4.1: Introduction
4.2: Background
4.2.1: How the project was set up
4.2.2: Ethical approval
4.3: Methodology
4.3.1: Overview of the study design 4.3.2: The choice of the research design 4.3.3: The children
4.3.4: The setting of the aims 4.3.5: Videotaping the sessions
4.3.6: Video analysis
4.3.7: Interpreting the video analysis data 4.3.8: Structured interviews
4.3.9: PSI forms
4.4: Results of the study
4.4.1: The music therapy reports 4.4.2: The video analysis
4.4.2.1: Children’s levels of engagement and amount of playing 4.4.2.2: Changes in vocalisations or words
4.4.2.3: Changes in negative behaviours
4.4.2.4: Other significant changes in the children’s behaviours
4.4.2.5: Changes in the children’s behaviours towards parents or therapist (other than ‘engaged)
4.4.2.6: Changes in the parent’s behaviours
- 132 - 4.4.3: The parents’ semi-structured interviews
4.4.3.1: W’s mother 4.4.3.2: J’s mother 4.4.3.3: Mi’s mother 4.4.3.4: ‘I’s mother 4.4.3.5: Ma’s father 4.4.3.6: E’s mother 4.4.3.7: R’s mother 4.4.3.8: M’s mother 4.4.3.9: H’s mother 4.4.3.10: B’s mother
4.4.4: The parents’ PSIs
4.4.5: Personal overview of each of the dyads results 4.4.5.1: W 4.4.5.2: J 4.4.5.3: Mi 4.4.5.4: ‘I’ 4.4.5.5: Ma 4.4.5.6: E 4.4.5.7: R 4.4.5.8: M 4.4.5.9: H 4.4.5.10: B
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4.1: Introduction
The overall aim of this study was to find out more about my own music therapy practice with children with autistic spectrum disorder. I felt that I was developing specific ways of working with this client group which I wanted to identify and explore. The approach I was using seemed to be successful not only for my own clients but also for other music therapists who had trained with me at Anglia Polytechnic University and were using all or some elements of the approach. I therefore thought it would be useful not only to define and identify this approach as I have done in the previous chapters in this thesis and in the video, but also to subject my work to more rigorous analysis.
To this effect, I set up two experimental research projects. The first investigation involved studying ten pre-school children with autistic spectrum disorder receiving weekly music therapy sessions at the Child Development Centre over a period of two school terms. This study will be described in this chapter. The second project involved comparing the results of music therapy diagnostic assessments with ADOS scores for thirty children attending the Croft Unit for Child and Family Psychiatry over a period of two years. This investigation will be described in Chapter 5.
The literature review in chapter 2 indicated that although there is a wide range of articles describing successful music therapy case studies and a number of articles outlining particular music therapy approaches in this field, there are relatively few experimental research investigations. The investigations that have been reported indicate that music therapy seems to be effective with children with autistic spectrum disorder, but that further research would be useful. Although there are some common points and overlaps between this research and previous projects, my study does not duplicate other work and is sufficiently different from previous research to warrant investigation.
In this project, I was interested in finding out more about my work with pre-school children with autistic spectrum disorder and their parents. I wanted to look at whether
- 134 - changes were occurring in the children and whether there were similarities in these
changes across the ten children I was studying.
The video that accompanies this thesis shows that I used my clarinet and playful movement in my work. I was therefore interested in finding out how I distributed my time playing different instruments and moving in the music therapy sessions, and how this varied across the ten children. As so much of my work relies on spontaneous,
intuitive musical improvisations, I felt it would be useful to use the video analyses to look more objectively at what I was doing with the different children.
In addition, I was interested in looking at how the parents benefited from being in the music therapy sessions with the children. The literature review showed how the behaviours of parents and children affect one another and I also felt that parents of pre- school children with autistic spectrum disorder were in particular need of support and encouragement. I therefore wanted to use the video analyses to look at whether the patterns of communication between the parent and the child changed during treatment and what these changes seemed to be associated with. I was interested to find out whether there were similarities and differences between the ways the ten different parents related to their children. I was also curious about how the parents felt about their children and whether these feelings changed in any way as a result of the music therapy intervention.
In my research investigation with ten pre-school children with autistic spectrum and their parents, my main research hypotheses were that:
- Progress towards achieving identified aims for each of the children could be identified over a period of 18 to 26 weeks.
- Across the ten children, it would become clear that music therapy was effective at achieving some aims, and less effective at achieving other aims.
- Patterns showing how progress is achieved over time will become clear.
- Parents’ patterns of interactions with their children, or perceptions of their children may change during the course of treatment.
- 135 - In this chapter, I will outline how the project was set up. In the methodology section I will explain why we chose a single subject experimental design, how we set treatment objectives and how we used music therapy reports, interviews, video-analyses and questionnaires to measure our results. Results of the investigation follow and are analysed.
To maintain confidentiality I have used the children’s first initial (and sometimes first two initials) and have always referred to the parents as individual children’s ‘Mum’ or ‘Dad’. However, when I refer to the video I have used the children’s full first name, as their name is used in the videotaped sessions. All the families gave written consent for this material to be used in the thesis and on the video.
4.2: Background
4.2.1: How the project was set up
I drew up an initial plan, explaining which and how many children I would investigate and what methods I would use to gather data. Malcolm Adams, clinical psychologist, acted as research consultant for this investigation. This plan was then discussed with the consultant neurological paediatrician at the Child Development Centre who was very encouraging and supported the project. We then appointed the music therapist, Emma Carter to work as a research assistant and to replace some of my clinical hours in order to allow me time to carry out the research. It was agreed that she would interview the parents, videotape all the sessions and analyse the videotapes. It was felt that it was important for an independent person other than myself to interview the parents and analyse the videos.
4.2.2: Ethical approval
In July 2000, before starting on this research investigation, I sent completed application forms, a five-page description of the proposed investigation and suggested consent forms
- 136 - and research information for parents to the Cambridge Local Research Ethics Committee. Consent forms and information sheets are included in Appendix 4.1 and 4.2. With one of the families who was not fluent in English, we employed an interpreter to explain these forms to the parents.
At the end of July 2000, the Cambridge Local Research Ethics Committee replied, approving the project (see Appendix 4.3).
4.3: Methodology
4.3.1: Overview of the study design
Ten pre-school children on the autistic spectrum who were referred to me for music therapy treatment at the Child Development Centre, Addenbrookes, were investigated. This number of children was chosen because it was a realistic number of children to investigate within the two year time span allocated for experimental work, and also because by studying ten children I was able to compare how different children with similar aims progressed and to evaluate what particular aims music therapy was effective at achieving.
It was hypothesised that progress towards achieving aims could be identified over a period of 18 to 26 weeks, and that patterns would emerge over time regarding which types of aims music therapy was particularly effective for and how progress was achieved with the ten children investigated. It was also hypothesised that parent’s behaviour
during the sessions, and their perceptions of their children might change during the course of treatment.
Each child received 18 to 26 weekly individual music therapy sessions (corresponding to two school terms) with their parent or carer in the room. Each of the sessions, as well as the ten-minute review of the session with the parent or carer immediately after the music therapy intervention, was video-taped, and the videos were subjected to analysis. The
- 137 - parents were also interviewed before and after treatment and completed a detailed
questionnaire to determine how they felt their child was functioning as well as to establish whether their perception of their child had changed during the treatment.
4.3.2: The choice of the research design
In this project I decided to focus purely on the music therapy sessions rather than
attempting to compare music therapy sessions to another therapeutic approach. This was partly because of the difficulty involved in matching pre-school children with autistic spectrum disorder with an appropriate control group and also because of the difficulty of finding any on-going individual therapy that these children might be involved in on a weekly basis that I could compare music therapy sessions with. Although the lack of a control group means that my results are weakened because progress in the children could be attributed to maturation, my main focus in this study was to find out more about my work rather than to ‘prove’ that music therapy was effective. One of the strengths of this design was that I was able to look at which particular aims were being met for individual children because it was possible to compare progress on different aims. In addition, because I was studying ten children and their parents, I was able to look at which aims music therapy was particularly successful at achieving, across the ten children.
Another important consideration was to use a system, which enabled me to analyse the work I was doing, as it was being practised, rather than modifying the work for the purposes of the research. This was the same consideration that I had had when setting up my two previous music therapy research projects and I was therefore able to use
methodologies that I had used in my two previous research projects, (Oldfield and Adams 1995; Oldfield, Bunce and Adams, 2003). The research design I used here, as in my previous investigations, was a series of Single Subject Experimental Designs (Kazdin, 1982; Morley and Adams, 1989).
As I mentioned in Chapter 1, the design I used was not a traditional Single Case Design where base line observations are made, treatment is applied and then changes are
- 138 - evaluated; this original Single Case Design Model was designed for clinical interventions where sudden marked changes occur (Kazdin 1982). In my work with pre-school children with autistic spectrum disorder, I was not expecting sudden marked changes but was hoping for gradual slow and progressive changes and I therefore gathered information by making many repeated measurements of each session. It could be argued that the research design would have been strengthened by adding a base line period. Nevertheless it is not clear what activities it would have been appropriate to use for all ten children across the baseline period.
All the sessions were videotaped and then analysed by the research assistant, using a five- second sampling system developed in my previous research projects. Five-second
samples were used because some of the children only responded in small ways and it was felt that if longer time samples had been used important responses might have been missed. In fact the analysis showed that many of the recorded behaviours occurred across consecutive five-second intervals, indicating that this interval was short enough to
capture important aspects of the children’s behaviour.
The research assistant did not start analysing videotapes until treatment on a particular child was complete and she didn’t feed back her results to me until all the experimental work had been completed. These detailed observations of every single session meant that I could get an objective view of what was occurring in the music therapy sessions, as well as evaluating the parents’ feedback, which occurred after every session.
In addition, the parents were interviewed and they completed questionnaires before and after the treatment, providing us with additional data, to supplement the information obtained from the video analyses.
4.3.3: The children
Over the years, I have worked with a wide range of children with autistic spectrum disorder, of different ages and different levels of abilities. Sometimes, I have treated
- 139 - children on their own, sometimes, with their parents or carers and sometimes in groups. The length of time I have worked with the children has also varied from a few weeks to several years of weekly sessions.
In this project, I decided to investigate pre-school children with autistic spectrum disorder who I saw individually with their parents over a period of 18 to 24 weeks (corresponding to two school terms). This decision was taken because, while most children with autistic spectrum disorder seem to benefit from music therapy treatment, early intervention may be the most effective time to set up healthy patterns of communication. These patterns need to be explored and shared with parents who would naturally be in attendance with very young children. The parents themselves also often particularly benefit from support and encouragement at this time. From my clinical experience it appears that, at this age, two terms is usually enough time to enable changes to occur which will hopefully then help the child into nursery, primary school or special education.
Over a period of twenty-six months, ten pre-school children (under four) with autistic spectrum disorder who were referred to music therapy at the Child Development Centre were included in the investigation. After the first two music therapy assessment sessions, which aimed to determine that the child would benefit from further music therapy treatment, I invited the mother (or primary carer) to participate in the study. I explained about project, gave her an information sheet, and asked her to sign a consent form. (Appendix 4.1 and 4.2). In this way I had a consecutive cohort of children.
Thus the criteria for taking part in the investigation were that:
- the child was referred to me for music therapy treatment at the Child Development Centre;
- the initial music therapy assessment indicated that the child and the parent would benefit from regular individual music therapy treatment;
- the child was on the autistic spectrum; - the child was of pre-school age;
- 140 - No families who met these criteria were excluded from the project.
During this twenty-six month period a total of twelve pre-school children with autistic spectrum disorder were referred to music therapy. Only one of these children was not considered suitable for music therapy, so all other eleven children referred were included in the project. One of these eleven children left the area after only four treatment sessions and was replaced by another child. The child who we felt would not benefit from music therapy treatment was extremely anxious when he came into the treatment room, and showed no curiosity or interest in any of the instruments and had no reactions to musical sounds or changes. I felt that it would be quite traumatic for this child and his mother to continue with music therapy sessions and that other approaches would probably be more successful.
From previous clinical experience, this ratio of one child in eleven not being suitable for music therapy treatment seems fairly representative. I would usually only expect about one in ten referrals to music therapy not to be considered suitable for treatment.
Although all the children referred to me already had a diagnosis of autistic spectrum disorder, each of the experimental subjects received an ADOS test (Autistic Diagnostic Observation Schedule) before taking part in the study. This was to ensure that a common diagnostic procedure had been used for each of the children. Some of the children had learning difficulties and others did not, but all of the children scored as being on the autistic spectrum disorder.
The children were all between the ages of two and four. The youngest was two years and five months old when he started music therapy sessions and the oldest was four years and one month old. The average age of the children when starting music therapy sessions was three years and six months old.
Nine of the children were boys and one was a girl. A parent was present for each of the sessions with all of the children except for one child whose mother only attended every
- 141 - two weeks because she had to look after a younger sibling on alternate weeks. Nine of the parents were the mothers of the child, one child came with his father. On a few occasions, when the ‘usual’ parent wasn’t available, the other parent replaced them. The children were usually aware of the change, but not distressed or unduly disturbed in any way. Occasionally, grandparents, other relatives or close friends of the families observed sessions, in addition to the main carer, when the parents requested this and when we felt this would not be disruptive to the session.
Table 4.1 summarises some of the details about the children and the families involved in the project.
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Table 4.1: Description of the Child Development Centre Project
children
C h ild re n Sex Age at start of treatment Total number of sessions Family circumstances People present with child Siblings Other informationW M 3y 11m 24 Mum and Dad Mum, for 15 out of 24 sessions
One older brother, plus a younger brother also with ASD
Mum was looking after W’s brother in another group at CDC on 9 occasions J M 3y 5m 25 Mum and Dad Mum One older sister
Mi M 2y 5m 24 Single Mum Mum Older sister with Aspergers I F 3y 3m 20 Mum and Dad Mum Older sister Ma M 3y 9m 18 Mum and Dad Dad every
week, on one occasion Mum also attended
No siblings Dad’s command of English was patchy.
Communication was not always straightforward E M 3y 8m 20 Mum and Dad Mum Two older
brothers R M 4y 1m 26 Mum and Dad Mum One twin
brother and two older sisters M M 3y 3m 22 Mum and Dad Mum One older sister H M 3y 5m 21 Single Mum Mum on all but
one occasion when Dad attended No siblings Parents estranged but Dad involved in some of the caring. B M 3y 5m 22 Mum and Dad Mum on 20
occasions, Dad on 2, both plus new baby on 1. Baby brother born during treatment.
All of the children had had two music therapy assessment sessions with me before starting treatment. None of them had received music therapy treatment before the project started. Three of the children attended a general music group for mothers and toddlers or
- 143 - for nursery children in Cambridge at the same time as having music therapy sessions. The two types of musical interventions were fundamentally different. The music groups