Social-Emotional Benefits of Drumtastic Ability Beats® Dyadic Partnership Between a College Veteran with PTSD and an Elementary Student in a Special Education Setting

Therapeutic Recreation Journal

Therapeutic Recreation Journal Vol. LIII, No. 2 • pp. 175–184 • 2019 https://doi.org/10.18666/TRJ-2019-V53-I2-9129

Case Report Social-Emotional Benefits of Drumtastic Ability Beats® Dyadic Partnership between a College Veteran with PTSD and an Elementary Student in a Special Education Setting

Lyn Litchke Abstract Casey Finley This case report investigated Drumtastic Ability Beats® in an elementary Special Education program highlight- ing the relationship between a college veteran with PTSD partnered with a student with intellectual developmental disorder and ADHD. The results pre-post for the veteran showed Perceived Stress Scale improved 22.7%; Hospi- tal Anxiety and Depression Scale- Anxiety decreased 37.5%, and Depression increased by 37.5%. Less than 1% positive change on both the Physical Activity Enjoy- ment Scale and Connor Davidson Resiliency Scale. The student Social Personal Relationship Scale increased 54% in relating to others and 51% in self-responsible social behavior. Smiley-o-Meter demonstrated improved mood from a 3 nervous/unsocial to 8 excited/delighted. This study demonstrates the value of TR interventions in a special education program in a school setting with regard to social-emotional behaviors.

Keywords ADHD, drumming, intellectual disorder, posttraumatic stress disorder, social-emotional, special education

Lyn Litchke is an associate professor of Therapeutic Recreation in the Department of Health and Human Performance at Texas State University. Casey Finley is currently pursuing a master’s degree in Recreation and Leisure Sciences with a concentration in Therapeutic Recreation at Texas State University. Please send correspondence to Lyn Litchke, [email protected]

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The purpose of this case report was to explore the social-emotional benefits of Drumtastic Ability Beats® dyadic drumming as a therapeutic recreation (TR) intervention in an elementary special education school setting. This report highlights the relationship between a Hispanic female veteran college student with posttraumatic stress disorder (PTSD) who was partnered with a young African American male with intellectual developmental disorder (IDD) and attention deficit hyperactivity disorder (ADHD). The elementary school selected can best be described as a Title I school cam- pus. Title I schools are defined as campuses with a student population of at least 40% low-income (Texas Education Agency [TEA], 2018). The demographics of this elementary school included 70.8% of students considered as economically disadvantaged with 13.7% enrolled in the special education program (TEA, 2018). The Drumtastic Ability Beats® intervention took place in a classroom at the school once a week for 45 minutes per session over a six-week period. Drumtastic Ability Beats® is an evidence-based program that combines rhythmic drumming, education, fitness, and music created to help improve the physical, mental, social, and emotional health of children, teens, young adults, and older adults. (Ek- ins et al., in press; Willemin, Litchke, Liu, & Ekins, 2018). In addition, the program protocol provides modifications and alternative strategies for implementation for participants with physical or mental disabilities (Drums Alive, 2018). We also selected a dyadic drumming intervention based on the biological concept of reciprocal rhythmic entrainment. This entrainment process consisted of interpersonal action synchronization, whereby two intergenerational partners physically and socially coordinated their behavior intentionally adjusting toward and eventually locking into a common rhythm (Kleinspehn-Ammerlahn et al., 2011; Trost et al., 2014). Overall, there are many positive benefits of how rhythm affects the brain. Rhythm synchronizes the frontal lobe and lower areas of the brain, producing feelings of insight, understanding, and integration that persist long after the experience (Guzic, Tonkin, Roberts, & Demuth, 2011). Research confirms the sound of drumming generates dy- namic neuronal connections in all parts of the brain, even where there is significant damage or impairment (Guzic et al., 2011). Further, the brain synchronizes to strong beat music enhancing attentional and emotional networks, which suggests a link between emotions and proprioceptive feedback (Guzic et al., 2011). Several research studies point to the positive social-emotional impact of different styles of group drumming for children with specific needs including: low-income (Ho, Tsao, Bloch, & Zeltzer, 2011); IDD or developmental disabilities (Ekins et al., in press; Lock & Clark, 2009; Wright et al., n. d); behavioral health challenges and youth at risk (Flores, van Niekerka, & le Roux, 2016; Stone, 2005; Wood, Donovan, & Lambin, 2013); and those on the autism spectrum (ASD; Guzac et al., 2011; Lowry et al., 2018; Wil- lemin et al., 2018). More specifically, Ho et al. (2011) found group drumming built significant social-emotional skills among children affected by low incomes and helped eliminate the stigma of therapy in a school setting. In addition, children with IDD and behavioral challenges who engaged in an African drum circle showed positive improvements in motor coordination, memory, attention, eye contact and aggression (Locke & Clark, 2009). Specific to Drumtastic Ability Beats® interventions for children with IDD, the drumming experience reached them at an emotional level allowing for development of excitement and joy in movement and learning (Ekins et al., in press) and improved

176 Social-Emotional Benefits of Drumtastic Ability Beats ® mood for children with ASD (Willemin et al., 2018). Generally, drumming can promote social interaction, vocal responses, self-awareness, and fun helping children with disabilities to develop and expand retention, coordination, self-esteem, and physical and cognitive functioning (Guzac et al. 2011). Furthermore, for teens and young adults, drumming has also demonstrated improvement in symptoms and reduced severity of conditions related to mental health. Specifically, young adults with mental health issues who engaged in group drumming for six weeks showed significant improvements in symptoms associated with depression, social resilience, and mental well-being (Fancourt et al., 2014). In addition, Snow and D’Amico (2010) found a majority of at-risk high school students reported the group drumming helped them with stress, anger and lack of motivation, as well as self- confidence. Finally, Blankett and Payne (2005) and Winkelman (2003), who studied teens and adult substance abuse disorders showed group drumming had a calming effect and helped them deal with their high-stress lives. We also purposefully integrated the use of dyadic partnership drumming within the group setting due to the impact of synchronization on social skills when two people drum together. Dyadic drumming focuses on the biomusicological entrainment process whereby a person synchronizes their rhythm to an external perceived rhythm until the same pattern is achieved. Reciprocity occurs when two people physically and socially synchronize their actions together when drumming. This practice can then carry over into a wide range of social situations with different partners in real world settings such as school, home, and community promoting success in one’s social life (Kleinspehn-Ammerlahn et al., 2011). Method

Participants This case report focused on two specific participant partners from a larger cohort based on their unique characteristics. The child participant, Jake (pseudonym), was recommended by the behavior specialist at the school based on his difficulty in self- regulating his behavior and communicating with peers and teachers in the special education program. He displayed severe behavior problems, impulsivity, and decreased attention span. Jake was a 10-year-old male, who was diagnosed with IDD and ADHD. At the time of the intervention, Jake was residing with grandparents due to both parents being incarcerated. The college student participant, Megan (pseudonym), was selected based on her interest in the study and past involvement in numerous TR veteran activities provided by the TR graduate program at the university. Megan was a female in her early 30s, a graduate student, mother of two young daughters, and veteran who was diagnosed with PTSD. She also was struggling to manage her education, mental health issues, and parenting. These two cases were of particular interest due to the rise in prevalence over recent years of children being diagnosed with IDD and ADHD (Centers for Disease Control and Prevention, 2016) and PTSD in veterans (PTSD Foundation of America, 2017). The APA (2013) characterizes IDD as presenting with significantly lower than average scores on a test of mental ability, limitations in activities of daily living, challenges in

177 Litchke and Finley effective communication, difficulty in social situations, and school activities. In addition, ADHD presents behavioral patterns of hyperactivity, impulsivity, and inattention, often leading to impairments in social, educational, and work environments. PTSD is triggered by exposure to a traumatic event, whether being involved or as a witness, and causes impairments in social and emotional domains, including physical reactions and emotional distress: Some of these physical and emotional symptoms may include hyperarousal, anxiety, nightmares, flashbacks, and difficulty with personal and work relationships (APA, 2013). Assessments The college student participant was asked to complete four self-assessments at the beginning and end of the six-week study. Those assessments included the Physical Ac- tivity Enjoyment Scale (PACES); Perceived Stress Scale (PSS), Hospital Anxiety and Depression Scale (HADS), and Connor-Davidson Resilience Scale (CDR). Briefly, The PACES was developed for the college-age population to measure participant-reported enjoyment of an activity via 18 questions on a bipolar seven-point scale (Kendzier & DeCarlo, 1991). Kendzier and DeCarlo (1991) examined the PACES with college students on two separate activities and found that the internal consistency and test-retest reliability were very high. The PSS was used to measure how different situations influence a person’s perceived stress and social function over the last month (Fancourt et al., 2016). The PSS consisted of 10 questions, each question used a 5-point Likert Scale beginning with never (0) to very often (4). Results were categorized into low = 0-13; moderate = 14-26; high = 27-40. Internal consistency reliability, factorial validity, and hypothesis validity of the PSS are well reported. In general, the psychometric properties of the PSS for use with college students on the 10-item PSS were found to be superior to those of the 14-item PSS, while those of the 4-item scale fared the worst (Lee, 2012). Measuring perceived stress was vital to our study since Megan’s perception of stress could affect her involvement and ability to interact successfully with Jake. The HADS contains 14 questions measuring symptoms of anxiety and depression based on the respondent’s feelings over the previous week. Results were interpreted into three categories: normal = 0-7; borderline abnormal = 8-10; abnormal = 11- 21. HADS was found to perform well in assessing the symptom severity and cases of anxiety (A) disorders and depression (D) in the general population, with a Cronbach’s alpha for HADS- A (mean .83) and for HADS-D (mean .82; Bjelland, Dahl, Haug, & Neckelman, 2002). Finally, the CDR was used to assess the individual’s resiliency under a range of stressors (Fancourt et al., 2016). The college participant indicated which statement pertained to him/her on a 5-point Likert Scale beginning with not true at all (0) to nearly true all the time (4). Overall, the 10-item CDR displays excellent psychometric properties and allows for efficient measurement for college students with good internal consistency and construct validity (Campbell-Sills & Stein, 2007). Observational data were collected pre and post all six sessions by Megan in reference to Jake’s social behaviors using the Social and Personal Relationship Scale (SPRS). The SPRS was created by the PI as a pilot instrument based on the goals of the Drum- tastic Ability Beats® curriculum which were to improve social skills and personal relationships with others. The instrument was piloted for use in a previous study (Wil- lemin et al., 2018). This assessment provided information regarding the participant’s demonstration of social relationships with others and self-responsible social skills. The

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SPRS includes 20 items measured on a 5-point Likert-scale which describe the child’s self-responsible social behavior (e.g., expresses self-creativity, accepts responsibility for own behavior) as well as each participant’s demonstration of social relationship with others (e.g., shows concern when others are upset, takes turns). Results were categorized into low social skills = 0-32; moderate social skills= 33-66; and high social skills= 67-100. Additionally, the PI created another pilot instrument based on the Fun Toolkit (Read, 2008) called the Smiley-o-Meter mood scale, to measure changes in mood of participants before and after each session. The Smiley-o-Meter included 8 large emoji mood faces, each with a one-word description of mood and a number on a scale from 1-8 consecutively. For example, a sad emoji face was a bright yellow face with black ink eyes and downturned mouth with a tear running down the cheek. Underneath the face was the word SAD with a corresponding number 2. The numbers under each emoji face indicated the position of the emotional emoji face on the scale and were later used for data analysis purposes. The emoji faces were large and posted on the wall for the child participant to be able to point, state, or stand next to the mood he was feeling before and after each drum class. Megan would ask Jake before and after each class how he was feeling according to the Smiley-o-Meter. Megan then recorded her impression of his mood on the scale before and after each class. Finally, Megan completed a focused narrative progress note before and after each class on Jake’s response to the intervention. The narrative field notes consisted of subjective and objective observations of the social-emotional responses of Jake during the dyadic group drumming. Megan was instructed to record the following: (a) objective observations-what she saw and heard from Jake, (b) subjective information-general impressions of Jake’s response to intervention, and (c) note changes in behavior from session to session. Planning Procedure The PI of this study met with key personnel at the local elementary school including the director of special education, special education program coordinator, school principal, and lead teacher to review overall program concept and logistics. These spe- cialists each had a role in the approval of the Drumtastic Ability Beats® curriculum with modifications, student schedules, meeting the individualized education plans, and connection to parents of students to garner consent for participation. The team identified the two main special education goals for their students: (a) social skills and (b) emotional behavioral function. The PI, who is also a Certified Therapeutic Recre- ation Specialist (CTRS), added strategies for working specifically with children who have IDD/ADHD to help meet their social-emotional/behavioral needs such as a quiet space, 1:1 partner assistant, multisensory approach, repetitive rhythms and move- ments, and a structured routine. The Drumtastic Ability Beats® and dyadic partnership overall aim was to meet these student needs. Once the proposal was accepted, the Institutional Review Board (IRB) application process was successfully completed and approved by the university and the school dis- trict. The lead teacher sent the consent form home to the child participant’s guardian to read and sign giving consent for his participation in this study. Next, the classroom, dates and times were arranged for Drumtastic Ability Beats® to occur during the fall school semester. Meanwhile, the PI recruited the female college veteran who volun- tarily signed the consent to participate. 179 Litchke and Finley

Four special education classes consisting of 8-12 students each along with 15 TR college students agreed to engage in the intervention. The TR students were divided among the 4 classes, and then these four classes came at separate times to keep the class size manageable. On the first day of the intervention Jake and Megan became partners after Jake self-selected her as he entered the room. Megan and Jake attended the Friday class from 11:30-12:15 for 6 sessions. Intervention Protocol The primary intervention used in this study was Drumtastic Ability Beats® com- bined with dyadic within-group drumming. Drumtastic Ability Beats® encompasses the philosophy of an all inclusive - no participant left behind program (Drums Alive, 2018), while the dyadic drumming promoted a social partnership between college student Megan and her student Jake. The Drumtastic Ability Beats® equipment provided to each participant was a large exercise stability ball (referred to as a drum), a large bucket to hold the ball in place; and two pair of drumsticks (one traditional pair and another set adorned with colored scarves). The drums were placed throughout the classroom in a four-person cross shaped pod formation to create a dyadic within-group drumming experience. In addition, lavender scented towels, and yoga mats were used at the close of class for relaxation. The music accompanying the instruction was selected based on popular children’s songs and to elicit maximum engagement in motion and singing of lyrics. The Drumtastic Ability Beats® protocol used in this study was modified based on the previous works of the original pilot study by Willemin et al. (2018). Based on findings of this study, the following 45-minute session protocol was developed. The routine consisted of (a) 4-minute welcome and Smiley-o-Meter check-in with partner; (b) 5-minute partner warmup paired with singing songs and chants while drumming to the beat; (c) 5-minute call and response games and drumming repetition; (d) 7-minute choreography drum routine; (e) short 3-minute restoration quiet break with lights dimmed lying on floor or on stability ball; (f) 5-minute flow choreography with scarf drum sticks; (g) 12-minute yoga relaxation including lavender partner massage, stretches, deep breathing, rhythmic chanting, and closing with positive affirmation; and (h) 4-minute Smiley-o-Meter check-out closure with partner. Megan would greet Jake as he entered the classroom and guide him to the large Smiley-o-Meter emoji faces posted on the wall and ask him how he was feeling. Then they would select a pod and claim their two drums standing next to each other in the four-person pod with another college student and child participant. Throughout each intervention, Megan’s role was to monitor Jake’s behavior, assist if necessary with movement, drumming, and rhythmical cognitive activities by modeling and verbally cueing proper body mechanics. In addition, she helped him with socialization skills, teamwork, and creating a positive sense of social-emotional well-being, without dis- couraging his participation in either individual or group activity. Results To analyze the results for each instrument, percent change was calculated by taking the difference between the pre and post scores. Then dividing by the original number and multiplying the answer by 100. Percent change calculator used this formula:

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(y2 - y1) / y1)*100 = percentage change. Where y1 is the first value and y2 represents the second value. The college veteran’s PSS total scores changed pre to post from a 22 to 17 (∆ = 22.7%), which classified Megan in the moderate stress range pre and post. Specifi- cally, she was less nervous, felt like more things were going her way, more able to cope with all the things she had to do, and showed less difficulty in things piling up. The HADS showed a decrease in anxiety of 3 points from an 8 to a 5 (∆ = 37.5%). Thus, she reduced her anxiety symptoms from borderline abnormal (8-10) to normal (0-7). She experienced a decrease in tension despite restless interactions with Jake during drumming sessions. However, for depression, Megan’s pre-score was 5 and post was 8, showing her symptoms of depression increased by 3 points for a percent change 37.5%. According to the HADS, her pretest score total placed her in the normal range (0-7) for depression. Yet, the posttest score total placed her on the cusp of borderline abnormal (8-10). Accordingly, this could be due to the fact she self-reported losing more interest in her appearance. Despite this, Megan did report changes in being able to enjoy the things she used to in life, and looking forward to enjoying things in her future. For example, she had signed up for two outdoor adventure veteran trips (e.g., hiking and canoeing) over the break. The PACES revealed only a slight improvement from a total score of 116 to 117. Megan revealed she became more absorbed in the drumming activity, found it more pleasant, yet felt less good physically doing it. She demonstrated an increase in her enthusiasm and energy while drumming through physical displays of exuberant full body engagement personally and with Jake. Due to her increased activity in the intervention, it was more physically demanding because of her increased aerobic exertion. Her ability to feel exhilaration in the experience went up as she also felt there was nothing else she would rather be doing. The CDR pre-score was 26 and post-score was 27, showing a slight increase in resiliency as Megan felt less discouraged by failure. According to the SPRS two subcategories: Social Relationship with Others and Self-Responsible Social Behavior, Jake showed improvement in both areas. For Social Relationship with Others, Jake showed a positive change of 20 points from a pre-score of 17 to a post-score of 37, demonstrating a percent change of 54%. The largest changes (on a 5-point Likert scale) were noted in specific areas of taking turns (1 to 4), taking on a leadership role in activity (1 to 5), and listening to others (1 to 4). For Self-Re- sponsible Social Behavior area, the pre-score was 19 and the post-score was 39, reveal- ing an increase in 20 points with a percent change of 51.2%. Noteworthy changes in specific characteristics related to: participating as a follower (2 to 4), self-confidence while moving (2 to 5), sense of accomplishment (2 to 5), accepting responsibility of own behavior (1 to 4), respect for self (2 to 5), and following directions (2 to 4). The Smiley-o-Meter revealed over the 6 sessions, Jake’s mood transformed from a 3 nervous/unsocial to an 8 excited/delighted. Featured notes from Megan’s reported observations of Jake stated:

Cooperative and presented with elated mood stating: “It’s not Drumtastic its Fantastic!” Displayed leadership role by standing in front with the instructor and assisting leading class by telling instructor what to do next. He initiated effort to remain calm and collected during relaxation yoga and lotion.

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Conclusion This case study demonstrates the value of a TR intervention in special education in a school setting with emphasis on developing social-emotional skills. Highlighted in this intervention was the unique aspect of creating a rhythmic dyadic drumming partnership between a student with disabilities and a college veteran with PTSD. As suggested by Duffy and Fuller (2000) perhaps it is the combination of the benefits of rhythmic music and the building of a therapeutic relationship which accounts for progress or helps maintain interest over time. Moreover, the mutual exchange and collaboration which occurred in a drumming partnership can benefit positive social interaction (Flores et al., 2016) like we witnessed with Jake and Megan. Currently, in the Texas special education arena, there are three main focus areas where TR can help students: (a) positive social-emotional skills, (b) acquisition and use of knowledge and skills (including early language/communication), and (c) use of appropriate behaviors to meet their needs (TEA, 2018). Since CTRSs are trained to work as part of an interdisciplinary team we can contribute to the Essential Knowledge and Skills Standards during the curriculum planning process (e.g., music education and physical education) and to individualized education plans for students in special education (TEA, 2018). The Drumtastic Ability Beats® dyadic partnership program as a viable TR intervention can be replicated with other populations in school settings such as children with autism, learning disorders such as dyslexia and dyscalculia, and behavioral health disorders. Future studies are planned to expand the investigation on the rhythmic impact of drumming in other academic areas such as reading and math performance via Drumtastic Ability Beats® Curriculum math in motion and language arts in motion. In addition, the SPRS and the Fun-o-meter will be continued to be studied to measure the validity and reliability of these instruments, a recognized limi- tation to the generalizability of this case report. Moreover, TR interventions for college veterans with PTSD involving volun- teerism or service-learning need to be explored due to the compelling research showing helping others can aid in wellness and recovery. Known as “the caring cure,” Jen- kinson et al. (2013) reviewed 40 studies on the link between volunteering and health from the past 20 years, and found volunteering is associated with lower depression, increased well-being, and a 22% reduction in risk of dying early (p. 773). In addition, there has been an increase in individuals, more commonly those in the military community, seeking complementary and integrative health options for mental health needs (Walker & Pacik, 2017). Therefore, having unique interventions (e.g., Drumtas- tic Ability Beats® dyadic group drumming) as a form of complimentary treatment can help in reducing the stigma of seeking out mental health treatment that is an obstacle for many veterans (Acosta et al., 2014). Stigma in the military context is regarded as a process in which service men and women perceive or internalize a “brand” or “marked” identity about themselves or anyone with a mental health disorder (Acosta et al., 2014). Furthermore, college students are showing higher levels of stress, which are associated with avoidance coping strategies and increased depression, which can often lead to decreased use of counseling services (Dyson & Renk, 2006). Thus, CTRSs need to continue to explore complementary and alternative ways to expand new and unique service partnerships to incorporate aspects of mental wellness in schools and community settings by adding a service-learning or volunteer component.

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