Andrew Littlefield, MT-BC, NICU-MT. The Florida State University

Transcription

1 Running head: The Use of Music Therapy Within the Relationship Development Intervention for Children With Autism Spectrum Disorders 1 The Use of Music Therapy Within the Relationship Development Intervention for Children with Autism Spectrum Disorders Andrew Littlefield, MT-BC, NICU-MT The Florida State University

2 The Use of Music Therapy Within the Relationship Development 2 Abstract This study aimed to identify shared goal areas between music therapy and the Relationship Development Intervention (RDI). Additionally, music therapists working with children with autism spectrum disorders rated their knowledge of various autism treatment modalities, including RDI. Music therapists in the Southeastern United States (N = 4) were asked to submit their goals for clients with autism. These reported goals were compared to the levels of Experience Sharing described in the RDI program. 32% of reported music therapy goals shared commonality with one of more levels of Experience Sharing. Within the communication domain, 53% of common goals were found. Using a Likert scale of 1-4, music therapists rated their knowledge of RDI at 2. This rated slightly below the average reported knowledge of all autism treatment models (2.16). The researcher concludes that music therapy can indeed augment RDI therapy, and suggests future research focus on specific interventions used in each treatment.

3 The Use of Music Therapy Within the Relationship Development 3 The Use of Music Therapy Within the Relationship Development Intervention for Children With Autism Spectrum Disorders Music therapy has been shown by several studies to be significantly effective in reaching the goals of clients with Autism Spectrum Disorder. Studies have examined the effectiveness of music therapy for teaching emotional understanding and context (Katagiri, 2009), social interaction (Kern & Aldridge, 2006), behavior modification (Brownell, 2002), and even speech production (Lim, 2010) for children with Autism. However, this field of research has thus far been very limited. Current estimates state that 1 out of every 110 is diagnosed with autism, with the rate of diagnosis increasing between 10-17% annually (Autismspeaks.org). As this population continues to grow at such a rapid pace, music therapy research must also increase. While these studies have focused on specific objectives using specific techniques, fewer studies have examined the effectiveness of music therapy as a whole on the generally accepted goal areas for children with Autism Spectrum Disorder. In 2005, Kaplan examined the goals addressed by music therapists working with children with autism across a 2-year span. The findings show that Behavioral/Psychosocial and Language/Communication goals were addressed for a far higher percentage of clients than musical, cognitive, or perceptual/motor goals. These findings compliment the results of other studies involving the use of music therapy within established Autism curriculum programs, such as the SCERTS model. The SCERTS model is an education model for students on the Autism Spectrum that centers around three domains: Social Communication, Emotional Regulation, and Transactional Support (scerts.com). Two studies have examined how music therapy can augment this program. The first study surveyed music therapists from across the country to determine what goals and objectives from the SCERTS model they address, even if they are unfamiliar with the model (Walworth, 2007). The study identified 27 SCERTS goals currently assessed by music

4 The Use of Music Therapy Within the Relationship Development 4 therapists, though none of these goals came from the Transactional Support domain. A follow-up study, also by Walworth (2009) examined video-taped music therapy sessions. This allowed the researcher (who is well versed in SCERTS) to identify goals, rather than relying on self-report. This study found that music therapists address Transactional Support more than Social Communication and Emotional Regulation. Another widely used treatment model for Autism Spectrum Disorder is the Relationship Development Intervention (RDI) developed by Dr. Steven Gutstein. This model centers on building the necessary relationship skills to allow people on the Autism Spectrum to thrive socially (Gutstein, 2002). The program centers on Gutstein s 6 Levels of Experience Sharing. This sequential developmental theory breaks developmental milestones into levels and stages of relationship building skills acquired by typically developing children. Gutstein s theory centers on the idea that children with autism do not naturally develop these skills, and require remedial therapy (Gutstein, 2000). The program is designed to allow parents, teachers, and therapists to coach children through the program, providing opportunities for their child to respond in more flexible, thoughtful ways to novel, challenging and increasingly unpredictable settings and problems, and teach the student how to incorporate these skill sets into everyday life (Gutstein, 2007). Seeing as this model is specifically developed to be integrated into all aspects of a client s life, it would be prudent to examine how music therapy can augment RDI. However to date, no such research exists. Walworth (2007, 2009) has shown that music therapists currently are addressing a vast array of important social skills with their clients on the Autism Spectrum through her examination of the SCERTS model. It is not unreasonable to hypothesize that similar results could be found through an examination of music therapy and the RDI model. This study will aim to: 1) Identify which RDI goal areas are being addressed by music therapists

5 The Use of Music Therapy Within the Relationship Development 5 2) Measure music therapists level of knowledge RDI and other autism treatment models

6 The Use of Music Therapy Within the Relationship Development 6 Method Participants for this study were music therapists located within the Southeastern United States who served clients with ASD (N = 4). A total of 15 surveys were sent out, with 4 being returned, for a response rate of 27%. All participants gave consent to be in the study. Participants made up a convenience sample and were solicited via . Surveys were completed and submitted online. A modified version of the survey used in Walworth s 2007 study was utilized. For the current study, participants were asked to make a list of goals and objectives they are currently addressing with their clients with ASD, as well as what activities and materials they most frequently use to address these goals and objectives. Additionally, participants were asked to rank their knowledge of several widely used ASD intervention methods, including the Relationship Development Intervention, on a Likert scale of 1-4. A score of 1 was defined as I have never heard of this model, while a score of 4 was defined as I am very familiar with this model.

7 The Use of Music Therapy Within the Relationship Development 7 Results Reported goals from surveys were combined and categorized into six domain areas: social, emotional, motor, communication, academic, and musical. Goals that could be classified under multiple domain areas were placed into the domain of best fit. Goals were then cross referenced to the levels and stages of Experience Sharing (Table 1) using a matrix chart (Table 2). For each music therapy goal that applied to an Experience Sharing stage, a marker was placed on the matrix chart. A total of 25 different goals were reported. Of these, 8 were classified under the communication domain, 8 under the social domain, 5 under the academic domain, 3 under the motor domain, 1 under the musical domain, and 0 under the emotional domain. With 25 reported goals and 24 stages of Experience Sharing, there were a total of 600 possible shared goal areas. The actual number of shared goal areas was counted and divided by the total possible to calculate a percentage of shared goals. A total of 193 (32%) of shared goals were found. When divided by the individual domains, communication goals yielded the highest percentage and amount of goals at 101 out of 192 possible shared goals (53%). The social domain area followed with 72 out of 192 possible shared goals (38%). Motor goals shared 18 out of 72 possible goals (25%). Finally, the academic domain shared 2 goals out of a possible 120 (2%). The musical domain shared no common goals out of 24 possible goals (0%), while the emotional domain was excluded as no goals for this domain were reported. Reported levels of knowledge of each autism treatment model were compiled (Table 3 and Table 4). A mean score of 2.16 across all treatment modalities was found, with a median score of 1.5

8 The Use of Music Therapy Within the Relationship Development 8 and a mode of 1. Mean reported level of knowledge for the Relationship Development Intervention was slightly lower than the average at 2, with a median score of 1.5. The highest mean for reported level of knowledge came from Applied Behavior Analysis at M = 4, followed by Discrete Trial Training (M = 3), Floortime (M = 2.5), RDI (M = 2), SCERTS and TEACCH (M = 1.75), Pivotal Response Treatment (M = 1.25), and finally the Son-Rise program (M = 1). Discussion The findings of this study show that music therapy can augment Relationship Development Intervention, working alongside the program to strengthen its core goal areas. Initial inspection of the numbers may lead one to think that there is a lack of commonality between music therapy and RDI, however several considerations must be made regarding the two approaches. RDI is an approach that is solely focused on the social and communication deficits present in students with autism. Its singular function is represented in its name: to allow children with autism to develop meaningful relationships. Music therapy encompasses many different domains, not just communication and social. RDI does not concern itself with academic, motor, or musical goals. The much higher percentage of shared goals in the communication and social domains reflect this. One issue that was raised during the study was the fact that comparing music therapy goals to the levels of Experiences Sharing is a bit like comparing apples to oranges. Music therapy goals are frequently observable, measurable milestones. The stages of Experience Sharing, and the RDI model in general, is a bit more nebulous. While the stages of Experience Sharing can indeed be viewed as milestones, similar to music therapy goals, they act in a more sequential nature. Therefore, we see some long stretches where specific music therapy goals do or do not apply.

9 The Use of Music Therapy Within the Relationship Development 9 Similarly, it is difficult to compare specific goals to RDI because the model is less about what the goals are for a client, but rather how these goals are approached. Future studies may wish to investigate common RDI intervention activities with music therapy intervention activities to compare and contrast the two, and determine a fit from there. One of the alarming findings of this study is the general lack of knowledge regarding various popular autism treatment models. Outside of Applied Behavior Analysis, reported level of knowledge for other treatment models were relatively low. If music therapists were more educated and informed on these treatment models, a greater number of shared goals might be found. In order for music therapy to thrive with the autism population, this deficit must be addressed. Music therapists will likely find themselves working with a number of clients who subscribe to any number of treatment models, and the more music therapists can adapt to augment various treatment models, the more success the field will have. It would be a disservice to clients to allow a personal bias to force a modality that is incongruent with the client s preferred model in treatment. It is reasonable to assume that music therapy can and does work alongside the RDI treatment model. With the amount of shared goals already in place, the two models compliment each other well. RDI centers on developing a client s ability to interact spontaneously and thrive in relationships. Music therapy provides a non-threatening environment with multiple opportunities for human interaction and spontaneity. With further education and research, music therapy can continue to grow in the autism population.

10 The Use of Music Therapy Within the Relationship Development 10 References Katagiri, J. (2009). The effect of background music and song texts on the emotional understanding of children with autism. The Journal of Music Therapy, 46 (1), Kern, P., & Aldridge, D. (2006). Using embedded music therapy interventions to support outdoor play of young children with autism in an inclusive community-based child care program. The Journal of Music Therapy, 43 (4), Brownell, M. D. (2002). Musically adapted social stories to modify behaviors in students with autism: four case studies. The Journal of Music Therapy, 39 (2), Lim, H. A. (2010). Effect of Developmental Speech and Language Training Through Music on speech production in children with Autism Spectrum Disorders. The Journal of Music Therapy, 47 (1), Kaplan, R. S., & Steele, A. L. (2005). An analysis of music therapy program goals and outcomes for clients with diagnoses on the Autism Spectrum. The Journal of Music Therapy, 42 (1), DeLoach, D. (2007). The use of music therapy within the SCERTS model for children with Autism Spectrum Disorder. The Journal of Music Therapy, 44 (1), Walworth, D. D., Register, D., Engel, J. N. (2009). Using the SCERTS model assessment tool to identify music therapy goals for clients with Autism Spectrum Disorder. The Journal of Music Therapy, 46 (3), Gutstein, S. E. (2000). Autism Aspergers: Solving the relationship puzzle: A new developmental program that opens the door to lifelong social & emotional growth. Arlington, TX: Future Horizons Inc. Gutstein, S. E., Burgess, A. F., Montfort, K. (2007). Evaluation of the Relationship Development Intervention program. Autism, 11 (5), Gutstein, S. E., & Sheely R. K. (2002). Relationship Development Intervention with young children: Social and emotional development activities for Asperger Syndrome, Autism, PDD, and NLD. London, England & Philadelphia, PA: Jessica Kingsley Publishers Ltd. What is Autism?

11 The Use of Music Therapy Within the Relationship Development 11 Prizant, Wetherby, Rubin, Laurent (2007). What is SCERTS?

12 The Use of Music Therapy Within the Relationship Development 12 Table 1 Levels and Stages of Experience Sharing Level 1 Tuning In (birth 6 months) Emotional Attunement Child reacts to facial expressions, head movements, and voice tones of others. Sets stage for introduction of novelty Social Referencing Child responds and reacts to facial expressions of others. Distress can be eased by referencing parents calm and positive facial expressions Excitement Sharing Child begins to pay closer attention to facial expressions, gaining meaning from emotions conveyed Simple games Child can anticipate elements of interactions (facial expression, added novelty) Level 2 Learning to Dance (6 12 months) Shared Frameworks Parents teach structures and sequences through repetitive instructions Variations add the Spice Child tolerates and understands variations, discriminates between essential and non-essential framework of interactions. Dancing Lessons Child is able to co-regulate, participate in turn taking. Moving Together Move from sequential to simultaneous synchronized activity, active regulation Level 3 Improvising and Co-creating (12 18 months) Co-variation Child begins adding variation to play at same rate as adult. Fluid Transitions Play transitions between activities seamlessly. Improvisation Scripted interaction no longer necessary, interactions improvised. Co-Creations Improvisations turn into original games. Level 4 Sharing Outside Worlds (18 30 months) Perception Sharing Purpose of interactions no longer simply to coordinate actions with adult, but can share their experiences with others. Points to novel stimuli to direct adult s attention, can tell when adult s attention is fixed on stimulus. Perspective Taking Child able to understand that two people in different locations may not be able to see something in the same way. Can learn that another s perspective can sometimes provide more information. Unique Reactions Child is able to understand that different people can have different emotional reactions to same experience, or that another person looking at the same object can notice things the child does not. Adding Imagination Child understands pretending, phrases not taken literally, can understand multiple uses for objects.

13 The Use of Music Therapy Within the Relationship Development 13 Level 5 Sharing Minds (30 48 months) Sharing Ideas Role-playing is introduced to pretend play, along with role-reversals. Exciting Differences Child learns that their ideas and viewpoints are not always shared with everyone. Learns other children have unique interests and ways of doing things. The Inside and Outside Worlds Child realizes that others have inward thoughts and feelings, true emotions are not always conveyed on face. Can feign emotions, recognized difference between teasing and cruel name-calling. The Primacy of Minds Now that child understands that others have inward feelings, can now understand that physical proximity is not same as sharing experiences. Can try to understand another s feelings by more than just their actions or facial expressions. Level 6 Binding Ourselves to Others (48+ months) Unique Selves Begin to develop sense of personal identity, can compare and contrast identity with others. Belonging to Groups Child develops desire to belong to group, shows pride in membership, can coordinate actions to maintain membership. Playmates and Pals Begins to understand and develop more complex friendships. Friendships no longer are formed based on shared physical attributes or strictly shared activities. Desire to have friends visit home, understand their actions impact friendship, show desire to maintain friendship. Enduring Friendships Child views friendships as enduring relationships, which take shape and change over time. Requirements for friendship develop into psychological traits, such as trust, or more abstract ideas.

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17 The Use of Music Therapy Within the Relationship Development 17 Table 3 Modality Mean Reported Knowledge Applied Behavior Analysis 4 Discrete Trial Training 3 Floortime (DIR) 2.5 RDI 2 SCERTS 1.75 TEACCH 1.75 Pivotal Response Training 1.25 Son-Rise Program 1 Total 2.16

18 The Use of Music Therapy Within the Relationship Development 18 Table 4