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Section 22
The Language of Music: Working with Children with Autism

Question 22 | Test | Table of Contents

Zack
Zack was five-and-a-half when I first met him. His diagnosis was Pervasive Development Disorder — Not Otherwise Specified (PDD-NOS), along with apraxia¹ of speech. Many professionals consider autism to be a spectrum disorder ranging from severe to light. At the severe end is what we generally think of as autism: a withdrawn, nonverbal child sitting in a corner, rocking, hand-flapping, and possibly exhibiting self-abusive behaviors. A lack of awareness of the relationship of the body to the environment makes it difficult to perceive distant objects or discern where the body ends and the environment begins (Miller and Eller-Miller, 1989, 2000). This is why many children with autism may not respond to a verbal request but suddenly become aware of your existence if you touch them. Children diagnosed with PDD-NOS are slightly less affected by these problems and may have more understanding of language (receptive language ability) and perhaps a few words they can speak (expressive language ability).

Speech will probably never be Zack's primary mode of expressive communication. He is nonverbal, except for about five words. Individuals with autism have difficulty with expressive verbal communication due to the neural setup (or perhaps mis-setup) in their brain, and for Zack, the pathways from the brain to the muscles for speech are also miswired. His father, I believe, is also somewhere on the autistic spectrum. Initially resistant to this possibility, Zack's father now recognizes his own autistic tendencies and believes that he was on the autism spectrum as a child, if not still on it at the lighter end.

My first meeting with Zack was uneventful. I chose a set of tomtoms and a cymbal, while deciding against a snare drum because it creates too many complex high-pitched sounds. (I was wary about the cymbal for the same reason, but took the risk.) I played the piano while his mother attempted to get him to beat time on a drum using drumsticks. While on task, which was about 10 percent of the time, Zack beat the drums in a musically sensitive way. What he did with the cymbals was fascinating: instead of bashing them with the sticks and making a horrendous sound, Zack gently scraped the drumstick across the cymbal to make a soft sound. When I played the piano, Zack would remove my hands from the keys and play the first three white keys on the left over and over. "OK, Zack," I thought, "you play the piano and I'll play the drum." When I played the drum, he would also remove my hands from it. Zack's mother explained that he did not like anyone else to play an instrument, not just me. Frequent requests by Zack to go to the bathroom appeared to be an escape mechanism.

The three following meetings went similarly, with little meaningful communication between Zack and me. We each did our own things, side by side, in the same room. Such parallel actions are a common trait of autistic play. Zack seemed to have no idea of what I wanted him to do.

Frustrated, I talked with his mother. The parents of a child spend more time with him or her than any therapist or doctor can. They know their child's preferences, dislikes, strengths, and weaknesses. Zack's mother came up with the idea of using an activity board and a time board. An activity board contains a Velcro strip, to which one can attach pictures of various activities; an additional square with the words "do this" is placed below the picture of the initial task. A time board is fashioned in a similar way, but with the numbers 1,2, and 3, and a sign for "all done."

The tasks were broken down into tiny steps: picking up the stick, tapping the drum four times, stopping, and putting the stick down. Suddenly Zack demonstrated his ability to understand and do as I had asked. Mirroring what I did, he picked up the stick, tapped the drum four times, and put the stick down. I communicated with Zack! The activity and time boards visually communicated to him exactly what was expected, and the tasks were broken down into discrete portions that he could understand.

Zack was very happy during that session, giving me hugs and generally showing great pleasure. There were many fewer trips to the bathroom. Like all of us, when Zack understood what was expected and was able to do it, he overflowed with infectious happiness.

Sam
Sam is a 12-year-old boy with Asperger syndrome. People with high-functioning autism (HFA) and Asperger syndrome (AS) are considered to be at the lighter end of the autism spectrum. They are often very verbal, and commonly have average to above-average IQs. But the communication challenge presents itself in other ways — for example, in carrying on monologues about their favorite interests and not perceiving nonverbal cues, such as the listener looking at his watch, that it is time to stop. No matter where the individual with autism lies on the spectrum, there are still challenges in communication and social interaction, restricted interests, and repetitive motions (APA, 2000) as well as a degree of sensory integration dysfunction (Smith-Myles, Cook, Miller, Rinner, and Robbins, 2000; Huebner and Dunn, 2001).

Sam had recently been rejected from a private school specializing in Asperger syndrome for being "too low functioning." His mother, a professional musician, knew Sam had much musical talent but had yet to find anyone who could teach him how to read music. At our first meeting, she also expressed concerns about the difficulties Sam would begin to face as he entered adolescence.

As with all the children I work with, I requested that a parent (or significant caretaker) join in the lessons. Not only are parents the experts on their child. The lessons give them another way to relate to their child, and they can do additional work with the child between lessons. Occasionally, though, the presence of the parent distracts the child from learning. In those cases I start by working only with the child and then gradually involve the parent.

In my first lesson with Sam I made gridlines on a notebook-sized piece of paper, resulting in a 7-row by 10-column matrix.

After placing a few A's on the first line, B's on the second, down to G on the last line, I asked Sam if he would like to continue. Eager to do so, he quickly took the paper and started filling in the blank spaces with letters. Many people on the autism spectrum have a strong need for order and completion. A piece of paper that looked like this:
soon looked like this:

Sam's need for order and completion enabled him to complete an assigned task, and in the process work on fine-motor control and penmanship. Arranging his environment to take advantage of this characteristic worked much better than treating this need for order and completion as aberrant behavior.

Later on during the lesson, I started cutting the individual squares from the piece of paper and then passed the job over to an eager Sam. While he worked on this project, I drew a treble clef and staff on a larger piece of paper along with a lighter dashed line for middle C. Then I drew a B on the middle line and asked Sam if he knew where C went. He responded with an anxiety-filled "no!" I drew the letter in the space above the B. A query about where D belonged elicited the same response. I now asked if Sam could just guess where the letter D might go. Now he answered correctly, and I had him writing the letters in the right places on the staff. With the letter placements marked out, Sam was now able to place those lettered squares he previously cut out onto the staff in the right locations upon my request.

Soon we were spelling words such as "bag," "dad," "eat," and "ace," followed by simple songs such as "Twinkle, Twinkle Little Star" and "Mary Had a Little Lamb," which I then played on a musical recorder.

Shortly thereafter we ran out of space on that sheet of paper and it was time to make another sheet of staff paper. Sam's anxiety rose dramatically at my request that he draw the staff lines and the treble clef this time. However, his reluctance melted away just as quickly when I offered him assistance in drawing.

During the second lesson, we progressed to writing the note letters on yellow Post-It notes and sticking them on both the staff paper and the piano keyboard. As Sam began to play "Hot Cross Buns," at first with the yellow stickies bearing note names and then without, his mother was so overwhelmed with emotion that she broke down in tears. Sam looked over at her and with just a bit of nudging from me gave his mother a big hug. Who said that those with Asperger syndrome are emotionless?

It appeared that Sam was very anxious about failing at tasks. When he understood that he was in a safe environment without penalties for making mistakes, he did very well. I suspect that Sam's behavioral challenges in school were a result of not feeling safe academically. During my first lesson with Sam, much of the conversation centered on his concern for what an F grade meant and that it was not good to get such a grade. But the next time I saw Sam, there was no mention of grades.

Sometimes Sam would immediately reject a request with "no!" only to commence the task a few seconds later. Perhaps his "no!" was in reality a bid for more processing time. Other than easily being overwhelmed with anxiety over failing, Sam seems to enjoy the continuing sessions and is a pleasure to work with.

By placing the notes on this staff in this manner, Sam learned how to read music and apply it to a piano keyboard. The difference between this approach and traditional music education is that the primary goal of decoding musical notation was incidental to the activity from Sam's point of view. In other words, a more traditional way to teach music would involve spending a lot of time sitting in a chair, explaining and showing Sam the names for the lines of the staff, notes, and their relationships. Using a kinesthetic approach engaged Sam in the creation of his own learning materials, which served to reinforce the physical activities of putting the notes in the right place on the staff, followed by placing them on the piano keyboard. For people on the autism spectrum, it seems important for the physical aspect of the body to be in order before attending to the emotional and cognitive aspects. Additionally, by assisting in the creation of his own resources, Sam probably felt ownership of the learning materials and the activity. I was able to work with him not only on music, but on communication, taking turns, and fine-motor control.

When the time comes for Sam to get his first piano book, he will have a good background in the musical concepts presented in the text, having already ascended the initial learning curve involved in reading, understanding, and converting notation to music on the piano keyboard. He also now has a skill that will help him to interact with others. Perhaps the school that rejected Sam was too low functioning for him.
- Shore, Stephen, Screening, The language of music: working with children on the autism spectrum; Journal of Education; 2002; Vol. 183; Issue 2.

Personal Reflection Exercise #8
The preceding section contained information about using music to work with autistic children.    Write three case study examples regarding how you might use the content of this section in your practice.

Update
Effectiveness of Music Therapy in Children
with Autism Spectrum Disorder:
A Systematic Review and Meta-Analysis

- Ke, X., Song, W., Yang, M., Li, J., & Liu, W. (2022). Effectiveness of music therapy in children with autism spectrum disorder: A systematic review and meta-analysis. Frontiers in psychiatry, 13, 905113.

Peer-Reviewed Journal Article References:
Hillman, H. (2018). Child-centered play therapy as an intervention for children with autism: A literature review. International Journal of Play Therapy, 27(4), 198–204.

Wang, Q., Hoi, S. P., Wang, Y., Lam, C. M., Fang, F., & Yi, L. (2020). Gaze response to others’ gaze following in children with and without autism. Journal of Abnormal Psychology, 129(3), 320–329. 

Yi, H., Siu, Q. K. Y., Ngan, O. M. Y., & Chan, D. F. Y. (2020). Parents’ experiences of screening, diagnosis, and intervention for children with autism spectrum disorder. American Journal of Orthopsychiatry, 90(3), 297–311. 

QUESTION 22
Why do many children with autism not respond to a verbal request but suddenly become aware of your existence if you touch them? To select and enter your answer go to Test.