15041611Voices: A World Forum for Music Therapy1504-1611GAMUT - Grieg Academy Music Therapy Research Centre (NORCE &
University of Bergen)10.15845/voices.v19i1.2732ResearchThe Significance of the Process of Music Therapy for Children with
Multiple Social and Communication Disabilities: Case StudiesKnapik-SzwedaSara Martaknapik.sara@gmail.comUniversity of Silesia, Faculty of Pedagogy and Psychology,
Department of Children’s Creativity Expression in Pedagogy, Katowice, PolandEslava-MejiaJuanitaKeithDouglasGottfriedTali13201919119920171362018Copyright: 2018 The Author(s)2018This is an open-access article distributed under the terms of the
http://creativecommons.org/licenses/by/4.0/, which permits
unrestricted use, distribution, and reproduction in any medium, provided the
original work is properly cited.https://voices.no/index.php/voices/article/view/2732
Music therapy is an interdisciplinary branch of science and a form of therapy which
enables establishing contact with every human being by means of an aesthetic sound
message. The aim of this paper is to present the influence of music therapy
procedures on communicative and social areas of the development of children with
multiple disabilities, namely two boys. Moreover, the research activity is also
concentrated on the ways music influences particular cases, namely which chosen music
therapy strategies. The article presents individualizing research in a qualitative
dimension. The outline of the research project is presented with its problem matters,
research objectives, methods (of individual case study), and research techniques, as
well as a detailed description of the research tool - The Individualized Music
Therapy Assessment Profile (IMTAP) recommended by the American Music Therapy
Association (AMTA). The results presented in a detailed description and observation
schedule as well as data collected from interviews demonstrates and, at the same
time, answers the research question that music therapy is a useful and effective form
of therapy in the case of two boys with multiple disabilitities – to improve social
and communicative functioning of the their development.
Introduction
Music therapy (MT) is an interdisciplinary field of science and form of therapy,
nowadays increasingly popular, which creates the possibility of comprehensively
influencing each individual. It has a large psychological, medical, and pedagogical
potential utilized for numerous supportive and therapeutic actions. The richness of
means, techniques, methods, and approaches in the field of music therapy makes it
possible to adjust actions to the needs, habits or interests of the participants of
therapy (Wheeler, 2015).
The essence of MT is the relationship that develops between a participant and a
therapist, built on the foundation of musical properties (various musical elements, such as: melody, rhythm, harmony, dynamics,
tempo, colour and articulation, Nordoff, Robbins, 2007). The above-mentioned
elements form an inseparable whole, thus making music a strong therapeutic tool. “Its
strength consists in its elastic, polysemous, multi-style and multi-genre nature” (Stachyra 2012, p. 62, all quotations are rendered by
a translator). A proper comprehension of music and its meaning in the
therapeutic process is crucial, since music constitutes a non-verbal channel of
communication with the world – it crosses verbal barriers and is understood
simultaneously on multiple levels (Stachyra,
2012). Tadeusz Natanson (1978,,
the
"father" of Polish music therapy) defined MT as, “a method of behaviour that
utilizes the manifold influence of music on the psychosomatic system of a human being on
multiple levels” (p. 51). Natanson thus referred to the very essence of music and its
influence on an individual.
The World Federation of Music Therapy1 gives a detailed definition of MT and emphasizes its comprehensive approach to an
individual; the approach aims to meet the “psychological, emotional, mental, social and
cognitive needs of an individual” as part of the process of fulfilling the designated
therapeutic purpose (Stachyra, 2009, p. 62).
That is why it plays such a major role in case of people with multiple disabilities who
are the subject of this study.
According to the definition, a person with multiple disabilities is a person with at
least two disabilities caused by one or numerous factors in various periods of time
(Twardowski, 2009, p. 290). The high number
of disabilities and their complexity often results in the lack of verbal and social
communication, movement, or emotional disorders. Frohlich (1998) described people with multiple disabilities as restricted
in terms of overall functioning – on the physical, emotional as well as cognitive level
(p. 11–12). He characterized the specificity of these people’s needs and their
fulfilment, which arises from the degree and multitude of overlapping restrictions. He
enumerated the need for closeness in order to experience the surrounding reality; the
need to be helped by a teacher or a therapist in order to establish contact with the
world; and the need of a person who understands, cares, and establishes contact despite
the lack of unambiguous communications (p. 14–15). Kielin (2014) emphasized that the primary need of each person,
regardless of their disability, is the need to communicate, which is more important than
physiological needs such as eating or drinking (p. 20). Moreover, he stressed that the
therapist’s responses to the child’s messages, the pace adjusted to the child's pace and
forming attunement or matching to the communicative forms between the therapist and the
child are the bases for pre-intentional communication. Communication is extremely
important at all stages of life. Its lack disturbs social relations and the child’s
ability to express their intentions, choices, or needs. MT can turn out to be extremely
helpful in that area (Klein, 2014, p.14).
Diverse forms of work in the field of music therapy and a properly adjusted attitude of
the therapist ensure the possibility of matching the actions with the most crucial needs
of an individual and thus, fulfilling the therapeutic purposes on the level of
communication or social development (McLaughlin
& Adler, 2015). Thanks to varied music therapeutic experiences, the
participant may achieve therapeutic goals. These experiences are as follows:
improvisation, recreating, composition, and listening (Bruscia, 1998).
The first experience, improvisation, involves a spontaneous creation
without preparation. The creation can be vocal, instrumental, vocal and instrumental, or
movement-related. The therapist’s task is to instruct the participant and to demonstrate
and inspire them to undertake a musical activity. There are two techniques of
improvisation: imitating and accompanying (Wigram,
2007). Imitating involves the music therapist empathically copying the actions
of the participant– the musical expression, body movements, behaviour, and reactions.
Imitating allows the child to understand that the therapist wants to meet on the child’s
level of perception and consciousness via the means of musical synchronization. After a
while, the child begins to notice the therapist’s actions and gradually allows them to
establish an interaction. The technique of accompanying, on the other hand, is
supporting in nature. It makes it possible to form a frame where the child takes on the
role of a soloist. The therapist provides a rhythmical, harmonious, or melodious
background to the participant’s musical actions – this accompaniment is an expression of
the therapist’s acceptance and empathy. Such actions make the participant feel
important, appreciated, and make it possible to play more freely and confidently, while
concentrating on creating.
The processing and recreating of music belong to the second experience of
MT (Bruscia, 1998, p. 116–125).These are carried out by singing together
known or lesser-known songs or recreating them by playing various instruments. The
purposes of processing and recreating are to shape the abilities to cooperate, encourage
sharing of emotions, express changeable desires and emotions, by recreating, and
possibly modifying the musical material, develop the cognitive zone, and improve
performance in that area (e.g. concentration, memory or other thought-related processes
but also achieve better communication and integration in a social group).
The third experience– composition – involves the participant writing the
lyrics to known songs, composing songs or works. Through composition, the participant
improves communication with the group and the therapist and explores their own emotions,
values, ideas, and thoughts.
The fourth experience of musical therapy is listening, which can be associated
with relaxation and visualization. Its purpose is to relax and stimulate the
participant. An individual develops the ability to listen, concentrate, activate
imagination and projection by listening to diverse music (Bruscia, 1998, p.
116–125).
The Subject Matter and Range of the Study
This article is both a description and a summary of the project that studied the
potential usefulness of music therapy as a tool in working with children with multiple
disabilities. Since this field was only studied to some minor extent, the project was
qualitative in nature and focused on two cases. Its purpose was to assess the effects of
actions related to MT on the communication and social skill domains of development of
the participating children. The research was also directed at determining the way music
influences various cases, that is – exploring which of the MT strategies (improvisation,
recreating, composition, and listening) influence the development of communicative and
social abilities and skills of the participating children.
The Methodological Characteristics of the Study
The author’s research perspective was based on a naturalist paradigm. The main task of
studies of this type was an overall cognition of an individual, understanding their
psychological and physical traits (Juszczyk, 2013, p. 96–97). Behaviours or reactions
caused by specific actions or in other words, the details of the therapeutic process,
are emphasized (Creswell 2013). In this case,
music therapy is the acting agent. Crucial factors of a phenomenological qualitative
study constitute the changes arising from the individual’s experience and the
interactions between the participant and the researcher (Creswell, 2013).
The objective of this research was to support the communicative and social development
of two children with multiple disabilities, including visual and hearing impairments,
through MT. The purpose of this research was to investigate the effectiveness of music
therapy on the communication and social skill domains of development among children with
multiple disabilities and present the programme of MT-based techniques, as well as the
methods verifying their applications (detailed reports of the sessions and audio/video
recordings of the research process). The following questions guided the study:
What is the effectiveness of MT in improving the
development of a child with multiple disabilities?
How does MT benefit the communication ability of
children with multiple disabilities?
How does MT benefit the level of social behaviours of
children with multiple disabilities?
Which MT techniques contribute to the improvement of
communication ability and social skills in individual cases?
In her work, the author applied the following procedures: a) individual case method,
also known as the individual case study (Krasoń
& Konieczna-Nowak, 2016); b) systematic and direct observation,
whilethe researcher collected data by means of continuous observation
and by participating in the events (Juszczyk,
2005);c) structured observationwas maintained,
while the researcher took into account the precisely defined categories of a child’s
reactions or behaviour(Łobocki,
2011); d) informal overt interview(Gilroy, 2009, p. 154) was conducted with the parents of the
participating children, informing the respondents of the interview, although not of its
purpose (Juszczyk, 2013, p. 145); e)
semi-structured interviews were conducted, while the researcher had a prepared set of
questions but also took into account the freedom and openness of conversations, asked
additional questions not specified in the list, allowed the elaboration on some answers
and introduction of new subjects (Gilroy 2009, p.
154). Crucial techniques used in the project also included the in-depth
analysis of documents and content analysis, whichrevealed musical and
non-musical behaviors of the clients (Gilroy
2009).
The main data collection tool was the Individualized Music Therapy
Assessment Profile (IMTAP; Baxter et al., 2007). The IMTAP is
recommended by the American Music Therapy Association (AMTA) as a basic tool for
monitoring the changes brought on by the MT intervention and assessing its results. The
IMTAP is meant to assess the current developmental level of a patient/client in all
domains of development. It finds an application in assessing both children and adults.
In her research project, the author analyzed three areas of functioning of the studied
cases: the communication area, divided into Receptive Communication (RC; auditory
perception) and expressive communication (EC) areas, as well as the social skills (SOC)
area (Baxter, et al. 2007, p. 57–78).
The area of Receptive Communication (RC)comprises with the awareness of
sounds and silence, positioning the head or looking towards the source of a sound,
imitating simple musical motives, following orders, reactions to changes in music,
singing/vocalization and rhythmicality. The area of Expressive Communication
(EC)comprises all the client's attempts at communication, including eye
contact, facial expressions, gesticulation, signs, alternative and supporting
communication, and vocalizations. The third area ofSocial Skills
(SOC)includes reacting to hearing one’s own name, being interested in
activities, indicating a common area of focus, correctly interacting with the therapist,
alternate actions. Data analysis focused on the occurrence or the lack of the occurrence
of a given behaviour in a specific domain (Baxter et al., 2007).
Further on, the author will present the profiles of two boys with multiple disabilities,
elaborate on the forms of music therapy applied in their cases and describe the analysis
of the MT interventions in the light of its significance to the development of the
communication and social skill of these children.
Case Studies
The current research project2 was conducted during 2014–2015 and included two participating children with
multiple disabilities. Karol participated in individual MT sessions in his kindergarten
from September 2014 to June 2015 (35 sessions) and Piotr participated in individual MT
sessions conducted at his home from December 2014 to July 2015 (25 sessions). The weekly
MT sessions of the two children lasted 30 to 45 minutes.
Case I
Karol was 4-years old at the time of the study. He got involved in numerous
activities if they were pleasurable or interesting for him – frequently it was music.
He had multiple disabilities, including epilepsy, encephalopathy, visual impairment,
a serious heart defect (tetralogy of Fallot which resulted in multiple
hospitalizations and was operated on three times), and low muscle tone (hypotonia).
Karol’s global development was significantly delayed. Music therapy in Karol’s case
was based on improvisation, singing familiar songs, and creating new vocal and
instrumental arrangements.
The first observation period
During MT sessions Karol displayed the need for closeness, especially with a
parent. Each time his parent left the room made him emotionally unstable, which
made interactions with him much more difficult. Karol reacted positively to sounds
and jingling objects, which prolonged his attention ability. Moreover, he became
much livelier when he heard music. He displayed emotional disregulation during
numerous activities.
Initially, Karol attended dyadic sessions with a parent, although he was not able
to engage in musical activities, since he mostly displayed the need for closeness
with the parent and attempted to cuddle. Over the MT process, he started to
display interest in instruments which he put into his mouth, bit, looked at
closely from all sides, used them to both produce strange sounds and discover new
ways of making them – such behaviours occurred several times during a single
session (SOC: A3 – showing interest in the activities presented3, A4 – displaying a shared area of focus) At times Karol pressed instruments
(especially a guitar, a drum or a rattle) against his face and hit them for
increased stimulation. He accepted instrument changes (SOC: B5 - accepting
changes) and performed new actions associated with them (e.g. hit the drum’s
membrane, attempted to shake the rattle; SOC: B3 – finishing tasks within the time
frame). The therapist established musical interaction with Karol and attempted to
match his musical forms, which were short and chaotic, often impulsive. To draw
Karol’s attention to musical connection, the therapist made changes in rhythm,
melody, or harmony (e.g. changes in musical idioms), and yet Karol did not seem to
react. Karol was neither emotional, nor responsive for a musical relationship with
the therapist.
At times during sessions, Karol seemed absent or unengaged. When withdrawn, he
listened to the audio material created by the therapist (RC: A1 – shows awareness
of sounds, silence)4 (SOC: E3 – accepting musical contact). During the a
cappella vocal improvisations (singing without the accompaniment of an
instrument), the client sometimes angled his head towards the source of the sound
(RC: A3 – glances at/observes the sound source). Karol's musical actions
(including playing simple instruments) were mostly based on auto stimulating
actions that prevented him from establishing a connection with the therapist.
During these musical productions he displayed significant rhythmicality and the
ability to repeat fixed rhythmical patterns – he preserved the same intervals
between each sound played, which can signify a well-developed sense of hearing
(RC: A5 – imitates simple musical motives), (RC: E1 - plays at the same pace as
the therapist, matching at least one beat to the 4/4 metre), (SOC: C1 – prediction
of one own movement during sessions with the therapist). During initial sessions,
Karol created short vocalizations. They took on the form unrelated to the
therapist’s musical material, therefore were most probably an unconscious product
(EC: E3 – vocalizations are subconscious)5, non-imitative in nature (EC: D2 – vocalizations are not imitative). When
the therapist initiated the vocalizations, Karol reacted with his own
vocalizations with a significant delay (EC: E4 – vocalizations appear with
delays); at the same time, his vocalizations diverged from typical speech in terms
of speed and fluency (EC: E5 – vocalizations stray form the speed and fluency of
typical rhythmical speech).
The second observation period
The change occurred in March of 2015, when Karol, in his constant difficulties to
concentrate, began to notice the therapist’s musical responses, thus broadening
his own awareness regarding another person, the environment, or musical activities
(RC: A1 -shows awareness of sounds, silence). Karol's playing on the instruments
(initially short) became stable, rhythmical, and conscious (RC: A5 – imitates
simple musical motives; E1 - plays at the same pace as the therapist, matching at
least one beat to the 4/4 metre; E2 – imitates simple rhythmical schemes). During
the sessions there were moments when Karol put his hands against the guitar and
listened attentively to its sound, concentrating on it for a longer period of time
(SOC: A3 – showing interest in the activities presented). Free creation using
instruments (instrumental improvisations) and sharing an instrument with the
therapist (especially a drum, a guitar or a piano; SOC: A4 – displaying a shared
area of focus) resulted in Karol maintaining contact with the therapist longer
(SOC: A2 - showing awareness of the therapist’s presence). During joint musical
activities, Karol displayed increasing awareness of changing musical elements such
as pace, melody or mood of a given material (RC: C1 - shows awareness of major
changes in pace; C2 – shows awareness of major changes on melody; C5 - shows
awareness of major changes in mood).
An important social and communicative factor obtained by Karol during these
sessions was the ability to exchange musical material with the therapist. He hit
the drum and waited for the therapist’s response. Karol initiated a musical
contact, which influenced him positively in terms of emotions – the fact confirmed
by his smile, increasing motivation, and involvement in musical actions. Sometimes
during the sessions, Karol became a musical leader. He also became more and more
active in singing and in vocalizations based on vowels a, o, u, i
and the phrase dada (EC: C1 – vocalizations show quality
in terms of the key; C2 – vocalizations adjusted to the dynamics of musical
activities; C3 – vocalizations of a moderate range of melodies). The vocalizations
lasted longer. During the last session, the therapist sometimes paused in his
playing and waited for Karol's response, which took on a vocal form. Vocalizations
were caused by audio stimulation (the therapist singing the boy’s favourite song
or an instrumental improvisation; RC: D1 -vocalizes in response to an audio
stimulation; D6 – vocalizes in response to specific musical styles/idioms) and
were a response to the therapist’s singing (RC: D3 -vocalizes in response to the
non-melodious instruments) or took on the form of free vocal improvisations with
the therapist (EC: D1 - the participants vocalizes together with the therapist).
The free vocal improvisations were not imitative in nature (EC: D2 – vocalizations
are not imitative) but rather were mostly schematic (EC: E6 - vocalizations are
schematic) and diverged from the pace and fluency of typical rhythmical speech
(EC: E5 – vocalizations stray form the speed and fluency of typical rhythmical
speech), however they also occurred much more frequently than during the
beginnings of therapy.
Yet another factor influencing Karol's awareness of the surroundings was the need
to choose the activity for the session (SOC: E11 – playing the role of leader in
an activity). This occurred with the help of large images (the Picture
Communication System, PCS – a form of alternative communication;
Kaczmarek, 2015; EC: A1 -attempts at communicating; A3 – communicating needs and
desires) that depicted appropriate activities (e.g. hugging; EC: A5 -
communicating emotional states and the development of ideas), items (e.g. a swing)
or instruments (a guitar or a drum). Thanks to the music therapist’s cooperation
with a specialist in the field of alternative communication, symbols that enabled
the boy to consciously establish relations with the environment were introduced to
the therapy, thus making it possible for him to decide on his preferences or
activities (SOC: B4 – when possible, initiating new activities by the
participant). The application of these symbols resulted in the formation of a
specific structure of actions, which increased Karol’s awareness of the
therapeutic situation and the changes occurring during sessions (SOC: A10 –
presenting the understanding of rules and structure of activities; A12 –
displaying signs of the knowledge of the therapeutic situation ; B5 – accepting
changes; B6 - participation in structured sessions).The increase in musical
engagement might indicate better sensory integration and the sense of security in
the relation with the therapist (SOC: E6 -maintaining musical interaction).
Karol's later activities and his relationship with the therapist – based on trust
– gradually lead the child to achieve independence in making choices and
decisions, which resulted in the boy’s growing development possibilities (SOC: A5
- establishing proper interactions with the therapist). Karol was also able to
perform alternating actions, especially in rhythmical playing on the drum or the
guitar’s resonator (SOC: C1 - prediction of one’s own movement during sessions
with the therapist; C3 - sustaining the alternation using hints; E5 - imitating
the therapist’s play). It is during such improvisational actions that Karol
awaited the therapist’s response (SOC: C4 - waiting for the therapist’s response
in the correct moment; D2 - maintaining focus in relation to the therapist), which
shows a growing ability to maintain reciprocity in his relationship with the music
therapist. The ability to exchange rhythmical beats, which much less frequently
took on the form of stimulation, also manifested itself in playing simultaneously
with the therapist (SOC: E4 - playing in parallel/simultaneously to the therapist;
E8 - cooperating with the therapist). Recreating client’s favourite songs (e.g the
welcome song enumerating various body parts or the farewell song) and the shared
area of focus directed at performing them, (RC: A4 - differentiates between two
various sounds; SOC: A6 - participation in structured sessions; A7 - being
flexible in the development of musical activities without refusal or
discomfort/stress) resulted in Karol's communicating with the therapist, and in
consequence, also his kindergarten group, with much more motivation and joy (SOC:
A9 - working to identify the therapeutic purposes during the sessions). He also
accepted the therapist’s help in leading and aiding him in showing activities
associated with a song well-known to him (SOC: E1 - accepting a controlled
interaction; E2 - accepting changes in a controlled interaction; E10 - showing
flexibility when playing a known musical structure). The relationship between the
therapist and Karol was strong enough for the child to express it with a hug or a
smile (SOC: E13 - showing the skills to express a social relationship). During the
sessions, Karol's activeness increased significantly and improved his
well-being.
According to the interview6 with Karol’s mother, she emphasized that during the MT sessions, the
changes in the communication, social, motor and emotional skills as well as the
change in the communication ability were the most important to both her and her
child. She perceived Karol's musical communication, his ability to imitate vocally
or instrumentally (Karol repeating the rhythmical beats to the drum – during
initial sessions – with his leg, later – with his hand; a major improvement in
vocalization, which made the boy enjoy making various sounds; the introduction of
PCS to the music therapy sessions) as part of this communication. Joint vocal and
instrumental improvisations were described by her as dialogues, wherein she
observed the cooperation and alternating nature of the child’s and the therapist’s
actions (social aspect). At the same time, she emphasized the crucial role of the
therapist’s approach, methods of reaching the child and interactions established
as well as the therapist himself (“many things depend on the therapist”). The
child’s mother also stressed that music therapy positively influenced her son’s
emotions. It helped develop the ability to “vent bad emotions” redirecting the
child’s attention to his favourite songs, which make him smile and cause him to
relax (“emotional balm”). In the mother's opinion, MT increased his mobility,
developed manipulation in small motor skills (using instruments), and in gross
motor skills (all movement-related actions, dancing with each other, marching to
music). Karol’s mother noticed that due to the deficit of sight, he treats hearing
as compensation. Music therapy enabled him to develop it and assimilate new
sounds. His mother commented, “Music therapy is beneficial. Very beneficial.
There’s no way we’ll resign. This music will help him and will accompany him.”
In Karol’s case, the experiences of improvisational music therapy and singing
familiar and popular songs significantly improved his social and communication
skills. Continuing them may not only deepen his competence but also may lead to
him gaining new abilities – both in terms of communication and social skills.
Case II
Piotr7 was 4-years old at the time of the study. He showed great musical sensitivity.
He was interested in music, the more so, in the course of the process, music became
for him an important element of communication with the world. He was diagnosed with
refractory epilepsy, polymorphic seizures, and hypoxic-ischemic encephalopathy. He
was born a completely healthy child, but a bacterial infection in a hospital caused a
serious damage to his brain and resulted in the appearance of symptoms such as sight
impairment and general developmental delays in communication, social, motor, and
cognitive domains. Music therapy with Piotr was based on improvisational music
therapy and the neurologic music therapy techniques (NMT), which is a music therapy
model that advocates for using music elements to improve cognitive, sensory, and
motor dysfunctions visible in neurological disorders in particular (Bukowska, 2012). The main assumptions of the
method are based on a neurophysiological model of perception and music production. In
music therapy interventions, the following sensory-motor techniques are used:
therapeutic instrumental music performance (TIMP) and patterned sensory
enhancement(PSE; Hurt-Thaut & Johnson, 2016). TIMP
involves playing musical instruments to exercise and stimulate functional movement
patterns (Thaut, 2005). In this case, TIMP
was used when the therapist chose to place the musical instruments below Piotr's
hands. The second technique, PSE uses the rhythmic, melodic, harmonic, and dynamic
acoustical elements of music to provide temporal, spatial, and force cues for
movements that reflect functional exercises and activities of daily living (Thaut et al., 1991). PSE, in this case was
used to regulate client’s motor and emotional state.
The first period of observation
Piotr began individual music therapy at home in December 2014 and continues to
this day. The sessions last approximately 45 minutes, although their length is
always adjusted to the child’s current physical and mental state.
MT with Piotr started with an in-depth analysis of his state and his reactions to
musical actions. During the initial sessions, he was minimally active. Lack of
willingness to establish any contact with the therapist was demonstrated. Despite
his sight impairment, Piotr was closing his eyes (SOC: B2 - showing awareness of
the therapist’s presence), turning his head away (SOC: E12 - free use of skills
related to independence and interdependence of the therapist; EC: A1 - attempts at
communicating; EC: B2 - gesticulations), tried to withdraw, remaining inactive,
which could suggest he was aware of what was going on around him (RC: A1 - shows
awareness of sounds, silence). He showed no reaction to the appearing instruments
(guitar, drum) and the therapist’s voice. However, he was not visibly resistant –
he "surrendered" to all the therapist’s actions without defiance. He seemed
indifferent, but at the same time accepted being steered during all musical
actions, e.g. when the therapist directed his hand to the guitar’s strings, the
drum’s membrane or pressed his hand against the guitar to make him feel the
instrument’s vibrations (SOC: E1 - accepting a controlled interaction; E2 -
accepting changes in a controlled interaction). Vocalization was very short
(approx. 2 seconds) and resembled a sigh (EC: D2 - vocalizations are not
imitative), but the child’s behaviour indicated that, despite its shortness, he
was aware of it (EC: E3 - vocalizations are subconscious).
During the first three sessions, Piotr reacted to sounds with a certain degree of
oversensitivity, since each unexpected musical stimulus provoked a short epilepsy
fit. At that time, during the sessions, Piotr was continuously monitored. This
enabled the therapist to observe and recognize the child’s reactions to the
instrument being used, its volume, way of making sounds, the musical phrase
produced by the therapist and each of the therapist’s movements and actions. For
the good of the child, the therapist had to adapt to each, even the smallest,
movement of the child, therefore most of his actions were direct results of the
observed physiological activities of the child – the regularity of his breathing,
turning his head to the sides, or opening his eyelids. The therapist followed such
signals, applied appropriate improvisation techniques (imitation and accompanying; Wigram 2004), and could turn Piotr’s musical
and non-musical activities into their joint musical material. During the
improvisation, the therapist introduced a structure based on a repeating guitar
accompaniment. As part of the accompaniment, at certain points the therapist
created a pause in the music to increase the client’s attention or observe his
reactions to the lack of a musical stimulus. It has already been mentioned that
during initial sessions Piotr was neither active and involved nor willing to
establish contact. There were only moments when he opened his eyes when he heard a
certain guitar phrase or moved his right hand more vigorously (RC: A4 -
differentiates between two various sounds). In case of the latter, the therapist
attempted to follow the child’s hand by putting a drum under it to make Piotr
aware to the purpose of his movements. The therapist did not introduce any diverse
forms of musical expressions – such as wide range of the dynamics or idioms
(containing differences in harmony and emotional tension) – knowing that each
sudden change might cause an epileptic seizure.
The second period of observation
As time passed, thanks to regular therapy sessions and cooperation with the
parents, Piotr's activeness gradually began to increase. His body movements became
freer and his vocal activities, initially involving only grunting or muttering,
turned into short vowel-based vocalizations. Piotr began to turn his head towards
the source of the sound (RC: A2 - turns head towards the sound source) and became
still after hearing new sounds, when receiving a new audio stimulus (RC: A3 -
glances at/observes the sound source). The most important change to occur during
the MT process was the decreasing frequency of epileptic events (obviously
connected to the general improvement of Piotr's state, application of
properly-selected medications and Piotr gradually becoming accustomed to the
sessions). This made it possible for the forms of musical improvisation to become
longer, more intense, and most importantly for Piotr to discover his freedom and
desire to sing at his own discretion, by using his possibilities and skills –
confirmed by the above-mentioned vocalizations, leg motions, or general body
movements (SOC: A2 - showing awareness of the therapist’s presence; B8 -
appropriate development of activeness; EC: A1 - attempts at communicating; B2 -
gesticulations). Such actions were Piotr's method of communication, perception,
and interaction with the therapist.
Music therapy sessions in June and July indicated that Piotr's awareness of the
therapeutic situation, the activeness and the structure of the sessions, was
rising (SOC: A10 - presenting the understanding of rules and structure of
activities; A12 - displaying signs of the knowledge of the therapeutic situation;
B6 - participation in structured sessions). The following musical and non-musical
behaviours were indicators of this awareness (SOC: A3 - showing interest in the
activities presented): changing movements in response to a phrase sang by the
therapist (RC: A1 - shows awareness of sounds, silence); all sound-related
productions of the child: vocalizations, babbling, other specific creations
occurring in response to singing (RC: D1 - vocalizes in response to an audio
stimulation; D3 - vocalizes in response to the therapist’s singing) or the
therapist’s repeating musical motive; Piotr's movements or vocalization in
response to unfamiliar melodies (EC: B4 - combination of gesticulations and
vocalizations; C1 - vocalizations show quality in terms of the key); adjusting the
key of his own vocal creations to match the creations of the therapist (RC: D5 -
vocalizes in response to melodious instruments; D8 - sings in the proper key with
the therapist); increased concentration during rests (breaks in music; RC: C2 -
shows awareness of major changes in melody). Gradually, Piotr joined the
improvisation at his own free will, by filling in the rests, purposefully created
by the therapist (RC: D9 - vocalizes during a musical rest initiated by the
therapist; SOC: C4 - waiting for the therapist’s response in the correct moment).
Moreover, in these moments, Piotr found room for his own expression which resulted
in the appearance of musical alternation (dialogue with the therapist) – the
therapist presented short musical motives with a guitar accompaniment and paused
in certain moments to wait for the child’s response; there always was one,
although after various periods of time (SOC: A5 - establishing proper interactions
with the therapist; C1 - prediction of one’s own movement during sessions with the
therapist; C3 - sustaining the alternation using hints). Piotr’s mother expressed
her opinion in an interview, saying that these musical dialogues that she called
“musical discussions” positively influenced her child’s communicative competence
(SOC: E5 - imitating the therapist’s play; E6 - maintaining musical interaction)
as well as his well-being (smiling; SOC: A9 - showing attitude positive to
others). Epileptic seizures occurred sometimes during the sessions, but after each
such disruption, Piotr returned to the interrupted musical activities (SOC: D3 -
returning to the interrupted activities, with hints, after disruptive actions). By
analyzing the process of cooperation with the child, the therapist noticed a
certain regularity in his behaviour – Piotr was vocally active when the
accompaniment assumed the minor key of a given musical material (EC: C5 -
vocalizations take on the length of sentences; SOC: E6 - maintaining musical
interaction), at that time he also took on the role of a musical leader who, in
specific moments, was independent from the therapist’s musical material (RC: D6 -
vocalizes in response to specific musical styles/idioms; SOC: E11 - playing the
role of a leader in an activity; E12 - free use of skills related to independence
and interdependence of the therapist; EC: D1 - the participant vocalizes together
with the therapist). As time passed, the number of sounds in his vocalizations
visibly increased (Piotr smoothly went from a single vocalization to two or even
three sounds, e.g. ahh, ooo,
oogahh; EC: E5 - vocalizations stray from the speed and
fluency of typical rhythmical speech), and his concentration level was higher than
in any other form of musical accompanying (a similar phenomenon of preferring
certain musical activities also occurred with Karol; SOC: A4 - displaying a shared
area of focus; A9 - showing attitude positive to others; D1 - maintaining the
length of focus; D2 - maintaining focus in relation to the therapist; EC: C4 -
vocalizations take on the length of word phrases).
The nature of the improvisations (especially during the last sessions) was
nostalgic. Phrases were mostly based on several sounds occurring in one-second
intervals (EC: C3 - vocalizations of a moderate range of melodies), but sometimes
the therapist presented intervals of a wider range, e.g. sixth, seventh, imitated
by the boy after a while (RC: A4 - differentiates between two various sounds; D11
- imitates rising musical intervals higher than the major second; D14 - imitates
gradually rising musical motives with an interval range greater than a second,
immediately after hearing them; SOC: E10 - showing flexibility when playing a
known musical structure). Piotr emanated the desire to express himself – when the
therapist increased the dynamics of improvisation, the child’s voice became
significantly stronger (RC: C3 - shows awareness of major changes in dynamics;
SOC: E8 - cooperating with the therapist; EC: C2 - vocalizations adjusted to the
dynamics of musical activities). In the child’s vocalization, a fragmentation of
rhythmical values, which made the impression of increasing the pace and the
dynamics of improvisation, could be heard (SOC: B4 - when possible, initiating new
activities by the participant). Clear rhythm-emphasizing accents were also
obvious. Piotr's vocalizations were at times imitative (EC: D3 - imitative
vocalizations) and at times, depending on his state, delayed (EC: E4 -
vocalizations appear with delays). The therapist attempted to encourage his
movements, especially small motor skills. She often placed his hands on various
instruments to help him sensorily experience them and their sounds (SOC: E1 -
accepting a controlled interaction). These forms of musical involvement put the
client not only in control over the execution, but also over the decision about
the musical nature of all the actions undertaken with the therapist, which is a
crucial developmental aspect in both the communicative and social sphere (SOC: C5
- maintaining alternation without hints; E3 - accepting musical contact).
The interview8 with Piotr's mother revealed that she noticed visible changes in her
child’s communication brought on by the MT interventions. The areas of change
indicated by her included: becoming more sensitive, the joy heard in the sounds
created, musical discussions, and the activation of the oral domain. Asked about
the change in Piotr's social ability,his mother claimed the question was not so
simple, since Piotr’s social skills depend on his physical and mental state as
well as the number and intensity of the seizures. The child’s activeness during
sessions – not only in the forms of vocalization or dialogues, but also the fact
that he used his whole body (hands and legs) to play instruments was to his mother
both an enormous positive surprise and, at the same time, a confirmation of the
success of the music therapy.
The mother emphasized that the time when her child began music therapy was hard
for them, mostly due to the high number of seizures. One of her expectations for
the MT was that “music would bring him calmness and pleasure.” As it turned out,
it gave him much more – not only calmness and joy but also improved his
communication through the “musical discussions” and motor skills by activating his
hands, legs, and whole body. Familiar songs, which were heard in his day-to-day
life at home, sang or listened to with his parents (Four
Elephants or a song about a crocodile in the Nile), and the vocal and
instrumental improvisations used during the music therapy sessions were the forms
of musical activities that contributed to the development of Piotr’s social and
communication domains.
When asked about the benefits of MT, Piotr's mother responded, “Music therapy is
definitely a beneficial type of therapy. I absolutely recommend it, since it
improves the development in its entirety […]. Healthy children also have music,
why should disabled children be deprived of it?” Continuing her response, the
mother emphasized, "Music therapy is very important. I wouldn’t say it’s the most
important, but it gives my child pleasure. He not only makes an effort during
sessions, but also feels joy”.
Conclusions
The results of the study briefly summarized in this article – presented in full in the
detailed description and in the observation schedule – as well as the interview data,
show that music therapy was a beneficial and successful form of therapy in case of both
children with multiple disabilities. In both cases it positively influenced their
musicality, resulting in visible changes – in Karol’s case helping develop rhythmical
skills, sustain rhythm, and imitate a rhythm; in Piotr’s case – aiding in the
development of sensitivity to melody, the ability to lead a vocalization in a given key,
and the awareness of untangling musical phrases also in the form of vocalizations.
Aside from the improvements observed within the children's musical skills, non-musical
goals were also addressed. In Karol’s case, MT contributed to communicative
changes such as: moving from withdrawal to noticing the therapist’s musical
responses, increasing awareness of another person, the environment or musical
activities, becoming aware of the changing musical elements (the pace, melody or mood of
a given material), and visible activeness in singing or vocalizations. Music therapy
also reinforced the following social skills: free instrument-based creation
of music (instrumental improvisations), sharing the instrument (especially the drum,
guitar or piano) with the therapist while keeping the same area of focus or sustaining
eye contact, positively reacting to song-based greetings and farewells with the boy
understanding the meaning of the structure, initiating musical contact with the
therapist and accepting the therapist when co-creating improvisations or songs,
developing alternation, displaying the desire to work with the therapist, assuming
numerous roles (e.g. the role of a leader or a follower), as well as the ability to
express a social relation in the form of a hug, the sense of closeness to the
therapist.
With Piotr, there were also changes in both development domains. In the
communication domain these changes included: the awareness of sounds,
silence, distinguishing sounds, sensitivity to changes in melody, dynamics, mood in the
improvisations presented, vocalizations occurring as a response to the therapist’s
singing, the ability to imitate sounds and find appropriate moments for musical
responses, and the willingness to establish and sustain communication via body
movements. Within the social domain there were indications of changes such
as: displaying interest in the activities and the growing desire to interact with the
therapist during the vocal and instrumental alternations, the awareness of the structure
of sessions or the therapist’s presence, improving attention when making musical
dialogues, and taking on numerous roles during improvisations (the role of a leader of
the improvisation while the therapist becomes an accompanist, or the role of a person
co-dependent on the therapist’s musical material).
Both Karol’s and Piotr’s musical behaviours translated to non-musical behaviours in the
social and communication domains. The social domain included: alternation, maintaining
focus, awareness of the interactions, and the musical dialogue in the structure of a
conversation (one person creates, the other listens and receives). The communication
domain included: the ability of a vocal and instrumental expression, the attempts to
communicate through vocalization, body, gestures, imitation, as well as, the increasing
motivation to express one’s needs, ideas, emotional states and choices.
The benefits of MT appeared to be meaningful in both cases. In Karol’s case the
experiences of music therapy such as improvisation and recreating (singing
familiar and popular songs) resulted in numerous benefits to the child’s development
confirmed by the description of the MT process and the interview with his mother. In
Piotr’s case, familiar songs (recreating) also applied outside of MT and
vocal and instrumental improvisations with the use of a drum or a guitar
(used during MT) were the forms of activity that contributed to the development of the
social and communication domain.
Discussion
Music therapy was a beneficial form of therapy in the case of both children with
multiple disabilities. Improvisational music therapy (Bruscia, 1998) and neurologic music therapy (Hurt-Thaut & Johnson, 2016) facilitated an opportunity for
the children to gain greater awareness, engage, and communicate better. These results
support previous findings, indicating that improvisational music therapy may initiate
communication, increase interaction with others, and increase reciprocal musical
exchanges by responding to musical suggestions and initiating musical ideas (Goodman, 2007; Nordoff Robbins, 2007; Oldfield,
2006; Watson, 2007; Wheeler 2013). The research based on NMT focuses
mainly on using musical elements in the treatment of people with Parkinson’s disease
(de Dreu, van der Wilk, Poppe, Kwakkel, &
van Wegen, 2012), with brain injury (Hurt, Rice, McIntosh, & Thaut, 1998) and cerebral palsy (Baram & Lenger, 2012; Howell, Flowers, & Wheaton 1995; Kwak 2007). There are no clear studies referring to the usage of
NMT techniques in the therapy of children with multiple disabilities.
The subjective nature of the qualitative study and its interpretative nature make it
impossible to generalize and draw conclusions regarding the beneficial effect of music
therapy on the communication and social skills of children with multiple disabilities.
The study described here did not provide statistical generalizations and had no such
ambitions (Flick, 2012, p. 81), but it allows
the so-called internal generalization, which “stretches the conclusions of studies
across a given group or situation” (p. 81).
Further studies on the subject, especially mixed projects utilizing the individualism
and subjectivity of a qualitative study as well as the objectivity and accuracy of a
quantitative study are required to develop and popularize MT as a form of therapeutic
work with people with multiple disabilities. The study of the influence of music therapy
on communication and social skills should also be expanded through the use of both
standard and non-standard research tools in order to increase objectivity.
https://www.wfmt.info/WFMT/About_WFMT.html
The author has ethical clearance from University of Silesia in Katowice.
A numerical subcategory in a letter category on a given scale.
The Receptive communication (RC) observation schedule. The
explanation and specific data can be found in appendix no. 1.
The Expressive communication (EC) observation schedule. The
explanation and specific data can be found in appendix no. 2.
The interview was conducted in the early 2016 with the consent of the boy’s mother
who also agreed for its audio recording. The fragments quoted are part of the
transcript of the recorded interview, which is translated to English for the purpose
of this manuscript.
Name has been changed to protect the client’s anonymity.
The interview was conducted in the early 2016, with the consent of the boy’s mother
who also agreed for its audio recording. The fragments quoted are part of the
transcript of the recorded interview, which were translated for the purpose of this
manuscript.
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Appendix 1: The Receptive communication observation schedule (personal
elaboration on the basis of: Baxter et al. 2007, p. 57–78).
Appendix 2: The Expressive communication observation schedule (personal
elaboration on the basis of: Baxter et al. 2007, p. 57–78).
Appendix 3: The Social skills observation schedule (personal
elaboration on the basis of: Baxter et al. 2007, p. 57–78).