*Article* **A Music Therapy Intervention for Refugee Children and Adolescents in Schools: A Process Evaluation Using a Mixed Method Design**

**Evelyn Heynen 1,\* , Vivian Bruls <sup>2</sup> , Sander van Goor <sup>3</sup> , Ron Pat-El <sup>4</sup> , Tineke Schoot <sup>2</sup> and Susan van Hooren <sup>1</sup>**


**Abstract:** Refugee children and adolescents have often experienced negative or traumatic events, which are associated with stress and mental health problems. A specific music therapy intervention is developed for this group in school settings. The aim of the present study was to set the first steps in the implementation of this intervention. A process evaluation was performed using a mixed method design among refugee children and adolescents (6–17 years) at three different schools in the Netherlands. Interviews were conducted with teachers and music therapists before, at the midpoint, and after the intervention. At these moments, children completed a classroom climate questionnaire and a visual analogue scale on affect. The results indicate that the intervention strengthens the process of social connectedness, resulting in a "sense of belonging". The intervention may stimulate inclusiveness and cultural sensitivity, and may contribute to a safe environment and the ability of teachers to adapt to the specific needs of refugee children. Refugee children and adolescents showed a decrease of negative affect during the intervention. When implementing the intervention in schools, it is important to take into account the initial situation, the prerequisites for the intervention, the professional competence, the experience of music therapists, and the collaboration and communication between the professionals involved.

**Keywords:** music therapy; refugee children/adolescents; process evaluation; sense of belonging; affect; resilience

#### **1. Introduction**

In the past decade, the rising number of people entering Europe and the USA in search of safety has captured the world's attention. Up to 50% of them are children and adolescents, with a total of 25,000 unaccompanied minors applying for asylum annually across 80 countries [1]. Most of them have negative and traumatic experiences in their home country, while travelling to Europe, and during the search for a safe new home. They lost their social network, have to deal with uncertainties surrounding their future, and may experience cumulative stress of forced migration. This has shown to be strongly related with stress and mental health disorders [2,3], such as post-traumatic stress disorder, depression, anxiety, and substance use disorders [3–8]. Untreated, these disorders may become chronic and undermine functioning [9–11].

In schools, stress and instability is also recognized in refugee children, as for example seen in fewer social relationships and less positive integration and participation [12], resulting in a higher school drop-out compared with non-refugee children. Refugee children show a higher rate of concentration problems, more aggressive incidents, anxiety, and worry

**Citation:** Heynen, E.; Bruls, V.; van Goor, S.; Pat-El, R.; Schoot, T.; van Hooren, S. A Music Therapy Intervention for Refugee Children and Adolescents in Schools: A Process Evaluation Using a Mixed Method Design. *Children* **2022**, *9*, 1434. https://doi.org/10.3390/ children9101434

Academic Editor: Dafna Regev

Received: 15 August 2022 Accepted: 10 September 2022 Published: 21 September 2022

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**Copyright:** © 2022 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https:// creativecommons.org/licenses/by/ 4.0/).

more about their own safety and safety of others [4,12]. This behavior has been shown to influence classroom climate and the relationship between children and teachers [13]. Proper programs to prevent or address these problems are urgently needed.

Due to their daily contact with the children, schools obtained a growing role in helping refugee children and adolescents in preventing or adapting their (mental health) needs [14]. Positive education can prevent children from psychosocial problems and can improve learning and integration, strengthen psychological well-being, and prevent children from the development of mental health problems [14]. In order to address mental health of refugee children in schools, it is necessary to use specific programs that are sensitive for culture, take language difficulties into account, and have a solid evidence base. There is actually only a small amount of research focusing on interventions in refugee children that promote mental health or moderate stress in terms of resilience [15,16]. In fact, given the large number of children and adolescents displaced by war, there are regrettably few treatment studies available, and many of them were of low methodological quality [17].

Non-verbal interventions such as music therapy have shown to improve a positive psychosocial development of the child, reduce stress, and strengthen their resilience [18]. The use of music can serve to bridge the gap between languages and cultures, since it is universal to all cultures [19]. Neuroscientific studies have shown that music decreases physiological arousal and modulates activity in brain structures that are involved in emotional and motivational processes [20,21]. It is assumed that methodologically using music in therapy can strengthen the impact of music. Music therapy gives opportunities for self-expression and strengthening their (ethnic) identity [22,23]. In a group, music therapy provides opportunities for sharing and communicating on beliefs and hope for the future. In this line, it promotes peer-support and social engagement [24]. The intervention "Safe & Sound" is a music therapy intervention for children and adolescents who experienced negative and traumatic events during war and flight [18,25]. The intervention aims to focus on aspects such as helping each other, working together, feelings of safety, and collaborative learning. In practice, the intervention is already used in Dutch primary schools as a prevention strategy. Studies on the effectiveness of interventions in this population are sparse. This study aimed to set the first steps in the implementation of the intervention and in investigating the perceived effects of a music therapy intervention in refugee children. A process evaluation was conducted in order to obtain insight in the process and process results of the intervention "Safe & Sound" in general and on affect and the learning climate experienced by the refugee children and adolescents. A second aim was to identify influencing factors for the implementation of the intervention in schools. In addition, we wanted to evaluate whether the intervention was conducted as intended (treatment integrity).

#### **2. Methods**

#### *2.1. Design*

The current research was conducted as a mixed-methods (embedded design) longitudinal study, in which both quantitative as well as qualitative methods were applied [26]. A process analysis was conducted in three different schools in the Netherlands. At three measurement moments, interviews were conducted with teachers and music therapists and questionnaires were filled in by the children and adolescents: before the start of the intervention after the summer holidays (T0), at the midway-point of the intervention in autumn (after one month, T1), and after completion of the intervention before the Christmas holidays (after three month T2). In addition, after each session, music therapists answered questions on treatment integrity.

The schools consisted of two elementary schools and one secondary school. These schools have specific classes with educational programs for non-native children and adolescents (most of them are refugees and asylum seekers). The educational programs have the aim to help them integrate and learn the new language and regular knowledge and skills. Schools were recruited by the professional network of the music therapist who developed the intervention. During recruitment, schools were informed about the topic

and the method of the research. All schools gave consent to participate in the music therapy sessions and the present study. An information meeting was held after consent with all participating teachers at each school.

#### *2.2. Participants*

The participants consisted of refugee children and adolescents even as their music therapists and teachers. The children and adolescents were non-native, between the age of 6 to 17 years following education at elementary or secondary schools (for more information see results Section 3.1). All teachers involved in the class for non-natives were asked to participate. One of the music therapists was the developer of the intervention "Safe & Sound (SG)". Two other music therapists were recruited by a formal application procedure. Inclusion criteria for music therapists were a bachelor's degree in music therapy and at least three years of experience with children or adolescents and/or trauma-related problems. In addition, these therapists received an additional two-day training on trauma and resilience from the music therapist who developed the intervention. Before participation, informed consent was obtained from children, their parents, teachers, and music therapists.

#### *2.3. Music Therapy Intervention "Safe & Sound"*

The music therapy intervention "Safe & Sound" was developed in order to strengthen resilience and self-control of children/adolescents who grow up under difficult circumstances such as refugees. In addition, the purpose of the intervention was to prevent or decrease psychosocial complaints and problems which result from a stressful or traumatic event in the past.

The intervention "Safe & Sound" includes two key elements, a classroom-based intervention and an individual intervention. The classroom sessions are embedded in the educational program of the participating schools. During the present study, classroom sessions consisted of ten sessions with a maximum duration of one hour per session. During these sessions, the music therapist worked on a positive climate in the group and aimed to optimize the prerequisites for the learning process, i.e., feeling safe and relaxed and open for new (learning) experiences. During the sessions, the therapist and children work together on interpersonal goals, such as listening to each other, helping each other, and trusting each other. Each classroom session has a specific theme (e.g., making new friends, sharing stories, dealing with difficult situations and emotions, and their talents), which were also based on topics that children want to share with each other or on characteristics of the atmosphere in the group. Finally, children/adolescents of the class present the song they worked out through the sessions to their teachers and parents/care givers, who are stimulated to discuss the song with their child.

During group sessions, music therapists are vigilant for children/adolescents who display behavioral issues or are at risk for further development of (trauma related) psychosocial problems. Music therapists are trained to signal these issues and will discuss this with the teacher of the group, the parents/care givers, school psychologist, or school doctor. If there are indications for further support of the psychosocial development of the child, individual sessions of "Safe & Sound" can be indicated. These individual sessions focus on the individual needs and possibilities of the child/adolescent and can thus provide attention and support to the psychosocial development of the child/adolescents. Those individual sessions mainly focus on stabilization and further try to set important first steps in the treatment of trauma-related problems, always in collaboration with the personal environment of the child/adolescent. If there are signals for need of further treatment, this will be discussed with the child/adolescent family, (remedial)teachers, and school doctor/psychologist.

During the time of the intervention, there was supervision and intervision for the music therapists held by the developer of "Safe & sound (SG)" during two group and two individual sessions.

#### *2.4. Procedure 2.4. Procedure*

individual sessions.

school doctor/psychologist.

Directly after the start of the class year 2019/2020, parents and children/adolescents were informed by teachers about the goal and the procedure of the intervention and the study. The intervention "Safe & sound" was offered to all children/adolescents in the participating classes. Children/adolescents of one class participate together in a session one hour each week within a fixed schedule. If children/adolescents were considered for the individual sessions, parents were informed and asked for their approval. Individual sessions were indicated when teachers report psychological (anger, stress, anxiety, sadness) or physical (sleeplessness, pain) problems. Children/adolescents received questionnaires at T0, T1, and T2. Furthermore, music therapists and teachers were interviewed at T0, T1, and T2. After every music therapy session (both classroom sessions and individual sessions), music-therapists completed a questionnaire on treatment integrity (see Figure 1). Directly after the start of the class year 2019/2020, parents and children/adolescents were informed by teachers about the goal and the procedure of the intervention and the study. The intervention "Safe & sound" was offered to all children/adolescents in the participating classes. Children/adolescents of one class participate together in a session one hour each week within a fixed schedule. If children/adolescents were considered for the individual sessions, parents were informed and asked for their approval. Individual sessions were indicated when teachers report psychological (anger, stress, anxiety, sadness) or physical (sleeplessness, pain) problems. Children/adolescents received questionnaires at T0, T1, and T2. Furthermore, music therapists and teachers were interviewed at T0, T1, and T2. After every music therapy session (both classroom sessions and individual sessions), music-therapists completed a questionnaire on treatment integrity (see Figure 1).

focus on the individual needs and possibilities of the child/adolescent and can thus provide attention and support to the psychosocial development of the child/adolescents. Those individual sessions mainly focus on stabilization and further try to set important first steps in the treatment of trauma-related problems, always in collaboration with the personal environment of the child/adolescent. If there are signals for need of further treatment, this will be discussed with the child/adolescent family, (remedial)teachers, and

During the time of the intervention, there was supervision and intervision for the music therapists held by the developer of "Safe & sound (SG)" during two group and two

*Children* **2022**, *9*, x FOR PEER REVIEW 4 of 22

#### *2.5. Data Collection Methods 2.5. Data Collection Methods*

#### 2.5.1. Interviews 2.5.1. Interviews

Semi-structured interviews were conducted with teachers and music therapists to gain more insight in the process of embedding the intervention and its results in the participants' perspective. Interviews focused on the group and individual part of the intervention. The interview questions were based on the guideline for process evaluations of Movisie [27]. The main topics for the teachers were appreciation, experiences, the scope, and the influencing factors for treatment (success and failure). Topics of interviews for Semi-structured interviews were conducted with teachers and music therapists to gain more insight in the process of embedding the intervention and its results in the participants' perspective. Interviews focused on the group and individual part of the intervention. The interview questions were based on the guideline for process evaluations of Movisie [27]. The main topics for the teachers were appreciation, experiences, the scope, and the influencing factors for treatment (success and failure). Topics of interviews for music therapists focused on the execution of the intervention of "Safe & Sound" and its results. The interviews were audiotaped and transcribed for analyses.

#### 2.5.2. Measurement Instruments

In order to evaluate the experiences of participating children and adolescents, a possible language barrier was taken into account by using simple language, conforming to the principles of "Easy language" [28]. In order to allow the participation of children and adolescents with different cultural backgrounds and a broad age range (6–17 years), we selected instruments with a visual attractive format and piloted the items and answer methods in a subsample of refugee children and adolescents. Based on this, we decided to limit the number of items, to include items on somatic complaints, and to include visuals, see Appendices A and B.

• Visual analogue scale to measure positive and negative affect

The visual analogue scale (VAS) is a psychometric measurement method designed to document the characteristics of emotions and symptom severity. In the present study, children/adolescents were shown a horizontal line (10 cm) and asked to mark their level of positive and negative affect on the line ([29] VAS, Appendix A). On the left side is the minimum score ("*don't feel the emotion at all*" = 0), and on the right is the maximum score ("*feel the emotion really strongly*" = 10). The score on the VAS is the number of centimeters (with one decimal) between the minimum score and the line indicated by the participant. A high score on the VAS means that the emotion is experienced to a high degree. Acceptable psychometric properties have been reported for a digital VAS for measuring anxiety [30]. In the present study, six items were investigated for negative affect (headache, stomach ache, angry, easily angered, sad, annoyed, anxious) and two for positive affect (happy, pride).

A CFA was conducted in R version 4.1.2 with the lavaan package, version 0.6–9 [31]. A correlated two-factor model with negative and positive affect as two correlated factors were modeled for each time point separately, which resulted in three CFAs. CFI, RMSEA, and SRMR were used as fit measures, with *CFA* > 0.90, *RMSEA* and *SRMR* < 0.08 as cutoff values for adequate model fit. The correlated two-factor models showed very poor fit (see Table 1). *CFI* was highest for T1 (*CFI* = 0.82), and substantially lower for the other time points. RMSEA and SRMR were all well above the threshold of 0.08. An inspection of the performance of each item showed that item "easily angered" loaded poorly (below 0.2) on negative affect at every time point. The removal of "easily angered" improved the fit somewhat, with SRMR getting closer to an adequate threshold, but overall, the model fits were poor. The poor fit is reflected in the low reliabilities of the scales. McDonald's omega was low for positive affect (around 0.45), and just about acceptable for negative affect (between 0.63 and 0.68) [32]. Therefore, we only used negative affect in the subsequent analyses.


**Table 1.** Fit measures and McDonald's omega for the VAS variables positive and negative affect.

\*\*\* = *p* < 0.001.
