Foster Care Trends in the United States: Ramifications

for Music Therapists

DEBORAH LAYMAN, DAVID HUSSEY, and SARAH LAING Beech Brook, Cleveland, Ohio

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ABSTRACT: There has been a dramatic increase in the number of Of these children, an estimated 117,000 are awaiting adop­
children placed in foster care in America over the last two decades. tion (U.S. Department of Health and Human Services, 2000).
Many of these children display significant emotional and behavioral
disturbances, as well as delays in academic achievement. With the
The majority of children in out-of-home care are in foster
increasing numbers of children in foster care and the passage of the homes. In 1994, approximately 65% of all placed children
Adoption and Safe Families Act of 1997, it is important for music resided in foster homes or relative foster homes (U.S. Depart­
therapists to consider the implications this growth may have for prac­ ment of Health and Human Services, 1997). Efforts to address
titioners working with youth. Music therapy is a nonthreatening and the growing number of children in out-of-home care are fur­
inviting medium that offers the foster child a safe haven in which to
explore feelings, behaviors, and therapeutic issues related to abuse, ther impacted by the passage of the Adoption and Safe Fam­
neglect, and family disruption. Music therapy may help children to ilies Act of 1997 and Welfare Reform. The Adoption and Safe
establish meaningful relationships, build self-esteem, address issues Families Act mandates that parents whose children are in state
of mourning and abandonment, and assist in acquiring basic aca­ custody 12 out of the past 22 months will potentially lose
demic skills. custody permanently, which could result in an even greater
number of children in foster care awaiting adoption. In addi­
tion, due to Welfare Reform, more and more families are ex­
Nearly half a million children in the United States today
hausting their benefits and are at risk for not being able to
have been removed from their birth families because of abuse
provide for their children, which could result in more children
or neglect. Many have been cast aside as very young children.
entering care or remaining in care longer (McGowan &
Some will never return to their birth parents (Barbell, 1998).
Most are unseen to the community at large, but the service Walsh, 2000). Since 1983, spending on foster care has dra­
needs are immense for these children, their birth parents, and matically increased at all levels of the government in response
the foster parents who care for them. When the issues sur­ to the growing number of children in care and the increasing
rounding foster care and the child welfare system are com­ needs of families. According to the United States General Ac­
plex, music therapy can play a vital role in the lives of these counting Office, for every federal dollar spent on foster care
children and their families. in 1993, just 12 cents was spent on other child services com­
pared with 40 cents in 1983 (Haerian, 1998). Foster care is
Overview of Foster Care in the United States an extensive and complex program area overwhelmed by in­
creasing service demands and limited resources.
There has been a dramatic increase in the number of chil­
dren placed in foster care in America over the last two de­ Foster Care Defined
cades. In 1977, there were more than 520,000 children in
care. When the Child Welfare Act of 1980 (PL 96-272) was Contemporary foster care has its roots in English Elizabe­
passed, this number declined to 275,000 in 1984 due to the than Poor Laws, which were designed to protect society from
escalating cost of foster care and the increase in attempts to the poor. During the 18th and early 19th centuries, being de­
find children permanent placements. However, the number pendent was considered a sin, hence a strong air of disap­
began to rise again and by the end of 1993, there were an proval and rejection of homeless children. These children
estimated 450,000 children in foster care, nearly double the were forced to become self-supporting at very early ages. In
number in 1984 (Terpstra & McFadden, 1993). Currently there early 19th century America, the first orphanages began due
are approximately 520,000 children in out-of-home care in to the heavy increases in immigration and corresponding rise
the United States—more than a 65% increase in just 10 years. in unemployment (Haerian, 1998). Immigrants unable to find
work abandoned their children along the streets. In the mid
19th century, Reverend Charles Loring Brace started placing
Deborah L. Layman, M.M., MT-BC, is the clinical music therapy researcher at
these children on trains throughout the West to be cared for
Beech Brook in Cleveland, Ohio.
David L. Hussey, Ph.D., is an assistant professor of justice studies at Kent State by farm families. Between 1854 and 1929, over 150,000 or­
University and also serves as the Director of Research at Beech Brook. phaned and abandoned children were placed into family
Sarah J. Laing, M.M.Ed, MT-BC, a native of South Africa, is currently in private homes by way of these "orphan trains" (Terpstra & McFadden,
practice in northeast Ohio. She has worked with at-risk children and their
1993).
families in the Cleveland area and Beech Brook.
The authors wish to thank the Kulas Foundation for its generous support of this
In 1899, the first juvenile court in America was established.
research This was the first legal process designed to serve the best in­
© 2002, by the American Music Therapy Association terests of the needy child. In 1909, the first White House con­

38
Foster Care Ramifications for Music Therapists 39

ference on children debated the issues of these children and future deprives the child of being able to establish a sense of
determined that poverty alone was an "insufficient" reason to belonging. The lack of belonging and the sense of being an
place children in alternative care (Haerian, 1998). This deter­ outsider to one's own family and community contribute to
mination led to the formation of the Federal Children's Bureau these children's difficulty in staying emotionally invested and
in 1912, which is responsible for developing policies for attached to themselves and others. These children are often
health care, financial support, mental health, abuse and ne­ not sure exactly where and how they fit in to their foster fam­
glect, placement services, and adoption of children. Its efforts ilies (Guerney, 1982). It is likely that foster children have had

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led to policies mandating payment for foster families and aid­ multiple placements before joining a particular family as well.
ed in the development of social work as a profession. This process of disruption and discontinuity can lead to psy­
Foster care in the United States is viewed as an alternative chological maladjustment and difficulties in establishing basic
living arrangement for children while their parents are unable trust (Bohman, 1990).
to care for them (Haerian, 1998). In other words, foster care Children in foster care have also been documented as
is full-time substitute parental care provided to children whose showing delays in academic attainment. In one study of foster
parents cannot provide suitable care for them (Gillis-Arnold, care children, almost one-third of their sample were behind
Crase, Stockdale, & Shelley, 1998). It is designed to be a tem­ their age-appropriate grade level (Fanshel, Finch, & Grundy,
porary arrangement until the child is reunited with the bio­ 1989). A significant minority of other children and adolescents
logical family or placed for adoption. Many children, how­ in foster care attend special education classes to meet their
ever, remain in care for a long time. They are never returned challenging educational needs (Whittaker, Fine, & Grasso,
to their birth parents nor adopted. Many move from one foster 1989). A large percentage of children are required to relocate
placement to another. to a different school when placed in foster care. Clearly this
Traditional foster care has historically focused on providing type of change, at a time of increased vulnerability, can sig­
care and nurturance rather than addressing mental health is­ nificantly affect children's abilities to cope well in the school
sues. However, trends have shifted and child welfare experts environment. These findings support other studies that point
have observed an increasing number of foster children who to the educational deficits children have as they enter foster
need specialized care (Goerge, 1990). As a result of the grow­ care (Canning, 1974; Cohen, 1991).
ing demands that increasing numbers of emotionally disturbed Understanding the etiology of cognitive, behavioral, and
children are placing on the child welfare system, resources emotional difficulties presented by children entering treatment
and attention are being directed toward a more intensive form foster care can enable foster parents and caseworkers to de­
of foster care known as treatment, specialized, or therapeutic velop more appropriate treatment plans. To assist in this un­
foster care. derstanding, treatment foster care families are provided with
Currently, treatment foster care programs are seen as alter­ many different therapies, in-home service intervention, and
natives to residential treatment centers as well as a step-down emergency services. They receive ongoing education and
service for children transitioning out of psychiatric inpatient training as well.
or residential treatment programs. The overall goal of treat­
ment foster care is to provide help for the special needs child The Creative Arts Therapies with Foster Care Children
within a family setting. These children often'present with prob­ The creative arts therapies are the intentional use of art,
lems in five domains of psychosocial functioning: 1) inability music, dance/movement, drama, and poetry in psychotherapy,
to tolerate intimacy, 2) impulsivity, 3) fear of rejection, 4) ag­ counseling, special education, or rehabilitation by a trained
gression, and 5) low self-esteem (Dore & Eisner, 1993). Each therapist (Johnson, 2000). Many studies have been conducted
of these dimensions reflects adverse early life experiences in­ applying the creative arts therapies as treatment for emotion­
cluding abuse, neglect, insecure early attachments, and in­ ally disturbed children and adolescents. Poetry therapy has
consistent caregiving. been utilized in addressing sexual abuse issues (Bowman &
The stresses of the child's leaving his or her own family and Halfacre, 1994) and self-expression (Abell, 1998). Dance/
adjusting to a new family are manifold. In addition to sepa­ movement therapy has been applied with troubled youth in
ration from parents and feelings of rejection and abandon­ residential schools (Payne, 1988); inpatient psychiatric ado­
ment, the foster child often experiences a strong ambivalence lescents (Johnson & Eicher, 1990); and at-risk African Ameri­
toward the foster parents. Even if the child emotionally cares can adolescents (Farr, 1997). Drama therapy is another one of
for the foster family, memories and loyalties regarding the bi­ the creative arts therapies that has been applied in the treat­
ological family can be confusing and painful, contributing to ment of maladjusted children (Lowenstein, 1983); resistant
behavioral difficulties. These behavioral difficulties are often and rebellious adolescents (Emunah, 1985); sexually abused
the result of an incomplete mourning process, in which un­ adolescent girls (MacKay, Gold, & Gold, 1987); and children
resolved loss issues play a major part (Kime, 1994). The un­ and adolescents with conduct disorder (Dunne, 1988). Finally,
certainty inherent in foster care and the ambiguous and am­ art therapy has been utilized in the treatment of seriously emo­
bivalent status of the foster child regarding membership in tionally disturbed adolescents to increase self-awareness and
both the biological family and the foster family are unique reduce anxiety (Tibbetts & Stone, 1990); early adolescents to
stressors experienced by foster children. Uncertainty about the increase appropriate social skills (Walsh, 1990); adolescent
40 Music Therapy Perspectives (2002), Vol. 20

substance abusers to gain insight into their disease (Cox & behaviors and therapeutic issues such as self-esteem or ag­
Price, 1990); sexual abuse survivors (Levens, 1994; Bowman gression. Since many of the children in foster care display
& Halfacre, 1994); emotionally disturbed young people to in­ educational deficiencies as well, music therapy can also assist
crease social and communication skills (Williams & Wood, the special needs child in improving academic performance.
1977); and children with emotional disturbances to increase Music therapy can set the occasion for a child to establish
relationship development (Abell, 1998). a meaningful relationship with an adult (the music therapist),
One study illustrates the application of a creative arts ther­ as well as with his/her foster family and/or biological family,

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apy with foster care children. Johnston, Healey, and Tracey- through musical play and interaction. Children frequently
Magrid (1985) discussed a multi-modal group counseling ap­ have a natural interest in music which can assist in laying the
proach that integrated the use of drama therapy. Fifteen Afri­ groundwork for the building of a therapeutic relationship. Mu­
can American foster care children participated in a group sic therapy can facilitate the development of new relation­
summer stock theater in which issues such as conflict reso­ ships, prosocial skills, and feelings of positive attachment to­
lution and responsibility for one's actions and behaviors were wards authority figures. Issues of abandonment and mourning,
addressed. Pre- and post-test measures demonstrated a signif­ which are often experienced by the foster child, can also be
icant difference in interpersonal cognitive problem solving. addressed in the music therapy setting. These factors can lead
Following this intervention, the children were better able to to better placement success (Stone & Stone, 1983).
think through the steps needed to reach a desired goal.

Music Therapy with Emotionally Disturbed Children

Music therapy can set the occasion for a child to
Music therapy has also been documented as a useful ther­
establish a meaningful relationship with an adult
apeutic intervention with emotionally disturbed or trauma­
tized children. For example, Mayers (1995) endorsed song
(the music therapist), as well as with his/her foster
writing with traumatized children as a means of decreasing family and/or biological family, through musical play
anxiety. Salas (1990) documented the use of music to increase and interaction.
expression of inner feelings, increase self-esteem and self-ex­
pression, and to facilitate a sense of pride in developing orig­
inal music. Burkhardt-Mramor (1996) addressed the applica­ A positive self-concept is also a strong predictor of place­
tion of music therapy to treat attachment disorders. Frisch ment success (Pardeck, 1985). The immediate success that fos­
(1990) acknowledged that music may be perceived as a gift ter care children can experience in the music therapy setting
for children sensitive to deprivation. In this manner, music is very reinforcing to the child that perhaps does not have
allows the traumatized or disturbed child the opportunity to many positive life experiences. Another factor in placement
make choices and put personal thoughts in song. Frisch also success, the reduction of behavioral problems, can be facili­
identified the use of music to aid in making transitions, as well tated by music therapy as well. Music therapy creates a suc­
as providing frequent opportunities for change, because it is cessful, nonthreatening environment for the child which re­
inherently non-confrontational, nonthreatening, and indirect. sults in a decrease of externalizing behaviors such as aggres­
The music-making process itself can contain modulation, sion and impulsivity. Techniques utilized in a music therapy
changes in tempo, etc. In addition, music has been docu­ session may include live music production, song writing, mu­
mented to improve math scores (Miller, Dokow, & Greer, sical social stories (accompanied by music making), impro­
1974); to aid in development of age-appropriate social and visation, lyric analysis, movement to music, or receptive mu­
emotional behavior (Merle-Fishman & Marcus, 1982); and to sic listening.
provide much-needed structure for emotionally disturbed chil­ At the child mental health treatment agency where the au­
dren (Merle-Fishman & Marcus). thors are employed, the music therapists receive many refer­
Currently the literature addressing the application of music rals from treatment foster care case managers. Demographics
therapy to foster care children is scant. The treatment base for for the treatment foster care population served by the agency
music therapy with severely emotionally disturbed children, are noted in Table 1.
which includes many foster care children, is also quite limited. As the data illustrate, a large number of the children in this
Yet, anecdotal evidence suggests that music therapy can be a treatment foster care sample have experienced significant his­
powerful tool in addressing the primary needs of foster care tories of abuse, neglect, and an average of more than four out­
children. Foster care children frequently present with neuro­ of-home placements prior to entry to the agency. These ad­
cognitive deficits, severe histories of trauma, and significant versities highlight the need for special services which may
emotional disturbances. These emotional disturbances include include music therapy. Referrals for music therapy services
decreased impulse control, increased fear of rejection, in­ range from the need to increase appropriate expression of
creased aggression, decreased self-esteem, and inability to tol­ feelings and increase self-esteem to issue-specific reasons (i.e.,
erate intimacy (Dore & Eisner, 1993). Since music therapy is prepare for reunification with biological family, facilitate ac­
an inherently non-threatening and inviting medium, it offers ceptance of new foster home, etc.). Each referred child is ini­
the foster care child a safe haven in which to explore feelings, tially assessed and then placed either in music therapy, placed
Foster Care Ramifications for Music Therapists 41

Table 1 Table 2
Profile Characteristics of Treatment Foster Care Population Frequency of Treatment Foster Care Referrals

119 Referral reasons Frequency (%)

Mean age at admission 9.7 (SD = 4.03)
Development of social skills 75
Male 40.3%
Accepting/following adult direction 70
Female 59.7%
Identification and/or expression of feelings 65
African American 88.2%

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Development of reciprocal relationships 65
Caucasian 5.0%
Development of appropriate expression 65
Other 6.7%
Attention to task 60
I.Q. 82.8* (SD = 13.92)
Accepting structure or transition 60
Permanent custody 37.60%
Exploration of non-verbal communication 50
Age at first out-of-home
Impulse control 45
placement 5.52 (SD = 3.39)
Issue-specific 45
Mean total number of
Anger management 40
out-of-home placements 4.48 (SD = 3.39)
Self-esteem or self-concept 40
History of child neglect 41.2%
Problem-solving or decision-making 35
History of child physical abuse . 17.6%
Disturbance in mood 35
History of child sexual abuse 2.5%
Coordination/Control development (motor skills) 25
History of parental alcohol use 42.0%
Academic development 20
History of parental drug use 76.5%
History of parental prostitution 8.4%
History of parental incarceration 20.2%
History of parental mental illness 16.0%
History of homelessness 9.2% Anna came from a household which consisted of a single
History of domestic violence 7.6% mother who had a history of homelessness, substance abuse,
Mean length of stay (days) 425 (SD = 260) inadequate supervision for children, and medical neglect.
Median length of stay (days) 384 Anna and her siblings were reported as being dirty and having
poor hygiene; they were neglected educationally as well. By
the time she turned seven years old, Anna had experienced
on the waiting list for music therapy, or referred to another three out-of-home placements (i.e., foster homes), the first of
therapy. Table 2 identifies the frequency of referral reasons for which occurred at age three.
twenty of the most recent foster care referrals. Anna was referred to music therapy services by her foster
Most common reasons included development of social care case manager to address numerous issues including ap­
skills, accepting/following adult directions, development of propriate identification and expression of feelings, managing
appropriate expression, development of reciprocal relation­ interpersonal conflict, accepting rules and/or transition, and
ships, and identification and/or expression of feelings. low academic skills. Presenting problems included bed-wet­
The foster children referred to music therapy services gen­ ting, lying to adults and authority figures, and learning prob­
erally fall into three categories: 1) 2-9 years old; 2) 10-18 lems in school.
years old; and 3) sibling/family groups. Unique characteristics The focus of music therapy intervention was three-fold: 1)
and needs of each of these groups have been observed, along to increase the ability to follow adult directions; 2) to increase
with some striking similarities. Each foster child has experi­ turn taking skills; and 3) to increase appropriate use of words
enced some form of victimization involving neglect, physical to communicate wants. Several music therapy techniques
abuse, and/or sexual abuse. However, each child's history dif­ were employed throughout sessions including live music pro­
fers in the severity of the abuse. In planning appropriate treat­ duction (playing instruments and singing), song writing, lyric
ment strategies for these groups, both the child's history as analysis, improvisation, musical role playing, and learning by
well as his/her functioning levels are considered. Music ther­ music (a form of psycho-education). Many different instru­
apy is a viable modality for each of these groupings because ments were also utilized in sessions: drums, piano, omni­
it is so versatile. Techniques such as song writing and live chord, keyboard, xylophone, and singing. The structure of the
music production can be transferred and adapted to fit the music therapy sessions was activity-based and included use
very different treatment needs of a 2-year-old and a 15-year­ of a wide variety of visual aids to create a concrete environ­
old. ment that promoted the learning process in a nonthreatening,
In order to demonstrate the utility and application of music rewarding medium.
therapy, an illustrative case example from each group is pre­ In her relationship with the music therapist, Anna was easily
sented. engaged and compliant. However, she tended to leave an ac­
tivity area without using her words to communicate that she
Anna—age 7 was finished (even though she was a verbal child). Anna re­
Anna, one of seven siblings, is an African-American female sponded well when redirected to "use your words" to tell the
with a history of neglect and abandonment. She was born music therapist what she wanted. This expression of wants was
prematurely and tested positive in cocaine screening at birth. incorporated into a "my turn/your turn" structure. Using this
42 Music Therapy Perspectives (2002), Vol. 20

Table 3
Music Used in Anna's Treatment

Song Titles Song Source Selected Lyrics

You Cot to Talk, Talk, Talk Thompson & Hilderbrand (1995) You got to talk, talk talk
If you want to solve
Those problems

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I've Cot a New Way to Talk (rewrite) Saltzman & Raposo (1985) I've got a new way to talk
I'm telling the truth
Talk about my problems
When I talk, I tell the truth
Give a Little Whistle Washington & Harline (1940) Always let your conscience be your guide
When you get in trouble and you don't
know right from wrong
My Truth Song Original song written by Anna I tell my mommy and daddy
I tell the truth
Time to Talk (rewrite) Raffi, Pike & Smyson (1985) It's time to tell the truth right now, even
though it's hard to do

concrete and visual approach, Anna wrote her name and the musical game of dressing and undressing a bear puppet while
music therapist wrote her name, one after the other, on a chart singing about what areas of the body are appropriate to ask
similar to this: to touch (head, hands, give a hug, etc.) and areas that are
private (anything that is under your clothes/bathing suit).
Anna
While Anna dressed and undressed the puppet, the music
Music therapist therapist sang as she pointed to certain areas of the puppet's
Anna body (therapist pointed to head) "Can we touch him here?
Music therapist Yes, yes!"; (therapist pointed to stomach) "Can we touch him
there? No, No! 'Cause that's his private area." This concrete
Anna looked at this chart frequently in session to determine
approach to learning appropriate vs. inappropriate touch
whose turn it was to select the next musical activity. When it
worked very well for Anna. Learning became a game for her
was Anna's turn, she selected the instrument and the music
but it was also successful as no other reports of inappropriate
therapist structured the musical activity that addressed a spe­
touch were reported by the foster parents following that ses­
cific goal at the selected instrument. When finished with her
sion.
turn, Anna placed an X in the blank next to her name. It was
Anna also shut down and refused to talk to her foster par­
then the music therapist's turn to choose the activity. This
ents whenever she had a problem or did something wrong.
structure continued throughout each session. Anna also dem­
When she would talk, Anna frequently told lies, which greatly
onstrated inappropriate personal boundaries frequently during
disturbed the foster parents. During music therapy sessions,
the first few sessions as she often hugged the music therapist
songs addressing learning how to talk about your problems to
without asking. Once again, Anna responded when redirected
those you trust and how to tell the truth were utilized. These
to "use your words to ask for a hug" and was encouraged by
songs (and activities related to the music) were used to create
the music therapist assuring her that she would "never say
'no'." It was important for Anna to learn how to be discrimi­ a "Truth in Talking" songbook. Selections from this songbook
nate in hugging people she knows well versus those she does are listed in Table 3.
not know as well. Each selection of music presented a nonthreatening, indi­
Several inappropriate behaviors that occurred outside of the rect means to address difficult issues for Anna. Anna appeared
music therapy room were also addressed in session. One be­ to really connect with one song—"Give a Little Whistle." She
havior involved Anna touching a 3-year-old male's groin on talked about how the boy in the story lied, then his nose grew.
two occasions in the foster home. A psycho-educational ap­ Anna shared that this boy wanted to be real but couldn't when
proach was used in the music therapy sessions to address this he lied. With wide eyes, she then exclaimed, "And then the
issue. A song entitled "Good Touch/Bad Touch" was utilized whale ate him when he lied! Bad things happen when you
to delineate what exactly is a good touch and what is a bad lie!" This song appeared, in retrospect, to be the turning point
touch. When this song was first played for Anna, she became in her lying in the foster home. Following this session, the
very evasive and verbalized her desire to go on to the next foster parents reported that Anna's lying had dramatically de­
activity. However, she began to listen to the song as she drew creased and she was easily redirected to "tell the truth" when
pictures representing a good touch (someone giving a hug) she would begin to tell a lie.
and a bad touch (hitting someone). Anna then engaged in a A "truth chart" was also used in the foster home to reward
Foster Care Ramifications for Music Therapists 43

Anna's Truth-Telling in Foster Home Sam was removed from his biological mother's care follow­
ing the stabbing. A reunification attempt was made when Sam
was 5 years old. He was removed again from the biological
mother's care due to medical neglect at age 6. Since the age
of 6, Sam has resided in foster homes.
Sam was referred to music therapy to address multiple is­
sues: development of reciprocal relationships, development of

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social skills, increasing attention to task, increasing verbal
skills, increasing nonverbal communication, and increasing
motor skills. At time of music therapy assessment, Sam dem­
onstrated poor social skills, ritualistic behaviors around the
Weekl Week 2 Week 3 Week 4 Weeks
foster home, and physical limitations (including blindness in
Figure 7. Anna's truth-telling in the foster home. one eye, braces on legs, and hemiparesis). Sam often pre­
sented himself as functioning beyond his abilities in social
settings. He appeared to have learned several social phrases
Anna for telling the truth. When she told the truth to her foster by rote; it could not be determined whether or not he fully
parents, she earned one sticker. At the end of the week, if she understood these phrases since they were occasionally out of
had five or more stickers on that chart, Anna earned one point context. For example, in response to a simple "yes/no" ques­
in music therapy towards receiving a rhythm instrument of her tion, he would answer, "Well, what do you think?", "Guess,"
choice (since she had expressed a desire to earn her own). "Well, hell, yea, Momma," or "Now you're asking for it."
Once Anna earned a total of five points (five weeks), she re­ These phrases were commonly used by Sam in social settings
ceived the rhythm instrument. This procedure of generalizing and were frequently misinterpreted by the community.
behavior to the foster home and reinforcing it both at home Sam received music therapy services from the ages of 10­
and in session was very successful (refer to Figure 1 for re­ 12. Focus of music therapy intervention was three-fold: 1) to
sults). increase verbal expression; 2) to increase social skills; and 3)
It is important to note the critical involvement of the foster to enhance adjustment to the foster home and community.
parents. They were responsible for the implementation of the Several music therapy techniques were employed throughout
truth chart in the home. Each foster parent attended one ses­ sessions including adapted live music production (playing in­
sion as well. During these sessions, Anna shared her "Truth struments and singing), improvisation, musical social stories,
in Talking" songbook and demonstrated some of the songs in and learning by music. Many different instruments were used
this book (found in Table 3). Anna appeared very proud to in sessions: drums, piano, omnichord, keyboard, and singing.
share her work and both foster parents gave appropriate pos­ The structure of the music therapy sessions was activity-based
itive feedback. The music therapist also consulted weekly with and included many visual cues to create a concrete learning
the foster parents to find out what was happening at home, at environment, as well as to redirect Sam back to task when
school/and documented progress regarding the truth chart. distracted.
The foster parents helped to shape treatment strategies and Although limited by his hemiparesis, Sam attempted all in­
aided in transferring therapeutic gains made in the session to struments independently, making appropriate adaptions. His
the home environment (e.g., played cassette tapes of songs occasional reluctance to sing into the microphone may have
used in session, read through lyric sheets with Anna, etc.).This represented low self-esteem issues; however, when encour­
involvement on the foster parents' part was vital to general­ aged, Sam explored sound effects with this medium. His most
izing the progress Anna made in the .music therapy sessions. preferred instrument was the keyboard, with the drum set a
close second. Using letter- and color-coding, Sam matched to
Sam—age 10
sample with slow, yet accurate, motor actions.
Sam is an African-American male in the permanent custody Sam demonstrated a steady improvement in direct verbal
of the child protective services agency. He experienced six responses throughout treatment. Modeling of alternate phrase
out-of-home placements by the age of eight. Sam's biological structure during communication, paired with verbal praise,
mother was sixteen years old when she gave birth to Sam, a successfully shaped Sam's responses into direct "yes/no"
healthy newborn. However, when Sam was three months old, questions. He gradually began to substitute use of "yes" or
he suffered neurological trauma which left him with physical "no" to answer questions, replacing his inappropriate social
and development handicaps. Sam's mentally ill uncle had re­ rote phrases.
peatedly stabbed Sam, which resulted in multiple stab wounds The use of a musical social story to address social skill de­
to the head, face, and chest. Sam lost a significant amount of velopment was a major technique utilized throughout ses­
blood and experienced cardiac arrest as a result of the stab­ sions. Areas of expected social behavior in the home, school,
bing. After surgery and hospitalization, Sam was left with se­ and community were primarily addressed in this manner. Each
vere visual impairment, partial paralysis (hemiparesis) on the chapter of the story was specific to a situation in Sam's daily
right side, and mental retardation. routine. Input was obtained from the case manager, foster
44 Music Therapy Perspectives (2002), Vol. 20

mother and school, and incorporated into the story where Sam girls to learn and practice appropriate interaction skills in a
was the main character. Chapter 1 discussed expected behav­ reinforcing environment.
ior in the music therapy room addressing expressive language. A variety of music therapy techniques were used to address
An excerpt of lyrics from this chapter is as follows: "He an­ this goal including live music production (playing instruments
swers questions with a 'yes' or a 'no.' When he doesn't un­ and singing), improvisation, and learning by music (a form of
derstand, it's okay for Sam to say, 'I don't understand.'" Sam psycho-education). Many different instruments were also uti­
responded positively to this medium by smiling and making lized in sessions: drums, piano, omnichord, keyboard, xylo­

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verbal corrections while requesting the stories be read to him. phone, guitar, small rhythm instruments, and singing. An ac­
Desired behaviors included safe interactions, motor on-task tivity-based session structure created opportunities for Susie
behavior, verbal on-task behavior, appropriate responsiveness, and Sally to explore appropriate interaction with instruments.
and reciprocal play. These behavioral themes were reinforced Use of visual aids also enhanced the concrete environment
through performance on a variety of instruments. Sam imitated that promoted social skill development in an indirect, rein­
behaviors when modeled by the music therapist, responded forcing medium.
positively to verbal praise, and was observed replicating be­ Susie and Sally were generally compliant with the music
haviors noted in the social story while in the home and com­ therapist on an individual basis, sharing instruments and tak­
munity. ing turns. However, when the structure changed to interacting
As a result of unsafe behavior exhibited in the home, Sam's with each other, both girls quickly regressed. Susie had much
foster mother removed his keyboard as punishment. The key­ difficulty in sharing with Sally; she often tantrumed, cried, and
board was very reinforcing to Sam and aided in transference kicked her feet while lying on the floor. This infantile behavior
of music therapy skills to the home environment, so this re­ (further exacerbated by her nickname, "baby") occurred
moval was detrimental. The music therapist implemented a whenever it was Sally's turn to play an instrument. Susie was
behavioral reinforcement system allowing Sam to "earn the musically redirected to "use your words" to tell the music
keyboard back." Sam was required to demonstrate "safe" be­ therapist and her sister what she wanted, instead of tantruming
havior around water and electricity in the home. This non­ and shutting down. When Susie tantrumed, Sally repeatedly
traditional goal area was also incorporated into the music gave in to her demands and relinquished her turn to please
therapy setting by singing songs about safety and by modeling Susie. Sally was then encouraged to "keep your turn" rather
of "safe" behavior around electrical musical equipment in the than giving it to her sister, as this behavior continually rein­
session room. Demonstration of "safe" behaviors in the home forced the negative behavior exhibited by Susie. Sally was also
and in session resulted in Sam earning points towards earning directed to ignore Susie's outbursts and remain on task.
his keyboard. In order to further address the concept of taking turns and
Music appeared to be very reinforcing to Sam. At the ter­ sharing, a chart was used to indicate each girl's turn. Using
mination of individual music therapy services, the music ther­ this visual approach, the music therapist wrote each girl's col­
apist recommended that Sam join a music therapy group in or-coded name on a chart (similar to the one used by Anna).
order to practice and transfer his newly acquired skills. In addition to this chart, name badges were worn by each girl
in session. During session, Sally was directed to "look at
Susie and Sally—ages 3 and 4 chart" to determine whose turn it was to play the instrument.
Names were crossed off of the chart as each girl had her turn.
Susie and Sally are biological sisters (from a sibling group Sally took a leadership role in using this chart, often reminding
of four) placed in temporary custody of child protective ser­ the music therapist and Susie.
vice. By the ages of 2 and 3, (respectively) the girls had ex­ Appropriate personal space was also an issue in music ther­
perienced two out-of-home placements (foster homes). Susie apy sessions. Many of the girls' disagreements involved one
and Sally were removed from their biological mother's care of the girls entering into the other girl's space. Susie and Sally
due to an imminent risk from low birth weight, issues of med­ were encouraged to "ask first" before intruding on the sister's
ical neglect, lack of utilities, and exposure to domestic vio­ space. They were also directed to state, "You're in my space!"
lence. The maternal grandmother also reported that the bio­ as a reminder to the sister if personal space was invaded.
logical mother abused drugs, didn't feed the children, and Both Susie and Sally responded positively to verbal praise
frequently hit them. Susie and Sally were physically aggressive and encouragement throughout treatment. Consistent, repeti­
and used abusive language in their social interaction. tive modeling of appropriate behavior by the music therapist
Susie and Sally were referred to music therapy services to was successful in teaching social skills to the girls as well.
address multiple needs: to decrease anxiety, to increase ap­ Likewise, the musical setting appeared to be very reinforcing,
propriate verbal expression of wants and needs, to increase as evidenced by the gradual increase in cooperative play and
appropriate social skills, to increase anger management, to decrease in tantruming behavior. During the last two music
increase impulse control, and to increase acceptance of adult therapy sessions, Susie began to experience remorse for hitting
directions/structure/transitions. Susie and Sally often kicked, her sister (both accidentally and on purpose), and she started
screamed at, and hit each other when attempting to interact. apologizing to Sally for this behavior. This was the first ex­
Sibling music therapy intervention set the occasion for the pression of remorse observed on the part of Susie towards her
Foster Care Ramifications for Music Therapists 45

sister, and suggests the potential for significant progress with ments. As a medium, music therapy has enormous range and
further music therapy intervention. versatility in meeting the diverse needs and developmental
The foster mother also played a vital role during the music ranges of foster care youth. Due to the non-threatening and
therapy intervention. She participated in most sessions, ver­ reinforcing nature of music, it may be ideally suited to address
bally reinforcing Susie and Sally for their appropriate inter­ skill deficits, particularly cognitive, social and communication
actions and behavior, while ignoring the inappropriate behav­ skill deficits which can significantly impair interpersonal func­
ior. The foster mother began to transfer interaction skills tioning. An important next step in the music therapy field will

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learned and practiced in session to the home as well. Both be to develop and refine intervention protocols which can be
the case manager and foster mother strengthened generaliza­ individually tailored to address common problem areas en­
tion of treatment strategies outside of the session room. This countered by music therapists working with this population.
transference and generalization of skills were critical in Susie A final implication relates to ongoing effect of intervention
and Sally's development of reciprocal relationship skills. and the need to be able to maintain and build upon the treat­
ment gains made in the confines of the music therapy session.
Discussion and Implications In order for music therapy to be most fruitful, the music ther­
This article examines the emergence of music therapy into apist should collaborate closely with the case manager and
a new and challenging field—an area in which practitioners the foster family. It is essential that the music therapist involve
are struggling to find useful theory and research to help guide the foster family in the treatment process in order to secure
treatment. With the increasing numbers of children in foster the generalization of skills and behaviors learned in session
care, it is important that music therapists consider the ramifi­ to the home and school environments. Often the music ther­
cations this growth will have for the profession. There are at apist will involve the foster parent in the sessions and train
least three major implications highlighted by this article.These the parent on how to use music to interact with the child as
implications address challenges in assessment, intervention, they mutually work toward achieving therapeutic goals. In
and the maintenance of therapeutic gains. working with children who have such significant clinical is­
Due to the increasing numbers of emotionally disturbed sues, it is critical for music therapists to think of ways to max­
children in foster care settings, music therapists will need to imize the power of treatment interventions, particularly inter­
be diligent in screening referred children for histories of out­ ventions which appear to be able to achieve short term pos­
of-home placements. A simple question, "Have you ever lived itive outcomes. The generalizing or transferring of treatment
away from your parents?" can be a useful screening question gains from one setting to another requires close collaboration
to explore a history of foster care involvement. Adult caretak­ with significant others in the child's life. It also draws upon
ers can be asked a similar question, "Has your child ever lived the creativity of the music therapist to be able to translate
apart from you?" Children who have a history of current or session interventions into real-world strategies which can be
past foster care involvement are likely to have experienced successfully implemented by teachers, caretakers, and others.
significant abuse or neglect, and therefore need to be carefully
and comprehensively assessed for a wide variety of associated
problems. The music therapist may be the first or only treat­ In working with children who have such significant
ment professional that the child and family have had contact clinical issues, it is critical for music therapists to
with and this provides a critical opportunity for much needed
think of ways to maximize the power of treatment
assessment, evaluation, and referral. Foster care children are
interventions, particularly interventions which ap­
well-known to present with significant and previously undi­
agnosed physical, emotional, and behavioral problems that
pear to be able to achieve short term positive out­
seriously impact healthy development. It is essential that the comes.
music therapist network with caretakers, school personnel,
and treatment agents in order to obtain a complete and ac­
curate picture of the child's needs. (The authors are currently
in the process of piloting a music therapy assessment specif­ REFERENCES

ically designed for SED children.) Abell, S. C. (1998). The use of poetry in play therapy: A logical integration. The Arts
A second challenge for music therapists working with foster in Psychotherapy, 25(1), 45-49.
Barbell, K. (Director of Foster Care, Child Welfare League of America). (1998, Jan­
care children is in the area of intervention. Due to the fact
uary 9). Take This Heart. Cleveland, Ohio: Public Broadcasting Service.
that only the most seriously abused children who are abused Bohman, M. (1990). Outcome in adoption: Lessons from longitudinal studies. In D.
or neglected are removed from their homes, foster care chil­ Brodzinsky & M. Schechter (Eds.), The Psychology of adoption (pp. 93-106).
dren can present with significant histories of trauma, victimi­ Oxford, England: Oxford University Press.
zation, and extremely high levels of emotional and behavioral Bowman, D. O., & Halfacre, D. L. (1994). Poetry therapy with the sexually abused
adolescent: A case study. The Arts in Psychotherapy, 21(\), 11-16.
disturbance. Many of the referred children will require inten­
Burkhardt-Mramor, K. M. (1996). Music therapy and attachment disorder: A case
sive and highly specialized treatment regimes, that are care­ study. Music Therapy Perspectives, 14(2), 77-82.
fully orchestrated in conjunction with larger intervention ef­ Canning, R. (1974). School experiences of foster children. Child Welfare, 53, 582­
forts designed to achieve safe and permanent family place­ 587.
46 Music Therapy Perspectives (2002), Vol. 20

Cohen, D. L. (1991). Foster care reforms often ignore problems children face in care. Community Alternatives: International Journal of Family Care, 5(1), 115­
school. Education Week, 1, 15-17. 134.
Cox, K. L., & Price, K. (1990). Breaking through: Incident drawings with adolescent Thompson, K. M., & Hilderbrand, K. M. (1995). You've got to talk, talk, talk. On
substance abusers. The Arts in Psychotherapy, 17(4), 333-337. Safe & Sound [cassette]. Akron, OH: Twin Sisters Productions.
Dore, M. M, & Fisner, E. (1993). Child related dimensions of placement stability in Tibbetts, T. J., & Stone, B. (1990). Short-term art therapy with seriously emotionally
treatment foster care. Child & Adolescent Social Work Journal, 10(4), 301-317. disturbed adolescents. The Arts in Psychotherapy, 17(2), 139-146.
Dunne, P. B. (1988). Drama therapy techniques in one-to-one treatment with dis­ U.S. Department of Health and Human Services, Children's Bureau. (1997). National
turbed children and adolescents. The Arts in Psychotherapy, 15(2), 139-146. study of protective, preventive and reunification services delivered to children

Downloaded from https://academic.oup.com/mtp/article/20/1/38/1081012 by Icahn School of Medicine at Mount Sinai user on 23 February 2021
Emunah, R. (1985). Drama therapy and adolescent resistance. The Arts in Psycho­ and their families. Washington, DC: U.S. Government Printing Office.
therapy, 12(2), 71-79. U.S. Department of Health and Human Services, Children's Bureau. (2000). Adop­
Fanshel, D., Finch, S., & Crundy, J. (1989). Foster children in life-course perspective: tion & Foster Care Analysis and Reporting System. Washington, DC: U.S. Gov­
The Casey Family Program experience. Child Welfare, 68(5), 467-478. ernment Printing Office.
Farr, M. (1997). The role of dance/movement therapy in treating at-risk African Amer­ Walsh, R. T. (1990). A creative arts program in social skills training for early adoles­
ican adolescents. The Arts in Psychotherapy, 24(2), 183-191. cents: An exploratory study. The Arts in Psychotherapy, 17(2), 131-137.
Frisch, A. (1990). Symbol and structure: Music therapy for the adolescent psychiatric Washington, N., & Harline, L. (1940). Give a little whistle. On Pinocchio [CD].
inpatient. Music Therapy, 9(1), 16-34. Burbank, CA: The Walt Disney Company.
Cillis-Arnold, R., Crase, S. )., Stockdale, D. F., & Shelley, M. C. (1998). Parenting Whittaker, J. K., Fine, D., & Grasso, A. (1989). Characteristics of adolescents and
attitudes, foster parenting attitudes, and motivations of adoptive and nonadop­ their families in residential treatment intake: An exploratory study. In E. A. Bal­
tive foster parent trainees. Children and Youth Services Review, 20(8), 715-732. cerzak (Ed.), Group Care of Children: Transitions Toward the Year 2000. Wash­
Goerge, R. M. (1990). The reunification process in substitute care. Social Service ington, DC: Child Welfare League of America.
Review, 64(3), 422-457. Williams, G. H., & Wood, M. M. (1977). Developmental Art Therapy. Baltimore:
Guerney, L. F. (1982). The effectiveness of foster care as supplemental parenting. In University Park.
M. E. Kostelnik & H. E. Fitzgerald (Eds.), Child nurturance: Vol. 2. A biennial
series. New York: Human Sciences Press.
Haerian, M. (1998). Foster care. In H. S. Ghuman and R. M. Sarles (Eds.), Handbook
of Child and Adolescent Outpatient, Day Treatment and Community Psychiatry
(pp. 377-384). Philadelphia: Brunner/Mazel.
Johnson, D. R. (2000). Creative therapies. In E. B. Foa and T. M. Keane (Eds.), Effec­
tive Treatments for PTSD: Practical Guidelines from the International Society for
Traumatic Stress Studies (pp. 356-358). New York: The Guilford Press.
Johnson, D. R., & Eicher, V. (1990). The use of dramatic activities to facilitate dance
therapy with adolescents. The Arts in Psychotherapy, 17(2), 157-164.
Johnston, J. C., Healey, K. N., & Tracey-Magrid, D. (1985). Drama and interpersonal
problem solving: A dynamic interplay for adolescent groups. Child Care Quar­
terly, 14(4), 238-247.
Kime, S. (1994, Summer). Leaving and grieving: Loss issues of foster children. Con­
nections (ATTACh newsletter). .
Levens, M. (1994). The use of guided fantasy in art therapy with survivors of sexual
abuse. The Arts in Psychotherapy, 21(2), 127-133.
Lowenstein, L. F. (1983). The treatment of extreme shyness in maladjusted children
by implosive, counseling and conditioning approaches. lnterdisciplinaria,4(2),
115-130.
MacKay, B., Gold, M., & Gold, E. (1987). A pilot study in drama therapy with ad­
olescent girls who have been sexually abused. The Arts in Psychotherapy, 14(\),
77-84.
Mayers, K. S. (1995). Songwriting as a way to decrease anxiety and distress in trau­
matized children. The Arts in Psychotherapy, 22(5), 495-498.
McGowan, B. G., & Walsh, E. M. (2000). Policy challenges for child welfare in the
new century. Child Welfare, 79(1), 11-27.
Merle-Fishman, C. R., & Marcus, M. L. (1982). Musical behaviors and preferences
in emotionally disturbed and normal children: An exploratory study. Music Ther­
apy, 2(1), 1-11.
Miller, M., Dokow, L., & Greer, R. D. (1974). The contingent use of music and art
for improving arithmetic scores. Journal of Music Therapy, 11, 57-64.
Pardeck, J. T. (1985). A profile of the child likely to experience unstable foster care.
Adolescence, 20(79), 689-695.
Payne, H. (1988). The use of dance movement therapy with troubled youth. In C. E.
Schaefer, et al (Ed.), Innovative Interventions in Child and Adolescent Therapy
(pp. 68-97). New York: John Wiley & Sons.
Raffi, Pike, D., & Simpson, B. (1985). Time to sing. In The Second Raffi Songbook.
New York: Crown Publishers, Inc.
Salas, J. (1990). Aesthetic experience in music therapy. Music Therapy, 9(1), 1-15.
Saltzman, M., & Raposo, J. (1985). New way to walk. In The Sesame Street Song­
book. New York: Macmillan Publishing Company.
Stone, N. M., & Stone, S. F. (1983, January). The prediction of successful foster
placement. Social Casework: TheJournal of Contemporary Social Work, 11-17.
Terpstra, J., & McFadden, E. J. (1993). Looking forward to new directions in foster