Drumming to a New Beat: a Group Therapeutic Drumming and Talking Intervention to Improve Mental Health and Behaviour of Disadvantaged Adolescent Boys

Children Australia Page1of9 C The Author(s) 2017 doi:10.1017/cha.2017.40

Drumming to a New Beat: A Group Therapeutic Drumming and Talking Intervention to Improve Mental Health and Behaviour of Disadvantaged Adolescent Boys

Karen Emma Martin and Lisa Jane Wood School of Population and Global Health, University of Western Australia, Crawley, Western Australia, Australia

Background: This research examined the impact of a programme integrating therapeutic music and group discussions (Holyoake’s DRUMBEAT programme) on disadvantaged adolescents’ mental wellbeing, psychological distress, post-traumatic stress symptoms and antisocial behaviour. Method: Students displaying antisocial behaviours in grades eight to ten at three socio-economically disadvantaged secondary schools in Perth, Western Australia were invited to participate in a 10-week DRUMBEAT programme (incorporating drumming with djembes, therapeutic discussions and a ﬁnal performance). Eight DRUMBEAT programmes were held in 2014. Pre- and post-intervention questionnaires measured mental wellbeing (Warwick–Edinburgh Mental Wellbeing Scale), psychological distress (Kessler-5), post- traumatic stress symptoms (Abbreviated Post-Traumatic Stress Disorder Checklist- Civilian Version) and antisocial behaviours (Adapted Self-Reported Delinquency Scale). Results: Of the 62 students completing DRUMBEAT, 41 completed pre- and post-questionnaires. Post-programme boys scored an average 7.6% higher mental wellbeing (WEMWBS) (p = .05), 19.3% lower post-traumatic stress symptoms (A PCL-C) (p = .05) and 23.9% lower antisocial behaviour (ARSDC) (p = .02). These changes were not evident for girls. No signiﬁcant differences were detected for differences in psychological distress for either gender. Conclusion: This research highlights the potential of the DRUMBEAT programme as an effective, targeted strategy to reduce post-traumatic stress symptoms and antisocial behaviour and increase mental wellbeing in socio-economically disadvantaged adolescent boys.

Keywords: mental wellbeing, adolescent boys, music therapy, post-traumatic stress, psychological distress, antisocial behaviour

Background behaviour (i.e., aggression, rule-breaking and oppositional Thementalhealthofchildrenandadolescentsisanes- behaviours) (Rasche et al., 2016), lower physical activity, calating international concern. World-wide up to 20% of smoking and alcohol consumption (Patel, Flisher, Hetrick, children and adolescents experience a mental illness and & McGorry, 2007). These behaviours have a distinct impact in many countries suicide is the leading cause of death on an individual’s long-term health, academic prospects and for young people (World Health Organization, 2001). The future employment (Jacka et al., 2011; Siegel & Welsh, 2011). large impact of youth mental illness is costly to individu- Thus, although in Australia mental illness is already the als and society. Mental disorders are an antecedent to self- largest contributor to burden of disease (disability-adjusted harm, suicidal thoughts and suicide (Prince et al., 2007) life years lost) for those aged 15–24 (Australian Institute of and a precursor to adulthood major depression, anxiety disorder, illicit substance abuse/dependence, and intimate partner violence victimisation (Kessler, Angermeyer, & An- ADDRESS FOR CORRESPONDENCE: Dr Karen Martin, Asst Professor, thony, 2007; McLeod, Horwood, & Fergusson, 2016). Fur- School of Population and Global Health, The University of thermore, a constellation of other health risk factors is asso- Western Australia (M431) 35 Stirling Hwy, Crawley, Western ciated with poor mental health in youth including antisocial Australia 6009, Australia. E-mail: [email protected]

Downloaded from https://www.cambridge.org/core. University of Western Australia Library, on 31 Oct 2017 at 02:39:25, subject to the Cambridge Core terms of use, available at https://www.cambridge.org/core/terms. https://doi.org/10.1017/cha.2017.40 Karen Emma Martin and Lisa Jane Wood

Health and Welfare, 2011), it is likely that the costs to society djembe), group therapeutic discussions and relationship extend well beyond the health domain. building to assist people experiencing, or at risk of prob- Increasingly, evidence is starting to ‘unpick’ the complex lematic health and social outcomes. DRUMBEAT was de- web of disordered mental health and behavioural function- signed initially for Australian Aboriginal youth in the West- ing in adolescents. For instance, research indicates that ag- ern Australian Wheatbelt region by an Aboriginal elder and gression may be facilitated by post-traumatic stress disorder Holyoake staff. The aim of the DRUMBEAT programme is and psychological distress (Rasche et al., 2016). There are to promote social understanding, compassion and connec- vast immediate and long-term social and economic impacts tion through a team drumming experience. Facilitators gain of problematic behaviour (Siegel & Welsh, 2011) stemming accreditation after attending a 3-day training course. The from childhood. Longitudinal data indicates that persistent DRUMBEATprogramme is facilitated by at least one accred- antisocial behaviour is associated with mental health prob- ited facilitator who leads group discussions and rhythms lems, substance dependence, financial problems and crimi- and harmonies with djembes. The programme incorporates nal behaviour in adulthood (Moffitt, Caspi, Harrington, & teaching drumming and sound making skills to participants Milne, 2002). (who sit in a circle) via analogies, role play, games and group There is also burgeoning understanding about the rela- activities. The programme includes goal setting (with a focus tionships between mental health and physiology (Cacioppo on generating competence and confidence) and culminates et al., 2000; Klimecki, Leiberg, Lamm, & Singer, 2013; in a group performance to an audience. After an initial ses- Walters & Kiehl, 2015). For instance, an examination of just sion, incorporating learning base rhythms and developing over 2600 college students in Ohio identified that chron- group guidelines, six learning modules are covered includ- ically lonely individuals recorded elevated mean salivary ing (1) rhythm of life, (2) relationships, (3) harmony, (4) cortisol levels across the day (Cacioppo et al., 2000). Like- individuality and self-expression, (5) emotions and feelings wise, behaviour has been noted to be associated with neu- and (6) teamwork. Sessions eight and nine focus on develop- rophysiology. Magnetic resonance imaging was used in a ing and practicing harmonies to deliver at the performance study of 191 incarcerated youth in the United States to ex- scheduled for session ten. plore grey matter volumes of the amygdala (associated with Despite some difficulties with evaluating music interven- fear conditioning) and hippocampus (associated with be- tions in the school setting (Crooke, 2014), there is evidence havioural control and memory problems) (Walters & Kiehl, that group music programmes delivered at school may have 2015). Their results noted that higher reported ‘fearless- a positive impact on adolescent socio-emotional outcomes ness’ was associated with lower amygdala grey matter vol- (Jackways, 2014; Uhlig, Jansen, & Scherder, 2017). For in- ume and higher reported ‘disinhibition’ was associated with stance, evaluation results of the Rap and Sing Music Therapy lower hippocampal grey matter volume. Promisingly, there programme held in a school in the Netherlands identified is the building evidence around brain plasticity with new that psychological wellbeing, self-description, self-esteem information that activities can actually change functioning and emotion regulation of 190 grade eight students im- areas of the brain. Neuroimaging research has discovered proved significantly post-programme when compared to a that a mindfulness-based intervention resulted in increases control group (Uhlig et al., 2017). The DRUMBEAT pro- in brainstem grey matter concentration concurrently with gramme has been implemented in schools widely in Aus- improvement in psychological wellbeing (Singleton et al., tralia and more recently in North America, the United 2014). Klimecki et al. (2013) investigated the impact of Kingdom, New Zealand, Canada and Anguilla. Previously, compassion training on functional neuronal responses us- DRUMBEAT has been shown to increase self-esteem and ing functional magnetic resonance imaging (fMRI). They reduce reported behaviour incidents in primary and sec- noted that, compared to their control group, compassion ondary school students (Wood, Ivery, Donovan, & Lam- training elicited increased neuronal activity in a brain re- bin, 2013). The value of implementing programmes such gion associated with positive affect and affiliation (Klimecki as DRUMBEAT in school settings includes high reach et al., 2013). Music interventions are likewise postulated and extended contact which assists with programme up- to impact brain regions and thus emotions and behaviour. take, accessibility and completion (Clarke, Morreale, Field, Onestudynotedthatactivationofthebrainacousticsensory Hussein, & Barry, 2015). A plethora of mental and be- streams (as measured using electrophysiological and auto- havioural programmes suitable for school implementa- nomic instrumentation) led to changes in mental health tion exist (for a comprehensive list of Australian program- and dysfunctional behaviours in youth diagnosed with gen- mes, see https://www.mindmatters.edu.au/tools-resources/ eralised anxiety disorder or adjustment disorder (Kazymov, programs-guide), however schools can struggle to identify Mamedov, Alieva, & Chobanova, 2014). Music therapy has which intervention is likely to be the most suitable and suc- also been seen to improve behavioural and developmental cessful for their students. This is particularly problematic as outcomes in children and adolescents with psychopathology many therapeutic programmes have not been evaluated by (Gold, Voracek, & Wigram, 2004). external researchers and there are few rigorous school pro- DRUMBEAT is a multicomponent programme incor- gramme evaluations published. In addition to being effec- porating therapeutic use of music (i.e. drumming on a tive, a programme needs to fit into school setting limitations

2 CHILDREN AUSTRALIA

such as budgets and timetabling, term length and teacher theresearchatanytime.Theywerealsoinformedthatthey expectations. Additional issues with running programmes could still participate in the DRUMBEATprogramme if they in disadvantaged schools, such as low attendance and dif- declined or withdrew their involvement in the research. In- ficulties gaining parental consent, also need to be consid- formed written consent to participate in the research was ered. With its combination of therapeutic components and gained from both the student and their parent/guardian. structured programme, a study exploring the potential im- This project involved minimal risk to participants. As the pact of DRUMBEAT on students’ mental and behavioural research involved measurement of mental health constructs, outcomes in disadvantaged schools was warranted. the students and parents were informed (via the information and consent forms) that the school psychologist would be Aim and Hypothesis notified about students who exceeded normal thresholds for The aim of this study was to identify if mental wellbeing, psychological distress and post-traumatic stress scores. Stu- psychological distress, post-traumatic stress symptoms and dents who exceeded these thresholds could continue with antisocial behaviour changed for adolescents following their the DRUMBEAT programme and the research. Participa- attendance at a 10-week DRUMBEAT programme. It was tion in the DRUMBEAT programme did mean that students hypothesised that the DRUMBEAT programme, delivered would miss one class per week for 10 weeks. This however, in the school setting, would be associated with increased was considered by the school staff to be appropriate consid- mental wellbeing, and reduced psychological distress, post- ering the social, learning and behavioural difficulties being traumatic stress symptoms and antisocial behaviour in boys faced by the students and the potential benefit of their par- and girls. ticipation in the DRUMBEAT programme.

Methods Instruments and Measurement Design The pre- and post-programme questionnaires included four instruments: (1) Warwick Edinburgh Mental Wellbe- A single group pre-test/post-test research design was implemented. Initially, a control group (using a wait-list) was ing Scale (WEMWBS) (Tennant et al., 2007), (2) Kessler 5 (K5) (Australian Institute of Health and Welfare, 2009), proposed, however due to low student consent responses, (3) Abbreviated Post-traumatic stress disorder (PTSD) and a limited data collection time-frame, this was not possible. Checklist – Civilian version (A PCL-C) (Lang et al., 2012) and (4) Adapted Self-Reported Delinquency Scale (ASRDS) Sample selection (Carroll, Durkin, Houghton, & Hattie, 1996; Mak, 1993). This study sought to recruit schools within areas of low These instruments were chosen due to their brevity, socio-economic status (SES) due to the association between readability and constructs (as below). socio-economic disadvantage and higher rates of mental (1) Mental Wellbeing was assessed using the 14 item War- health disorders (Sawyer et al., 2000) and antisocial and wick Edinburgh Mental Wellbeing Scale (WEMWBS) (Ten- delinquent behaviours (Losel, Carson, & Bull, 2003). Thus, nant et al., 2007). This is a validated measure of positive three schools were purposely selected from three of the low- mental wellbeing (content validity .89, internal reliability est socio-economic areas within the Perth metropolitan re- .87, test–retest .83). This instrument asks respondents to sig- gion, with one school each located in the northern, eastern nify which response best describes their experience over the and southern corridors. last 2 weeks;1= none of the time, 2 = rarely, 3 = some of the Initial contact regarding the research was made with each time, 4 = often, 5 = all of the time, for feelings and thoughts school’s psychologist. Once formal written approval was such as ‘I’ve been feeling cheerful’.All feelings and thoughts provided by the Principal, potential student participants are positive thus a higher score indicates higher mental well- were identiﬁed and agreed upon by school psychologists, being (resultant score between 14 and 120). This instrument student services coordinators and/or grade coordinators. wasrecentlytestedinanAustraliansampleandperformed Selection criteria included students within grades eight to well in adolescents aged 13–16 (Hunter, Houghton, & Wood, ten (grade mix of groups decided by each school) who dis- 2015). played antisocial behaviour. The uptake of the programme (2) Psychological distress was measured using the Kessler and research was approximately 50% of those invited – this 5(K5).TheK5isanadaptedversionoftheKessler6 was mainly due to the failure of students to return a signed (K6) (Australian Institute of Health and Welfare, 2009). consent form from their parent/guardian. Recent testing of the K6 in adolescents demonstrated the scale to have .79 sensitivity and .83 speciﬁcity (Furukawa, Ethical Considerations Kessler, Slade, & Andrews, 2003). The K5 was adapted for Approval for the study was gained from the institutional use with Australian Aboriginal populations. This adaptation ethics committee and the state education department. Stu- involved the removal of the statement ‘I feel worthless’ as it dents were told that their participation in the DRUMBEAT is considered potentially offensive to Aboriginal and Torres programme and the research was completely voluntary and Strait Islanders (Australian Institute of Health and Welfare, that they could withdraw from either the programme and/or 2009). This K5 instrument asks respondents – During the

CHILDREN AUSTRALIA 3

past 30 days, about how often did you feel a) nervous, b) hope- facilitators with organising the DRUMBEAT programmes, less, c) restless or fidgety, d) so depressed that nothing could co-facilitated the programme, and assisted the researchers cheer you up, e) that everything was an effort.Responseop- with data collection. tions include; 1 = none of the time, 2 = a little of the time, Each research participant was assigned a unique confi- 3 = some of the time, 4 = most of the time, and 5 = all of the dential code to identify the school, DRUMBEAT group and time. Responses were summed to generate a total K5 score student. A risk management plan was created by the research (resultant score between 5 and 25). team and school staff whereby the research team alerted the (3) Post-traumatic stress symptoms were measured us- school when a student scored equal to or higher than 12 on ing the Abbreviated PTSD Checklist – Civilian version (A the K5, or 14 on the A PCL-C. PCL-C) (sensitivity .92, specificity .72, efficiency .75) (Lang Ahardcopyofthequestionnairewascompletedat et al., 2012). This instrument includes six questions ask- the first session (or second session for first-week absent ing respondents to indicate, how much, in the last month members). The questionnaires were designed to be self- (1 = not at all; 2 = a little bit; 3 = moderately; 4 = quite a completed, however the DRUMBEAT facilitators and/or bit; 5 = extremely), they had been bothered by; a) repeated, UWA researchers were available to assist students with ques- disturbing memories, thoughts, or images of a stressful experi- tionnaire completion. Questions were read aloud (quietly ence; b) feeling very upset when something reminded you of a to avoid student discomfort) to any students experienc- stressful experience; c) avoiding activities or situations because ing literacy issues. The post-programme questionnaire was they reminded you of a stressful experience; d) feeling distant completed at the final DRUMBEAT session after the perfor- or cut off from other people; e) feeling irritable or having angry mance. Students who did not attend the last DRUMBEAT outbursts; and f) having difficulty concentrating. Responses session were asked by the school liaison or DRUMBEAT fa- were summed to generate a total A PCL-C score (resultant cilitator to complete the questionnaire as soon as possible score between 6 and 30). after programme completion. (4) Antisocial behaviours were measured using the Of the eight DRUMBEAT programmes, four were held Adapted Self-Reported Delinquency Scale (ASRDC) (good- within a northern corridor school, three at the eastern cor- ness of fit >.85, internal consistency .67 to .91) (Carroll ridor school and one at the southern corridor school. One et al., 1996). The ASRDC is a Western Australian adaptation programme at the eastern corridor school finished early of the Australian Self-reported Delinquency Scale (Mak, (after only seven sessions) due to the co-facilitator being 1993). The ASRDC asks respondents to indicate how often unwell and a late start. This programme did not include a they have behaved in a particular way in the past month. This performance and these data were excluded from analysis. questionnaire incorporates 11 questions asking respondents The final dataset included three ‘girl only’ groups (grades In the past 1 month how often (Never, 1–3 times, 4–6 times, 8–9, 9–10, 8–10), three ‘boy only’ groups (all grades 8–9) once a month, more than once a month, more than once a and the one ‘mixed gender’ group (grades 8–9). Group sizes week they have; a) deliberately damaged your own property ranged from 8–10 participants, however one grade 8–9 boy or that of others, b) disrupted other people’s games or activities only group had only five participants. (e.g., classwork) c) sworn at others or called them names, d) not done your classwork or homework, e) hit, pushed, punched Data Treatment and Analysis or slapped someone else, f) been unable to concentrate in the Analyses of questionnaire data were completed by the first classroom, h) disrupted the class by calling out or by being author using SPSS V21. Total scores for each student were out of your seat, i) teased or made fun of someone else, j) calculated for the WEMWBS, K5, A PCL-C and ASRDC been sent out of the classroom, k) been suspended from school, scales from the pre- and post-programme questionnaires. l) skipped class or wagged school? Responses were summed If one response was missing within an individual measure to generate a total antisocial score (resultant score between construct (e.g. A PCL-C), the individual’s mean for that 11 and 66). construct was imputed. Data were excluded from analysis if two or more responses were missing within a construct. Procedure Previously published thresholds were used to categorise A series of eight DRUMBEAT programmes were delivered mental stress for each student into binomial categories. For within the three schools over a seven-month period (be- the K5 (Commonwealth of Australia, 2005), scores less than tween May 2014 and November 2014). Six programmes or equal to 11 were classified as none to mild psychological were single sex (three male, three female) and two pro- distress (consistent with a diagnosis of no or mild depression grammes incorporated mixed genders. Each DRUMBEAT and/or anxiety disorder), scores 12 or greater were classified programme was facilitated by an accredited DRUMBEAT as moderate to severe psychological distress (consistent with facilitator assigned to deliver the programmes within the a diagnosis of moderate to severe depression and/or anxiety schools. Each facilitator also had either a certificate or de- disorder). For the post-traumatic stress symptoms variable gree in youth work and had facilitated DRUMBEATto disad- (Lang & Stein, 2005), scores less than 14 were classified vantaged youth previously. A school liaison staff member or as PTSD unlikely, scores 14 or a greater were classified as school psychologist at each school assisted the DRUMBEAT possible PTSD (i.e., showing signs of PTSD thus should be

4 CHILDREN AUSTRALIA

TABLE 1 Participant mental wellbeing, psychological distress, post-traumatic stress symptoms and antisocial behaviour scores pre- and post-DRUMBEAT; all participants and by gender.

Boys (n = 17) Girls (n = 24) Time All mean (sd) mean (sd) mean (sd)

Mental wellbeing (WEMWBS) Range 14–70. Pre 51.2 (8.8)ˆb 52.4 (7.6)∗b 50.4 (9.7) Higher score = higher mental wellbeing Post 53.5 (8.8)ˆb 56.4 (9.0)∗b 51.5 (8.2) Psychological distress (K-5) Pre 11.9 (3.6) 10.8 (3.7) 12.7 (3.4) Range 5–25. Higher score = higher psychological stress Post 11.6 (4.2) 10.9 (4.3) 12.0 (4.1) Post-traumatic stress symptoms (A PCL-C) Pre 13.9 (5.5) 14.2 (5.0) 13.7 (5.9) Range 5–30. Higher score = higher post-traumatic stress symptoms Post 13.1 (5.4) 11.9 (5.1)∗ 13.9 (5.5) Antisocial behaviour (ASRDC) Pre 25.1 (11.3)∗b 31.1 (13.7)∗a,b 20.9 (6.8)∗a Range 11–66. Higher score = more antisocial behaviour Post 22.4 (10.3)∗b 25.1 (13.0)∗b 20.5 (7.6)

ˆp < .08, ∗p < .05, a = difference between boys and girls mean scores, b = differences between pre- and post-DRUMBEAT means scores, sd = standard deviation, WEMWBS = Warwick Edinburgh Mental Wellbeing Scale, K-5 = Kessler 5, A PCL-C = Abbreviated Post-traumatic Stress Disorder (PTSD) Checklist – Civilian version, ASRDC = Adapted Self-Reported Delinquency Scale. pre = pre-DRUMBEAT, post = post-DRUMBEAT programme.

referred for clinical assessment). These categories were used At baseline, boys were more likely to report higher an- to provide names of students exceeding thresholds to the tisocial behaviour than girls (p = .003). No significant dif- school psychologist. ferences were detected between boys’ and girls’ baseline Descriptive statistics were also generated for each out- mental wellbeing, psychological distress or post-traumatic come continuous variables (see Table 1) and age. Repeated stress symptoms. Bivariate analysis of all participants sug- measures tests for differences between means were used to gested reduced antisocial behaviour (p = .05) and improved examine for differences between pre- and post-programme mental wellbeing post-DRUMBEAT (p = .07); no changes for WEMWBS, K5, A PCL-C and ASRDC scores (see were observed for psychological distress or post-traumatic Table 1). Analysis by gender was then undertaken (see stress symptoms scores. Gender split results however, in- Table 1). Due to the small sample size, further analysis by dicated that there were significant improvements in boys’ subgroup was not appropriate. mental wellbeing (p = .05), post-traumatic stress symptoms (p = .05) and antisocial behaviour (p = .02) after DRUM- Results BEAT when compared to programme start. These changes were not evident for girls. Following participation in the Baseline data were available for 63 adolescents. These re- DRUMBEAT programme, on average boys’ recorded 7.6% = sults indicated that 57.1% (n 36) of participants were higher WEMWBS scores (mental wellbeing), 19.3% lower A experiencing moderate to severe psychological distress (i.e., PCL-C scores (post-traumatic stress symptoms) and 23.9% = exceeded normal threshold score for the K5), 49.2% (n 31) lower ARSDC (antisocial behaviours). No significant dif- high PTSS (exceeded normal threshold score for A PCL-C) ferences were detected for psychological distress changes = and 34.9% (n 22) both moderate to severe psychological between pre- and post-DRUMBEAT programme for either distress and high post-traumatic stress symptoms. Antiso- gender. cial behaviour (ASRDC scores) were strongly positively associated with both psychological distress (K5 scores) (Spear- man’s r = .36, p = .009) and post-traumatic stress symptoms Discussion (A PCL-C scores) (Spearman’s r = .42, p = .002). With youth mental health and suicide being such a catas- Of the 84 students who enrolled in a DRUMBEAT pro- trophic issue in Australia and internationally (World Health gramme, 62 (73.8%) students completed the whole pro- Organization, 2001), ascertaining which group programmes gramme (due to incomplete programme at one school are most effective in reducing psychological distress and and students withdrawing from the programme or leav- improving mental wellbeing in children and adolescents is ing school). Of these, 41 (66.1%, 24 girls and 17 boys) essential. In this study, boys reported significantly higher completed the programme and both the pre- and post- mental wellbeing, reduced post-traumatic stress symptoms programme questionnaires (mainly due to school absences). and lower antisocial behaviour after participating in the Themeanageofthefinal41samplewas13.8years(SD = .7) DRUMBEAT programme. This therapeutic drumming and with 17.0% (n = 7) identifying themselves as an Abo- talking programme holds promise in being able to assist riginal and/or Torres Strait Islander. Country of origin large numbers of disadvantaged boys experiencing mental was not asked due to perceived sensitivities relating to and behavioural issues. tensions at two of the schools between different cultural In this study, sample baseline post-traumatic symptom groups. scores indicated that 34.9% of the participants were likely

CHILDREN AUSTRALIA 5

to be experiencing PTSD. This proportion highlights the It is important to identify mechanisms underpinning importance of addressing this mental health problem. Par- the impact of interventions; however, the observed bene- ticipation in the DRUMBEAT programme led to a near 20% fits from DRUMBEAT participation can only be speculated average decrease in boys’ post-traumatic stress symptoms. at this stage. The multiple components integrated within Programme content within DRUMBEAT does not specifi- DRUMBEAT such as education, music, motor activity and cally address traumatic experiences or symptoms, however behavioural mimicry likely contribute to improved men- it is likely that some programme components assist with tal wellbeing and reduced post-traumatic stress and an- trauma recovery. Research exploring drumming and its im- tisocial behaviour. The DRUMBEAT programme includes pact on PTSD is rare, however one published study noted educational strategies evidenced as being characteristic of that returned soldiers experiencing PTSD experienced re- effective social and emotional interventions in schools such duced post-traumatic stress symptoms after participating as teaching cognitive and affective skills, competence en- in a group drumming programme (Bensimon, Amir, & hancement and empowering, interactive teaching methods Wolf, 2008). Further research exploring the potential im- (Clarke et al., 2011). Music has been noted previously to pact of DRUMBEAT on post-traumatic stress symptoms provide a calming effect for those listening to or ‘making’ within children and young people is warranted. music, and this is increasingly demonstrated through ob- Our study also signified that higher average mental well- jective measurement. For example, prior research in a psy- being was evident for boys after DRUMBEAT participation. choneurology clinic in Azerbaijan identified that a music Mental wellbeing is increasingly being recognised as an im- therapy intervention led to normalising of emotional status portant protective factor against mental illness (Gargiulo & and reduction of heart rate and blood pressure for ado- Stokes, 2009). Maximising mental wellbeing in adolescent lescents diagnosed with anxiety and/or adjustment disorder populationsisconsideredapriorityinattemptstoreduce (Kazymov et al., 2014). Due to a strong neuronal connection the burden of mental illness in populations, and as a preven- between motor experience and empathic processes, coordi- tive strategy for future physical and mental health (Clarke nated movement (used in drumming) is also theorised to be et al., 2011). Prior research with adolescents also indicated a contributor to empathy and pro-social behaviour devel- that DRUMBEAT increases self-esteem (Wood et al., 2013), opment (Behrends, Muller,¨ & Dziobek, 2012). Behavioural and it is likely that DRUMBEAT contributes to supportive mirroring is also suggested to play a role in creating affil- bi-directional relationships between self-esteem and mental iation, rapport and social cohesion (Lakin & Chartrand, wellbeing. 2003), and another component within DRUMBEAT that These study results also demonstrate that boys partici- could contribute to emotional and social changes. Thus, the pated in significantly less antisocial behaviour after partic- mirroring of movement and eye contact, combined with ipating in DRUMBEAT. This aligns closely with previous the sensorimotor activities associated with the drumming research (Wood et al., 2013) in which objective measures itself may improve mood (Shuman, Kennedy, DeWitt, Edel- of antisocial behaviours in school (behavioural incident blute, & Wamboldt, 2016) and strengthen group cohesion. reports)reducedfor29%ofDRUMBEATparticipants.Ado- Another potential factor generating positive changes is the lescent antisocial behaviour leads to high social, interper- link between post-traumatic stress and antisocial behaviour sonal and financial costs to individuals, families and com- as noted in the baseline data analyses and prior research munities (Piotrowska, Stride, Croft, & Rowe, 2015), and is (Vermeiren, 2003). Participation in DRUMBEAT may di- an ongoing stress and burden for teachers and school admin- rectly reduce post-traumatic stress and antisocial behaviour; istrators (Sullivan, Johnson, Owens, & Conway, 2014). The however, it is also possible that there are some bi-directional time taken by school staff to address antisocial behaviour changes that are generated. For example, a reduction in post- is significant, with 90% of school teachers and leaders traumatic stress symptoms resulting from DRUMBEATpar- reporting that behaviour management accounts for at least ticipation may also lead to lower antisocial behaviour – this 10% of their time (Australian Government Department of change in behaviour may then further reduce stress. Further Education and Training, 2014). Bringing together groups of exploration of mechanisms underpinning changes to men- boys exhibiting antisocial behaviours is certainly a challenge tal health and antisocial behaviours via multicomponent for DRUMBEAT facilitators, however the potential positive programmes such as DRUMBEAT would be valuable. impact on behaviour is likely to have far-reaching benefits It is important to consider alternative explanations for for the boys as they mature, and school staff and peers our study findings. Another change in the participants’ en- alike. vironments unrelated to DRUMBEAT could have led to the The findings that psychological distress was not lower changes in outcomes. Although a waitlist group had been after being involved in DRUMBEAT were contrary to expec- proposed to generate a comparison group, due to the dif- tation. It is possible that changes to psychological distress ficulty in retrieving signed consent forms and programme take time and that DRUMBEAT may reduce psychological timing, this was not achievable. Another factor impacting stress in the longer term. Longer term follow-up would as- the mental health and antisocial behaviour of participants sist with examining the potential of DRUMBEAT to impact mayhavebeenchangestobehaviourorextrasupportof- psychological distress. fered by school staff after being informed about students

6 CHILDREN AUSTRALIA

exceeding normal K5 and/or post-traumatic stress symptoms and antisocial behaviour in socioeconomically disad- toms thresholds, although staff reported they were already vantaged adolescent boys. Further research incorporating alerted to the mental health states of these students hence larger samples and a control group will assist with verify- their referral to DRUMBEAT. Unfortunately, the uptake of ing these findings and exploring potential moderators or the DRUMBEAT programme was only approximately 50% confounders impacting programme success. of children within the invited sample. The school liaison staff did note this as being related to students forgetting to return consent forms (and a common dilemma faced in school-based programmes at these low SES schools). How- Acknowledgements ever, this does indicate potential selection bias within this The authors would like to thank all those who assisted study; for example, the participants in our sample may be with facilitating this work including; the participating stu- more receptive to new programmes or have increased con- dents, school staff, DRUMBEAT facilitators and manage- nectedness to the school. Not being able to compare differ- ment and our Research Assistants; Shannen Vallesi, Char- encesforstudentswhodidnotreturnconsentformsisalsoa lotte Schiefler, Nick Wood,Julian Ming and Madeleine Ford. limitation of the study. Without consent we were not able to collect any data for those students who did not return their consent forms. Social acceptability bias may have impacted Financial Support the self-reporting of participants with the adolescents being aware of expected changes following DRUMBEAT par- Dr Karen Martin was supported by the Western Australian ticipation. Due to higher than expected absences, student Health Promotion Foundation (Healthway) through a Post- withdrawal from the programme or school and the one in- doctoral Research Fellowship (#23347) during this research. complete programme, the sample size was lower than antic- ipated thus reducing the power to detect changes. This study did not follow-up participants after they had participated in Competing Interest Statement DRUMBEAT thus it is unclear if self-reported mental health The authors have declared that they have no competing or states and behaviour returned to pre-programme states. potential conflicts of interest. The strengths of this study include the pre- and post- design using population validated measures of psychological distress, mental wellbeing and antisocial behaviour (al- Original Work Statement though note the A PCL-C has only been used in adolescents This original research has not been previously published in a Chinese adapted version (Hou et al., 2011)). Further, the and is not under consideration in the same or substantially DRUMBEAT programme was held at multiple sites increas- similar form in any other peer-reviewed journal. All au- ing external generalisability. Despite the challenges involved, thors listed have contributed sufficiently to the project to be the evaluation of a programme within a real-world setting included as authors and are listed on the manuscript title enhances the relevance of the results. page. To the best of our knowledge, no conflict of interest, Additional research with larger samples and a con- financial or other, exists. trol/comparison group will assist with building evidence about the impact of DRUMBEAT. A larger sample size will also enable exploration of outcomes related to participant References characteristics (e.g., higher antisocial behaviours, cultural background) and/or programme components (e.g., facil- Australian Government Department of Education and itator, number of sessions attended). Sex differentials are Training. (2014). Safe schools toolkit. In Positive behaviour management.Retrievedfromhttp://www.safeschoolshub. also important to further explore, and this is particularly edu.au/safe-schools-toolkit/the-nine-elements/element- relevant with evidence that adolescent girls report higher 5/introduction. stressors in specific domains (e.g., interpersonal), and re- Australian Institute of Health and Welfare. (2009). Measuring spond more strongly to stressors (Hankin, Mermelstein, & the social and emotional wellbeing of Aboriginal and Torres Roesch, 2007). For girls, DRUMBEAT may have impacted Strait Islander peoples. Canberra: AIHW. ‘internalising’ behaviours, such as self-harm and thus fur- Australian Institute of Health and Welfare. (2011). Young Aus- ther research is needed to establish the possible impact of tralians: Their health and wellbeing 2011. Canberra: AIHW. DRUMBEAT on girls in other outcomes. Behrends, A., Muller,¨ S., & Dziobek, I. (2012). Moving in and out of synchrony: A concept for a new intervention fostering empathy through interactional movement and Conclusion dance. TheArtsinPsychotherapy,39(2), 107–116. The DRUMBEAT programme shows promise as a poten- Bensimon, M., Amir, D., & Wolf, Y. (2008). Drumming tially effective targeted strategy to significantly improve through trauma: Music therapy with post-traumatic sol- mental wellbeing and reduce post-traumatic stress symp- diers. TheArtsinPsychotherapy,35(1), 34–48.

CHILDREN AUSTRALIA 7

Cacioppo, J. T., Ernst, J. M., Burleson, M. H., McClintock, Jacka,F.,Pasco,J.,Williams,L.,Leslie,E.,Dodd,S.,Nicholson, M. K., Malarkey, W. B., Hawkley, L. C., . . . Berntson, G., . . . Berk, M. (2011). Lower levels of physical activity G. G. (2000). Lonely traits and concomitant physiologi- in childhood associated with adult depression. Journal of cal processes: The MacArthur social neuroscience stud- Science and Medicine in Sport, 14(3), 222–226. ies. International Journal of Psychophysiology, 35(2), 143– Jackways, A. (2014). The relationship between music ther- 154. apy goals, health goals and education goals in a transition Carroll, A., Durkin, K., Houghton, S., & Hattie, J. (1996). school for adolescents with mental health needs, Masters An adaptation of Mak’s self-reported delinquency scale thesis, Massey University of Wellington and Victorian Uni- for Western Australian adolescents. Australian Journal of versity of Wellington. Psychology, 48(1), 1–7. Kazymov, A., Mamedov, A., Alieva, D., & Chobanova, O. Clarke,A.M.,Morreale,S.,Field,C.-A.,Hussein,Y.,&Barry, (2014). Autonomic and psychophysiological correlates of M. (2015). What works in enhancing social and emotional the effects of music therapy in neurotic disorders. Neuro- skills development during childhood and adolescence. A science and Behavioral Physiology, 44(1), 60. review of the evidence on the effectiveness of school-based Kessler, R., Angermeyer, M., & Anthony, J. (2007). Life- and out-of-school programmes in the UK. A report produced time prevalance and age-of-onset distributions of men- by the World Health Organization Collaborating Centre for tal disorders in the World Health Organisation’s World Health Promotion Research, National University of Ireland Mental Health Survey Iniative. World Psychiatry 6, 168– Galway. 176. Clarke, A., Friede, T., Putz, R., Ashdown, J., Martin, S., Blake, Klimecki, O. M., Leiberg, S., Lamm, C., & Singer, T. (2013). A., . . . Platt, S. (2011). Warwick-Edinburgh mental well- Functional neural plasticity and associated changes in pos- being scale (WEMWBS): Validated for teenage school stu- itive affect after compassion training. Cereb Cortex, 23(7), dents in England and Scotland. A mixed methods assess- 1552–1561. doi:10.1093/cercor/bhs142 ment. BMC Public Health, 11(1), 487. Lakin, J. L., & Chartrand, T. L. (2003). Using nonconscious Commonwealth of Australia. (2005). Australian mental behavioral mimicry to create affiliation and rapport. Psy- health outcomes and classification network kessler -10 chological science, 14(4), 334–339. training manual. Parramatta, NSW: NSW Institute of Lang, A. J., & Stein, M. B. (2005). An abbreviated PTSD check- Psychiatry. list for use as a screening instrument in primary care. Be- Crooke, A., & McFerran, K. (2014). Recommendations for haviour Research and Therapy, 43(5), 585–594. the investigation and delivery of music programs aimed at Lang,A.J.,Wilkins,K.,Roy-Byrne,P.P.,Golinelli,D.,Chavira, achieving psychosocial wellbeing benefits in mainstream D., Sherbourne, C., . . . Craske, M. G. (2012). Abbreviated schools. Australian Journal of Music Education, (1), 15–37. PTSD Checklist (PCL) as a guide to clinical response. Gen- Furukawa, T. A., Kessler, R. C., Slade, T., & Andrews, G. (2003). eral hospital psychiatry, 34(4), 332–338. The performance of the K6 and K10 screening scales for Losel, F., Carson, D., & Bull, R. (2003). The development psychological distress in the Australian national survey of delinquent behaviour. Handbook of Psychology in Le- of mental health and well-being. Psychological Medicine, gal Contexts (2nd ed.) (pp. 245–268). West Sussex: John 33(02), 357–362. Wiley & Sons Ltd. Gargiulo, R. A., & Stokes, M. A. (2009). Subjective well-being Mak, A. S. (1993). A self-report delinquency scale for Aus- as an indicator for clinical depression. Social Indicators Re- tralian adolescents. Australian Journal of Psychology, 45(2), search, 92(3), 517–527. 75–79. Gold, C., Voracek, M., & Wigram, T. (2004). Effects of McLeod, G., Horwood, L., & Fergusson, D. (2016). Adoles- music therapy for children and adolescents with psy- cent depression, adult mental health and psychosocial out- chopathology: A meta-analysis. Journal of Child Psychol- comesat30and35years.Psychological Medicine, 46(7), ogy and Psychiatry, 45(6), 1054–1063. doi:10.1111/j.1469- 1401. 7610.2004.t01-1-00298.x. Moffitt, T. E., Caspi, A., Harrington, H., & Milne, B. J. (2002). Hankin, B. L., Mermelstein, R., & Roesch, L. (2007). Sex Males on the life-course-persistent and adolescence- differences in adolescent depression: Stress exposure limited antisocial pathways: Follow-up at age 26 and reactivity models. Child development, 78(1), 279– years. Development and Psychopathology, 14(01), 179– 295. 207. Hou,F.S.,Ting,L.,Juan,L.,HU,X.Q.,LIU,Z.Y.,&Ping,Y. Patel, V., Flisher, A. J., Hetrick, S., & McGorry, P.(2007). Mental (2011). The effects of demographic features on differences health of young people: A global public-health challenge. in sensitivity between PCL-C and SCL-90 scores in a follow- The Lancet, 369(9569), 1302–1313. up study in secondary school students in the Wenchuan Piotrowska, P. J., Stride, C. B., Croft, S. E., & Rowe, R. (2015). earthquake region. Biomedical and Environmental Sciences, Socioeconomic status and antisocial behaviour among 24(6), 642–648. children and adolescents: A systematic review and meta- Hunter, S. C., Houghton, S., & Wood, L. (2015). Positive men- analysis. Clinical Psychology Review, 35, 47–55. tal well-being in Australian adolescents: Evaluating the Prince, M., Patel, V., Saxena, S., Maj, M., Maselko, J., Phillips, Warwick-Edinburgh Mental Well-being Scale. The Aus- M. R., & Rahman, A. (2007). No health without mental tralian Educational and Developmental Psychologist, 32(02), health. The Lancet, 370(9590), 859–877. 93–104.

8 CHILDREN AUSTRALIA

Rasche,K.,Dudeck,M.,Otte,S.,Klingner,S.,Vasic,N.,&Streb, Tennant, R., Hiller, L., Fishwick, R., Platt, S., Joseph, S., Weich, J. (2016). Factors inﬂuencing the pathway from trauma to S., . . . Stewart-Brown, S. (2007). The Warwick-Edinburgh aggression: A current review of behavioral studies. Neurol- mental well-being scale (WEMWBS): Development and ogy, Psychiatry and Brain Research, 22(2), 75–80. UK validation. Health and Quality of Life Outcomes, Sawyer,M.G.,Kosky,R.J.,Graetz,B.W.,Arney,F.,Zubrick, 5(1), 63. S. R., & Baghurst, P. (2000). The national survey of mental Uhlig, S., Jansen, J., & Scherder, J. (2017). “Being a bully isn’t health and wellbeing: The child and adolescent component. very cool. . .”: Rap & Sing Music Therapy for enhanced Australian and New Zealand Journal of Psychiatry, 34(2), emotional self-regulation in an adolescent school setting – 214–220. a randomized controlled trial. Psychology of Music, advance Shuman, J., Kennedy, H., DeWitt, P., Edelblute, A., & online publication. doi:10.1177/0305735617719154 Wamboldt, M. Z. (2016). Group music therapy impacts Vermeiren, R. (2003). Psychopathology and delinquency in mood states of adolescents in a psychiatric hospital setting. adolescents: A descriptive and developmental perspective. TheArtsinPsychotherapy,49, 50–56. Clinical Psychology Review, 23(2), 277–318. Siegel, L. J., & Welsh,B. C. (2011). Juvenile delinquency: Theory, Walters, G. D., & Kiehl, K. A. (2015). Limbic correlates of fear- practice, and law. Cengage Learning. lessness and disinhibition in incarcerated youth: Exploring Singleton, O., Holzel,¨ B. K., Vangel, M., Brach, N., the brain–behavior relationship with the Hare Psychopa- Carmody, J., & Lazar, S. W. (2014). Change in brain- thy Checklist: Youth Version. Psychiatry Research, 230(2), stem gray matter concentration following a mindfulness- 205–210. based intervention is correlated with improvement in Wood, L., Ivery, P., Donovan, R., & Lambin, E. (2013). psychological well-being. Frontiers in Human Neuro- “To the beat of a different drum”: Improving the social science, 8(33) https://doi.org/10.3389/fnhum.2014.00033. and mental wellbeing of at-risk young people through Sullivan, A. M., Johnson, B., Owens, L., & Conway, R. (2014). drumming. Journal of Public Mental Health, 12(2), 70–79. Punish them or engage them? Teachers’ views of unpro- doi:10.1108/JPMH-09-2012-0002. ductive student behaviours in the classroom. Australian World Health Organization. (2001). Mental health: New un- Journal of Teacher Education, 39(6), 4. derstanding, New Hope: World Health Organization.

CHILDREN AUSTRALIA 9