Music Therapy Perspectives Advance Access published June 27, 2016

Music Therapy Perspectives Advance Access published June 27, 2016 Investigating the Effectiveness of a Developmental, Individual Difference, Relation...
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Music Therapy Perspectives Advance Access published June 27, 2016

Investigating the Effectiveness of a Developmental, Individual Difference, Relationship-Based (DIR) Improvisational Music Therapy Program on Social Communication for Children with Autism Spectrum Disorder JOHN A. CARPENTE, PHD, MT-BC, LCAT

Associate Professor, Molloy College, Rockville Centre, NY Founder/Director, Rebecca Center for Music Therapy at Molloy College, Rockville Centre, NY

The DIRFloortime Model The Developmental Individual Difference Relationshipbased model (DIRFloortime) is one of several DSP models. DIRFloortime is a caregiver-mediated home-based intervention that involves training parents to maximize interactions with their children to improve social reciprocity and functional pragmatic communication (Greenspan & Wieder, 2006a; Simpson, 2005; Solomon, Van Egeren, Mahoney, Huber, & Zimmerman, 2014). The DIRFloortime model involves the implementation of child-led strategies within a developmental approach in order to foster communication skills within a social context (Greenspan, 1992; Greenspan & Wieder, 1997, 2006b; Pajareya & Nopmaneejumruslers, 2011, 2012; Solomon, Necheles, Ferch, & Bruckman, 2007; Casenhiser, Shanker, & Stieben, 2013). The model seeks to facilitate social communication skills via affective-relational experiences that are based on the child’s interests in order to foster engagement, relatedness, communication, and high-level thinking, that is, symbolism and abstraction, within a social context. Thus, the task of the therapist is to provide developmentally appropriate relational experiences that are based on the child’s lead, all within the context of the child’s relationship with the therapist. The DIR model provides clinicians and parents with a framework for assessing and conceptualizing the needs of individuals. The “D” is concerned with the child’s developmental capacities. The “I” deals with the child’s individual differences, and the “R” describes his/her learning relationships with others. Thus, the model provides therapists with a guide for creating an intervention plan that takes into consideration each child’s unique differences and strengths in order to foster social, emotional, and intellectual development rather than simply focusing on isolated behaviors (Greenspan, 1992; Greenspan & Wieder, 2006a, 2006b).

Background Individuals with Autism Spectrum Disorder (ASD) display challenges related to social communication skills (American Psychiatric Association, 2013). These challenges generally impact the individual’s ability to experience shared attention, express and understand nonverbal and verbal communication, maintain peer relationships, and engage in social reciprocity. Treatment programs based on the behavioral model constitute the predominant therapeutic approach (Schreibman, 2005). According to this model, ASD is a learning difficulty that can be addressed with operant conditioning strategies using discrete behavioral trials to increase language and socialization and decrease repetition. The literature, however, indicates limitations regarding the use of highly structured therapist-led behavioral interventions. For example, behavioral gains did not typically generalize to new settings or maintain over time (Schreibman, 2005; Harris et al., 2015; Ingersoll, Lewis, & Kroman, 2007; Paul, 2008). Results also indicated a lack of spontaneity and overdependence on prompts (Ingersoll, 2008; Schreibman, 2005; Schreibman et al., 2015). As a result of these findings, interventionists are now consistently incorporating Developmental Social Pragmatic (DSP) John A.  Carpente, Associate Professor of Music Therapy at Molloy College, is the founder and director of the Rebecca Center for Music Therapy and Center for Autism at Molloy College. Address correspondence concerning this article to John A. Carpente, PhD, MT-BC, LCAT, The Rebecca Center for Music Therapy at Molloy College, 1000 Hempstead Ave., NY Rockville Centre 11571. E-mail: [email protected] © the American Music Therapy Association 2016. All rights reserved. For permissions, please e-mail: [email protected] doi:10.1093/mtp/miw013

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strategies within research protocols such as following the child’s lead and contingent imitation while considering their developmental capacities, and teaching communication skills within a social context (natural environment) (Dawson et  al., 2010; Schreibman et al., 2015) as a means of improving communication (Casenhiser, Shanker, & Stieben, 2013; Dawson et al., 2010; Green et al., 2010; Hwang & Hughes, 2000; Ingersoll, Dvortcsak, Whalen, & Sikora, 2005; Kasari, Gulsrud, Wong, Kwon, & Locke, 2010; Prizant, Wetherby, Rubin, & Laurent, 2003).

ABSTRACT:  The purpose of this study was to examine the effectiveness of improvisational music therapy carried out within a DIRFloortime framework in addressing the individual social communication needs of children with Autism Spectrum Disorder (ASD). Participants included four children enrolled in a therapeutic day school, 4–8 years of age, and diagnosed with ASD. Each child participated in twenty-four 30-minute individual DIR-based improvisational music therapy sessions over the course of 13 weeks. The Functional Emotional Assessment Scale (FEAS) was used to evaluate changes in social communication skills. Results indicated improvements in areas of self-regulation, engagement, behavioral organization, and two-way purposeful communication.

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Improvisational Music Therapy Similar to the DIRFloortime model, improvisational music therapy (IMT) may also adopt a client-led relationship-based framework when working with children with ASD (Alvin & Warwick, 1991; Carpente, 2012; Geretsegger, Holck,

Carpente, Elefant, & Kim, 2015; Holck, 2004a; Kim, Wigram, & Gold, 2008; Nordoff & Robbins, 2007). Child-led IMT may be viewed as a developmental approach noted for providing a meaningful framework, similar to early mother-infant interaction, which is used to promote shared focus of attention, turn-taking, and emotional attunement (Holck, 2004b; Kim, Wigram, & Gold, 2008). When working within a child-led framework, the therapist may improvise music that generally follows the child’s focus of attention and interests in order to establish a relationship while fostering engagement, relatedness, and communication (Alvin & Warwick, 1991; Carpente, 2013; Geretsegger, Holck, Carpente, Elefant, & Kim, 2015; Holck, 2004b; Kim, Wigram, & Gold, 2008; Nordoff & Robbins, 2007). The process of tuning into the child’s musical and non-musical expression has been an integral feature of clinical practice and is an essential skill of an improvisational music therapist (Alvin & Warwick, 1991; Bruscia, 1987; Geretsegger, Holck, Carpente, Elefant, & Kim, 2015; Nordoff & Robbins, 2007). Working in music as a therapeutic intervention has shown to be potentially more effective than other mediums to engage children with ASD, and may provide unique opportunities for them to interact nonverbally compared with play-based interactions (Kim, Wigram, & Gold, 2008). The structure and predictability found in music provides a context and vehicle for reciprocal interactions and promotes flexibility and social engagement from which relationships emerge (Bruscia, 1987, 2014; Geretsegger, Holck, Carpente, Elefant, & Kim, 2015; Nordoff & Robbins, 2007). While children with ASD are generally found to have impaired perception of linguistic and social auditory stimuli (Boddaert et  al., 2004), they are also reported to possess either intact or sometimes superior musical perception regarding pitch perception (Bonnel et al., 2003; Heaton, 2005), melody discrimination (Applebaum, Egel, Koegel, & Imhoff, 1979; Mottron, Peretz, & Menard, 2000), pitch recall (Heaton, Hermelin, & Pring, 1998), the ability to disembed notes within chords (Heaton, 2003), and improvising melodies (Thaut, 1988). Studies have also indicated that individuals with ASD have a strong affinity for musical stimuli when compared to other auditory and visual stimuli (Blackstock, 1978; Thaut, 1987), as well as for displaying the ability to understand affective connotations in music (Heaton, Hermelin, & Pring, 1999). DIRFloortime and Client-Led Improvisational Music Therapy Floortime and client-led improvisational music therapy share many similarities in terms of their philosophy and approach. Both are child-led, relying on the therapist’s ability to be creative, flexible, spontaneous, and emotionally attuned with the child. In addition, both highly value the child–therapist relationship as being the vehicle for development and clinical progress (Carpente, 2011, 2014). Finally, the aim of both methods is to engage the child in affective back-and-forth reciprocal experiences within a social context to foster social communication capacities. However, they differ in mediation, setting, duration/intensity, and evidence base. Family involvement and caregiver delivery are an essential aspect of most DSP interventions. Several randomized control trials have evaluated the effectiveness of caregiver mediated DSP interventions (Aldred, Green, & Adams, 2004; Green et al.,

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The “D” refers to six levels of development that define the child’s fundamental capacities for 1) shared attention and selfregulation, 2)  relatedness and engagement, 3)  two-way purposeful communication, 4)  shared problem-solving, 5)  symbolic thinking, and 6) bridging ideas. According to Greenspan (1992), these capacities are the building blocks and foundation for higher levels of thinking and relating such as the ability to sustain long chains of communication in a back-and-forth purposeful manner, create and share ideas, and think symbolically and abstractly. Table 1 illustrates the six developmental levels of social-emotional functioning. The “I” represents Individual differences and refers to how the child processes information such as receptive and expressive language, motor and sensory stimuli (e.g., touch, sound, and other sensations), auditory input, visual-spatial information; and motor-planning and sequencing abilities. For each of the six developmental levels described in Table 1, the therapist is required to understand the individual differences of the child, and determine how they interfere with his/her ability to move up the developmental sequence (Greenspan & Wieder, 2006a, 2006b). The term “Relationships” pertains to how the child interacts with others (e.g., family members, teachers, therapists, and caregivers) in order to inform the therapist as to the patterns and modes of interaction that should be included in the therapeutic program to support development. Relationships and the learning experiences that occur in them are an essential component of the DIRFloortime model. According to Greenspan and Shanker (2004), relationships are the vehicle for affect-based developmentally appropriate interactions that are necessary for healthy development. Each facet of the DIRFloortime model complements the other. First, it is essential to understand the child’s level of developmental functioning (see Table 1). Second, it is important to understand the child’s individual differences and how they may be interfering with his/her development. Finally, it is imperative to assess and understand the child’s mode of relating and managing relationships with others. Once there is a developmental and sensory portrait of the child, it is the therapist’s task to support the individual differences while providing the child with relational experiences that will help guide him/ her to achieve the highest potential within the six developmental levels. Floortime is an intervention method that is integral to the DIR therapeutic process. It is a clearly defined five-step skill sequence that guides the therapist or parents to follow affectively toned interactions through gestures and words in order to help move the child up the developmental ladder by first establishing a foundation of shared attention. Table  2 illustrates the five steps that make up the Floortime method. Thus, the DIR portion of the model helps conceptualize the child, helping the therapist in drawing up a comprehensive assessment, while Floortime is the treatment intervention that is guided by the child’s profile.

Music Therapy Perspectives

Occurs 2–5 months

Occurs 4–10 months

Occurs 10–18 months

Occurs 18–30 months of age

Occurs 30–42 months

Level II: Attachment and engagement in relationship

Level III: Two-way purposeful communication

Level IV: Behavioral organization, problem-solving, and internalization

Level V: Representation capacities

Level VI: Representation differentiation

Internal emotional regulation and homeostasis. Integrates and utilizes sensory stimuli, i.e., sight, smell, sound, touch, and taste to self-regulate; maintain availability for interaction while stabilizing awareness of sensations to remain calm and alert Forming a special relationship with a parent or caregiver; builds a foundation for future relationships Purposeful and meaningful communication using gestures, vocalizations, facial expressions in order to open and close 5 or more circles of communication (pre-verbal communication, reading and processing gestural cues) Developing a complex sense of self. Engages in a continuous flow of back-and-forth interactions; engaging is shared problem-solving while opening and closing at least 10 or more circles of communication; experiencing and comprehending range of emotions, e.g., pleasure, assertiveness, curiosity, intimacy, fear, anger Internal representation (symbolic thinking). Learns to represent events, things, feelings symbolically; engage in pretend (symbolic) play; functional speech continues to develop Bridges between ideas and feelings and connects ideas Logically; developing abstract thinking and able to answer questions dealing with what, when, how, and why questions

Description

At risk for ASD

A child at risk for ASD will display challenges using words and/or phrases meaningfully and engaging in pretend play; he/she may repeat words (echolalia). A child at risk for ASD will engage in memorized scripts with random ideas; or use words and ideas out of context.

A child at risk for ASD will exhibit challenges in initiating and sustaining back-and-forth interactions of emotional signals (e.g., showing mom or dad a toy) and may engage in perseverative behavior patterns.

An infant at risk for ASD may display challenges in maintaining engagement, and may withdraw from interaction and become self-absorbed. An infant at risk for ASD may display a lack of interest in others, or engage in brief back-andforth exchanges with very little initiative, and may engage in random behaviors.

An infant at risk for ASD may exhibit challenges in sustaining attention to sensory stimulation, e.g., sights or sounds, and may prefer to engage in perseverative behaviors.

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*All information within this table is from Greenspan & Wieder (2006a, 2006b).

Occurs 0–3 months of age

Chronological age

Level I: Shared attention and regulation

Developmental milestones

Table 1. Six Developmental Levels of Social–Emotional Functioning

Music Therapy Program on Social Communication for Children with Autism Spectrum Disorder 3

Music Therapy Perspectives

4 Table 2. Six Steps to Administering Floortime™

Floortime technique Observation

Approach

Follow the child’s lead

Child closes the circle of communication as the therapist opens the circle

Listening to and watching the child’s facial expressions, tone of voice, gestures, body posture, use of or lack of words, how he/she navigated around the room, separates from caregiver) Once assessing the child’s mode of interacting or responding, the therapist can approach the child with clinically appropriate music, words/lyrics, gestures, and affect. He/she can open the circle of communication with the child by acknowledging the child’s emotionality, then elaborating and building on whatever interests the child at the moment After the initial approach, therapist follows the child’s lead by joining the child in whatever they are doing while being a supportive play partner, creating music that supports, reflects, and/or enhances what the child is playing As therapist follows the child’s lead, he/she extends and expands the play-making, providing supportive music and comments about the child’s play without being intrusive; providing opportunities for the child to express ideas while guiding them into various musical directions to foster problem-solving and reciprocity When child is approached, he/she closes the circle when he/she builds on the therapist’s comments with comments and/or gestures, and/or ideas of his/her own. One circle flows into another, and many circles may be opened and closed in quick succession as one interacts with the child. By building on each other’s ideas and gestures, the child begins to appreciate and understand the value of two-way communication

*All information within this table is from Greenspan & Wieder, 2006a, 2006b).

2010; Kasari, Gulsrud, Wong, Kwon, & Locke, 2010; Ingersoll, 2008, Wetherby & Woods, 2006). Results indicated significant improvement in the children’s ability to share attention, and engage with parents and communicate reciprocally after seven months to one year of monthly three-hour parent training visits to the home, and six to ten twenty-minute caregiver-mediated Floortime sessions at home (Pajareya & Nopmaneejumruslers, 2012, Casenhiser, Shanker, & Stieben, 2013; Solomon, Van Egeren, Mahoney, Huber, & Zimmerman, 2014). IMT is typically delivered by a highly skilled music therapist in a clinical setting. The two RCTs that have assessed the effectiveness of IMT for children with ASD have found improvements in joint attention and affective sharing after delivering 30–45-minute IMT sessions once a week for 12 to 16 weeks (Kim, Wigram, & Gold, 2008; Gattino et al., 2011). While caregiver interventions are now considered evidence-based (Wheeler, Williams, Seida, & Ospina, 2008; Wong et  al., 2015) music therapy, including IMT is regarded as promising but not sufficiently evidenced for improving social interaction in children with ASD (Rossignol, 2009). Several randomized control trials suggest that IMT as an intervention for young children with ASD can improve responding to joint attention and some forms of initiating joint attention (Kim, Wigram, & Gold, 2008), affective sharing and initiating behavior (Kim, Wigram, & Gold, 2009), nonverbal communication skills (Gattino, Riesgo, Longo, Leite, & Faccini, 2011), and the parent–child relationship (Thompson, McKerran, & Gold, 2013; Thompson, 2012; Oldfield, 2001). This study will (1) translate and apply DIRFloortime to IMT principles as a means for improving core features of ASD based on a standardized, criterion-referenced rating scale developed to evaluate social communication via play context (Functional Emotional Assessment Scale) and (2) examine the effectiveness of a DIR-based improvisational music therapy

(IMT) intervention in addressing individual social communication skills of children with ASD. The guiding research question was: Do children with ASD receiving DIR-based IMT improve their social communication functioning, as assessed by the Functional Emotional Assessment Scale (FEAS)? Method Participants Four participants enrolled in a therapeutic day-school were selected by the school psychologist for participation in the study based on the following criteria: 1) a diagnosis of ASD, 2) newly enrolled at the therapeutic day-school, 3) 4–8 years of age, and 3)  no prior experience in music therapy. Each parent of the participants was asked to sign a consent form for their child’s participation in the study. All personal information and data was kept strictly confidential (pseudonyms are used throughout this paper to identify the subjects). The study was reviewed and approved by an East Coast University and the therapeutic dayschool’s Institutional Review Board (IRB). Measure The Functional Emotional Assessment Scale (FEAS) (Greenspan, DeGangi, & Wieder, 2001) was used as a pre- and post-test to measure each child’s progress toward social communication development. The FEAS, a play-based assessment instrument, is a valid and reliable, age-normed, observational instrument that has been used in several DIRFloortime studies (Solomon, Necheles, Ferch, & Bruckman, 2007; Solomon, Van Egeren, Mahoney, Huber, & Zimmerman, 2014; Liao et al., 2014; Dionne & Martini, 2011; Pajareya & Nopmaneejumruslers, 2011, 2012). The FEAS was designed to determine a child’s social communication capacities based on the six developmental

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Extend and expand play

Procedures

Music Therapy Program on Social Communication for Children with Autism Spectrum Disorder

Procedures Each child participated in a total of 26 DIR-based IMT sessions over the course of 13 weeks. Each treatment session lasted 15–30 minutes, depending upon the child’s tolerance, and was given twice per week. The first and last sessions involved pre- and post-testing administered by a psychologist who is DIRFloortime certified and highly experienced in administering the FEAS. The other 24 sessions consisted of individual DIR-based improvisational music therapy conducted in the school’s music therapy treatment room. This room was equipped with a video recorder that was used to record all sessions. Various instruments, which require no prior skills or experience, were available to the children, including a snare drum, 12-inch crash cymbal, 12-inch tambourine and buffalo drum, 24-inch floor tom, chromatic set of resonator bells, pentatonic xylymba, chromatic xylophone, two pitched reed horns, an acoustic piano, and an acoustic and electric guitar. In addition, a variety of sizes of drumsticks and mallets with various textured handles were made available. Intervention The DIR-based IMT involved the therapist implementing three procedural phases (see Table 3) in tandem with Floortime techniques illustrated in Table  2. Each phase is identified by its own objectives and musical–clinical techniques, and each requires different developmental capacities on the part of the child. Therefore, the child’s capacity to engage in musical play will determine the working phase or phases of the session. Hence, the therapist follows and moves through a sequence of

stages to achieve each phase, always beginning and reverting back to following the client’s musical–emotional lead (Phase 1). IMT was employed within the context of a child-led DIR-based approach. Thus, the therapist created music based on the child’s musical responses, and/or movements, and/or emotionality, and inclinations or tendencies to foster engagement, relatedness, attunement, and social communication. The music therapist created music that met and followed the child’s musical–emotional lead in order to foster engagement, relatedness, social interaction, and communication. The clinically improvised music was based on the child’s reactions, responses, and emotional state as a means to join the child’s play and foster relationship and shared attention. Hence, the task of the therapist was to provide music that deepened the child’s experience in play and fostered a continuous flow of affective back-and-forth interactions though a range of musical contexts and frameworks. The course of improvising musical experiences included a process of three phases: 1) following the child’s musical–emotional lead, 2) twoway purposeful musical-play, and 3) affect synchrony in musical play. See Table 3 for an illustration of the sequence and operational definitions for each of the three phases. Phase 1: Following the Child’s Musical–Emotional Lead Phase 1, “following the child’s musical–emotional lead,” involved the therapist observing the child while creating music around his/her natural inclinations, emotional interests, and musical (e.g., instrument, vocal, and/or movement) and nonmusical responses (e.g., gestural and/or facial expressions). Clinical techniques such as reflecting, synchronizing, and/or enhancing (Bruscia, 1987) are implemented within musical frameworks in order to meet the child’s affect and to foster engagement and joint attention. Phase 2: Two-Way Purposeful Musical Play Phase 2, “two-way purposeful musical play,” included the therapist transitioning from a child-led to a therapist-led interaction by providing musical experiences that sought out a response from the child. The therapist-led experience was focused on redirecting the child’s attention and music in order to elicit a musical response that in turn closed or completed a circle of communication (e.g., punctuating the end of a phrase, vocally or via cymbal play; gesturally responding to the therapist’s music; adjusting to the therapist’s change in music). This phase included the therapist incorporating elicitation and redirection techniques (Bruscia, 1987) as a means of fostering reciprocal musical play (two-way purposeful musical play). The child’s responses may have been expressed via a glance, and/or instrument play, and/or vocalization, and/ or movement, and/or facial expression. At any time during or after the transition into Phase 2, the therapist may revert back to Phase 1 if the child demonstrated difficulty transitioning and/or withdrawing from the interaction. Phase 3: Affect Synchrony in Musical Play “Affect synchrony,” Phase 3, involved the therapist providing music experiences that included a range of elements, that is, tempo and dynamics, within a consistent predictable musical structure while incorporating a range of clinical techniques such as empathy, structuring, elicitation, redirection, and leaving spaces (Bruscia, 1987). The task of the therapist in this phase

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milestones listed in Table 1. The FEAS includes six subtests that relate directly to Greenspan’s six functional developmental levels and the ages at which typically developing children are expected to attain them (Greenspan, DeGangi, & Wieder, 2001): 1) self-regulation and in shared attention (0–3 months); 2) attachment and engagement (2–5  months); 3)  two-way, purposeful communication (10–12 months); 4) behavioral organization and problem-solving (18–30  months); representational capacities (create ideas, use words or phrases meaningfully, engage in pretend play, and think symbolically [18–30 months]); and (6) representational differentiation (build bridges between ideas, think logically and sequentially, answer “why” questions, thinking abstractly, that is, representation differentiation (30–42 months). The FEAS scoring system is based on a three-point scale for each of six levels of emotional capacity. Items are rated as 0– not at all or very brief; 1–present some of the time, observed several times,or consistently present many times. Thus, high scores on the FEAS indicate a higher developmental level and in turn signify greater social communication. The ratings can be summed to obtain subtest scores as well as total scores (Greenspan, DeGangi, & Wieder, 2001). Cutoff scores, illustrated in Table 8, are used to determine whether the child is classified as “deficient,” “at risk,” or “normal.” The FEAS pre- and post-test ratings were summed to obtain subtest and total scores. FEAS scores were compared to the cutoff scores to determine the child’s classification, in each developmental level, as “deficient,” “at risk,” and “normal.” Pre- and post-test comparisons of classifications were the primary outcome measure and were compared for each child to determine if progress was made on their overall score and on each subtest.

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Music Therapy Perspectives

6 Table 3. Musical–Clinical Intervention Procedural Phases

Phases

Procedure

Outcome

I. Following the child’s musical– emotional lead

Empathy techniques: reflecting, synchronizing , and/or enhancing (Bruscia, 1987)

II. Two-way purposeful musical play

Elicitation and redirection (1987)

Build rapport with the child by creating an accepting musical environment that is respectful of his/her differences, reactions, and responses; guides therapist in understanding child’s musical tendencies , preferences, sensitivities, and preferred musical media (2013); and helps foster self-regulation and joint attention as the child is available for back-and-forth interaction Child to engage in back-andforth musical play in which the interaction shifts between childand therapist-led (2013)

III. Affect synchrony in musical play

Empathy, elicitation, structuring and redirection (1987) (through a range of tempo and dynamics)

Therapist observes, listens, and creates musical experiences based on child’s reactions, responses, and initiated behaviors; music is focused on meeting the child’s affect; therapist may focus on the client’s sense of dynamics, tempo, rhythm, and pace of motor movements and utilization of the instruments, while being attentive to any vocal sounds being expressed (Carpente, 2013) Musically, the therapist improvises and initiates music that offers or expresses a musical question, statement, and/or partial statement seeking a musical response (2013) Therapist creates musical experiences incorporating a range of elements and contexts that provide child with opportunities to initiate, respond, and engage in a continuous flow of affective musical interactions (2013)

Child initiates and responds to musical ideas and cues via a range of musical elements; engaging in long chains of back-and-forth reciprocal affective musical interactions exchanging roles leading and following in play (2013)

was to create opportunities for the client to initiate and respond while exchanging leadership and followership in musical play. Data Analysis The FEAS pre- and post-test ratings for each child were summed to obtain subtest scores that were totaled to obtain the total score and compared to the cutoff scores to classify the child as either “deficient,” “at risk,” or “normal” (Greenspan, DeGangi, & Wieder, 2001) (see Figure 1). Pre- and post-subtest classification levels at pre- and post-test were compared for each child in order to assess progress on overall social communication and developmental capacities. Results A comparison of pre- and post-test classification levels on the FEAS will be presented followed by a description of the client process and therapist method for each of the four cases and an integration of the quantitative and qualitative data. FEAS Scores Comparisons of pre- and post-test scores on the FEAS for each case (see Figures 2–5) will be discussed in terms of classification (i.e., “deficient,” “at risk,” or “normal”) according to cutoff scores (see Table 8) and clinical descriptions. Figure 1 illustrates a comparison of the four participants pre- and posttest scores on the FEAS. Each participant’s score is displayed

Figure 1. Percentage of children who advanced at least one classification level on the FEAS. * 50% of the children scored “normal” at pre-test in area IV and maintained a score of “normal” at pre-test Thus, all of children (100%) scored “normal” at post-test in level IV.

for each developmental area in the form of raw scores and subscores, level of functioning, and number of functioning levels changed (see tables 4–7). All participants (100%) were classified as “deficient” on overall social communication scores at pre-test. At post-test, two of the four (50%) advanced two classification levels from “deficient” to “normal.” At pretest all four (100%) participants were scored as “deficient” on four of the six subscales: attachment and engagement (level II), two-way purposeful communication (level III), representational

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Clinical techniques

Music Therapy Program on Social Communication for Children with Autism Spectrum Disorder

1

illustrates the percentage of children who advanced at least one classification level on the FEAS. (Note that at pre-test two children [50%] scored “normal” on behavioral organization [level IV] and maintained this score following treatment. Therefore, at post-test all children scored “normal” on level IV.)

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Case Studies

Changes in Developmental Levels Pre

Post

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Case 1: Kyle Area I

Area

Area III

Area IV

Area V

Area

Figure 2. Kyle’s changes in developmental levels. Changes in Developmental Levels

Pr

Post

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1

0

Area I

Area

Area III

Area IV

Area V

Area VI

Figure 3. Elaine’s changes in developmental levels. Changes in Developmental Levels Pre

Post

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0

Area I

Area II

Area III

Area IV

Area V

Area VI

Figure 4. Anthony’s changes in developmental levels. Changes in Developmental Levels Pre

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1

0

Area I

Area

Area III

Area IV

Area V

Area VI

Figure 5. Michele’s changes in developmental levels. capacity (level V), and representational differentiation (level VI). Two (50%) of the four participants scored “normal” on behavioral organization and problem-solving (level IV) at pre-test, and two were rated as “deficient.” In addition, two participants scored “at risk” on self-regulation and shared attention (level I). At post-test three of the four (75%) were considered “normal” on self-regulation and shared attention, engagement, and behavioral organization. In the area of two-way purposeful communication, two of the four participants (50%) had progressed one level to “at risk” and one had progressed two levels to “normal.” All of the participants had progressed one or two levels on at least one of the six developmental levels. Figure 1

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L e v e l s

Kyle was deficient in all developmental areas at pre-test and made no functional progress on any of the areas except for behavioral organization and problem-solving (level IV), in which he advanced two levels to “normal.” See Table  4 for Kyle’s pre- and post-test raw scores and changes in functioning level. Generally, during Kyle’s first six treatment sessions, he exhibited difficulty adapting to the musical environment due to his complex sensory system, for example craving vestibular and proprioceptive inputs. He presented with a mixed-reactivity sensory system and challenges in self-regulation. Thus, it was difficult to engage him musically as he consistently withdrew, emotionally and/or sensorily, from any attempts to join him in play. Following session six, the therapist shortened the length of sessions, and provided various sensory stimuli (e.g., deep pressure on his arms and legs, clay for tactile input, and a rocking game chair for vestibular input) within the musical experiences that catered to Kyle’s individual differences in order to foster self-regulation and shared attention. During this time, the therapist provided Kyle with his required sensory diet within musical-play experiences. While his ability to maintain self-regulation and engage in vocal play began to emerge, interactions were fragmented, brief, and lacked a continuous flow. During sessions 13 through 16, Kyle began to display the ability to engage in music experiences, via vocal play, for longer periods (3–4 measures of 4/4 at a time). In addition, his ability to adapt and problem-solve in musical play began to emerge in the form of turn-taking, predicting, and imitating brief melodies and short melodic rhythms. During these experiences, the therapist began interactions by musically following Kyle’s lead (treatment phase 1) by creating music that mirrored and reflected his play and emotionality, while incorporating spaces into the music for Kyle to fill in. In addition, short repeated melodic phrases were created within simple harmonic frameworks, that is, ii–V–I, that included simple rhythms to create call-and-response (turn-taking) and imitation opportunities. As treatment continued, from sessions 16 to 25, Kyle continued to demonstrate the ability to problem-solve by joining into musical play, rhythmically and tonally, as well as reading and responding to musical cues that created imitation and turn-taking experiences. Generally, interactions continued to be brief and lacked a continuous flow of back-and-forth play. It appeared that the musical conditions needed to maintain sameness in terms of staccato phrasing, short motifs, and fixed dynamics. The therapist provided musical experiences that generally shifted between treatment Phases 1 and 2 (following and redirecting for two-way purposeful play), always reverting back to following his lead in order to help Kyle re-engage in play. In summary, as reflected in the Kyle’s FEAS post-test, his challenges in the ability to sustain self-regulation (level I)

Music Therapy Perspectives

8 Table 4. Comparison of Kyle’s Pre- and Post-FEAS Scores

Areas

Post-test

Raw scores

Raw scores

Subscores

Subscores

8 (Deficient) 2 2 2 2 1 0 0 6 (Deficient)

7 (Deficient) 2 2 0 2 1 1 0 7 (Deficient)

2 0 0 2 0 2 0 0 5 (Deficient)

2 1 1 2 0 0 1 0 6 (Deficient)

1 1 1 2 0 (Deficient)

1 1 2 2 2 (Normal)

0 0 1 (Deficient)

0 2 0 (Deficient)

0

0 0 0 1 0 0 0 0 (Deficient)

0 0 0 0 0 0 0 0 (Deficient)

0

0 0 0 0 0

0 0 0 0 0

made it difficult for him to engage (level II) in continuous twoway purposeful communication (level III). His ability to adapt to musical experience in the areas of joining into play interactions, turn-taking, and imitation appeared to be reflected in his gains in level IV of the FEAS (behavioral organization and problem-solving). Figure 2 illustrates Kyle’s changes in developmental levels.

Change in functioning level 0

0

0

+2

Case 2: Elaine Elaine’s pre-test FEAS scores indicated “normal” on behavioral organization and problem-solving (level IV), “at risk” on self-regulation and shared attention (level I), and “deficient” in all other developmental areas, that is, engagement, twoway purposeful communication, representational capacities, and representation differentiation. Following treatment, Elaine

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I. Self-regulation Attentive to play with toys Explores objects/toys freely Remains calm during play Touching textured toys/caregiver Shows content affect Focused without distraction Appears over aroused II. Forming relationships and engagement Emotional interest in caregiver Relaxed when near caregiver Anticipates with curiosity Uncomfortable with caregiver Initiates closeness to caregiver Avoids caregiver Socially references caregiver Communicates from across space III. Two-way purposeful communication Opens circles of communication Initiates intentional actions Closes circles of communication Uses words, gestures, or sounds IV. Behavioral organization and problem-solving Communicates in several modes Copies caregiver & incorporates V. Representational capacity Engages in symbolic play Engages in pretend play Communicates intentions Expresses dependency Expresses pleasure/excitement Expresses assertiveness Creates 2 or more unrelated ideas VI. Representational differentiation Bridges 2 unrealistic idea Bridges 2 realistic ideas Use pretend to express dependency Use pretend to express pleasure Expresses assertiveness in pretend

Pre-test

Music Therapy Program on Social Communication for Children with Autism Spectrum Disorder

9

Table 5. Comparison of Elaine’s Pre- and Post-FEAS Scores

Areas

Post-test

Raw scores

Raw scores

Subscores

Subscores

11 (At risk) 2 2 2 2 1 1 1 11 (Deficient)

12 (Normal) 2 2 2 2 1 2 1 16 (Normal)

2 1 1 2 2 1 2 1 5 (Deficient)

2 2 2 2 2 2 2 2 7 (At risk)

+1

0 1 2 2 3 (Normal)

2 1 2 2 4 (Normal)

0

1 2 3 (Deficient)

2 2 7 (At risk)

+1

0 2 0 0 0 0 1 1 (Deficient)

1 2 2 1 1 0 0 4 (Normal)

+2

1 0 0 0 0

2 2 0 0 0

had advanced to “normal” on all developmental areas except for representational (level V), in which she improved to “atrisk.” See Table 5 for Elaine’s pre- and post-test raw scores and changes in functioning level. Treatment sessions 1 through 5 included Elaine craving motion as she moved aimlessly around the music room while playing each instrument in an unrelated manner. Generally,

Change in functioning level +1

+2

she appeared to become easily dysregulated and unengaged while moving and displayed difficulty self-regulating. When engaged in instrument play, she exhibited challenges maintaining engagement and relatedness, as well as difficulty adapting to dynamic and tempo changes. Sessions 6 through 10 consisted of the therapist attempting to guide Elaine’s perseverative movements into interactive

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I. Self-regulation Attentive to play with toys Explores objects/toys freely Remains calm during play Touching textured toys/caregiver Shows content affect Focused without distraction Appears over aroused II. Forming relationships and engagement Emotional interest in caregiver Relaxed when near caregiver Anticipates with curiosity Uncomfortable with caregiver Initiates closeness to caregiver Avoids caregiver Socially references caregiver Communicates from across space III. Two-way purposeful communication Opens circles of communication Initiates intentional actions Closes circles of communication Uses words, or sounds, or gestures IV. Behavioral organization and problem-solving Communicates in several modes Copies caregiver & incorporates V. Representational capacity Engages in symbolic play Engages in pretend play Communicates intentions Expresses dependency Expresses pleasure/excitement Expresses assertiveness Creates 2 or more unrelated ideas VI. Representational differentiation Bridges 2 unrealistic idea Bridges 2 realistic ideas Use pretend to express dependency Use pretend to express pleasure Expresses assertiveness in pretend

Pre-test

Music Therapy Perspectives

10 Table 6. Comparison of Anthony’s Pre- and Post-FEAS Scores

Areas

Post-test

Raw scores

Raw scores

Subscores

Subscores

10 (Deficient) 2 2 2 0 1 2 1 12 (Deficient)

13 (Normal) 2 2 2 2 1 2 2 16 (Normal)

2 2 0 2 2 1 1 2 5 (Deficient)

2 2 2 2 2 2 2 2 8 (Normal)

+2

1 1 1 2 3 (Normal)

2 2 2 2 4 (Normal)

0

1 1 5 (Deficient)

1 1 14 (Normal)

+2

1 2 0 0 0 2 0 0 (Deficient)

2 2 2 2 2 2 2 7 (Normal)

+2

0 0 0 0 0

2 2 2 0 1

dance experiences, following her lead of movement in order to foster self-regulation, engagement, and relatedness. Her dance-like interactions were generally accompanied by the therapist providing legato and lyrical singing, playing the piano in ¾ tempo, and incorporating words that Elaine offered via her repetitive and echolalic vocalizations. During sessions 11 through 15, Elaine demonstrated a significant increase in her ability to self-regulate for extended

Change in functioning level +2

+2

periods during musical play. This was evident by her ability to sustain musical interaction via instrument play and movement to the waltz-like music being presented. When engaged in instrument play, she demonstrated the ability to interact in a related manner on the drum and cymbal by playing the basic beat and engaging in call-and-response play, punctuating ends of phrases on the cymbal. In addition, while engaged in these robust musical interactions, Elaine exhibited affective

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I. Self-regulation Attentive to play with toys Explores objects/toys freely Remains calm during play Touching textured toys/caregiver Shows content affect Focused without distraction Appears withdrawn/sluggish II. Forming relationships and engagement Emotional interest in caregiver Relaxed when near caregiver Anticipates with curiosity Uncomfortable with caregiver Initiates closeness to caregiver Avoids caregiver Socially references caregiver Communicates from across space III. Two-way purposeful Communication Opens circles of communication Initiates intentional actions Closes circles of communication Uses sounds/words/gestures IV. Behavioral organization and problem-solving Communicates in several modes Copies caregiver & incorporates V. Representational capacity Engages in symbolic play Engages in pretend play Communicates intentions Expresses dependency Expresses pleasure/excitement Expresses assertiveness Creates 2 or more unrelated ideas VI. Representational differentiation Bridges 2 unrealistic ideas Bridges 2 realistic ideas Use pretend to express dependency Use pretend to express pleasure Expresses assertiveness in pretend

Pre-test

Music Therapy Program on Social Communication for Children with Autism Spectrum Disorder

11

Table 7. Comparison of Michele’s Pre- and Post-FEAS Scores

Areas

Post-test

Raw scores

Raw scores

Subscores

Subscores

11 (At risk) 2 2 2 2 1 1 1 6 (Deficient)

13 (Normal) 2 2 2 2 2 2 1 16 (Normal)

0 2 0 2 2 0 0 0 4 (Deficient)

2 2 2 2 2 2 2 2 7 (At risk)

+1

0 1 1 2 0 (Deficient)

2 1 2 2 4 (Normal)

+2

0 0 0 (Deficient)

2 2 2 (Deficient)

0

0 0 0 0 0 0 0 0 (Deficient)

0 2 0 0 0 0 0 0 (Deficient)

0

0 0 0 0 0

0 0 0 0 0

extra-musical responses such as smiling and socially referencing the therapist with eye glances and nonverbal vocalizations. Her challenges related to postural control and motor planning made it difficult for her to sustain a continuous flow of basic beating; however, she maintained engagement and relatedness through facial expressions and social referencing. The therapist incorporated these extra musical responses into

Change in functioning level +1

+2

the music while implementing musical spaces and exaggeration of Elaine’s responses in order to foster two-way purposeful play and reciprocal interactions (treatment phase 2). Musical styles and frameworks, such as flamenco and Latin, were used during instrument play because of their boldness, clarity of tempo, rhythmic nature (included syncopation), and emphasis on a strong downbeat. These musical interventions

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I. Self-regulation Attentive to play with toys Explores objects/toys freely Remains calm during play Touching textured toys/caregiver Shows content affect Focused without distraction Appears over aroused II. Forming relationships and engagement Emotional interest in caregiver Relaxed when near caregiver Anticipates with curiosity Uncomfortable with caregiver Initiates closeness to caregiver Avoids caregiver Socially references caregiver Communicates from across space III. 2-way purposeful communication Opens circles of communication Initiates intentional actions Closes circles of communication Uses sounds/words/gestures IV. Behavioral organization and problem-solving Communicates in several modes Copies caregiver & incorporates V. Representational capacity Engages in symbolic play Engages in pretend play Communicates intentions Expresses dependency Expresses pleasure/excitement Expresses assertiveness Creates 2 or more unrelated ideas VI. Representational differentiation Bridges 2 unrealistic ideas Bridges 2 realistic ideas Use pretend to express dependency Use pretend to express pleasure Expresses assertiveness in pretend

Pre-test

Music Therapy Perspectives

12 Table 8. Functional Emotional Assessment Scale Profile Form (Cutoff Scores)

Subtest

Normal

At Risk

Deficient

Self-regulation & interest in the world Forming relationships and engagement 2-way purposeful communication Behavioral organization and problem-solving Representational capacity Representational differentiation Total Score

12–14

11

0–10

14–16

13

0–12

8–10 2–4

7

0–6 0–1

8–14 2–10 48–96

8–14

7 0–1 0–45

46–47

(i.e., styles) were implemented to foster Elaine’s beating on the drum and the cymbal. In addition, these styles provided experiences that contained drastic contrast between staccato and legato articulation, as well as harmonic tension and resolution points in the music. Furthermore, these musical interventions reflected Elaine’s affect, and incorporated opportunities for her to predict and lead musical play interactions. Her musical responses were mostly expressed via instrument play as well as through facial expressions, gestural cues, and vocalizations. As the sessions progressed, her responses increased relationally and communicatively. Thus, there was an increase in spontaneous language during improvised song making. She also began to seek out the therapist and initiate play interactions and ideas. During these experiences, in which she displayed an increase in self-regulation, engagement, and two-way purposeful communication, the treatment phases shifted from phase 1, following her lead, into phase 2 (two-way purposeful musicalplay), and at times venturing into phase 3 (affect synchrony). Thus, musical-play interactions varied between therapist-led and child-led experiences During sessions 16 through 19, musical-play interactions continued to increase in robustness, range, and continuity as the therapist continued to embrace and respect Elaine’s selfstimulatory behaviors via musical and movement experiences. Following her lead appeared to foster sustained self-regulation and longer periods of engagement and enabled the interaction to move into treatment phases 2 and 3. During sessions 20 through 25, Elaine showed more initiation in continuously seeking out play interactions with the therapist. She also began to lead interactions and require less support in the form of therapist following her lead. Toward the end of treatment, Elaine began to display capacities in her ability to create and connect ideas (musical play, words, gestures, etc.) with the therapist’s while sustaining joint attention and relatedness in a continuous flow of backand-forth interactions. The robustness of the interactions provided opportunities for her to explore and experience a range of musical play that included non-referential and referential improvisations as well as improvised songwriting. Her capacities in musical play appeared to be reflected in her progress to “normal” FEAS scores in the areas of self-regulation (level

Case 3: Anthony At pretest Anthony scored “normal” on behavioral organization (level IV) but “deficient” in all other developmental areas. At post-test he had advanced two levels to “normal” in the areas of self regulation (level I), engagement (level II), twoway purposeful communication (level III), representational capacities (level IV), and representational differentiation (level VI). See Table 6 for Anthony’s pre- and post-test raw scores and changes in functioning level. During sessions 1 through 10, Anthony presented with challenges in self-regulation as well as the ability to engage in relational musical play. He consistently withdrew from musical interactions, physically and/or emotionally. Generally, Anthony presented with a flat affect and typically engaged in instrument play in a one-dimensional manner (playing only loud and fast) and unrelated to the therapist’s music. Anthony appeared to have difficulty understanding and/or being aware of the therapist and therapist’s music. Sessions 11 through 18 featured a combination of childled (treatment phase 1) and therapist-led (phase 2) treatment phases that consisted of the therapist implementing predictable musical structures and familiar songs. The rational of this strategy was to cater to Anthony’s strong memory skills as a means to foster self-regulation and longer periods of relatedness. Repetition and predictability from session to session appeared to assist Anthony in engaging in related play for a sustained period of time. Pre-composed songs that required specific musical responses helped develop Anthony’s musical resources such as auditory discrimination, musical range (dynamics and tempo) related to changes in the therapist’s music, and gestural/affective cues related to musical responses. More importantly, however, Anthony’s improved ability to respond to the therapist’s music illustrated his awareness of another person as well as his ability to comprehend and respond to musical changes as they occurred in time. During sessions 18 through 25, as sessions progressed, the familiar songs began to expand and include a variety of spontaneous musical changes in tempo, dynamics, tonality, phrasing, and articulation that called out for Anthony’s participation. As his involvement in play increased and musical-relational capacities expanded, improvisation was incorporated within the familiar songs on a regular basis. During improvisational experiences, treatment phases easily transitioned from child- to therapist-led and back to childled and so forth as the therapist implemented techniques of elicitation and redirecting to foster Anthony’s ability to regulate, relate, and musically adapt through a range of musical contexts. His emerging musical–social resources appeared to be assimilated into more spontaneous music-making experiences. Anthony initiated lyrical content, which included singing to his favorite doll, as well as requesting specific instruments and

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(Greenspan, DeGangi, & Wieder, 2001)

I), engagement (level II), two-way purposeful communication (level III), behavioral organization and problem-solving (level IV), and creating, that is, representational capacities (level V) and bridging ideas with the therapist, that is, representational differentiation (level VI). Figure 3 illustrates Elaine’s changes in developmental levels.

Music Therapy Program on Social Communication for Children with Autism Spectrum Disorder

offering song ideas. To that end, he engaged in higher levels of musical interaction such initiating and assimilating and differentiating musical ideas, via a range of affect and musical expressivity. These capacities seemed to be indicated in his post-test FEAS scores by advances from “deficient” to “normal” in all areas. Figure  4 illustrates Anthony’s changes in developmental levels. Case 4: Michele

back-and-forth musical pauses. Her ability to maintain selfregulation and engage via a range of musical experiences had expanded. In addition, because of the increase in attention and engagement, Michele’s ability to engage in twoway purposeful musical play had emerged. These capacities demonstrated in musical play appeared to be reflected in her improved FEAS post-test scores. Her FEAS scores indicated “normal” on self-regulation (level I), engagement (level II), and behavior organization (level IV). In addition, she improved to “at-risk” in the areas of two-way purposeful communication (level III). Figure  5 illustrates Michele’s changes in developmental levels. Discussion The results of this case series of DIR-based IMT are consistent with evidence from other IMT studies showing its effectiveness for improving social communication skills in children with ASD (Alvin & Warwick, 1991; Edgerton, 1994; Holck, 2004b; Gattino et  al., 2011; Kim, Wigram, & Gold, 2008, 2009; Robbins & Robbins, 1991; Nordoff & Robbins, 2007; Thompson, McFerran, & Gold, 2013). In addition, the results align with non-music-therapy DSP approaches such as DIRFloortime that emphasize the importance of following the child’s lead while considering developmental capacities within the context of a relationship to improve social communication (Casenhiser, Shanker, & Stieben, 2013; Dionne & Martini, 2011; Ingersoll, Dvortcsak, A., Whalen, C., & Sikora, 2005; Mahoney & Perales, 2003, 2005; Pajareya & Nopmaneejumruslers, 2011, 2012; Solomon, Necheles, Ferch, & Bruckman, 2007; Solomon, Van Egeren, Mahoney, Huber, & Zimmerman, 2014). This study is one of the first in music therapy to demonstrate improvement on social communication among children with autism using a standardized, criterion play-based observation tool as an outcome measure. While the sample in this study is small, these results suggest that gains in social communication, after receiving IMT delivered by a music therapist, generalized to a toy play-based context in an environment not associated with music therapy. Therefore, the data suggest that the principles underlying DIR-based IMT may produce improvements in social communication of children with ASD despite significant differences in setting, mediator, and medium. However, without a control group, it is difficult to know whether the changes in the FEAS scores were directly attributable to the IMT intervention. Furthermore, additional in-depth, repeated, and objective measures of child development, for example IQ, language, and so forth, could have been added to improve the measurement of the outcomes. The difference in the duration and intensity of the DIRbased IMT intervention used in this study and the standard DIRFloortime intervention is significant. Children in this study received a total of 13 hours of IMT, one hour a week over 13 weeks. This is consistent with other IMT studies that have yielded significant improvement in social communication with children with ASD (Robbins & Robbins, 1991; Nordoff & Robbins, 2007; Kim, Wigram, & Gold, 2008, 2009; Gattino et al., 2011). DIRFloortime studies, however, ranged from seven weeks (Dionne & Martini, 2011) to 12  months (Solomon, Necheles, Ferch, & Bruckman, 2007; Solomon, Van Egeren, Mahoney, Huber, & Zimmerman, 2014) and involved

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At pretest, Michele scored “deficient” on all developmental areas except for self- regulation (level I), in which she scored “at-risk.” Following treatment, her post-test indicated “normal” on self-regulation (level I), engagement (level II), and behavioral organization (level IV). She scored “at-risk” on two-way purposeful communication (level II) and maintained a score of “deficient” on representational differentiation (level V) and representational differentiation (level VI). See Table 7 for Michele’s pre- and post-test raw scores and changes in functioning level. During sessions 1 through 9, Michele exhibited difficulty with engaging in musical play due to challenges in her ability to sustain self-regulation, attention, motor plan, and process sensory information. These differences consistently interfered with her ability to interact. In addition, her sensory system appeared to easily overload, in which she withdrew from musical interactions in an under-reactive manner. She appeared unaware of the musical surroundings and presented with challenges related to understanding the functional purpose of the instruments. These difficulties impacted her ability to comprehend basic social dynamics of relating and communicating in musical play. During sessions 10 through 18, she began to display islands of capacity of self-regulation and shared attention while engaged in instrument play with the therapist. The therapist continuously followed her lead by improvising music that reflected her play and emotionality while incorporating simple short melodic phrases, vocally while utilizing percussion, that contained clear cadences. These phrases were repeated in order for her to become familiar with the musical motifs, thus helping her engage and attend to musical play. She began to display an increase in self-regulation and appeared to become more affectively connected to musical play by smiling and offering nonverbal vocalizations that displayed prosody and musical contours. She also began to exhibit the ability to engage in brief turn-taking experiences and occasionally completed musical phrases, in a related manner, when playing percussion and pitched reed horns while therapist accompanied vocally and with various non-pitched percussive instruments. Although these new social–musical capacities began to emerge, Michele displayed difficulty sustaining the play interactions whereby they were brief, fragmented, and lacked a continuous flow back-and-forth interaction. During these musical experiences, the therapist generally reverted back to treatment phase 1, following her lead in order to re-engage Michele in musical play. During the final sessions of treatment, Michele became increasingly responsive to musical cues (e.g., dynamics, tempo, and affect) in the form of relational and communicative instrument play as well as adaption, such as joining into play, turn-taking, and cause-and-effect relationships during

13

Music Therapy Perspectives

14

Implications for Clinical Practice Implications of this study for IMT are closely related to clinical practice. Although it is imperative to understand a child’s musical responses and create musical goals based on his/her musical relatedness, it is equally important to understand biological factors that may impinge upon a child’s ability to engage in musical play. Thus, as indicated in this study, a child who has difficulty engaging in conventional musical play may be experiencing factors completely unrelated to music (e.g., difficulties with motor-planning, postural control, auditory and/or visual processing, sensory modulation and integration, expressive or receptive language, and/or self-regulation). Furthermore, because treatment focuses primarily on facilitating relatedness and communication in children with ASD, it is important to look for these qualities both within and outside music, such as in a smile, a gaze, or a hug. Of course, these responses can be accepted and processed within the context of musical play, or may be a result of a musical interaction. However, in all of their forms, these responses should be regarded as communicative and related responses. Current trends in ASD research indicate the increased use and effectiveness of developmentally based strategies on social communication of children with ASD (Casenhiser, Shanker, & Stieben, 2013; Dawson et al., 2010, Ingersol, 2008; Ingersoll, Dvortcsak, Whalen, & Sikora, 2005; Prizant, Wetherby, Rubin, & Laurent, 2003; Schreibman, 2005; Schreibman et al., 2015). This research seeks to follow in the direction of these new developments and adds to the existing body of IMT and ASD literature (Aigen, 2005; Edgerton, 1994; Nordoff & Robbins,

2007; Geretsegger, Holck, Carpente, Elefant, & Kim, 2015; Kim, Wigram, & Gold, 2008, 2009; Thompson, McFerran, & Gold, 2013). References Aigen, K. (2005). Music-centered music therapy. Gilsum, NH: Barcelona Publishers Aldred, C., Green, J., & Adams, C. (2004). A new social communication intervention for children with autism: Pilot randomised controlled treatment study suggesting effectiveness. Journal of Child Psychology and Psychiatry, 45(8), 1420–1430. Alvin, J., & Warwick, A. (1991). Music therapy for the autistic child (2nd ed.). Oxford: Oxford University Press. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing. Applebaum, E., Egel, A. L., Koegel, R. L., & Imhoff, B. (1979). Measuring musical abilities of autistic children. Journal of Autism and Developmental Disorders, 9(3), 279–285. Blackstock, E. G. (1978). Cerebral asymmetry and the development of early infantile autism. Journal of Autism and Childhood Schizophrenia, 8, 339–353. Boddaert, N., Chabane, N., Gervais, H., Good, C. D., Bourgeois, M., Plumet, M. H.… Brunelle, F. (2004). Superior temporal sulcus anatomical abnormalities in childhood autism: A voxel-based morphometry MRI study. Neuroimage, 23(1), 364–369. Bonnel, A., Mottron, L., Peretz, I., Trudel, M., Gallun, E. & Bonnel, A. M. (2003). Enhanced pitch sensitivity in individuals with autism: A signal detection analysis. Journal of Cognition Neuroscience, 15(2), 226–235. Bruscia, K. E. (1987). Improvisational models of music therapy. Springfield, IL: C. Thomas. Bruscia, K. E. (2014). Defining music therapy (3rd ed.). Gilsum, NH: Barcelona Publishers. Carpente, J. A. (2011). Addressing core features of autism: Integrating NordoffRobbins music therapy within the developmental, individual-difference, relationship-based (DIR®)/FloortimeTM model. In A. Meadows (Ed.), Developments in music therapy practice: Case study perspectives. Gilsum, NH: Barcelona Publishers. Carpente, J. A. (2012). DIR®/Floortime™ Model: Introduction and considerations for improvisational music therapy. In P. Kern & M. Humpal (Eds.), Early childhood music therapy and autism spectrum disorders: Developing potential in young children and their families. Philadelphia: Jessica Kingsley Publishers. Carpente, J. A. (2013). The Individual Music-Centered Assessment Profile for Neurodevelopmental Disorders (IMCAP-ND): A clinical manual. Baldwin, NY: Regina Publishers. Carpente, J. A. (2014). Individual Music-Centered Assessment Profile for Neurodevelopmental Disorders (IMCAP-ND): New developments in musiccentered evaluation. Music Therapy Perspectives, 32(1), 56–60. Casenhiser, D. M., Shanker, S. G., & Stieben, J. (2013). Learning through interaction in children with autism: Preliminary data from asocial-communication-based intervention. Autism, 17(2), 220–241. Dawson, G., Rogers, S., Munson, J., Smith, M., Winter, J., Greenson, J., et al. (2010). Randomized, controlled trial of an intervention for toddlers with autism: The Early Start Denver Model. Pediatrics, 125, 17–23. Dionne, M., & Martini, R. (2011). Floor time play with a child with autism: A singlesubject study. Canadian Journal of Occupational Therapy, 78(3), 196–203. Edgerton, C. L. (1994). The effect of improvisational music therapy on the communicative behaviors of autistic children. Journal of Music Therapy, 31(1), 31–62. Gattino, G. S., Riesgo, R. D. S., Longo, D., Leite, J. C. L., & Faccini, L. S. (2011). Effects of relational music therapy on communication of children with autism: A  randomized controlled study. Nordic Journal of Music Therapy, 20(2), 142–154. Geretsegger, M., Holck, U., Carpente, J., Elefant, C., & Kim, J. (2015). Common characteristics of improvisational music therapy with children with autism spectrum disorder: Developing a treatment guide. Journal of Music Therapy, retrieved from http://oxfordjournals.org/ Green, J., Charman, T., McConachie, H., Aldred, C., Slonims, V., Howlin, P., & Pickles, A. (2010). Parent-mediated communication-focused treatment in children with autism (PACT): A randomized controlled trial. The Lancet, 375(9732), 2152–2160.

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monthly home visits to train parents as well as a minimum of two hours a day of parent-mediated treatment (Solomon, Necheles, Ferch, & Bruckman, 2007; Solomon, Van Egeren, Mahoney, Huber, & Zimmerman, 2014; Dionne & Martini, 2011; Liao et  al., 2014). Whether IMT offers advantages for improving social communication in children with ASD is a question that deserves further research using larger samples and rigorous experimental methods. In addition, the development of a valid and reliable musictherapy-based assessment instrument is needed to objectively compare gains in social communication in an IMT context with those made in a toy play-based context. An observational tool validated against the FEAS as well as an ASD diagnostic instrument such as the Autistic Diagnostic Observational Schedule (ADOS) would also allow for a comparison of the DIRFloortime and DIR-based IMT. The single group design of this study cannot rule out the possible effect of maturation and curriculum of the therapeutic day-school in which the children in this study were enrolled. Future studies are needed that will use sample sizes large enough to randomly assign participants to conditions and identify pretreatment characteristics expected to effect results. In addition, future studies investigating the effectiveness of IMT should include follow-up data to assess the maintenance of improvements in social communication over time and an “interaction only” condition to determine whether it is the one-one interaction or the intervention provided that is responsible for the results.

Music Therapy Program on Social Communication for Children with Autism Spectrum Disorder

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