By Keren Abramson, S.-L.P.

The following discussion is designed to have relevant application to children presenting with Autistic Spectrum Disorder (ASD), Pervasive Developmental Disorder (PDD), Hyperlexia and related disorders.

From Leo Kanner's (1943) initial description of children diagnosed with early infantile autism until recent developmental approaches that encompass the broad range of individuals with Autistic Spectrum Disorder (ASD), abnormal social and communication development has maintained prominence as a key symptom.  The acquisition of language, and intent to communicate are crucial prognostic indicators.  Functional language skills demonstrated by early school age have been found to be powerful in predicting these children's later skills. Current views of the specific characteristics of their language deficits focus on pragmatic difficulties (how language is used for various purposes).

Current trends in language intervention and communication programmes for children with ASD are numerous. Structured approaches are frequently recommended. Often both the stimuli and the child's responses are determined by the adult.  Clinical observations and research with these children has repeatedly shown their special responsiveness toward and high interest in musical stimuli. In studies investigating the use of structured music therapy techniques, positive effects were found in a vast array of cognitive, speech, language and social skill areas. The value of incorporating principles and practices of music in the treatment of a variety of disorders, including dysfluency, aphasia, voice, speech and language has been long realised by speech-language pathologists.

In his recognised work Awakenings, Sachs (1987) discussed the influence of music on patients with neurological impairments. Studies are currently underway to investigate the reasons for the effectiveness of music therapy with autism and the cerebral mechanisms involved in the brain's perception of music. In the past, music was believed to be primarily found in the right hemisphere. Exploration of different aspects of music (melody, rhythmic patterns, speech prosody, pitch and tonality) has revealed that right and left hemispheres are both active, but for different functions, and that music processing is a complex task that cannot be viewed in terms of simplistic right and left hemispheric strategies. The perception of music appears to require integrated hemispheric functioning with subcortical involvement as well.

In a recent journal article (Music Therapy Perspectives 200, Vol. 18), Kathleen Wager, Music Therapist, cited that Thaut (1980) theorized that rhythm might be absorbed on a physiological level that bypasses the cognitive deficits of children with autism. Because music can simultaneously stimulate areas of the brain that control autonomic, affective, and cognitive processes, one might theorize that the effectiveness of music therapy with persons with autism may lie in the brain's attempt to function in an integrated manner to process the various aspects of music- melody, harmony and rhythm. She added that Costello (1996) and Sigmon (1996) both commented on the lack of longitudinal studies examining the epidemiology, communication, social, and emotional development of persons with autism. The music therapy literature lacks studies concerning the effects of long-term music therapy treatment on children or adults with autism. Music therapy applications have dealt successfully with several of the behaviours associated with autism and other neurological impairments. Some of the symptoms included in the American Psychological Association's (1994) definition of autism are: mutism, atypical language, need for sameness,  rigid, stereotyped play with small objects,  lack of imagination and playfulness, isolated areas of ability, and infancy or childhood onset. Musical activities such as singing, drumming and playing melodies have been reviewed in the literature as having had significant impact on the improvement of skills provided through a modality that utilises the strengths of the preferred learning style of clients with autism and children with pervasive developmental disorder.

The use of musical activities can have an impact on:

· Fine and Gross Motor Skill Development- Hands and fingers are used with most instruments. Body movement is involved in rhythmic functions. Cornish & McManus (1996) reported that children with autism and learning disorders have an increased incidence of left-handedness, ambiguous handedness and a disassociation between hand preference and hand skill.

· Motor planning- Staum (1988) suggested that rhythm may override poorly established motor patterns and reduced motor functioning. Ozonoff and Cathcart (1998) reported that visual tasks that rely on hand/eye integration and motor skills are better understood than those requiring abstract reasoning and executive functions.

· Speech and Verbal Intelligibility- Cohen (1992) found that singing, the use of rhythmic speech drills, and the use of nonsense speech vocal exercises caused changes in fundamental frequency of speech, variability of speech rate, and an increase in verbal intelligibility of speech in neurologically impaired persons.

· Listening Skills- Individuals can have opportunities to listen to others, imitate modelled sounds, rhythms, melodies, words, maintain a tempo consistent with the music heard, and start and stop with music stimuli. Volume, pitch and rate components can be demonstrated and modified.

· Interaction with and Awareness of Musical Stimuli- Autistic clients have often demonstrated an ability to memorize melodies, but have difficulty with rhythmic responses that are often impulsive, compulsive or chaotic (Toigo, 1992). Predictable, repetitive drumming is often a good starting point. In Kathleen Wager's four-year case study (2000) she found that hearing a piece in its entirety before learning the melody was helpful, and interesting melodies with a variety of pitches were more easily learned than melodies with repeated pitches.

· Joint Attention – Playing and singing music can be a non-threatening way to engage in symbolic interaction when verbal communication is limited. There is opportunity for affective expression by and towards the child. If a comfort level can be established between individuals at this point, it is often easier to make a gentle transition into more verbal activities. Methods of doing this are best done on an individual basis with professional guidance.

· Increasing Communicative Interest and Skills- When a child is involved in a musical activity (e.g. singing) one has an opportunity to observe his motor speech skills, imitation abilities, musicality, learning style(s), areas of high interest, non-verbal communication skills, affect and emotional triggers, as well as the way he relates to himself, others around him and his environment. If he accompanies his music with movement, gesture and animation, one can learn more about him. The knowledge gained from this vantage point can often provide strategies for bridging into meaningful interaction. Once communicative comfort has been established with reliability and predictability, channels towards higher interest in functional interpersonal skill development often open up.

Music can provide a basis and reference point for receptive and expressive speech and language skill development. At least three-quarters of all speaking autistic children demonstrate echolalia, although the reason for this is still unknown (Frith, 1989). Results of major studies (Prizant&Duchan, 1981), (Prizant&Rydell, 1984), led Tager-Flusberg (1985) to state, "Echolalia and stereotypical language are now seen as primitive strategies for communicating, especially in the context of poor comprehension."  The repetitive elements inherent in musical activities and the children's strong interest lend themselves towards a medium for enhancing development of interaction abilities. Language expansion techniques, visual cuing and use of props and books to reference to word meanings,  word and text revisions, are but a few techniques that can serve this end. Improvisational music therapy methods have been strongly suggested by Edgerton (1994) as being efficient in autistic children's communicative behaviours.
 

Music can soothe, stimulate, entertain. It often evokes feelings that words cannot express.  The therapeutic values are being investigated in neonatal units and geriatric centres. Classical music has been used to calm young children. As sound, rhythm and associated musical features impact on various areas of the brain, emotions, mental and physical reactions become activated. Many children with Autistic Spectrum Disorder (ASD) and related disorders show a strong affinity to music. Sachs has discussed the "connection with life" that music allows those who seem otherwise to be cut off from communication.

 It is important to incorporate elements of music into a child's programme in order to stimulate his intent to communicate, develop interaction strategies, improve receptive and expressive speech and language skills, assist with fine and gross motor skill development, and help to provide him with a leisure activity. Since many of these children exhibit sensory processing difficulty (sensory integration problems, heightened sensitivity and reactions to specific stimuli and/or aspects of them that result in sensory defensiveness, low, high or fluctuating arousal levels, difficulty with overload, competing messages, and figure/ground discrimination, to list common examples), one must customize music applications to meet personal variations and profiles.

 Music as an effective therapeutic medium, can be combined with other techniques and programmes to help an individual with undeveloped and/or impaired communication skills to become motivated and trained to reach a higher functional level with greater enjoyment.
 
 
 

The author gratefully acknowledges Miriam Hendeles, Music Therapist, Los Angeles, California for sharing information pertaining to music therapy.

Specific reference data on any of the above-cited sources will be supplied on request. Correspondence regarding this, or the article should be addressed to:
Keren Abramson,  Speech-Language Pathologist,
307 Sheppard Ave. W., Toronto, Ontario M2N 1N7.