Introduction
In fact, music therapy is essential for preventing students with ADHD from school failure, low self-esteem, and social rejection. Although music therapy is one of the related services under IDEA for supporting students with disabilities for meeting their individualized education program (IEP) goals, music therapy as a related service is associated with many challenges. Policy-makers should be inform that music would effectively enhance classroom behaviors and improve on-task behavior of students with ADHD. Combining music therapy with other interventions and/ or classroom instructions would improve classroom behaviors and to enhances on-task behavior of students with ADHD which result in creating more opportunities for learning.
Learning to follow classroom instructions and to spend appropriate time on-task are major goals for students’ social, personal, and educational development. However, students with ADHD have difficulties following classroom instructions, and they have additional barriers when it comes to on-task behavior. Together, the problems add up, becoming a significant barrier for academic achievement in children who have ADHD. ADHD is a neurobiological disorder that is affected by both genetic and environmental factors. In addition, as defined in the Diagnostic and Statistical Manual of Mental Disorders (2013), ADHD is a neurodevelopmental disorder characterized by disorganization, inattentive, impulsive, and overactive behaviors.
In addition, because few research studies have been completed on music therapy as a related service, future studies should be conducted to determine how students with ADHD perform with musical intervention. In order to inform policy-makers of the importance of music therapy as a related service, this paper discusses the effects of music on the brain form a neuroscientific perspective. In particular, this paper focuses on the effects of music therapy on the brain of students with ADHD which positively reflect on the academic performance of students with ADHD to notify policy-makers of the benefits from using music therapy as a related service. There is a need for a better understanding of how music therapy might influence the academic and behavioral development of students with ADHD. Moreover, this literature review is dedicated to reviewing obstacles associated with the eligibility for or access to related services in special education; in particular, challenges related to music therapy as a related service under IDEA for individuals with disabilities. Therefore, this paper highlights how the advocacy efforts made by advocacy groups or institutions such as the American Music Therapy Association (AMTA) has influenced the policies regarding music therapy as a related service under IDEA for students with disabilities.
In order to contribute to the literature, this review has the following research questions:
- how the advocacy efforts made by advocacy groups or institutions such as the American Music Therapy Association (AMTA) has influenced the policies regarding music therapy as a related service under IDEA for students with disabilities.
- From a neuroscientific perspective, how would music intervention improve classroom behaviors and academic outcomes of students with ADHD as a way to inform policy-makers of the importance of music therapy as a related service?
Review of Related Literature
Music Therapy as a Related Service
Congress established IDEA in 1975 which mandates public schools to provide an adequate education to students with disabilities (Siegel, 2011). The main purpose of IDEA is providing a Free Appropriate Public Education to students with special needs (FAPE). (IDEA) is the American law that ensures services to all individuals with disabilities, and it governs how states and public agencies provide eligible individuals who have disabilities with early intervention, special education and related services. IDEA consists of four parts, including, Part A states general provisions whereas, Part B relates directly to school age children (3-22 years of age). In addition, Part C is related to early intervention (0-3 years of age), and Part D relates to teachers preparation.
Under Part B of IDEA, individuals with disabilities may qualify for related services such as music therapy. The term “related services” is defined by IDEA in section 300.34(a) of Title 34, Code of Federal Regulations as Related services means transportation and such developmental, corrective, and other supportive services as are required to assist a child with a disability to benefit from special education, and includes speech-language pathology and audiology services, interpreting services, psychological services, physical and occupational therapy, recreation, including therapeutic recreation, early identification and assessment of disabilities in children, counseling services, including rehabilitation counseling, orientation and mobility services, and medical services for diagnostic or evaluation purposes. Related services also include school health services and school nurse services, social work services in schools, and parent counseling and training. (34 CFR 300.34(a)).
IDEA was not the only legislation piece that addressed the issue of music therapy. In 2001, the US Department of Education passed the No Child Left Behind (NCLB) Act to improve the effectiveness of education interventions (Sze, 2005). According to the given Act, schools should have ensured that all children, irrespective of their special educational needs, met annual educational objectives and demonstrated sound academic achievements (Sze, 2005). This state of affairs denoted that educators witnessed a significant challenge to deal with children with disabilities and make them achieve progress. Sze (2005) admits that music therapy was considered a useful tool to cope with the task above since it is an ancient method for healing, which “neutralizes negative feelings, increases stress tolerance level,” and others (p. 79). However, it is impossible to mention that the NCLB was explicitly designed to widen the use of music therapy. Instead, the Act stipulated the goals, and the phenomenon under consideration was chosen as a way to achieve them.
It can be obviously noted in the definition above that music therapy is not specifically included in the list of related services (Wilson, 2002), and this what creates the challenge and confusion about securing music therapy as a related service for students with disabilities in some states. Therefore, AMTA initiated an action advocating for a policy clarification for the public law related to music therapy as a related service, and this effort was recognized at the state level (Humpal, 2006).
One should also state that the NCLB was widely criticized for setting high goals and standards, which meant that a new legislation piece was necessary, and the ESSA appeared. President Barack Obama signed this regulation in 2015 to address and improve the nation’s education system (Sharp, 2016). Thus, the ESSA resulted in the fact that a significant part of education authority was shifted from federal governments to state ones, which allowed local agencies to address the existing challenges in a timely manner.
It is also necessary to mention that the ESSA contributed to the spread of music therapy. It is so because the regulation introduced the concept of specialized instructional support personnel (SISP), including music therapists and others (National Alliance of Specialized Instructional Support Personnel, n.d.). The legislation piece also made state and local agencies engage in timely consultation with SISP members (National Alliance of Specialized Instructional Support Personnel, n.d.). That is why it would be a violation of the ESSA if an eligible child does not have access to music therapy.
The American Music Therapy Association (AMTA)
The AMTA is one of the non-profit and professional associations that was established in 1950. Today, the AMTA consists of more than 8,000 music therapists and other members. The mission of the AMTA focuses on the development and improvement of using music as a therapy in many different settings such as special education, rehabilitation, and community; in addition, the AMTA’s mission is improving the public awareness of the benefits of music therapy. In addition, the AMTA is considered to be the pioneer in this type of therapy because the AMTA determines the educational and clinical training standards for music therapists. Thus, AMTA is committed for providing high quality and comprehensive information about the music therapy profession. In order to achieve this goal, AMTA and its seven regions hold a conference yearly (American Music Therapy Association www.musictherapy.org).
AMTA has been advocating for securing access to high quality music therapy services for individuals with disabilities. Unfortunately, in the past, it was difficult for providers, parents, and advocates to secure music therapy as a related service under Part B of IDEA for students with disabilities because of the confusion as music therapy is not specifically listed in the statutory list of examples of related services. As a result, the executive director of AMTA, Ms. Andrea Farbman, wrote a letter on behalf of the AMTA in April 5, 2000 to the Assistant Secretary Judith Heumann seeking for a letter of policy clarification from the Office of Special Education Programs (OSEP)regarding the provision of music therapy as a related service for students with disabilities (Humpal, Colwell, & American Music Therapy Association, 2006).
As a result of the advocacy made by the AMTA, the OSEP clarified the confusion about the requirements of music therapy as a related service under IDEA. In the policy clarification letter, the OSEP stated that the list of related services in the definition is not “exhaustive”. Although music therapy is not specifically listed as a related service, it may be considered as such under IDEA (Simpson, 2002). In addition, King & Coleman, (2000) mention that the Senate Report on Public Law-94-142 indicated that the related services listed in the definition is “not exhaustive and may include other developmental, corrective, or supportive services (such as artistic and cultural programs, and art, music, and dance therapy), if they are required to assist a child with a disability to benefit from special education”, and this will not change anything in the basic definition of related services or the Senate Report’s comments (IDEA Amendments of 1997, Part A, Section 602.22).
The above clarifications of the recognition of music therapy as a related service under IDEA aligns with the guidance provided in the Questions and Answers document on Individualized Education Programs (IEPs), Evaluations, and Reevaluations which was issued in June 2010 by the U.S. Department of Education (U.S. Department of Education, 2011). In 2006, the new, final regulations of the implementation of Part B of the Individuals with Disabilities Improvement Act of 2004 were released. The information from the Federal Register / Vol. 71, No. 156 / Monday, August 14, 2006 / Rules and Regulations, page 46569 that relates to music therapy in the final regulation indicates exactly the same clarification language that the list on related services is not exhaustive and may include other services. This new, final regulations of the Part B of IDEA were a result of the hundreds and thousands of comments were submitted requesting to add additional different services to the list of related services (U.S. Department of Education, 2011).
This advocacy efforts illustrate the misinterpretation of the defection of related services in some states; however, this obstacle remained in the state of New York. Unfortunately, clarification regarding the music therapy as a related service had never been provided by the New York State Education Department. This resulted in some school districts rejecting or discontinuing music therapy services because they stated that the state of New York has never approved music therapy as a related service. Therefore, in 2013, Elizabeth Schwartz, an AMTA member, initiated an advocacy action and requested a policy official clarification letter from the U.S. Department of Education to present it to the state. This resulted in obtaining an official letter that clarifies the recognition of music therapy as a related service under IDEA which can be used to secure this type of therapy for students with disabilities in the state of New York (American Music Therapy Association, 2013).
In addition to the pervious advocacy efforts made by the AMTA, the AMTA and the Certification Board for Music Therapists (CBMT) started a collaborative effort in 2005 for a State Recognition Operational Plan to move form state advocacy level to federal advocacy level. According to the Mid-Atlantic Region of the AMTA (n.d.), this legislation is of significance since it ensures that all individual states recognize the importance of music therapy to make this service more available to citizens. The State Recognition Operational Plan aims at reaching the outcome that state agencies will have music therapy as one of their recognized professions (MAR-AMTA, n.d.). It is necessary to implement a few specific steps to cope with the task above. These actions include identifying states that need urgent assistance, analyzing their data, offering legislative or regulatory actions, and others (MAR-AMTA, n.d.). One should also admit that the plan under consideration implies essential benefits. It refers to the fact that state recognition of music therapy will ensure that clients and patients are given high-quality service. Thus, the State Recognition Operational Plan has attempted to make the sphere of music therapy more official.
Another challenge related to music therapy is the misconceptions about music therapy and music education. Researchers and policymakers should clarify the misconceptions about music therapy and music education, and these discrepancies should be communicated to stakeholders such as parents and practitioners. The distinction between music therapy and music education is that music education focuses on teaching music in general such as teaching students how to use musical instruments or perform using voice or singing. However, music therapy focuses on using music to help students achieve physical, cognitive, emotional, and social goals (Smith, 2018). It refers to the fact that numerous activities, including singing, listening to music, creating it, and others, can help children with disabilities cope with various challenges. For example, they include socializing, expressing emotions, motivating learning, and many others (Smith, 2018). Consequently, the difference between the two areas manifests itself in the fact that music therapy is a wider concept that can lead to health benefits in addition to promoting learning performance and improving academic outcomes. Simultaneously, music education is a teaching practice that is performed to ensure that children master certain skills in the music domain.
In addition to the misconceptions about music therapy and music education, there is also misconceptions about music therapists and music teachers regarding to their roles. Thus, policy-makers should comment on the difference between these professionals to ensure that appropriate specialists provide the services under analysis. According to Smith (2018), music educators are individuals with teacher education, who are trained to utilize specific methods to make students master learning materials. These specialists teach children with and without disabilities to sing, play musical instruments, make music, and others (Smith, 2018). In particular, these professionals act as teachers of all the other school disciplines. On the contrary, “with degree in music therapy, you would instead use music as a therapeutic tool that helps clients through the emotional and physiological effects it produces.” Such professionals typically deal with special education needs students because therapy is necessary to assist individuals with health, economic, social, and other issues. According to the AMTA (2015), “music therapists develop music therapy treatment plans specific to the needs and strengths of the client who may be seen individually or in groups” (para. 5). Consequently, there is a fundamental difference between music therapists and music teachers.
In addition to the information above, it is reasonable to comment on music therapists’ preparation. It has already been mentioned that a degree in music therapy is needed. According to the AMTA (2015), a person requires at least a bachelor’s degree or its equivalent to start a career in the music therapy field. Cohen and Behrens (2002) admit that it is also reasonable to seek Doctoral and Master’s degrees to improve their professional skills, which can result in a longer and more successful professional path. Furthermore, a person should complete pre-internship and internship training at the AMTA-approved programs (AMTA, 2015). These two steps provide individuals with sufficient professional knowledge and allow them to gain the required skills. However, additional efforts are needed for a person to become a music therapist.
The information above refers to the fact that such professionals should have additional certification. The CBMT offers the Music Therapist – Board Certified (MT-BC) credential to ensure that all specialists follow national standards (AMTA, 2015). Thus, the given credential ensures that a music therapist has sufficient knowledge, abilities, and experience to provide their service to children. An individual should successfully complete an academic and clinical training program to be awarded the credential (AMTA, 2015). All these steps are necessary to ensure that music therapists can understand the special needs of children with disabilities and know how to address them.
Furthermore, it is worth considering that music therapists should meet specific expectations when it comes to their practice. Pizzi (2020) admits that the Code of Ethics regulates professional behaviors in the given sphere. According to the AMTA (2015), music therapy practice includes conducting a patient’s assessment, developing and implementing an individualized treatment plan, eliminating possible barriers between the therapist and the patient, and many others. This information supports Thompson’s (2020) claim that reflexivity plays a crucial role in music therapy practice. Finally, one should draw attention to the fact that this practice does not focus on training and educating children with disabilities. Thus, Ghetti (2011) admits the benefits of child life training, but the researcher indicates that this issue is not necessary to demonstrate advanced music therapy practice standards. This point has also highlighted the difference between musical therapists and teachers.
School districts violate IDEA’s obligations by failing to affirmatively provide students with disabilities with high quality access to all necessary related services that appropriately meet their needs. For instance, This policy clarification explicitly task schools to evaluate students with disabilities to determine whether they would qualify or related services such as music therapy based on the students’ needs. Then, provide them with high quality access.“When a school is aware of a student’s disability, or has reason to suspect a student has a disability, and the student needs or is believed to need special education or related services, it would be a violation of Section 504 if the school delays or denies the evaluation.”
In addition to seeking for the policy clarification in that letter, the executive director of AMTA requested another policy clarification regarding the standards for appropriate personnel who offer music therapy as one of the related services.
Music and ADHD
Prevalence and Indicators of ADHD
ADHD is one of the high prevalence disorders. ADHD was not included in the Diagnostic and Statistical Manual (American Psychiatric Association) until 1980 which results in a global increase in the prevalence of children with ADHD (Helle-Valle, Binder, Anderssen, and Stige, 2017). Among children in schools, ADHD is a popular reason for mental health referral (Walker and Gresham, 2014) as it appears in 5% of children (Gehricke et al., 2017). As a result of the high prevalence of ADHD, Walker and Gresham, (2014) state that there is at least one student with ADHD in each typical classroom, and boys are more likely to be diagnosed with ADHD than girls.
The prominent characteristics of ADHD are inattention, hyperactivity, and impulsivity. Nonetheless, Nowadays, technology and Neuroscience take us beyond what we ever thought as ADHD can be diagnosed through magnetic resonance imaging (MRI). It is interesting to mention that Gehricke et al.’ study (2017) was one of the first to investigate the structure and function of the brain of children and adults with ADHD and how it relates to a diagnose of ADHD. The study used Voxel-wise linear regression models to examine the MRI data collected for this study, and the findings indicate that increase white matter concentration and decrease grey matter concentration is associated with ADHD diagnosis in children and young adults. One of the best ways to predict ADHD diagnosis is to measure the white matter concentration in the brain, and MRI based data correctly predicted 83% of the ADHD diagnoses (Gehricke et al., 2017). Furthermore, study by Gehricke et al. (2017) corroborates that there is a stronger association between micro- and macrostructural changes and ADHD symptoms in childhood compared to ADHD symptoms in adults.
In addition to diagnosing ADHD through MRI, MRI also can indicate that the brain of students with ADHD functions differently from the brain of students without ADHD. Individuals with ADHD have smaller brain sizes compared to people who do not have ADHD (citation). Gehricke et al. (2017) present that individuals with ADHD have dysfunction in the superior longitudinal fasciculus (SLF) and in the cortico-limbic, and they have audio-visual, motivational, and emotional deficits. Moreover, Friedman and Rapoport, (2015) indicate that ADHD leads to volume reductions in the prefrontal cortex, parieto-temporal regions, basal ganglia, and cerebellum. Friedman and Rapoport, (2015) state that ADHD also leads to degradation in the person’s cognitive abilities; however, these deteriorations are not ubiquitous, and people with ADHD have different cognitive profiles. The nature of the disorder is complicated, and more research is needed to determine the exact mechanisms that cause cognitive degradation (Friedman and Rapoport, 2015).
Due to the brain differences, inattention, hyperactivity, and impulsivity are the symptoms of ADHD in the classroom. In addition, Barkley (2003), provides additional details about ADHD symptoms by stating that children with ADHD have difficulties with focusing on details, organizing tasks, and sustaining attention during various activities. Children who have ADHD may have problems with discipline, as they are not able to stay in one place and be occupied with one task for a long period of time, and they frequently cannot wait their turn or be patient to listen to a question or task description until the end (Barkey, 2003). Especially notable is the emphasis was made by Mautone et al., ( 2009) on the academic difficulties that students with ADHD encounter such as the inability to complete seatwork independently or inaccuracy of seatwork when it is completed. According to Mautone et al., (2009), disruptive classroom behaviors and lack of study skills are other effects of ADHD on students. Compared to their peers, students with ADHD show lower performance on tests (Mautone et al., 2009), and they fail to graduate due to the academic underachievement (Hedin et al., 2011). Based on the characteristics of students with ADHD, students would benefit from some types of interventions in the classroom such as music intervention.
Music intervention
The positive influence of music on people’s psychological state has been acknowledged, and certain attention has been paid to the impact music has on the learning of students with ADHD. Serrallach et al. (2016) found that the interhemispheric asynchronies in auditory cortices related to ADHD were less pronounced in students practicing musical instruments. Marcuzzi and Romero-Naranjo (2017) shed light on the central aspects to concentrate on when developing music interventions for students with ADHD. The researchers emphasize that rhythm is the basic element that proved to have a major impact on learners (Marcuzzi & Romero-Naranjo, 2017). Slater and Tate (2018) also found the positive role rhythm plays on the learning of students with ADHD. Neuroscientific research identified the role rhythm can play in decreasing timing deficits that are commonly found in children with ADHD (Slater & Tate, 2018). Dymnikowa (2017) examined the effectiveness of an intervention aimed at training working aural musical memory. The intervention improved the attention and overall performance of students diagnosed with ADHD.
The literature introduces evidence that music positively affects the brain of individuals with ADHD. According to Parker, (2020) playing and experiencing music can enhance brain plasticity and improve cognitive function. From a neuroscientific perspective, music in general has its benefits on the brain when listening to it or playing it. Playing music and listening to it can improve cognitive people intellectual functioning. Maloy and Peterson, (2014) emphasize what Parker, (2020) proposes by reporting that pleasurable music can be used to increase dopamine levels in the brain. Based on the general positive impact of music in the brain, it can be inferred that music in particular can improve the function of the brain of students with ADHD. Maloy and Peterson, (2014) state that using music as an external auditory stimulation with students who have ADHD could enhance memory performance. In addition, Parker, (2020) mentions that brain performance of students with ADHD increases by a specific level of auditory stimulation such as music. From this, it may be concluded that music intervention would improve the function of the brain of students with ADHD.
Music can be used as an effective external stimulation for enhancing on-task behavior of students with ADHD. Maloy and Peterson, (2014) and Parker, (2020) underline the use of music as an external stimulation to improve on-task behavior of students with ADHD; however, the study conducted by Parker (2020) is an extension to Maloy and Peterson’s study 2014). In order to address the gap in the literature Parker conducts a quantitative study to examine the effectiveness of listening to Baroque style music at a specific level “just above the threshold of hearing” in improving on task behavior of students with ADHD. Parker, (2020) compares students’ on-task behavior with intervention (listening to Baroque style music while performing a task) with their on-task behavior without intervention (not listening to music). Parker finds that listening to Baroque style music improves the duration of on-task behavior of students with ADHD; thus, he recommends applying music intervention in the classroom to enhance on-task behavior of students with ADHD (p.120). Parker’s study proves that music would regulate the prefrontal cortex and parietal cortex of the brain of students with ADHD. Therefore, it can be concluded that student with ADHD would benefit from music intervention in term of enhancing their attention span which in turns improve on-task behavior.
In addition, music can enhance the attention span of students with ADHD. Especially notable is the emphasis was made by Maloy and Peterson, (2014) on the academic benefits of an external stimulation such as music while working on a task for students with ADHD. They demonstrate that attention span of students with ADHD could be enhanced by music which positively reflects on performing tasks. To illustrate, students with ADHD have attention deficits, and this means the inability to maintain attention on tasks; thus, the enhancement in their attention span by using music could benefit them on spending more time on the tasks. Maloy and Peterson, (2014) investigate the effectiveness of music intervention as an external stimulation on task performance of children and adolescents who have ADHD, and they indicate that music intervention has minimal positive impacts in improving task performance of children and adolescents with ADHD.
Additional aspects other than attention and memory have gained momentum recently. Madjar et al. (2020) explores the effects a music intervention could have on the reading comprehension of elementary-school students with and without ADHD. It was found that music improved ADHD students’ reading comprehension while no such effects were observed with children without the disorder under study. The positive effects of music on children with mental disorders have been acknowledged, and the improvements in learning, memory, and emotional aspects were also researched (Hosseini & Hosseini, 2018). Hosseini and Hosseini (2018) also found that group interventions had more pronounced positive results compared to individual therapy.
Although quite substantial empirical data concerning the positive influence of music on children’s learning is available, the educational system only partially employs this kind of information to improve the quality of the services provided. Music has been a part of the educational paradigm, but educators tend to pay less attention to this aspect due to the scarcity of time and the need to meet established objectives. Hedemann and Frazier (2017) stated that diverse school-based interventions were introduced and proved to be effective. After-school programs have a positive impact on the development of children with special needs, including those diagnosed with ADHD (Hedemann & Frazier, 2017). However, the lack of resources and associated issues in rural schools and educational establishments located in low-income neighborhoods make the implementation of such programs hard, or even impossible. There is a limited number of policies enacted on a state or federal level, although governments try to improve inclusive incentives.
It is noteworthy that the neuroscientific approach is increasingly used when exploring the effects of music intervention on students with ADHD. Kasuya-Ueba (2019) implemented a review of novel techniques utilized in neuroscientific research of the effects of music on children with mental disorders such as ADHD or ASD. For instance, functional near-infrared spectroscopy proved to be an effective instrument to measure children’s attention. However, numerous gaps are still apparent and require detailed investigation. For instance, the long-term effects of music initiatives are still unclear. Qualitative data is also necessary to identify the motivation of educators and students with ADHD, as well as their perceptions regarding the design of interventions and their outcomes. Clearly, it is critical to assess the effectiveness of diverse interventions targeting students of different ages, so that appropriate policies could be introduced in the U.S. educational system.
Conclusion
Thus, this literature review highlights the effectiveness of music as an intervention for students with ADHD. In particular, this current paper reviews the related literature from a neuroscientific perspective to shed the light upon the effects of music intervention on the academic performance and behavioral development of students with ADHD. It is evident that music can enhance the brain of students with ADHD; therefore, music intervention can be used as an effective tool for improving academic and behavioral development of students with ADHD. For this reason, this paper proposes a policy for implementing music intervention individually or in groups within the classroom.
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