Evidence-Based Complementary and Alternative Medicine 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 a stronger eﬀect may have been achieved by working with groups of 10–15 students at a time [41, 42, 80, 81] or by 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 9 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 (η2p = 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