Case Examples of Music Therapy for Autism and Rett Syndrome [1 ed.] 9781937440169

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Case Examples of Music Therapy for Autism and Rett Syndrome Compiled by Kenneth E. Bruscia

Case Examples of Music Therapy for Autism and Rett Syndrome Copyright © 2012 by Barcelona Publishers All rights reserved. No part of this e-book may be reproduced and/or distributed in any form whatsoever. E-ISBN: 978-1-937440-16-9 Distributed throughout the world by: BARCELONA PUBLISHERS 4 White Brook Road Gilsum NH 03448 Tel: 603-357-0236 Fax: 603-357-2073 Website: www.barcelonapublishers.com SAN 298-6299 Cover illustration and design: © 2012 Frank McShane

Table of Contents Music Therapy for Autism

CASE ONE Addressing Core Features of Autism: Integrating Nordoff-Robbins Music Therapy (NRMT) within the Developmental, Individual-Difference, Relationship-Based (DIR®)/FloortimeTM Model John Carpente CASE TWO Music Therapy for a Nonverbal Autistic Adult Ginger Clarkson CASE THREE Establishing Communication with a Boy with Autism Utilizing Recorded Music Barbara Crowe CASE FOUR Melodic Song as Crying—Rhythmic Song as Laughing: A Case Study of Vocal Improvisation with an Autistic Child Gianluigi DiFranco CASE FIVE The Girl Who Barked: Object Relations Music Psychotherapy With An Eleven-Year Old Autistic Female Janice Dvorkin and Misty Erlund CASE SIX Original Song Drawings in the Treatment of A Developmentally Disabled, Autistic Adult Rosemary Fischer CASE SEVEN Henry’s Transition through Music Rika Ikuno CASE EIGHT Sharing Sessions with John Anna Jones and Amelia Oldfield CASE NINE Off-Beat Music Therapy: A Psychoanalytic Approach to Autism Edith Lecourt

CASE TEN Meeting Rich: Individual Music Therapy with a Man Who Has Severe Disabilities Roya Rafieyan Music Therapy for Rett Syndrome CASE ELEVEN Unravelling Hidden Resources of a Girl with Rett Syndrome Cochavit Elefant CASE TWELVE Music Therapy for a Girl with Rett’s Syndrome: Balancing Structure and Freedom Tony Wigram

Introduction Kenneth E. Bruscia Case examples provide very unique and valuable insights into how different forms of therapy are practiced, as well as how clients respond to those therapies. This e-book describes various ways that music therapy has been used to help individuals with autism and Rett Syndrome. It has been compiled not only to provide practical information to students and professionals in music therapy and related fields, but also to inform all those affected by autism or Rett Syndrome about the potential benefits of music therapy. This introduction is intended to help readers better understand and contextualize each case example presented in the book, not only within the field of music therapy, but also within the literature on autism and Rett Syndrome. To do this, it provides basic information on autism, Rett Syndrome, music therapy, and case examples. About Autism and Rett Syndrome Over the last few decades, autism, variously called autistic spectrum or simply autistic disorder, has been defined and classified in many different ways, primarily because symptoms can vary widely according to individual, age, and/or severity. Nevertheless, there is a consensus in the basic characteristics that define autism (American Psychiatric Association, 2000). First, autism is a “pervasive developmental disorder,” that is, it is characterized by significant abnormalities and impairments in development that are usually manifested before the age of three years. Second, a person with autism experiences significant problems in any of these three areas: 1) Social interaction: Problems may include impairments in expressive nonverbal behavior, failure to form peer relationships, lack of interest in interacting spontaneously with others, the lack of interpersonal reciprocity, and so forth. 2) Communication: Problems may include failure to adequately develop and use speech and language, an inability to engage others in conversation, the use of repetitive, stereotypic, or idiosyncratic languages, and difficulty with engaging in make-believe or social imitative play. 3) Behavior: Problems may include preoccupation with stereotyped and restricted patterns of interest, inflexible adherence to routines, stereotyped and repetitive motor mannerisms, and preoccupation with parts of objects. Rett Syndrome (or Rett’s Disorder) is a neurodevelopmental disorder also included in the “Autistic Spectrum.” The child with Rett’s has a normal development prenatally and perinatally, but after five months begins to show impaired psychomotor development and decelerated growth in head size. The following symptoms also appear: loss of hand skills, poorly

coordinated gait and trunk movement, loss of social skills, and severe impairments in speech and language. Along with these problems, individuals with autism and Rett syndrome have many resources and strengths that can they bring to bear in furthering their development. Though these resources and strengths are not usually discussed in formal definitions, the case examples in this book provide myriad perspectives not only on how the above problems are manifested differently by each individual, both within and outside of a musical context, but also how these problems can be addressed through carefully designed music experiences. About Music Therapy (Based on Bruscia, 1993) Definition and Applications In music therapy, the therapist and client use music and all of its facets—physical, emotional, mental, social, aesthetic, and spiritual—to help the client improve or maintain his or her health. In some instances, the client’s needs are addressed directly through music and its intrinsic therapeutic properties; in others, they are addressed through the relationships that develop between the music, client, therapist, and other participants. Music therapy is used with individuals of all ages and with a variety of conditions, including psychiatric disorders, medical problems, physical handicaps, sensory impairments, developmental disabilities, substance abuse, communication disorders, interpersonal problems, and aging. It is also used for self-development purposes, such as improving learning, building self-esteem, reducing stress, supporting physical exercise, and facilitating a host of other health-related activities. Given its wide applications, music therapists may be found in general hospitals, psychiatric facilities, schools, prisons, community centers, training institutes, private practices, and universities. Basic Premises The thing that makes music therapy different from every other form of therapy is its reliance on music as the primary medium for promoting the client’s health. Every session involves the client in a music experience of some kind. The main ones are listening to, recreating, improvising, and composing music. These will be described in more detail in the next few paragraphs; however, it is important to explain immediately that clients do not have to be musicians to participate in or benefit from music therapy. In fact, because most clients have not had previous musical training, the music activities and experiences used in therapy sessions are always designed to take advantage of the innate tendencies of all human beings to make and appreciate music at their own developmental levels. Of course, in clinical situations, music therapists may encounter clients who have physical or mental impairments that interfere with one or more of these basic musical potentials. Therefore, care is always taken to adapt music therapy experiences to the unique musical capabilities and preferences of each client. Music therapists also screen clients who may have adverse psychological or psychophysiological reactions to participation in music.

Four Basic Music Experiences Used in Therapy To understand how music therapy works, it is necessary to examine the unique nature of each of the four types of music experience—listening to, recreating, improvising, and composing. In those therapy sessions that involve listening, the client takes in and reacts to live or recorded music in the style preferred by the client. The client may respond through activities such as relaxation or meditation, structured or free movement, perceptual tasks, freeassociation, story-telling, imaging, reminiscing, drawing, and so forth. Music listening experiences are used with clients who need to be activated, soothed, or further developed— either physically, emotionally, intellectually, and/or spiritually—as these are the kinds of responses that music listening elicits. In those therapy sessions that involve re-creating music, the client sings or plays precomposed music. This may include learning how to produce sounds, imitating musical phrases, learning how to sing, learning to read notation, participating in group sing-along’s, performing a song or piece, participating in a musical show or drama, and so forth. Re-creative experiences are most appropriate for clients who need to develop sensorimotor skills, learn adaptive behaviors, maintain reality orientation, master different role behaviors, identify with the feelings and ideas of others, work with others cooperatively, or merely share in the joy of making music—as these are the main aspects of singing or playing pre-composed music that have therapeutic implications. In those therapy sessions that involve improvising, the client makes up his or her own music extemporaneously, singing or playing whatever arises in the moment. The client may improvise freely and spontaneously or according to the musical or verbal guidance of the therapist. Sometimes the client is asked to improvise sound portraits of feelings, events, persons, or situations that are being explored in therapy. The client may improvise with the therapist, with other clients in a group, or alone, depending on the therapeutic objective. Improvising music is most appropriate for clients who need to develop spontaneity, creativity, freedom of expression, self-awareness, communication, and interpersonal skills—as these are the basic components of improvising. In those sessions that involve composing, the therapist helps the client to write songs, lyrics, or instrumental pieces, or to create any kind of musical product, such as music videos or audiotape programs. Usually the therapist simplifies the process by engaging the client in aspects of the task within their capability (e.g., generating a melody, or writing the lyrics of a song) and by taking responsibility for more technical aspects (e.g., harmonization, notation). Activities involving composing music are used with clients who need to learn how to make decisions and commitments, or find ways of working in an organized way toward a goal. Most often, clients create compositions (especially songs) around significant events, people, or relationships in their lives, or to express thoughts and feelings that they are exploring in therapy. In addition to strictly music experiences, music therapists often engage clients in verbal discussions. Clients may be encouraged to talk about the music, their reactions to it, or any thoughts, images, or feelings that were evoked during the experience. Clients may also be

encouraged to express themselves through the other arts, such as drawing, painting, dance, drama, or poetry. Music therapy sessions for children often include various games or play activities which involve music. The case examples that follow highlight the goals of music therapy for individuals with autism or Rett syndrome, and the different kinds of music experiences used to address these goals. Thus, a key to reading these cases is to pay close attention to how each type of music experience affords clients many different opportunities to not only confront their problems within the music, but also to explore healthier ways of dealing with or resolving them. This leads to the next important topic—the ways that case examples can be read or studied for greatest insight. About Case Examples For purposes of the present discussion, case examples can be divided into two main types: clinical cases, and research cases. A clinical case is a professional report written by the therapist, client, or observer to describe what transpired during and upon completion of the music therapy process with an individual client or group. The report is usually based on recordings of the session or notes and logs kept by the therapist and/or client. Efforts are made to present an accurate and unbiased account of the therapy process to the extent possible, and theories are often used to substantiate or contextualize the therapeutic approach. Objective data may or may not be provided to verify or document the report. In contrast, a research case is a data-based report, provided by the therapist or researcher, to document or verify the specific therapeutic effects of a particular music therapy protocol on an individual client or group. As such, a research case operationally defines and measures how the independent variables (e.g., treatment methods used by the therapist) act upon the dependent variables (e.g., targeted treatment outcomes for the client), when all other relevant variables and conditions are controlled. Perhaps the best way to derive the most benefits from a clinical or research case is to read it from a particular perspective, and to interrogate the case or group of cases from that perspective. Essentially, the reader adopts a particular lens or viewpoint to study the case(s), and then asks questions that arise as a result. Three of the most helpful reading perspectives are: scientific, personal, and clinical perspectives, each of which poses very different questions for the reader to ponder. Reading from a Scientific Perspective Scientists usually look for answers to two basic questions when reading a case. First, is the case credible? That is, how accurate were the perceptions and interpretations of the writer, and how trustworthy are the findings and conclusions presented? Of course, this is not a question that only scientists pose. One’s natural propensity as a reader is to question the truth value of what is read. Certainly, if the reader is involved in some way with an individual with autism or Rett syndrome, the truth value of the case is of vital interest. That leads to the second scientific question: Can the information learned in this case be applied to other cases? Or even more rigorously, can the findings of this case be generalized to

similar or matched cases? Here too, readers who are directly affected by autism or Rett syndrome are as interested in this question as scientists and researchers. Their interest is in whether individuals with autism or Rett’s in their own lives can derive the same benefits of music therapy as the client in this case did. Scientists or researchers can also glean other very important information from case studies. Because clinical cases provide rich descriptions of the therapy process, they usually provide myriad ideas for what needs to be studied scientifically. By describing what seemed to work and or not work for a particular client, a clinical case reveals to the researcher which clinical protocols and therapeutic outcomes warrant further research, while also suggesting specific hypotheses that might be tested. Moreover, because events unfold naturally in a clinical case as they do in real life, and because variables cannot be controlled as in laboratory research, the clinical case gives very important information on what specific variables must be considered when doing research, not only the most likely independent and dependent variables that are likely to be related, but also what extraneous variables need to be controlled. Of course, a research case can provide the same insights, to some degree, as a clinical case; they too offer valuable information on potential independent, dependent, and extraneous variables to consider. The greatest advantage of the research case is not only that it provides objective evidence of what works or doesn’t work in therapy, but also because it can reveal the “effect size” of the therapeutic change. That is, a single-case research study can show how big an effect the independent variable had on the dependent variable, or the extent to which the treatment protocol was effective in inducing therapeutic change in the client. Though this effect and its size cannot be generalized, careful replication of research cases and meta-analysis can begin to build a case for the establishment of clinical cause-effect relationships. Reading from a Personal Perspective By their very nature, case examples invite the reader to identify with one or more characters involved in the case, and then move from identifying with one character to identifying with another. The characters may include the client, the therapist, other clients, loved ones, and so forth. Identifying with people involved in the case not only helps the reader to understand first-hand what each character is experiencing, but also gives the reader an opportunity to compare how the character reacted with how the reader would react. Here are some examples: 1) Identifying with the client: What must the client be thinking or feeling about the therapist, music, other clients, or loved one? If I were the client, would I think or feel the same? What does this client need and want from those involved in the therapy process, and would I need or want the same? These same questions can be posed for every client involved in the case. 2) Identifying with the therapist: What must the therapist be thinking or feeling about the client, the music, the other clients, or the client’s loved one? Would I think or feel the same? What kind of person would I be if I were working with this client? What is the therapist trying to do, and would I try to do the same?

3) Identifying with loved ones: What must the loved one be thinking or feeling about the client, the therapist, the music, and other clients? If I were a loved one, would I think or feel the same? What does this person need or want, and would I need or want the same? Does this person believe that music therapy will help, and would I? How does the loved one feel about the therapist, and how he or she is relating to the client? Does the therapist know what he or she is doing? The fascinating thing about taking an empathic position is that once one successfully steps into one character’s shoes, and becomes sensitive to who he or she is, an endless number of additional empathic positions arise, and one’s entire personal reaction to the case becomes enlivened. Reading from a Clinical Perspective A clinical perspective is concerned primarily with methodological questions that are most often posed by other clinicians. Clinicians want to know what does and does not work when working with a client in music therapy. Practically speaking then, they are most interested in the following kinds of questions: 1) Based on this case, what should I be looking for in clients? What client needs and resources do I have to address more in my own work? How can I assess these facets of the client in music therapy? 2) Based on this case, what kind of therapist-client relationship is best for this kind of client, and what is the best way of forming such a relationship? 3) What is the role of music in working with this clientele? What types of music experiences are most therapeutically relevant and effective? What styles of music are most appropriate? 4) Based on this case, what are the best ways of responding to the client when he or she is acting out, abreacting, resisting, or not progressing? 5) Based on this case, what clinical criteria should be used in evaluating the client’s therapeutic progress? Other Case Studies on Music Therapy for Autism The case examples in this e-book were taken exclusively from various books published by Barcelona Publishers. Thus, these cases, though typical, may not comprise a representative sample of all clinical practices in music therapy for individuals with autism. Several other case examples have been written, which further elaborate how individuals with autism can derive therapeutic benefits from music. Here is a list of other published case examples: Agrotou, A. (1988). A case study: Lara. British Journal of Music Therapy, 2(1), 17–23. Alvin, J., & Warwick, A. (1991). Music Therapy for the Autistic Child (Second Edition). New York: Oxford University Press.

Brown, S. (1994). Autism and music therapy—Is change possible and why music? British Journal of Music Therapy, 8(1), 15–15. Brownell, M (2002). Musically adapted social stories to modify behaviors in students with autism: Four case studies. Journal of Music Therapy, 39(2), 117–144. Bryan, A. (1989). Autistic group case study. British Journal of Music Therapy, 3(1), 16–21. Bunt, L. (2002). Suzanna’s story: Music therapy with a pre-school child. In L. Bunt and S. Hoskins (Eds.), The Handbook of Music Therapy, pp. 71–83. New York: Brunner-Routledge. Goldstein, C. (1964). Music and creative arts therapy for an autistic child. Journal of Music Therapy, 1(4), 135–138. Hoelzley, P. (1991). Reciprocal inhibition in music therapy: A case study involving wind instrument usage to attenuate fear, anxiety, and avoidance reactivity in a child with pervasive developmental disorder. Music Therapy: Journal of the American Association for Music Therapy, 10(1), 58–76. Hooper, J., McManus, A., & McIntyre, A. (2004). Exploring the link between music therapy and sensory integration: An individual case study. British Journal of Music Therapy, 18(1), 15–23. Howat, R. (1995). Elizabeth: A case study of an autistic child in individual music therapy. In T. Wigram, B. Saperston & R. West (Eds.), The Art and Science of Music Therapy: A Handbook (pp. 238–260). Chur, Switzerland: Harwood Academic Publishers. Kern, P., Aldridge, D., & Wakeford, L. (2007). Improving the performance of a young child with autism during self-care tasks using embedded song interventions: A case study. Music Therapy Perspectives, 25(1), 43–51. Levinge, A. (1990). “The use of I and Me:” Music therapy with an autistic child. British Journal of Music Therapy, 4(2), 15–18. Pasiali, V. (2004). The use of prescriptive therapeutic songs in a home–based environment to promote social skills acquisition by children with autism: Three case studies. Music Therapy Perspectives, 22(1), 11–20. Tyler, H. (1998). Behind the mask: An exploration of the true and false self as revealed in music therapy. British Journal of Music Therapy, 12(2), 60–66. Wager, K. M. (2000). The effects of music therapy upon an adult male with autism and mental retardation: A four–year case study. Music Therapy Perspectives, 18(2), 131–140. Other Writings on Music Therapy for Rett Syndrome Although music therapists have taken a special interest in children with Rett’s, much less has been written on the topic as compared to autism. Thus, the present list includes types of writings other than case studies. Bergström-Isacsson, M., Julu, P. O. O., & Witt-Engerström, I. (2007). Autonomic responses to music and vibroacoustic therapy in Rett syndrome: A controlled within-subject study. Nordic Journal of Music Therapy, 16(1), 42-59. Elefant, C., & Lotan, M. (2004). Rett syndrome: Dual intervention - music and physical therapy. Nordic Journal of Music Therapy, 13(2), 172-182.

Elefant, Cochavit. (2009). Music therapy for individuals with Rett syndrome. International Journal on Disability and Human Development, 8, 359-368 Go, T., & Mitani, A. (2009). A qualitative motion analysis study of voluntary hand movement induced by music in patients with Rett syndrome. Neuropsychiatric Disease and Treatment, 5, 499-503. Hadsell, N. A., & Coleman, K. A. (1988). Rett syndrome: A challenge for music therapists. Music Therapy Perspectives, 5, 52-56. Maroldt, Bettina. (2003). "My hands won't do it!" - Individual music therapy in a case of Rett Syndrome. Musiktherapeutische Umschau, 24(3), 215-226 Merker, B., Bergstrom-Isacsson, M., & Engerstrom, I. W. (2001). Music and the Rett disorder: The Swedish Rett center survey. Nordic Journal of Music Therapy, 10(1), 42-53. Sokira, J. (2007). Interpreting the communicative behaviors of clients with Rett syndrome in music therapy: A self-inquiry. In A. Meadows (Ed.), Qualitative Inquiries in Music Therapy: A Monograph Series, Volume 3, (pp. 103-131). Gilsum, NH: Barcelona Publishers. Wesecky, A. (1986). Music therapy for children with Rett syndrome. American Journal of Medical Genetics. Supplement 1, 253-257. Wigram, T. (1991). Music therapy for a girl with Rett's syndrome: Balancing structure and freedom. In K. E. Bruscia (Ed.), Case studies in music therapy (pp. 39-54). Phoenixville, PA: Barcelona Publishers. Wigram, T. (1997). Vibroacoustic therapy in the treatment of Rett syndrome. In T. Wigram, & C. Dileo (Eds.), Music vibration and health (pp. 149-156). Cherry Hill, NJ: Jeffrey Books. Wigram, Tony & Lawrence, Margaret. (2005). Music therapy as a tool for assessing hand use and communicativeness in children with Rett Syndrome. Brain & Development, 27, S95S96. Wigram, T. & Elefant, C. (2009). Therapeutic dialogues in music: Nurturing musicality of communication in children with autistic spectrum disorder and Rett syndrome. Malloch, Stephen [Ed], Trevarthen, Colwyn [Ed]. Communicative musicality: Exploring the basis of human companionship. New York, NY, US: Oxford University Press, US; pp. 423-445. Wylie, M. E. (1996). A case study to promote hand use in children with rett syndrome. Music Therapy Perspectives, 14(2), 83-86. Yasuhara, Akihiro & Sugiyama, Yuriko. (2001). Music therapy for children with Rett syndrome. Brain & Development, 23, S82-S84. References for Introduction American Psychiatric Association (APA) (2000). Diagnostic and Statistical Manual of Mental Disorders—Fourth Edition, Text Revision. Washington DC: American Psychiatric Association. Bruscia, K. (1993). Music Therapy Brief. Retrieved from temple.edu/musictherapy/FAQ.

Case Examples of Music Therapy for Autism and Rett Syndrome

Taken from: Meadows, A. (Ed.) (2011). Developments in Music Therapy Practice: Case Study Perspectives. Gilsum NH: Barcelona Publishers. \

CASE ONE Addressing Core Features of Autism: Integrating Nordoff-Robbins Music Therapy With The Developmental, Individual-Difference, Relationship-based Dir®/Floortime™ Model John A. Carpente Introduction

This chapter is based on the author’s clinical experiences developing a music therapy program at a Developmental, Individual-Difference, Relationship-based (DIR®) school in a large metropolitan area in the United States. Although terms, concepts, and philosophy are grounded in Nordoff-Robbins Music Therapy (NRMT), definitions, clinical interpretations and rationale have been modified based on the DIR® Model in an attempt to integrate NRMT and DIR®/Floortime™ (Greenspan & Weider, 2006a). The rationale for this is an attempt to develop a population-based music therapy assessment and treatment intervention that focuses on establishing and achieving musical goals in relation to social-emotional development in children with neurodevelopmental disorders that affect relating and communicating, specifically autism spectrum disorders. To that end, assessment and conceptualizing the child to determine intervention planning includes both DIR® and NRMT. Clinical Setting This clinical work takes place at a Developmental, Individual-Difference, Relationshipbased (DIR®) school located in New York City. The school serves 107 children, ages four to 18, with neurodevelopmental disorders of relating and communicating, including Pervasive Developmental Disorders (PDD). The school offers a variety of services, including music and art therapy, speech therapy, occupational and physical therapy, psychology, and social work. This case study details individual music therapy with Matthew, a seven-year-old boy diagnosed with Pervasive Developmental Disorder-Not Otherwise Specified (PDD-NOS) who displayed difficulties in his ability to self-regulate, engage, relate, and communicate. In this clinical work, NRMT and the DIR®/Floortime™ model were used in tandem. The chapter describes a five-month process in which interactive musical experiences helped to facilitate Matthew’s ability to self-regulate, engage, relate, and purposefully communicate. NRMT was used as the primary treatment approach and focused primarily on musical goals and the establishment of musical relationships between therapists (intern and therapist) and child. DIR®

was used as the primary means of conceptualizing and assessing the child’s strengths and needs and evaluating the child’s progress in these areas (Carpente, 2009). Foundation Concepts NRMT and the DIR®/Floortime™ Model The DIR® model, developed by Drs. Greenspan and Weider (Greenspan & Weider, 2006b), provides a comprehensive framework for assessing and treating the child. It centers on facilitating foundational components of child development in the areas of relating, communicating, and thinking through the development of relationships via interactive play Floortime™ (Greenspan & Weider, 2006a, 2006b). Rather than simply focusing on isolated behaviors, the model takes a global perspective of the child regarding functional developmental capacities, biological processing differences, and emotional interactions between the child and caregiver (Greenspan & Weider, 2006a, 2006b). The term “Development” in the DIR® model refers to where the child is developmentally, based on social-emotional development. According to Greenspan and Weider (2006a) developmental milestones include six levels of emotional development (Functional Emotional Developmental Levels, or FEDL) important to children with autism spectrum disorders (ASD) of any age: • • • • • •

Regulation and shared attention Engagement and relatedness Two-way purposeful communication Shared problem solving Creative use of ideas Building bridges between ideas

The Term “Individual-Difference” refers to how the child processes information such as motor and sensory capacities, touch, sound, and other sensations. It also includes auditory and visual-spatial processing, motor-planning, and sequencing abilities. For each of the six developmental stages described above, the therapist looks at the particular “individual differences” of the child and determines how they interfere with the child’s development (Greenspan & Weider, 2006b). Finally, the term “Relationships” in the DIR® model refers to how the child interacts with others and what patterns of interaction, and affects, should be included in the treatment plan to support and enhance the child’s development. As can be seen, each component of the DIR® model complements the other. First, it is important to understand at what level the child is functioning developmentally. Secondly, one must ascertain what stands in the way of a child’s development, in regard to how the child is processing information about him or herself. Lastly, it is critical to know how the child relates to others in the world. Once there is a developmental picture and a sensory profile of the child, the therapist can guide the child into ways of interacting and relating that will provide the

proper sensory input necessary to move him/her up the developmental ladder (Greenspan & Weider, 2006a). Nordoff-Robbins Music Therapy and the DIR® Model The driving force of the DIR® model, which parallels NRMT, is Floor-time™. Floortime™ (Greenspan & Weider, 2006a) is a systematic way of using play to help the child to develop. Similarities between Floortime™ and NRMT are that they both involve improvisation, creativity, spontaneity, emotionality, and a playful spirit. The main difference between Floortime™ and NRMT is in the medium. NRMT primarily involves the use of live interactive musical experiences, while Floortime™ primarily involves the use of objects and symbolic and sensory toys. In NRMT, the therapist (music maker) observes the child and follows his/her lead using music as the primary medium. The music being improvised attempts to create affective and emotionally charged experiences intended to help the child regulate, musically engage and interact in a joint musical relationship (Carpente, 2009). Both are action-based approaches in which the child is an active and leading participant in the process. Both approaches view relationships as a core component of child development. Both focus on the creative process (dynamics) between the child and the therapist. Finally, both models respect the individual differences of each child and view whatever the child is doing as important (e.g., respecting idiosyncratic and self-stimulatory behaviors without attempting to extinguish them, but to embrace them and help make them interactive and communicative). The primary focus of both approaches is to bring the child into a shared world from isolation. The idea is not to pull the child “kicking and screaming,” but have the child want to be in the shared world. Role of Therapist/Music The therapist’s task is to improvise music built around the child’s musical responses, reactions, and/or movements, while considering the child’s individual differences (Carpente, 2009). The primary focus of the improvised music is to create and offer experiences that will facilitate musical relatedness and communication in order to help the child move up the developmental ladder. Because the primary focus is on the quality of musical interactions between the child and therapist, “the musical process is the clinical process” (Aigen, 2005, p. 94). This means that the therapist’s primary concern is to develop and incorporate musical interventions that deepen the child’s musical engagement and interaction in order to increase relatedness and communication. In short, musical goals are clinical goals (Aigen, 2005). What a child accomplishes musically is regarded as a clinical or therapeutic accomplishment. However, although the focus is on musical goals and the widening of the child’s musical experiences, it is clear that these goal areas can also address cognitive, expressive, sensory, communication, and social areas. In considering all that is involved in achieving the above musical goals (motor planning, auditory cuing, fine and gross motor skills, visual-spatial processing, and sensory modulation), it becomes clear that developmental goals are realized through musical goals and experiences (Carpente, 2009).

Background and Current Information History Reportedly, Matthew was the product of an uncomplicated, full-term pregnancy and Csection delivery. He weighed 6 lbs. 8 oz. at birth and no complications were indicated. Developmental milestones were met within normal limits by age two; however, speech was delayed. Matthew was three years old when he was diagnosed with Pervasive Developmental Disorder-Not Otherwise Specified (PDD-NOS) and speech apraxia. In addition, testing revealed a Mental Development Index of