Research articlePilot randomized controlled trial of Tuning Relationships with Music: Intervention for parents with a trauma history and their adolescent
Introduction
Parents with an history of childhood interpersonal trauma, defined as repeated abuse or neglect committed by someone trusted or depended upon (van der Kolk, Roth, Pelcovitz, Sunday, & Spinazzola, 2005), often struggle in responding to their own children. They are more likely to be harshly punitive (Lieberman, Van Horn, & Ghosh Ippen, 2004) and to negatively attribute angry, threatening or coercive intentions to their children (Schechter et al., 2015). Unresolved trauma can interfere with processes related to optimal caregiving (Schore, 2001) at a neurobiological, emotional and behavioral level. This can affect parents’ ability to respond in ways that promote and coach their children’s emotional competence (appropriate emotion understanding and regulation) (Eisenberg, Cumberland, & Spinrad, 1998). Parents experiencing emotional numbing or avoidance in the aftermath of traumatic events may be further compromised in their capacity to notice, then respond consistently and sensitively to children’s nonverbal and verbal auditory and visual cues that signal their emotional state (Schechter et al., 2015).
Parents’ difficulties may also be considered from the perspective of attachment theory, which provides a way to understand the crucial importance of caregivers and the strategies employed by children to maintain proximity to an attachment figure, even when they are threatening or unavailable (Bowlby, 1969). Where parents have had to employ insecure or disorganized attachment strategies in order to cope with an abusive or neglectful caregiver in childhood, the experience of danger is central in organizing their own caregiving behavior (Crittenden, 2006). Parents’ dismissive/unresponsive or preoccupied /reactive responses may therefore be understood as an attempt to create a sense of safety, but cause disrupted interactions that induce a sense of fear in their children (Riggs & Kaminski, 2010).
Parents who struggle with nonverbal emotion recognition and expression are more likely to overprotect or parent intrusively (Thorberg, Young, Sullivan, & Lyvers, 2011), or to use unsupportive parenting strategies (Cuzzocrea, Barberis, Costa, & Larcan, 2015) when their child experiences emotions. Their children may therefore not learn effective ways to express emotions, or to accurately interpret others’ nonverbal expressions. Children can then experience difficulties regulating emotion in the parent-child relationship and other social contexts. These difficulties have been associated with mental health problems in childhood including depression (van Beek & Dubas, 2008) and social anxiety (McClure & Nowicki, 2001). Parents’ and children’s interlocking difficulties with recognizing, accurately interpreting and responding to the other’s nonverbal cues may mean that mutually regulating and enjoyable interactions are not able to develop. Instead, maladaptive interactions that reinforce emotionally dysregulated responses become entrenched. Processes such as reciprocal nonverbal communication of anger may further exacerbate these interactions, which are associated with greater parent-adolescent conflict (Eisenberg et al., 1998).
Negative cycles of interaction may escalate in both prevalence and intensity when a child reaches adolescence, which is often an emotionally challenging time for families (Kim, Conger, Lorenz, & Elder, 2001). Parents with an interpersonal trauma history may experience their adolescent’s normal strivings for autonomy and independence, and increased emotionality as rejecting and reminiscent of earlier abuse or neglect (van Ee, Kleber and Jongmans, 2016) As a result, conflict may remain heightened and unresolved, with detrimental implications not only for open parent-adolescent communication, but also for the adolescent’s social, emotional and behavioral functioning (Moed et al., 2015) and mental health (Crowell et al., 2013).
Evidence-based therapies have not been developed to address the challenges faced by parents with a trauma history; instead, existing interventions have been modified to meet their needs (Carr, 2014). Parents receiving treatment for Post-Traumatic Stress Disorder (PTSD) may be offered family therapy that incorporates interventions such as Trauma-Focused Cognitive Behavioral Therapy (Bisson, Roberts, Andrew, Cooper, & Lewis, 2013) as part of an integrated approach. Therapies for children who have experienced trauma include working with parents, and may address parental trauma where it impacts on the parent-child relationship (Lieberman et al., 2004). However, evidence of the effectiveness of interventions that address parenting difficulties for parents with a trauma history is limited (Maliken & Katz, 2013). A review of the research on challenges and treatment for parents with PTSD recommends systemic approaches that highlight the restoration of safety, re-establishment of secure attachment relationships and regulation of arousal in response to trauma triggers evoked by parent-child interaction (van Ee et al., 2016). These recommendations may also apply for parents with a history of childhood abuse or neglect, who may not meet criteria for PTSD, and/or may exhibit comorbid conditions (van der Kolk et al., 2005). Achieving these goals may require attention to parent emotion socialization practices that are known to shape children’s emotion regulation and non-verbal processes that may drive negative escalating cycles (Colegrove & Havighurst, 2017). Therefore an approach focusing on teaching emotion socialization and nonverbal communication skills may be indicated when intervening therapeutically with parents who have experienced childhood interpersonal trauma and their children.
Nonverbal communication may be thought of as a ‘musical’ process where rhythm, pitch, tone and volume of the voice are used to convey inter-subjective recognition and sharing of emotional states (Stern et al., 1998). Music is used by parents in all cultures to engage children in responsive patterns of relating (Nakata & Trehub, 2004), and is extensively utilized by adolescents to communicate and manage emotions (Hallam, 2010). Music both activates and deactivates amygdala activity (Koelsch & Siebel, 2005), and modifies heart and respiration rates to assist relaxation and stress reduction (Chanda & Levitin, 2013). Music may therefore help parents learn how to respond to their child’s nonverbal communication (Jacobsen, McKinney, & Holck, 2014) and enhance emotion regulation strategies for both parent and adolescent (Fancourt, Ockelford, & Belai, 2014).
Tuning Relationships with Music was developed to address parent-adolescent conflict where a parent has experienced childhood abuse or neglect, using music to target nonverbal communication as a part of effective interpersonal functioning. Tuning Relationships with Music focuses on teaching parents skills in emotion regulation (including managing trauma triggers), then adaptive emotion socialization skills (emotion coaching) to respond to their adolescent using skills such as ‘turning toward’, ‘sitting with’ and ‘softened start-up’ (Gottman, Katz, & Hooven, 1996; Havighurst, Harley, Kehoe, & Pizarro, 2012) Focusing on emotion coaching is the basis of an evidence-based parenting program entitled Tuning in to Teens, (Havighurst et al., 2012) from which psycho-educational materials were taken for use in Tuning Relationships with Music. Tuning Relationships with Music teaches dyads skills in identifying, empathically responding to and regulating their own emotions as a precursor to the parent learning emotion coaching. Using instruments that require no musical training, dyads master nonverbal elements of emotional expression and empathic response (i.e. volume, tempo, turn taking) before verbal equivalents are introduced. Adolescents are asked to adopt the role of ‘expert’ in how they feel and what they need from their parent, to accept their parent’s efforts to use skills learned in therapy, and to give constructive feedback about what assists them to regulate and communicate their emotions. Once skills are mastered, dyads revisit conflict issues and practice working through these nonverbally with music. Parents are then supported to use emotion coaching during verbal conflict discussions, whilst maintaining an awareness of nonverbal communication. Adolescents are supported to remain engaged in the conflict discussion, to regulate their emotional response, and to use ‘turning toward’ and ‘softened start up’ when communicating with their parent.
This study aimed to evaluate the effectiveness of Tuning Relationships with Music with parents and adolescents where a parent had experienced childhood abuse or neglect, and where the dyad reported conflict in their relationship. The study had four aims. The first was to assess whether parents were able to relate responsively to their adolescent after completing Tuning Relationships with Music. The second was to investigate how successful Tuning Relationships with Music was in reducing parent-adolescent conflict. The third was to examine changes in emotion coaching practices including parents’ capacity to empathize with their adolescent’s negative emotions. The final aim was to consider whether there were any resulting improvements in the adolescent’s mental health.
Section snippets
Participants
Parent-adolescent dyads were recruited (December 2015–June 2017) from adolescent clinical services, family services and an existing University of Melbourne research study (see Fig. 1). Dyads were referred by staff, or could self-refer. An initial meeting informed dyads about the trial, obtained consent/assent to participate, and screened for eligibility. Dyads were eligible if (1) the adolescent was 10–18 years, (2) the parent reported experiences of childhood abuse or neglect on the Childhood
Preliminary analyses
All data were screened for missing values. Data was missing for two participants (7.7%) at follow-up. Missing participants’ pre-intervention data was carried forward, using an intention-to-treat approach for all calculations. T tests, Mann–Whitney U tests and chi-square analyses found no significant differences between intervention and waitlist control (TAU) participants at baseline on all socio-demographic, screening and outcome variables.
One hundred percent of intervention participants
Discussion
Tuning Relationships with Music aimed to improve nonverbal communication and reduce parent-adolescent conflict where parents had a history of childhood abuse or neglect and dyads were presenting with a conflictual relationship. The intervention taught dyads to reduce conflict by focusing on nonverbal communication and parent emotion socialization practices. After completing Tuning Relationships with Music, parents were observed to be less reactive and more responsive with their adolescent, and
Limitations
Recruitment of a sample with childhood interpersonal trauma and a conflictual parent-adolescent relationship resulted in a small sample size – a larger sample would have improved the power to detect differences between intervention and TAU participants. Boys were more likely than girls to decline to participate in the study. Further studies may explore how to successfully engage boys in Tuning Relationships with Music (TRM). Only one father participated in the study, possibly reflecting the
Conclusion
This pilot study found that Tuning Relationships with Music, an intervention for parents with a trauma history and their adolescent, led to a reduction in the dyad’s conflict by assisting parents to be less reactive and more skilled at accurately recognizing and responding to their adolescent’s nonverbal communication. Replication with a larger sample is warranted. This study makes a contribution to the existing research on parent-adolescent intervention and suggests that a focus on nonverbal
Conflict of interest
The first author declares a conflict of interest in that as the creator of Tuning Relationships with Music, she may benefit from positive reports of this intervention.
Acknowledgements
Ms Colegrove received financial support through an Australian Government Research Training Program Scholarship. The authors are grateful to participating families and referring services.
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