Music Therapy Perspectives Advance Access published June 27, 2016
Investigating the Effectiveness of a Developmental,
Individual Difference, Relationship-Based (DIR)
Improvisational Music Therapy Program on Social
Communication for Children with Autism Spectrum
Disorder
JOHN A. CARPENTE, PHD, MT-BC, LCAT
Associate Professor, Molloy College, Rockville Centre, NY
Founder/Director, Rebecca Center for Music Therapy at
Molloy College, Rockville Centre, NY
The DIRFloortime Model
The Developmental Individual Difference Relationshipbased model (DIRFloortime) is one of several DSP models.
DIRFloortime is a caregiver-mediated home-based intervention that involves training parents to maximize interactions
with their children to improve social reciprocity and functional
pragmatic communication (Greenspan & Wieder, 2006a;
Simpson, 2005; Solomon, Van Egeren, Mahoney, Huber, &
Zimmerman, 2014). The DIRFloortime model involves the
implementation of child-led strategies within a developmental approach in order to foster communication skills within
a social context (Greenspan, 1992; Greenspan & Wieder,
1997, 2006b; Pajareya & Nopmaneejumruslers, 2011, 2012;
Solomon, Necheles, Ferch, & Bruckman, 2007; Casenhiser,
Shanker, & Stieben, 2013). The model seeks to facilitate social
communication skills via affective-relational experiences that
are based on the child’s interests in order to foster engagement,
relatedness, communication, and high-level thinking, that is,
symbolism and abstraction, within a social context. Thus, the
task of the therapist is to provide developmentally appropriate
relational experiences that are based on the child’s lead, all
within the context of the child’s relationship with the therapist.
The DIR model provides clinicians and parents with a framework for assessing and conceptualizing the needs of individuals.
The “D” is concerned with the child’s developmental capacities.
The “I” deals with the child’s individual differences, and the “R”
describes his/her learning relationships with others. Thus, the
model provides therapists with a guide for creating an intervention
plan that takes into consideration each child’s unique differences
and strengths in order to foster social, emotional, and intellectual
development rather than simply focusing on isolated behaviors
(Greenspan, 1992; Greenspan & Wieder, 2006a, 2006b).
Background
Individuals with Autism Spectrum Disorder (ASD) display
challenges related to social communication skills (American
Psychiatric Association, 2013). These challenges generally impact
the individual’s ability to experience shared attention, express
and understand nonverbal and verbal communication, maintain
peer relationships, and engage in social reciprocity. Treatment
programs based on the behavioral model constitute the predominant therapeutic approach (Schreibman, 2005). According to this
model, ASD is a learning difficulty that can be addressed with
operant conditioning strategies using discrete behavioral trials
to increase language and socialization and decrease repetition.
The literature, however, indicates limitations regarding the use
of highly structured therapist-led behavioral interventions. For
example, behavioral gains did not typically generalize to new
settings or maintain over time (Schreibman, 2005; Harris et al.,
2015; Ingersoll, Lewis, & Kroman, 2007; Paul, 2008). Results also
indicated a lack of spontaneity and overdependence on prompts
(Ingersoll, 2008; Schreibman, 2005; Schreibman et al., 2015).
As a result of these findings, interventionists are now consistently incorporating Developmental Social Pragmatic (DSP)
John A. Carpente, Associate Professor of Music Therapy at Molloy College, is the
founder and director of the Rebecca Center for Music Therapy and Center for
Autism at Molloy College.
Address correspondence concerning this article to John A. Carpente, PhD, MT-BC,
LCAT, The Rebecca Center for Music Therapy at Molloy College, 1000 Hempstead
Ave., NY Rockville Centre 11571. E-mail: [email protected]
© the American Music Therapy Association 2016. All rights reserved.
For permissions, please e-mail: [email protected]
doi:10.1093/mtp/miw013
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strategies within research protocols such as following the child’s
lead and contingent imitation while considering their developmental capacities, and teaching communication skills within
a social context (natural environment) (Dawson et al., 2010;
Schreibman et al., 2015) as a means of improving communication (Casenhiser, Shanker, & Stieben, 2013; Dawson et al., 2010;
Green et al., 2010; Hwang & Hughes, 2000; Ingersoll, Dvortcsak,
Whalen, & Sikora, 2005; Kasari, Gulsrud, Wong, Kwon, & Locke,
2010; Prizant, Wetherby, Rubin, & Laurent, 2003).
ABSTRACT: The purpose of this study was to examine the effectiveness of improvisational music therapy carried out within a
DIRFloortime framework in addressing the individual social communication needs of children with Autism Spectrum Disorder (ASD).
Participants included four children enrolled in a therapeutic day
school, 4–8 years of age, and diagnosed with ASD. Each child participated in twenty-four 30-minute individual DIR-based improvisational
music therapy sessions over the course of 13 weeks. The Functional
Emotional Assessment Scale (FEAS) was used to evaluate changes in
social communication skills. Results indicated improvements in areas
of self-regulation, engagement, behavioral organization, and two-way
purposeful communication.
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Improvisational Music Therapy
Similar to the DIRFloortime model, improvisational music
therapy (IMT) may also adopt a client-led relationship-based
framework when working with children with ASD (Alvin
& Warwick, 1991; Carpente, 2012; Geretsegger, Holck,
Carpente, Elefant, & Kim, 2015; Holck, 2004a; Kim, Wigram,
& Gold, 2008; Nordoff & Robbins, 2007). Child-led IMT may
be viewed as a developmental approach noted for providing
a meaningful framework, similar to early mother-infant interaction, which is used to promote shared focus of attention,
turn-taking, and emotional attunement (Holck, 2004b; Kim,
Wigram, & Gold, 2008). When working within a child-led
framework, the therapist may improvise music that generally
follows the child’s focus of attention and interests in order to
establish a relationship while fostering engagement, relatedness, and communication (Alvin & Warwick, 1991; Carpente,
2013; Geretsegger, Holck, Carpente, Elefant, & Kim, 2015;
Holck, 2004b; Kim, Wigram, & Gold, 2008; Nordoff &
Robbins, 2007). The process of tuning into the child’s musical and non-musical expression has been an integral feature
of clinical practice and is an essential skill of an improvisational music therapist (Alvin & Warwick, 1991; Bruscia, 1987;
Geretsegger, Holck, Carpente, Elefant, & Kim, 2015; Nordoff
& Robbins, 2007).
Working in music as a therapeutic intervention has shown
to be potentially more effective than other mediums to engage
children with ASD, and may provide unique opportunities
for them to interact nonverbally compared with play-based
interactions (Kim, Wigram, & Gold, 2008). The structure and
predictability found in music provides a context and vehicle
for reciprocal interactions and promotes flexibility and social
engagement from which relationships emerge (Bruscia, 1987,
2014; Geretsegger, Holck, Carpente, Elefant, & Kim, 2015;
Nordoff & Robbins, 2007). While children with ASD are generally found to have impaired perception of linguistic and
social auditory stimuli (Boddaert et al., 2004), they are also
reported to possess either intact or sometimes superior musical perception regarding pitch perception (Bonnel et al., 2003;
Heaton, 2005), melody discrimination (Applebaum, Egel,
Koegel, & Imhoff, 1979; Mottron, Peretz, & Menard, 2000),
pitch recall (Heaton, Hermelin, & Pring, 1998), the ability to
disembed notes within chords (Heaton, 2003), and improvising melodies (Thaut, 1988). Studies have also indicated
that individuals with ASD have a strong affinity for musical
stimuli when compared to other auditory and visual stimuli
(Blackstock, 1978; Thaut, 1987), as well as for displaying the
ability to understand affective connotations in music (Heaton,
Hermelin, & Pring, 1999).
DIRFloortime and Client-Led Improvisational Music Therapy
Floortime and client-led improvisational music therapy
share many similarities in terms of their philosophy and
approach. Both are child-led, relying on the therapist’s ability
to be creative, flexible, spontaneous, and emotionally attuned
with the child. In addition, both highly value the child–therapist relationship as being the vehicle for development and
clinical progress (Carpente, 2011, 2014). Finally, the aim of
both methods is to engage the child in affective back-and-forth
reciprocal experiences within a social context to foster social
communication capacities. However, they differ in mediation,
setting, duration/intensity, and evidence base.
Family involvement and caregiver delivery are an essential
aspect of most DSP interventions. Several randomized control
trials have evaluated the effectiveness of caregiver mediated
DSP interventions (Aldred, Green, & Adams, 2004; Green et al.,
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The “D” refers to six levels of development that define the
child’s fundamental capacities for 1) shared attention and selfregulation, 2) relatedness and engagement, 3) two-way purposeful communication, 4) shared problem-solving, 5) symbolic thinking, and 6) bridging ideas. According to Greenspan
(1992), these capacities are the building blocks and foundation for higher levels of thinking and relating such as the ability
to sustain long chains of communication in a back-and-forth
purposeful manner, create and share ideas, and think symbolically and abstractly. Table 1 illustrates the six developmental
levels of social-emotional functioning.
The “I” represents Individual differences and refers to how
the child processes information such as receptive and expressive language, motor and sensory stimuli (e.g., touch, sound,
and other sensations), auditory input, visual-spatial information; and motor-planning and sequencing abilities. For each of
the six developmental levels described in Table 1, the therapist is required to understand the individual differences of the
child, and determine how they interfere with his/her ability to
move up the developmental sequence (Greenspan & Wieder,
2006a, 2006b).
The term “Relationships” pertains to how the child interacts with others (e.g., family members, teachers, therapists,
and caregivers) in order to inform the therapist as to the patterns and modes of interaction that should be included in the
therapeutic program to support development. Relationships
and the learning experiences that occur in them are an essential component of the DIRFloortime model. According to
Greenspan and Shanker (2004), relationships are the vehicle
for affect-based developmentally appropriate interactions that
are necessary for healthy development.
Each facet of the DIRFloortime model complements the
other. First, it is essential to understand the child’s level of
developmental functioning (see Table 1). Second, it is important to understand the child’s individual differences and how
they may be interfering with his/her development. Finally, it is
imperative to assess and understand the child’s mode of relating and managing relationships with others. Once there is a
developmental and sensory portrait of the child, it is the therapist’s task to support the individual differences while providing
the child with relational experiences that will help guide him/
her to achieve the highest potential within the six developmental levels.
Floortime is an intervention method that is integral to the
DIR therapeutic process. It is a clearly defined five-step skill
sequence that guides the therapist or parents to follow affectively toned interactions through gestures and words in order
to help move the child up the developmental ladder by first
establishing a foundation of shared attention. Table 2 illustrates the five steps that make up the Floortime method. Thus,
the DIR portion of the model helps conceptualize the child,
helping the therapist in drawing up a comprehensive assessment, while Floortime is the treatment intervention that is
guided by the child’s profile.
Music Therapy Perspectives
Occurs 2–5 months
Occurs 4–10 months
Occurs 10–18 months
Occurs 18–30 months of age
Occurs 30–42 months
Level II: Attachment and engagement in
relationship
Level III: Two-way purposeful
communication
Level IV: Behavioral organization,
problem-solving, and internalization
Level V: Representation capacities
Level VI: Representation differentiation
Internal emotional regulation and homeostasis.
Integrates and utilizes sensory stimuli, i.e., sight,
smell, sound, touch, and taste to self-regulate;
maintain availability for interaction while
stabilizing awareness of sensations to remain calm
and alert
Forming a special relationship with a parent
or caregiver; builds a foundation for future
relationships
Purposeful and meaningful communication
using gestures, vocalizations, facial expressions
in order to open and close 5 or more circles of
communication (pre-verbal communication,
reading and processing gestural cues)
Developing a complex sense of self. Engages
in a continuous flow of back-and-forth
interactions; engaging is shared problem-solving
while opening and closing at least 10 or more
circles of communication; experiencing and
comprehending range of emotions, e.g., pleasure,
assertiveness, curiosity, intimacy, fear, anger
Internal representation (symbolic thinking). Learns
to represent events, things, feelings symbolically;
engage in pretend (symbolic) play; functional
speech continues to develop
Bridges between ideas and feelings and connects
ideas
Logically; developing abstract thinking and able
to answer questions dealing with what, when,
how, and why questions
Description
At risk for ASD
A child at risk for ASD will display challenges
using words and/or phrases meaningfully and
engaging in pretend play; he/she may repeat
words (echolalia).
A child at risk for ASD will engage in memorized
scripts with random ideas; or use words and ideas
out of context.
A child at risk for ASD will exhibit challenges
in initiating and sustaining back-and-forth
interactions of emotional signals (e.g., showing
mom or dad a toy) and may engage in
perseverative behavior patterns.
An infant at risk for ASD may display challenges
in maintaining engagement, and may withdraw
from interaction and become self-absorbed.
An infant at risk for ASD may display a lack of
interest in others, or engage in brief back-andforth exchanges with very little initiative, and may
engage in random behaviors.
An infant at risk for ASD may exhibit challenges
in sustaining attention to sensory stimulation, e.g.,
sights or sounds, and may prefer to engage in
perseverative behaviors.
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*All information within this table is from Greenspan & Wieder (2006a, 2006b).
Occurs 0–3 months of age
Chronological
age
Level I: Shared attention and regulation
Developmental
milestones
Table 1.
Six Developmental Levels of Social–Emotional Functioning
Music Therapy Program on Social Communication for Children with Autism Spectrum Disorder
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Music Therapy Perspectives
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Table 2.
Six Steps to Administering Floortime™
Floortime technique
Observation
Approach
Follow the child’s lead
Child closes the circle of communication as
the therapist opens the circle
Listening to and watching the child’s facial expressions, tone of voice, gestures, body
posture, use of or lack of words, how he/she navigated around the room, separates
from caregiver)
Once assessing the child’s mode of interacting or responding, the therapist can
approach the child with clinically appropriate music, words/lyrics, gestures, and affect.
He/she can open the circle of communication with the child by acknowledging the
child’s emotionality, then elaborating and building on whatever interests the child at
the moment
After the initial approach, therapist follows the child’s lead by joining the child in
whatever they are doing while being a supportive play partner, creating music that
supports, reflects, and/or enhances what the child is playing
As therapist follows the child’s lead, he/she extends and expands the play-making,
providing supportive music and comments about the child’s play without being
intrusive; providing opportunities for the child to express ideas while guiding them into
various musical directions to foster problem-solving and reciprocity
When child is approached, he/she closes the circle when he/she builds on the
therapist’s comments with comments and/or gestures, and/or ideas of his/her own.
One circle flows into another, and many circles may be opened and closed in
quick succession as one interacts with the child. By building on each other’s ideas
and gestures, the child begins to appreciate and understand the value of two-way
communication
*All information within this table is from Greenspan & Wieder, 2006a, 2006b).
2010; Kasari, Gulsrud, Wong, Kwon, & Locke, 2010; Ingersoll,
2008, Wetherby & Woods, 2006). Results indicated significant
improvement in the children’s ability to share attention, and
engage with parents and communicate reciprocally after seven
months to one year of monthly three-hour parent training visits
to the home, and six to ten twenty-minute caregiver-mediated
Floortime sessions at home (Pajareya & Nopmaneejumruslers,
2012, Casenhiser, Shanker, & Stieben, 2013; Solomon, Van
Egeren, Mahoney, Huber, & Zimmerman, 2014).
IMT is typically delivered by a highly skilled music therapist in
a clinical setting. The two RCTs that have assessed the effectiveness of IMT for children with ASD have found improvements in
joint attention and affective sharing after delivering 30–45-minute IMT sessions once a week for 12 to 16 weeks (Kim, Wigram,
& Gold, 2008; Gattino et al., 2011). While caregiver interventions are now considered evidence-based (Wheeler, Williams,
Seida, & Ospina, 2008; Wong et al., 2015) music therapy,
including IMT is regarded as promising but not sufficiently evidenced for improving social interaction in children with ASD
(Rossignol, 2009). Several randomized control trials suggest
that IMT as an intervention for young children with ASD can
improve responding to joint attention and some forms of initiating joint attention (Kim, Wigram, & Gold, 2008), affective
sharing and initiating behavior (Kim, Wigram, & Gold, 2009),
nonverbal communication skills (Gattino, Riesgo, Longo, Leite,
& Faccini, 2011), and the parent–child relationship (Thompson,
McKerran, & Gold, 2013; Thompson, 2012; Oldfield, 2001).
This study will (1) translate and apply DIRFloortime to IMT
principles as a means for improving core features of ASD
based on a standardized, criterion-referenced rating scale
developed to evaluate social communication via play context
(Functional Emotional Assessment Scale) and (2) examine the
effectiveness of a DIR-based improvisational music therapy
(IMT) intervention in addressing individual social communication skills of children with ASD. The guiding research question was: Do children with ASD receiving DIR-based IMT
improve their social communication functioning, as assessed
by the Functional Emotional Assessment Scale (FEAS)?
Method
Participants
Four participants enrolled in a therapeutic day-school were
selected by the school psychologist for participation in the study
based on the following criteria: 1) a diagnosis of ASD, 2) newly
enrolled at the therapeutic day-school, 3) 4–8 years of age, and
3) no prior experience in music therapy. Each parent of the
participants was asked to sign a consent form for their child’s
participation in the study. All personal information and data
was kept strictly confidential (pseudonyms are used throughout
this paper to identify the subjects). The study was reviewed and
approved by an East Coast University and the therapeutic dayschool’s Institutional Review Board (IRB).
Measure
The Functional Emotional Assessment Scale (FEAS)
(Greenspan, DeGangi, & Wieder, 2001) was used as a pre- and
post-test to measure each child’s progress toward social communication development. The FEAS, a play-based assessment
instrument, is a valid and reliable, age-normed, observational
instrument that has been used in several DIRFloortime studies
(Solomon, Necheles, Ferch, & Bruckman, 2007; Solomon, Van
Egeren, Mahoney, Huber, & Zimmerman, 2014; Liao et al., 2014;
Dionne & Martini, 2011; Pajareya & Nopmaneejumruslers,
2011, 2012). The FEAS was designed to determine a child’s social
communication capacities based on the six developmental
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Extend and expand play
Procedures
Music Therapy Program on Social Communication for Children with Autism Spectrum Disorder
Procedures
Each child participated in a total of 26 DIR-based IMT sessions over the course of 13 weeks. Each treatment session
lasted 15–30 minutes, depending upon the child’s tolerance,
and was given twice per week. The first and last sessions
involved pre- and post-testing administered by a psychologist who is DIRFloortime certified and highly experienced in
administering the FEAS. The other 24 sessions consisted of individual DIR-based improvisational music therapy conducted
in the school’s music therapy treatment room. This room was
equipped with a video recorder that was used to record all
sessions. Various instruments, which require no prior skills or
experience, were available to the children, including a snare
drum, 12-inch crash cymbal, 12-inch tambourine and buffalo drum, 24-inch floor tom, chromatic set of resonator bells,
pentatonic xylymba, chromatic xylophone, two pitched reed
horns, an acoustic piano, and an acoustic and electric guitar.
In addition, a variety of sizes of drumsticks and mallets with
various textured handles were made available.
Intervention
The DIR-based IMT involved the therapist implementing
three procedural phases (see Table 3) in tandem with Floortime
techniques illustrated in Table 2. Each phase is identified by
its own objectives and musical–clinical techniques, and each
requires different developmental capacities on the part of the
child. Therefore, the child’s capacity to engage in musical play
will determine the working phase or phases of the session.
Hence, the therapist follows and moves through a sequence of
stages to achieve each phase, always beginning and reverting
back to following the client’s musical–emotional lead (Phase 1).
IMT was employed within the context of a child-led DIR-based
approach. Thus, the therapist created music based on the child’s
musical responses, and/or movements, and/or emotionality, and
inclinations or tendencies to foster engagement, relatedness,
attunement, and social communication. The music therapist created music that met and followed the child’s musical–emotional
lead in order to foster engagement, relatedness, social interaction, and communication. The clinically improvised music was
based on the child’s reactions, responses, and emotional state
as a means to join the child’s play and foster relationship and
shared attention. Hence, the task of the therapist was to provide music that deepened the child’s experience in play and fostered a continuous flow of affective back-and-forth interactions
though a range of musical contexts and frameworks. The course
of improvising musical experiences included a process of three
phases: 1) following the child’s musical–emotional lead, 2) twoway purposeful musical-play, and 3) affect synchrony in musical
play. See Table 3 for an illustration of the sequence and operational definitions for each of the three phases.
Phase 1: Following the Child’s Musical–Emotional Lead
Phase 1, “following the child’s musical–emotional lead,”
involved the therapist observing the child while creating music
around his/her natural inclinations, emotional interests, and
musical (e.g., instrument, vocal, and/or movement) and nonmusical responses (e.g., gestural and/or facial expressions).
Clinical techniques such as reflecting, synchronizing, and/or
enhancing (Bruscia, 1987) are implemented within musical
frameworks in order to meet the child’s affect and to foster
engagement and joint attention.
Phase 2: Two-Way Purposeful Musical Play
Phase 2, “two-way purposeful musical play,” included
the therapist transitioning from a child-led to a therapist-led
interaction by providing musical experiences that sought
out a response from the child. The therapist-led experience
was focused on redirecting the child’s attention and music in
order to elicit a musical response that in turn closed or completed a circle of communication (e.g., punctuating the end
of a phrase, vocally or via cymbal play; gesturally responding
to the therapist’s music; adjusting to the therapist’s change in
music). This phase included the therapist incorporating elicitation and redirection techniques (Bruscia, 1987) as a means of
fostering reciprocal musical play (two-way purposeful musical play). The child’s responses may have been expressed via
a glance, and/or instrument play, and/or vocalization, and/
or movement, and/or facial expression. At any time during or
after the transition into Phase 2, the therapist may revert back
to Phase 1 if the child demonstrated difficulty transitioning
and/or withdrawing from the interaction.
Phase 3: Affect Synchrony in Musical Play
“Affect synchrony,” Phase 3, involved the therapist providing music experiences that included a range of elements, that
is, tempo and dynamics, within a consistent predictable musical structure while incorporating a range of clinical techniques
such as empathy, structuring, elicitation, redirection, and leaving spaces (Bruscia, 1987). The task of the therapist in this phase
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milestones listed in Table 1. The FEAS includes six subtests that
relate directly to Greenspan’s six functional developmental
levels and the ages at which typically developing children are
expected to attain them (Greenspan, DeGangi, & Wieder, 2001):
1) self-regulation and in shared attention (0–3 months); 2) attachment and engagement (2–5 months); 3) two-way, purposeful
communication (10–12 months); 4) behavioral organization and
problem-solving (18–30 months); representational capacities
(create ideas, use words or phrases meaningfully, engage in pretend play, and think symbolically [18–30 months]); and (6) representational differentiation (build bridges between ideas, think
logically and sequentially, answer “why” questions, thinking
abstractly, that is, representation differentiation (30–42 months).
The FEAS scoring system is based on a three-point scale for
each of six levels of emotional capacity. Items are rated as 0–
not at all or very brief; 1–present some of the time, observed
several times,or consistently present many times. Thus, high
scores on the FEAS indicate a higher developmental level and
in turn signify greater social communication. The ratings can
be summed to obtain subtest scores as well as total scores
(Greenspan, DeGangi, & Wieder, 2001). Cutoff scores, illustrated in Table 8, are used to determine whether the child is
classified as “deficient,” “at risk,” or “normal.”
The FEAS pre- and post-test ratings were summed to obtain
subtest and total scores. FEAS scores were compared to the cutoff scores to determine the child’s classification, in each developmental level, as “deficient,” “at risk,” and “normal.” Pre- and
post-test comparisons of classifications were the primary outcome measure and were compared for each child to determine
if progress was made on their overall score and on each subtest.
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Music Therapy Perspectives
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Table 3.
Musical–Clinical Intervention Procedural Phases
Phases
Procedure
Outcome
I. Following the child’s musical–
emotional lead
Empathy techniques: reflecting,
synchronizing
, and/or enhancing
(Bruscia, 1987)
II. Two-way purposeful musical
play
Elicitation and redirection
(1987)
Build rapport with the child by
creating an accepting musical
environment
that is respectful of his/her
differences, reactions, and
responses; guides therapist in
understanding child’s musical
tendencies
, preferences, sensitivities, and
preferred musical media (2013);
and helps foster self-regulation
and joint attention as the child
is available for back-and-forth
interaction
Child to engage in back-andforth musical play in which the
interaction shifts between childand therapist-led (2013)
III. Affect synchrony in
musical play
Empathy, elicitation, structuring
and redirection (1987) (through
a range of tempo and dynamics)
Therapist observes, listens, and
creates musical experiences
based on child’s reactions,
responses, and initiated
behaviors; music is focused
on meeting the child’s affect;
therapist may focus on the
client’s sense of dynamics,
tempo, rhythm, and pace
of motor movements and
utilization of the instruments,
while being attentive to any
vocal sounds being expressed
(Carpente, 2013)
Musically, the therapist
improvises and initiates music
that offers or expresses a
musical question, statement,
and/or partial statement seeking
a musical response (2013)
Therapist creates musical
experiences incorporating
a range of elements and
contexts that provide child
with opportunities to initiate,
respond, and engage in a
continuous flow
of affective musical interactions
(2013)
Child initiates and responds
to musical ideas and cues via
a range of musical elements;
engaging in long chains of
back-and-forth reciprocal
affective musical interactions
exchanging roles leading and
following in play (2013)
was to create opportunities for the client to initiate and respond
while exchanging leadership and followership in musical play.
Data Analysis
The FEAS pre- and post-test ratings for each child were
summed to obtain subtest scores that were totaled to obtain
the total score and compared to the cutoff scores to classify the
child as either “deficient,” “at risk,” or “normal” (Greenspan,
DeGangi, & Wieder, 2001) (see Figure 1). Pre- and post-subtest classification levels at pre- and post-test were compared
for each child in order to assess progress on overall social
communication and developmental capacities.
Results
A comparison of pre- and post-test classification levels on
the FEAS will be presented followed by a description of the
client process and therapist method for each of the four cases
and an integration of the quantitative and qualitative data.
FEAS Scores
Comparisons of pre- and post-test scores on the FEAS for
each case (see Figures 2–5) will be discussed in terms of classification (i.e., “deficient,” “at risk,” or “normal”) according to
cutoff scores (see Table 8) and clinical descriptions. Figure 1
illustrates a comparison of the four participants pre- and posttest scores on the FEAS. Each participant’s score is displayed
Figure 1. Percentage of children who advanced at least one
classification level on the FEAS. * 50% of the children scored
“normal” at pre-test in area IV and maintained a score of
“normal” at pre-test Thus, all of children (100%) scored “normal” at post-test in level IV.
for each developmental area in the form of raw scores and
subscores, level of functioning, and number of functioning
levels changed (see tables 4–7).
All participants (100%) were classified as “deficient” on
overall social communication scores at pre-test. At post-test,
two of the four (50%) advanced two classification levels from
“deficient” to “normal.”
At pretest all four (100%) participants were scored as “deficient”
on four of the six subscales: attachment and engagement (level II),
two-way purposeful communication (level III), representational
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Clinical techniques
Music Therapy Program on Social Communication for Children with Autism Spectrum Disorder
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illustrates the percentage of children who advanced at least one
classification level on the FEAS. (Note that at pre-test two children [50%] scored “normal” on behavioral organization [level
IV] and maintained this score following treatment. Therefore, at
post-test all children scored “normal” on level IV.)
0
Case Studies
Changes in Developmental Levels
Pre
Post
2
L
e
v
e
l
s
7
Case 1: Kyle
Area I
Area
Area III
Area IV
Area V
Area
Figure 2. Kyle’s changes in developmental levels.
Changes in Developmental Levels
Pr
Post
2
1
0
Area I
Area
Area III
Area IV
Area V
Area VI
Figure 3. Elaine’s changes in developmental levels.
Changes in Developmental Levels
Pre
Post
2
L
e
v
e
l
s
1
0
Area I
Area II
Area III
Area IV
Area V
Area VI
Figure 4. Anthony’s changes in developmental levels.
Changes in Developmental Levels
Pre
Post
2
L
e
v
e
l
s
1
0
Area I
Area
Area III
Area IV
Area V
Area VI
Figure 5. Michele’s changes in developmental levels.
capacity (level V), and representational differentiation (level VI).
Two (50%) of the four participants scored “normal” on behavioral
organization and problem-solving (level IV) at pre-test, and two
were rated as “deficient.” In addition, two participants scored “at
risk” on self-regulation and shared attention (level I).
At post-test three of the four (75%) were considered “normal” on self-regulation and shared attention, engagement, and
behavioral organization. In the area of two-way purposeful
communication, two of the four participants (50%) had progressed one level to “at risk” and one had progressed two levels
to “normal.” All of the participants had progressed one or two
levels on at least one of the six developmental levels. Figure 1
Downloaded from http://mtp.oxfordjournals.org/ at AMTA Member Access on June 29, 2016
L
e
v
e
l
s
Kyle was deficient in all developmental areas at pre-test
and made no functional progress on any of the areas except
for behavioral organization and problem-solving (level IV),
in which he advanced two levels to “normal.” See Table 4
for Kyle’s pre- and post-test raw scores and changes in
functioning level.
Generally, during Kyle’s first six treatment sessions, he
exhibited difficulty adapting to the musical environment due
to his complex sensory system, for example craving vestibular
and proprioceptive inputs. He presented with a mixed-reactivity sensory system and challenges in self-regulation. Thus, it
was difficult to engage him musically as he consistently withdrew, emotionally and/or sensorily, from any attempts to join
him in play. Following session six, the therapist shortened the
length of sessions, and provided various sensory stimuli (e.g.,
deep pressure on his arms and legs, clay for tactile input, and
a rocking game chair for vestibular input) within the musical experiences that catered to Kyle’s individual differences in
order to foster self-regulation and shared attention.
During this time, the therapist provided Kyle with his
required sensory diet within musical-play experiences. While
his ability to maintain self-regulation and engage in vocal play
began to emerge, interactions were fragmented, brief, and
lacked a continuous flow.
During sessions 13 through 16, Kyle began to display the
ability to engage in music experiences, via vocal play, for longer
periods (3–4 measures of 4/4 at a time). In addition, his ability to
adapt and problem-solve in musical play began to emerge in the
form of turn-taking, predicting, and imitating brief melodies and
short melodic rhythms. During these experiences, the therapist
began interactions by musically following Kyle’s lead (treatment
phase 1) by creating music that mirrored and reflected his play
and emotionality, while incorporating spaces into the music for
Kyle to fill in. In addition, short repeated melodic phrases were
created within simple harmonic frameworks, that is, ii–V–I, that
included simple rhythms to create call-and-response (turn-taking) and imitation opportunities.
As treatment continued, from sessions 16 to 25, Kyle continued to demonstrate the ability to problem-solve by joining
into musical play, rhythmically and tonally, as well as reading and responding to musical cues that created imitation and
turn-taking experiences. Generally, interactions continued to
be brief and lacked a continuous flow of back-and-forth play.
It appeared that the musical conditions needed to maintain
sameness in terms of staccato phrasing, short motifs, and fixed
dynamics. The therapist provided musical experiences that generally shifted between treatment Phases 1 and 2 (following and
redirecting for two-way purposeful play), always reverting back
to following his lead in order to help Kyle re-engage in play.
In summary, as reflected in the Kyle’s FEAS post-test, his
challenges in the ability to sustain self-regulation (level I)
Music Therapy Perspectives
8
Table 4.
Comparison of Kyle’s Pre- and Post-FEAS Scores
Areas
Post-test
Raw scores
Raw scores
Subscores
Subscores
8 (Deficient)
2
2
2
2
1
0
0
6 (Deficient)
7 (Deficient)
2
2
0
2
1
1
0
7 (Deficient)
2
0
0
2
0
2
0
0
5 (Deficient)
2
1
1
2
0
0
1
0
6 (Deficient)
1
1
1
2
0 (Deficient)
1
1
2
2
2 (Normal)
0
0
1 (Deficient)
0
2
0 (Deficient)
0
0
0
0
1
0
0
0
0 (Deficient)
0
0
0
0
0
0
0
0 (Deficient)
0
0
0
0
0
0
0
0
0
0
0
made it difficult for him to engage (level II) in continuous twoway purposeful communication (level III). His ability to adapt
to musical experience in the areas of joining into play interactions, turn-taking, and imitation appeared to be reflected in
his gains in level IV of the FEAS (behavioral organization and
problem-solving). Figure 2 illustrates Kyle’s changes in developmental levels.
Change
in functioning
level
0
0
0
+2
Case 2: Elaine
Elaine’s pre-test FEAS scores indicated “normal” on behavioral organization and problem-solving (level IV), “at risk” on
self-regulation and shared attention (level I), and “deficient”
in all other developmental areas, that is, engagement, twoway purposeful communication, representational capacities,
and representation differentiation. Following treatment, Elaine
Downloaded from http://mtp.oxfordjournals.org/ at AMTA Member Access on June 29, 2016
I. Self-regulation
Attentive to play with toys
Explores objects/toys freely
Remains calm during play
Touching textured toys/caregiver
Shows content affect
Focused without distraction
Appears over aroused
II. Forming relationships
and engagement
Emotional interest in caregiver
Relaxed when near caregiver
Anticipates with curiosity
Uncomfortable with caregiver
Initiates closeness to caregiver
Avoids caregiver
Socially references caregiver
Communicates from across space
III. Two-way purposeful
communication
Opens circles of communication
Initiates intentional actions
Closes circles of communication
Uses words, gestures, or sounds
IV. Behavioral organization
and problem-solving
Communicates in several modes
Copies caregiver & incorporates
V. Representational
capacity
Engages in symbolic play
Engages in pretend play
Communicates intentions
Expresses dependency
Expresses pleasure/excitement
Expresses assertiveness
Creates 2 or more unrelated ideas
VI. Representational
differentiation
Bridges 2 unrealistic idea
Bridges 2 realistic ideas
Use pretend to express dependency
Use pretend to express pleasure
Expresses assertiveness in pretend
Pre-test
Music Therapy Program on Social Communication for Children with Autism Spectrum Disorder
9
Table 5.
Comparison of Elaine’s Pre- and Post-FEAS Scores
Areas
Post-test
Raw scores
Raw scores
Subscores
Subscores
11 (At risk)
2
2
2
2
1
1
1
11 (Deficient)
12 (Normal)
2
2
2
2
1
2
1
16 (Normal)
2
1
1
2
2
1
2
1
5 (Deficient)
2
2
2
2
2
2
2
2
7 (At risk)
+1
0
1
2
2
3 (Normal)
2
1
2
2
4 (Normal)
0
1
2
3 (Deficient)
2
2
7 (At risk)
+1
0
2
0
0
0
0
1
1 (Deficient)
1
2
2
1
1
0
0
4 (Normal)
+2
1
0
0
0
0
2
2
0
0
0
had advanced to “normal” on all developmental areas except
for representational (level V), in which she improved to “atrisk.” See Table 5 for Elaine’s pre- and post-test raw scores and
changes in functioning level.
Treatment sessions 1 through 5 included Elaine craving
motion as she moved aimlessly around the music room while
playing each instrument in an unrelated manner. Generally,
Change
in functioning
level
+1
+2
she appeared to become easily dysregulated and unengaged
while moving and displayed difficulty self-regulating. When
engaged in instrument play, she exhibited challenges maintaining engagement and relatedness, as well as difficulty
adapting to dynamic and tempo changes.
Sessions 6 through 10 consisted of the therapist attempting to guide Elaine’s perseverative movements into interactive
Downloaded from http://mtp.oxfordjournals.org/ at AMTA Member Access on June 29, 2016
I. Self-regulation
Attentive to play with toys
Explores objects/toys freely
Remains calm during play
Touching textured toys/caregiver
Shows content affect
Focused without distraction
Appears over aroused
II. Forming relationships
and engagement
Emotional interest in caregiver
Relaxed when near caregiver
Anticipates with curiosity
Uncomfortable with caregiver
Initiates closeness to caregiver
Avoids caregiver
Socially references caregiver
Communicates from across space
III. Two-way purposeful
communication
Opens circles of communication
Initiates intentional actions
Closes circles of communication
Uses words, or sounds, or gestures
IV. Behavioral organization
and problem-solving
Communicates in several modes
Copies caregiver & incorporates
V. Representational
capacity
Engages in symbolic play
Engages in pretend play
Communicates intentions
Expresses dependency
Expresses pleasure/excitement
Expresses assertiveness
Creates 2 or more unrelated ideas
VI. Representational
differentiation
Bridges 2 unrealistic idea
Bridges 2 realistic ideas
Use pretend to express dependency
Use pretend to express pleasure
Expresses assertiveness in pretend
Pre-test
Music Therapy Perspectives
10
Table 6.
Comparison of Anthony’s Pre- and Post-FEAS Scores
Areas
Post-test
Raw scores
Raw scores
Subscores
Subscores
10 (Deficient)
2
2
2
0
1
2
1
12 (Deficient)
13 (Normal)
2
2
2
2
1
2
2
16 (Normal)
2
2
0
2
2
1
1
2
5 (Deficient)
2
2
2
2
2
2
2
2
8 (Normal)
+2
1
1
1
2
3 (Normal)
2
2
2
2
4 (Normal)
0
1
1
5 (Deficient)
1
1
14 (Normal)
+2
1
2
0
0
0
2
0
0 (Deficient)
2
2
2
2
2
2
2
7 (Normal)
+2
0
0
0
0
0
2
2
2
0
1
dance experiences, following her lead of movement in order
to foster self-regulation, engagement, and relatedness. Her
dance-like interactions were generally accompanied by the
therapist providing legato and lyrical singing, playing the
piano in ¾ tempo, and incorporating words that Elaine offered
via her repetitive and echolalic vocalizations.
During sessions 11 through 15, Elaine demonstrated a significant increase in her ability to self-regulate for extended
Change
in functioning
level
+2
+2
periods during musical play. This was evident by her ability
to sustain musical interaction via instrument play and movement to the waltz-like music being presented. When engaged
in instrument play, she demonstrated the ability to interact
in a related manner on the drum and cymbal by playing the
basic beat and engaging in call-and-response play, punctuating ends of phrases on the cymbal. In addition, while engaged
in these robust musical interactions, Elaine exhibited affective
Downloaded from http://mtp.oxfordjournals.org/ at AMTA Member Access on June 29, 2016
I. Self-regulation
Attentive to play with toys
Explores objects/toys freely
Remains calm during play
Touching textured toys/caregiver
Shows content affect
Focused without distraction
Appears withdrawn/sluggish
II. Forming relationships
and engagement
Emotional interest in caregiver
Relaxed when near caregiver
Anticipates with curiosity
Uncomfortable with caregiver
Initiates closeness to caregiver
Avoids caregiver
Socially references caregiver
Communicates from across space
III. Two-way purposeful
Communication
Opens circles of communication
Initiates intentional actions
Closes circles of communication
Uses sounds/words/gestures
IV. Behavioral organization
and problem-solving
Communicates in several modes
Copies caregiver & incorporates
V. Representational
capacity
Engages in symbolic play
Engages in pretend play
Communicates intentions
Expresses dependency
Expresses pleasure/excitement
Expresses assertiveness
Creates 2 or more unrelated ideas
VI. Representational
differentiation
Bridges 2 unrealistic ideas
Bridges 2 realistic ideas
Use pretend to express dependency
Use pretend to express pleasure
Expresses assertiveness in pretend
Pre-test
Music Therapy Program on Social Communication for Children with Autism Spectrum Disorder
11
Table 7.
Comparison of Michele’s Pre- and Post-FEAS Scores
Areas
Post-test
Raw scores
Raw scores
Subscores
Subscores
11 (At risk)
2
2
2
2
1
1
1
6 (Deficient)
13 (Normal)
2
2
2
2
2
2
1
16 (Normal)
0
2
0
2
2
0
0
0
4 (Deficient)
2
2
2
2
2
2
2
2
7 (At risk)
+1
0
1
1
2
0 (Deficient)
2
1
2
2
4 (Normal)
+2
0
0
0 (Deficient)
2
2
2 (Deficient)
0
0
0
0
0
0
0
0
0 (Deficient)
0
2
0
0
0
0
0
0 (Deficient)
0
0
0
0
0
0
0
0
0
0
0
extra-musical responses such as smiling and socially referencing the therapist with eye glances and nonverbal vocalizations.
Her challenges related to postural control and motor planning made it difficult for her to sustain a continuous flow
of basic beating; however, she maintained engagement and
relatedness through facial expressions and social referencing.
The therapist incorporated these extra musical responses into
Change
in functioning
level
+1
+2
the music while implementing musical spaces and exaggeration of Elaine’s responses in order to foster two-way purposeful
play and reciprocal interactions (treatment phase 2).
Musical styles and frameworks, such as flamenco and Latin,
were used during instrument play because of their boldness,
clarity of tempo, rhythmic nature (included syncopation), and
emphasis on a strong downbeat. These musical interventions
Downloaded from http://mtp.oxfordjournals.org/ at AMTA Member Access on June 29, 2016
I. Self-regulation
Attentive to play with toys
Explores objects/toys freely
Remains calm during play
Touching textured toys/caregiver
Shows content affect
Focused without distraction
Appears over aroused
II. Forming relationships
and engagement
Emotional interest in caregiver
Relaxed when near caregiver
Anticipates with curiosity
Uncomfortable with caregiver
Initiates closeness to caregiver
Avoids caregiver
Socially references caregiver
Communicates from across space
III. 2-way purposeful
communication
Opens circles of communication
Initiates intentional actions
Closes circles of communication
Uses sounds/words/gestures
IV. Behavioral organization
and problem-solving
Communicates in several modes
Copies caregiver & incorporates
V. Representational
capacity
Engages in symbolic play
Engages in pretend play
Communicates intentions
Expresses dependency
Expresses pleasure/excitement
Expresses assertiveness
Creates 2 or more unrelated ideas
VI. Representational
differentiation
Bridges 2 unrealistic ideas
Bridges 2 realistic ideas
Use pretend to express dependency
Use pretend to express pleasure
Expresses assertiveness in pretend
Pre-test
Music Therapy Perspectives
12
Table 8.
Functional Emotional Assessment Scale
Profile Form (Cutoff Scores)
Subtest
Normal
At Risk
Deficient
Self-regulation & interest in the
world
Forming relationships and
engagement
2-way purposeful communication
Behavioral organization and
problem-solving
Representational capacity
Representational differentiation
Total Score
12–14
11
0–10
14–16
13
0–12
8–10
2–4
7
0–6
0–1
8–14
2–10
48–96
8–14
7
0–1
0–45
46–47
(i.e., styles) were implemented to foster Elaine’s beating on the
drum and the cymbal. In addition, these styles provided experiences that contained drastic contrast between staccato and
legato articulation, as well as harmonic tension and resolution
points in the music. Furthermore, these musical interventions
reflected Elaine’s affect, and incorporated opportunities for her
to predict and lead musical play interactions.
Her musical responses were mostly expressed via instrument play as well as through facial expressions, gestural
cues, and vocalizations. As the sessions progressed, her
responses increased relationally and communicatively.
Thus, there was an increase in spontaneous language during improvised song making. She also began to seek out
the therapist and initiate play interactions and ideas. During
these experiences, in which she displayed an increase in
self-regulation, engagement, and two-way purposeful communication, the treatment phases shifted from phase 1, following her lead, into phase 2 (two-way purposeful musicalplay), and at times venturing into phase 3 (affect synchrony).
Thus, musical-play interactions varied between therapist-led
and child-led experiences
During sessions 16 through 19, musical-play interactions
continued to increase in robustness, range, and continuity as
the therapist continued to embrace and respect Elaine’s selfstimulatory behaviors via musical and movement experiences.
Following her lead appeared to foster sustained self-regulation
and longer periods of engagement and enabled the interaction
to move into treatment phases 2 and 3.
During sessions 20 through 25, Elaine showed more initiation in continuously seeking out play interactions with the
therapist. She also began to lead interactions and require less
support in the form of therapist following her lead.
Toward the end of treatment, Elaine began to display capacities in her ability to create and connect ideas (musical play,
words, gestures, etc.) with the therapist’s while sustaining
joint attention and relatedness in a continuous flow of backand-forth interactions. The robustness of the interactions provided opportunities for her to explore and experience a range
of musical play that included non-referential and referential
improvisations as well as improvised songwriting. Her capacities in musical play appeared to be reflected in her progress
to “normal” FEAS scores in the areas of self-regulation (level
Case 3: Anthony
At pretest Anthony scored “normal” on behavioral organization (level IV) but “deficient” in all other developmental
areas. At post-test he had advanced two levels to “normal” in
the areas of self regulation (level I), engagement (level II), twoway purposeful communication (level III), representational
capacities (level IV), and representational differentiation (level
VI). See Table 6 for Anthony’s pre- and post-test raw scores and
changes in functioning level.
During sessions 1 through 10, Anthony presented with challenges in self-regulation as well as the ability to engage in
relational musical play. He consistently withdrew from musical interactions, physically and/or emotionally. Generally,
Anthony presented with a flat affect and typically engaged in
instrument play in a one-dimensional manner (playing only
loud and fast) and unrelated to the therapist’s music. Anthony
appeared to have difficulty understanding and/or being aware
of the therapist and therapist’s music.
Sessions 11 through 18 featured a combination of childled (treatment phase 1) and therapist-led (phase 2) treatment
phases that consisted of the therapist implementing predictable musical structures and familiar songs. The rational of this
strategy was to cater to Anthony’s strong memory skills as a
means to foster self-regulation and longer periods of relatedness. Repetition and predictability from session to session
appeared to assist Anthony in engaging in related play for a
sustained period of time.
Pre-composed songs that required specific musical
responses helped develop Anthony’s musical resources such
as auditory discrimination, musical range (dynamics and
tempo) related to changes in the therapist’s music, and gestural/affective cues related to musical responses. More importantly, however, Anthony’s improved ability to respond to the
therapist’s music illustrated his awareness of another person
as well as his ability to comprehend and respond to musical
changes as they occurred in time.
During sessions 18 through 25, as sessions progressed,
the familiar songs began to expand and include a variety of
spontaneous musical changes in tempo, dynamics, tonality, phrasing, and articulation that called out for Anthony’s
participation. As his involvement in play increased and
musical-relational capacities expanded, improvisation was
incorporated within the familiar songs on a regular basis.
During improvisational experiences, treatment phases easily
transitioned from child- to therapist-led and back to childled and so forth as the therapist implemented techniques of
elicitation and redirecting to foster Anthony’s ability to regulate, relate, and musically adapt through a range of musical
contexts.
His emerging musical–social resources appeared to be
assimilated into more spontaneous music-making experiences.
Anthony initiated lyrical content, which included singing to
his favorite doll, as well as requesting specific instruments and
Downloaded from http://mtp.oxfordjournals.org/ at AMTA Member Access on June 29, 2016
(Greenspan, DeGangi, & Wieder, 2001)
I), engagement (level II), two-way purposeful communication
(level III), behavioral organization and problem-solving (level
IV), and creating, that is, representational capacities (level V)
and bridging ideas with the therapist, that is, representational
differentiation (level VI). Figure 3 illustrates Elaine’s changes in
developmental levels.
Music Therapy Program on Social Communication for Children with Autism Spectrum Disorder
offering song ideas. To that end, he engaged in higher levels
of musical interaction such initiating and assimilating and differentiating musical ideas, via a range of affect and musical
expressivity. These capacities seemed to be indicated in his
post-test FEAS scores by advances from “deficient” to “normal” in all areas. Figure 4 illustrates Anthony’s changes in
developmental levels.
Case 4: Michele
back-and-forth musical pauses. Her ability to maintain selfregulation and engage via a range of musical experiences
had expanded. In addition, because of the increase in attention and engagement, Michele’s ability to engage in twoway purposeful musical play had emerged. These capacities demonstrated in musical play appeared to be reflected
in her improved FEAS post-test scores. Her FEAS scores
indicated “normal” on self-regulation (level I), engagement
(level II), and behavior organization (level IV). In addition,
she improved to “at-risk” in the areas of two-way purposeful communication (level III). Figure 5 illustrates Michele’s
changes in developmental levels.
Discussion
The results of this case series of DIR-based IMT are consistent with evidence from other IMT studies showing its
effectiveness for improving social communication skills in
children with ASD (Alvin & Warwick, 1991; Edgerton, 1994;
Holck, 2004b; Gattino et al., 2011; Kim, Wigram, & Gold,
2008, 2009; Robbins & Robbins, 1991; Nordoff & Robbins,
2007; Thompson, McFerran, & Gold, 2013). In addition, the
results align with non-music-therapy DSP approaches such
as DIRFloortime that emphasize the importance of following
the child’s lead while considering developmental capacities
within the context of a relationship to improve social communication (Casenhiser, Shanker, & Stieben, 2013; Dionne
& Martini, 2011; Ingersoll, Dvortcsak, A., Whalen, C., &
Sikora, 2005; Mahoney & Perales, 2003, 2005; Pajareya
& Nopmaneejumruslers, 2011, 2012; Solomon, Necheles,
Ferch, & Bruckman, 2007; Solomon, Van Egeren, Mahoney,
Huber, & Zimmerman, 2014).
This study is one of the first in music therapy to demonstrate
improvement on social communication among children with
autism using a standardized, criterion play-based observation
tool as an outcome measure. While the sample in this study is
small, these results suggest that gains in social communication,
after receiving IMT delivered by a music therapist, generalized
to a toy play-based context in an environment not associated
with music therapy. Therefore, the data suggest that the principles underlying DIR-based IMT may produce improvements
in social communication of children with ASD despite significant differences in setting, mediator, and medium. However,
without a control group, it is difficult to know whether the
changes in the FEAS scores were directly attributable to the
IMT intervention. Furthermore, additional in-depth, repeated,
and objective measures of child development, for example IQ,
language, and so forth, could have been added to improve the
measurement of the outcomes.
The difference in the duration and intensity of the DIRbased IMT intervention used in this study and the standard
DIRFloortime intervention is significant. Children in this
study received a total of 13 hours of IMT, one hour a week
over 13 weeks. This is consistent with other IMT studies that
have yielded significant improvement in social communication with children with ASD (Robbins & Robbins, 1991;
Nordoff & Robbins, 2007; Kim, Wigram, & Gold, 2008, 2009;
Gattino et al., 2011). DIRFloortime studies, however, ranged
from seven weeks (Dionne & Martini, 2011) to 12 months
(Solomon, Necheles, Ferch, & Bruckman, 2007; Solomon, Van
Egeren, Mahoney, Huber, & Zimmerman, 2014) and involved
Downloaded from http://mtp.oxfordjournals.org/ at AMTA Member Access on June 29, 2016
At pretest, Michele scored “deficient” on all developmental
areas except for self- regulation (level I), in which she scored
“at-risk.” Following treatment, her post-test indicated “normal” on self-regulation (level I), engagement (level II), and
behavioral organization (level IV). She scored “at-risk” on
two-way purposeful communication (level II) and maintained
a score of “deficient” on representational differentiation (level
V) and representational differentiation (level VI). See Table 7
for Michele’s pre- and post-test raw scores and changes in
functioning level.
During sessions 1 through 9, Michele exhibited difficulty
with engaging in musical play due to challenges in her ability to sustain self-regulation, attention, motor plan, and process sensory information. These differences consistently
interfered with her ability to interact. In addition, her sensory
system appeared to easily overload, in which she withdrew
from musical interactions in an under-reactive manner. She
appeared unaware of the musical surroundings and presented
with challenges related to understanding the functional purpose of the instruments. These difficulties impacted her ability
to comprehend basic social dynamics of relating and communicating in musical play.
During sessions 10 through 18, she began to display islands
of capacity of self-regulation and shared attention while
engaged in instrument play with the therapist. The therapist
continuously followed her lead by improvising music that
reflected her play and emotionality while incorporating simple short melodic phrases, vocally while utilizing percussion,
that contained clear cadences. These phrases were repeated in
order for her to become familiar with the musical motifs, thus
helping her engage and attend to musical play. She began to
display an increase in self-regulation and appeared to become
more affectively connected to musical play by smiling and
offering nonverbal vocalizations that displayed prosody and
musical contours. She also began to exhibit the ability to
engage in brief turn-taking experiences and occasionally completed musical phrases, in a related manner, when playing
percussion and pitched reed horns while therapist accompanied vocally and with various non-pitched percussive instruments. Although these new social–musical capacities began
to emerge, Michele displayed difficulty sustaining the play
interactions whereby they were brief, fragmented, and lacked
a continuous flow back-and-forth interaction. During these
musical experiences, the therapist generally reverted back to
treatment phase 1, following her lead in order to re-engage
Michele in musical play.
During the final sessions of treatment, Michele became
increasingly responsive to musical cues (e.g., dynamics,
tempo, and affect) in the form of relational and communicative instrument play as well as adaption, such as joining into
play, turn-taking, and cause-and-effect relationships during
13
Music Therapy Perspectives
14
Implications for Clinical Practice
Implications of this study for IMT are closely related to
clinical practice. Although it is imperative to understand a
child’s musical responses and create musical goals based on
his/her musical relatedness, it is equally important to understand biological factors that may impinge upon a child’s ability to engage in musical play. Thus, as indicated in this study,
a child who has difficulty engaging in conventional musical
play may be experiencing factors completely unrelated to
music (e.g., difficulties with motor-planning, postural control, auditory and/or visual processing, sensory modulation
and integration, expressive or receptive language, and/or
self-regulation).
Furthermore, because treatment focuses primarily on
facilitating relatedness and communication in children with
ASD, it is important to look for these qualities both within
and outside music, such as in a smile, a gaze, or a hug.
Of course, these responses can be accepted and processed
within the context of musical play, or may be a result of
a musical interaction. However, in all of their forms, these
responses should be regarded as communicative and related
responses.
Current trends in ASD research indicate the increased use
and effectiveness of developmentally based strategies on social
communication of children with ASD (Casenhiser, Shanker, &
Stieben, 2013; Dawson et al., 2010, Ingersol, 2008; Ingersoll,
Dvortcsak, Whalen, & Sikora, 2005; Prizant, Wetherby, Rubin,
& Laurent, 2003; Schreibman, 2005; Schreibman et al., 2015).
This research seeks to follow in the direction of these new
developments and adds to the existing body of IMT and ASD
literature (Aigen, 2005; Edgerton, 1994; Nordoff & Robbins,
2007; Geretsegger, Holck, Carpente, Elefant, & Kim, 2015;
Kim, Wigram, & Gold, 2008, 2009; Thompson, McFerran, &
Gold, 2013).
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