Developmental delay by David Aldridge

Developmental delay David Aldridge Collected Papers

Pergamon

A PRELIMINARY STUDY OF CREATIVE MUSIC THERAPY IN THE TREATMENT OF CHILDREN WITH DEVELOPMENTAL DELAY DAVID ALDRIDGE, PhD, DR. RER. MED. DAGMAR GUSTORFF and DR. RER. MED. LUTZ NEUGEBAUER*

This paper has two main purposes. The first is an attempt to demonstrate that creative music therapy is a viable therapeutic form for developmentallydelayed children, and in doing so elucidate what it is in the therapy that is valuable. For referring patients, paediatricians and payers (possible funding agencies and third-party medical insurers) alike, we need to present evidence that the work that we are engaged in has a value that makes sense to them. Although we, as therapists and researcher, are convinced of the value of our own work according to our criteria, we too are seeking ways to understand how what we do is effective. The process of looking at clinical practice, sometimes from a different perspective, gives the possibility to gain a valuable insight into what we are doing, to promote that work in other settings and to broaden the basis of our teaching. The second purpose is to present an integrated approach to music therapy research that combines both a quantitative approach, as shown by measuring changes, and a qualitative approach, as argued from the interpretation of empirical data. Although this second purpose may seem rather unorthodox, the reason underlying it is that we hope to show that in music therapy research we can creatively adapt techniques and forms of argumentation to suit our needs and that we do not have to take a polarized stance either for or against qualitative or quantitative methods. Indeed, to maintain an ideological position is to fall into the trap of methodolatry on one hand or scientism on the

other. Research methods are simply tools for structuring our thinking and gathering the evidence that we will use to support our arguments. In some ways we are rehearsing a debate that has already been comprehensively argued in both the fields of nursing (Dzurec & Abraham, 1986, 1993) and social psychology (Shadish & Fuller, 1994). By relating both sets of information it may be possible to generate insights not available from the two types of information separately (Heyink & Tymstra, 1993). The overall aim of our research then is to present our work with children suffering from a variety of developmental challenges and propose that by using a particular form of assessment available to other music therapists we can see quantitatively that a beneficial change occurs. The reason for that change, we will argue, is attributable to specific qualities of creative music therapy. The music therapy approach taken here is based upon that of Nordoff and Robbins (1977) improvised music therapy, which has its origins in working with handicapped children. However, although there is a wealth of case study material in the music therapy literature concerning music therapy with children and a considerable literature suggesting the value of music therapy for child development (Wilson & Roehmann, 1987), there have been few controlled studies of Nordoff and Robbins music therapy with handicapped children. An important feature of childhood development is

'David Aldridge is Professor for Clinical Research Methods at the University of Witten Herdecke, Germany. Dagmar Gustorff and Lutz Neugebauer are CO-Directors of the Institute for Music Therapy at the University of Witten Herdecke

David Aldridge

Developmental delay papers

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the acquisition of speech and the ability to communicate meaningfully with another person. Music therapy encourages children without language to communicate and has developed a significant place in the treatment of mental handicap in children. How such communication is achieved, and how in some instances it leads to speech, are as yet unknown. Indeed, the very ability to develop and achieve speech in normal children is a miracle of daily living that continues to baffle linguists and psychologists. Although this paper makes no attempt to solve the riddle of how speech is brought about, we will attempt to demonstrate how music therapy helps developmentally-challenged children progress toward a richer communicative life. Developmental delay can be the consequence of various difficulties, physical, mental or social (Peterson & Schick, 1993). Children who are developmentally challenged experience the same emotional conflicts and difficulties as normal children; however, they are also more likely to experience rejection when they fail to meet standards of expectation associated with their chronological age. This rejection can lead to behavioral disturbances. The successful social integration of children with developmental delay relies upon a sensitive and adaptable social environment, as does the sequence of development itself. If the environment is both modified to meet the needs of the children and to enhance communication possibilities according to their potential, then we may expect fewer behavioral problems. Children who are developmentally delayed face the same developmental tasks and challenges and have the same needs to be loved, stimulated and educated, as normal children. What they face is a progression that may be slower and perhaps limits their future capabilities. Our therapeutic task is to respond to abilities and potentials so that those limitations themselves are minimized. If both environment and the individual are important for developmental change, the therapist provides, albeit temporarily, an environment in which individual change can occur. Child Development and Challenges to Theory Child development itself is subject to various theories and is a continuing source of active academic debate. All children are now conceived of as very active constructive thinkers and learners, rather than passive copiers of what is given to them (Case, 1993; Lewis, 1993). Children select and transform what is

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meaningful for them from the context within which they find themselves. What. is selected and transformed is in pan in accordance with their cognitive abilities, yet these abilities are not separate from other related developmental processes. Each child may differ in his or her development. Furthermore, children not only take from the environment, they too give out signals that modify their environment. Infants give clues to their mothers about how they expect them to react. Improvised creative music therapy, with its emphasis on activity within a dynamic personal relationship, may play a role in encouraging development particularly when it focuses on communicative abilities. The idea that children change in regular stages that are governed by their biology and that they become progressively better in a linear evolutionary development is being challenged (Florian, 1994; Ross, Friman & Christophersen, 1993; Spieker & Bensley, 1994; Wagner, Torgesen & Rashotte, 1994). Morss (1992) called for an interpretative, as opposed to a causal-explanatory, approach to human experience and proposed that studies of infancy are often studies of scientists studying infancy, and, like Sipiora (1993), found that the infant under study is often absent. Sipiora criticized Piaget for skewing the natural choice of questions answerable only by children to those of an adult consciousness. Pure observation cannot always distinguish children from their beliefs and it is the inner life of the children, what they wish to communicate, that should be the focus of our attention (Florian, 1994; Wagner, Torgesen & Rashotte, 1994). Siege1 (1993) reminded us that this debate is not entirely new and, interestingly for the creative arts therapies, that nonverbal tasks are the best means of representing the thinking of very young children. She also emphasized that Piagetian developmental stages are not supported empirically and what may seem to be an orderly sequence of acquisition may indeed be an artefact of the way in which tasks are structured. The outcome of this debate is that in understanding children we are encouraged to study processes not products, that those processes when related to assessment will always occur in a dialogue between child and therapist. If we return briefly to the secondary purpose of this paper, we can propose that a qualitative method of research will be necessary to look at this process of developmental change as it occurs between therapist and child, and a quantitative method can help us to identify specific changes

Developmental delay papers

CHILDREN WITH DEVELOPMENTAL DELAY The above challenge to Piagetian orthodoxy is based partly on a questioning of the orthodoxy of the spoken word as being primary (Siegel, 1993). Some authors are concentrating on how children perform in the world, which is a "world-of-others," as the principal focus for attention. Play is seen as a mental act including unconscious fantasies and wishes, a physical act that is observable and a necessary awareness that what is being enacted is "play." Play, when defined by its functions, facilitates the libidinization of the body and is an area of importance bridging the realms of the personal and the social (Mash, 1993). For Vygotsky (1978), this intermediary realm, the distance between what children can do on their own and what they can do with the help of an adult, is referred to as the proximal zone. It is such a "zone" that we find in creative music therapy. Musical activity is based upon what the child can do in musical play, but the potential of what the child can do further is based upon what child and therapist are capable of together. Furthermore, with an emphasis on the activity of musical playing within the context of a personal relationship, the libidinization of the body is achieved as a communicative act. In our work we emphasize the role of the therapist as encouraging and providing the context in which musical communication takes place. The therapeutic relationship is a relationship that mirrors the primary relationship of learning to communicate in which development emerges. Vandenberg (199 l ) reminded us that looking, hearing, smelling, sucking and grasping are some of the early reflexes for assimilating objects and the basis from which cognitive development emerges. At birth, children are most responsive to the human voice through hearing. It is this orientation to the social world of others that is of such importance. The special relationship with others is something that is "elaborated from those primitive forms of attunement" (p. 1282). This is a reflection of the position taken by Stem (Neef, 1993) that the infant has a core self that is in a relationship with the core self of the other, and this relationship forms a crucial axis of development. The symbolic world of the child is imbued with the relationship with the caregiver and others of significance. Our proposal is that such a relationship is essentially "musical. " Aldridge (1989) has emphasized the importance of rhythmic interaction for the development of language and socialization in the infant. From birth the infant has the genetic basis of an individually entrained physiology (i.e., a self-synchronicity). The infant has

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its own time, yet the process of socialization and the use of language depend upon entraining those rhythms with those of another. Cycles of rhythmic interaction between infants and mothers reflect an increasing ability by the infant to organize cognitive and affective experience within the rhythmic structure provided by the parent. This organization, however, is not a one-sided phenomenon. Infants produce forms of expression and gesture that are not imitations of maternal behavior. Both baby and mother learn each other's rhythmic structure and modify their own behavior to fit that structure. Arousal, affect and attention are learned within the rhythm of a relationship. The competence of infants is not solely a quality inherent within the individual. Individuals are located in particular environments, those of their significant relationships. Gaussen (1985) criticized maturational models of child assessment in that they do not take into account the variability and individual differences of the developmental processes. Assessment methods rely on how the child responds and moves; they tell little about what the child knows and responds to. Such a criticism echoes that of the authors above who wish to know more of the inner life of the child, a life that is not solely dependent upon intact motor responses. Nevertheless, communication is dependent upon motor coordination, and motor responses, as we shall read below, are important indicators that a child is developing. For the parent, rather than the theoretician and psychologist, the pragmatics of understanding the child are based upon what that child can do. Furthermore, communication is also dependent upon doing. What that "doing" means is important, but achieving that "doing" and coordinating with another person are primary. Hence the value of nonverbal therapies and the establishment of a communicative relationship before the complexities of lexical meaning are necessary. Motor Development: Gesture and Communication

The development of children demands many integrated skills. One important skill is to control motor activity, that is, to be able to draw and write, handle a knife and fork, play with a ball and run. Children who do not master such activities are often labelled as clumsy, whereupon they meet with disapproval from their peers and often family members. On reaching play-school or school age these children find them-

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selves facing ridicule. Such ridicule may then lead to a lack of self-esteem and confidence, which is further exacerbated by social withdrawal (Winemiller & Mitchell, 1994). Once such children find they cannot perform "properly" they give up trying. The consequences of such personal and social handicap as clumsiness or perceptual-motor dysfunction remain into adult life. There are three main processes assumed to be necessary for the performance of motor skills: kinesthesis, muscle control and timing (Laszlo & Sainsbury, 1993). Kinesthesis is the sense that conveys information about the position and movement of the body and limbs. This sixth sense, referred to by Sacks as "proprioception," is a sense we have in our bodies and is that continuous but unconscious sensory flow from the movable parts of our body (muscles, tendon, joints), by which their position and tone and motion is continually monitored and adjusted, but in a way which is hidden from us because it is automatic and unconscious. (Sacks, 1986, p. 42) Proprioception is indispensable for our sense of self in that we experience our bodies as our own. Muscle control refers to the way in which movement is directed and controlled spatially. These movements must also be coordinated and this involves timing. Laszlo (Laszlo & Sainbury, 1993), however, argued that kinesthesis is the overarching factor that unites both direction and timing in the control of posture, in error detection and in memorizing movements. Indeed, the coordinating of action involves the whole body and, von Hofsten (1993) asserted, can only be understood as a purposive dynamic future-oriented interaction between the organism and the external world. Actions originate not from reflexes, but from spontaneously produced, purposeful controlled movements (i.e., actions develop through action). Yet this action must be structured and thisstructure is that of time. Active music therapy would seem to be an ideal medium for encouraging purposeful controlled movement in a time structure that is formed yet flexible. Gestures also help us understand what a child means and at what stage of understanding a child is in (Alibali & Goldin-Meadow , 1993; Goldin-Meadow , Alibali & Church, 1993). Gesture is spontaneous and often idiosyncratic, whereas speech conforms to an established form. Some expressive events may be better encoded in communications as gestures for some

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children at their stage of understanding in that gesture maps the phenomena closely. Indeed gestures in a communication dialogue are preverbal and do not need the extra abstract and lexical dimension of speech. It is such gestural activities that are actively utilized in the repertoire of play songs used in the Nordoff and Robbins approach. Active music therapy then would seem to be a relevant therapy form as it concentrates on, and fosters, the use of purposive coordinated movements that occur in a context of time and relationship, offering a form for communication without words. Developing Children and Music Therapy Twelve patients were assessed, selected and randomly allocated into two groups of six children (see Figure 1). Each child was to receive individual music therapy. This formed a treatment group and an initial non-treatment group to serve as a waiting-list control. The non-treatment group received music therapy after waiting for three months, while the previously treated children had a break from therapy. Our intention was to stay as close to the clinical practice of music therapy as possible. This intention influenced the timing of the treatment stages in that a course of music therapy treatment takes about three months followed by a three-month pause. Similarly, we could only ever take on six new patients in one treatment period. All the subjects of this study would receive music ther-

Figure I . Allocation of children to treatment groups and study design.

Developmental delay papers

CHILDREN WITH DEVELOPMENTAL DELAY apy, and the maximum treatment delay after intake would be for three months. Entrance criteria were that the children should be 4-6.5 years in chronological age with a developmental age of 1S-3.5 years and that the selected children had no previous experience of music therapy. Children were excluded from the study if they had a physical problem that was degenerative, if they were currently receiving psychopharmaceutical treatment or if they were currently attending another form of creative art therapy. Playschool or kindergarten attendance was not interrupted. The use of waiting list controls and alternating treatment periods met our ethical demands for the treatment of children in terms of clinical research in that both procedures mirrored our normal practice. Furthermore, the study was clearly explained to all the participating parents and caregivers of the children, who were assured that refusal to take part in the study would not disqualify their childrenfor treatment. Similarly, all participants were asked to give permission for the use of the data as part of a research project and for possible publication. Referrals were from a local paediatrician who assessed the children before treatment began (at intake). We had previously set the criteria for the clinical assessment of developmental change (see below). A medical student, trained in the assessment of children, saw the children and their caregivers every three months to assess any clinical changes according to the medical criteria (Tests 1 , 2 , 3 , and 4 after intake). She was initially "blind" as to whether the children were in the treatment or non-treatment group. The main assessments were developmental according to psychological and functional criteria (the Griffith's test, see below), and musical according to the Nordoff and Robbins rating scales. Music therapy sessions were recorded on audiotape and later indexed according to music therapy criteria. Our main hypothesis was that there would be greater developmental changes in the music therapy treatment group, in the first session of the treatment period, compared with the no-treatment group. Our secondary hypothesis was that by the end of the two treatment sessions both groups would have changed equally. The Griffiths Scale and the Nordoff and Robbins Rating Scale F ,

Ruth Griffiths, as a psychologist, spent a great deal of time observing babies and small children. From

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these observations she developed a series of scales that could be used to gain insight into areas of leaming in young children. The function of these scales was not to say categorically what the reason may be for a child's slowness to learn, rather to diagnose those areas of a child's capability and to provide a profile of capabilities from which the child may respond to treatment. This emphasis on the positive potential of the scales was attractive initially for our work as it reflected, and had features complementary with, the approach of Nordoff and Robbins music therapy (see Table 1) in focusing on the inherent potential~of the child rather than concentrating on the known pathologies. Reading her book (Griffiths, 1954), which was written 4 0 years ago, is a fascinating insight into the rigor of a scientist who clearly has a love for children, and how that rigor can be applied in the assessment of behavior. Sometimes creative arts therapists criticize science for seemingly leaving out the individual and thereby losing any relevance for treatment. With Griffiths, however, there is a constant reminder that these scales were crafted from a devotion to the lot of those children who were in need so that we, as carers of those children, could better our own observations to meet their needs. There are six subscales that have equal degrees of difficulty. Each subscale tests a different avenue of learning with the intention of discovering true potentialities in the handicapped child (Griffiths, 19701 1984, pp. 171-172). Once such potentials are recognized, help can be brought as early as possible when needed. Indeed, the tests are intended to educate the carers and the educators about the needs of the child. Although the central plank of the work is to provide a differential diagnosis of mental status (see Figure 2), that diagnosis is clearly linked with potentials for treatment. Attempts were made by Nordoff and Robbins as early as 1964 to develop rating scales for individual music therapy (Weaver & Clum, 1993). However, these evaluative scales proved to be difficult to compose and adequately meet the complexity of musical responses. Two years later, scales for evaluating autistic children in the day center were adapted for music therapy use and evolved as Scale 1. ChildTherapists Relationship in Musical Activity and Scale 11. Musical Communicativeness. Scale I evaluates the relationship between child and therapist as it develops from what may be total obliviousness, through limited response to a stability and confidence in the mutuality of playing music together. It must be stressed that it is in the musical

Developmental delay papers

ALDRIDGE, GUSTORFF AND NEUGEBAUER Table l A comparison of contents of the Griffiths Scales and the Nordoff and Robbins Rating Scales Griffiths' Subscales

Nordoff and Robbins Rating Scales

A: Locomotor Development pushes with feet, lifts head, kicks vigorously, begins to crawl, climbs, can walk on tiptoe, catches a ball. hops and skips. B: Personal-Social Scale responds to being held, smiles, resists adult taking a toy away, anticipatory movements, plays "pat-a-cake," plays with other children, has a special friend.

C: Hearing and Speech most intellectual of the scales, indicative of hearing problems; startled by sounds, vocalization other than crying, searches for sound visually, listens to music*, listens to conversations. rings bell, likes rhymes and jingles, enjoys s t o r y - b k , develops words and speech, names objects, defines by use, comprehends sentences.

D: Hand and Eye Co-ordination (observe the hands of the child) follows visually moving objects, uses hands for exploration, points with fingers, likes holding toys, plays with bricks, scribbles freely, builds a tower, folds paper, copies shapes, draws recognizable figures and objects. E: Performance Tests measures skill in manipulation, speed of working and precision with an awareness of the child's eagerness and persistence; searches for a toy under a cup, manipulates cubes and boxes, opens screw-topped jars, makes patterns.*** F: Practical Reasoning recognition of differences in size and categorizing as "bigger," this scale measures the ability to reason in "embryo." Any child before he or she can express ideas verbally can look, listen, think and learn the foundations of knowledge and the way in which the mind works in apprehension of the environment.

Scale 11: Musical Communicativeness musical communication is realized through 3 modes of activity; instrumental, vocal and bodily movement. Scale I: Child Therapists Relationship in Musical Activity Item 1-3. Child appears oblivious to the therapists, fleeting signs of awareness, awareness of the situation leads to rejection. Item 6: Child comes to the session with obvious pleasure and establishes a consistently recurring positive response to the therapy situation. Scales I and 11: Musical Communicativenesst Ranges from uncommunicative, non-responsive beating which is disordered, impulsive or haphazard or compulsive beating of inflexible tempo or pattern**; leading to child beats with some musical organization, and recognizes salient components of the music, rhythm or melody or harmony. Child finds musical activity meaningful and satisfying. Child communicates with others and communicates his understanding of musical objectives. The child comes to the session with obvious satisfaction and pleasure, and enjoys being active in the music. Scale 11: Musical Communicativeness Musical communication is realized through 3 modes of activity; instmmental, vocal and bodily movement.

Scale 11: Musical Communicativeness His beating shows an awakening recognition and some anticipation of salient components of the music; rhythmic pattern, melodic rhythm, change of dynamics, phrase structure.

Scales I and 11: Musical Communicativeness~ He adopts and sustains the mode(s) of musical response available to him, shows purposeful involvement with the musical activity. The child's interest centers strongly upon particular musical activities which he finds meaningful and satisfying. He pursues these activities with purposefulness.

*There is an overall neglect of musical ability. **Moves from pathology to ability, yet lacks the neutrality of the Griffiths' scales which assess all stages as milestoneslpotentials ***There is, however, no mention of musical patterns. tAfter Item 6 the Nordoff and Robbins scales converge.

activity that the relationship is developed, and the vocabulary used to evaluate the performance of the child is mainly musical. Whereas Nordoff and Robbins stress that the evaluation is of the relationship itself, the language itself places emphasis on evaluat-

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ing the child (i.e., we would not expect that the therapist is totally oblivious of the child). Scale I1 attempts to evaluate both the state of musical communication in the session and, "provides an index to the personality development of a child

Developmental delay papers

CHILDREN WITH DEVELOPMENTAL DELAY

ievereiy retarded childv Severe hearing loss

M n ' s syndrome

A = locomolor development = personal-social relationship C = hearing and speech

Slow child

Average ability chi!d

D = hand and eye cocxdination E = performance tests F = practical reasoning

Figure 2. Examples of Griffith's profiles for varying groups of children.

through assessing the character and consistency of the musical communicativeness he manifests'' (Nordoff & Robbins, 1977, p. 193). The scale includes three vocal and body modes of activity-instmmental, movement, which provide an aggregate rating on l 0 levels of communication ranging from "no communicative response" through active participation to an intelligent musical commitment. Both scales are rather rough and ready and have never really been validated in clinical practice. Indeed, after level 6, both scales converge and could be conceivably collapsed into one scale. However, the scales do provide an available clinical guide to practice and evaluation.

Results A clinical trial, even with limited numbers, is an exercise in good will, good planning and good fortune. Although planning to treat 12 children, we "lost" 4 children in the study, lost in the sense that 4 children could not be included in the end results for a variety of reasons. One boy during the first sessions of music therapy was discovered to be profoundly deaf rather than being mentally handicapped and developmentally delayed, which meant that he had to be finding seems to point to fitted with hearing aids. T h i ~ music therapy assessment as a valuable diagnostic method for developmenta!ly delayed children simply because it brings attention to active hearing in an almost naturalized setting. One other child had been abused by a member of her family and it was not

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possible to continue the full program of treatment and assessment. Two children came from families of ethnic minorities and it was both difficult to get them to music therapy sessions and to maintain the continuity of follow-up. By the end of the study there were two unbalanced groups, similar in chronological age, but different in mental age despite the random allocation. We see in Figure 3, which illustrates the Griffiths subscale scores for the children in both groups, in comparison with Figure 2, that the children range from what is considered to be severely delayed to the "slow" child. Five, out of the eight children, failed to score on the practical reasoning scale (Subscale F). Subscale F is heavily dependent upon speech and represents the general language deficits in these children. However, we see by the final assessment sessions, Figure 4, that all the children have developed some capacity for practical reasoning. Indeed all the children improve, as would be expected. Children develop with or without music therapy. But the rate at which they develop and how this is possibly influenced by music therapy is the subject of this study. We see in Figure 5 that the changes in the Griffiths scores do indeed differ according to which group the children are in. During the same period of time from intake, the first treatment group (A) changes more than the children who are on the waiting list (measured at Test l). When the waiting list group is treated and then tested (at Test 21, and the children who were treated take a rest, the newly treated children start to

Developmental delay papers

Group A

6 L m

0 Kathlean

Sophie

David

Zena

Tomrny

Group B lrn

A B C D E F

Salty

A = locomotor development B = personal-social relationship C = hearing and s p c h

A B C D E F

Suzie

D = hand and eye coardination E = performance tests F = practical reasoning

NOW lhal four of lhe children in Gmup A. and one chiid in Gmup B, do not score on the practical reasonong scale

Figure 3 . Griffiths Quotient intake profiles.

catch up in their development. Such differences can be demonstrated at a level of statistical significance (at Test l df = l , F = 7.072, P = 0,045) and support our initial hypotheses that music therapy will bring about an initial change. Although it appears clear that music therapy does make a difference to the development of these children, it does not immediately tell us why music therapy helps or what indeed is changing specifically. It makes sense here to look at

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the individual subscale changes of the Griffiths scale. When we look at the subscale changes (see Table 21, there are significant differences between the groups. First, there is a continuing significant difference on the hearing and speech subscale and the statistic points to a significantly changing ability to list& and communicate. The personal-social interaction subscale (B) also proves to be the significant differentiator at Tests l and Tests 3. After Test 3, the

Developmental delay papers

CHILDREN WITH DEVELOPMENTAL DELAY Group A

'T----

David

Kathleen

Sophie

Zena

Tornrny

D = hand and eye coardination E = pcrfomance tests F = practical reasoning

A = locomotor development B = personal-social relationsh~p C = hearing and speech

Figure 4 . Griffiths Quotient final assessment profiles.

children in Group A have received two treatment periods of music therapy. It must be noted here that Tests 2, 3 and 4 are all made after children have been treated at least once with music therapy. Music therapy seems to have an effect on personal relationship, emphasizing the positive benefits of active listening and performing, and this in turn sets the context for developmental change. Howevtx, the groups also differ initially on hand-eye coordination (subscale D), and this is not surprising given that the playing of musical instruments demands such manipulative and perceptive skill.

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Although focused listening in a personal-social relationship sets the scene for music therapy and provides the context in which change can occur, a further investigation of the data reveals an important variable related to hand-eye coordination that is correlated with significant clinical changes when the children are tested. Subscale D, which measures hand and eye coordination and is taken to be demonstrative of nonverbal communication (Muenzenmaier, Meyer & Ferber, 19931, is significantly correlated with change throughout the series of test times. At Test l (Pearson r 0.915, Bonfen-oni p 0.001) and Test 2 (Pearson r

Developmental delay papers

ALDRIDGE, GUSTORFF AND NEUGEBAUER

Q no music therapy

A with music therapy

no music therapy

with music therapy

no music therapy

Group A

Group B

n e s e changes are lhe mean changes from when the children were measured at inlake; lhaf is, lhe inlake is the baseline, zero. The test scores, l ,2,3 and 4 are the mean changes in the Griffilhs quotienls for each group at three months, six months, nine monlhs and one year fouowing the inital measurement at intake. Note at test 4 in Group B lhere appears to he a regression in the changes.

Figure 5. Group differences in Griffiths test score means changes from intake.

0.903, Bonferroni p 0.002), hand-eye coordination is correlated with the hearing and speech scale change, scale C. A change occurs on both scales of nonverbal communication and potential verbal communication. Furthermore, at Test 3, hand-eye coordination is correlated with changes in the performance tests, scale E (Pearson r 0.902, Bonferroni p 0.033), and later at Test 4, hand-eye coordination is correlated with changes in practical reasoning (Pearson r 0.933, Bonferroni p 0.010). The active element of musical playing, which demands the skills of hand and eye coor-

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dination and listening, appears to play a significant role in developmental changes. Case Vignettes Although it may be unorthodox to include clinical case studies alongside statistical reasoning, we believe that a time has come when we can have the freedom to add some variety to the way in which our work is presented. There are no statutes that say case vignettes are banned from such work and, as most of us know from reading the work of other clinicians,

Developmental delay papers

CHILDREN WITH DEVELOPMENTAL DELAY Table 2 Effect of treatment group on subscale scores Subscale

Test time

A: locomotor development

Test l error Test 2 error Test 3 error Test 4 error Test 1 error Test 2 error Test 3 error Test 4 error Test l error Test 2 error Test 3 error Test 4 error Test l error Test 2 error Test 3 error Test 4 error Test 1 error Test 2 error Test 3 error Test 4 error Test 1 error Test 2 error Test 3 error l Test 4 error

B: personal-social

C: hearing and speech

D: hand-eye co-ordination

E: performance tests

F: practical reasoning

Univariate F tests: *significant p < 0.05; **significant p < 0.01

David Aldridge

Developmental delay papers

ALDRIDGE, GUSTORFF AND NEUGEBAUER what we often really need to know is how the statistical relevance comes to have any clinical relevance. In these two examples we see that although clear developmental changes accessible to assessment take place, it is the qualitative subtleties of personal meaning that play an important role for the parents. In the first study, a clear quantitative change takes place in the Griffiths test score (see Figure 7). In the second example, although no clear objective change occurs in the test scores over time (see Figure 6), the parents see important qualitative changes that they perceive as improvements.

Dora Dora, the child of a mentally handicapped mother and a socially disturbed father, was adopted at birth. While experiencing feeding difficulties she put on weight. She was developmentally delayed, hyperactive and often uncontrollable. As a baby she received physiotherapy because she started to walk late and, at the time therapy began, was still in diapers. Her major problem was presented as episodes of agitation and restlessness after which she appeared to have lost much of what she had previously learned. Following such episodes she said that she would fall or her head would fall off. An electroencephalogram showed no obvious signs of pathology. Socially she was distant from other children and adults, was extremely anxious in the presence of others and protected her eyes with her arms clamped to the sides of her head. She would not listen to others or make eye contact. Sometimes her voice had a strange "fairy-tale" character. She had been seen by a child psychiatrist. At the beginning of the music therapy Dora cried a lot and had t o be held in the arms of the CO-therapist throughout the session. When he tried to put her down she cried even louder. Eventually she responded to the musical structure offered to her and, although making no eye contact with the therapist at the piano, rang a small bell with her finger. Gaining in confidence, while remaining in the arms of the cotherapist, she played the cymbal continuously. When asked if she had finished playing, she replied clearly that she had. Eventually, in the fourth session, she had confidence to play a drum alone. Now there was no crying and she looked confidently at the therapist. The therapist had composed a special "Good-bye song" for her and she sang, too! By the tenth session, her musical playing was formed and she played a crescendo alone.

David Aldridge

At first Dora told her adoptive mother that she would not come to music therapy, but, after the first few sessions, appeared to come gladly. At home she displayed both sympathy for others and sadness. That she herself could be emotional was an important experience for her mother. Similarly, Dora made it clear she was happy to see her mother and said that she loved her. Although previously distant, she now cuddled others and was happy to be cuddled. After two music therapy sessions Dora began to sleep well, and sleep alone, which was a great benefit for the parents. When she had an episode of agitation she said that she no longer needed to be held and could manage alone. Instead of using single words, she combined words together as phrases and could say "I," "we" and "you" in the proper context. After the second treatment block, she became dry during the day. The table in her bedroom, once used for changing her diapers, became a desk. Although not being particularly comfortable at the kindergarten, she started to make friends. Sophie Sophie was a much wanted child, as her mother had previously miscarried twice. Although being able to sit alone at four months, she failed to crawl and failed to pull herself up to stand. There appeared to be no organic cause for such delay. The physiotherapist found that Sophie had difficulties with both her fine and coarse motor control. Although able to hear normally, she failed to speak. Sophie also played alone and was not interested in distractions. After a virus infection and a fever of up to 42 degrees centigrade when she was unconscious for a short time, she became very anxious. An electroencephalogram showed no obvious signs of irregularity. In the first session Sophie clung to her mother and was carried into the therapy room by the CO-therapist, on whose arm she remained. Her hands shook, she whimpered and was very anxious. She played a small bell and a chime bar so quietly that they could hardly be heard. In the second session she was also very withdrawn and came crying into the room. However, with the support of the CO-therapistshe played single tones on the piano, sat on the CO-therapist's lap and played separately both drum and cymbal. By the fourth session she was able to come into the therapy room alone and, after a while, came to the piano where she played single unrelated tones, which

Developmental delay papers

CHILDREN WITH DEVELOPMENTAL DELAY at times accidentally met the music played for her by the therapist. Sophie was very insecure in the musical pauses and immediately retreated from rhythmical impulses. However, in the fifth session she played more often in relationship to the music, using both hands to beat the drum in parallel and alternately. She was surer in the therapeutic relationship and made considerably more effort to play, even when it was manually difficult for her. After this treatment period Sophie's mother described her as being much freer in daily life. For example, she investigated alone the family's newly acquired caravan. When travelling on the local bus, she greeted the child next to whom she sat. When the door bell rang, she opened the door. When she wanted to play with her mother she would find the toys herself, a reverse of the previous situation. She showed more initiative. Furthermore, although speaking in a general babble, she could remember words and situations. If misunderstood, she would become annoyed and show it. In the next treatment period her playing on Intake

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drum and cymbal at first remained impulsive. But, by the seventh session she came happy and expectant directly to the piano where she played with more security. A significant change came about in the eighth session where she was constantly active and the musical aspects of her playing were more recognizable. She could accompany, and play, changing tempi, decide between loud and soft playing, repeat musical motifs and brought some continuity to her playing that was no longer spoiled by small distractions. Her accidental changes were supported in the music so that they became parts of the musical whole, and she worked hard to maintain the musical relationship. In the following ninth session Sophie's playing sounded ambivalent and not so related as in the previous week. She seemed withdrawn and unsure in what she did. However, by the next session she was restored to her previous level of progress and was able to express herself in diverse musical activities. With help, she was able to play the drum with parallel and alternative arm movements and by the final session Test4 Kathleen Ă&#x201A;

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Sophie

Zena

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No With No With MT MT MT MT These changes are the individual changes in the overall Griffiths test score from when the children were measured at intake. The intake score for each child is now the baseline, zero for indicating further comparative changes from the original scores. The test scores, 1.2.3 and 4 are the changes in the Griffiths quotients for each child at three months, six months, nine months @ o n e year following the inital measurement at intake. With MT = the children had music therapy treatment before this test and after the last test. No MT = the children had no music therapy prior to this test and after the previous test.

Figure 6. Changes in the Griffiths test scores for treatment group A from intake to final assessment

David Aldridge

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had many developed musical improvisational possibilities at her disposal. Sophie's mother described her daughter as being much more capable of playing with her brother, and both able to dress herself and put on her shoes. Although she was defiant when asked to repeat a word, for instance, she babbled more and often repeated the first syllable of a word that she had heard. Sophie was more independent. On visiting a friend of her mother's, Sophie had gone to the refrigerator to fetch a drink when no one had understood that she was thirsty. She had become much more aware, and appeared to be surprised by her own capabilities. The consequences were that she became braver and more energetic in taking new things on, would play with others and sit next to her brother or her parents. On going to bed, she took her teddy bear with her along with other cuddly toys. For her mother it was a personal breakthrough when Sophie allowed her hair to be cut and styled and agreed to wear a slide in her hair. Although the individual developmental profiles of Intake

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both the above children can be seen in Figures 6 and 7, it is important to emphasize here the role of parental observation. When therapeutic change occurs, the primary arena for expression of that change is not solely in the therapy room. What parents are expecting is that children will be different at home. These changes are often subtle and too varied for a standardized questionnaire. Therefore, the personal interview with the parents is of equal importance for understanding changes in children. How we weave subjective and objective results together is the creative nature of our inquiry, and we can do this once we have established the criteria, fpr the way in which our data are collected. Discussion Children will develop. Some develop slower than others, and for an even smaller minority that development is delayed through a variety of causes. We argue, like others before us, that music therapy can facilitate development and enhance its rate in those

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No With No With MT MT MT MT These changes are the individual changes in the overall Griffiths test score from when the children were measured at intake. The intake score for each child is now the baseline, zero for indicating further comparative changes from the original scores. The test scores, 1.2.3 and 4 are the changes in the Griffiths quotients for each child at three months. six months, nine months and one year following the inital measurement at intake. With MT = the children had music therapy treatment before this test and after the last test. No MT = the children had no music therapy prior to this test and after the previous test. Figure 7. Changes in the Griffiths test scores for treatment group B from intake to final assessment.

David Aldridge

Developmental delay papers

CHILDREN WITH DEVELOPMENTAL DELAY children whose development is in some way impaired. When we speak of developmental change we are in the main speaking about the ability to communicate either nonverbally or verbally. Indeed, the parents of the children treated in this study had an expectation that what they and their children did together would make some sense to them, that their children could communicate needs, desires and emotions, and that they, too, the parents and caregivers, could communicate their feelings to the children. That Sophie could show both sadness and happiness were considered to be important for her mother. That she could also cuddle was a significant milestone in the emotional relationship of child and mother. In this study we have gone some way to fulfilling our first purpose in demonstrating that developmental change can be perceived according to standardized testing in the context of clinical research. The Griffiths test is acceptable to us and to referrers in that it is based upon a broad base of clinical observations and makes sense when applied to the lives of the children being assessed. Like music therapy itself, the emphasis is on eliciting the potential of the children. We can say that children, when they partake in improvised creative music therapy, achieve significant developmental milestones in comparison with those children who are not treated. Later, when a comparison group of children is treated, they too rapidly achieve developmental goals. It must be mentioned here that at no stage in the study was music therapy targeted to specific developmental achievements or aimed at particular behavioral activities. What we were interested in was what developmental changes took place, rather than trying to manipulate children so that targeted changes occurred. The reason for not specifying behavioral goals is that creative music therapy is not based on such a behavioral plan of identifying specific clinical aims that would detract from the essential aim of making music together. As all the children were so completely different, as is the nature of developmental delay, the same target variable could not apply to all the children. Furthermore, as this was a preliminary study, we could not know what we were to focus on before we had made the study. However, there is a paradox inherent in creative music therapy in that we emphasize the musical activity as paramount in therapy, yet it is the behavioral changes that we champion as therapeutic success. Our initial purpose was also to discover what it is

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in the activity of making music that is important. Clearly, the activity of listening, in a structured musical improvisational context, without the lexical demands of language, is a platform for communicational improvement. The building blocks of language, rhythm, articulation, sequencing (Alien, Barone & Kuhn, 1993), pitch, timbre (Annett, 1993) and turntaking (Blampied & France, 1993) are musical in nature. Focused listening to another person, we would argue, is also a prerequisite of effective mutual communication and dialogue. Furthermore, musical dialogue in the music therapy relationship seems to bring about an improvement in the ability to form and maintain personal social relationships in other contexts. Hand and eye coordination, which is dependent on a wider body awareness, appears to be the third vital component in developmental change. That hand movement plays such an important role is also supported by the literature emphasizing the role of nonverbal communication and gesture in the subtle aspects of emotional expression (Barrett, 1993), the acquisition of language (Millard et al., 1993) and in cognitive development (Alibali & Goldin-Meadow, 1993; Goldin-Meadow, Alibali & Church, 1993). The active playing of a drum demands that the child listen to the therapist who in turn is listening to and playing for him or her. This act entails the physical coordination of a musical intention within the context of a relationship. We would argue that this unity of the cognitive, gestural, emotional and relational is the strength of active music therapy for developmentally challenged children. In addition, the importance of the visual system in generating speech is necessary to bear in mind. Shuren , Geldmacher and Heilman ( 1993) proposed that there is a visual semantic system storing codes for concrete words and picture names and a verbal system for conceptual knowledge of a more abstract type. Both systems work together, yet the second is more dependent upon internal stimuli or self-generated dialogues. The activation of hand and eye together in this study, visual-semantic and gestural, may have had an influence on the speech-related practicalreasoning sub-scale F, which all children exhibited by the end of the study. The proximal zone, where child and therapist play together, awakening a potential and extending the possibilities of the child, appears to be an important concept for music therapy and is critical in achieving new creative possibilities in the therapeutic relation-

Developmental delay papers

ALDRIDGE, GUSTORFF AND NEUGEBAUER ship. Although the musical therapeutic relationship is the domain of this zone, the means of achieving this relationship is in the encouragement of active listening. Yet, such listening is also related to performing. The intention to communicate is brought into a structure so that communication can be achieved as performance. In this case the structure is musical, has the advantage of flexibility and is built upon the capabilities of the individual child. His or her own capabilities, no matter how limited, are brought into the mutual realm of musical relationship with the therapist and therefore are open to variety and, thereby, development. The caregivers of the children in this study said that a benefit of music therapy was that they could enjoy their children and what the children did began to make more sense. If through this "making sense" a child achieves independence by the expression of needs, desires and wishes, and the ability to act accordingly, then we have gone some small way in our study to demonstrate a benefit of creative music therapy. Listening and performing in the musical relationship, that is, action and purposeful movement in a relational context, appear to be the building blocks of developmental change and of relevance for cognitive change. That these factors are pre-verbal, and not language dependent, would argue for the importance of creative arts therapies in the treatment of developmentally delayed infants. Our secondary purpose was to find a suitable research approach integrating quantitative and qualitative methods. We have used empirical data that can be analyzed statistically, but, as in all statistical methods, the analysis must be applied and interpreted. By using multivariate techniques, we have chosen to investigate the relationship between variables as shown by our data. The relationship between variables, although suggested as significant by the analysis, must be interpreted as clinically significant by the researcher and further validated by the clinicians. As Dzurec and Abraham (1986) remarked: In other words, for the researcher using multivariate analysis, as for the researcher using phenomenology, meaning is not inherent in data as they are analysed, but is implied by the researchers view of reality and the construction of reality to be conveyed in a given situation. Hence attribution of meaning to objective data collected using either multivariate analysis or phenomenology is a subjective task. (p. 61)

David Aldridge

The above work needs to be validated with a larger population of children and is best considered as a pointer in a general direction rather than as a conclusive statement. We found the clinical controlled trial to be a rather clumsy approach for our purposes. Even a small number of children are radically different in their capabilities. The treatment approach could not, in practice, be blinded from the assessor in the first phase as parents would ask her when their child would eventually get to music therapy. What did emerge was the importance of a reliable assessment instrument such as the Griffiths profile that could be systematically applied over longer treatment, and no treatment, periods. Longitudinal single case designs would appear to be appropriate for further studies. Ideally, we would have also used a child musical development scale if one had been available. The Nordoff and Robbins scales are not reliable instruments for comparative research, but they d o provide a guide to individual assessment. For future researchers, it is important to repeat that the interview with the parents or caregivers is of equal value in that subtle individual and relational changes are reported that would otherwise escape the attention of a questionnaire or formal assessment instrument. A qualitative study would emphasize in the future the relationship between the musical processes of change and the various changes as they occur in the life of the child at home. We would want to ascertain that patterns of communication occurring in the music therapy sessions could indeed be transferred to other situations with siblings or caregivers. Although we can make generalizations from the above work, it is important for music therapists as researchers to stay in contact with the single child. This does not invalidate group research methods. As we see here, the comparison of groups has alerted us to significant changes. Hopefully, future research will reflect the creative tensions between generalizibility and specificity-what we can say about music therapy with children in general and what happens to the individual child in the process of therapy. Quantitatively, we have assessed changes through the collection of data according to a particular instrument, the Griffiths test. Qualitatively, we have interpreted those data to develop inferences from what is observed. References Aldridge, D. (1989). Music, communication and medicine: Discussion paper. Journal of the Royal Society of Medicine. 82(12), 743-6.

Developmental delay papers

CHILDREN WITH DEVELOPMENTAL DELAY Alibali, M., & Goldin-Meadow, S. (1993). Gesture-speech mismatch and mechanisms of learning: What the hands reveal about a child's state of mind. Cognitive Psvchologv. 25. 468523. Alien, K. D., Barone, V. J., & Kuhn, B. R. (1993). A behavioral prescription for promoting applied behavior analysis within pediatrics. Journal of Applied Behavior Analysis, 26(4), 493502. Annett, M. (1993). Biological asymmetry and handedness. International Journal of Behavioral Development. 16(4), 629-630. Barren, K. ( 1993). The development of non-verbal communication of emotion: A functionalist perspective. Journal of Non-Verbal Behavior. 17(3), 145- 169. Blampied, N. M., & France, K. G. (1993). A behavioral model of infant sleep disturbance. Journal of Applied Behavior Analysis, 26(4), 4 7 7 4 9 2 . Case, R. (1993). Theories of learning and theories of development. Educational Psychologist. 28(3), 219^233. Dzurec, L., & Abraham, I. (1986). Analogy between phenomenology and multivariate statistical analysis. In P. Chinn (Ed.), Nursing research methodology: Issues and implementation.

Gaithersburg, MD: Aspen. Dzurec, L., & Abraham, I. (1993). The nature of inquiry: Linking quantitative and qualitative research. Advances in Nursing Science, 1 6 ( \ ) , 73-79. Florian, J. E. (1994). Stripes do not a zebra make, or do they? Conceptual and perceptual information in inductive inference. Developmental Psycholog\. 30( l), 88- 101. Gaussen, T. (1985). Beyond the milestone model-A systems framework of infant assessment procedures. Child Care. Health and Development. I I . 131- 150. Goldin-Meadow, S., Alibali, M., & Church, R. (1993). Transitions in concept acquisition: Using the hand to read the mind. Psychological Review, 100(2), 279-297. Griffiths, R. (1954). The abilities of babies. London: University of London Press. Griffiths, R. (1 984). The abilities of young children. High Wycombe: ARICD. (original work published 1970) Heyink, J., & Tymstra, T. (1993). The function of qualitative research. Social Indicators Research. 29. 29 1-305. Laszlo, J. l., & Sainsbury, K. M.(1993). Perceptual-motor development and prevention of clumsiness. Psychological ResearchĂ&#x192;â&#x20AC;&#x2DC;Psychologisch Forschung, 55(2), 167- 174. Lewis, J. M. (1993). Childhood play in normality, pathology, and therapy. American Journal of Orthopsvchiatp, 63(1), 6- 15. Mash, E. J. (1993). Rochester symposium on developmental psychopathology (vol 3)-Models and integrations. Canadian Journal of Behavioural Science-Revue Canadienne Des Sciences du Comportement. 25(4), 628-632. Millard, T., Wacker, D. P., Cooper, L. J., Harding, J . , Drew, J . ,

Plagmann, L. A., Asmus, J . , Mccomas, J., & Jensenkovalan, P. (1993). A brief component analysis of potential treatment packages in an outpatient clinic setting with young children. Journal of Applied Behavior Analvsis. 26(4), 475-476.

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I NdevelopmenCI~O~ Morss, J . (1992). Making W ~ V ~ S - D ~ C O ~ Sand tal psychology. Theoretical Psychology, 2(4), 445465. Muenzenmaier, K., Meyer, I., & Ferber, J. (1993). Childhood abuse and neglect-Reply. Hospital and Community Psychiatry. 44(12), ll93-ll94. Neef, N. A. (1993). Introduction. Journal of Applied Behavior Analysis, 26(4), 4 19. Nordoff, P., & Robbins, C. (1977). Creative music therapy. New York: John Day. Peterson, L.. & Schick, B. (1993). Empirically derived injury prevention rules. Journal of Applied Behavior Analysis, 26(4), 45 1-460. Ross, L. V., Friman, P. C., & Christophersen, E. R. (1993). An appointment-keeping improvement package for outpatient pediatrics-Systematic replication and component analysis. Journal of Applied Behavior Analysis, 26(4), 4 6 1 4 6 7 . Sacks, 0. (1986). The man who mistook his wife for a hat. London: Pan. Shadish, W., & Fuller, S. (1994). The social psychology of science. London: Guilford Press. Shuren, J., Geldmacher, D., & Heilman, K. (1993). Nonoptic aphasia: Aphasia with preserved confrontation naming in Alzheimer's disease. Neurology. 43. 1900- 1907. Siegel, L. S. (1993). Amazing new discovery-Piaget was wrong. Canadian Psvcholo~v-Psychologie Canadienne, 34(3), 239245. Sipiora, M. (1993). Repression in the child's conception of the worl&A phenomenological reading of Piaget. Philosophical Psychology, 6(2), 167- 180. Spieker, S. J., & Bensley, L. (1994). Roles of living arrangements and grandmother social support in adolescent mothering and infant attachment. Developmental Psychology. 30(\), 102-1 11. Vandenberg, B. (1991). Is epistemology enough? An existential consideration of development. American Psychologist, 46(12), 1278-1286. von Hofsten, C. (1993). Prospective control: A basic aspect of action development. Human Development. 36, 253-270. Vygotsky, L. (1978). Mind in society. Cambridge, MA: Harvard University Press. Wagner, R. K., Torgesen, J. K., & Rashotte, C. A. (1994). Development of reading-related phonological processing abilities-New evidence of bidirectional causality from a latent variable longitudinal study. Developmental Psychology, 30( 1), 73-87. Weaver, T . L., & Clum, G. A. (1993). Early family environments and traumatic experiences associated with borderline personality disorder. Journal of Consulting and Clinical Psychology, 6/(6), 1068-1075. Wilson, F., & Roehmann, F. (1987). Music and child developmem. St. Louis, MO: MMB Music. Winemiller, D. R., & Mitchell, M. E. (1994). Development of a coding system for marital problem solving efficacy. Behaviour Research and Therapy. 32( l). 159-164.

Developmental delay papers

J Autism Dev Disord (2007) 37:1264–1271 DOI 10.1007/s10803-006-0272-1

ORIGINAL PAPER

Use of Songs to Promote Independence in Morning Greeting Routines For Young Children With Autism Petra Kern Æ Mark Wolery Æ David Aldridge

Published online: 22 November 2006 Springer Science+Business Media, LLC 2006

Abstract This study evaluated the effects of individually composed songs on the independent behaviors of two young children with autism during the morning greeting/entry routine into their inclusive classrooms. A music therapist composed a song for each child related to the steps of the morning greeting routine and taught the children’s teachers to sing the songs during the routine. The effects were evaluated using a single subject withdrawal design. The results indicate that the songs, with modifications for one child, assisted the children in entering the classroom, greeting the teacher and/or peers and engaging in play. For one child, the number of peers who greeted him was also measured, and increased when the song was used. Keywords Music Therapy Æ Child Care Program Æ Inclusion Æ Autism Æ Transitioning Æ Collaborative Consultation

P. Kern Frank Porter Graham Child Development Institute, University of North Carolina at Chapel Hill, Chapel Hill, USA M. Wolery Department of Special Education, Vanderbilt University, Nashville, USA D. Aldridge Chair of Qualitative Research in Medicine, University of Witten-Herdecke, Witten, Germany P. Kern (&) School of Music, University of Windsor, 401 Sunset Avenue, Windsor, ON, N9B 3P4, Canada e-mail: PetraKern@prodigy.net

Introduction Providing early intervention services to young children with autism spectrum disorders is supported by substantial research and program evaluation data (Dawson & Osterling, 1997; National Research Council, 2001). Some of this research argues for providing services in inclusive classes in community-based programs (Strain, McGee, & Kohler, 2001). However, for children with autism to benefit from such placements, attention must be given to their individualized learning needs (Strain et al., 2001). Children in early childhood classes experience multiple transitions each day between activities and routines as well as to and from the classroom. Examples are initial arrival at the classroom, engaging in play, moving from one area of the classroom to another, going outdoors and coming back from outdoors, moving to a snack area, and going to a cot for naptime (Alger, 1984; Baker, 1992). Young children often spend large amounts of time in these classroom transitions (Carta, Greenwood, & Robinson, 1987). For many young children with and without autism, the initial transition into a classroom each day can result in crying, clinging to the caregiver, and active avoidance of the class. Their parents and other caregivers may be uncertain about how to respond to these behaviors (Alger, 1984). These behaviors also may result in similar reactions from classmates and avoidance of the entering child (Osborn & Osborn, 1981). Transitions, including the initial daily transition into the class, may be difficult for young children with autism (Dawson & Osterling, 1997; Mesibov, Adams, & Klinger, 1997). In addition, they may lack an understanding of symbolic gestures such as waving

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hello or good-bye or at least may engage in these greeting behaviors less than age mates (Hobson & Lee, 1998). Recommended strategies for promoting successful transitions of children with autism include using (1) structure and predictable routines (Marcus, Schopler, & Lord, 2001; Trillingsgaard, 1999), (2) visual cues (Bryan & Gast, 2000; Schmit, Alper, Raschke, & Ryndak, 2000), and (3) songs (Baker, 1992; Furman, 2001; Gottschewski, 2001; Williams, 1996). Songs are a common occurrence in early childhood classes and are used by a wide range of professionals for skill promotion, entertainment, and expression of emotions (Enoch, 2001; Furman, 2001; Humpal, 1998). In music therapy, ‘‘hello’’ and ‘‘good-bye’’ songs are used frequently to establish predictable routines and structure, provide undivided attention, and communicate a welcome (Bailey, 1984; Nordoff & Robbins, 1995). Using songs to promote successful transitions is recommended for young children with autism (Furman, 2002; Humpal & Wolf, 2003; Snell, 2002), but no previous study evaluated greeting and good-bye songs on the performance of young children with autism during the morning arrival time. Studies on interest in music and relative strength of musical abilities in some children with autism (Applebaum, Egel, Koegel, & Imhoff, 1979; Thaut, 1987, 1988) and the effectiveness of music therapy interventions (Bunday, 1995; Kostka, 1993; Wimpory, Chadwick, & Nash, 1995) suggest music therapy is a viable treatment option for individuals with autism. For instance, songs have been used to supplement the use of social stories to support social interaction in children with autism (Brownell, 2002; Pasiali, 2004). Key recommendations for educating young children with autism (e.g., individualization, structure and predictability, emphasis on strengths and individual needs) can be incorporated in music therapy protocols or are part of the nature of music itself (American Music Therapy Association (AMTA), 2002). Although not studied systematically, music therapy can include embedding music therapy principles and strategies into ongoing routines of children’s days using a collaborative and consultative model of service delivery (Furman, 2001, 2002; Snell, 2002). The purpose of this study was to evaluate the effects of individually composed greeting songs implemented by classroom teachers on the independent performance of two young children with autism during the morning greeting routine. Three research questions were asked: (1) Does the use of an individually composed song, sung by teachers, increase appropriate independent performance during the morning arrival routine of young children with autism; (2) Can classroom teachers

apply the principles important to music therapy in a particular routine, and (3) Does use of the song increase interactions between the child with autism and his peers?

Method Participants Two boys, Phillip and Ben, with autism participated in the study. Phillip was a 3 year 5 month-old African American, and Ben was a 3 year 2 month-old European American. Licensed psychologists who were not involved in the study used the DSM-IV criteria (American Psychiatric Association, 2000) when establishing their diagnoses. On the Childhood Autism Rating Scale (Schopler, Reichler, & Renner, 1988), both boys were placed in the mild to moderate range. Prior to the study, Phillip and Ben had been enrolled for 10 months in an inclusive community-based child care program affiliated with an university. They were selected for the study on the request of their parents and classroom teachers and therapists. Both boys had limited speech, and the Picture Exchange Communication System (PECS) (Bondy & Frost, 1994) was being used. Ben was beginning to use a few functional words. Phillip and Ben showed limited social interactions with peers, played primarily when supported by adults, and engaged in stereotypic behaviors. Both children exhibited difficulties with transitions, although objects were used successfully with some transitions other than the morning arrival transition. The morning arrival transition was problematic for both boys. Phillip would refuse to enter the classroom, scream, or lie on the floor. Ben would hold on to his caregiver, cry, and ignore efforts of the teachers to welcome him. Phillip and Ben were interested in and responded well to music. They preferred listening to selected musical pieces, and participated in classroom musical activities. Other participants included the target children’s classmates with parental consent (n = 13), the target children’s respective caregivers (n = 2), and classroom teachers (n = 5). The class size of Phillip’s class was seven children (including him) ages 2 to 3 years and included both males and females from different ethnic groups. Five of his classmates were developing typically, and one had disabilities. Ben’s class had eight children (including him) ages 3 to 4 years and included both males and females from different ethnic groups. Five of the children were developing typically and two had disabilities. All adults in the classroom

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participated based on their schedules, which included staggered start times to cover the entire child care day. They had diverse educational backgrounds, ranging from high school diploma to Baccalaureate degree with certification in early childhood education. Their teaching experience ranged from 1 to 4 years. Phillip and Ben’s caregivers (a mother and nanny, respectively) participated in the study on a daily basis by bringing them to their classrooms and participating in the greeting time procedures. The teachers and caregivers did not have prior experience with music therapy interventions. Setting The inclusive university-affiliated child care program in which the study occurred held accreditation from the National Association for the Education of Young Children (NAEYC) and the State’s highest quality ranking for child care programs. The classrooms followed the recommended practice guidelines of NAEYC (Bredekamp & Copple, 1997) and the Division for Early Childhood (Sandall, McLean, & Smith, 2000). Specialists such as music therapists, occupational therapists, speech language pathologists, physical therapists or special educators worked with the individual child or a group of children in the ongoing classroom routines or as a consultant to the classroom teachers (McWilliam, 1996). Cubbies for children to place their personal items were located in the hall outside each classroom. The study occurred during the morning greeting routine. In the mornings, children arrived individually over a 1.5 h period. The usual routine was for each child, and his/her parent, to place personal items in the child’s cubby and then enter the classroom together. All children would be greeted by, and greet, the teacher and peers, then engage in play. The classroom curriculum allowed free play during the morning arrival time. Children engaged in different play areas by themselves or with each other. The parents signed the child in and had a brief conversation with the teacher before saying ‘‘good-bye’’ to the child and leaving the classroom. Materials Before the study, the teachers used a laminated picture (10 · 10 cm) communication symbol (Mayer-Johnson, 1992) showing a waving stick figure and the word ‘‘Hello’’ printed on the top using 18 pitch letters and the Arial font. This symbol was used in the study to assist the target participants in greeting classroom

teachers and peers, regardless of their language and communication skills when entering the classroom in the morning. The first author composed a greeting song unique to each target participant.1 The music was composed to match each child’s personality with the lyrics conveying the demands of the desired five-step morning greeting routine (see below). To emphasis the detachment from the caregiver, step four, which reflected the ‘‘good-bye’’ part, differed musically in melody and mood from the other steps. All other steps followed the same melody, but used different lyrics. Some of the lyrics were flexible to allow the children to choose different peers and describe the daily weather condition. A practice CD containing the song and the song transcriptions were given to the teachers and caregivers during a staff/caregiver training session. The intention of the songs for both children was to ease the transition from home to school, to increase their independent performance (i.e., independent functioning) during the five-step morning greeting routine, and to support their interaction with peers (i.e, engaging in greeting peers). Design Single subject research designs were used. For Phillip, an A-B-A-B withdrawal design (Aldridge, 2005; Tawney & Gast, 1984) was used. The baseline condition (A) consisted of the existing greeting routine, and the treatment (B) involved using the song during the greeting routine. For Ben, a modification of this design was used; specifically, an A-B-C-A-C design. The baseline (A) was the existing greeting routine, the treatment (B) was the use of the song during the greeting routine, and the C condition was a modification of the song. Staff/caregiver training activities occurred prior to baseline measures. Baseline Condition (A) In the baseline condition, the child and caregiver entered the center, placed the child’s belonging in his cubby in the hallway, and picked up the picture symbol showing the stick figure waving ‘‘Hello,’’ which was attached with Velcro to the child’s cubby. They then entered the classroom, and a classroom teacher initiated the greeting routine, which was similar to that used with classmates. Five steps were followed: (1) the target child enters the classroom 1

Interested readers can contact the first author to get a music score.

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independently; (2) the target child greets a person (teacher or peer) in the classroom verbally and/or hands over the picture symbol; (3) the target child greets a second person (teacher or peer) in the classroom verbally and/or hands over the picture symbol; (4) the target child says/waves ‘‘good-bye’’ to the caregiver, who leaves the classroom; and (5) the target child engages in appropriate play with a toy or material found in the classroom. A system of least prompts (Wolery, Ault, & Doyle, 1992) was used to assist the target child in responding independently to each step of the greeting routine and ensure the child completed each step of the routine. Staff/Caregiver Training Activities Initially, the first author consulted with the caregivers and teachers to identify realistic intervention goals and acceptable procedures for use in the greeting routine. Before baseline measures, she composed and recorded the individual songs, and gave them to the caregivers and teachers. During a circle time in the children’s classrooms, the first author led the children and teachers in learning and singing the songs. She also gave precise instructions to the teachers and caregivers about how to approach and assist the target children in greeting and interacting with peers musically. The teachers were encouraged to include all peers who would come forward voluntarily to greet the target child in the greeting routine during all phases (baseline, intervention, and reversal). Staff training ended after 2 weeks when the teachers and respective caregiver sang the song correctly and indicated that they were comfortable with the procedures. Intervention (B) In the intervention condition, the procedures used in the baseline were continued. The only change was the use of each child’s greeting song. The songs had lyrics matching each of the five steps of the greeting routine. The teacher began singing the song as the child entered the classroom, and sang the lyrics for each step as it was occurring. Modified Intervention (C) For Ben, the number of independently completed steps did not change substantially with the introduction of the song. Based on an analysis of the situation, we concluded Ben began to cry when separating from his caregiver and this interfered with independent performance of the steps. Thus, the fourth step (saying

‘‘good-bye’’) was eliminated, and his caregiver left the classroom as Ben entered it. Other procedures remained the same. Response Definitions and Measurement Two adult behaviors and five child behaviors were measured through direct observation using event recording. Data were collected during morning arrival time, when the teachers and peers were present. The observation started when the target child and his caregiver entered the classroom. The observation ended when the target child picked up a toy/material in the classroom, even if he had not said ‘‘hello’’ or ‘‘good-bye.’’ Data collection sessions lasted between 2 and 10 min. Phillip was observed for a total of 28 sessions across 2 months. Data collection for Ben was initiated 5 months later, and occurred in 31 sessions over 3 months. The adult behaviors were: Prompting was defined as a teacher or caregiver assisting the child in performing a step in the routine. This assistance was either verbal (e.g., ‘‘Say, Hello’’) or physical (e.g., the adult put her hand on the child to help in the exchange of the picture). No adult prompt was defined as the teacher or caregiver not giving a prompt for a step of the greeting routine. The child behaviors for each step of the routine were as follows. Independent response was defined as the child performing the behavior required in each step of the routine without any adult assistance. Prompted response was defined as the child performing the step of a routine but receiving adult prompt to do so. No response was defined as the child not responding, even when prompted. Error was defined as the child either not following the sequence of the routine or engaging in an appropriate behavior not prescribed by the routine, and Inappropriate response was defined as the child engaging in problematic behavior (i.e., tantrums). These categories were coded for each of the five steps of the morning greeting routine. An additional category was added for Ben to identify the number of classmates with and without disabilities who greeted him independently during the routine. This category was added because of informal observations with Phillip indicating peer greeting behavior changed during the course of the intervention. The number of peers greeting independently was defined as peers receiving the ‘‘Hello’’ symbol from Ben without verbal or physical prompting from an adult. Some observations were videotaped with a Panasonic AG-195 Camcorder and analyzed immediately afterwards.

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Observer Training and Interobserver Agreement Before the baseline condition, a music therapist (first author), a special educator and a research assistant observed and recorded the behaviors of teachers and children in the morning greeting routine. Training was concluded when inter-observer agreement was at 80% for three consecutive observations. During the study, inter-observer agreement checks occurred in a mean of 22% of the observations for each condition and child. The percentage of agreement was calculated using the point-by-point method (Tawney & Gast, 1984). The number of agreements were divided by the number of agreements plus disagreements with the quotient multiplied by 100. Overall, inter-observer agreement ranged from 75 to 100%, with a mean of 94%.

Phillip’s performance steadily moved toward independence. After 10 sessions in intervention, Phillip’s performance appeared consistent, as evidenced by three consecutive sessions with four independent steps at the same level; thus, the intervention was withdrawn. Phillip’s performance immediately decreased and by the second day of the second baseline condition, his performance returned to the initial baseline levels with two independent steps (again entering the classroom and finding a toy to play with). After three days, the song intervention was re-introduced. Immediately, Phillip’s performance increased. After four sessions, Phillip’s performance was equal to his performance at the end of the initial intervention condition. His performance remained steady at this level until the ninth session of intervention where Phillip performed all of the steps of the routine independently.

Results

Ben

Phillip

In the initial baseline condition, Ben’s performance was stable as shown in Fig. 2. In the majority of the sessions, he had one independent step completed, entering the classroom independently. On session four of the first baseline condition, Ben did three independent steps. With the introduction of the song intervention, Ben’s performance was variable. Ben responded in the majority of sessions with one independent response, as in the baseline condition. In four of 12 mornings, Ben completed more than one of the steps independently. Given the lack of substantial change in his performance, the ‘‘good-bye’’ step was eliminated and the caregiver left the classroom as he entered (Condition C). This produced an abrupt and sharp increase in the number of steps completed independently. He consistently had three of four steps done independently. After five sessions of stable performance, the intervention was

Baseline

Intervention

Baseline Intervention

4 3 2 1 0 0

16 18

24 26

Number of Independent Responses

During the initial baseline condition, Phillip’s performance was stable as shown in Fig. 1. In all sessions except the fourth, Philip completed two steps of the routine independently. In the fourth session, he did not do any step independently. The steps he did independently were entering the classroom and finding a toy with which to play. With the introduction of the song intervention, Phillip’s performance initially dropped to one step independently (entering the classroom), but after two days of song intervention, Phillip’s performance was back at baseline level. By the forth day of intervention, Phillip’s performance was above baseline level and by the sixth session, Phillip’s performance was consistently higher than the baseline level. The trend during the intervention condition indicates

Baseline

Intervention

Modified Baseline Modified Intervention Intervention

4 3 2 1 0 0

Sessions

10 12 14 16 18 20 22 24 26 28 30 32

Sessions

Fig. 1 Number of independent responses performed by Phillip during the morning greeting routine in baseline and intervention sessions

Fig. 2 Number of independent responses performed by Ben during the morning greeting routine in baseline, intervention, and modified intervention sessions

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withdrawn. An immediate decrease in his independent behavior occurred. With the re-introduction of the intervention, the data resulted in an abrupt and sharp increase in the number of independent steps. Ben completed all four steps independently. This high level of performance was stable during the last condition. The number of peers who greeted Ben without adult prompting are shown in Fig. 3. During the initial baseline condition, no peers greeted Ben during the greeting routine. With the use of the song intervention, two peers greeted him independently on 9 of 12 days, and four, three, and one peer greeted him on the remaining days. With the modified intervention, two peers greeted him on three of five days, but on one day no peers greeted him and on the other day, one peer greeted him. The removal of the song in the second baseline resulted in more variable data. Two peers greeted him independently on two of five days; on the second day, three peers greeted him, but on the last two days, one peer greeted him. The reintroduction of the modified intervention resulted in two peers greeting him on three of four days, with one peer greeting him on the first day of the condition. Thus, initiation of the song intervention resulted in an increase in the number of peers greeting Ben, but withdrawal of the song in the second baseline did not result in data patterns similar to the first baseline. Neither the modification of the intervention nor the withdrawal of the song intervention returned the peers’ behavior to baseline conditions, with the exception of one day.

Discussion

Number of Peers Greeting Ben

This study evaluated the effects of embedding a music therapy intervention (using original greeting songs) in the morning arrival routine on the independent functioning of two young boys with autism. It also examined Baseline

Intervention

Modified Baseline Modified Intervention Intervention

4 3

2 1 0 0

10 12 14 16 18 20 22 24 26 28 30 32

Sessions

Fig. 3 Number of peers greeting Ben during the morning greeting routine in baseline, intervention, and modified intervention sessions

whether teachers could implement the songs in the context of that routine after receiving consultation and training from a music therapist; and, finally, whether use of the songs influenced classmates’ greetings to one target child. As shown, the data support the use of individualized songs implemented in this manner to facilitate independent entry into classrooms. As such, it adds to the literature on how to include young children with autism in inclusive classrooms (Strain et al., 2001). In this study, individualized greeting songs matching the participants’ personality (based on the music therapist’s judgments) and the demands of the morning greeting routine were effective in facilitating a smooth transition from home to the child care program. These findings support the recommendation to use songs to ease transitioning for individuals with autism (Baker, 1992; Furman, 2001; Gottschewski, 2001). These effects occurred, with the teacher rather than the music therapist implementing the songs in the morning greeting routine. The teachers did not use songs for this purpose prior to this study, did not know the songs until they were taught by the music therapists, and did not have formal musical training or experience with music therapy interventions. In addition, the training time was relatively short. This study replicates and extends earlier studies showing that classroom teachers can embed intervention strategies successfully into ongoing routines, when training and monitoring were provided (Kemmis & Dunn, 1996; Venn et al., 1993). However, despite their success, teachers were challenged with parts of the musical characteristics of the songs. For example, in both cases the teachers did not implement the change in music indicating the good-bye part of the songs (step four of the greeting routine). Interestingly, and perhaps coincidentally, it was exactly this part that distressed both target children. This raises the question if the implementation of the change in music signaling the ‘‘goodbye’’ part would have changed the target children’s performance during this step. No data are available to suggest the change in the music would produce positive outcomes, but future research should examine this possibility. Other explanations exist for the children’s difficulty with this step such as the lack of understanding of conventional gestures and the fact that it signaled the caregiver leaving. Clearly, high quality staff development activities and ongoing collaborative consultation seem to be critical components for appropriate and successful implementation of teachermediated interventions using music therapy principles. In this study, maintaining teacher’s comfort level, motivation, and monitoring of the teachers’ use of the procedures were needed.

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The use of the songs also potentially had positive effects on peers’ greeting behavior and interaction toward the target children. This was noted informally for Phillip and then measured formally for Ben. Peers volunteered in singing and greeting the target children during their morning arrival time, or participated by giving their input to the song (e.g., statements about the weather condition) while engaging in other activities. The song intervention seemed to pique the interest of peers and evoke a positive view toward Ben. This change seemed to be affected by the intervention alone and was not contingent on Ben’s performance. That is, the greeting song motivated the peers to interact with Ben, but his performance did not change until after the peers had regularly greeted him. However, the number of peers greeting him did not return to the levels of the initial baseline during the second baseline condition. The teachers, parents of the target children, and parents of other classmates reported the intervention was effective and valuable. The mother of one of Phillip’s peers said that before the intervention her child was intimidated by Phillip’s inappropriate behavior at greeting time. With the implementation of the song, this classmate ran to school hoping to arrive before Phillip so he could participate in Phillip’s greeting song. Phillip’s mother reported she was very pleased by the success of the intervention and requested further songs for other challenging situations. Ben’s caregiver said: ‘‘I think this was perfect for Ben. He had a hard time leaving me in the mornings, but with the help of the Good Morning Song the transition became much easier for Ben.’’ After evaluating the song intervention with Phillip’s classroom teacher, she came to the following conclusion: ‘‘Transitions into the classroom were stressful for the children, parents, and teachers. The Hello Song allowed us to implement a simple intervention each day. The song is great, and helped all of us tremendously.’’ These comments, the teachers willingness to use the song intervention within daily classroom routines, and the request for new songs addressing other challenging behaviors (i.e., waiting and hand washing) is some evidence of the social validity of the procedures and effects. This study has several limitations; for example, only two participants were studied because of their need for intervention during the morning arrival time. Replication of this study for additional participants is recommended. Further, for Ben, a modification was needed before the song was successful. Thus, it is unclear whether the modified intervention would have been effective if Ben had not experienced the original intervention. Also, the music therapist composed original

songs for each child; thus, these data do not indicate whether a teacher, without assistance from a music therapist, could adapt a pre-composed song (referred to as the ‘‘Piggybacking’’ technique) and produce similar results. Another limitation concerns the lack of maintenance and generalization data. This study suggests future studies should focus on the effects of songs in other challenging routines for young children in inclusive classes. Similarly, studies focusing on using songs to promote other skills (e.g., social and communicative abilities) should be implemented. Finally, systematic studies of the effects of songs designed for young children with autism should contain measures of the effects on their peers. Do such songs change the behaviors and attitudes of peers toward their classmates who have autism? Acknowledgement This study is a part of a series of single case studies investigating embedded music therapy interventions for the inclusion of young children with autism spectrum disorders in a community-based, university-affiliated Family and Child Care Program. The authors wish to acknowledge Dr. Ann N. Garfinkle for her contributions to the study. Gratitude also goes to the children and families, teachers and colleagues for their participation, dedication, and collaboration in this study.

References Aldridge, D. (Ed.) (2005). Case study designs in music therapy. London, England; Bristol, PA: Jessica Kingsley Publishers. Alger, H. A. (1984). Transitions: Alternatives to manipulative management technique. Young Children, 39(6), 16–25. Applebaum, E., Egel, A. L., Koegel, R. L., & Imhoff, B. (1979). Measuring musical abilities of autistic children. Journal of Autism and Developmental Disorders, 9, 279–285. American Association of Music Therapy (AMTA) (2002). Music therapy and individuals with diagnosis on the autism spectrum. Retrieved February 12, 2005 from the Internet: http:// www.musictherapy.org/factsheets/autism.html. American Psychiatry Association (APA) (2000). Diagnostic and statistical manual of mental disorders (4th ed.), Text Revision. Washington, DC: Author. Baker, B. S. (1992). The use of music with autistic children. Journal of Psychosocial Nursing Mental Health Service, 20(4), 31–34. Bailey, L. M. (1984). The use of songs in music therapy with cancer patients and their families. Journal of Music Therapy, 4, 5–17. Bredekamp, S., & Copple, C. (Eds.). (1997). Developmentally appropriate practice in early childhood programs (Rev. ed.). Washington, DC: National Association for the Education of Young Children. Brownell, M. K. (2002). Musically adapted social stories to modify behaviors in students with autism: Four case studies. Journal of Music Therapy, 39, 117–144. Bryan, L. C., & Gast, D. L. (2000). Teaching on-task and onschedule behaviors to high-functioning children with autism via picture activity schedules. Journal of Autism Development Disorder, 30, 553–567.

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Bondy, A. S., & Frost, L. A. (1994). The picture exchange communication system. Focus on Autism, 9, 1–19. Bunday, E. M. (1995). The effects of signed and spoken words taught with music on sign and speech imitation by children with autism. Journal of Music Therapy, 32, 189–202. Carta, J. J., Greenwood, C. R., & Robinson, S. (1987). Application of an eco-behavioral approach to the evaluation of early intervention programs. In R. Prinz (Ed.), Advances in the behavioral assessment of children and families (Vol. 3, pp. 123–155). Greenwich, CT: JAI Press. Dawson, G., & Osterling, J. (1997). Early intervention in autism. In M. J. Guralnick (Ed.), The effectiveness of early intervention (pp. 307–326). Baltimore: Paul H. Brookes. Enoch, A. (2001). Let’s do it again. All Together Now! (ATN), 7(1), 5–7. Furman, A. (2001). Young children with autism spectrum disorder. Early Childhood Connections, 7(2), 43–49. Furman, A. (2002). Music therapy for learners in a community early education public school. In B. L. Wilson (Ed.), Models of music therapy interventions in school settings (2nd ed., pp. 369–388). Silver Spring, MD: The American Music Therapy Association, Inc. Gottschewski, K. (2001). Autismus aus der Innenperspektive und Musiktherapie [Autism from an inside-out perspective and music therapy]. In D. Aldridge (Ed.), Kairos V: Musiktherapie mit Kindern: Beitraege zur Musiktherapie in der Medizin (pp. 40–57). Bern; Goettingen; Toronto; Seattle: Verlag Hans Huber. Hobson, R. P., & Lee, A. (1998). Hello and goodbye: A study of social engagement in autism. Journal of Autism and Developmental Disorders, 28, 117–127. Humpal, M. E. (1998). Information sharing: Song repertoire of young children. Music Therapy Perspectives, 19, 37–38. Humpal, M. E., & Wolf, J. (2003). Music in the inclusive environment. Young Children, 58, 103–107. Kemmis, B. L., & Dunn, W. (1996). Collaborative consultation: The efficacy of remedial and compensatory interventions in school context. The American Journal of Occupational Therapy, 59, 709–717. Kostka, M. J. (1993). A comparison of selected behaviors of students with autism in special education and regular music classes. Music Therapy Perspectives, 11, 57–60. Mayer-Johnson, R. (1992). The picture communication symbols. Solana Beach, CA: Mayer-Johnson, Co. Marcus, L., Schopler, E., & Lord, C. (2001). TEACCH Services for preschool children. In J. S. Handelman & S. L. Harris (Eds.), Preschool education programs for children with autism (2nd ed., pp. 215–232). Austin, TX: Pro-Ed. McWilliam, R. A. (Ed.) (1996). Rethinking pull-out services in early intervention: A professional resource. Baltimore, MD: Paul H. Brookes. Mesibov, G. B., Adams, L., & Klinger, L. (1997). Autism: Understanding the disorder. NY: Plenum Press. National Research Council (2001). Educating children with autism. Committee on educational interventions for children

with autism. Division of Behavioral and Social Science and Education. Washington, DC: National Academy Press. Nordoff, P., & Robbins, C. (1995). Greetings and goodbyes: A Nordoff-Robbins collection for the classroom use. Bryn Mawr, PA: Theodore Presser. Osborn, K., & Osborn, D. (1981). Discipline and classroom management. Athens, GA: Education Association. Pasiali, V. (2004). The use of prescriptive therapeutic songs in a home-based environment to promote social skills acquisition by children with autism: Three case studies. Music Therapy Perspectives, 22(1), 11–20. Sandall, S., McLean, M. E., & Smith, B. J. (2000). DEC: Recommended practices in early intervention/early childhood special education. Longmont, CO: Sopris West. Schmit, J., Alper, S., Raschke, D., & Ryndak, D. (2000). Effects of using a photographic cueing package during routine school transitions with a child who has autism. Mental Retardation 38, 131–137. Schopler, E., Reichler, R., & Renner, B. (1988). The Childhood Autism Rating Scale (CARS). Los Angeles, CA: Western Psychological. Snell, A. M. (2002). Music therapy for learners with autism in a public school setting. In B. L. Wilson (Ed.), Models of music therapy interventions in school settings (2nd ed., pp. 211–275). Silver Spring, MD: The American Music Therapy Association. Strain, P. S., McGee, G. G., & Kohler, F. W. (2001). Inclusion of children with autism in early intervention environments. In M. J. Guralnick (Ed), Early childhood inclusion: Focus on change (pp. 337–363). Baltimore: Paul Brookes. Tawney, J. W., & Gast, D. L. (1984). Single subject research in special education. Columbus: Merrill. Thaut, M. H. (1987). Visual versus auditory (musical) stimulus preferences in autistic children: A pilot study. Journal of Autism and Developmental Disorders, 17, 425–432. Thaut, M. H. (1988). Measuring musical responsiveness in autistic children: A comparative analysis of improvised musical tone sequences of autistic, normal and mentally retarded individuals. Journal of Autism and Developmental Disorders, 18, 561–571. Trillingsgaard, A. (1999). The script model in relation to autism. European Children Adolescence Psychiatry, 8(1), 45–49. Venn, M. L., Wolery, M., Werts, M. G., Morris, A., DeCesare, L. D., & Cuffs, M. S. (1993). Embedding instruction in art activities to teach preschoolers with disabilities to imitate their peers. Early Childhood Research Quarterly, 8, 277–294. Williams, D. (1996). Autism: An inside-out approach. London, Bristol, PA: Jessica Kingsley. Wimpory, D., Chadwick, P., & Nash, S. (1995). Brief report: Musical Interaction Therapy for children with autism: An evaluative case study with two-year follow-up. Journal of Autism and Developmental Disorders, 25(5), 541–552. Wolery, M., Ault, M. J., & Doyle, P. M. (1992). Teaching students with moderate and severe disabilities: Use of response prompting strategies. White Plains, NY: Longman.

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Psychometric Results of the Music Therapy Scale (MAKS) for Measuring Expression and Communication

Music and Medicine 2(1) 41-47 ª The Author(s) 2010 Reprints and permission: http://www. sagepub.com/journalsPermissions.nav DOI: 10.1177/1943862109356927 http://mmd.sagepub.com

Dorothee von Moreau, Dr. rer. medic., music therapist (bvm, DMtG), Dipl. Psychologist,1 Heiner Ellgring, Dr. rer. nat., Dipl. Psychologist,2 Kirstin Goth, Dr. phil. nat., Dipl. Psychologist,3 Fritz Poustka, Prof. Dr. med., Professor emeritus,3 and David Aldridge, PhD, FRSM4

Abstract The Music Therapy Rating Scale (MAKS), originally developed in 1996, was evaluated again in 2009 using a sample of 62 children from a psychiatric unit and from different primary schools, with measures at three different time points during therapy process. The scale is intended as an objective rating of a client’s musical behavior. The evaluation of the scale was to determine any possible ambiguity or weakness in the discriminatory power of the scale items. After excluding such items, the results show high reliability (a > .75) and good objectivity with trained raters (r > .70) for the two main scales and a significant sensitivity to change. Keywords musical communication, musical expression, music therapy, rating scale MAKS

There has been an urgent need for evaluation in music therapy over the past years, and specific assessment instruments for music therapy are still missing, especially for patients who cannot be evaluated by verbal tests (Aldridge, 1996; Tischler, 2000). It is important in clinical practice that we describe in detail the patient’s mental state and psychic structure. Therefore, we need to identify specific criteria for the assessment of a client’s musical expression. The question remains as to how we interpret what we hear in a musical context in terms of both relationship and expression and the implications of this interpretation for therapy.

Music Therapy Rating Scales Music therapy rating scales already exist in the literature (for an overview, see Phan Quoc, 2007; Sabatella, 2004). Many of them, however, are neither specific to music therapy nor validated. In Germany, semantic differentials are often used for describing improvised music during music therapy intervention. These differentials are bipolar adjective lists with scales divided into five or seven intervals to rate a subjective impression of what is heard. They were used by music therapy researchers in the 1990s due to a shortage of specific scales for music therapy (Burrer, 1992; Inselmann & Mann, 2000; Pechr, 1996; Steinberg & Raith, 1985; Steinberg, Raith, Rossnagel, & Eben, 1985; Vanger, Oerter, Otto, Schmidt, & Czogalik, 1995; Zahler, 2002).

David Aldridge

As specific music therapy rating scales, Bruscia’s Improvisation Assessment Profiles are often used in music therapy research in English-speaking countries (Bruscia, 2001), but these have yet to be validated. Maler’s (1989) scale is partly validated but is very complicated in applying ratings and is no longer implemented. The Nordoff/Robbins rating scales (Nordoff, Robbins, Fraknoi, & Ruttenberg, 1980a, 1980b), used primarily with children with disabilities, are now under evaluation. Schumacher’s Assessment of the Quality of Relationship (Schumacher, 1999; Schumacher & Calvet, 2007; Schumacher & Calvet-Kruppa, 1999) is currently being evaluated for its application to people with mental disorders other than autism. Pavlicevic’s Music Interaction Rating scale (Pavlicevic, 1991, 2007), describing the patient’s level of contact during musical improvisation in music therapy, has been validated for use with psychiatric patients. The challenge of

Freies Musikzentrum, Munich, Germany University of Wu¨rzburg, Wu¨rzburg, Germany 3 Goethe University, Frankfurt am Main, Germany 4 Nordoff-Robbins-Zentrum, Witten, Germany (nordoff_robbins@mac.com) 2

Corresponding Author: Dorothee von Moreau, Institut fu¨r Musiktherapie, Freies Musikzentrum, Munich, Germany Email: dvmoreau@web.de

Developmental delay papers

Music and Medicine 2(1)

Table 1. The Music Therapy Rating Scale (MAKS): Expression and Communication Subscales MAKS Expression scale: rating improvised solo playing (14 items) (Dealing with the instrument) Range of melody (TR) Initiative (IN) (Form/musical figure) Form (FG) Structure (ST) Variation (VR) (Vitality/dynamics of expression) Suspense/tension (SP) Power (SK) Vitality (LB) Flow (SF) Dynamics (DY) (Quality of expression) Sound quality (KQ) Quality of expression (AU) Clarity of emotions (EA) Resonance/involvement (EL)

Communication scale: rating improvised duo playing with the therapist (13 items) (Engagement) Autonomy (AT) Inner participation (BT) (Formal aspects) Need of space (RA) Length of playing intervals (DA) Logic structure (LA) (Regarding the other) Reference (BZ) Intensity of contact (KI) Contact behavior (KV) Variability in acting (VV) Dominance (DO) (Quality of expression) Quality of flow (DQ) Quality of affects (AQ) Quality of play (SQ)

For scoring purposes, all items were divided into seven levels. Each level was operationalized, creating precise descriptions to avoid ambiguity (of some items; see Table 2). This scale was validated in 1996 by an initial evaluation process with 52 raters on the basis of 10 video scenes of different adolescent patients in a psychiatric clinic (Moreau, 1996, 2003). Scores allowed significant differentiation between clients with various psychiatric disorders (p < .001). The results for objectivity (mean interrater correlation: Kendall’s tau ¼ .4 for the Expression scale and .3 for the Communication scale) needed to be improved, but the retest results suggested that a training of the raters may slightly improve the score for objectivity. The experiences of Plum (Plum, Lodemann, Bender, Finkbeiner, & Gastpar, 2002) and Isermann (2001), testing the practicability of the scale in a clinical context with adults with schizophrenia, encouraged us to revise the scale and to reevaluate it in a clinical setting.

Aim and Hypotheses

Hypothetical categories are in brackets.

The main task of the actual study was to evaluate the MAKS again with trained raters, according to the general psychometric criteria of objectivity and reliability and to establish its usefulness, clinical applicability, and relevance.

measuring the music therapy outcome with young and adolescent psychiatric patients, however, has not been addressed. A question remains about whether scales, conceptually based on developmental psychology, are appropriate for children without developmental disabilities or severe psychiatric disorders, but who are, nevertheless, unstable in both emotional expression and social interaction. We identified the need for a music therapy rating scale specifically for measuring musical behavior on more than one dimension in order to depict the client’s behavior that included dissent, inconsistency, and ambivalence. A rigorous scale could then be used for the initial assessment process and for a final assessment at the end of therapy, making it a useful tool for an evaluation of therapy outcome. While we have diagnostic scales, we have no rating scales for assessing therapeutic change.

1. Testing reliability shows to what extent the scales are free of measurement error. The a priori criterion for accepting reliability according to psychometric standards (see Bortz & Do¨ring, 2006) was set at a Cronbach’s alpha greater than .75. 2. The objectivity of a scale shows to what extent the raters agree in their judgment. The a priori criterion for accepting objectivity according to psychometric standards was set at a Pearson’s interrater correlation greater than .7. 3. Sensitivity to change shows to what extent the scale will detect the development of the client’s musical expression or communication skills throughout the duration of therapy. The a priori criterion for accepting the hypothesis was significance (tested by MANOVA with the factors Psychopathology and Time of Measurement), p < .05, for the within-subject factor Time.

Development of the Scale and First Results of Validation

Methodological Design Procedures

Development of the Music Therapy Rating Scale (MAKS) began in 1994 with a survey of music therapy experts (Moreau, 1996). In a process of item testing and reduction, the scale has been modified in clinical practice for several years. For the final version, the MAKS was composed of two subscales. One, the Expression scale, is 14 items for rating a client’s improvisational musical performance in a solo playing. The second, the Communication scale, is 13 items for rating a client’s improvisational musical performance in duo playing with the therapist (for an overview of the scale’s categories see Table 1).

For the rating of the children’s musical behavior, we produced video recordings of each child in a standardized assessment session of about 15 minutes at three measurement points in time (t1 ¼ at the beginning, t2 ¼ in the middle, and t3 ¼ at the end of music therapy treatment or music workshop). In each assessment session, the child was asked to play by hand a large African drum alone, and then in a second episode to play it together with the therapist. During the duo play, the therapist was instructed to answer the child’s offering on contact with

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Table 2. Music Therapy Rating Scale (MAKS) Item Examples: Expression and Communication Subscales Expression scale: Initiative (frequency of the client’s own ideas) No initiative (only plays when requested and/or offered assistance)

Very low-level initiative (reproduces only familiar musical patterns)

Low-level initiative (1-2 ideas)

Normal High-level initiative initiative (2-3 ideas) (3-4 ideas)

Very high-level initiative (more than 4 ideas)

Extreme-level initiative (cannot restrain him- or herself)

Communication scale: Dominance (level the client places him- or herself under or above the therapist) Strongly subordinate (does not play or falls silent)

Moderately subordinate (conformist)

A little subordinate (partly conformist)

empathy and to stay cautious neither to force nor to push the child’s reactions more than necessary. From the videos of each assessment session, the therapist chose a representative scene of solo playing of 20 to 30 seconds for the rating of musical expression and a representative scene of duo playing with the therapist of 30 to 40 seconds for the rating of musical communication. The therapist decided which part of the video was typical or representative of the child’s behavior at that time of treatment. Finally, we had six video episodes for each participant, containing one solo and one duo scene from each time segment (t1, t2, t3). These video scenes from all children were assembled in random sequence and recorded on CDs for rating by three independent observers who had been trained in using the MAKS. These raters, three music therapy colleagues from different music therapy training backgrounds and with 3 to 5 years’ music therapy experience with children, watched the videos and scored the musical behavior of the children using the MAKS.

A little dominating (decisive, inviting)

Moderately dominating (influential)

Strongly dominating (overwhelming)

Distribution of main diagnoses

F90

F91

F92

F93

F94

F98

F84

F44 healthy

Figure 1. Main diagnoses (International Classification of Diseases, Version 10) of the children’s sample.

Instruments For the evaluation of the children’s improvisational solo and duo play, we used the Expression and Communication scales of the MAKS, as described above. In addition, the children’s parents filled out a personality questionnaire, the Junior Temperament and Character Inventory (JTCI 7-11 R; Goth, Cloninger, & Schmeck, 2003; Goth & Schmeck, 2008). The personal nurse at the hospital or the parents, for the nonclinical group, filled out a short psychopathology questionnaire, the Strengths and Difficulties Questionnaire (SDQ; Goodman, 2001; German translation, Woerner et al., 2002).

Participants Thirty-eight inpatients from a university hospital for child and adolescent psychiatry attended group music therapy sessions over a period of 4 weeks to 10 months, depending on the length of their hospital stay. Most of the patients had a main diagnosis of hyperkinetic disorder, F90, according to the International Classification of Diseases, Version 10 (ICD-10), and most had multiple diagnoses (see Figure 1). In addition, 24 healthy children from different primary schools attended a music workshop of 10 sessions over a period

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Equal

of 3 to 4 months. We selected only boys and only those children without impaired intelligence to assure that the groups were homogeneous in gender and cognitive ability—although the children differed in age (see Table 3). Neither group differed in creativity (ANOVA p ¼ .958, tested by JTCI 7-11 R), but they differed significantly in all other categories of temperament and character (ANOVA p < .010, tested by JTCI 7-11 R). We found significant differences in the SDQ total score (w2 test p ¼ .025), in the categories prosocial behavior (w2 test p ¼ .000) and problems with peers (w2 test p ¼ .008). However, to our surprise, there were aspects of psychopathology in both groups. Some healthy controls displayed severe or minor social and emotional problems. The clinical group was poorer in both psychosocial adaptation and social skills.

Results Reliability The results for scale reliability were taken from the data of the 62 children’s first assessments (t1) at the beginning of therapy.

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Table 3. Characterization of the Clinical Sample

Age (years, months) Sex

Inpatient participants (n ¼ 38)

Control participants (n ¼ 24)

9, 9 (+1, 7) Male

8, 1 (+1, 5) Male

The intelligence score (IQ) in the clinical group was taken from axis III of the International Classification of Diseases, Version 10 (Remschmidt et al., 2002). In the healthy group, IQ was controlled by school.

Table 4. Reliability of the Expression (A) and Communication (K) Subscales for Each Rater (G, C, B)

Expression scale A: alpha (rit)

A: alpha* A: rit-range* Communication scale K: alpha (rit) K: alpha* K: rit-range*

.80 FG (.23) ST (–.16) EA (.15) .88 .39-.74

.72 FG (–.20) ST (–.01) .83 .36-.74

.75 FG (.11) ST (–.22) EA (.21) .83 .27-.81 (KQ)

.85 DA (.01) BZ (.08) .88 .34-.85

.76 DA (.03) BZ (.13) .78 .21-.64 (KV)

.81 DA (.11) BZ (–.02) .84 .23-.72 (LA)

For the subscales, alpha and rit ¼ results for all items; alpha* and rit-range* ¼ results with reduced items. FG ¼ form; ST ¼ structure; EA ¼ clarity of emotions; DA ¼ length of the play the client takes compared to the therapist; BZ ¼ reference or extent of extraverted or introverted orientation.

We analyzed the ratings of each single observer separately to get an idea of the stability of these results. A first analysis on all items of the Expression scale and all items of the Communication scale showed a Cronbach’s alpha coefficient greater than .70, but the corrected item total correlations of some items were below the criterion of .3 (see Table 4). As these items (FG ¼ form; ST ¼ structure; EA ¼ clarity of emotions; DA ¼ length of the play the client takes compared to the therapist; and BZ ¼ reference or extent of extraverted or introverted orientation) also had low objectivity scores, they were removed for a new analysis (in Table 4, see alpha* and ritrange*). The results then fulfilled the criterion alpha of greater than .75, and the range of the corrected item total correlation was improved too.

Objectivity The scale’s objectivity was measured by the interrater correlation of all three raters (Pearson’s coefficient) for each single item to detect nonobjective items. We took the data of all children and all assessment sessions. These results were compared to the results gained in the first evaluation process (Moreau, 1996), and the results gained immediately after the rater training. Almost all items of the Expression scale fulfilled the 44

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criterion (marked by the black line; see Figure 2) in one of the contexts (initial study in 1996, after training situation, and actual study)—except those items that were already mentioned in case of reliability: FG (form), ST (structure), and EA (clarity of emotions). In the Communication scale, we identified the items KI (intensity of contact) and DQ (dynamic quality) as not showing sufficient psychometric properties. For the total score analysis of the Expression scale and the Communication scale, we used only those items with sufficient discriminatory power and that loaded on a stable factor in the factor analysis. Based on this selection criteria, the total score of the Expression scale, (without items FG ¼ form, ST ¼ structure, EA ¼ clarity of emotions) showed an interrater correlation of r ¼ .9, and the total score of Communication scale (without items RA ¼ need of space, DA ¼ length of playing intervals, BZ ¼ extent of extraverted or introverted orientation or reference) was r ¼ .7.

Sensitivity for Change We tested sensitivity for change by MANOVA analysis with the factors Psychopathology (SDQ total score) and Time of Measurement (t1, t2, t3). For this analysis, we took the MAKS Expression total score and the MAKS Communication total score (all items of each scale except the weak items, as described above). The analysis of the solo plays showed significant changes over time in musical expression (withinsubject factor time: p ¼ .023). Analyzing the duo plays, we had even stronger effects of significant changes in musical communication (within-subject factor time: p ¼ .001). We can conclude that the MAKS is sensitive to discrete changes in musical expression and communication.

Discussion After excluding the weak items for all total score analyses, the total scores of the Expression scale and the total scores of the Communication scale present sufficient objectivity and reliability. The results on the level of item with different training conditions suggest that good training is absolutely necessary for using the scale. The items of form (FG) and structure (ST) did not show sufficient interrater, nor corrected total item correlations. These items are ambiguous in operationalization, difficult to rate, and do not contribute to explaining musical expression skills. Other items like length of the play the client takes compared to the therapist (DA) and the extent of extraverted or introverted orientation (BZ) need better training. Children in a psychiatric setting often change their orientation while playing with an adult person and hardly show stable patterns. The items clarity of emotions (EA) or intensity of contact (KI) can be removed from the scale. Ratings of intensity of contact or clarity of emotions do not depend on observable behavior but on the rater’s personal impression. The scale has limitations when asked to portray the quality of various

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0.7

0 TR

0.7

0 AT

actual study

training

initial study

Figure 2. Objectivity (Pearson’s correlation coefficient ¼ y-axis) of the items (x-axis) of the Expression scale (Figure 2a) and the Communication scale (Figure 2b).

emotions or the intensity of contact between persons. On the other hand, the item inner participation (BT), operationalized by attention, is easier to observe. The MAKS is a rating scale constructed by music therapy experts specifically for evaluating music therapy. The accurate description of each interval of the items allows a detailed reflection of a client’s musical behavior. Therefore, the MAKS is more precise than semantic differential tests and presents a wider field of musical expression or communication skills as the scales examine more than one aspect of behavior. Inconsistent, or contradictory behavior of the client may be portrayed comparing the solo- and the duo-playing conditions and also comparing different aspects of musical expression, for example, tension (SP) and loudness (SK), or tension (SP) and movement (LB).

during music therapy. As an interval scaled rating instrument, the scale allows strong statistical methods for data analysis. When the week items are eliminated, the scale fulfills the necessary psychometric standards of reliability and objectivity when it is used by well-trained raters. It is sensitive to change and can portray a child’s development during therapy. For further research, we have to determine group-specific characteristic profiles with regard to diagnosis, age, and/or gender to be able to give a clear diagnostic statement related to a patient’s MAKS profile. Declaration of Conflicting Interests The author(s) declared no potential conflicts of interests with respect to the authorship and/or publication of this article.

Conclusion

Funding

The MAKS is a scale constructed specifically to evaluate the musical expression and communication skills that occur

We would like to thank Andreas-Tobias-Kind-Stiftung, Hamburg, Germany, for financial support for this study.

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References Aldridge, D. (1996). Music therapy research and practice in medicine: From out of the silence. London: Jessica Kingsley. Bortz, J., & Do¨ring, N. (2006). Forschungsmethoden und Evaluation fu¨r Human- und Sozialwissenschaftler [Research methods and evaluation for human and social scientists]. Heidelberg, Germany: Springer. Bruscia, K. E. (2001, March 02). Response to the forum discussion of ‘‘IAP’s’’ on the Nordic Journal Web site, http://www.hisf.no/njmt/ forumiaplist.html Burrer, S. (1992). Musiktherapeutishe Einzelfallforschung: Rating von 20 Improvisationsausschnitten aus einer musiktherapeutischen Behandlung [Single case research of a music therapy process: Rating of 20 scenes of musical improvisation from music therapy]. Unpublished thesis, Fachhochschule Heidelberg. Goodman, R. (2001). Psychometric properties of the Strengths and Difficulties Questionnaire. Journal of the American Academy of Child and Adolescent Psychiatry, 40, 1337-1345. Goth, K., Cloninger, C. R., & Schmeck, K. (2003). Das Junior Temperament und Charakter Inventar fu¨r das Grundschulalter—JTCI 7-11 [The Junior Temperament and Character Inventory for children of elementary schools—JTCI 7-11]. University Clinic for Psychiatry and Psychotherapy with children and adolescents, University of Frankfurt, Frankfurt am Main, Germany. Goth, K., & Schmeck, K. (2008). Das Junior Temperament und Charakter Inventar: Eine Inventarfamilie zur Erfassung der Persoenlichkeit vom Kindergarten- bis zum Jugendalter nach Cloningers biopsychosozialem Perso¨nlichkeitsmodell [The Junior Temperament und Character Inventory: An inventory system for rating the personality from nursery school up to youth according to Cloninger’s Biopsychosocial Model of Personality]. Go¨ttingen, German: Hogrefe. Inselmann, U., & Mann, S. (2000). Emotionales Erleben, Ausdruck und Kommunikation in Musikimprovisationen. Eine qualitativquantitative Einzelfallstudie [Emotional experience, expression and communication in musical improvisations: A qualitativequantitative single case study]. Psychotherapie, Psychosomatik, Medizinische Psychologie, 50, 193-198. Isermann, H. (2001). Einzelfalluntersuchung einer Gruppenmusiktherapie mit schizophrenen Patienten [A case study of group music therapy with schizophrenic patients]. Unpublished thesis, Hochschule Enschede. Maler, T. (1989). Klinische Musiktherapie. Ausdrucksdynamik, Ratingskalen und wissenschaftliche Begleitforschung im Luebecker Musiktherapie-Modell [Clinical music therapy: Dynamics of expression, rating scales and scientific research within the Luebeck music therapy model]. Hamburg, Germany: Dr.R.Kraemer. Moreau, D. v. (1996). Entwicklung und Evaluation eines Beschreibungssystems (MAKS) zum Ausdrucks- und Kommunikationsverhalten in der Musiktherapie [Development and evaluation of a rating system (MAKS) on expression and social behavior in music therapy]. Unpublished thesis, University of Wu¨rzburg, Wu¨rzburg, Germany. Moreau, D. v. (2003). MAKS: A scale for measurement of expressive and musical behavior. Music Therapy Today, 4(4). Retrieved July 25, 2003, from http://www.musictherapyworld.net 46

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Nordoff, P., Robbins, C., Fraknoi, J., & Ruttenberg, B. (1980a). Ratingskalen fu¨r improvisatorische Einzel-Musiktherapie. Teil I [Rating Scales for Improvisational Individual Music Therapy: Part I]. Musiktherapeutische Umschau, 1, 99-121. Nordoff, P., Robbins, C., Fraknoi, J., & Ruttenberg, B. (1980b). Ratingskalen fu¨r improvisatorische Einzel-Musiktherapie. Teil II [Rating Scales for Improvisational Individual Music Therapy: Part II]. Musiktherapeutische Umschau, 1, 185-202. Pavlicevic, M. (1991). Music in communication: Improvisation in music therapy. Unpublished dissertation, University of Edinburgh, Scotland. Pavlicevic, M. (2007). The Music Interaction Rating Scale (schizophrenia) (MIR(S)): Microanalysis of co-improvisation in music therapy with adults suffering from chronic schizophrenia. In T. Wosch & T. Wigram (Eds.), Microanalysis in music therapy: Methods, techniques and applications for clinicians, researchers, educators and students (pp. 174-185). London: Jessica Kingsley. Pechr, M. (1996). Musikalische und psychologische Parameter in experimenteller Therapiemusik—Depressive und Normalgesunde im Vergleich zweier Messinstrumente [Musical and psychological parameters in experimental therapy music—A comparison of depressive and healthy persons using two instruments of measurement]. Musiktherapeutische Umschau, 17, 115-128. Phan, Quoc, E. (2007). Forschungsansaetze zur Operationalisierung von emotionalem Ausdruck und Interaktion in der musiktherapeutischen Improvisation [Research approaches to the operationalising of emotional expression and interaction in music therapy improvisation]. Musiktherapeutische Umschau, 28, 351-361. Plum, F. J., Lodemann, E., Bender, S., Finkbeiner, T., & Gastpar, M. (2002). Gruppenmusiktherapie mit schizophrenen Patienten. Entwicklung des Kontaktverhaltens, des improvisatorischen Spielausdrucks und der Psychopathologie [Group music therapy with schizophrenic patients: Development of social behavior, improvisational expression and psychopathology]. Nervenheilkunde, 10, 522-528. Remschmidt, H., Schmidt, M., & Poustka, F. (2002). Multiaxiales Klassifikationsschema fu¨r psychische Sto¨rungen des Kindes- und Jugendalters nach ICD-10 der WHO [Multiaxial Classification Chart for Psychic Disorders of Children and Young Adults according to ICD-10 of WHO]. Bern, Switzerland: Huber. Sabatella, P. E. (2004). Assessment and evaluation in music therapy. An overview from literature and clinical practice. music therapy today. Music Therapy Today, 5(1). Retrieved February 6, 2006, from http://www.musictherapyworld.net Schumacher, K. (1999a). Musiktherapie und Saeuglingsforschung [Music therapy and infant research]. Frankfurt am Main, Germany: Peter Lang. Schumacher, K., & Calvet, C. (2007). The ‘‘AQR-instrument’’ (Assessment of the Quality of Relationship)—An observation instrument to assess the quality of a relationship. In T. Wosch & T. Wigram (Eds.), Microanalysis in music therapy: Methods, techniques and applications for clinicians, researchers, educators and students (pp. 79-91). London: Jessica Kingsley. Schumacher, K., & Calvet-Kruppa, C. (1999b). The AQR: An analysis system to evaluate the quality of relationship during music therapy. Nordic Journal of Music Therapy, 8, 180-192.

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Steinberg, R., & Raith, L. (1985). Music psychopathology II: Assessment of musical expression. Psychopathology, 18, 265-273. Steinberg, R., Raith, L., Rossnagel, G., & Eben, E. (1985). Music psychopathology III: Musical expression and psychiatric disease. Psychopathology, 18, 274-285. Tischler, B. (2000). Ist Musiktherapie empirisch begruendbar? [Is music therapy empirically reasonable?] Musiktherapeutische Umschau, 21, 312-323. Vanger, P., Oerter, U., Otto, H., Schmidt, S., & Czogalik, D. (1995). The musical expression of the separation conflict during music therapy: A single case study of a Crohn’s disease patient. Art in Psychotherapy, 22, 147-154. Woerner, W., Becker, A., Friedrich, C., Klasen, H., Goodman, R., & Rothenberger, A. (2002). Normative data and evaluation of the German parent-rated Strengths and Difficulties Questionnaire (SDQ): Results of a representative field study. Zeitschrift fu¨r Kinder- und Jugendpsychiatrie und Psychotherapie, 30, 105-112. Zahler, E. (2002). Frei improvisierte Musik in der Musiktherapie als Medium fuer Ausdruck und Kommunikation von Emotionen. Eine musikpsychologische Studie zur musiktherapeutischen Grundlagenforschung [Free improvised music in music therapy as a medium for expression and communication of emotions: A music psychology study for music therapy basic research]. Unpublished thesis, University of Vienna, Austria.

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Bios Dorothee von Moreau, Dr. rer. medic., music therapist (bvm, DMtG), Dipl. Psychologist, is a psychological psychotherapist with clinical practice at the University Clinic of Child and Adolescent Psychiatry and Psychotherapy in Wu¨rzburg and Frankfurt am Main, Germany, and chairperson of the postgraduate music therapy training BWM at the Freies Musikzentrum in Munich, Germany. Heiner Ellgring, Dr. rer. nat., Dipl. Psychologist, is a professor at the Institute for Psychology, University of Wu¨rzburg, Wu¨rzburg, Germany. Kirstin Goth, Dr. phil. nat., Dipl. Psychologist, is a psychologist in the Department of Psychiatry, Psychosomatics and Psychotherapy for Children and Young Adults at Goethe University, Frankfurt am Main, Germany. Fritz Poustka, Prof. Dr. med., professor emeritus, Clinic for Psychiatry, Psychosomatics and Psychotherapy for Children and Young Adults at Goethe University, Frankfurt am Main, Germany. David Aldridge, PhD, FRSM, is codirector of Nordoff-RobbinsZentrum, Witten, Germany.

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