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Background Although the neuroscience of music’s adaptive influence—and trauma’s deleterious influence—on brain development has been extensively studied, clinical research is limited regarding what effects live music participation may have on trauma-reactive symptomatology in the specific setting of a long-term psychiatric residential treatment facility (PRTF) for children. Purpose Building from a conceptual framework that theorizes a complex interplay of maladaptive/protective factors shaping phenotypic outcomes after experienced childhood maltreatment, we hypothesize that regular participation in live music therapy (LMT), an inherently active and interactive form of music-based intervention, can help reduce externalizing behaviors and, by extension, involvement in psychiatric emergencies (codes) as well as receipt of as-needed medications (PRNs) among youth hospitalized at trauma-focused PRTFs. Methods To test our hypothesis, we retrospectively examined whether regular engagement with LMT made a difference from treatment as usual (TAU) in reducing average codes and PRNs among 12 patients at a trauma-focused PRTF for youth ages 8–12 years with a history of childhood maltreatment. Average codes and PRNs were initially calculated for each patient per intervention period, followed by interrupted time series analysis looking at change in collective average codes and PRNs per week among the study population for the 4 weeks before, 8 weeks during, and 4 weeks after participation in weekly, hour-long LMT sessions (the intervention). Results Following the intervention, roughly 90% of patients showed a downward trend in average codes and PRNs. Although interrupted time series analysis reflected a net reduction in average codes and PRNs during and following the intervention, it is not possible to say from this whether LMT was contributory beyond TAU due to the lack of a control group. Conclusion This pilot study aimed to investigate the effects of LMT at a trauma-focused PRTF for youth. To our knowledge, this is the first published attempt to assess the objective outcome measures of change in codes and PRNs following music-based intervention in this setting. While we were unable to separate the effects of LMT from TAU due to study limitations, our results support further investigation of the role LMT could play in attenuating acute externalizing symptomatology among trauma-reactive youth hospitalized at PRTFs with a potential benefit of reducing overmedication among this at-risk population.