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Innovative Psychotherapy Techniques in Child and Adolescent Therapy, Second Edition.
Therapists who treat children and adolescents are confronted with unique problems that often challenge traditional methods of intervention. This Second Edition is an indispensable resource, revised and updated to provide therapists with a wide variety of valuable treatment and nontraditional intervention techniques, such as expressive arts, relaxation, deep pressure/touch, confrontational, stress-challenge, nature-oriented, and modeling therapy. The Second Edition provides important, clinically proven techniques, including:
* Wilderness/Challenge programs for youth
* The use of dance movement therapy with troubled youth
* Musical interaction therapy for autistic children
* Pet therapy
* The video playback technique with children
* Hypnotic techniques for children with anxiety problems
* Touch therapy for infants, children, and adolescents
* Therapeutic use of computers with children
* Biofeedback with children and adolescents
* Programmed distance writing for acting out adolescents
* Guided imagery with children and adolescents
* Bibliotherapy for children and teens
* Focusing as a therapeutic technique with children and adolescents.
These techniques cut across diagnostic categories and theoretical orientations and can be integrated within all therapeutic styles.
Disc. music, dance, journal writing & imagery; adventure- based techniques; biofeedback; hypnosis, touch, pets/animals
EXPRESSIVE ARTS TECHNIQUES.
Musical Interaction Therapy for Children with Autism (D. Wimpory & S. Nash).
The Use of Dance Movement Therapy with Troubled Youth (H. Payne).
Imagery—A Tool in Child Psychotherapy (M. Johnson).
Programmed Distance Writing in Therapy with Acting-Out Adolescents (L. L'Abate).
Wilderness Therapy for Adolescents (D. Berman & J. Davis-Berman).
Rational-Emotive Adventure Challenge Therapy (S. Leeds).
Biofeedback with Children and Adolescents (T. Culbert).
Therapeutic Applications of Computers with Children (L. Aymard).
Video Self Modeling and Related Procedures in Psychotherapy (P. Dowrick).
Hypnotic Techniques for the Treatment of Children with Anxiety Problems (R. Griffin).
Focusing as a Therapeutic Technique with Children and Young Adolescents (B. Santen).
Animal-Assisted Therapy Interventions with Children (G. Mallon).
Touch Therapy for Infants, Children, and Adolescents (M. Hernandez-Reif & T. Field).
Bibliotherapy: The Use of Children's Literature as a Therapeutic Tool (D. Ginns-Gruenberg & A. Zacks).
DAWN C. WIMPORY and SUSAN G. NASH
THE SOCIAL interaction deficit in autism has devastating implications for most aspects of development (Wimpory, 1995). This chapter outlines the use of Musical Interaction Therapy in seeking to facilitate social interaction experiences between young children with autism and their caregivers. The use of Musical Interaction Therapy with a wider age range and in a school setting is well established at Sutherland House School in Nottingham.
By the age of 2 1 /2 , children with autism show impairments in social relationships, particularly in their use of eye contact, turn-taking, and sharing experience; they also show impairments in body language and spoken language, and preoccupations indicating rigidity of thought patterns (DSM-IV; American Psychological Association [APA], 1994). ". . . [E] very kind of impairment in autism has links with every other impairment in the syndrome. They all overflow into and pervade each other, and it is indeed the interaction between different parts of the syndrome which is most characteristic of autism" (Newson, 1987, p. 36).
Musical Interaction Therapy was originally developed in Nottingham, UK, by music/ drama and teaching staff at Sutherland House School for children with autism (Christie & Wimpory, 1986). It is currently practiced and developed by Speech and Language Therapist, Wendy Prevezer, and Music Therapists, Rhian Saville and Ruth Spencer, working with teaching staff at Sutherland House where it continues to receive the support of developmental psychologists from the Early Years Diagnostic Centre, Professor Elizabeth Newson, and Sutherland House's director, Phil Christie. Musical Interaction Therapy is also practiced and developed by the first author and Music Therapy staff in North Wales where research has validated its efficacy (Wimpory, 1995; Wimpory, Chadwick, & Nash, 1995). Any implementation of Musical Interaction Therapy should take place within an interactive program that focuses on gesture and eye contact as well as the main area addressed by Musical Interaction Therapy, which encourages the development of preverbal conversation skills or social timing.
A brief background to the therapeutic applications of music for children with autism will be presented before a description of Musical Interaction Therapy and how it is implemented. We then hope to illustrate how Musical Interaction Therapy works by presenting two case studies. These are followed by a summary and suggestions for future research.
THERAPEUTIC APPLICATIONS OF MUSIC FOR CHILDREN WITH AUTISM
Children with autism are often reported to be particularly responsive both to music and to music therapy (e. g., Alvin, 1978; Applebaum, Egel, Koegel, & Imhoff, 1979; Benenzon, 1976; DeMyer, 1979; Sloboda, Hermelin, & O'Connor, 1985; Thaut, 1987, 1988). Hypo-or hyper-responsivity to sound is claimed by some to be an inherent feature of these children (e. g., Ornitz & Rivo, 1968, cited in Nelson, Anderson, & Gonzales, 1984). It is possible that the repetitive form and content of most music appeals to children whose difficulties often include (or lead to) obsessive repetitive behavior or fixations on objects that move repetitively. Music appears to soothe and/ or to provide stimulation and even background music may enable such children to be more relaxed (Skelly, 1992). Although children with autism seem to be responsive to music, they are reported to have specific difficulties in dealing with temporal perception (Condon, 1975; Evans, 1986; Hermelin & O'Connor, 1970), which could be linked to their early difficulties with communicative interaction. Temporal perception is closely related to rhythmic movement (Nelson et al., 1984) and normal children have much better movement rhythm than do children with autism during music-prompted movement activities (DeMyer, 1979). From the point of view of finding a means of motivating the child with autism and addressing the proposed fundamental deficit in temporal perception, the use of music is very appropriate.
Nelson et al. 's (1984) review of music activities as therapy for children with autism and other pervasive developmental disorders, is based on an understanding of the interaction of the specific disabilities within autism. Nelson et al. make several practical suggestions based on research findings, for tailoring musical input to the exact responses of individual children. For example, they suggest that stimuli of very short duration could be used so that stimuli do not become confused. They also advocate that the therapist attempt to move and speak in synchrony with the child. They suggest that the timing of stimuli could be as important as the quality of the stimulus. "Perhaps learning to control and therefore predict the timing of sounds will improve the child's ability to integrate sequences of sounds" (p. 110).
A review by Wimpory (1995) found that therapies based on developing a relationship between the therapist and the child with autism are the most frequently reported. These tend to be nondirective and are often based on psychodynamic theory. Such therapies generally involve both child and therapist improvising on musical instruments. Results of therapy are usually reported by the therapist in terms of changed quality of relationship between himself or herself and the child. In autism in particular, it is very difficult for advances attained in one setting to become evident in other settings, and subjective reports do not often include comment on any changes apart from those achieved in the therapy setting. Some studies claim considerable change in the child, but qualitative changes can be difficult to quantify and such studies have not been very constructive in guiding the music therapist in any specific method to use with children with autism, nor in explaining what elements of the therapy might be effective.
More recently, the emphasis has been shifting to attempt evaluated studies of detailed interventions. For example, Müller and Warwick (1993) used a traditional experimental design and systematic observations to look at a variety of hypotheses relating to changes in the communication of children with autism and changes in mother-child interaction that were achieved through music therapy. Results showed an increase in turn-taking, some increase in musical activity, and a decrease in stereotypic behavior (repetitive and unchanging patterns) during the sessions. This latter finding is in keeping with Nordoff and Robbins' (1971, 1972) work which indicates that stereotyped behavior may be reduced through matching rhythm and loudness and/ or vocalizing precisely to the child's playing. Kostka (1993) also found that the arm flapping and body swaying of a 9-year-old boy decreased in regular music classes. Müller and Warwick's work is notable in that it is conducted and reported in a way that allows practitioners to select strategies and predict their effects on their clients. Furthermore, it supports the mother-child interaction with the therapeutic use of live music, rather than limiting the aims of therapy to the therapist-child interaction.
THE ROLE OF MUSICAL INTERACTION THERAPY
Musical Interaction Therapy is an approach to therapy for children with autism that parallels those mother-baby interactions that lead to the development of language in the normal child. Musical Interaction Therapy offers enhanced and prolonged experience of preverbal interaction patterns supported by a musician, in response to the difficulties in social reciprocity or timing experienced by children with autism. The use of "support" in this context indicates that the music is part of any interaction in both making meaning more overt, and holding the sequence together. The aim of Musical Interaction Therapy is to elicit and develop whatever sociability the child may have, by the music providing opportunities for the child and familiar adult to tune into each other. In Musical Interaction Therapy, the music is used to form a dialogue that is very important in helping to develop this tuning in. Any social interchange such as a (preverbal) conversation begins with shared focus. The fact that the child with autism is not innately tuned in is a fundamental impairment. Normal infants appear to develop "communicative competence" through experience with adults acting as though they are engaging with them in conversation long before they are completely competent to do so. For example, parents will select their baby's most socially relevant behaviors to imitate, and comment on noises and movements from a wide repertoire as though these are purposeful. This social scaffolding (Bruner, 1983) prepares the child for producing meaningful language. Like normal infants, children with autism also need to experience preverbal conversation before using (verbal or nonverbal) language communicatively. However, their specific disabilities, particularly with nonverbal body language and its timing in communication, mean that caregivers need support to provide this. The handicaps of the baby with autism mean that although his mother tries to communicate with him, he cannot make sense of these early dialogues and so cannot participate. Although children with autism may learn to speak, they do not develop conversation skills in the natural way that other children do. Interventions with young children with autism should focus on the development of conversational skills and on encouraging social development (Phil Christie, Director, Sutherland House; in Wimpory, 1985). Musical Interaction Therapy has a crucial role to play in this respect.
WHAT DOES RESEARCH SHOW ABOUT MUSICAL INTERACTION THERAPY?
Our research has analyzed videorecordings of clinicians and preschoolers with autism during one-to-one play sessions (without music support) to determine how adults facilitate children's active participation in episodes of social engagement. An episode of social engagement was defined as the child looking toward the face of the adult while expressing some other communicative behavior (for example, vocalizing). In confirmation and extension of previous studies (Sigman, Mundy, Sherman, & Ungerer, 1986), adult strategies identified as positive included musical/ motoric activities and communicative turns oriented to the child's own focus of attention which included an element of "patterning" such as imitation, playful self-repetition, and social routines. Lap games with action rhymes and singing form a basis for proper intonation and timing when the child learns to speak. Musical Interaction Therapy capitalizes on the effectiveness of these strategies.
The use of Musical Interaction Therapy with the two children whose case studies are presented later has also been evaluated by research (Wimpory, 1995). The first of these was a long-term preschool, single case study (Heather) which compared pre-intervention baseline data with full Musical Interaction Therapy and follow-up assessments almost two years after completion of therapy (Wimpory et al., 1995). Onset of Musical Interaction Therapy was followed by improvements in the child's use of social acknowledgment (the time taken for Heather to acknowledge her mother), eye-contact, and initiations of interactive involvement. At two-year follow up these improvements were maintained and Heather's mother reported that she no longer showed frequent social withdrawal. The generalized emergence of teasing and pretend play during and following Musical Interaction Therapy has not been found in any other evaluated intervention for autism.
The other case study (Sian) attempted to separate out the relative effects of Musical Interaction Therapy's component parts. It found that exposure to full Musical Interaction Therapy was more effective in facilitating child sociability than was either passive exposure to prerecorded Musical Interaction Therapy music or regular supportive visits (without music) to the child's mother from the Musical Interaction Therapy therapist. This conclusion was determined by the frequency of episodes of social engagement between the child (Sian) and her mother during videorecordings at home. The objective measures and developmental perspective of these Musical Interaction Therapy studies (Wimpory, 1995; Wimpory et al., 1995) extend beyond previous research in confirming the therapeutic applications of music employed live within an interactive approach.
OUTLINE OF MUSICAL INTERACTION THERAPY FOR PRACTITIONERS
The model supporting Musical Interaction Therapy is one of normal infant-parent interaction. Caregiver and musician aim to emulate this by focusing on the interactions between the caregiver and the child. This model also serves both to explain and guide the process of therapy over time in that the interaction tends to move from general to specific contributions from both partners (caregiver and child) and becomes increasingly intentional on the child's part. Urwin (1984) argues that the normal infant's "illusion of control" during communication may be essential for language acquisition. The musician starts by supporting or even filling in the roles of caregiver and/ or child which initially gives the experience of reciprocity. She moves over time to playing music in general support of the dyad's more genuine interaction as it becomes established and thereby transferable from the Musical Interaction Therapy setting.
Three themes can be identified as running throughout Musical Interaction Therapy at any stage of its active process. These are the active roles afforded to the child through the illusion of communicative control, the scaffolding of the interaction by the caregiver who, along with the child, is afforded varying degrees of a musician's musical support in their contribution to the interaction. The musician also provides scaffolding, but does so less over time. These themes will be developed throughout the chapter. Caregivers typically report that children with autism appear more relaxed during activities which involve what research has identified as musical motoric experiences (Wimpory, 1995). These would include playing in water, experiencing music, and rough and tumble play. Music is unique as a medium in that it is timing-based and therefore has the potential to afford support to the difficulties children with autism may have with respect to the timing of reciprocal interactions (Newson, 1984; Wimpory 1995).
DESCRIPTION OF MUSICAL INTERACTION THERAPY
During Musical Interaction Therapy, a caregiver who is familiar to the child (usually a parent with preschool children) attempts to engage with him or her. Their activities and the behavior of each individual is supported by the live music of a therapist. The live accompanying music of Musical Interaction Therapy enhances both the caregiver's behavior, and the child's perception of it. The caregiver and musician can thereby between them construct an experience of (apparent) give and take communication between the caregiver and child. Through this experience the child may ultimately play his or her own communicative role with intentionality. The musician is ready to fill in, support, or enhance either partner's role in the (initially) preverbal discourse so that the participants' experience of it is holistic rather than disjointed as is usually the case with autism.
The experience of the caregiver is that the music appears to make it easier for him or her to "get through" to the child. This may be because the child's perceptions of the caregiver's behavior are enhanced by the musical accompaniment (e. g., the child may find it hard to pick up on the tempo or mood of a spontaneous activity, but the accompanying music makes it more predictable). It may be because the Musical Interaction Therapy accompaniment enables both caregiver and child to feel more relaxed and so less inhibited in their communication with each other. Alternatively it may be that the musician's singing and playing alerts the caregiver to possibilities in communicating with the child of which he or she may have otherwise been unaware. The musician plays to make the adult more potent and to enable the child to notice his or her effect on others so that caregiver and child share the social control over an interactive sequence. Heather's case study (see p. 19) illustrates this. The mother felt herself to be a more active agent as a result of letting her child lead.
What Happens in a Session of Musical Interaction Therapy?
We normally employ videofilm to convey the techniques underlying Musical Interaction Therapy (Wimpory, 1985). For the purposes of this chapter, we have drawn on our own experience of Musical Interaction Therapy with preschoolers and are indebted to Eleri Turner for the use of her report giving a personal view of what it is like to implement Musical Interaction Therapy with children with autism (Turner, 1998). We are also indebted to former colleagues at the Early Years Centre and Sutherland House in compiling the following account for practitioners. Wendy Prevezer's (1998) booklet is perhaps the most practical and detailed of articles concerning Musical Interaction Therapy and we also draw closely on her work. This chapter is focused on preschool children with autism and Musical Interaction Therapy as conducted in the child's home. We would refer the reader to Prevezer for a more comprehensive coverage of how Musical Interaction Therapy can also be used with older or verbal children, in group work and school settings.
In our experience, the musician needs to have some training in facilitating communication with children but need not necessarily be a trained music therapist. The musician will have to work very closely with the caregiver of the child with autism and initially he or she will probably have to remind the caregiver of the aims of the therapy when caregiver and musician plan each session. The adult may need to be helped with ideas as to how to behave with the child, especially after a history of little interaction. The musician may need to reassure the caregiver that musical ability is not required and that while she builds up confidence, simply echoing what the child does is a start. Musical Interaction Therapy depends on a strong supportive relationship between musician and caregiver, particularly to enable the latter to risk trying out strategies that her instincts dictate, but which may not be part of her usual repertoire with her child, for example, blowing on the child's ear lobe, if the child responds to this, or making repetitive moaning noises that echo those of the child. The therapist needs to be sensitive to the current quality of the interaction (or lack of) between caregiver and child because her main aim is to facilitate that interaction. In addition to supporting the caregiver-child interaction, the therapist will sometimes use music or words during the sessions to suggest how the caregiver might act.
These authors are not aware of any research indicating that the use of particular instruments may be more effective than others in Musical Interaction Therapy. It is very likely that different children will respond differently to different instruments and a parent may have some idea of her child's preference. However, it is difficult to obtain any sort of music support for children with autism, and any instrument that does not obstruct the therapist's view of the adult-child pair can be used in addition to the adults' voices. We are currently engaged in research seeking to facilitate interaction without the use of musical instruments. It is unclear at present whether it is possible to compensate for the obvious advantage that a musical instrument affords in supporting the timing of interactions.
The adult caregiver is someone very familiar to the child with whom it is important for the child with autism to develop a relationship. In our North Wales client group, this is usually the mother. A parent will be the person most familiar with the expressions the child uses and ready to capitalize on them and will know the child's preferred routines. To maximize the benefits of Musical Interaction Therapy, the caregiver should spend time with the child between sessions, actively implementing the principles learned in the therapy sessions, even though there will not be the support of the musician. The shared attention which Musical Interaction Therapy is geared toward developing "needs to become a habit in order for quality relationships to develop" (Prevezer, 1998). We have found that the experience of interaction during Musical Interaction Therapy sessions motivates caregivers to continue with the techniques beyond the designated therapy.
Musical Interaction Therapy as practiced in North Wales, usually takes place in the family home. Familiarity with the setting helps the child and parent to be reasonably relaxed. The home is also the place where the developing relationship will be practiced, so less should be lost than when moving to the home from a different setting. Sessions can more easily use an "open door" policy if they take place at home. When the child can leave the room at will, it heightens the adults' awareness of how intrusive they may be. The adult tries to tune in physically as well as mentally to the child by, for example, lying or sitting on the floor or rocking. This makes her less threatening and more on the child's physical level. The caregiver may feel easier trying out these strategies at home.
When considering the setting, it is important to be aware of the role of toys or other objects. The ultimate aim of Musical Interaction Therapy is genuine social engagement, and the absorption of the child with autism in some toys may prevent social contact, so the use of such items should be kept to a minimum. However, a child's obsessional plaything or behavior may be used by the caregiver to encourage the child to notice an adult prior to social contact or the item may be used to develop shared attention. For example, an object could be placed within the caregiver's clothing or she could hold it to her mouth so that the child must seek contact with the caregiver to retrieve it.
Twice weekly sessions of Musical Interaction Therapy seem to be particularly effective in helping the child toward social engagement. Turner (1998) finds that prior to beginning the very first session it helps to have one session where she tries to make meaningful contact and dialogue with the child through free play. This helps her to get a general impression for the feel of the child and of the pleasure and difficulties in communicating with the child. If the caregiver is embarrassed about "making a fool of herself," the therapist can model behavior during the first visit so that the parent is more ready for another adult to witness what may be perceived as undignified behavior.
At first music may the help child tolerate the presence of the adults. Initial sessions should aim for the child to habituate to the presence of the adults and for both adults to tune in to the child, as well as to develop experience in working together. This is useful for the caregiver as well as the child. Before sessions begin, parent and musician should discuss what they wish to try during the session, how the child is feeling and hence what she is likely to be most responsive to. Possible behavioral problems can be anticipated and a decision made as to how to handle these. As sessions progress, they can decide on the finer details of how they are going to attempt, for example, pauses within particular routines. However, they will always be responsive to the child. For example, when the child is withdrawn, the mother will perform quiet actions, such as stroking the child's hair while singing the sentence "This is how I stroke your hair." The mother matches the level of intrusion to the child's level of tolerance. When the child seems more receptive, the mother may try to make the child anticipate her action: "This is how . . ." and then wait for some response before completing the sentence. Mothers treat their babies as though they mean to communicate. The caregiver in Musical Interaction Therapy acts as though everything the child does is intended as communication.
Eleri Turner (1998) discusses how it is seen as positive when the child seems to be in control over the duration of the session. She describes how every session is conducted within a framework of a hello and goodbye song. When the child becomes more receptive, he or she is encouraged to make a waving gesture for goodbye. Later the child may begin to initiate the end of a session by spontaneously waving a hand and/ or singing the goodbye song. Heather (see her case study later) learned to wave when after months of experiencing Musical Interaction Therapy sessions, she came to understand when they were finishing.
Lewis, Prevezer, and Spencer (1996) and Prevezer (1998) describe the strategies employed in Musical Interaction Therapy. Prevezer's organization of discussion of these strategies will be followed here: the use of imitation, running commentary and songs, and play routines. Each of these is used to give the child the illusion of communicative control, each helps the caregiver in scaffolding the interaction, and musical support is present throughout. It will be seen how the illusion of control may develop into negotiation of control and how music gives particular support to timing issues.
The first consideration is to tune in to the child and find an appropriate starting point, so that the child is interested but not overwhelmed. This is achieved by following the child's lead, for example, by imitating any sounds made by the child and copying the child's actions. In normal interaction, this gives significance to what the baby is doing and is often the basis for turntaking. Prevezer reports that copying obsessive behavior does not tend to encourage stereotyped behaviors. Repeated reflection of the child's behavior often draws the child into acting deliberately so as to be copied, and through physical imitation the child experiences simple turntaking. Imitation is an ongoing part of mother-baby interaction. For example, babbling can be incorporated into a conversational pattern of sound. The child learns that in a conversation, one person talks and the other listens, and then the other talks and is listened to. The caregiver and musician are therefore providing the framework of a dialogue and words may later be slotted into this. Prolonged straightforward imitation is not enough. It is important to be flexible and offer occasional variation to get the beginnings of reciprocity. Some children respond quite well to a bit of give and take, even in the first few sessions (Prevezer, 1998).
Giving a running commentary is a way of giving importance to what the child is doing. All the elements of music can be employed to achieve the appropriate match for mood or action. The accompaniment may or may not include words but is matched as closely as possible to the child's mood, vocalization, or movement, and it is kept simple. "A cinema pianist or organist accompanying a silent oldie movie, graphically illustrates how I musically imitate their [child with autism and caregiver] rhythmic movements and general mood on my harp" (Turner, 1998). With music support, the mother takes every opportunity to comment on any of the child's vocal utterances by imitating, setting up vocal turn-taking patterns or vocalizing simultaneously with the child's utterances. The music thus reflects and highlights the mood, timing, and meaning of the dyad's activities. For example, if the child happens to jump, the mother also jumps and, together with the musician, sings "jump, jump, jump away" with timing appropriate to the actions. As soon as the child stops jumping, the music and singing pauses in anticipation of her next move. The music becomes quieter if the child avoids her mother and more exciting if she approaches her-- gradually reaching a crescendo with the climax of dramatic games (such as "tickly under there!"). In this way the child can also learn that he or she can affect somebody by his or her own actions and vocalizations. He can come to understand what it is to leave a gap for somebody else's utterances before vocalizing again and what it is to share pleasure in covocalizing. Again these are rehearsals for part of the blueprint of meaningful use of words. Hence imitation and a running commentary enable the child to act intentionally so as to influence what his play partner or the musician will do. Spontaneous songs, if short, can be part of a running commentary.
Songs and Play Routines
Singing is a common part of mother-baby interactions. It is often accompanied by movement that gives meaning to the song, and through this experience of being handled and sung to, the baby develops social timing. For example, the caregiver may stop singing and wait for a response at the end of each line. If the baby vocalizes during her mother's turn, the caregiver stops the song and thereby stresses the importance of turntaking in vocalization. The baby quickly becomes relatively competent in social timing, so she and her mother have conversations before she acquires words.
Hence songs and play routines provide scaffolding for communication. Vocalization is an enjoyable experience in itself and singing together can give a feeling of bonding. This is part of the relationship the caregiver has with the musician as well as with her child. There are many levels at which a child may participate, and pauses can be introduced in a way that is less threatening than with the use of speech. Singing, unlike speech, enables adults to hold out their words and wait for a child's response. These pauses can be more or less dramatic and can help a child to anticipate points in a routine, creating a shared experience. The child can then begin to play the social games that normal babies find easy. Prevezer (1998) advises "Children with autism may need us to wait longer for a sign of their involvement, to be very responsive to the smallest flicker of eye contact, movement or sound, and to cue them in, helping to build up their anticipation by our facial expressions, getting slower and louder, or an exaggerated gasp."
Prevezer distinguishes between the use of set and flexible action songs. Set songs although less creative, still offer a familiar framework for the child. Within such songs, tempo, volume, pausing, and wording can be varied in response to the child. Short, simple rhymes (e. g., Wind the Bobbin, The Grand Old Duke of York, Incy Wincy Spider) expose the child to sequencing and timing. At the outset, the child may gently be put through the actions so that he or she may experience the meaning of words through his or her own physical experience. The child may come to imitate the mother's sequential actions and indeed may come to initiate a song by use of actions or singing the first word of a song. More flexible action songs are often also appropriate in the first session. These are still usually familiar and repetitive, but their content is more variable. For example, Prevezer describes how these songs can be used to follow a child's action to make a verse (e. g., walking or swaying); offering an action such as jumping to be watched or copied; performing an action on the child, such as patting; offering a cooperative action (e. g., rocking).
Play routines are patterned in the same way as song routines. Physical contact, often rough and tumble, may be involved. Children with autism often tolerate or enjoy repetitive physical activity such as being swung or tickled. The caregiver tries many different ways of drawing the child's attention to her and explores to find those forms of contact that the child can tolerate. It is almost always the case that children will initially only respond to rough and tumble and tickling and a child can become more used to being touched during these sessions. Prevezer (1998) suggests using timing here, as in the song routines, to facilitate opportunities for the child to join in. She suggests building up tension then pausing before a key point so as to allow the child to anticipate. She uses any sign of responsiveness on the child's part as though it is deliberately communicative to give a sense of turntaking. Obsessional interests may be used as the basis for play routines. Eleri Turner (1998) points out that Peek-a-boo games are used to help the child to experience anticipation, sequence, object permanence, and showing or sharing oneself with another person.
These strategies are geared to facilitate flexible development. As is the case with normal development, a certain amount of conditioning is involved and the use of Musical Interaction Therapy sometimes reflects this. For the child who has very restricted communication, the use of pointing as a gesture to indicate everyday needs would be one of the first things to work on. Pointing may enable a child to communicate even before he realizes that objects have names. The child is helped to point to whatever he finds rewarding within the Musical Interaction Therapy session, for example, bubbles. Or, when a child is motivated to want a repeat experience (e. g., blow on your tummy), the mother can negotiate eye contact as part of the deal for continuing. This negotiation does not have to be verbal. By the use of the reward of more blowing, the child may begin to give meaning to the use of eye contact. Silence from both musician and caregiver upon the child's departure and sustained until his or her return can be effective (for reasons accounted for by a behavioral approach).
HOW DO SESSIONS PROGRESS?
Turner (1998) reports that rich and varied free play is woven between more structured activity such as lap game songs. Both types of activities are used to support the child at whatever level of social tolerance he or she can endure at any given time and to gently extend the child's experience of communication. At the start of the sessions, she aims to trace the movements and mood of the caregiver-child dyad very closely as the caregiver attempts to recreate normal, very early mother and baby interaction. She may gently direct or suggest to the mother through music or vocal sounds what to do in response to the child. If the child is switching off to the adult, music may be used appropriately to regain the child's attention. Music is used in response to mood and to change mood. After about six sessions when the mother has found her bearings, the therapist draws back and the caregiver increasingly becomes the prime enabler, giving the child an illusion of control, enabling the child to participate in this joint enterprise. The mothers report that after a few months of twice weekly sessions, they get so engrossed in interplay with their child that they are not aware of the musician. At this stage, the therapist tends to concentrate less on imitation and focuses more on improvisation that is still based on the dyad.
Sessions are usually assessed informally by the musician and caregiver who discuss what has happened, how they and the child have responded, any changes that may have been apparent, and what new openings might be indicated for the following session.
The following accounts illustrate the practical and theoretical points made earlier and give a feel of how some of the strategies described could be implemented. We also hope to convey how receiving and participating in Musical Interaction Therapy felt to the children's families.
Heather has classic autism; she was diagnosed by the first author using Newson's (1978) criteria and DSM-III-R (American Psychiatric Association [APA], 1987). An independent clinician scored her autism as severe (48) on the Childhood Autism Rating Scale (Schopler, Reichler, & Renner, 1986).
As a baby (the third of four children), Heather was unhappy if cradled in her mother's arms and she would not snuggle up like other babies to breastfeed. Her mother was therefore forced to bottlefeed her and by three or four months Heather would only tolerate this if she was propped in a semi-sitting position facing away from her mother's body. As Heather became older, she never shared her toy play with others, neither by lifting them into someone else's view and vocalizing nor by pointing. She never imitated with the ease and sociability that her baby sister showed. Her mother learned to accept any physical contact from Heather without reciprocating because Heather would pull away if cuddled.
Heather was 3 1/2 years old at the start of her participation in Musical Interaction Therapy. Behavior modification had been successfully employed for obsessional screaming and tantrums 10 months previously. However, Heather remained without gestural or verbal communication and functioned at a learning disabled level.
Heather was filmed during seven months of 20-minute Musical Interaction Therapy sessions twice weekly. Before these sessions started, Heather was filmed on six occasions over a four-month baseline period playing with and without toys with her mother present. After the seven months, Heather continued to receive Musical Interaction Therapy for a further five months, but the sessions with music were not filmed. Her follow-up play-based assessment took place 20 months after all the Musical Interaction Therapy sessions had finished. A teaching film was used by the first author after the baseline period, to introduce Heather's mother to Musical Interaction Therapy (Wimpory, 1985). Play-based assessments were conducted for Heather in her local Child Development Center at the start and end of her seven months of evaluated Musical Interaction Therapy. These measures were used to determine the effect of Musical Interaction Therapy on Heather's sociability, communication, and pretend play skills (absent at the start of Musical Interaction Therapy).
Heather's mother recalls her introduction to Musical Interaction Therapy in the following way:
"The first time I met Miss Eleri Davies (Music Therapist, now Eleri Turner) I didn't believe we would ever be able to get through the wall of autism and discover our own daughter . . . she was almost totally noncommunicative and life was always quite a struggle. . . . Anyway, on this afternoon, I was introduced to Eleri by Dawn Wimpory and after talking to them both I said that I would try the therapy. I have to say that at that time I was very skeptical although by then I would have tried anything.
"The following Monday Eleri turned up with her harp and we went nervously upstairs. The whole weekend we had worried about how Heather would react to the therapy which would mean she would have to participate (which she hadn't done before). The whole thing rested on treating Heather [communicatively] not as a 3-year-old but going back to babyhood all over again. [Authors' note: Musical Interaction Therapy supports children with autism through preverbal communication. It should not be confused with any form of emotional regression therapy. Like other aspects of our intervention program it focuses on the developmental level the child has reached in the area we are aiming to develop. Thus, Musical Interaction Therapy is practiced alongside more advanced expectations of cognitive and self-help skills together with age-appropriate demands of motor development, and so on.]
"Eleri settled herself in a corner and began to play. Every action Heather did she played a tune to match and for the first time in her life Heather could be in charge! A frightening experience for me, knowing only too well how self-abusive she could be! The first 10 minutes were spent with Heather jumping about all over the bed and running round the room with me trying to keep up with her. Then a marvelous change came over her. Heather's whole body relaxed and she lay on the bed, snuggled up next to me as I rocked her to the tune of "Twinkle, twinkle, little star." To say I was overwhelmed is an understatement. It was the same intense feeling of wonder and joy as experienced at her birth."
At the time of the early Musical Interaction Therapy sessions, Heather's mother described her experience of them as "hard," tiring, and even embarrassing to begin with. Despite being told to anticipate good and bad sessions, she felt feelings of failure when the latter occurred. However, her overall experience of even the early sessions was positive and she found herself looking forward to them. Musical Interaction Therapy enabled her to have new experiences of Heather. "I never realized before how tense she was because I'd never been that close to her for long like I am in the Musical Interaction Therapy sessions." Heather's mother described her role in the sessions as initially feeling a bit intrusive in contrast to her inevitable wariness with Heather evolved from previous experience. " When I started it was like doing it with someone else's child . . . when your child is autistic the surface things are fine, it's deep down that you don't know them."
Heather's mother recognized that the Music Therapist "looked after me as well as looking after Heather . . . otherwise . . . there would've been tears with my husband in the evening." Despite her initial worries, she found, "I'm in control as much as the Music Therapist is, that's why it's good." Musical Interaction Therapy also enabled Heather's mother to realize that she could continue to respond to Heather at an appropriate communicative level outside of therapeutic sessions, "It's made me think more about how we were treating Heather, that maybe we could've been doing something differently and that was disappointing." This point emphasizes the value of employing this therapy and as soon as possible after diagnosis; no child with autism is too young for Musical Interaction Therapy.
Looking back, Heather's mother describes the outcome of Musical Interaction Therapy as follows: "So from that small beginning Heather (was) allowed to begin again (in terms of communication) without the fear and isolation. Months later Heather still loved her weekly sessions, each session bringing small delights as she continued to improve. She now performs her songs at the drop of a hat-- providing we all join in with her, much to everybody's delight. She withdraws from the world about her rarely and never as deeply as before.
"Heather has shown herself to have a strong personality of her own. For the first time, I have come to know my daughter as I know my other children. She is alert, inquisitive, and most of all, loving. If we are playing games, she will join in laughing and clapping with the sheer joy of knowing she understands what is going on around her.
"At the beginning, she advanced only during the therapy session, but with each session the effects lasted longer and longer until at last we have a daughter who can cope with her handicap-- who is coping with normal life. From being a tense child, she is now pliable and above all can show feelings of love to all of us. Life now is an adventure rather than a nightmare! It has helped me tremendously as well. I now have confidence to be a mother to Heather and it has given me the ability to ride over the bad times-- which are getting rarer-- in the knowledge that it's only a hiccup and that tomorrow the sunshine will be out again.
"I know that Musical Interaction Therapy was the best thing we ever did. The joy of a small pair of arms going round your neck and the warmth of that small body against you, together with those big blue eyes looking deep into yours, are so special after years of being pushed away, evaded, and rebuffed . . . Our home is now a place that is filled with sunshine and laughter and not tears and bewilderment."
The practice of Musical Interaction Therapy will vary depending on different children, therapist musicians, caregivers, and contexts. However, Heather's mother's own experience of Musical Interaction Therapy reflects the experience and intentions of her music therapist. Heather's mother reported that "by the end of that last session it felt like there was only Heather and me. It was like coming home."
Videos were taken before and after the start of therapy through good and bad days. Overall, the number of bad days declined and the good increased and became better in quality. Heather's readiness to initiate any social interaction was measured. This was a measure of the time it took before Heather took any social notice of her mother. Heather's avoidance of eye contact, her turntaking, and creative contributions to an interaction were also measured. After Musical Interaction Therapy, improvements were recorded in all these areas. Such improvements would not be expected as part of a developmental pattern of a child with autism. After therapy Heather was obviously much more aware of her mother. At first it was very difficult to play with Heather at all. In the play-based assessment session before therapy she gave eye contact perhaps once or twice in the whole session (nearly two hours). Afterwards, her eye contact was reliable, usually occurring at least once a minute. In the later months she would be looking about every 15 seconds at her mother. Before therapy Heather once managed to start a sequence of turntaking, afterwards she would start a sequence two or three times in a session. This would be turntaking using her voice, body, and eventually words.
After Musical Interaction Therapy, Heather showed an ability to creatively contribute to an interaction (for example, offering a new part of her body to be tickled). Some children with autism can turn take when they know a routine. It is very hard for them to spontaneously make up their own turns. An example from Heather toward the end of the seven-month session involved her mother capitalizing on her obsession with fluff. Heather used to get absorbed in picking bits of fluff from a bedspread that she would then put in her mouth. When she was doing this during a Musical Interaction Therapy session, her mother grabbed her hand and made an exaggerated, disgusted noise "bleurgh!" as she tickled Heather's hand. Heather laughed and did it again and again with her mother joining in, not actively picking up fluff but putting her hand out. The impression from the film clip is that Heather was laughing in anticipation some of the time. Eventually she put both her hands on the bedspread and laughed in apparent anticipation. Her mother repeated "bleurgh" and took hold of and tickled both hands. The music matched the movement throughout, for example, getting louder as the exciting climax of the tickle approached. Another example of Heather taking turns was when Heather approached her mother and put her face right up close, then withdrew. Heather's mother put her face very close to Heather's and blew a raspberry on Heather's mouth and withdrew. Heather then again approached her mother and held her face close to her mother's face. Her mother blew a raspberry noise to add emphasis to the turn.
Heather also showed some pretend play (dry washing up) and teasing behavior (when she knew she was expected to clap hands, she smiled and clapped her tummy instead).
Associated, positive reported developments that were not the specific aim of Musical Interaction Therapy were that Heather became more attached to her siblings and could play with her father in more sophisticated ways. Her coordination became better; her behavior at mealtimes improved and, rather than echoed sentences, she used individual words which were useful to her "hiya, up and again" and joining words "Heather wants it."
The examples described came from the Musical Interaction Therapy sessions. During the times without music, Heather's performance followed what she managed in the Musical Interaction Therapy sessions, but just lagged behind. After about a month, Heather began to be able to interact with her mother (albeit briefly) without music support. It would appear that Musical Interaction Therapy made more and more developments possible. After three months of Musical Interaction Therapy, Heather was much happier to stay for the sessions, possibly because she could do the lap games that occurred during the familiar routines. Although she needed to look away often at this stage, she also became able to face her mother and could express pleasure with her voice. After eight months, Heather would not tolerate her little sister going from the room and would want to go with her. Before Musical Interaction Therapy, Heather would not have noticed Katie coming or going.Sian
A second case study illustrates how Musical Interaction Therapy was used for Sian, a child with classic autism whose principal caregiver, her mother, Anita, was partially deaf, and English was not the family's first language. The application of Musical Interaction Therapy with Sian was designed to look at what components of Musical Interaction Therapy were most effective, separately and in combination. This was to establish that it was not just the social support from another adult that helped the caregiver in her relationship with her child; that any changes could be attributed to live music that was responsive to the child and mother.
Sian was a lively 3 1/2-year-old with autism, rated as "severely autistic" by an independent clinician using the Childhood Autism Rating Scale (Schopler et al., 1986). Although Sian's everyday behavior was at a learning disabled level, she was able to score an average level on the Griffiths Mental Development Scales (Griffiths, 1984). Her family (Indian) were staying in the United Kingdom to complete her father's training as a psychiatrist. Sian's mother had begun to lose her hearing during her pregnancy with Sian's older sister aged 9. Sian was described by her parents as a quiet baby who rarely cried, and who was quite happy to amuse herself for hours (" she didn't like us interfering"). Sian did not enjoy being cuddled and pushed away from her parents, preferring instead to play with blocks. Attempts to engage Sian tended to be one-sided. "We could play with her from our side . . . but she wouldn't try to interact in return." As a baby, Sian did babble to herself but not with communicative intent nor in a turntaking pattern with others. Sian did not use or understand gestures and neither did she display tantruming behavior, which can also fulfill a basic communicative role. By 2 years of age, Sian's frequency and quality of eye contact was diminishing, and her parents reported that she looked at them "as if we were part of an object, she wouldn't look at you for human qualities." By the time she was 3, Sian had withdrawn further socially, showing no interest in adults or children, and her smiles and laughter were more for herself than for other people.
The introduction of Musical Interaction Therapy needed particular care because of Sian's mother's (Anita) selective hearing difficulties. While she could respond relatively well to the music, she found it difficult to hear comments from the supporting professionals advising her how to proceed. Sessions were therefore brief ( just 10 to 20 minutes). The clinical psychologist would model and prompt Anita while the Music Therapist supported both Sian and whoever was attempting to engage with her. These sessions were concluded by a discussion of the strategies they had featured (e. g., imitation, particular action rhymes). After six weeks, when Anita was comfortable and confident about her role in Musical Interaction Therapy, sessions lasted for 30 to 60 minutes and proceeded without the clinical psychologist.
In overcoming the very real difficulties of hearing impairment and cultural isolation, Musical Interaction Therapy exploited the sensitivity and willingness of her mother and music therapist to work together in helping Sian. Good relationships between these adults and their advising clinical psychologist were essential. Sian's mother needed support in beginning to come to terms with the loss of her hearing and previous communicative competence while simultaneously offering her daughter the playful, and sometimes joyful, experiences that she needed. Musical Interaction Therapy in this situation clarified that caregivers cannot be expected to play therapeutically with their children with autism unless they feel able to play. Anita's playfulness was released through the support she experienced from the music therapist within and outside of sessions and through a strong counseling relationship with Sian's clinical psychologist that was sustained through the study (established prior to baseline measures). Clinical experience indicates that such counseling alone is not sufficient to effect changes in children with autism. However, without this additional support it would not have been possible for Anita to have facilitated the communicative experiences that Sian needed whilst simultaneously grieving the loss of her hearing and missing her family and community in rural India.
In practice, the strong relationship between Anita and the professionals was essential during the early Musical Interaction Therapy (training) sessions. Anita initially spent much time watching Eleri in a vain attempt to lip read what she should do next. Sian's clinical psychologist asked and then "told" Anita not to look at Eleri but instead to focus on Sian and to trust that Eleri would follow (rather than direct) their activities. The clinical psychologist's role became to guide Anita through tactile means or to show suggested activities (e. g., swaying) as appropriate. Unlike Eleri who had to stay by her harp, the clinical psychologist could move to within sight of Anita while she was playing with Sian. Anita's need for this gradually decreased over the six-week training period and the music therapist became more skilled at communicating with her using mimed signs for familiar routines and so on. They were able to proceed to full Musical Interaction Therapy without the presence of the clinical psychologist. The administration of Musical Interaction Therapy led to gains by all concerned. For example, through the experience of working with Anita's hearing difficulties, both professionals learned to develop and trust in less conventional means of communication.
Early Musical Interaction Therapy sessions with Sian relied upon her mother and the therapist trying out a number of actions (e. g., tickling, swinging Sian's legs up and down, swaying, rolling) and heavily tracing them with music and song to promote contact between Sian and her mother and ascertain what Sian enjoyed. It had been observed that Sian gave some eye contact to her mother when pressing her hand onto her mother's arm as part of a familiar ritual she had spontaneously developed. This ritual was used as a starting point for Musical Interaction Therapy.
Initially, sessions were very much led by the therapist (who suggested songs and actions, and mirrored the mother-child dyad's actions with music) and Sian's mother (who would try out various songs and actions, and imitate Sian both physically and vocally). Sian's role appeared fairly passive, as she wandered around the room, approaching and retreating from her mother. However, both therapist and mother were also quick to utilize any of Sian's behavior by treating it as if it were intentional. For example, if Sian happened to walk around her mother, this acted as a cue for therapist and mother to start singing "round and round," building up to a crescendo in pitch and loudness, the climax occurring as Sian and Anita fell onto the sofa. Similarly, if Sian happened to rub her face, this acted as a cue for singing "wash wash wash your face" (to the tune of Here we go round the mulberry bush), with Anita rubbing Sian's face either with her hands or using Sian's hands on Sian's face or her own face. Thus in initial sessions, little was required of Sian in terms of participation.
During these early sessions, eye contact from Sian was not a condition of continuing the music, although if given it was quickly reinforced by music/ tickling, and so on. Most of the songs and actions contained dramatic pauses and the music built up to a climax/ pause just prior to an action, thereby emphasizing timing. However, at first, Sian was not expected to participate at these points, and hence the music would often follow her actions rather than waiting for Sian to interject at the correct point (i. e., the music "fell down" when Sian did, rather than expecting Sian to fall down as cued by the music in later sessions).
The design of the study was: baseline; recorded music; musician's visits without music; training for Musical Interaction Therapy (because of Sian's mother's hearing problems); full Musical Interaction Therapy; baseline with Eleri's visits but no music. Recordings from each session were coded for episodes of social engagement and the total number of instances of vocalization and smiling. Full Musical Interaction Therapy led to the greatest change and instances of positive social behaviors became fewer when Musical Interaction Therapy was withdrawn. Success was not due to maternal social support.
Sian's father summarized the experience of his family with Musical Interaction Therapy as follows: "Sian was a very closed and distant child and she hardly communicated emotionally. She did not have a great variety of activities and had a very restricted pattern of behavior. Because we did not get any reaction from her, I and my eldest daughter Sandra became cold too in our response to Sian, though Anita my wife maintained some variety of activity with Sian, but I could see the strain on her.
"When music therapy was introduced, there was a sudden boost in the variety of Anita's response to Sian which soon started to permeate to us as well. Though it was slow, Sian started to respond to the variety . . . I think for Sian and all the rest of us, music therapy was more natural (than behavior or speech therapies) without many restrictions or boundaries. She showed more attention and interest in interacting, sharing, and reacting. With the music in the background, I think my wife, Anita, felt able to express herself and play with Sian, sometimes even without any reaction from her, which is expected in conversation sequence.
"At the end of every hour session, Anita and Sian were surprisingly more relaxed and cheerful. I think it was mutually very complementary too, both emotionally and physically . . . Sian has grown to be a more active and responsive girl."
One of the most valuable aspects of Musical Interaction Therapy is that, in addition to the effects of the techniques outlined earlier and the facilitative effects of live music, Musical Interaction Therapy affords a specific time and place where the search for and experience of shared attention and social engagement is given the status it deserves.
Both Sian's and Heather's Musical Interaction Therapy was followed by speech and language therapy and some behavior modification. The developments made possible through Musical Interaction Therapy facilitated the effectiveness of these therapies. It should be emphasized that the sorts of developments enabled through Musical Interaction Therapy do not occur naturally in children with autism, even over a long time-- Musical Interaction Therapy is responsible for these developments.
The cases studies presented here have illustrated how Musical Interaction Therapy works in attempting to facilitate social interaction with a child with autism. Musical Interaction Therapy is based on preverbal caregiver-child interaction and uses live music to elicit and develop the child's sociability. Musical Interaction Therapy offered constant musical support throughout sessions designed to help Heather and Sian have the illusion of control by scaffolding their interaction with their caregivers.
Single case study applications of Musical Interaction Therapy, without external controls or comparison groups, can only carry limited implications. However, our preliminary data are suggestive that Musical Interaction Therapy helped both Heather and Sian to develop their sociability. Comparable measures of preschool children with autism in specialist educational provision show high stability over time (Snow, Hertzig, & Shapiro, 1987). Heather's experience particularly reflected successful application of Musical Interaction Therapy. This echoed previous successes with the technique employed in different situations with different staff whilst the first author was working in Nottingham. The qualitative changes in the social interaction skills of these children justifies both our excitement about Musical Interaction Therapy and our continuing attempts to define its essential characteristics. This chapter has taken an academic and clinical perspective in identifying the developmental processes which may occur through the application of Musical Interaction Therapy by sensitive personnel working with pre-verbal preschoolers with classic autism. We can thereby use Musical Interaction Therapy to elucidate crucial processes which influence the d evelopment of social and symbolic functioning. However, Musical Interaction Therapy is not limited to this application alone, Prevezer (1998) identifies Musical Interaction Therapy as a technique that enables her to find out, and pursue, what works with a variety of children with related difficulties. All applications of Musical Interaction Therapy require that there is an atmosphere of spontaneity and a readiness to rely on intuition throughout and beyond the sessions. Furthermore, the process of Musical Interaction Therapy is always geared toward enabling the caregiver-child dyad to move toward a point of balance-- between structure and spontaneity, as well as adult/ child control (Prevezer, personal communication, August 24, 1998).
As outlined earlier, the essential aspects of Musical Interaction Therapy appear to be that the caregiver is supported by a therapist's live music as she "scaffolds" an interactive experience for the child to whom she affords the "illusion of communicative control." Our own theory of autism (Wimpory, 1995) is that proposed social timing difficulties inherent in the child (Newson, 1984) disable the development of preverbal social interaction, thereby inhibiting the development of teasing and other social/ symbolic skills. Applications of Musical Interaction Therapy are always socially demanding on the personnel concerned and constraints of the real world mean that there is always room for improvement in how Musical Interaction Therapy is employed and how much change is facilitated in the child. Where Musical Interaction Therapy is successfully applied the interactive patterns are so intrinsically rewarding that they become self-perpetuating even beyond the sessions. This may perhaps approach Frith's recommendation that any successful remedy "would have to be applied at the beginning of the chain of causal events that leads to Autism" (Frith, 1989, p. 184).
Rather than confirm a purely cognitive account of autism, the findings from Musical Interaction Therapy research and practice are more compatible with the interaction-based theoretical perspectives of Hobson (1994a, 1994b), Newson (1984), Wimpory (1995) and Fein, Pennington, Markowitz, Braverman, and Waterhouse (1986). The latter suggest that: "a minimum level of reciprocity may be necessary as a basis for a shared meaning and communicative intent, and social disinterest in autistic children may thus contribute to delays and failures in language and pretend play" (Fein et al., 1986, p. 208).
Preliminary evidence from previous research (Wimpory, 1995) is that Musical Interaction Therapy facilitates playful joint action formats which generalize beyond therapy and possibly serve to facilitate further social/ symbolic developments. However, existing studies cannot offer confirmation of a hypothesized deficit in social timing (Newson, 1978, 1987). Further research needs to determine this and the validity and efficacy of Musical Interaction Therapy in this respect. Although the evaluation of Sian's case study gave support to live Musical Interaction Therapy as opposed to prerecorded audiotapes of the same, it did not conclusively demonstrate that music is an essential component. Research is in progress to evaluate parental use of Interaction Therapy strategies without the support of live music. This strategy could be usefully incorporated into future research using a multiple baseline format with further case studies. However, our clinical experience is that the complete form of Musical Interaction Therapy socially affords an opportunity for caregivers to reach and interact with children with autism in ways usually beyond their previous experience.
The authors would like to thank Heather's and Sian's families, Eleri Turner, and Wendy Prevezer for their contributions. Work on this chapter was partially supported by the Wales Office for Research and Development in Health and Social Care.
A publication list relating to aspects of Musical Interaction Therapy as practiced at Sutherland House Nottingham, may be obtained from the Information Service, Early Years Diagnostic Centre, 272 Longdale Lane, Ravenshead, Nottinghamshire, NG15 9AH, UK.
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