MUSICAL INTERACTION THERAPY Music therapy is the “planned and creative use of music to attain therapeutic aims” (Australian Music Therapy Association Inc, 2005). Music therapy may focus on a variety of targets within the domains of physical, psychological, emotional, cognitive and social needs (Gold & Wigram, 2003). AUTISM AND MUSICAL INTERACTION THERAPY Key therapy targets for children with autism, e.g., increased use of pragmatic or general social skills can be incorporated into an autism-specific music-based approach called Musical Interaction Therapy (Wimpory & Nash, 1999). Musical Interaction Therapy is designed around interactive play between the child and parent or caregiver that parallels parent-child interactions which may lead to the development of communication and language skills (Wimpory & Nash, 1999). Musical Interaction Therapy allows children who display some verbal skills exposure to further verbal experiences, as well as providing non-verbal children the opportunity to communicate without words (Gold & Wigram, 2003). The presence of music can provide a child who has autism with predictability regarding an activity or interaction which is not as readily apparent in a spontaneous task, whilst providing the parent or caregiver a form of structure that enables them to slow down and repeat their interaction with their child (Wimpory & Nash, 1999). IMPLEMENTATION OF MUSICAL INTERACTION THERAPY Music therapy can take a variety of forms including improvisation which may be free-flowing or structured, active participation in songs, instrumental play or simply listening to music (Gold & Wigram, 2003). In accordance with other forms of therapy a child with autism may receive, the first step in Musical Interaction Therapy is to ensure that a thorough assessment of the child’s abilities has been conducted, or a recent assessment consulted so that therapy is individualised to the child’s needs (Bunt & Hoskyns, 2002). Musical Interaction Therapy is aimed at the developmental level the child with autism has reached; however more advanced skills may also be included in therapy sessions (Wimpory & Nash, 1999). Musical Interaction Therapy can be conducted by a Speech Pathologist and Music Therapist who may provide a greater level of musical expertise and live music to accompany the therapeutic aims identified by the Speech Pathologist (Berger, 2002). Many factors can influence the number, length and frequency of sessions a child receives; again the therapy program needs to be individualised to the child (Berger, 2002). Musical Interaction Therapy integrates three components which are present in all stages throughout the course of therapy (Bunt & Hoskyns, 2002). These three components described by Wimpory & Nash (1999) are: Scaffolding: The parent or caregiver provides the child with exposure to language related to the activity the child is participating in (Paul, 2001). Scaffolding is designed to increase and maximise the child’s active participation in a task (Shames, Wiig & Secord, 1998). Communicative control: Musical Interaction Therapy largely follows a child-centred approach. The child holds communicative control as the parent or caregiver is attuned to following the child’s lead in the session (Wimpory & Nash, 1999). A number of strategies can be employed, adapted, altered or expanded upon to suit the individual needs of a child in Musical Interaction Therapy. Prevezer (as cited in Wimpory & Nash, 1999) described the following strategies which can be successfully incorporated into Musical Interaction Therapy: Play routines: Play routines provide scaffolding for communication. They are advantageous as they form part of early social play between a parent or caregiver and a young child. Additionally, play routines often include physical contact which children with autism often tolerate or like particularly when the action is repetitive, for example, being tickled or swung around slowly Source: Prevezer (as cited in Wimpory & Nash, 1999). Tension-expectancy games: The use of timing is focused upon in these interactions. There is usually a build-up towards a key point; such games include ‘peek-a-boo’ or another spontaneous game resulting from the child’s actions. Tension-expectancy games are most often spoken or chanted using exaggerated intonation which draws the child into the game. Source: Prevezer (as cited in Wimpory & Nash, 1999). Singing: Singing is often a common part of parent-child interactions. The use of singing when accompanied by movements may lead to development of the child’s social timing. According to Burford (as cited in Wimpory & Nash, 1999) social timing is “a crucial element in the regulation of communicative movements and co-ordination of expressive behaviours”. Songs can provide a familiar and predictable structure for the child, with the option of providing variation in tempo, rhythm, volume and wording depending upon the child’s response. One advantage of singing in comparison to speech is that it enables exaggeration of words and pausing to see what the child’s response is. Pausing at the same point in a song when it is repeated numerous times can lead to anticipation by the child which results in a shared experience between the parent or caregiver and the child. Source: Prevezer (as cited in Wimpory & Nash, 1999). Imitation: A socially acceptable behaviour the child is performing is selected and imitated by the parent or caregiver. This may also result in turn taking and provide the child with the opportunity to be an effective communicator which may facilitate language development. Source: Prevezer (as cited in Wimpory & Nash, 1999). Parallel talk/play: The parent or caregiver talks about or provides a commentary regarding what the child is doing; alternatively, they may simply imitate the child’s movements (Paul, 2001). The accompanying music can be designed to reflect the activity or actions the parent or caregiver and child are doing (Wimpory & Nash, 1999). RECEPTIVE LANGUAGE AND MUSICAL INTERACTION THERAPY Musical Interaction Therapy can target receptive language skills through accompanying speech with a visual cue or movement, by slowing down and exaggerating words (e.g., during songs) and through tailoring language and responses to the child’s developmental level (Whipple, 2004). EXPRESSIVE LANGUAGE AND MUSICAL INTERACTION THERAPY A meta-analysis of nine quantitative studies found music therapy resulted in increased vocalisations, verbalisations and echolalia moving towards more functional communication (Whipple, 2004). PRAGMATICS AND MUSICAL INTERACTION THERAPY Musical Interaction Therapy is designed around interactive play between a parent or caregiver and child, therefore establishing eye contact, turn taking and joint attention can be incorporated into the activities the child participates in or is exposed to in therapy sessions (Wimpory & Nash, 1999). The degree to which these skills are focused on or the way in which they are targeted is variable and dependent upon the needs of the child. BEHAVIOUR AND SOCIAL SKILLS AND MUSICAL INTERACTION THERAPY A meta-analysis of nine quantitative studies found music therapy resulted in “increased appropriate social behaviours and decreased inappropriate, stereotypical and self-stimulatory behaviours” (Whipple, 2004). PROFESSIONAL TRAINING Musical Interaction Therapy can be conducted by a Speech Pathologist with a Music Therapist. To qualify as a Registered Music Therapist an accredited course offered at four universities around Australia must be undertaken (http://www.austmta.org.au). RESOURCES Depending upon the Speech Pathologists and Music Therapists methods the following resources may be required to conduct Musical Interaction Therapy: Tape recorder or CD player, tapes, CD’s and musical instruments (Bunt & Hoskyns, 2002). ADVANTAGES OF MUSICAL INTERACTION THERAPY There are numerous advantages to using Musical Interaction Therapy, these include: Musical Interaction Therapy was originally designed as an autism specific approach (Wimpory & Nash, 1999). The treatment is individualised to meet the needs of the child (Gold & Wigram, 2003). The parent or caregiver is heavily involved in the treatment (Wimpory & Nash, 1999). Musical Interaction Therapy utilises a client-centred approach (Wimpory & Nash, 1999). Musical Interaction Therapy can incorporate receptive language, expressive language, pragmatic, behaviour and social skills targets (Whipple, 2004, Wimpory & Nash, 1999). DISADVANTAGES OF MUSICAL INTERACTION THERAPY The disadvantages of Musical Interaction Therapy include: The preparation of therapy sessions may be very time consuming for the Speech Pathologist. EFFICACY OF MUSICAL INTERACTION THERAPY A review of the literature suggests that there is an evidence base which supports the use of music therapy as a treatment technique for children who have autism. Such studies include: A meta-analysis of nine quantitative studies comparing music to no-music conditions during the treatment of children with autism found that all music intervention regardless of the specific purpose or implementation achieved positive effects (Whipple, 2004). Edgerton (as cited in Gold & Wigram, 2003) observed the development of communicative in skills in eleven children who have autism throughout the course of music therapy and concluded that “there was a continuous increase in communicative acts and responses in all of the children”. A study by Wimpory & Nash (1999) indicated that Musical Interaction Therapy “facilitates playful joint action formats which generalise beyond therapy and possibly serve to facilitate further social/symbolic developments”. The research studies described represent level III evidence (Refer to Evidence Table). When determining whether to implement Musical Interaction Therapy with a particular child it is important to consider the child’s needs and individualise the program accordingly in conjunction with consultation from a Music Therapist.