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 6/9/2008 Music Therapy and the Emergence of Spoken Language in Children with Autism Christine Barton, MM, MT-BC | |||||||||||
| 'My child knew music before he knew words.' Kim, mother of an 8 year-old boy with autism and profound hearing loss. Introduction In 2007, the Center for Disease Control Prevention estimated that the prevalence of autism in the United States had risen to 1 in 150 children (Autism Society of America, 2008). Since boys are four times as likely to be diagnosed as girls, their incidence rate is an alarming 1 in 94 (Autism Society of America). This makes autism the fastest growing diagnosis in the United States, more than AIDS, diabetes, and cancer combined (Autism Speaks, 2008). The cause(s) of autism are still elusive, but environmental as well as genetic factors appear to contribute to its increasing occurrence (Autism Society of America). This crisis has focused national attention on the monetary, as well as personal costs, to the families of these children. And the race is on to find the treatments that yield the best outcomes. One of the positive predictors of social and intellectual development in children with autism is the acquisition of functional language by five years of age (Thaut, 1999). In this author's experience, music therapy is an intervention that can increase communicative behaviors in young children with autism. This article will briefly define autism, explain the effectiveness of music as a therapeutic tool with autistic children, look at the connection between music and language, and finally, provide examples of music therapy in action and ways to incorporate it into speech-language intervention sessions. Autism and Autism Spectrum Disorders (ASD) Autism is a complex, neurologically based developmental disorder (Autism Speaks, 2008). It is often referred to as a Pervasive Developmental Disorder (PDD) because delays in certain areas of functioning impact growth in other areas of development. It is a lifelong condition for which there is no known cause, protection, cure, or completely reliable treatment. However, early intervention can have a positive impact on an individual's ability to maximize the effectiveness of existing treatments (Autism Speaks). Autism is also frequently referred to as a spectrum disorder (ASD), meaning that there are many levels of developmental delay ranging anywhere from very mild to profoundly severe (Berger, 2002). On one end of the spectrum is the high-functioning, communicative individual, on the other, the minimally functional, nonverbal individual with severe developmental disabilities. Some of the hallmarks of the disorder include:
Music and Children with Autism When autism was first observed and defined by Leo Kanner in 1943, he noted a particular precocious musical orientation in the young boys he studied. At the age of one year, one boy "could hum and sing many tunes accurately" (Kanner, 1943, p.1). From a review of the literature regarding music and children with autism, Thaut concluded that:
Absolute Pitch One area that has caught the attention of researchers, as well as the media, is the prevalence of absolute pitch among the autistic population. The ability to identify the pitch of an isolated tone without any reference is known as absolute pitch (AP), or perfect pitch. Evidence suggests that the environment (early music training) and genetics contribute to the development of AP. The incidence in the general population is thought to be 1 in 10,000 (Brenton, Devries, Minnich, Barton, & Sokol, 2008). However, Brown et al. (2003) speculate that the prevalence in people with autism may be as high as 1 in 20. (In 20 years of practice, this author has known five autistic individuals with AP.) They also surmise that the gene associated with AP may be among the genes that also contribute to autism (Brown et al.) In a recent case study of a four-year-old with AP and autism, it was demonstrated that even though he had delays in speech and cognition, he scored perfectly on the tonal portion of the Gordon Primary Measures of Music Audiation Test (Gordon, 1979). The Music and Language Connection Music and language share a number of properties. According to Zatorre, Belin, and Penhume (2002), first they each follow a time-ordered, sequential, and developmental path. That is, one must first learn tones and phonemes, then melodies and words, before one can sing a song or speak in sentences. Second, all known human cultures make use of music and language. Third, both take advantage of pitch contour to convey meaning. Fourth, the terminology used to describe elements of speech and music (rhythm, duration, intonation, articulation, etc.) overlap. They differ in acoustic features and neural processing. Speech is produced only by the voice, yet music can be produced by the voice and any number of instruments. The spectral range (pitch) for speech is narrow and less complex than that of most pitched instruments. Zatorre et al. point out that even if the spectral information is removed from speech, as long as the temporal information (timing) remains true, decoding is still possible. However, in order to process music effectively, spectral resolution is critical. Based on studies of patients with brain-damage, they argue that the auditory cortices in both hemispheres are specialized, so that temporal resolution is better in the left and spectral resolution is better in the right (Zatorre et al.). Language deficits in some children may stem from difficulties in processing the rapid temporal aspects of speech. Intervention Using Music There are a number of reasons why music lends itself as a therapeutic tool. It:
Within the music therapy profession, there are a number of methodologies and clinical techniques to which therapists subscribe. One approach that has been used successfully to establish and increase communication behaviors in children with autism is called Creative Music Therapy. It was developed in the late 1960s and 70s by Paul Nordoff and Clive Robbins (2007). It is a clinical method where the therapist, through improvisation, is "searching out some mode of activity, or establishing some quality of relationship, whereby a musically purposeful connection may arise with the child that may become a harbinger to a process of therapeutic self-realization" (Nordoff & Robbins, 2007, p. 3). Another clinical improvisation technique has been defined by James Hillier as "the process whereby the therapist and client(s) improvise together for purposes of therapeutic assessment, treatment, and/or evaluation. In clinical improvisation, client and therapist relate to one another through the music, and the improvisation results in a musical product that varies in aesthetic, expressive, and interpersonal significance" (Hillier, 2006, as cited in Gardstrom, 2007, p. 12). In a study that measured the effectiveness of improvisational music therapy, Edgerton (1994) found that both musical as well as nonmusical communication behaviors in autistic children increased significantly as a result of a ten-week program of individual improvisational music therapy. These results are contradictory to the structured approaches that are commonly used with autistic children. This is not to say that the music therapy session is a free-for-all rather, within the session there are opportunities for improvisation to take place. For example, this therapist always begins with a greeting song at the door. It may include the child's name and a "how are you?" Then the child proceeds to the stairs and sings a descending scale (do-ti-la-so-fa-mi-re-do) on the way down and finally sits in the chair that is waiting in the music studio.  For some children who need more structure, a visual schedule is then presented with pictures of instruments, songs, or musical games from which to choose. Others need more freedom to explore the instruments that have been carefully positioned in the environment. Once the instruments, songs, or games have been chosen, either verbally or by physically moving to them, the music making begins. It is within this context that improvisation occurs. The following video clips illustrate this concept. Clip 1 and Clip 2 were captured during a music therapy assessment of a three-year old boy with autism. At the time of taping, the child had minimal spoken language development and little desire to initiate communication at that time. Notice the child's rather flat affect in both video clips. In this video clip, the therapist presents a drum to the client, who proceeds to play it. At first, the therapist put words to the sound of the drum, "Boom, boom, boom goes the drum." Eventually the words are faded out as the child starts to take the lead in the "musical conversation." The child is clearly initiating and directing the conversation. It is a perfect example of nonverbal communication. In this video clip, the child is introduced to the autoharp. Having never seen one before, he proceeds to hit it like a drum. After a moment of exploring the instrument, he spontaneously says, "good-bye" and the therapist seizes the opportunity to sing good-bye to the child. Video clip 3 was taken during a session several months later. The therapist purposely put her attention on the mother and the child spontaneously asked to "get the guitar." (This is a sabotage technique that teaches the child that listening and interacting can sometimes be unpredictable. It also allows the therapist an opportunity to assess whether the skills being taught are learned because of the situation or are actually being mastered and generalized.) The therapist then immediately responded by getting the guitar and making a game of "open the case." Notice the positive change in affect. It is important to establish communicative intent with the child. This can be done effectively through the use of appealing instruments, songs, activities, and the enthusiasm of the therapist. Often, a child�s repetitive motion (hand flapping) or vocal tic can be woven into the music. For example, if a child is jumping, the therapist could mimic that motion on a piano or drum and put the word jumping to a chant or melody. It affords the opportunity to put a "stop" or "freeze" into the song, to encourage the child to follow the therapist's directive. Likewise, imitating the child's vocal sounds and incorporating them into the music may then lead to production of a meaningful word. By first imitating the child, it signals communicative intent on the therapist's part. The next step is for the child to imitate the therapist. At that point, a "my turn-your turn" situation has begun. The door is now opened for conversation, be it spoken or musical. It is also important to get the child "hooked" on music. As mentioned earlier, music can be very motivating and appealing to the child with autism. Many parents have made the comment that music is the one stimulus their child continually seeks out. When something as enticing as an instrument is presented to the child (or kept somewhere out of sight) it prompts communicative attempts. One child this therapist worked with continually looked up at the ceiling. The therapist found a floor keyboard and when the child entered the room, her feet played notes. She immediately looked down! Since music is filled with rhythmic patterns, it can be intrinsically rewarding to children who display stereotypic patterns of behavior (Alvin & Warwick, 1991). Trying to match the activity level of the child by reproducing it on an instrument, such as a drum, may have the effect of getting their attention, particularly if the drum stops when they stop, or speeds up and slows down in response to their movements. Children often have their own beat and if they can transfer that to a drum, it can be a springboard for a number of songs or chants. Singing a child's name can be another way to draw them into communication. Incorporating Music into the Speech-Language Intervention Session By now the reader should have some idea of why music is motivating for the child with autism, how language and music intersect, and how music can be used as an intervention tool. The next step is to find a way for nonmusicians to include music into intervention in a way that feels comfortable to the speech-language pathologist or educator and provides success for the child. Fortunately, there is a resource that can help with that transition. The Listening Room at www.HearingJourney.com provides free access to music activities, as well as an introduction to the TuneUps Approach, a method of weaving music and spoken language together in an intervention session. In addition, www.BionicEar offers several webinars related to music and language, presented by this author and her colleague, Amy McConkey Robbins, CCC-SLP. Go to e-learning, habilitation, and finally Bringing Music to Life. Even though these sites have been developed for children with hearing loss, the focus is on language acquisition. To that end, the ideas are highly applicable to the child on the autism spectrum. It might also be helpful to read an interview of this author at www. SpeechPathology.com. West Music, www.westmusic.com, provides durable, high-quality, reasonably priced instruments. They have several music therapists on staff ready and willing to answer questions about instrument selection. Instruments useful in improvisation may include: low-sounding bass bars; metallophones tuned to different scales; guitars, banjos, and autoharps with strings that can be plucked or strummed; drums to hit or place hands on; a variety of small percussion instruments; bells to ring or tap; and color-coded keyboards. Pretend and real microphones can serve as prompts to elicit verbal responses, especially if placed in front of the child when a response is desired. Whistles and harmonicas stimulate oral motor movements. Remember, however, that the voice is the most important instrument you can own and singing with the autistic child can yield positive and, yes, miraculous results. ''In the world of music, the autistic child can feel safe and sometimes act like an ordinary child''References Alvin, J., & Warwick, A. (1991). Music therapy for the autistic child. New York: Oxford University Press. Autism Society of America. (2008). About autism. Retrieved May 1, 2008 from http://www.autism-society.org/site/PageServer?pagename=about_home Autism Speaks. (2008). What is autism? An overview. Retrieved May 1, 2008 from http://www.autismspeaks.org/whatisit/index.php Berger, D. S. (2002). Music therapy, sensory integration and the autistic child. London: Jessica Kingsley. Brenton, J. N., Devries, S. P., Minnich, H., Barton, C., & Sokol, D. K. (2008). Absolute pitch in a four year old boy with autism. Pediatric Neurology. (in press). Brown, W. A., Cammuso, K., Sachs, H., Winklosky, B., Mullane, J., Bernier, R., Svenson, S., Arin, D., Rosen-Sheidley, B., & Folstein, S. E. (2003). Autism-related language, personality, and cognition in people with absolute pitch: Results of a preliminary study. Journal of Autism and Developmental Disorders, 33(2), 163-167. Gardstrom, S. C. (2007). Music therapy improvisation for groups: Essential leadership competencies. Gilsum, NH: Barcelona Publishers. Gordon, E. (1979). Primary measures of music audiation. Chicago: G. I. A. Publications. Kanner, L. (1943). Autistic disturbances of affective conduct. Nervous Child, 2, 217-150. Retrieved May 18, 2008 from http://www.neurodiversity.com/library_kanner_1943.html. Nordoff, P., & Robbins, C. (2007). Creative music therapy: A guide to fostering clinical musicianship(2nd ed) . Gilsum, NH: Barcelona Publishers. Thaut, M. H. (1999). Music therapy with autistic children. In W. B. Davis, K. E. Gfeller, & M. H. Thaut (Eds.), An introduction to music therapy: Theory and practice (pp. 179-203). Boston, MA: McGraw-Hill. Zatorre, R. J., Belin, P., & Penhume, V. B. (2002). Structure and function of auditory cortex: Music and speech. TRENDS in Cognitive Science, 6(1), 37-46. | |||||||||||
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