Musicking in Early Intervention
Early Intervention as a Framework for Music Therapy with Caretakers and their Special-Needs Infants
My aim by writing this essay is to find an answer to the following question: How can music serve as a therapeutic intervention and tool in early intervention with caretakers and their special-needs infants? As early intervention (EI) is aimed at the family as a whole the following sub-questions are inevitable. How can music be used to make a meaningful contact with a special-needs infant? And how can music be used to make a meaningful contact with the infant's caretakers?
My interest in this subject stems from years of clinical work with handicapped children and an acquaintance with their parents/caretakers. The varying handicaps and developmental needs of these clients have called for varying theories and treatment approaches throughout their therapy processes. The effectiveness of music therapy procedures and the client's progress in music therapy has also varied. But what the handicapped children have had in common is a delight in music and musical expressiveness. In most cases they have been brought to music therapy by parents who have noticed their children's apparent interest in music. Their interest upon hearing music may have been expressed by spontaneous movements despite physical handicaps, spontaneous songlike utterances despite delayed speech, focused attention or other expressions while listening to music. Caretakers sensitive to their children's musical intelligence, and hoping for their optimal maximum obtainable development and well-being, sought the services of a music therapist, regardless of the way the children's interest was expressed interest..
While evaluating the effectiveness of music therapy with these children and the role of music therapy in their overall treatment scheme, the thought often occurs whether they could not have benefited from an earlier intervention of a musical nature. Another persisting thought is whether the private music therapy studio where they have received music therapy is not in a sense isolating rather than integrating. That is, neither encouraging them to express their utmost potential and their musical-selves beyond the music therapy room, nor informative enough for others trusted with their care.
An acquaintance with the children's caretakers has furthermore revealed glimpses of feelings, needs, and struggles associated with having a handicapped child. This has focused attention on the idea that parents of handicapped infants could benefit from music therapy no-less than their children.
To give birth to a handicapped child is something no one expects, and researches has revealed that the infant's handicap may negatively affect caretakers-infant interaction. Due to an infants handicap the family (the ecological unit) itself can be at risk and in need of intervention (Bruscia1998, p. 229). If not worked through, the caretaker's trauma might cause or contribute to the health problems of their family members. Inability to cope with the situation could also handicap the child further. The flow of intuitive interaction between the infant and its caretakers could be jeopardized whether due to a lack of responsiveness to the intuitive parenting, parental over-protection or over stimulation, parental emotional instability in times of crises or something else. Using music to attend to the needs of the caretakers as well as informing them about the importance of early music stimulation for their child (i.e. informed intuitive musicking/music stimulation) could have a lasting beneficial effects on all involved.
Throughout our lives development occurs within a context of various relationships. It is however the opinion of many that our first relationship with caretakers is of fundamental importance. A second generation of early intervention (EI), in the form of services and supports for children from birth until the age of six, accentuate that families maintain their central role as caregivers and that they acquire new knowledge and skills, which support that role. EI also emphasizes that in order to make a significant difference in growth and development the intervention is better when it is begun as early as possible. Other premises are that infants are active learners, influencing their environment as well as being influenced by it and that development is influenced by family life, culture, health and other external circumstances (Innocenti 2001, pp. 2-6).
Theorists like Daniel Stern (1998), Colwyn Trevarthen (1993,1995), and Ellen Dissanayake(2000) support the notion that music and intuitive musicking is the most effective method for early intervention. Growing evidence of early predispositions for musical perception in infancy and the extensive research on early sources of musical stimulation in infants care giving environment thus encourages one to examine the possible effect of informed intuitive music stimulation as a musical bridge builder for the developing special-need infant and his/her caretakers. Music-therapeutic intervention could play an important role for the development and well-being of these (special) families within the framework EI provides.
Intended for parents of handicapped infants, professionals in the field of early intervention and music therapists interested in working with this population, this paper is thus focused on the question: How can music-therapeutic intervention serve as a tool in early intervention with caretakers and their special-needs infants?
Early Intervention
"The special education and treatment of the handicapped child, which often starts in infancy, consists in team work between the family, the teacher, the physician, and the therapist. It cannot succeed unless all parties work together and are geared to a common goal, namely the welfare of a human being." (Alvin 1965/1980, p.1).
Early intervention defined
The societies of the world have not always shared the goal of welfare for all human beings. Throughout the ages, society's response towards the handicapped has revealed various reactions and emotions. The handicapped have been eliminated or left on their own to perish. They have been excluded from the activities and facilities of their society. And they have carried insulting labels like imbecile and fool. Although still carrying labels, attitudes towards the handicapped have changed. Today they benefit like other human beings from advances in research and government legislations.
Developments in neurobiological, behavioural, developmental and social sciences in the last three decades have led to major advances in understanding the conditions that influence how well children fare in the world, advancing today's early intervention or the so called second generation of EI (Shonkoff and Phillips 2001, p. 1, Sigurðsson 2001, p. 40).
Rye (2001, p. 7) refers to classical studies by Rene Spitz (1946), Harry Harlow (1962), John Bowlby (1969, 1980, 1988), Lev Vygotsky (1978) and Urie Bronfenbrenner (1979) as well as studies by Antonovsky (1987) and Rutter (1985), that which demonstrated the importance of opportunities for human contact, care and learning in the early years of children's development. In the interplay of various factors important for the infant's health, psychosocial development and learning, the quality of human relationship and the care experienced by the children seemed to serve a principal role. Concepts like attachment and bonding became the framework for studies in child-caregiver interaction. And in the eighties, Colwyn Trevarthen (1993,1995) and Daniel Stern (1998) also described an incredibly fine-tuned reciprocal communication between infants and their mothers through mutual use of sounds, mimicking and movement.
In its narrowest sense the term early intervention refers to what is done early in the life of a child to influence its developmental course. But in a broader framework research within EI seeks to find answers to questions such as: What aspects of the environment have the most significant influence on early development? What is needed to alter the course of development for the better? Although EI refers to children from birth to the age of six all the various definitions collectively emphasize the importance of influencing the developmental course of at-risk and disabled children with systematic interventions as early as possible. Interventions include various educational, developmental and therapeutic activities as well as support networks of a public and personal nature. That is support from family, friends, and other professional relationships that help families maintain their central role as caregivers and encourage the development of to develop new knowledge and skills (Innocenti 2001, p. 2; Sigurðsson 2001, pp.41; Shonkoff and Phillips 2001, p. 21).
Key factors in implementation of early intervention.
Cultural differences, the variety of available resources, implementation strategies, theoretical models, and EI extensive and multidisciplinary research base, make the scope of EI vast and complex. Major premises of development, certain assumptions regarding services, and goals and principles of early intervention are however shared where EI is successfully implemented. The following lists (core concepts) reflect the prevailing views of researchers, theorists and clinicians who study young children and frame our understanding of the nature of human development during early childhood (Shonkoff and Phillips 2001, pp. 22-32; Innocenti 2001, pp. 6-16).
Premises of development:
Relationships, and the effects of relationships on relationships are the building blocks of healthy development.
Human development is shaped by a continuous interaction between biology and experience.
The first few years of life are critical to subsequent development.
Regulation is an essential property of all living organisms, including physiological and behavioural regulations as well as those that influence complex behaviours involved in the expression of feelings, the capacity to pay attention and control impulses.
Children are active learners, influencing their environment as well as being influenced by it. This reflects the intrinsic human drive to explore and master ones environment.
Intervention is more effective when begun as early as possible, but the child remains vulnerable to risks and open to protective influences throughout the early years of life and into adulthood.
Family life, culture, health and other external circumstances influence development.
Individual differences among young children can make it difficult to distinguish normal variations and maturational delays from fleeting disorders and persistent impairments.
Development is shaped by the ongoing interaction among internal and external risk factors that increase the probability of a poor outcome and protective factors that increase the probability of positive outcome.
Children develop along an individual pathway which course is characterized by continuities and discontinuities, as well as by a series of significant transitions.
Effective intervention that changes the balance between risk and protection can alter the developmental course in early childhood.
Four assumptions regarding services:
Children at risk or with established disabilities have the right to specialized services to maximize their development and their possibility for success.
Families of children with disabilities often experience special needs and stresses.
The provision of earlier services might mean the achievement of the most favourable outcomes then for children and their families.
Because of the unique characteristics, needs, and resources of each family, an individualized approach to service planning and delivery is essential.
Goals and principles of early intervention:
The quality of a childs physical and social environment has a significant influence on the child's behaviour and long-term development.
EI is effective in reducing the impact of disabling conditions.
Parent involvement is essential in EI.
EI is most effective when professionals work together as an interdisciplinary team.
Professionals should focus on the child's strengths rather than its deficits.
Intervention needs to be developmentally based.
Individualized assessment is a necessary prerequisite to effective intervention.
Skills taught to children with disabilities may not generalize to other settings unless specific planning and training is designed towards that end.
These key factors conducive to the child's maximum growth and development concern elements in interpersonal relationships such as: sensitivity, reciprocity, affective warmth, non-intrusive patterns of interaction, and discourse-based social exchanges; as well as experiences organized by the family that involve social networks adapted for the special needs and talents of the child.
Nature through nurture.
The debate about nature versus nurture no longer exists. Researches in developmental neurobiology and developmental psychobiology, now emphasize their inseparability and complementarity. Nature and nurture or nature through nurture is now believed to be sources of stability and flexibility in human growth, their interaction resulting in human development (Shonkoff and Phillips 2001, p. 41). The infants responsiveness to its surroundings hinge significantly on genetically based ways of feeling, interpreting, and responding to environmental events. This emphasizes the importance of considering each infant's individuality and caring conditions that can counteract the expression of heritable vulnerabilities.
A distinction is made between the so-called experience-expectant and the experience-dependent processes influencing the architecture of the human brain. The experience-expectant processes are based on the expectation that certain experiences will occur that organize and structure essential behavioural systems. These include early visual and auditory stimulation for example, the lack of which can cause life-long detriments in behavioural functioning. The experience-dependent processes are based on new experiences that help to trigger new brain growth and refine existing brain structures. They rely on the unique life experiences that contribute to individual differences in brain growth and are the source of the human brains adaptability and lifelong plasticity (Shonkoff and Phillips 2001, p. 54).
Kennair (2000, p. 35), arguing against the notion that a certain period of early development determines the nature of the adult psychopathology, and the idea that song and instrumental music may be curative for pathology of early infancy, says: . . . development is something that happens to physiological structures brain structures. Once these have changed they process information differently. In his opinion, an overabundance of causal pathways may cause pathology. And one may not confuse a healing effect of an intervention with the identification of the causal pathway. Whether or not one agrees with Kennair's notion that the primacy of infancy is no longer the most likely model of pathology development, the following is not a source of any debate.
Neuroscientific research indicates that brain development which begins well before birth is characterized by remarkably rapid brain development in early childhood. Research also indicates that the brain has a lifelong capacity for growth and change. Animal studies have revealed that younger brains react more rapidly and to a greater degree to environmental variation. These studies also suggest that removal from complex environments results in decreasing benefits over time. As mentioned above, certain brain systems such as the auditory and visual systems need early environmental inputs to develop normally, other ones for example those involved in cognitive, emotional, and social development are now thought less sensitive to critical periods.
Animal studies have also shown that early or sustained stressful experiences such as disrupted care giving can cause detrimental effects resulting from over-activation of neural pathways that regulate fear-stress responses. Behavioural data on young children exposed to adverse experiences and the physiology of traumatized or deprived children are consistent with the animal studies (Shonkoff and Phillips 2001, p. 217). Thus early stimulation matters and especially for those who are born with conditions that affect their capacity to access and incorporate the stimulation needed to organize the developing nervous system.
Population served.
Early intervention is aimed at families and young children (0-6 years old) who are either defined as at-risk, or with established disabilities. At-risk conditions are grouped as either environmental risk conditions or biological risk conditions. The scope of possible environmental risk conditions varies between societies. The following are the most common ones: Caretakers unable to perform essential parenting functions due to either a disease, young age or a handicap; upbringing in a shelter or a foster care environment; violent, neglecting or abusive caretakers; upbringing in an unstable home environment; legal guardian not established. Infants with biological risk conditions are those born prematurely, children who fight life threatening or chronic diseases, and children who become injured or exposed to drugs or other intoxicants (Innocenti 2001, p. 3-4).
Children with established risk conditions are those born with chromosome abnormalities, neurological impairments, atypical developmental disorders, very low birth weight (less than 1000 grams), and a delay in cognition, physical/motor, speech and language, psychosocial, or self-help skills (Zervigon-Hakes, A.M. in Innocenti 2001, p. 5). In the United States and many other western countries the type of risk conditions affects to some degree the type of services offered. What works best for each one in the three categories mentioned above is still an unanswered question.
The families of these children are also being served within the framework of early intervention. And they are as varied as they are many. The caretakers, the siblings and even the grandparents life situation with regard to upbringing, education, experience, social- and work-status, and external support, are interwoven with culture and everything else that shapes a person, - his or her needs, dreams, hopes, personality, etc. Within EI a tapestry of multi-various relationships are thus formed. There are relationships between the infant and the parent (the mother or the father), between parents and the infant, between siblings, between grandparents and the infant, between the therapist and the caretakers, the therapist and the infant, between the different therapists and health professionals, etc. With regard to all the different relationships formed, both personal and professional, the clinical picture can become extremely complicated even to the extent that it hinders effective intervention. New role-relationships are formed, and reciprocal interpersonal relationships coloured by different interactive patterns, affective qualities and needs at any given moment (Hougaard 1996/1997, p. 132).
The future.
Empirically described qualities of caretakers-infants communication, and different clinical theories launched the modern era of early intervention. Various private and public programs were developed to implement governmental laws and regulations. For example the Head Start program and the Handicapped Children's Early Education in the United States, the Marte Meo program in Holland and the More Intelligent Sensitive Child program (MISC) developed by professor Pnina Klein in Israel (Shonkoff and Phillips 2001, p. 35, Rye 2001, p. 11).
In the early years, research on the influence of EI focused on the promotion of intelligence. Often this research showed a short-term impact on standardized IQ test performance, with a subsequent fade-out of effects during middle childhood. As the number of those who criticized conventional intelligence testing rose over the years investigators within EI shifted their focus. An approach to evaluation and intervention embedded within the child's natural environment and conducted in an ongoing information-gathering manner became advocated. Also, interest in measuring program effects shifted towards different target areas. Self-regulation, interpersonal skills and relationships, knowledge acquisition skills and problem-solving abilities became the focus of research. Emotional and social development, and the underlying functional capacities that lead to cognitive gains are today considered a better indicator of how well the child will fare in life than a measure of IQ (Shonkoff and Phillips 2001, p. 348, Sigurðsson 2000, p. 55).
For the future development of EI it is imperative to provide scientifically grounded portraits of the most important achievements of early childhood and the environmental conditions that either promote or impede their accomplishment. It is also necessary to point to directions for both action and further studies toward those ends. The use of knowledge to nurture, protect and ensure the health and well-being of all young children and their families is however an important objective in its own right, regardless of whether measurable returns can be documented in the future (Shonkoff and Phillips 2001, p. 36). This is a collaborative, interdisciplinary task that needs to be based on positive and healthy relationships between all involved.
Music therapy and early intervention
".we music therapists have more than ever an imperative to heighten and broaden our vistas to effect an impact globally that reaches far beyond the traditional treatment room. We must look to new ways and possibilities for bringing the essence of music therapy its profound humanness - - - to the ordinary people on planet Earth. Our intention is attainable. For we music therapists have as our therapeutic agent a universal means of human contact, communication, and expression music. The potential is unbounded" (Boxill in Bruscia 1998:230).
The theoretical framework.
Within the framework of early intervention and in the rapidly growing field of infant health, varied therapeutic concepts and clinical theories are borrowed and applied. Behavioural theories focus on teaching various skills, developmental theories focus on enhancing the natural growth process, cognitive theories focus on experience and action that help build thinking skills, family system theory focuses on the child within the family, and psychodynamic and interaction theories focus on the relationship between family members. In practice theories are combined, and they undergo modification to meet the needs of a new clinical population. As said above, in early intervention the population are infants and children from 0 to 6 years of age and their caretakers.
According to Stern pathologies of the above mentioned may consist of relationship disturbances that can be manifested as eating and sleeping disorders, attachment disturbances, early conduct disorders in the infant, or as parental anxieties, disturbances in parenting, and other forms of parent-infant disharmonies. Developmental lag, handicaps and other disabling conditions not originating in the parent-infant relationship are also included (Stern 1995, p. 2).
Stern advocates (1995, p. 2-4) that various parent-infant therapies work equally well and that it may be difficult to find differences in outcome between different therapies. What the different therapies share seems thus to account for more of the beneficial effects than the differences do. This notion explains why multidisciplinary teamwork can function, i.e. when the same client (caretakers-infant) is perhaps assessed and treated by different therapies without them ever consulting each other, as sometimes is the case.
According to Sterns belief the following can be assumed:
In all the different therapies there are common features (always present and always acting) that are non-specific to any one of the therapeutic approaches.
The different therapies have roughly equal outcomes but they arrive there by different mechanisms of therapeutic action.
Therapies can be combined to get better results than any one therapy alone.
If there are commonalities used by all the various parent-infant approaches different from those used in other domains we can perhaps talk about unique and coherent features belonging to parent-infant therapy.
A graphic model by Stern (1995, p. 15) shows how a support system (therapy) of a kind can act as a continuous maintaining force or as an episodic influence on different elements of the mother-infant-therapist interaction. If the support system or intervention is directed towards the mother this model holds that it will have its greatest effects on the mothers representations; affecting how she regards herself as a mother and a person, and consequently affecting what she does behaviourally with the baby. All the elements in this model are however always:
Present and acting,
Interdependent,
Dynamically and mutually influencing each other,
Reciprocal.
If music therapy interventions are successful in changing the primary caretakers feelings (representations) it will according to Stern have direct or indirect effects on all the other elements in the relationship. It will change how the mother subjectively experiences herself as a mother thus changing her interaction with the infant. This may alter the infant's behaviour that which adjusts to the new interactive reality and adjusts its representation of current and future interactions.
This model allows the different therapies to use different ports of entry into this single dynamically interdependent system. The interrelated nature of the system itself transforms specific clinical interventions into general clinical outcomes.
The nature of the system makes it also difficult to restrict therapeutic intervention to one port of entry alone. It constantly crosses boundaries between the interpersonal and the intrapersonal, the individual and the shared (Stern 1995, p. 16-17).
However, when compared to established therapeutic approaches the caretaker-infant relationship presents several unique aspects. And these aspects must be considered when designing treatment for this clinical population (Stern 1995, p. 2-4). They are:
The patient is not a person but a relationship between an infant and its caretakers. It is influenced by the past history on the caretaker's part but an evolving one on the infants part. In this context the term relationship disturbance is not clear.
To what extent the infant's psychological nature is the construct of the caretakers imagination is not known.
The infant is not diagnosed within a classification system such as DSM or ICD as having psychopathologies.
The caretakers see themselves as having a problem rather than an illness.
The caretakers and especially the mothers have a psychic organization referred to as the motherhood constellation - a mental life adapted to the reality of having an infant to care for. This reality cannot be viewed through the lens of a therapy intended for other sorts of patients.
Therapy takes place within a phase of which the prime function is to effect change, maturation, development and growth.
To identify the problem may be difficult. Often Caretakers often feel responsible for the infants state affecting normal responsibilities and defences of the target patient.
The mode of interaction is primarily nonverbal and pre-symbolic. A paralanguage or a gestural language of biological communication (Small 1998, p. 58). Pathology or difficulties dealt with are seen as the result of these preverbal interactions.
If we abandon the purely behaviouristic approach focusing treatment/therapy solely on what the caretakers and the infant do while interacting and bring into focus the different relationships and the representation of the interaction, the clinical picture becomes more complicated. Representation refers to the amalgam of remembered history, personal interpretation of relationship and interaction as perceived through the many lenses of fantasies, hopes, fears, family traditions, myths, important personal experiences, current pressures, etc. It is the caretaker's representations that are enacted in the interaction that influence the infant. The interaction between the caretaker and the infant is also the ground for the enactment of the infant's representations which influence the caretakers respectively.
Sterns models of psychopathology
In order to estimate the nature and extent of the clinical issues to be dealt with a model of some sort is needed. Within the framework of psychopathology, Stern discusses four main models each presenting both advantages and disadvantages (1995, p. 34-40). It is his belief that the most experienced clinicians use an eclectic mix of the four models in clinical intervention depending on the clinical material presented.
The first model The Distortion Model examines to what extent subjective reality has been distorted from some objective view of reality. An example of this would be the handicapped or developmentally delayed infant who is seen by the caretakers as completely normal and in need of no special interventions. In some cases the distortion model can be useful. A distorted optimistic view of the caretakers may predict better than an objective measure of the infants future possibilities. Also a positive distortion is a sign of maternal love or what Winnicott terms the primary maternal preoccupation ; the absence of which can be a grave prognostic sign in new parents. When the caretakers work in what Vygotsky (in Stern 1995:35) calls the child's zone of proximal development mothers intuitively teach their children at a level that is just a little ahead but not too far ahead of where their children currently function. The caretakers act as if the infant can actually do something it is not yet capable of, thus pushing the infants development forward.
The second model is the Dominant Theme Model. In this model the infant is woven into themes that have been ongoing and problematic in the life of the mother before the infants birth. Themes of this nature around which schemas-of-being-with evolve, allow no room for the infant to present itself as it actually is and to develop its own representational space. An example of this is: the replacement baby who takes the place of a dead family member, the baby who is needed as an antidepressant to animate a depressed mother; the baby who provides unconditional love, the baby as a normal infant or a perfect baby, etc. In Sterns opinion it is possible that the caretakers-infants life situation or motherhood may introduce themes that are unique to itself and not derivatives of other general psychodynamic themes.
A third model is the Narrative Coherence Model. In this model a narrative coherence of what was experienced is thought to have more influence on current psychological life and to be more predictive than what actually happened. It is not whether the caretaker's representation is distorted or dominated by a particular theme but the coherence, comprehensibility, consistency, plausibility, and emotional balance of the narrative that gives it the predictive power.
The forth model is the Out-Of-Developmental-Phase or Ontogenetic Model. Research has revealed that there is a sort of normal growth and development curve of the caretaker's schemas-of-being-with the infant. If the representations are out-of-phase, they provide a certain way of organizing and viewing possible psychopathologies. An example of this model would be a mother that gives birth to a premature baby. She has not had the normal time allotted to undo the specificity of her representations of the foetus as her infant to be. Her interactions with the infant reflect unfinished representations possibly disadvantaging the infant further who fights a developmental lag due to short gestational age. Caretakers representations may also become stuck long beyond a certain phase, or move in advance of things. Respectively making the infant either remain dependent or become independent before it is capable.
A distressing situation arises when caretakers are prevented from designing and elaborating a developmental course for their represented baby due for example to medical complications, developmental lag, or handicaps. The caretakers can neither rely on guidelines of normal development nor past experiences and it becomes extremely difficult to elaborate a meaningful representational structure of the future. Both the present and the future are coloured by a representational vacuum (Stern 1995:39).
Whatever the cause of the problem, the primary symptom is manifested in the context of interaction or in the context of formed relationships. Regulation of arousal and activation, regulation of affect quality and level, physiological regulation, teaching, etc., occur in an interactive process between the infant and its caretakers. The infant experiences its caretaker's depression for example through different types of depressive interactions. It is through observing how the caretakers and the infant relate to one another that one gains insight into the clinical issues in the caretakers-infant relationship (Stern 1995, p. 71).
What happens in the representational worlds of the expressive and receptive participants during partaking in one song for example? The cognitive sciences tell us that representations, memories, and motor programs are composed or constructed anew each time an act is committed or a memory is retrieved. This means that what is happening now will employ all the schema that are related to the present ongoing activity, mentally or physically. The relationship formed around a song theme or an improvisation focuses on the moment-to-moment interaction to activate and make conscious difference and perhaps latent representations. It is capable of eliciting change in implicit knowledge by influencing the moment of meeting as well as eliciting change in explicit knowledge through interpretations (Stern 1995, p. 58, Stern1998, p. 300).
Musicking as a tool in early intervention
Musicking is a term Christopher Small introduces in his book Musicking The Meanings of Performing and Listening (1998). Small believes that one cannot ask the question "What is the function of music in human life?" because in his opinion there is no such thing as music. Music is an activity he says, something that people do. The object or thing termed music is only an abstraction of the action. It is useful perhaps when conceptualising our world but dangerous because one may come to think of it as more real than the reality it represents (1998, p. 2). Small further believes that the fundamental nature and meaning of music lies in what people do with it. It is only by understanding what people do as they take part in a musical act that we can hope to understand its nature and the function it fulfils in human life (1998, p. 8).
To take part in a music act is of central importance to our humanness. And to music covers all participation in a musical performance, whether it is active or passive, sympathetic or antipathetic, constructive or destructive, interesting or boring (Small 1998, p. 9). In Smalls opinion every human being forms a kind of theory of musicking. That is, an idea of what musicking is and is not, and of the role it plays in our lives. But as long as it remains unconscious and un-thought about, it can be both controlling and limiting (1998, p. 13).
According to Dissanayake (2000, p. 73) infants are guided by their instincts to look to elders in a search for what is meaningful. And research has shown that parents use preverbal communication or musical elements intuitively with their new-borns not knowing about the importance of humming, singing, rocking and playfulness. This musical interaction supports the acquisition of speech, affects behavioural or emotional states in infants, and supports the development of musical, interpersonal and emotional intelligence. Parents do this most often without formal knowledge of its importance. At it's best, it is done lovingly, carrying with it emotional states, and it is also done playfully encouraging creativity and perhaps humour in later life, says Papousek (1996, p. 46-50).
It can be the role of the music therapist to inform caretakers about the importance of their intuitive musicking or the music stimulation in which they partake with their infants. To make caretakers of handicapped infants become aware of their theories of musicking in order to make better use of it for the benefit of themselves and their infants. To understand musicking is a part of understanding ourselves and our relationships with other people; be it our infants or other creatures with which we share our planet, as Small (1998, p. 13) stresses. If through musicking we can bring into existence relationships in our world as we wish them to be, as Small suggests, then it is possible for caretakers with the guidance of a music therapist to use music to learn about themselves, their infants, and their experiential world of relationships in all its complexity. And by knowing their world they learn how to live well in it (1998, p. 50).
Small builds his theory of musicking on Bateson's philosophy of mind the ability to give and respond to information which is connected to the larger network in which every living creature is united with the other ones. The mind relates to the environment by an active process of engagement with it. What holds the pattern together is the passing of information from the outside world to the inside world from the external to the internal pathways and reverse. Thus one can say that living things shape their environment as much as they are shaped by it (Small 1998, p. 53).
If the ultimate goal of music therapy is to induce some kind of change, it is done through relationships. And in early intervention the participants in various relationships are: the music therapist, the caretakers, the infants, perhaps siblings and other relatives and preferably other therapists. The possible clinical applications are diverse, targeting areas such as: physiology (for example: heart rate, blood pressure, respiration, electromyography, neurological functions and immune responses), psychophysiology (for example: pain, levels of arousal and levels of consciousness), sensor motor developments (for example: reflexive responses and their coordination, sensor motor schemes, and fine and gross motor developments), perception (for example: apprehension of figure-ground, part-whole and same-different relationships and discrimination of differences), cognition (for example: learning skills, knowledge, thought processes, and attitudes), behaviour (for example: activity level, efficiency and morale), emotions (for example: range of emotion; variability, appropriateness, and congruence of feelings; reactivity, expressivities, vitality, defences, anxiety, depression, motivation, and imagery), communication (for example: receptive and expressive speech and language skills and other nonverbal communication modalities), interpersonal relationships (for example: awareness, sensitivity, intimacy, tolerance of others, interaction skills, and role behaviours), creativity (for example: inventiveness, and problem-solving skills) (Bruscia 1998, p. 153-154).
Each family has unique characteristics, needs and resources and no one type of therapy or set of services can meet the needs of all of them. A positive change induced by a therapeutic intervention like music therapy can however have an extensive influence when generalizing to non-musical areas because of the interdependence in all areas of human functioning and the interdependence and reciprocal nature of the system at work (the clinical model).
In early intervention the emphasis is on supporting families in achieving their own goals. They may want to learn mediation qualities conducive for emotional communication and attachment. Their focus can be to gain insight or to build a support system, which helps them to endure. Their focus may also be on the infant, encouraging developmental milestones to emerge. The incredible diversity of the clinical population within early intervention and the possible music therapeutic interventions are overwhelming. Through musicking alone, with other caretakers, with their infants, with their music therapist, etc. the focus could be to prevent, cure, reconstruct, support, habilitate, rehabilitate, palliate, etc. But whatever theoretical background the music therapist has and whatever her therapeutic aim, the emphasis should be to work within the caretakers own frame of reference, helping them to discover their own resources, gain awareness of positive qualities of interaction, and how to use these qualities to form mediating relationships (Klein 2001, p. 32; Bruscia 1998, p. 155-157; Trolldalen 1997, p. 27).
Meeting the needs of the special-needs infant
To avoid focusing narrowly on the often complicated clinical picture of the premature, the handicapped or the sick infant we can state that the new-born carries with it his/her own way of making sense of the world and its relationships. Before birth the infant may learn which relationships are of value and which are not, what to remember and what not, and how to order experience into categories. This is the result of an active engagement with the world controlled not only by genetics and environmental factors but also relationships and experiences. The physical development of the human brain and the neural pathways that embody memory for example are profoundly influenced by our experience. Those pathways that are used develop and combine, while those which are not used weaken and die. All sensations and relationships experienced, whether love, fear, security, or pleasure undergone in infancy when neural development is expeditious, can thus determine not only the very anatomy of the brain but also the habitual paths of thought, how we engage in the world and what we value (Small 1998, p. 131).
According to Trevarthen(1993,1995), being part of culture is an innate human need. And the infants inborn motivation to comprehend the world is kept alive by sharing experiences and purposes with others in relationships. It is in the interplay of protoconversations between infants and their caretakers where emotions play a central role that meanings emerge. And it is also in relationships where cooperation and negotiation take place that the infant acquires the ability to think, understand and use language (Trevarthen 1995, p. 5; Johnsen, Sundet og Torsteinsson 2000, p. 68).
We cannot answer the question: How does the handicapped infant experience music? But like Small we can say that If everyone is born musical then everyone's musical experience is valid (1998:13). In his opinion the meaning of the act of musicking lies in the relationship. Not only the relationship between sounds and silences but between people who take part in whatever capacity. Too complex to be put into words perhaps but not too complex for minds to encompass. Caretakers sing differently when the infant is present compared to the way they sing when it is not. Where themes of separation and attachment preoccupy caretakers, the simple act of singing to and with the infant may prove both a positive and a successful intervention facilitating the infant's ability to thrive (Courtnage 2000:71).
The whole of musicking includes sensory stimulation (experience-expectant processes and experience-dependent processes), relationships and togetherness, representational worlds, moments of meaning, and intersubjectivity. The sensitive child born with intuitive sympathy, capable of sensing the caretaker's motivations and intentions responds to them and communicates with them from the day it is born and vice-versa (Johnsen, Sundet and Torsteinsson 2000, p. 68; Trevarthen 1993:54). At each moment issues such as trust, attachment, dependence, independence, control, autonomy, mastery, individuation, and self-regulation are being worked on in accordance with the development and capacities of each partner (Stern 1995, p. 70). These issues are life-long and so are the clinical ones stemming from them. The infant's development and growth however provide it with new behaviours and means for conducting the same issues, altering the form in which they are negotiated (Stern 1995:75). In all normalcy, the early experiences on which healthy brain development depends are ever-present in the infant's life. But as said before, concern needs to be devoted to those children which cannot due to a handicap or other risk factors obtain these experiences on which the developing nervous system depends (Shonkoff and Phillips 2001, p. 184).
The newborn infants are capable of imitating the expressions of other persons. With astounding accuracy they can read emotions in the face or voice and they can hear and learn to prefer subtle differences in speech that identify their caretakers. As early as two-month-old infants are capable and willing to enter protoconversations through varied coordinated expressions and gestures that sympathetic parents respond to (Trevarthen 1995:9). What happens if the infant cannot show its interest to others? What does the infant experience when it fails to squeal, growl, yell, laugh, smile or move in response to attending caretakers? What happens if there is a lack of the cooperative skills? How does this failure influence the child's developmental course and well-being? Just as we cannot know how the special-need infant experiences music we can only imagine the infants subjective experience of being in an unfulfilling relationship, or what it is like to be trapped in ones own body.
Like other infants, the handicapped, the premature and the sick need to be nurtured and loved. They also need to be in encouraging relationships that compensate for their lack of motivation or anything else that hinders natural developmental course and well-being. The environment of their homes, the behaviour of their caretakers, but most of all their relationship with caregivers who are emotionally invested in and consistently available to the infants affect what they learn, how they react to the events and people around them, and what they expect from themselves and others. Early attachments are not only important for the caretakers-infant relationship. They set the stage for other relationships, they foster the exploratory behaviour that is vital to early learning and appear to have consistent and enduring influence on young childrens social and emotional development. (Shonkoff and Phillips 2001, p. 226-236). Without appropriate environment and relationships to shape, facilitate, and encourage their development young children may become further handicapped.
Research challenging the notion that children are relatively passive players in the socialization process has shown the many ways in which infants contribute to their rearing environments, including influencing the parenting they receive. In a complex manner parenting interconnects with the infants inherited strengths and vulnerabilities to affect the pathways en route to adulthood. Another important finding is that infants and children have rich emotional/psychological lives and can suffer in ways that heretofore has never been realized. Parenting is always a challenging work and parenting a handicapped infant is much more so. This may be due to the fact that it is not clear what the infant needs or because the needs of the infants exceed the time, attention, and sensitivity that the parents can provide. The fact that the prevalence of atypical attachments to caretakers, and behavioural and psychological problems is more among the handicapped than the normal population tells a dramatic story (Sigursson 2001, p. 42; Shonkoff and Phillips 2001, p. 233-234).
Meeting the needs of the infant's caretakers.
In all normalcy pregnancy is a time of anticipation. Caretakers form mental worlds of the baby and of themselves as parents. This representational world which is made up of real objective and imagined subjective situations includes among other things the caretakers fantasies, hopes, dreams, memories and prophecies for the infant's future, and plays an important role in determining the nature of the caretakers relationship with the baby (Stern 1995, p. 18). This relationship begins prior to birth forming schema of being with the present and the future baby. Between the fourth and seventh months of gestation the richness, quantity and specificity of the schema about the infant to be grows. Between the seventh and ninth months however the positive representations are believed to be intuitively undone in order to protect the infant-to-be and the caretakers from becoming disappointed, should there be a discrepancy between the real infant and the one that dwells in their mind (Stern 1995, p. 23). Both positive and negative representations such as fear of deformity are thus undone, although they may flourish subconsciously.
Similar to the unique psychic organization formed with the birth of a baby and Stern calls the motherhood constellation so must a unique psychic organization or a constellation be formed with the birth of a handicapped baby. According to Stern this constellation can last for months or years and it determines a new set of action tendencies, sensibilities, fantasies, fears, and wishes. The period the caretakers of a handicapped infant enter is however not as transient as the motherhood constellation, and it involves subjective themes that may need a different therapeutic partnership (Stern 1995, p. 171-172). Following are some of the themes that emerge when a child is born. Themes that may not be specific to the motherhood constellation but to all those concerned for the well-being of their new-born infant. The different themes entail groups of ideas wishes, fears, memories and motives that influence the caretakers actions, feelings, interpretations, interpersonal relations, and other adaptive behaviours (Stern 1995, p. 173).
The life growth theme is concerned with ones capability to maintain the life and growth of the baby. Questions like: Can I feed the infant and make it grow physically? are manifestations of the mothers worries about whether she is a good enough mother and it also concerns worries about the infants ability to stay alive despite perhaps a profound handicap or a disease. The primary relatedness theme concerns the caretakers concern over their ability to emotionally engage with the baby. Will I be able to love that handicapped infant? Will I be able to respond to all its needs? Can I relate to the infant in a nonverbal, pre-symbolic, spontaneous, intuitive manner? The supporting matrix theme evolves around how the caretakers create and permit the necessary support systems to fulfil their obligations. In time of crises, for example when giving birth to a handicapped infant, the available support system is limited. Relatives and friends do not know how to behave. They do not know if it is proper or improper to congratulate the parents. The parents may feel abandoned and failing in keeping up a supporting matrix. In a state of shock they cannot make necessary use of the first information or initial support they receive. Their earlier parental experience does not suffice. Their pain, self-accusations, or other feelings may compromise their parental capabilities. They may become co-dependent, and fused with the baby in their parental role. They do not have any role-models to identify with. The caretakers need to feel surrounded and supported, guided, valued, appreciated, and instructed. The identity reorganization theme relates to the caretakers ability to transform their self-identity to permit and facilitate their parental functions. The model needed for identification is only partially there, due to the special needs of this unexpected constellation. Identifying with the caretakers own parents, does not provide the right model to feel secure in the new and difficult role (Stern 1995, p. 180).
To give birth to a handicapped or a sick child is an ordeal no one foresees. To use the words of a father who has a handicapped son: What were we supposed to do with the child which was not the one we had longed for or expected, - a child so fragile and vulnerable that we could loose him at any moment? (Ragnarsson 1997, p. 23). Living only in the moment; it felt like there had never been any past, the future was hidden in a haze and the present was almost unbearable. Ragnarsson's answer to the question: What it was like to have a handicapped child? changed from day to day. The answers were coloured by how he felt, how he managed to work through his emotions, and by his view of life and religion in general. He recognized also that society and culture were influential in shaping his answers.
Like so many in a similar position Ragnarsson was left to grieve, consciously or subconsciously, the loss of the perfect baby. He went through stages of denial, isolation, anger, bargaining and depression. He fought pain and sorrow, built defence mechanisms, and experienced going from a state of stupor to being constantly alert (1997:24; Kubler-Ross 1969). He forgot himself struggling and occupied with the different themes this new constellation brought on. He became co-dependent; a victim of his situation in an attempt to do everything he believed possible to compensate for his sons handicap. A long list of specialists, including a music therapist, was at his service, helping his son.
Whatever the means and the resources of the caretakers, Ragnarsson's task and other caretakers in a similar situation is coming to terms with or accepting the fact that their child differs from other infants in some way; that their infant is disabled, and needs special attention. And to accept the fact that it is possible to help but not to cure. Caretakers also have to integrate the child and the disability into their lives, learn to endure their own errors and shortcomings and to search for meaning in their loss. This is a difficult task, and in the process dysfunctional patterns of parenting may develop, as well as eliciting behavioural and emotional problems in the children.
Research has revealed that high levels of parenting stress are associated with dysfunctional parenting behaviour and negative interactions between parents and their child. Parenting stress has also been associated with an abnormal child's development and the presence of a diagnosed child's psychopathology. Parenting stress during the first three years of life is thought to be especially critical in relation to the child's emotional and behavioural development and to the developing of parent-child's relationship. Research data also indicates that it is possible to make gross predictions about the course of developing parent-child's relationships and the child's later adjustment (Abidin 1983/1995, p. 1-2).
In the caretaker-infant constellation there are various factors that can contribute to the parenting stress. The infant may display qualities that make it difficult for the caretakers to fulfil their parenting roles. Behavioural symptoms like restlessness, short attention span, distractibility, or an inability to adjust to changes in the physical or social environment can make the parenting task more strenuous and hinder the development of a positive relationship with the child. The interactions between the caretakers and the child fail to produce good feelings in the caretakers about themselves and they may even feel rejected by the child. This can be due to the fact that the child is defective in his or her response capability; the caretakers misinterpret or are unable to understand the child correctly; or the caretakers are depressed and project negative responses onto the child. The caretakers may feel that the child places many demands upon them. The child seems unhappy, it cries a lot or displays other signs of unhappiness. If the child is not as attractive, intelligent or pleasant as the caretakers had hoped, i.e. the child does not match the caretaker's expectations, poor attachment and even a rejection may become an issue in the caretaker-child's relationship (Abidin 1983/1995, p. 8-10).
"The avoidant/defensive behaviours of a premature infant, stressed by disturbing and often painful experiences in intensive care, may frustrate a mothers strong instincts to obtain affectionate contact. On the positive side, it is clear that instruction in how to pattern responses to an infant so as to encourage and reinforce calm and happy reaching-out on the part of the baby, and how to participate in a smoothly-changing shared communication, can benefit a mother in her response to an immature, handicapped, distressed, sick or emotionally disturbed young mind". (Fraiberg 1979, Preisler and Palmer 1986, and Trad 1990 in Trevarthen 1993, p. 68).
Inferences drawn from informal interviews with caretakers of handicapped children suggest that despite a number of available services and specialists in the field of early intervention, the needs of the caretakers in time of crises have not received enough attention. It seems that too often the caretakers themselves get lost in the role given to them as their infants best specialists, and in the emphasis which is placed on the children's developmental milestones. In spite of an adherence to Sterns reciprocal and dynamically interdependent system, various parent organisations and successful treatment programs it seems thus that the focus of early intervention strategies needs to be shifted more towards the caretakers wants. Acting in response to their needs, is of no less importance than attending to the needs of the infant, or as Trevarthen words it:
"Emotional disorders can weaken or destroy relationships between any two persons at any age. If one is too excited or depressed, or too fearful or aggressive, their mutual contact takes a form that reduces the chances of cooperation in awareness and action. This is true for exchanges between young infants and their mothers, and the play of protoconversation with a 2-month-old fails if either is in a disturbed or withdrawn state" (1993, p. 69).
No amount of empathy can eradicate all the difficulties and sorrows that caretakers of disabled infants are confronted with. But caretakers need to express their grief and to share their grief and worries without embarrassment or fear. They need to work through various emotions, to laugh with and to feel a support and a friendship from someone who has a similar experience. They need to feel accepted by an empathetic group.
This could for example be accomplished through musicking with a group of caretakers who laugh, cry, or otherwise share empathetic understanding in a musical relationship, or in a group where caretakers are informed about the importance of intuitive musicking for their children's as well as their own well-being. Supporting parents emotionally, respecting them and their relationship with their children, identifying and working through problems can all be done through musicking or music therapy.
Each parent is different from the other and caretakers search for a philosophy that best fits what they experience. Both the route to acceptance and the final destination will look different. The caretakers themselves create the meaning of their experiences and they are the ones who decide how to weave this thread into the larger design.
Conclusion
Early intervention is resource oriented with regard to caregivers as well as children's development as Maria Aarts, the founder of the Marte Meo early intervention program, emphasized so clearly in a lecture held on the 20th of May 2002, when introducing her program for the first time in Iceland. EI now emphasizes helping caregivers becoming aware of ways and qualities of interaction helpful for the infant. Instead of focusing on the infant's problems the approach focuses on increasing the caretakers awareness of positive qualities of interaction, and how to use these qualities to support the infants learning, developmental and interactive capabilities. It works within the caretakers' own frame of reference helping them to discover their own resources (Klein 2001, p. 13,32).
Caretakers need various skills in their role. They need personal skills to interact constructively with their child ensuring attachment relationship. They have to have organizational skills to manage their lives inside and outside the home, and problem-solving skills to address the many challenges that a child perpetually presents. A prerequisite for this is sensitivity to the child and an ability to read, interpret, and anticipate what the child needs and how the child is responding to the environment. Caretakers also need various information for different reasons: to understand puzzling behaviour, to set reasonable limits and expectations, to restore communication in the family, to resolve inner dialogue, and to regain some control over their own lives.
The grieving process that caretakers go through when faced with the non-finite loss of having a disabled child may complicate their parenting tasks mentioned above. If left alone with their feelings and emotions it may negatively effect not only the emotional and social development of their children but the various relationships and overall well-being in the family.
As important as it may be for caretakers to know which EI services are available, for whom and under what kind of circumstances, it is not enough. Meeting the caretaker's needs for emotional and personal support is also of paramount importance. It may change the caretaker's representation of who they are and who the infant is. As soon as everyone involved begins to see the relationship and the interaction more objectively the same one can start to undo negative representation and feel better in his/her role (Stern 1998:130).
Caretakers turn to professionals for support and guidance, but also because of their need to be taken care of and their need to nurture themselves. They need to be with someone they can ask questions, be with someone who listens to them, someone that hears what they are saying and not saying, and someone to whom they can surrender. Many parents also need companionship, and reassurance in the face of loneliness, pain, fear, anger, guilt and fatigue.
". . . There is no more self-evident truth in psychotherapy; every therapist observes over and over in clinical work that the encounter itself is healing for the patient in a way that transcends the therapist's theoretical orientation." says Yalom (1980, p. 401 in Hougaard 1996, p. 131). Research has also revealed that what seems to make a difference for a positive therapeutic outcome is not the technique as such but the therapeutic framework and the therapeutic relationship. Whatever the clinical method applied, a relationship is formed in the encounter. All interpersonal relationships may have certain things in common but they can also be focused on certain aspects believed to form the best therapeutic alliance for the client population.
Working with the unique client population of caretakers and their special-needs infants requires a broad clinical focus. The therapist's role can be that of a parent, a friend, a teacher, a trainer. At one time a passive or a neutral stance need to be taken and at other times a directive and an active one. When at times it may be necessary to focus on pathology and conflict, an active role on behalf of the therapist focusing on assets, capacities and strengths is in general more therapeutic. The therapist becomes a supporting matrix that validates, supports, and appreciates the caretakers. This allows their parental functions to become liberated, discovered and facilitated. It also supports their capacity to form positive distortions about the baby (Hougaard 1996, p. 133, Stern 1995, p. 187).
In accordance with interaction theorists like Daniel Stern and Colwyn Trevathen the old gestural language of biological communication should remain with us, and gain recognition. The intuitive musicking or the musical mother tongue, the vocal intonation, the bodily posture, movement and gesture, facial expression, etc. serve functions that cannot be expressed in words, and they function most specifically in the articulation and exploration of relationships. The usage of paralanguage is not determined entirely by instinct (come with the genes/hard-wired) in humans. Its meaning is learned throughout the life of each individual and it varies between them. The paralanguage, the gestures, the energy, the vocal intonation has more to tell us about the relationships between the caretaker and the infant and perhaps more about the quality and real meaning of the interaction than of which language or narrative accounts are capable (Small 1998, p. 62).
Musicking is capable of articulating human relationships in all their multilayered and multiordered complexity and changeability. Musicking reflects ideal relationships and shapes them (Small 1998, pp. 183-184, 210):
It is an instrument of exploration. It allows one to take part and to experience the relationship without committing oneself for more than the duration of the performance.
It is an instrument of affirmation of our own values, of who we are and of ideal relationships.
It is an instrument of celebration because it leaves those participating in a satisfying performance to feel that this is how the world really is and how they relate to it. It allows them to explore and affirm their values, and leaves them feeling more completely themselves, and in tune with the world and with their fellows.
Through informed intuitive musicking parents can be guided to state ideal relationship; to come closer to the non-verbal representational world of the infant and at the same time channel and formalize their schemas-of-being-with the infant. The song of a loving mother has a reference outside its own world of sound. The meaning of the song lies in the loving relationship that this act of musicking brings into existence. The relationship is different at the beginning of a song than at the end of the song and so is the subjective world of both the infant and the mother. Something changes between the participants in the shared performance. What the infant is and its relationship with a caretaker has evolved a little. They have realized who they are and their concepts of ideal relationships challenged their preconceived notions of them. The infant does not need to make any effort to enter into the world that musicking creates. It envelops the infant and the caretakers whether they want it or not (Small 1998:140). By allowing oneself to nurture through music and to be nurtured through music we enter into intimate supportive relationships through which we cannot only live, relive and correct the present and the past but also shape future relationships.
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