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Evidence-Based Complementary and Alternative Medicine
Volume 2011, Article ID 250708, 14 pages
doi:10.1093/ecam/neq072
Original Article
The Impact of Group Drumming on Social-Emotional
Behavior in Low-Income Children
Ping Ho,1JennieC.I.Tsao,
1Lian Bloch,2and Lonnie K. Zeltzer1
1Pediatric Pain Program, Department of Pediatrics, David Geffen School of Medicine, University of California, Los Angeles, USA
2Clinical Science Program, Department of Psychology, University of California, Berkeley, CA, USA
Correspondence should be addressed to Ping Ho, pingho@ucla.edu
Received 10 August 2009; Accepted 19 May 2010
Copyright © 2011 Ping Ho et al. This is an open access article distributed under the Creative Commons Attribution License, which
permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Low-income youth experience social-emotional problems linked to chronic stress that are exacerbated by lack of access to care.
Drumming is a non-verbal, universal activity that builds upon a collectivistic aspect of diverse cultures and does not bear the
stigma of therapy. A pretest-post-test non-equivalent control group design was used to assess the effects of 12 weeks of school
counselor-led drumming on social-emotional behavior in two fifth-grade intervention classrooms versus two standard education
control classrooms. The weekly intervention integrated rhythmic and group counseling activities to build skills, such as emotion
management, focus and listening. The Teacher’s Report Form was used to assess each of 101 participants (n=54 experimental,
n=47 control, 90% Latino, 53.5% female, mean age 10.5 years, range 10–12 years). There was 100% retention. ANOVA testing
showed that intervention classrooms improved significantly compared to the control group in broad-band scales (total problems
(P<.01), internalizing problems (P<.02)), narrow-band syndrome scales (withdrawn/depression (P<.02), attention problems (P
<.01), inattention subscale (P<.001)), Diagnostic and Statistical Manual of Mental Disorders-oriented scales (anxiety problems
(P<.01), attention deficit/hyperactivity problems (P<.01), inattention subscale (P<.001), oppositional defiant problems (P
<.03)), and other scales (post-traumatic stress problems (P<.01), sluggish cognitive tempo (P<.001)). Participation in group
drumming led to significant improvements in multiple domains of social-emotional behavior. This sustainable intervention can
foster positive youth development and increase student-counselor interaction. These findings underscore the potential value of the
arts as a therapeutic tool.
1. Introduction
Children under age 18 years represent a quarter of the
total population of the USA (74 million) [1]; 39% are low-
income, that is, living in families earning less than double
the federal poverty level [2]. Although European Americans
represent the largest number of low-income children (26%,
10.9 million), other groups are more disproportionately
represented: Latino (61%, 9.4 million), African American
(60%, 6.5 million), American Indian (57%, 0.3 million),
Asian American (30%, 0.9 million), children of immigrant
parents (58%, 7.4 million), children of native-born parents
(35%, 20.2 million) [2].
1.1. Mental Health Needs of Low-Income Youth. Low-income
youth are commonly exposed to stressors [3–12] that are
well-established risk factors for behavior problems and
school failure in the general youth population [13]. Corre-
spondingly, socioeconomic disadvantage is associated with
internalizing (e.g., depressive, anxious, somatizing, post-
traumatic stress) and externalizing (e.g., antisocial, aggres-
sive, delinquent, substance abusing) behavior in children
and adolescents [3,9,14–22]. The burden of chronic stress
held by low-income youth is compounded by poor access
to health and mental health care [1,22–26]. Moreover, low-
income families may be reluctant to obtain services, for
reasons ranging from stigma and attitude towards treatment
[27,28] to psychosocial and legal ramifications of reporting
problems [12,29,30]. Minority youth, in particular, are at
greater risk of encountering the “triple threat” of suboptimal
health, lack of access to care and inferior services [26].
Notwithstanding, relatively few mental health interven-
tions have targeted low-income youth, and most aim to
reduce a single problem behavior or deficit [31–37]in
contrast to a positive development approach of increasing
core assets that may influence a range of problem behaviors
2 Evidence-Based Complementary and Alternative Medicine
[38,39]. Positive youth development interventions facili-
tate positive outcomes through developmentally appropri-
ate achievements intended to address the “whole child”
[39].
1.2. Group Drumming for Positive Development, Cultural
Relevance and Stress Reduction. Group drumming is a
recreational music making activity that builds social-
emotional assets consistent with a positive youth develop-
ment approach. It is conducted in a circle and often led by
a facilitator whose role is to maximize a sense of community
through rhythmic dialogue. Group drumming is inclusive;
it is non-verbal, universal, and does not require previous
experience for participation. Furthermore, group drumming
is culturally relevant; it is an integral part of diverse cultures,
and supports the value of collectivism, shared by non-
European-based cultures [40].
Previous studies of adults [41–43] and adolescents [44]
have shown the biopsychosocial efficacy of group drumming,
using protocols involving reflection and self-disclosure to
reduce stress. These studies found neuroendocrine and
immune changes that were indicative of reduced stress in
normal adults with no previous experience in drumming
[41], reduced burnout and improved mood in long-term
care workers and nurses [42,43], and improved social-
emotional functioning in adolescents from a court-referred
residential treatment center [44]. Other art forms used in
therapeutic contexts with adults and children have also been
linked with improvement in biopsychosocial indicators of
stress [45–62].
The unique effectiveness of group drumming with reflec-
tion and self-disclosure [41], versus group drumming with-
out these components, suggests the possible added benefit
of integrating counseling activities with group drumming to
reduce social and emotional manifestations of stress in low-
income youth. Social–emotional skill building delivered in a
framework of drumming may also confer benefits without
the stigma of therapy.
1.3. Theoretical Rationale. According to Social Cognitive
Theory, group drumming combined with group coun-
seling activities would foster individual self-efficacy and
positive outcome expectations through enactive attainment,
vicarious experience, verbal persuasion and reduction of
physiological arousal [63]. Furthermore, collective efficacy
may grow through a shared sense of purpose [63]. In support
of this notion, Paulo Freire’s Empowerment Education
Theory of Dialogue and Praxis asserts that the development
of empathy through common experience enables more
meaningful reflection and dialogue, which in turn sets the
stage for action, or empowerment [64,65].
1.4. Research Objective. In summary, low-income youth are
in need of interventions to address social and emotional
behavior linked to chronic stress. Therefore, could a school-
based group drumming program, integrated with activities
from group counseling, improve social and emotional behav-
ior in low-income children?
2. Methods
2.1. Design and Population. Upon written approval by the
Institutional Review Board of the University of California,
Los Angeles, as well as the Program Evaluation and Research
Branch of the Los Angeles Unified School District (LAUSD),
we utilized a pretest-post-test non-equivalent control group
design to assess the effects of 12 weeks of school-counselor-
led drumming, aimed at social and emotional skill building,
on problem behavior in low-income fifth graders. Fifth
graders were targeted for early intervention because they
would be old enough to benefit from rhythm-based thera-
peutic activities involving reflection, and their peer-centric
developmental stage would lend itself well to group activities
[66]. The study was conducted in spring of 2007 at Napa
Street Elementary School in the LAUSD. Students at the
school were 89% Latino [67], of which ∼90% were US born
[68], 75% were of Mexican ethnicity [68] and 66% were
English learners [67]. Ninety-seven percent of the students in
the school participated in the reduced-price lunch program,
a statewide index of socioeconomic disadvantage [67].
2.2. Recruitment. Students from all four fifth-grade classes in
the school were recruited for the study. Since there were two
classesineachoftwodifferent academic scheduling tracks,
one class from each track was assigned to the experimental
condition, and the other class from each track was assigned
to the standard education control condition. Assignment to
treatment conditions was not randomized, due to school
administrative constraints. The students were told that the
study was being conducted to see how drumming might
affect their experience in school. They were also told that one
group would get weekly drumming for 12 weeks, while the
other group would get two sessions after the end of the study.
Of 106 students, 101 obtained parental consent for
participation (95%). In one case, non-participation was due
to parent refusal. In four cases, consent forms were not
returned, and parents could not be contacted. Students that
did not have consent to participate went into the control
classrooms during the intervention.
2.3. Demographics of Participants. Demographic character-
istics of the four classes can be found in Table 1. Of 101
participants in the study, 47 (46.5%) were male and 54
(53.5%) were female. Ninety-one (90%) were Latino, five
(5%) were African American, two (2%) were Filipino, two
(2%) were European American and one (1%) was Asian;
these percentages reflected the racial/ethnic demographics
of the school [67]. The mean student age was 10.5 years
(range 10–12 years). The 10 non-Latino students were spread
across all four classrooms. In total, 54 students received the
intervention and 47 students were in the standard education
control group. There were no significant differences in the
proportion of boys versus girls across the four classes. The
two experimental group teachers were a European American
male, age 43 years, and a Latina, age 33 years; the two control
groupteacherswereEuropeanAmericanfemales,ages30and
32 years. There was no loss of student or teacher participation
in either the experimental or control groups.
Evidence-Based Complementary and Alternative Medicine 3
Tab le 1: Demographic characteristics of the four classrooms.
TE1 (n=24) TE2 (n=22) TE3 (n=30) TE4 (n=25)
Condition D CN D CN
Sex
Girls 11 (45.8%) 13 (59.1%) 15 (50.0%) 15 (60.0%)
Boys 13 (54.2%) 9 (40.9%) 15 (50.0%) 10 (40.0%)
Age, mean (SD) 10.58 (0.58) 10.46 (0.67) 10.43 (0.57) 10.48 (0.51)
Race/ethnicity 23 Latino 21 Latino 25 Latino 22 Latino
1 European American 1 Asian 3 African American 2 African American
2 Filipino 1 European American
TE: teacher; D: drumming; CN: control.
2.4. Building Support from the School Community. Prior to
the beginning of the study, all faculty and a few stafffrom
Napa Street Elementary School attended a free in-service
drumming workshop at Remo Recreational Music Center in
North Hollywood, California. The purpose of this was to
increase support for the pilot study from the overall faculty
and, in particular, to increase compliance from those that
would be involved in the study.
2.5. Assessment. The quantitative assessment instrument
utilized was the Teacher’s Report Form (TRF)—the teacher
version of the Child Behavior Checklist—which yields a
variety of scales of adaptive functioning derived from a mixed
list of 120 factor-loaded items [69]. The TRF asks teachers
to rate each of their students on problem behaviors over
the past 2 months, with three possible response choices:
0=not true (as far as you know), 1 =somewhat or sometimes
true, 2 =very true or often true. TRF scale scores have been
standardized based on normative data from children 6–
18 years of age, and the instrument has been subjected to
extensive reliability and validity testing [69]. Use of the TRF
has been reported in >1000 peer-reviewed publications [70]
and its robustness has been demonstrated in multicultural
settings as well [71].
The wide range of problem behavior scales offered by the
TRF was advantageous, given that the study was exploratory
in nature and intended to inform the focus of assessments
in future research. The TRF yields three broad-band scales:
Total Problems (an aggregate of all items on the rating
form), Internalizing Problems (a composite of scores from
three narrow-band syndrome scales: Anxious/Depressed,
Withdrawn/Depressed, Somatic Complaints) and External-
izing Problems (a composite of scores from two narrow-
band syndrome scales: Rule-Breaking Behavior, Aggressive
Behavior). The TRF also derives three other narrow-
band syndrome scales: Social Problems, Thought Problems,
Attention Problems. In addition, it offers two subscales
for the syndrome scale of Attention Problems: Inattention
and Hyperactivity-Impulsivity. This set of empirically based
scales constitutes the core of the TRF.
Items on the TRF can also be used to generate six
scales that are consistent with categories from the Diag-
nostic and Statistical Manual of Mental Disorders, Fourth
Edition (DSM-IV), for the American Psychiatric Associa-
tion [72]: Affective Problems, Anxiety Problems, Somatic
Problems, Attention Deficit/Hyperactivity Problems, Oppo-
sitional Defiant Problems, and Conduct Problems. Further-
more, the TRF offers two subscales for the DSM-oriented
scale of Attention Deficit/Hyperactivity Problems: Inatten-
tion and Hyperactivity-Impulsivity. Finally, four other scales
can be scored using TRF items: Obsessive-Compulsive Prob-
lems, Post-traumatic Stress Problems, Sluggish Cognitive
Tempo, and Positive Qualities.
Both experimental and control teachers completed a TRF
for each student in her or his class within a 2-week window,
immediately prior to the start of the study and immediately
upon completion of the study. There was no missing data.
2.6. Protocol Development. The group drumming protocol
was co-developed by a drum circle facilitator, a public health
educator and the school counselor—a licensed clinical social
worker familiar with the social, emotional and cultural
needs of the research population. The intervention was
solely administered by the school counselor and delivered
to a whole classroom of students at a time, including the
teacher—in order to foster indirect benefits to students
through stress reduction, observational learning, and/or car-
ryover of session themes to the classroom. Prior to delivering
the intervention, the counselor attended a weekend training
session on drum circle facilitation and practiced facilitating
drum circles under supervision with five classrooms of stu-
dents at two socioeconomically similar elementary schools in
the LAUSD. This served to confirm the feasibility of working
with a whole classroom of students at a time.
To control for the integrity of the rhythmic component
of the intervention, the drum circle facilitator, who was
experienced in working with children, served as a silent
participant observer during the sessions and offered sugges-
tions for improvement during debriefing meetings. A lesson
plan was outlined in advance of each session based upon
the previous one, and it was delivered with consistency to
both classrooms designated to receive the intervention. Upon
completion of the study, a scripted manual was developed for
future research use.
2.7. Intervention. The intervention took place during the
school day, right after lunch, for 40–45 min weekly, over a
12-week period. It consisted of a hybrid of activities used in
4 Evidence-Based Complementary and Alternative Medicine
contemporary drum circles and in group counseling with
school-age pupils, to maximize development of social and
emotional skills through guided interaction, reflection, and
self-disclosure. Drums and rhythms were chosen to reflect
cultural diversity; drumming activities emphasized process
and not performance. Session themes included various
combinations of positive behavior, team building, positive
risk taking, self-esteem, awareness of others, leadership,
sense of self, expressing feelings, managing anger, managing
stress, empathy and gratitude. “Focus and listening” was a
constant theme.
Each session began with the whole group playing an
ongoing rhythm pattern to release stress, energize and
establish a sense of community. Focus and listening was
encouraged throughout the program via the use of non-
verbal cues and “call and response”-type activities, which
required the echoing back of an improvised rhythm played
by a member of the group. Rhythmic activities were also used
as the basis for lessons corresponding with session themes.
For example, in the session on positive behavior, participants
would simultaneously speak and beat the affirmation, “I am
responsible, I do the right thing”; this was followed by a
group discussion of the meaning of the affirmation for inte-
gration and internalization. In the session on sense of self and
awareness of others, children shared their favorite color, food
and animal while drumming to the syllables of the words.
In the session on expressing feelings and managing anger,
the group brainstormed ways to manage anger, learned a
spoken “calm down mantra”, and then expressed feelings on
the drums. In the session on team building and positive risk
taking, hand shakers were systematically passed around the
circle in increasingly rapid succession until many dropped;
this was followed by a discussion of the acceptability of
making mistakes in the learning process and how it feels to
give and receive. In the session on leadership, empathy and
gratitude, when students were given an opportunity to lead a
call and response from the center of the circle, other students
were asked how the leader may have felt, which segued into a
discussion of empathy and gratitude.
Session activities promoted the following constructs
found in effective positive youth development programs:
social-emotional-cognitive-behavioral-moral competence,
self-efficacy, clear standards for behavior, healthy bonding,
opportunities for prosocial involvement and recognition,
structure and consistency in program delivery [38]. A more
complete description of the group drumming protocol and
its development will be published in a separate article.
2.8. Statistical Analysis. To examine group differences in
the current sample, based on changes in scores from
baseline to post-intervention/control, difference scores for
the TRF scales were calculated by subtracting post-
intervention/control scores from baseline scores for all scales.
Preliminary analyses to examine the potential effect of the
sex of the child on baseline TRF scores did not reveal
any differences across the four classes. As the current
investigation used a quasi-experimental design and did not
randomly assign classrooms to study conditions, the drum-
ming and control classes were not combined. Therefore, a
0
5
10
15
20
25
Mean TO scale scores
TE 1 (D) TE 2 (CN) TE 3 (D) TE 4 (CN)
Classroom
Baseline
Post
Figure 1: Total problems—mean baseline and post-
intervention/control scores by classroom.
series of ANOVAs were conducted to examine the effect of
teacher (TE1 versus TE2 versus TE3 versus TE4) on each
of the TRF scales separately. In the event of a significant
omnibus F, Fisher’s least significant difference (LSD) post-
hoc tests were conducted to specify which groups differed.
The distributions of the TRF difference scores were examined
to ensure that assumptions for parametric analyses were
met. To normalize the distributions, outliers were identified
and excluded for individual scales as detailed below. As
recommended by Tabachnick and Fidell [73], distributions
of scores were examined within each classroom; values >2
SD from the mean were considered outliers. Effect sizes are
reported in the form of partial eta squared (η2
p).
3. Results
3.1. TRF Broad-Band Scales. Baseline, post-intervention/
control, and difference scores for TRF broad-band scales that
were statistically significant are displayed in Tab l e 2 .
Total Problems (TO—an aggregate of all items on the
rating form). For TO difference scores, there was an overall
significant group difference (F(3,97) =5.27, P<.01; η2
p=
0.14). Post-hoc tests showed that drumming teacher TE1
rated students as improving more on TO scores than the two
control teachers (TE2 and TE4) (Figure 1). Also, drumming
teacher TE3 rated students as improving more on TO scores
than control teacher TE4.
Internalizing Problems (IP—a composite of scores from
three narrow-band syndrome scales: Anxious/Depressed,
Withdrawn/Depressed, Somatic Complaints). For IP differ-
ence scores, the ANOVA showed a significant difference
among groups (F(3,97) =3.73, P<.02; η2
p=0.10). Post-hoc
tests indicated that drumming teacher TE3 rated students as
improving more on IP scores compared to control teacher
TE2 (Figure 2).
Externalizing Problems (a composite of scores from
two narrow-band syndrome scales: Rule-Breaking Behavior,
Evidence-Based Complementary and Alternative Medicine 5
Tab le 2: Mean (standard deviation) TRF broad-band scale scores by classroom.
TE1 (n=24) TE2 (n=22) TE3 (n=30) TE4 (n=25)
Condition D CN D CN
TRF scale
Baseline TO 7.6 (7.9) 15.5 (11.3) 10.7 (9.0) 18.0 (14.6)
Post-TO 3.6 (3.2) 17.4 (11.1) 7.4 (7.9) 20.4 (14.0)
Difference TO 4.0 (7.9) –1.9 (7.4) 3.3 (6.2) –2.4 (7.6)
Baseline IP 2.3 (3.1) 3.4 (2.5) 4.3 (4.8) 4.4 (4.1)
Post-IP 1.3 (1.4) 4.3 (2.8) 2.3 (2.2) 4.1 (3.4)
Difference IP 1.0 (3.2) –0.9 (3.1) 2.0 (3.5) 0.3 (2.6)
TE: teacher; D: drumming; CN: control; TRF: Teacher’s Report Form; Difference: difference score (post-intervention/control minus baseline); TO: total
problems; IP: internalizing problems. A positive value for difference scores indicates improvement whereas a negative value indicates worsening of symptoms.
0
1
2
3
4
5
6
Mean IP scale scores
TE 1 (D) TE 2 (CN) TE 3 (D) TE 4 (CN)
Classroom
Baseline
Post
Figure 2: Internalizing problems—mean baseline and post-
intervention/control scores by classroom.
Aggressive Behavior). Difference scores for externalizing
problems were not significant between groups.
3.2. TRF Narrow-Band Syndrome Scales. Baseline, post-
intervention/control and difference scores for TRF narrow-
band syndrome scales that were statistically significant are
displayed in Tabl e 3 .
Withdrawn/Depressed (WD). For WD difference scores,
two outliers were identified (both in drumming class 1).
Exclusion of these outliers normalized the distribution. The
ANOVA on WD difference scores showed a significant differ-
ence among groups (F(3,95) =3.75, P<.02; η2
p=0.11). Post-
hoc tests indicated that the two drumming teachers (TE1 and
TE3) rated students as improving more on WD scores post-
intervention compared to control teacher TE2 (Figure 3).
Attention Problems (AP). For AP difference scores, results
of the ANOVA indicated a significant difference among
groups (F(3,97) =5.69, P<.01; η2
p=0.15). Post hoc tests
showed that drumming teacher TE1 rated students as
improving more on AP scores post-intervention relative to
0
0.5
1
1.5
2
2.5
3
3.5
4
Mean WD scale scores
TE 1 (D) TE 2 (CN) TE 3 (D) TE 4 (CN)
Classroom
Baseline
Post
Figure 3: Withdrawn/depression—mean baseline and post-
intervention/control scores by classroom.
the two control teachers (TE2 and TE4) (Figure 4). In addi-
tion, drumming teacher TE3 rated students as improving
more on AP scores compared to control teacher TE4.
Inattention (IN—one of two subscales for Attention
Problems; the other being Hyperactivity-Impulsivity). IN
difference scores showed a significant difference among
groups (F(3,97) =7.16, P<.001; η2
p=0.18). Results of post-
hoc tests indicated that the two drumming teachers (TE1 and
TE3) rated students as improving more on IN scores post-
intervention compared to the two control teachers (TE2 and
TE4) (Figure 5).
Anxious/Depressed, Somatic Complaints, Social Problems,
Thought Problems, Rule-Breaking Behavior, Aggressive Behav-
ior, Hyperactivity-Impulsivity Subscale of Attention Problems.
Difference scores for these syndrome scales were not signifi-
cant between groups.
3.3. TRF DSM-Oriented Scales. Baseline, post-intervention/
control, and difference scores for TRF DSM-oriented scales
that were statistically significant are displayed in Tab l e 4 .
6 Evidence-Based Complementary and Alternative Medicine
Tab le 3: Mean (standard deviation) TRF narrow-band syndrome scale scores by classroom.
TE1 (n=24) TE2 (n=22) TE3 (n=30) TE4 (n=25)
Condition D CN D CN
TRF scale
Baseline WD 0.6 (1.5) 1.8 (1.8) 1.9 (2.1) 3.1 (3.0)
Post-WD 0.1 (0.5) 2.5 (2.1) 1.1 (1.3) 3.2 (2.6)
Difference WD 0.5 (1.6) –0.7 (2.4) 0.8 (1.3) –0.1 (1.6)
Baseline AP 4.2 (4.6) 9.7 (9.2) 3.1 (4.6) 9.1 (8.1)
Post-AP 1.8 (2.3) 10.8 (7.6) 2.6 (4.1) 10.6 (8.0)
Difference AP 2.4 (4.0) –1.1 (4.1) 0.5 (2.3) –1.5 (4.4)
Baseline IN 3.2 (3.7) 6.0 (5.5) 1.5 (2.9) 6.8 (7.1)
Post-IN 1.0 (1.7) 7.2 (4.9) 0.8 (1.8) 7.9 (6.5)
Difference IN 2.2 (3.1) –1.2 (3.3) 0.7 (1.5) –1.1 (3.7)
TE: teacher; D: drumming; CN: control; TRF: Teacher’s Report Form; Difference: difference score (post-intervention/control minus baseline); WD:
withdrawn/depressed; AP: attention problems; IN: inattention (subscale of AP). A positive value for difference scores indicates improvement whereas a
negative value indicates worsening of symptoms.
Tab le 4: Mean (standard deviation) TRF DSM-oriented scale scores by classroom.
TE1 (n=24) TE2 (n=22) TE3 (n=30) TE4 (n=25)
Condition D CN D CN
TRF scale
Baseline AN 0.5 (0.7) 0.1 (0.3) 0.5 (1.1) 0.3 (0.7)
Post-AN 0.04 (0.2) 0.4 (0.6) 0.2 (0.6) 0.4 (0.7)
Difference AN 0.46 (0.7) –0.3 (0.6) 0.3 (0.8) –0.1 (0.9)
Baseline AH 2.5 (2.8) 4.8 (4.7) 1.9 (2.8) 4.7 (4.5)
Post-AH 1.1 (1.5) 5.3 (4.3) 1.5 (2.5) 5.9 (4.8)
Difference AH 1.4 (2.4) –0.5 (1.9) 0.4 (1.6) –1.2 (2.9)
Baseline I 1.7 (1.9) 2.0 (2.1) 0.5 (1.2) 3.0 (3.3)
Post-I 0.6 (1.1) 2.5 (1.8) 0.2 (0.6) 3.6 (3.1)
Difference I 1.1 (1.5) –0.5 (1.0) 0.3 (0.9) –0.6 (1.8)
Baseline OD 0.04 (0.2) 0.3 (0.7) 0.9 (2.0) 0.6 (1.3)
Post OD 0.4 (1.2) 0.4 (1.2) 0.4 (1.3) 0.9 (1.6)
Difference OD –0.36 (0.2) –0.1 (1.0) 0.5 (1.2) –0.3 (1.0)
TE: teacher; D: drumming; CN: control; TRF: Teacher’s Report Form; Difference: difference score (post-intervention/control minus baseline); AN: anxiety
problems; AH: attention deficit/hyperactivity problems; I: inattention (subscale of AH); OD: oppositional defiant problems. A positive value for difference
scores indicates improvement whereas a negative value indicates worsening of symptoms.
Anxiety Problems (AN). For AN difference scores, one
outlier was identified (in drumming class 1); exclusion
of this outlier normalized the distribution of AN scores.
Results of the ANOVA on AN difference scores showed a
significant difference among groups (F(3,96) =4.97, P<.01;
η2
p=0.15) Post-hoc tests indicated that the two drumming
teachers (TE1 and TE3) rated students as improving more
on AN scores post-intervention than control teacher TE2
(Figure 6). In addition, drumming teacher TE1 rated stu-
dents as improving more on AN scores than control teacher
TE4.
Attention Deficit/Hyperactivity Problems (AH). For AH
difference scores, two outliers were identified (both in con-
trol class 4), and exclusion of these outliers normalized the
distribution. The ANOVA on AH difference scores showed a
significant difference among groups (F(3,95) =5.96, P<.01;
η2
p=0.14). Post-hoc tests indicated that drumming teacher
TE1 rated students as improving more on AH scores com-
pared to the two control teachers (TE2 and TE4) (Figure 7).
In addition, drumming teacher TE3 rated students as
improving more on AH scores relative to control teacher
TE4.
Inattention (I—one of two subscales for Attention
Deficit/Hyperactivity Problems; the other being Hyper-
activity-Impulsivity). For I difference scores, the ANOVA
results showed a significant difference among groups
(F(3,97) =7.51, P<.001; η2
p=0.19). Post-hoc tests indicated
that drumming teacher TE1 rated students as improving
more on I scores than the two control teachers (TE2 and
TE4) (Figure 8).
Evidence-Based Complementary and Alternative Medicine 7
0
2
4
6
8
10
12
14
Mean AP scale scores
TE 1 (D) TE 2 (CN) TE 3 (D) TE 4 (CN)
Classroom
Baseline
Post
Figure 4: Attention problems—mean baseline and post-inter-
vention/control scores by classroom.
0
1
2
3
4
5
6
7
8
9
10
Mean IN scale scores
TE 1 (D) TE 2 (CN) TE 3 (D) TE 4 (CN)
Classroom
Baseline
Post
Figure 5: Inattention (subscale of attention problems)—mean
baseline and post-intervention/control scores by classroom.
Oppositional Defiant Problems (OD). For OD difference
scores, results of the ANOVA indicated a significant differ-
ence among groups (F(3,97) =3.36, P<.03; η2
p=0.09). Post-
hoc tests showed that drumming teacher TE3 rated students
as improving more on OD scores than control teacher TE4
(Figure 9).
Affective Problems, Somatic Problems, Conduct Problems,
Hyperactivity-Impulsivity Subscale of Attention Deficit/Hyper-
activity Problems. Difference scores for these DSM-oriented
scales were not significant between groups.
3.4. TRF Other Scales. Baseline, post-intervention/control,
and difference scores for TRF other scales that were statis-
tically significant are displayed in Tab l e 5 .
Post-Traumatic Stress Problems (PT). For PT differ-
ence scores, results of the ANOVA showed a significant
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
Mean AN scale scores
TE 1 (D) TE 2 (CN) TE 3 (D) TE 4 (CN)
Classroom
Baseline
Post
Figure 6: Anxiety problems—mean baseline and post-inter-
vention/control scores by classroom.
0
1
2
3
4
5
6
7
8
Mean AH scale scores
TE 1 (D) TE 2 (CN) TE 3 (D) TE 4 (CN)
Classroom
Baseline
Post
Figure 7: Attention deficit/hyperactivity problems—mean baseline
and post-intervention/control scores by classroom.
difference among groups (F(3,97) =6.40, P<.01; η2
p=
0.17). Post-hoc tests indicated that drumming teachers
TE1 and TE3 rated students as improving more on PT
scores compared to control teacher TE2 (Figure 10). In
addition, control teacher TE4 rated students as improving
more on PT scores compared to the other control teacher
TE2.
Sluggish Cognitive Tempo (ST). For ST difference scores,
one outlier was identified (in control class 2). Exclusion of
this outlier normalized the distribution. The ANOVA on
ST difference scores showed a significant difference among
groups (F(3,96) =9.29, P<.001; η2
p=0.23). Post-hoc tests
indicated that drumming teacher TE1 rated students as more
improved on ST scores compared to the two control teachers
(TE2 and TE4), as well as the other drumming teacher TE3
(Figure 11). Also, drumming teacher TE3 rated students as
8 Evidence-Based Complementary and Alternative Medicine
0
0.5
1
1.5
2
2.5
3
3.5
4
4.5
Mean I scale scores
TE 1 (D) TE 2 (CN) TE 3 (D) TE 4 (CN)
Classroom
Baseline
Post
Figure 8: Inattention (subscale of attention deficit/hyperactivity
problems)—mean baseline and post-intervention/control scores by
classroom.
0
0.2
0.4
0.6
0.8
1
1.2
1.4
Mean OD scale scores
TE 1 (D) TE 2 (CN) TE 3 (D) TE 4 (CN)
Classroom
Baseline
Post
Figure 9: Oppositional defiant problems—mean baseline and post-
intervention/control scores by classroom.
improving more on ST scores than control teacher TE2, and
control teacher TE4 rated students as declining less on ST
scores than the other control teacher TE2.
Obsessive-Compulsive Problems, Positive Qualities. Differ-
ence scores for these other scales were not significant between
groups.
4. Discussion
This pilot study investigated the impact of group drumming
on social-emotional behavior in low-income, primarily
Latino, children with the specific aim of identifying the range
of behaviors that may show improvement with intervention.
The TRF was utilized to assess a myriad of problem
0
0.5
1
1.5
2
2.5
3
3.5
4
Mean PT scale scores
TE 1 (D) TE 2 (CN) TE 3 (D) TE 4 (CN)
Classroom
Baseline
Post
Figure 10: Post-traumatic stress problems—mean baseline and
post-intervention/control scores by classroom.
0
0.5
1
1.5
2
2.5
3
3.5
4
Mean ST scale scores
TE 1 (D) TE 2 (CN) TE 3 (D) TE 4 (CN)
Classroom
Baseline
Post
Figure 11: Sluggish cognitive tempo—mean baseline and post-
intervention/control scores by classroom.
behaviors. Students in the school counselor-led drumming
program improved significantly compared to the control
group in multiple domains of social-emotional behavior.
Significant changes were found in broad-band scales (total
problems and internalizing problems), narrow-band syn-
drome scales (withdrawn/depression, attention problems,
and inattention subscale), DSM-oriented scales (anxiety
problems, attention deficit/hyperactivity problems, inatten-
tion subscale, and oppositional defiant problems), and other
scales (post-traumatic stress problems and sluggish cognitive
tempo). On each of these scales, at least one drumming class
did better than at least one control class. These findings
support our hypothesis that a school-based group drumming
program, integrated with activities from group counseling,
Evidence-Based Complementary and Alternative Medicine 9
would improve social and emotional behavior in low-income
children.
4.1. Implications. The results of this study suggest that
group drumming combined with group counseling may
be used effectively to mitigate internalizing problems in
a low-income, predominantly Latino, population. This is
important not only because Latino youth tend to report more
internalizing problems than other youth [74–76], but also
because these types of problems are even difficult for their
caregivers [77] and physicians [17] to identify. In addition,
children manifesting behavior problems in the attention
spectrum (including sluggish cognitive tempo, which can be
a proxy for inattention) [78] seem to respond well to this
intervention.
The effectiveness of the intervention appears to have
been due to the combination of drumming and counseling
activities, based on surveys of the teacher participants and
anecdotal reports by the school counselor, observer, and
students involved in the study. In support of this assumption,
Bittman et al. evaluated six different protocols (resting
control, listening to drumming music, 50% instruction
and 50% drumming activity, 20% instruction and 80%
drumming activity, facilitated shamanic drumming, and
composite drumming involving reflection and self-disclosure
facilitated specifically by a music therapist) and found that
only the composite protocol led to neuroendocrine and
immune changes in adults, at a level indicative of stress
reduction [41].
The strength of this intervention was reflected in its
effectiveness within a realistic school context [79]. In the
name of sustainability, a school counselor was used to deliver
the intervention, rather than an expert drum circle facilitator.
Moreover, an entire classroom of a mixed composition of
up to 30 students was served at a time, despite the fact that
astrongereffect may have been achieved by working with
groups of 10–15 students at a time [41,42,80,81]orby
delivering it only to those screened for critical levels of need
[82–86]. In addition, implementation took place during the
school day after lunch, which is a difficult time of day to
teach based upon an informal survey of elementary school
teachers. Finally, study participants were in their spring
semester of fifth grade—the most challenging time of year
for the most potentially resistant group of elementary school
students.
The findings of this study are consistent with other
school-based, short-term, group interventions aimed at
improving behavior in low-income youth [80–82,85,87,
88]. Enhancing school-based services can reduce barriers to
mental health care [89,90], as they are the primary source of
such care for youth [90,91]. School settings are ideally suited
for preventive services, extended observation, and coordi-
nated care [89]. School counselor-led group drumming, as
conceived in this study, not only expands these possibilities in
culturally relevant ways but also offers an additional area in
which students can excel. The intrinsic value of drumming,
and the opportunity to develop competence in it, may lead to
continued participation [92], which may in itself be helpful
given the social, emotional and academic benefits that have
been linked to participation in music activities [93]and
organized activities in general [94]. The National Education
Association calls for the use of the arts as a “hook” to get the
growing number of Latino students interested in school [95].
School counselor-led group drumming can not only serve as
the “hook” but also close an opportunity gap that exists for
low-income youth [96,97].
4.2. Limitations. Several methodological issues in this pilot
feasibility study need to be considered, and future studies
should attempt to address these limitations. First, the effect
sizes in the current study (η2
p=0.09–0.23) were small due to
the sample size and inclusionary approach to recruitment;
however, one cannot underestimate the practical value of a
change in behavior of even one student in a classroom [84].
Smaller gains across a broader distribution of risk factors
may also have larger public health value [86,98], particularly
given variations in behavioral responses to stress based
on race, ethnicity, and gender [18,99–101]. Furthermore,
achieving an effect under challenging circumstances may
increase the value of the finding [79]. The effect sizes
reported in this study are comparable to those found in meta-
analyses of other interventions reported in the literature
[36,86,102,103].
Second, random assignment of classrooms to treatment
conditions was not feasible due to school administrative
constraints; however, selection bias was probably minimized
by the homogeneity of the study population. Third, teacher
raters were not blinded to the group assignment of the
students and, thus, may have been prone to reporting bias;
this is a major limitation of the pilot study. Future studies
should include cross-informant measures or utilize objective
observers in order to corroborate findings. Fourth, the lack of
an attention control group [104] and the necessary inclusion
of a “gifted” class in the experimental group may have had
unintended effects.
Finally, this study demonstrated that a group drumming
intervention could improve social-emotional indicators of
stress; however, in order to identify stress reduction more
definitively as the possible mechanism, corresponding bio-
logical indicators should be measured. Figure 12 shows
neuroendocrine, neuroimmune, autonomic nervous system,
and pain indicators of stress reduction that have been
associated with arts-based interventions in the scientific
literature [41,45–47,49,51–54,56–58,60].
4.3. Future Research. The results of this study suggest that
future investigations linking group drumming and social-
emotional behavior in a low-income, primarily Latino,
population should focus on assessment of problems in
internalizing and attention spectrum domains. However,
future studies should also involve larger samples, analyzed
for effects on different subgroups of youth by race, ethnicity
and gender, as differences in intervention effects have been
reported in each of these areas [35,80,81,86,87].
In order to determine the integrity of results over time,
follow up assessments would be necessary. It would also
be useful to assess the extent to which a sustained or
10 Evidence-Based Complementary and Alternative Medicine
Tab le 5: Mean (standard deviation) TRF other scale scores by classroom.
TE1 (n=24) TE2 (n=22) TE3 (n=30) TE4 (n=25)
Condition D CN D CN
TRF Scale
Baseline PT 0.8 (1.3) 1.3 (1.2) 1.8 (2.1) 2.9 (2.4)
Post- PT 0.3 (0.9) 2.2 (1.6) 0.6 (1.1) 2.5 (1.5)
Difference PT 0.5 (1.6) −0.9 (1.8) 1.2 (1.6) 0.4 (1.8)
Baseline ST 1.2 (1.5) 2.3 (1.7) 0.3 (0.7) 2.1 (2.8)
Post-ST 0.3 (0.5) 3.3 (2.1) 0.2 (0.5) 2.2 (2.6)
Difference ST 0.9 (1.4) −1.0 (1.4) 0.1 (0.3) −0.1 (1.6)
TE: teacher; D: drumming; CN: control; TRF: Teacher’s Report Form; Difference: difference score (post-intervention/control minus baseline); PT: post-
traumatic stress problems; ST: sluggish cognitive tempo. A positive value for difference scores indicates improvement whereas a negative value indicates
worsening of symptoms.
Drumming intervention for
social and emotional skill
buliding
Neuroendocrine
indicators
↓Plasma and salivary cortisol
↓DHEA to cortisol ratios
↑Oxytocin
Neuroimmune
indicators
↑Plasma and salivary IgA
↑Plasma IgG
↑NK cell activity and numbers
↑LAK cell activity
↑CD4+ Cells
↓HIV viral load
STRESS REDUCTION
Autonomi c ner vous
system indicators
↓Heart rate
↓Blood pressure
↓Respiratory rate
↑PO2in arterial blood
↑O2saturation of hemoglobin
Pain indicators
↓Sedative/analgesic use
↓Pain appraisal
↑Pain tolerance
Reduced internalizing and
externalizing behavior
Figure 12: Stress reduction as the proposed mediator between the drumming intervention and reduced internalizing and externalizing
behavior.
repeated intervention could mitigate behavior problems—
such as substance abuse, gang involvement, and school
dropout—that are not typically seen at the elementary
school level. Additionally, while this study has demonstrated
the effectiveness of group drumming for improving social-
emotional behavior in a normative sample, future studies
should assess its potential utility in a clinical population. The
participants in this study were a non-referred population
that showed baseline scores at or below the norm in all
behavior scales; therefore, clinical significance cannot be
inferred despite the statistically significant reductions in
problem behaviors reflected in these scales [4,9,18,69].
Future research should also investigate the effects of the
group drumming intervention on academic performance
[105,106], particularly given a meta-analysis of 300+ studies
that found academic achievement and behavior significantly
improved by social-emotional learning [107]. The study
reported here did not utilize the academic performance
portion of the TRF, in an effort to reduce the burden on
teacher respondents. Additionally, family participation may
Evidence-Based Complementary and Alternative Medicine 11
enhance the effects of the intervention, since family support
has been shown to buffer internalizing and externalizing
behavior in low-income youth [19,21,101,108–111].
Group drumming lends itself well to family involvement,
without the stigma of a mental health intervention [27,28].
Finally, future studies should evaluate the relative efficacy of
intervention delivery by other types of school personnel.
5. Conclusions
School counselor-led group drumming, integrated with
activities from group counseling, appears to improve the
social and emotional correlates of chronic stress in low-
income children. Through a positive development approach,
the program can increase core assets that may influence
a wide spectrum of behaviors, thus yielding broad public
health value. This sustainable program can increase student-
counselor interaction, provide a feasible alternative to tra-
ditional counseling methods that may lose efficacy over
time, and serve as a portal to mental health care for those
with unmet needs. The results of this study underscore the
potential value of the arts as a therapeutic tool.
Acknowledgments
The authors gratefully acknowledge the following individuals
who made this study possible: Mr Remo D. Belli, Dr Barry
Bittman, Dr Jeffrey Gornbein, Ms Christine Stevens, Mr
Mike DeMenno, Ms Karen Timko, Dr Petra Montante, Ms
Ileana De Monte, Ms Giselle Friedman, Ms Olga Diaz, Ms
Tina Gilmore, Ms Linda Gonzalez, Mr Rocky Sulka and the
staffof Napa Street Elementary School.
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