Music therapy for children with severe and profound multiple disabilities: a review of literature.
Music therapy for children with severe and profound
multiple disabilities: a review of literature.
The purpose of this literature review is to identify goals and methods of music therapy for children
with severe and profound multiple disabilities, and to clarify the various orientations used by
clinicians. The general goals described have been identified by different music therapists and chosen
for their representativeness and breadth of application. The orientations which clinicians take in
their work with these children are described according to according to
1. As stated or indicated by; on the authority of: according to historians.
2. In keeping with: according to instructions.
3. ?the practices outlined by Bruscia (1989).
While many examples from the literature for adults with severe and profound multiple disabilities
are also relevant for children, they have not been included in this review because of the school age
focus (approximately 3 to 18 years). As such, this includes the work of Wigram (1988), Hughes
(1995) and Schalkwijk (1994), among others. Further, while much of the music therapy literature for
children with autism autism?(?`t?z?m), developmental disability resulting from a neurological
disorder that affects the normal functioning of the brain. It is characterized by the abnormal
development of communication skills, social skills, and reasoning. ?shares similarities in orientation,
goal(s) and methods, it has also not been included unless there is a clear indication that the author is
referring to work with children who are severely or profoundly multiply disabled.
Identifying the Population
Children who are severely and profoundly multiply disabled have a combination of physical and
intellectual difficulties which, although caused by similar conditions, create unique qualities and
characteristics. These disabilities generally lead to severe limitations of movement, communication
and socialization socialization?/so?cial?iza?tion/ (so?shal-i-za?shun) the process by which society
integrates the individual and the individual learns to behave in socially acceptable ways.
n. . Such children may require total care and be medically at risk. Epilepsy epilepsy,?a chronic
disorder of cerebral function characterized by periodic convulsive seizures. There are many
conditions that have epileptic seizures. Sudden discharge of excess electrical activity, which can be
either generalized (involving many areas of cells in ?is common, and often not completely controlled
by medication (Orelove and Sobsey, 1991). These children may have other impairments, such as
hearing and vision loss. They vary considerably in their ability to understand and communicate
information. Some use simple language or symbolic communication Symbolic communication is
exchange of messages that change a priori expectation of events. Examples of this are modern
communication technology as also exchange of information amongst animals. ?(such as gestures or
picture symbols) while others may be unable to communicate needs or responses effectively. Their
physical abilities also vary considerably, from well developed fine motor skills such as reaching or
grasping, to a complete lack of independent physical movement. Sometimes these children will be
unable to comprehend or adapt to unfamiliar environments and events, and this may cause difficulty
in transitions, particularly from familiar to unfamiliar environments. Similarly, these children may
not show recognition of familiar people, including family, teachers and therapists.
In educational settings, the needs of each child are generally outlined in an Individual Educational
Program (I.E.P.) wherein where?in??
In what way; how: Wherein have we sinned?
1. In which location; where: the country wherein those people live.
2. ?goals are set by parents, educators, therapists and care staff. These goals are usually organized
in areas such as auditory auditory?/au?di?to?ry/ (aw?di-tor?e)
1. aural or otic; pertaining to the ear.
2. pertaining to hearing.
adj. , visual, tactile tactile?/tac?tile/ (tak?til) pertaining to touch.
1. Perceptible to the sense of touch; tangible.
2. Used for feeling.
3. , perceptual, sensori-motor, communication, cognitive, social and emotional development, and are
then addressed by various disciplines (Boxill, 1989). Alley (1979), Codding (1988) and Jellison (1988)
have reviewed various ways in which music therapy interventions have addressed the needs of
people with disabilities, and this also includes children with severe and profound multiple
General Music Therapy Goals
A number of interrelated in?ter?re?late??
tr. & intr.v. in?ter?re?lat?ed, in?ter?re?lat?ing, in?ter?re?lates
To place in or come into mutual relationship.
in ?goals have been identified by music therapists working with these children. These general goals
may singularly, or in combination, provide the focus of a program.
The first and most primary goal is fulfilling the child's basic needs. For Alvin (1976), this involved
creating an emotionally stable and predictable environment that fostered feelings of security, love
and acceptance along with finding ways of self expression. She felt that only then could the child
relate and develop. For Nordoff and Robbins (1971, 1977, 1983), fulfilling the child's basic needs
involves 'meeting the child musically', where the therapist matches the child's inner condition with
the music. As Bruscia (1987 p.46) has indicated, this serves three main functions: to create an
accepting, responsive environment; to make musical contact with the child; and to build trust and
The second goal found throughout the literature is developing the child's sense of self. Alvin (1976)
discussed this in terms of "relating self to objects" (Bruscia, 1987 p.91), where the main aim was to
enable the child to develop relationships with instruments, music, and the therapist. "In order to
form these relationships, developmental growth must take place in the physical, intellectual, and
social-emotional domains" (Bruscia, 1987 p.91). For Nordoff and Robbins (1971; 1977; 1983), self-
image is built by developing exploration and creativity. This is fostered by supporting the child's
music making, acknowledging, and developing the inner "music child". Boxill (1985) discusses self
image as built through a cycle or continuum of awareness, where the therapist approaches
treatment with "a view to awakening, heightening height?en??
v. height?ened, height?en?ing, height?ens
1. To raise or increase the quantity or degree of; intensify.
2. To make high or higher; raise.
v.intr. , and expanding [the child's] awareness" (Boxill, 1985, p. 75). Two main strategies are used:
reflection, a mirroring technique; and identification, a musical representation of the client and
The third general music therapy goal is establishing or re-establishing interpersonal relationships
(1). For Boxill (1985; 1989), this meant developing the child's ability to understand and be
understood by others through verbal and non-verbal means, where relationships may develop
between the child, therapist or other person, or child's, therapist's or other person's music.
Typically, this is developed through the contact song (Boxill, 1985, p.80), an improvised
v. im?pro?vised, im?pro?vis?ing, im?pro?vis?es
1. To invent, compose, or perform with little or no preparation.
2. ?or composed song which serves to affirm the therapeutic relationship, and enable interaction.
Nordoff and Robbins (1983) felt that developing interpersonal relationships was achieved by
developing expressive freedom, where musical options brought about increased possibilities for
interaction and the realization that music can be "interresponsive". Alvin (1976) discussed this
general goal as a two fold process: firstly, by establishing a relationship with the music therapist
through self awareness and exploration, and secondly, by transferring the model of the therapeutic
relationship to significant relationships in the child's life (for example, parents, siblings, peers)
outside the immediate therapy environment. Agrotou (1993) felt that one way interpersonal
relationships were established and developed was through ritualized play, the "creative rhythmical
formalisation Noun 1. formalisation - the act of making formal (as by stating formal rules governing
classes of expressions)
systematisation, systematization, rationalisation, rationalization - systematic organization; the act of
organizing something ?of certain patterns of interaction" (Agrotou, 1993 p. 183). The basic qualities
of this play are as follows: that each player's output is regular in length and falls into a predictable
regularity of tempo; and that each player's contribution is called a turn and that a pair of turns
constitutes a round, the building blocks of ritualized play.
Developing specific skills is the fourth general goal. There are two distinct ways of thinking about
this goal area. Firstly, developing specific skills can be part of the therapy process concerned with
"developing the music child" (Nordoff & Robbins, 1977) or developing "self awareness" (Boxill, 1985,
1989). In these orientations, skills are developed in order to increase expressive and interactive
opportunities that foster the child's development and self esteem. Secondly, developing specific
skills tan mean focusing on the acquisition or development of competencies which enable the child
to function with greater independence. This may include physical, emotional, cognitive, social or
1. Inclined to communicate readily; talkative.
2. Of or relating to communication.
com?mu ?development such as increasing the quantity, quality or duration of a skill. When this
orientation is taken, the acquisition of the skill often becomes the central focus of the therapeutic
process. For example, skills may include increasing eye contact (Knout knout??
A leather scourge used for flogging.
tr.v. knout?ed, knout?ing, knouts
To flog with a knout.
[French, from Russian knut, from Old Russian , 1987), using a switch toy (Holloway, 1980), or
reaching for and touching objects (Saperston, Chan, Morphew & Carsrud, 1980), where musical
activities provide a context, motivation or reinforcement for the development of the skill.
The fifth general goal is dispelling pathological 1. pathological - [scientific computation] Used of a
data set that is grossly atypical of normal expected input, especially one that exposes a weakness or
bug in whatever algorithm one is using. ?behaviour. For Nordoff and Robbins (1971; 1983),
dispelling pathological behaviour involves decreasing the incidence of maladjusted mal?ad?just?ed
Inadequately adjusted to the demands or stresses of daily living. ?or unhealthy behaviour and
developing healthy ways of expressing needs, emotions and responses to both people and the
environment. For Alvin (Bruscia, 1987), this involves developing a level of awareness that goes
beyond sensorimotor sensorimotor?/sen?so?ri?mo?tor/ (sen?sor-e-mo?ter) both sensory and motor.
Of, relating to, or combining the functions of the sensory and motor activities. ?experiences in order
to resolve conflicts that lead to pathology and isolation. For Boxill (1985), this involves increasing
the child's self awareness in order to free "misused, misdirected, unused [or] unoriented energy"
(Boxill, 1985, p.73). Agrotou (1993) believes that fixated fix?ate??
v. fix?at?ed, fix?at?ing, fix?ates
1. To make fixed, stable, or stationary.
2. To focus one's eyes or attention on: fixate a faint object.
?and repetitive behavior(s) is a form of communication associated with grief or loss. Through the
establishment of ritualized patterns of communication and intervention, she provides a reliable and
predictable environment for working through these behaviors. Dispelling pathological behavior may
also include decreasing self-stimulatory behaviour (Knout, 1987) or cueing other behaviours
The sixth and final general goal is developing an awareness and sensitivity to the beauty of music
(Pfeifer, 1982). This involves "cultivating an awareness of, appreciation for, and satisfaction from
beauty through experiential ex?pe?ri?en?tial??
Relating to or derived from experience.
ex?pe ri?en ?involvement with music" (Pfeifer, 1982, p.5). As Salas (1990, p.5) discussed, this
experience may lie in intramusical structures and relationships, or in music's ability to connect with
human emotion, "giving voice to currents of feelings far beyond what is expressible in language".
Orientations to Practice
When addressing these goals, music therapists take a number of orientations to practice. An
orientation is defined by a therapist's stance or theoretical approach to clinical work. This includes
their beliefs about music, their role, and their relationship to the child. It is represented by the type
of goals and methods used in working with these children and the meaning given to the therapy
experience. Bruscia (1989) describes a number of areas of practice, and the following orientations
are based on his categorization.
These examples are meant to be illustrative il?lus?tra?tive??
Acting or serving as an illustration.
il?lus tra?tive?ly adv.
Adj. 1. ?and not a comprehensive categorization of all music therapists working with this client
group. Further, there is no intention to imply that the examples given are the therapist's only
orientation to practice.
When music therapists take a recreational orientation, they are concerned with providing musical
experiences for entertainment, recreation, diversion and leisure (Bruscia, 1989). These experiences
can include concerts, plays, or special events where children perform music, perform with music (for
example dancing), or where music performance is a shared experience that unites all members of
the event (for example singing hymns at a church service). In these situations, the music therapist
usually acts as coordinator, either of the musical portions or the entire event. Sometimes this
requires writing or arranging music, creating a play, or preparing taped music to be used at the
event For example, Shoemark (1988) and Coull and Meadows (1990) created and produced plays
with music as special events in a school setting. In doing so, they focused on the following: providing
performance oriented opportunities for children to demonstrate skills that they had developed (Coull
& Meadows, 1990; Shoemark, 1988); providing an opportunity for a school to join together in
community (Coull & Meadows, 1990); providing enjoyment for family and friends (Shoemark, 1988) ;
and, maintaining the dignity of children by involving them appropriately by age and ability
When music therapists take a behavioral orientation, they are concerned with "the influence of
music (on children] to increase, decrease, modify, or reinforce carefully designed targeted
behaviors" (Bruscia, 1989 p.114). From the literature reviewed, music therapists typically place less
emphasis on the dynamics of the therapeutic relationship and are more concerned with changes in
the child's behavior to meet an identified goal(s). As such, programs are developed with specific
goals in mind and structured interventions formulated to meet these goals. For example, Wolfe
(1980) used selected recorded music recorded music?n -> m?sica grabada??attached to a mercury
switch A mercury switch is a switch whose purpose is to allow or interrupt the flow of electric
current in an electrical circuit in a manner that is dependent on the switch's physical position or
alignment relative to the direction of the "pull" of earth's gravity. ?to increase the head control of
children with cerebral palsy cerebral palsy?(s?r?`br?l p?l`z?), disability caused by brain damage
before or during birth or in the first years, resulting in a loss of voluntary muscular control and
coordination. . Music acted as a reward for these children, which they were able to hear when
keeping their heads in an upright position. In another study designed to reinforce behavior,
Holloway (1980) used both passive (contingent music listening) and active (instrument playing)
music reinforcers to increase the pre-academic and motor skills of children in an institutional
setting. Other examples of behavioral interventions include programs designed to elicit responses
such as reaching for and touching objects (Saperston, Chan, Morphew & Carsrud, 1980), following
directions (Dorow, 1975), and changing activity level (Dorow & Horton, 1982; Kaufman & Sheckart,
1985; Reardon & Bell, 1970).
In adopting an educational orientation, the music therapist "places an emphasis on curricular or
developmental goals ..." (Bruscia, 1989 p. 70). In the literature reviewed in this discussion, two
distinct orientations can be found. This first, described by Bruscia (1989) as music therapy in special
education, focuses on the use of music to gain nonmusical skills and knowledge. The second,
described as developmental music therapy, focuses on a broader range of goals that address delays
or obstacles to developmental growth in all areas of the child's life (e.g. sensory, cognitive,
communicative, social, emotional, affective affective?/af?fec?tive/ (ah-fek?tiv) pertaining to affect.
1. Concerned with or arousing feelings or emotions; emotional.
2. ). Each will be briefly discussed.
When music therapists focus on the use of music to develop non-musical skills and knowledge, they
are typically concerned with reinforcing and maximizing the educational goals of a child's I.E.P.. For
example, Alley (1977, 1979), Jellison (1977, 1979), Krout (1987) and Presti (1984) describe the role
of the music therapist in an educational setting as one who provides a systematically structured
program of activities to meet educational/ curricula goals. In meeting these goals, Jellison (1979)
describes how the music therapist should derive a sequence of short term objectives or behavioral
tasks, determine an acceptable performance criteria for their achievement, and then implement a
series of activities to meet these criteria. As such, the music therapist takes on an instructional role
in the child's development, focusing on overt behavior and functional adaptation.
Some music therapists take a broader approach to the child's development, incorporating
sensorimotor, communicative, cognitive, affective, intrapersonal in?tra?per?son?al??
Existing or occurring within the individual self or mind.
in tra?per ?and interpersonal needs in an integrated way. This approach, which Bruscia (1989) calls
developmental music therapy, "is concerned with autobiographical material, family background,
private emotions, and personality development" (Bruscia, 1989 p.74) in ways that help children
overcome delays and accomplish tasks that meet their unique needs. Examples of this approach
include the work of Agrotou (1993), Alvin (1976), Boxill (1985, 1989), Howat (1995), Nordoff and
Robbins (1971, 1977, 1983), Shoemark (1991) and Warwick (1995). For Nordoff and Robbins (1971,
1977, 1983), therapy involves three interrelated stages: meeting the child musically, where the
therapist's music creates an accepting environment; evoking musical responses, where the therapist
stimulates the child to explore and create music, both instrumentally and vocally; and developing
musical skills, expressive freedom and interresponsiveness. In this approach, both recreative
v. rec?re?at?ed, rec?re?at?ing, rec?re?ates
To impart fresh life to; refresh mentally or physically.
To take recreation.
?and improvisational techniques are used. An increased emphasis is placed on the dynamics of the
therapeutic relationship, and while sessions may have a structure or plan prior to each session, the
therapist is likely to spontaneously respond to the child, altering the content of the session
accordingly. Further, the therapist places an emphasis on self inquiry as a way of understanding the
Music therapists that adopt a healing orientation use "musical experiences and the relationships that
develop through them to heal the mind, body, spirit, to induce self-healing, or to promote wellness"
(Bruscia, 1989 p.93). In this orientation, primary value is placed on the music therapist's
experiences of the child(ren) as part of understanding the therapy process, and self inquiry is central
to this. The work of Nordoff and Robbins (1971, 1977, 1983) falls into this category because the
therapeutic experience allows the child to heal and change from within, activating the child's 'inner
resources'. As Bruscia (1989 p. 94) discusses, Nordoff and Robbins give the music therapist as
healer healer?Mainstream medicine A romantic synonym for physician. See Traditional healing.
?four main functions: "1) to accept the [child] with respect and reverence, 2) to work through
various relationships that develop through the music, 3) to create music that will activate the
[child's] inner resources, and 4) to continually develop one's own musical life".
Major Treatment Methods
When these orientations are taken to meeting the general goals previously described, music
therapists use both active and receptive treatment methods in individual and group settings. Both of
these methods will be discussed separately.
Active methods refers to the therapy that "takes place within and through the [child's] efforts to
perform, improvise im?pro?vise??
v. im?pro?vised, im?pro?vis?ing, im?pro?vis?es
1. To invent, compose, or perform with little or no preparation.
2. , or create music, either alone or with others. Here the active experience either provides
therapeutic benefits directly, as the main stimulus for change, or it leads to a response process that
parallels or triggers a therapeutic change experience" (Bruscia, 1991, p. 65). Active methods include
instrumental activities, improvisation improvisation
Creation of music in real time. Improvisation usually involves some preparation beforehand,
particularly when there is more than one performer. Despite the central place of notated music in
the Western tradition, improvisation has often played a role, from the , vocal activities and
An instrumental activity involves the child manipulating an instrument in order to produce some
kind of sound. Typically, instruments that are used include hand held percussion
percussion?/per?cus?sion/ (per-kush?un) the act of striking a part with short, sharp blows as an aid
in diagnosing the condition of the underlying parts by the sound obtained. , drums, cymbals
cymbals?(s?m`b?lz), percussion instruments of ancient Asian origin. They consist of a pair of slightly
concave metal plates which produce a vibrant sound of indeterminate pitch. ?and xylophones.
Sounds can be "organized or unorganized, consist of random groups of sounds, short series of
pulses, intermittent or prolonged beating, or rhythmic patterns of varying length and complexity"
(Bruscia, 1987, p.48).
Instruments are typically selected according to the child's ability and interest, and may be adapted
to maximize success and independence. In adapting instruments, the music therapist may position
them for the child's easy access and provide splints splints
inflammation of the interosseous ligament between the small and large metacarpal bones of horses
and an accompanying periostitis and exostosis production on the small metacarpal bone. The
metatarsal bones are similarly but less frequently involved. ?and grips in order to grasp smaller
instruments and mallets. Instruments may be physically altered or other devices, such as levers or
frames may be built. For example, Clark and Chadwick (1980) and Elliott, Macks, Dea and Matsko
(1982) describe a range of adaptations to instruments designed to maximize the child's access and
independence. Music technology, such as computers and synthesizers, has also been adapted to
utilize the synthesizer's touch sensitivity and potential to produce a wide variety of sounds using
similar movements (Meadows, 1991).
Evoking Instrumental Sounds
There are several reasons why music therapists use instrumental activities. The first of these is to
evoke sound or music making responses from the child. Here, the music therapist helps the child to
produce sounds through the exploration of instrument timbre timbre
Quality of sound that distinguishes one instrument, voice, or other sound source from another.
Timbre largely results from a characteristic combination of overtones produced by different
instruments. , texture and shape (Pfeifer, 1989). Sometimes adapting the instrument or providing
physical assistance is necessary. When the child explores an instrument, it is a way of stimulating
them, making contact, establishing intent and engaging them in the therapy process. This goal is
particularly important for the child with a physical disability because such activities physically
stimulate them and assist them in understanding and controlling their bodies.
Nordoff and Robbins.(1971, 1977) evoke musical responses by engaging the child in music making
on instruments through modeling, verbal encouragement or instruction, and/or physical assistance.
Once the child begins to play, the therapist concentrates on the way the sound is produced,
responding to the dynamics, timbre, melody and level of organization the child shows. In this way,
the therapist begins from the child's music, and engages the child by imitating, contrasting, pausing
or structuring the musical experience in certain ways. These techniques apply more readily to
children who are physically capable of using instruments, where the process centers around
developing ways to express feelings, explore, or participate in instrumental activities.
Developing Instrumental Skills
The second goal is to develop instrumental skills. Two types of skills are emphasized, the first of
which is to develop an expressive musical language. Here the music therapist fosters the child's
ability to express personal feelings, explore and create sounds, and interact with others through the
playing of an instrument(s) (Alvin, 1976; Boxill, 1985, 1989; Nordoff & Robbins, 1971, 1977).
In developing expressive music skills, a common intervention is improvisation, where the therapist
and child spontaneously make music together. This may comprise the child and/or therapist
improvising with piano, voice, guitar, melodic me?lod?ic??
Of, relating to, or containing melody.
me?lod i?cal?ly adv. ?or percussive per?cus?sive??
Of, relating to, or characterized by percussion.
per?cus sive?ly adv. ?instruments, either alone or in combination. Improvisations can vary in their
complexity from simple sound forms to multi-dimensional compositions. For example, Nordoff and
Robbins (1971; 1977) discuss developing expressive musical skills through improvisation in terms of
'expressive freedom' and 'inter-responsiveness', where developing a musical language gives the child
new or improved expressive options and choices. Other examples include the work of Alvin (1971),
Boxill (1985), Howat (1995), Nordoff & Robbins (1971, 1977, 1983), Shoemark (1991) and Wigram
The second area is developing specific music skills, and involves the child learning and playing an
instrumental part in a composition. Typically, this is structured around recreative activities, where
the child rehearses and performs their part (3). While a number of therapeutic objectives, such as
attending to the task and behaving appropriately, are implied in this activity, the emphasis remains
on music making. The therapist may write music for specific goals (Levin, Levin & Safer, 1974;
Purvis & Samet, 1976), adapt it from existing literature (Boxill, 1985, 1989), or write it specifically
for the child, type of activity or goal (Boxill, 1985, 1989; Nordoff & Robbins, 1971, 1977).
Developing Music-Related Skills
The third goal area is developing music-related skills. Typically, goals focus on either those non-
music skills developed in the process of music-making, or the non-music skills developed where
music is used to motivate or reinforce specific skills. Bruscia (1991) has outlined a number of
general objectives, which include "developing sensorimotor skills, learning adaptive behaviours,
maintaining reality orientation, mastering different roles, identifying with the feelings of others, and
working co-operatively toward a common goal" (Bruscia, 1991, p.7). This goal area shares many
similarities with the previous goal (developing instrumental skills). The main difference is in the
emphasis placed by the music therapist. In this particular goal area, the emphasis is placed on the
skills (for example behavior, motor skills or attention) associated with the instrumental activity. In
the previous goal area, the emphasis was placed on the process of music making.
A wide range of music-related goals have been addressed in the literature (Alley. 1977; Hanser,
1987; Pfeifer, 1982). These include developing eye-hand coordination and motor skills such as
shaking, striking and grasping (Pfeifer, 1982; Krout, 1987); imitative im?i?ta?tive??
1. Of or involving imitation.
2. Not original; derivative.
3. Tending to imitate.
4. Onomatopoeic. ?behaviour and turn taking (Boxill, 1985): and following directions (Lathom &
Eagle, 1982). Typically, these goals share a close relationship with the child's I.E.P., where the music
therapist specifically addresses one or more of these goals in the child's music therapy program.
A vocal activity is one which, is focused on the child producing any sound that can be made orally.
Vocal sounds can be "sustained or unsustained, pitched or unpitched, verbal or non-verbal. They
may be unrelated single tones, short motifs, melodic patterns Melodic patterns are repetitive
patterns that can be used with any scale. It is used primarily for use in solos because, when
practiced enough, it can be extremely useful when improvising. , or short phrases" (Bruscia, 1987
p.47). Nordoff and Robbins (1983) and Boxill (1985) discuss singing as a direct and intimate self
extension, with the potential to integrate perceptual, cognitive and expressive capacities As with
instrumental activities, goals for vocal activities can be divided into three main areas: evoking vocal
responses, developing vocal skills, and developing music-related skills.
Evoking Vocal Responses
In evoking vocal responses, the music therapist helps the child to produce any vocal sound in a
musical context. This goal is usually most relevant in three specific situations. Firstly, for children
who have profound disabilities as a way of stimulating a response or fostering interaction (Boxill,
1985; Cunningham, 1975; Johnson, 1975; Nordoff & Robbins, 1971, 1977). Secondly, for children
with physical disabilities which impede im?pede??
tr.v. im?ped?ed, im?ped?ing, im?pedes
To retard or obstruct the progress of. See Synonyms at hinder1.
[Latin imped ?their ability to produce vocal sounds. And thirdly, for children who are withdrawn or
lack self confidence and need specific vocal support and encouragement (Nordoff & Robbins, 1971,
Nordoff and Robbins (1977, 1983) use a number of techniques to elicit vocal responses. These
include improvisational techniques such as a) making vocal sounds while musically reflecting the
child's emotional state, b) singing phrases that describe what the child is doing, feeling or
experiencing, and c) imitating the child's vocal sounds or words, matching the musical and
emotional qualities. Recreative techniques include a) presenting material the child is able to copy,
add to or develop, b) introducing a familiar song or tune and encourage the child to sing along, and
c) varying the instruments used in accompaniment. Techniques that can use either method include
a) providing opportunities to complete phrases, add sounds, syllables or words, and b) combining
vocalizing with movement or instrument playing.
Developing Vocal Skills
Developing vocal skills involves the therapist increasing the range, length, type, accuracy and/or
quality of the child's vocal sounds. Two types of goals are emphasized in the literature: developing
an expressive vocal language, and developing music-related skills.
In developing an expressive vocal language, the music therapist is primarily concerned with
stimulating, supporting and developing the child's vocal expression(s). These include both verbal and
non-verbal expressions of the child's here-and-now experience with the therapist, either in group or
individual sessions. Boxill (1985) gives the example of an agitated ag?i?tate??
v. ag?i?tat?ed, ag?i?tat?ing, ag?i?tates
1. To cause to move with violence or sudden force.
2. , hyperactive person, "when encouraged to hum a melody, may create his or her own sense of
calm through the vibratory vibratory?/vi?bra?to?ry/ (vi?brah-tor?e) vibrating or causing vibration.
vibrating or causing vibration; vibritile. ?effect of the music, as well as the emotional gratification
GRATIFICATION. A reward given voluntarily for some service or benefit rendered, without being
requested so to do, either expressly or by implication. ?it affords" (Boxill, 1985, p. 101).
For Nordoff and Robbins (1983), developing an expressive vocal language involves presenting a
variety of songs with different emotional qualities that gives the child a range of emotional
experiences. In so doing, the child's personality can become integrated in the act of singing and is
functionally organized by the musical structure and content of the song itself. "Such a variety of
emotional experience is vital to music therapy for it enhances responsiveness ... and simultaneously
fosters the personal development of (the child)" (Nordoff & Robbins, 1983, p. 32).
Developing vocal skills comprises many music-related skills. Typically, these are either the non-
music skills developed in the process of singing and music making, or the non-music skills developed
where singing is used to motivate or reinforce specific skills. These include the broad categories of
receptive language, expressive language and academic skills (Pfeifer, 1982). For example, vocal
activities can address the child's ability to attend (Wylie, 1983), turn take, listen, and make eye
contact (Krout, 1987). Songs can reflect a skill or knowledge that is learnt in the classroom. For
example, songs can describe colours and seasons (Purvis & Samet, 1976), providing a learning
context for the child.
Movement activities focus on the physical well-being and development of the child. As an active
method, movement activities are those where the child moves their body independently in a musical
context. This includes gross motor activities, basic locomotor lo?co?mo?tor?or lo?co?mo?tive
Of or relating to movement from one place to another.
of or pertaining to locomotion. ?activities, structured and free psychomotor
psychomotor?/psy?cho?mo?tor/ (si?ko-mo?ter) pertaining to motor effects of cerebral or psychic
1. ?movements, and perceptual motor activities (Boxill, 1985), where the music therapist plays or
selects music which supports and stimulates the child's movements.
In movement activities, two main goals are emphasized: maintaining or increasing gross and fine
motor skills (Robbins & Robbins, 1988); and educating the child to physically interact with the
environment in ways that help them to learn about themselves, the environment and others around
them (Boxill, 1989). More specific goals include increasing body awareness body awareness,
n the felt sense of embodiment; consciousness of our somatic feelings.
alternative medicine... ?(Boxill, 1985), identifying body parts (Levin, Levin & Safer, 1984), increasing
muscle control (Lathom & Eagle, 1982; Robbins, 1988), maintaining range of movement (Robbins &
Robbins, 1988) and integrating movements (Krout, 1987; Levin, Levin & Safer, 1984).
Typically, movement programs are designed for groups, where children have similar needs, and may
be coordinated with physiotherapists (Robbins & Robbins, 1988). Live or recorded music may to
used, chosen specifically for the type of activity or experience undertaken. Live music can be
improvised from an established song repertoire (Robbins & Robbins, 1988; Wigram, 1992). For
example, improvised music can support or imitate im?i?tate??
tr.v. im?i?tat?ed, im?i?tat?ing, im?i?tates
1. To use or follow as a model.
a. ?the movement(s) undertaken. Songs can describe the movement (for example stretching), the
context of the movement (for example, identifying body parts), or be a medium by which the
movement occurs (for example, the child spontaneously responding to the music).
The second major area of interventions for children with severe and profound multiple disabilities
are receptive methods. As Bruscia (1989 p.43) describes, receptive methods refer to "the therapy
that takes place when the child listens to, takes in, or receives the music itself"_ Three main
receptive methods can be identified in the music therapy literature These are sensory stimulation
n in acupuncture, the practice of inserting needles into skin and tissue to coax the body into using its
energy to heal itself. , movement, and contingent listening.
Sensory stimulation refers to the therapist's use of musical and other media to arouse, excite and
activate the child: In all interventions, the emphasis is on engaging the child in any type of response
that will foster activity and awareness of themselves, objects and others. For example, this can
include singing or playing to the child in order to change affect (e.g. eye contact) or manipulating
the child's arms and hands to explore an instrument, watching for changes in awareness and
Typically, there are three elements to this type of intervention, and they can be used separately or'
together when working with a child. The first element is auditory stimulation, or the therapist's
efforts to stimulate the child by improvising (Johnson, 1975), singing songs (Dorow & Horton, 1982;
Kaufman & Sheckart, 1985) or playing pre-recorded music (Wigram, 1981). Secondly, this can
involve the use of textures, fabrics and other materials to physically stimulate the child. For
example, fabrics can be gently rubbed over the child's arms, hands or feet, while textures can be
placed in the child's hand(s) or between fingers. Thirdly, the therapist can physically stimulate and
manipulate the child's body by touching, massaging or carefully moving body parts. For example, the
therapist may massage the child's arm and hand as a way of making contact or building trust.
Alternatively, the same technique may be used as a preparation for instrument playing, stimulating
the child's body and then placing the instrument so that the child can explore it, either
independently, or with assistance.
As a receptive method, movement activities refer to the therapist's caring and purposeful
1. Having a purpose; intentional: a purposeful musician.
2. Having or manifesting purpose; determined: entered the room with a purposeful look.
?manipulation of the child's body in a musical context to meet his/her physical well-being and
development. These activities are specifically designed for children who have little or no voluntary
control over their bodies, or lack the understanding to move in purposeful or controlled ways
(Weigall & Meadows, 1995). These programs are usually designed and run with physiotherapists
because of the high level of expertise required in understanding the physical makeup of children and
limitations to their movements. Programs are usually run for groups, and there is generally a very
high student staff ratio as children require individualized in?di?vid?u?al?ize??
tr.v. in?di?vid?u?al?ized, in?di?vid?u?al?iz?ing, in?di?vid?u?al?iz?es
1. To give individuality to.
2. To consider or treat individually; particularize.
The music therapist has two main functions in these programs. Firstly, to provide the structure of
the sessions, or secondly to work with a child providing physical intervention. Providing the
structure to sessions includes both musical and verbal elements. Musically this involves selecting
songs (both live and recorded) and improvising to connect, support, and facilitate the child's
Verbally, it means acting as a guide to staff members throughout the session. Providing physical
intervention means working with a child while recorded music is played.
These movement programs have three related elements. The first of these is to focus on maintaining
the child's physical functioning, including range of movement, muscle tone, and body symmetry (for
example, maintaining posture). Secondly, an emphasis is placed on the quality of the interactions
between therapist and child. As these children usually receive constant physical handling, care is
taken to make the interaction as positive and sensitive as possible. Thirdly, while the adult moves
the child's body, independent movement is encouraged and supported at all times.
Contingent music listening refers to the therapist's application of live or recorded music to reinforce
or reward appropriate non-musical behavior. Typically, the music therapist will identify, shape,
reinforce and reward a desired behavior(s), with the music functioning in the last two elements of
the sequence. For example, contingent listening has been used to reinforce imitative behavior
(Meltzer, 1974), reaching and touching objects (Saperston, Chan, Morphew, & Carsrud, 1980), head
positioning (Wolfe, 1980), motor skills (Dorow, 1975; Holloway, 1980) and foster positive
interactions and acceptance among students in a mainstream music classroom (Jellison, Brooks &
Noun 1. huck - toweling consisting of coarse absorbent cotton or linen fabric
toweling, towelling - any of various fabrics (linen or cotton) used to make towels , 1984).
One way of presenting the music therapy literature for children with severe and profound multiple
disabilities is by goal, orientation and method. This gives an indication of the ways music therapists
work with these children, showing both the diversity and similarities in overall approach.
Given the diverse goals of music therapists, there seems to be many similarities in the methods used.
For example, instrumental and vocal activities were used to meet all the general goals identified in
this review. It appears, therefore, that it is not so much the methods that are different as the
meaning given to the therapy experience. For example, when a child first plays an instrument
independently, it can be framed in two entirely different ways. From a behavioral orientation, it may
be an example of following directions and playing attention to the task. From a broader educational
perspective (developmental music therapy) on the other hand, it may be the child's first
communication of intent or interaction.
It follows that the general goals identified earlier in this review are not really 'general' at all. They
reflect an orientation or orientations to practice by music therapists that value certain types of
goal(s) for these children. For example, the first goal of fulfilling the child's basic needs reflects a
developmental music therapy or healing orientation that places an emphasis on the quality of the
therapeutic environment and the relationship with the therapist. It has not been identified as a goal
when working from other orientations.
Taking another perspective, the general goal of developing specific skills means different things in
different orientations. From a behavioral orientation, developing skill; means targeting and
systematically working toward the mastery of a specific skill, task or behavior that was identified by
the therapist to meet adaptive or educational needs. Typically, music listening is used to reward or
reinforce the child and the music therapist takes on an instructional role. From a healing
orientation, developing skills means fostering, allowing and encouraging the child to develop his/her
own unique ways of communicating and interacting to become whole. As such, sessions take place
spontaneously and develop in unique and unpredictable ways. A central focus is placed on the music
as a representation of the process, perhaps without necessity for interpretation or explanation.
Further, the therapist uses his/her own experiences to further understand this process.
In closing, while music therapist's goals and methods give an indication of the ways in which therapy
is approached with these children, it is the therapist's orientation to practice which gives meaning to
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Tony Meadows *, MMT MMT Million Metric Tons
MMT M?decins Ma?tres-Toile
MMT Methadone Maintenance Treatment
MMT Multiple Mirror Telescope
MMT Mission Management Team (International Space Station)
MMT Military Training Technology , RMT RMT?right mentotransverse (position of the fetus).
RMT?1. Registered Massage Therapist 2. Renal mesenchymal tumor ?
* Tony Meadows is an Australian-trained music therapist currently enrolled in a doctoral program at
Temple University, Philadelphia, USA.
(1) This goal was originally identified by Gaston (1968).
(2) Pfeifer cited Eagle (1978) as the primary source for this goal. However, as this is acknowledged
as a personal communication (Pfeifer, 1982 p.32), Pfeifer is used as the source.
(3) Performance can take place either within the therapy session or to peers, family and/or others.
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