that parents were singing songs from the group with their children. They reported using music to help with household tasks. Seventy-nine per cent of parents reported feeling more comfortable singing and using music with their children. Ninety-six per cent of families stated that they would like to participate in another Sing & Grow programme. Some of these parents now attend other types of programmes. The most common "improvements" suggested by participants were for smaller groups, or for longer programmes, however generally there were not many suggestions made.

Case Vignettes (4)

The following case vignettes demonstrate how music therapy techniques were used with parent-child dyads to address core issues. The first two examples describe how music was used in this setting to increase parent-child interactions to assist in strengthening relationships. The remaining three vignettes describe how music was used in this programme to encourage and facilitate increased parental participation and engagement.

Example 1

In each session parents and children were provided with opportunities to share quality time. Quiet music was used to encourage parents to sit or stand with and rock or hold their children to facilitate physical closeness and bonding. Bonding and intimacy was also encouraged in each session through face-to-face play and gentle touch.

During a programme conducted at a crisis accommodation service for young women it was observed that most of the mothers appeared hesitant to participate in gentle play and were more confident with rougher play with their babies, such as swinging and tickling. Over the course of the programme the music therapist modelled gentle play and nurturing interactions, and the mothers were encouraged to use these interactions. One mother in the group responded positively to this encouragement and began to interact and play gently with her child and enjoy rocking her baby. Often her child would become so relaxed he would fall asleep. These sessions served as access visits for this mother during the first half of the programme and she continued attending sessions after she had regained full custody of her child.

Example 2

A programme was conducted with women who had issues related to bonding and interacting with their children, often as a result of personal abuse. At the mid-evaluation one parent wrote, "I feel this program has helped me feel more relaxed with relating to my baby of 16 month". At the completion of the programme she wrote that Sing & Grow was "very useful in that I learnt something to help me bond with my [age] baby (to do something I had no idea to do)". Another participant stated, "I did not have it in me to experience with my baby the interaction I have learnt through [the] group and I am so very thankful and grateful to have had this kind of encouragement and support".

Example 3

Opportunities were provided in each of the sessions for parents to assist their children to participate in the activities, which were aimed at promoting developmental growth in cognitive, physical, and social skills. This provided opportunities for parents to expand their existing repertory of skills in interacting and playing with their child through music. For some parents these sessions provided an environment for new learning in how to assist and facilitate participation in musical play that is conducive to child development, and it was observed that some parents, who did not usually have close contact with their children during play, changed their behaviour to indicate learning of new skills in this regard.

Two-year old Jonathon attended a young parent programme with his mother each week. In early sessions he had difficulty sitting and attending to the activities of the session. His mother used verbal prompts to encourage him to sit in the circle and to participate with the main group, however she sat at the back of the room during the first sessions. During weeks three and four she came forward to sit on the floor with the group. She encouraged Jonathon to sit on her lap and she helped him with hand-over-hand facilitation to do actions to the songs. This assisted him to both focus on the tasks of the group and to learn the songs and accompanying actions. In the remaining sessions, Jonathon often stood and danced when music was played, and participated in singing and actions more independently. He also began vocalising during songs.

Example 4

Elena was 5 months old when she began attending a Sing & Grow conducted at a youth agency that supported young parents. During the first session Elena was encouraged to participate in gross motor movement activities with facilitation from her mother. This included balance work on the therapy balls aimed at increasing vestibular strength, upper body control, and spatial awareness. Elena did not enjoy these activities. She could only sit on the ball for the accompanying song briefly before she became upset. Her mother was then encouraged to place her on her tummy on the ball to participate in rocking, balance, and reaching for toys and instruments. Elena became immediately distressed and started crying. During their second session Elena began to smile and vocalise when she was placed on the ball for the accompanying song and participated for its duration. At the end of the song the music therapist commented on how much her tolerance to the activity had improved since the previous session and her mother proudly announced, "We have been singing the bounce song every day at home and practicing". Elena continued to improve in her tolerance of spending time on her stomach, and by week six she demonstrated her enjoyment of this part of the session.

Example 5

Language development remains an area that requires extra attention in all of the Sing & Grow programmes. For some parents, the concept of modelling or imitating language sounds for their child's development is novel and requires practice and the relinquishing of self-consciousness. During sessions the music therapist modelled such interactions for the parents and encouraged participation in these parts of sessions.

Tia was 7-months-old when she began participating in a Sing & Grow offered at a crisis care facility for young women. During the first 2 weeks neither Tia nor her mother vocalised or sang during sessions. In week 3 Tia's mum was observed singing the songs and modelling playful sounds and Tia responded by participating in vocal play. From week 6 onwards her mother was observed to sing actively and interact vocally with Tia who responded with increased vocalisations.

Discussion

Sing & Grow accessed and employed the creative and welcoming aspects of musical interaction to support and facilitate successful interactions between parents and their young children. This programme was well attended by the parents compared to similar programmes (Coren & Barlow, 2004), and attendance far exceeded the estimates in the original proposal. If parents did not find the programme inviting they would not have attended. The use of the programme, therefore, by so many of those referred, stands as a testament to the potential of the Sing & Grow programme to offer new skills to many parents.

The case vignettes offer support for this programme's successful use of musical interaction in a group context to assist families to extend their repertory of skills in interactive play. While children's access to appropriate stimulation in the form of developmental play is delivered by the programme, the focus of the programme has been on the ways in which parents can lead and support their children's play as well as develop a wider range of interactions such as "gentle play", "co-active play," and vocal play skills, and this emphasis is proposed to continue. The vignettes highlight the strengths of this approach in being able to support parents (3) to refine and extend their skills of interaction with their children.

The comments from participants highlighted above showed that it was not only the music therapy group leader who was noting the observable changes in parental interaction. Participants expressed how they had learned new skills, and also indicated gratitude for the assistance they received. The Australian government continues to give provision for the care of children through a range of measures such as Sing & Grow. The great achievement of this programme to date has been its ability to reach such a large number of families, representing a range of community groups who might otherwise experience difficulties in accessing support for their needs. Given that low socio-economic status is one of the key features of the cohort of 426 families, who were assessed to need this service and consequently referred, it was important to note that Sing & Grow addressed, in a creative way, family difficulties that can arise through the complexities of poverty and its antecedents.

Sing & Grow is an ongoing intervention that is continuously evolving to provide best practice and meet the needs of a diverse and changing client population. While this is not a research project, the authors feel it is important to report on the outcomes of work being conducted on a day-to-day basis in Australia, particularly ground breaking, creative, and positive programmes such as this. The recent three-year government funding extension is testament of Sing & Grow's success in meeting identified outcomes.

Conclusion

Music is a creative and interactive process that can be used in a therapeutic setting to assist parents and their children to interact and bond (Abad & Edwards, 2002; Oldfeld & Bunce, 2001, 2003). Furthermore, music has been described in the music therapy literature as a suitable means to help young children learn and develop cognitively, physically, and socially (Oldfield & Bunce, 2001; Shoemark, 1996). Through the Sing & Grow initiative parents are provided with opportunities to participate in a familiar activity with their children and share a quality experience. Sing & Grow provides music within a therapeutic context and works towards strengthening the quality and range of family interactions in early childhood.

The use of music therapy to assist parents to extend their repertory of successful and nurturing parental behaviours in interaction with their young children is relatively new. The Sing & Grow initiative is unique because it has harnessed the resources of the government to underpin the development of a wide ranging programme that is proposed to be delivered throughout Australia, and already more widely in the world, through the introduction of a pilot Sing & Grow programme in Ireland in 200314. Music therapy has a role to support families whose social circumstances have the potential to adversely impact on the current and future functioning of their children by providing opportunities to strengthen family relationships and interactions.

References

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(1) Jane Edwards and Brandy Walker wrote the initial bid while working at the University of Queensland, School of Music in 2000, and the grant was approved in that year. Vicky Abad took up the full-time post as Director of Sing & Grow, Playgroup Queensland, in June 2001.

(2) In a review of studies of parent-training programmes it was reported that the drop-out rate for participants in the treatment groups ranged from 6% to 44% (Barlow & Coren, 2004). In addition, in a study of group programmes for teenage parents, drop out was noted to range from 8% to 33% (Corer & Barlow, 2004).

(3) While only mothers were present in the vignettes described, fathers have also accessed the programme.

(4) With thanks to the Annual Journal for the New Zealand Society for Music Therapy for permission to use here some of the vignette material published in Abad (2000).

Vicky Abad PGDipMusThy BAMus RMT

Director, Sing & Grow Project, Playgroup, Queensland.

Jane Edwards PhD RMT,

Senior Lecturer, Irish World Music Centre, University of Limerick, Ireland.