A Music Therapy Treatment Model Autistic Children

MICHAEL H. THAUT, Ph.D., R.M.T. Michigan State University

for

ABSTRACT: An attempt was made to develops general music ther­apy treatment model for autistic children which is directed toward their specific areas of deficiencies and dysfunctioning. The model was based on results and experiences from an 8-month university research project. Four relevant treatment areas for music therapy with autistic children are included: (a) impaired language develop­ment, (b) impaired socio-emotional development, (c) impaired de­velopment of cognitive areas, and(d) perceptual motor disturbances. For each treatment area, aspects of pathology and diagnostic char­acteristics are outlined and sequencer of pertinent music therapy techniques are identified.

The suggested treatment model was originally developed

as part of a master’s thesis research project, conducted by the author between October 1979 and June 1980 and de­signed to explore the potential of music therapy in the treat­ment of autistic children.

The project was carried out in four parts: 1. A review of clinical and research literature was carried

out. Treatment areas where successful clinical experiences with music therapy had been documented were systemati­cally surveyed and possible new treatment foci were sug­gested based upon relevant research findings,

2. Clinical experience gathered with 10 autistic children (age range 5 to 14 years) during the time of the project in­dicated four prospective treatment areas: development of language, socioemotional, cognitive, and perceptual motor skills.

3. An experimental study was designed to give children a stimulus choice between auditory, musical, and visual stim­ulus conditions. The autistic children chose the musical time involvement significantly longer than two control groups of normal children equated by mental and chronological age respectively.

4. In a second experiment, autistic children’s improvised tetrachordic tone sequencer were analyzed for complexity, rule adherence, originality, rhythm, and restriction. In a com­parative analysis, autistic children’s tone sequencer ap­proached scores of normal children and received significantly higher scores than those of mentally impaired children.

The complete results of the research project are reported elsewhere (Thaut, 1980). Based on those results, a treatment model was developed where music therapy techniques were described in their specific application to relevant treatment

areas. Since then, the model has been used in the clinical education of university music therapy students working with autistic children. Revisions, additions, and modifications have helped to improve the original concept. This paper tries to present the theoretical, experimental, and clinical experience accumulated since the model was developed.

General Objectives andPreconditions Diagnosis

Before setting up a treatment plan, careful consideration of diagnostic findings should take place. Results from neu­rological assessments and differential diagnosis would partic­ularly help in applying symptom-oriented and efficient music therapy treatment. In order to emphasize the application of consistent diagnostic criteria, the use of Rutter’s (1978a) or Ornitz and Ritvo’s (1976) list of criteria is recommended. It is suggested that both lists complement each other under specific etiological considerations. For screening purposes or developmental assessments, the Psychoeducational Profile (Schopler & Reichler, 1979), the A.S.I.E.P. (Krug, Arick & Al­mond, 1980), or the Assessment of Autism Checklist (Gilliam, 1979) are recommended.

Etiology

There is evidence in the research literature suggesting the likelihood that autism has a neurophysiological cause in terms of some organic brain disorder. This disorder manifests itself in a variety of perceptual, cognitive, and motor disturbances. Ornitz (1974) has stated that perceptual disturbances are of fundamental importance in autism. They manifest themselves in perceptual inconstancy, lack of cross-modal associations, distortion of normal receptor hierarchy, dependence on kin­esthetic feedback, and sensorimotor disintegration. Music therapy, working on the level of sensory perception in dif­ferent modalities as well as integrating sensorimotor process­es, can explain its treatment approach under these etiological considerations. Further, evidence is provided by electro­physiological investigations about brain hemispheric special­ization which supports the frequent observation that autistic children are able to perceive and process musical stimuli de­spite their various other perceptual deficits (Applebaum, Egel, Koegel, & Imhoff, 1979; DeLong, 1978; Tanguay, 1976).

Treatment Michael H. Thaut, Ph.D., R.M.T., completed his M.M. and Ph.D. degrees at Michiagan State University. He Currently works at Riverside Correctional fa­

cility, Psychiatric Center, Ionia, Michigan 1984, by the National Association for Music Therapy, Inc.

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Recent experiences in treatment programs for autistic chil­dren point out the efficiency of educational settings (Bartak & Rutter, 1973; Rutter & Bartak, 1973). Thus it is recom-

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mended that music therapy integrate its treatment concept in a comprehensive special education program for autistic children. If this is not possible, there should be, nevertheless, an attempt to adapt consistent treatment criteria in educa­tional and therapeutic settings. Music therapy should stress parental cooperation in all stages of treatment. Music therapy should use a structural and developmentally based approach to set up its treatment: (a) macro-structure (long-term goals and assessment of learning steps); and (b) micro-structure (or­ganization of learning situations and sequencing of activities in order to facilitate appropriate behavior).

. . . autistic children are able to perceive and process musical stimuli despite their various oth­er perceptual deficits (Applebaum et. al., 1979; DeLong, 1978; Tanguay, 1976).

Basic Level

Learning processes in autistic children are always hampered by perceptual problems such as lack of concentration, fluc­tuating attention, fading eye contact, and preoccupation with ritualistic behaviors. Therefore, it is suggested that one em­phasize (a) rigid insistence on eye contact,(b) frequent recall of attention,(c) repetition of instruction in consistent word­ing until appropriate effort of response has been made, and (d) encouragement of perservance during performance. These principles have been very useful in the author’s experience to gradually shape attentive behavior in autistic children.

Impaired Language Development

Etiology and Diagnostic Criteria

Language deficiencies are listed in all diagnostic systems as a major autistic symptom. The acquisition of language is con­sidered to be a crucial aspect in further social and intellectual development of the child. It is assumed that a specific cog­nitive impairment affects the four aspects of the language system, namely, conceptualization, symbolization, compre­hension, and production. So far no convincing etiological ex­planation exists about the brain pathology responsible for the autistic language disorder. Autistic children seem to suffer from a disorder which impairs central coding processes and also strongly affects social and other cognitive skills (Rutter, 1978b). Music therapy techniques work on production pro­cesses as well as try to stimulate mental processes in respect to conceptualization, symbolization, and comprehension.

Expressive language behavior of autistic children seems to fall roughly into three categories. The category of lowest functioning is characterized by muteness or occasional bab­bling which is sometimes accompanied by pointing at or showing desired items. The children with oral motor apraxia must also be grouped in this category. A second category comprises children with noncommunicative speech or lim­ited communicative intent. Main characteristics are various forms of echolalia, pronoun reversal, lack of core of verbs, or

Music Therapy Perspectives (1984), Vol. 1, NO. 4

use of speech limited to labeling/requesting items. Only a small number of higher functioning autistic children acquire functional speech beyond labeling/requesting. The speech patterns, however, are characterized by syntactical problems, limited vocabulary and semantic concepts, and poor intona­tion patterns as well as lack of emotional attachment (Wing, 1976).

Proficiency in understanding written or spoken language ranges from complete unresponsiveness and incomprehen­sion to limited understanding of simply constructed sen­tences. The nine-word language test by Churchill (1978) has been found useful in the author’s experience in determining level of understanding and identifying breakdown in the re­spective input or output channels (visual, auditory, motor).

Music Therapy Techniques

1. On a basic level the therapist should try to support and facilitate the desire or necessity for the child to communi­cate. Improvised musical accompaniment of the child’s ha­bitual expressions (crying, laughing, sounds, movements) is intended to demonstrate a communicative relationship be­tween a particular sound, rhythmic pattern, or movement and some expression exhibited by the child. The autistic child might perceive sounds or movements better than verbal ap­proaches. Awareness of music and of a relationship between music and own action might serve as a motivational factor for the desire to communicate.

Intermediate Level

2. If the child has understood and used communicative intentions and responses, words or phrases may be combined with a melodic or rhythmic pattern and a body movement. The technique is intended to appeal to a maximum of per­ceptive channels in the child. Considering the specific per­ceptual pathology of autistic children, the integration of, for example, an auditory rhythmic pattern and a kinesthetic cue can facilitate perceptual awareness and comprehension in a teaching situation. As a starting point, names or action words lend themselves easily to this technique.

3. Autistic children, as was frequently observed during this project, tend to recognize the melodic/rhythmic shape of words or sentences better than the actual semantic meaning. This may lead to curious results when retaining the intonation patterns but changing sentence content. The author’s use of strong melodic/rhythmic patterns in verbal instructions, along with action patterns or flash cards to secure the word con­tent, were found beneficial in maintaining better attention to and comprehension/retention of the spoken word. For ex­ample, chants were widely used in combination with body percussion patterns as a teaching technique to aid the above described goals.

4. If the child exhibits undifferentiated vocal expressions, oral motor exercises such as playing wind instruments or oral

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motor imitation practice can strengthen awareness and func­tional use of lips, tongue, jaws, and teeth.

Complex level

5. If the child has grown in his perceptual abilities, imitation sequences which employ motion patterns with melodic/ rhythmic accompaniment may be introduced. Gross motor imitation such as moving to music, dancing, clapping hands, circling arms, etc. should proceed gradually to more precise imitative behavior (e.g., fine motor imitation such as playing with fingers). Oral motor imitation with various silent mouth positions would follow. Next oral vocal motor imitation where single sounds are imitated should be presented. An integra­tive technique would maintain gross and fine motor move­ments during the oral imitation process and use, for example, words of the respective body parts (arm, eye, ear, foot, hand, etc.) as teaching items. It would be advantageous to integrate auditory, motor, and kinesthetic processes during the vocal­ization exercises.

6. If some kind of speech (e.g., some labeling abilities) has been acquired, various activities for intonation problems or fluency may be implemented. Melodic shaping of vocal expressions, awareness of high/low and soft/loud, and stress patterns may be introduced by stimulation of free singing impulses through the accompaniment of the child’s vocal expressions by organum chord progressions. Free singing of the therapist along with his/her improvisations can also aid the above described goals and evoke songlike response by the child.

7. Sound vocalization may be supported by bringing reson­ating instruments (chime bars) close to the child’s ears. Reso­nating sounds seem to help to stabilize and encourage the voice in terms of duration and volume. Full chords on the piano may have the same effect after the child shows some progress in sustaining sounds. However, an autistic child’s perceptual sensitivity may change dramatically from day to day and too close a contact with a sound source may produce undesirable overstimulation. Exercises of sustaining sounds have also been used in this project to help children who have problems with combining syllables or letters smoothly and meaningfully (oral motor apraxia). Although in some cases a positive effect was observed, no claims of validated success can be made at this point.

8. Singing vowels by sustaining long sounds helps to further refine the inflection of speech. Graphic notations can facili­tate the child’s efforts: watching the movement of a pen on paper, drawing lines or curves following the melody of the sentence also appeals to the fascination for geometrical shapes and forms exhibited by some autistic children (Alvin, 1978).

9. Breathing can be generally trained by playing wind in­struments. This activity exercises breathing processes, capac­ity, and laryngeal functions (Alvin). It also can aid the refine­ment of oral motor function and the awareness of physical resistance in the breathing process by the pressure of wind entering the lungs and the instrument in controlled ways.

Impaired So&-Emotional Development

Etiology and Diagnostic Criteria

The traditional autistic diagnostic criteria of maintenance of sameness and aloofness are combined in this treatment area. The social withdrawal was viewed as a primary autistic feature for many years. Most of the etiological considerations and treatment attempts centered around possible causes for this behavior. This might have been the reason for viewing autism for a long time primarily as a psychiatric condition (Kanner, 1943). Today the impaired socio-emotional devel­opment is considered to be a manifestation of some kind of physical disorder. Various perceptual and cognitive dysfunc­tions are emphasized as underlying factors for the socio­emotional behavior deficiencies (Churchill, 1972; Reichler & Schopler, 1971). A central deficit in encoding stimuli and building concept formation is assumed; this impairs all types of complex behavior. Less is known, however, about neuro­biological factors underlying the formation of social behavior. The features of impaired socio-emotional behavior are most pronounced in early childhood (Wing, 1978). Main charac­teristics are listed below grouped in three categories.

1. Deviant eye contact; limpness/stiffness when held; ab­sence of social smile; lack of physical responsiveness.

2. Lack of affective responsiveness and empathy; aloofness; lack of social play/role play; lack of peer relations; lack of attention; lack of perseverance; anxiety.

3. Attachment to objects (often as obsessive preoccupa­tion); use of others as extension of self; maintenance of same­ness in environment.

Autistic children . . . tend to recognize the me­lodic/rhythmic shape of words or sentences bet­ter than the actual semantic meaning.

All of these features may change after 5 or 6 years of age in terms of intensity. The social aloneness, however, markedly remains (Wing, 1978).

Music Therapy Techniques

Basic Level

1. Autistic children very often physically reject or ignore social contact attempts by other persons especially if they are in an early stage of relationship building. Therefore, it can be more fruitful at times to initially provide an object relation for the child (e.g., through playing instruments). Shape, sound, and touch of the instrument will often fascinate the child. A variety of instruments may be offered and freedom of explo­ration should be given. The experience in this project has shown, however, that the selection and exploratory use of an instrument should be structured from the very beginning to minimize motility rituals or sensory overload. A cymbal, for example, can sometimes be too intruding with its ringing sound, or the child might start spinning the cymbal which

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will often elicit hand flapping, finger flicking, or almost hyp­notic staring at the spinning object. In a therapeutically struc­tured situation, however, instruments can serve as interme­diary objects between client and therapist, providing a potential point for mutual contact, enjoyment without grasp of abstract concepts, and satisfaction of a need for self­expression.

2. In addition to step 1, listening experiences (e.g., piano improvisation) can be provided. Additional tactile and visual experience helps to establish awareness of sound and of another person doing something in proximity to the child.

3. After a period of getting to know each other or becom­ing aware of each other, physical contact should be gradually offered through, for example, (a) moving to music and hold­ing the child’s hands, or (b) leading the child’s hands to a particular instrument.

4. Eventually step 3 should be extended by the therapist’s becoming a more leading part of an activity. Hands might be used in a more directive manner, Ieading the child’s hands on the keyboard, in clap-slap activities, et;. The therapist can also try to match or imitate vocal sounds of the child. This

setting of the therapy program provides the physical condi­tions for it. The main goals in a group of autistic children are to establish (a) tolerance level for the presence of or the phys­ical contact with other peers, and (b) a growing distinction between self and other group members. Movement and dance experiences or action songs in circles emphasize and clarify group concepts. Physical contact such as holding hands or facing each other frequently provides the experience of another person’s presence. A one-to-one client/staff ratio might be necessary in the beginning.

9. Orff methods can be successfully used for advanced group participation. Dance songs or instrumental pieces with Orff instruments combine movement, singing, body percus­sion, and instrument playing. Pentatonic scales and ostinato patterns provide a structured musical framework. The rondo form can foster social learning by emphasizing the contrast between self (solo) and others (tutti). Imitations of stereo­typed or ritualistic behavior in rondo form can help to tern­porarily decrease this behavior.

Impaired Development of Cognitive and Other Areas

might lead to some interesting pre-verbal “conversations.” Etiology and Diagnostic Criteria

Intermediate Level

5. On this level the emphasis should be placed on thera­peutic experiences where definite demands on a child’s at­tention and responses are made via some musical coopera­tion. The therapist thus sets up activities in a goal-oriented manner: leading movement imitations, clap/slap gamer, lum­mi stick practices, or addition of ostinato patterns and rhythms to musical improvisations.

Cognitive deficits are viewed as results of some organic brain dysfunction which cause perceptual problems on dif­ferent levels (Rutter, 1978a). Demonstrable deficits include memory functioning, motor and perceptual integration, and some social features (Churchill, 1978). Nature and boundaries of cognitive deficits are not yet fully discovered. In early clin­ical observations autistic children often were suspected of possessing high intelligence which was only masked by autis­tic symptoms (Kanner, 1943).

6. Demands of social learning in a musical one-to-one re­lationship can be established by structuring musical activities with dynamics, speed, rests, movements, dance steps, alter­nate playing patterns, and melodic imitations. Resonator bells, xylophones, metallophones, and other percussion instru­ments are useful for these musical interactions. The therapist may improvise (e.g., on the piano) music for particular move­ments: running, hopping, walking, standing still, sitting down, standing up, etc. Acquired behavior, however, should never become ritualistic. Frequent changes of the movement se­quence or the musical tempo are indicated.

. . . the selection and exploratory use of an in­strument should be structured from the very be­ginning to minimize motility rituals or sensory overload.

Investigations in intellectual functioning of autistic children now usually agree that their IQ-distribution functions in the same way as in any other group of the population (Rotter, 1978a). Mental retardation and autism can clearly coexist as well as autism and higher intellectual functioning. Assess­ments of cognitive abilities try to demonstrate the impor­tance of showing not only what autistic children can do but also how much they can learn to do. Specific cognitive def­icits seem to become essential features in autism (Wing, 1978). In order to be a valid diagnostic criterion, the cognitive dys­functioning must be out of keeping with the autistic child’s mental age (Rutter, Schaffer, & Sheperd, 1975).

Complex Level

7. After two years of therapy in a university music therapy clinic, one lo-year-old boy started to respond to mood im­provisations on the piano, contrasting happy (leaping, rhythmic accentuated patterns) and sad (slow progressions of tone clusters). He imitated the pattern on the piano, adding a smiling face and swaying trunk movements for “happy,” and laid his head down on the keys during the “sad” tone clus­ters. Pictures with facial expressions and flash cards can be used as additional cues during these mood improvisations.

8. The child might be introduced to a group situation if the

Impairment in verbal understanding, abstraction, sequenc­ing, temporal information, and decoding and encoding in­formation in auditory and visual modes is most often en­countered as a symptomatic feature. Autistic children also make only impaired use of symbols in play, organization, rule

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retrieval and evoked internal representations in memory, and gestures.

“Gestalt”-perception and -recall of information apparently function better than analytical (sequential) perception and recall of information in both visual and auditory modes (Her­melin & O’Connor, 1970; Ritvo & Provence, 1953).

Music Therapy Techniques

Music therapy experiences function as mediators and facil­itators of cognitive concepts. The following conceptual areas were used in this project as teaching items on intermediate and complex session levels.

1. Labeling concepts. Following directions of one or more steps and identifying musical objects by (a) pointing at, (b) playing, (c) recognizing different sound, (d) recognizing dif­ferent shape,(e) recognizing name of instrument.

2. Number concepts. “How many,” “Give me one/ two . . .,” add and subtract numbers by building scales with resonator begs, chimes, etc.

3. Color concepts. Using instruments with different colors. Using a set of keys or bars with different colors. Using colored graphic notations.

4. Auditory memory. Imitation of single tones up to longer tone sequences. Playing a sound (from tape or live) and let­ting the child find the instrument to which that sound be­longs.

5. Auditory-motor memory. The therapist teacher (by visu­ally and verbally modeling) different chants with various body percussion accompaniment. The therapist then recites only the chant and requests the child to perform the appropriate body motions along with the chant. Thus, the child has to remember the words of the chant (though not produce them) and the correct body motions.

6. Matching skills.(Also applicable for color concepts, form perception, language training.) Matching colors, shapes, names of musical objects with word cards, picture cards, hand signs, verbal responses. Activities are intended to work on audito­ry/visual perception and motor and verbal expression.

7. Form perception. Ordering and completing of tone scales consisting of bars, bells, etc. in different sizer. Building geo­metric constructions with drums or chime bars.

8. Decoding and encoding symbols. Applying graphic no­tations using colors and geometrical shapes.

9. Integration of music in the learning environment. Learning action words or spatial concepts as parts of songs (also of dance/movement), e.g., “jump, walk” or “up, down.” Alter­nation of instructional learning and music listening during a learning task to achieve and maintain heightened perceptual procession and attention (Litchman, 1977). Alternation of time units with instructional learning and musical play (Graham, 1976).

The last two techniques were not used in this project, but both references show data in support of an improved learn­ing environment.

Perceptual and Motor Disturbances

Etiology and Diagnostic Criteria

Perceptual and motor functioning are both components of the sensori-motor development of children. A discussion of the nature and importance of perceptual-motor or sensori­motor function, its development, and related theories goes far beyond the scope of this paper. The interested reader might be referred to the writings of Bruner (1968). Cratty (1973). Flavell (1963), or Piaget (1965).

In autistic children one sees both developmental delays and constant manifestations of pathological behavior in the perceptual-motor area, the latter often described as inability to adequately modulate sensory input (Ornitz, 1970) and mo­tor output (Ornitz, 1974). Ornitz (1974) suggested a relation­ship between motor behavior and the faulty processing of sensory input as a linking symptom between perceptual and motor disturbances.

Ornitz and Ritvo (1976) not only view perceptual distur­bances as primary but as underlying all other autistic symp­toms. They put forward the notion of a central perceptual disturbance in terms of some brain pathology. Neurophys­iological explanations center around the theory of perceptual inconstancy (imbalance between neurophysiological state of excitation and inhibition), extended to the theory of sensori­motor inconstancy. Research focuses on the vestibular reac­tivity in the brain stem (Ornitz, 1970, 1974; Ornitz & Ritvo, 1966) and the operation of homeostatic brain stem reflexes (MacCulloch & Williams, 1971; Piggot, Ax, Bamford, & Fetz­ner, 1973). LeLord, Laffont, Jusseaume, and Stephant (1973) have suggested defective interactions of sensory receptive pathways in the brain.

Most frequently encountered characteristics of perceptual disturbances include dependence on motor feedback to make sense out of perception; tactile and kinesthetic receptor preference (Schopler, 1965); hypo­ and hyper-sensitivity to sensory input (staring, catatonic-like arresting, visual and tactile detail scrutiny, covering ears, behaving as if deaf, over­reaction to sounds); failure to imitate behavior; preoccupa­tion with isolated sensory impressions; avoidance of new sen­sory experience; lack of cross-modal associations in different sensory modalities; and stimulus overselectivity (distorted perception of complex stimulus with several components) (Ornitz & Ritvo, 1976).

Motor disturbances were not originally included in diag­nostic lists. They were often viewed as part of the criterion maintenance of sameness. Kanner (1943) had even empha­sized good motor skills in autistic children. Poor motor de­velopment is usually understood as part of the distorted per­ception of ego boundaries, resulting in poor body image and disturbed motor functions. A disturbance in Central Nervous System (CNS) functioning is suggested (Ornitz & Ritvo, 1976) in respect to motility disturbances since they are likely not to be affected by environmental factors such as presence of persons or objects. Looking at a spinning top or cymbal fre­quently elicits patterns of motility disturbances. A

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neurophysiological relationship between faulty perception of sensory input and occurence of motility patterns is suggested by Ornitz and Ritvo (1976).

Most frequently encountered characteristics of motor dis­turbances are no functional use of hands; delayed gross and fine motor development; poor body awareness/image; poor laterality; poor perceptual-motor integration; self injury; mo­tility disturbances (self spinning and object spinning, toe walking, head banging, body rocking, hand flapping, finger flicking).

Music Therapy Techniques

All techniques are intended to work on (a) perceptual and motor development, and (b) the integration of different sen­sory experiences and appropriate motor responses.

Basic level

1. The autistic child can learn to relate tactile, visual, and auditory stimuli through manual exploration of instruments. The appropriate use of hands and fingers can be encouraged and practiced with this activity.

2. In the beginning of therapy, it is often necessary to break stereotyped motility patterns. Rhythmic activities with snare drums, cymbals, claves, etc. at tempos other than the tempo of body rocking may aid this goal.

3. Movement in physical contact with the therapist should already begin at a basic level to prepare the child for specific developmentally oriented motor interventions. The music therapist should at this point become familiar with the de­velopmental sequences of fundamental motor patterns. Movement to music also aids the integration of tactile/kin­esthetic and auditory perception and the differentiation of self/nonself. Exercises to improve the body resistance of the child might be incorporated here, by positioning the child on the floor or against the wall and rhythmically exerting pressure on arms or knees.

Intermediate Level

4. On this level imitation exercises should begin which work on more refined body awareness such as stretching, extend­ing arms or legs, stepping back and forward, moving arms up and down, crossing the body at mid-line by hitting each oth­er’s lummi sticks crosslaterally, or imitating crosslaterally by perhaps placing different instruments in right and left hand and playing together the instrument in the left hand, then the instrument in the right hand. Therapist and client should be seated facing each other during these activities. In the beginning the child might have difficulty imitating crosslater­ally. A frequent observation in this project was that when the therapist extended his left arm sideways and started to shake, for example, a maraca, the child started shaking his maraca with the left hand as well but tried to bring his arm over to the right side to mirror the therapist’s arm. Physical cuing might be appropriate at this point to give the child a feeling for the desired movement.

Music Therapy Perspectives (1984), Vol. 1, No. 4

5. After the imitative responses are shaped through the previous step, developmentally based imitation exercises should take place using uni-, bi-, ipsi-, and crosslateral limb movements.

Movement to music also aids the integration of tactile/kinesthetic and auditory perception and the differentiation of self/nonself.

6. If basic perceptual awareness has been established, that is, the child does not strike instruments erratically or use them for stereotyped motility patterns, playing instruments can be used to work on the development of gross and fine motor skills. Visuo-motor exercises might be incorporated by plac­ing resonator bells in different spacings apart from each other on a table and having the child strike the bells simultaneously or sequentially with the respective hand. Functional use of fingers can be practiced by playing with mallets, plucking strings, or playing keyboard.

Complex Level

7. Percussion playing was very useful during this project to work on any type of limb coordination or motor sequencing problem involving, for example, different laterality patterns or right/left awareness. Action songs can incorporate learn­ing of body parts or can help to practice spatial concepts. Rhythmic/musical accompaniment was widely used to work on fundamental motor patterns such as hopping, skipping, walking, heel-toe balancing, or general strengthening and gymnastic-type exercises.

8. On a more mature level the child can acquire command over concepts of pitch, loudness, and tempo by responding with the desired quality on percussion-type or Orff instru­ments. A perceptual learning sequence would start with each concept separately and eventually combine, for example, soft and fast or loud and slow playing. Different combinations of cues might be used, comprising auditory verbal, auditory mu­sical, and visual modes. A sole reliance on the auditory mu­sical cue would show the most matured perceptual ability.

Conclusions

The treatment model presented has divided the complex­ity of a therapeutic situation into separate areas and has de­velopmentally sequenced steps although the reality of ther­apy often yields a much more interwoven and interconnected picture. The model approach has been chosen for method­ological reasons, however, because music therapists have to be able to justify and explain their treatment steps for every level and stage of the child’s pathology as well as the overall therapeutic development according to the client’s diagnostic background and the particular pathological characteristics in­volved. Therefore, it has been attempted in this model to tie aspects of the etiology/diagnostic characteristics, character­istics of music as a therapeutic medium, and appropriate mu­sic therapy techniques together in a systematic fashion.

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