Wednesday, December 19, 2007

Read and Sing for Christmas: Up On the Housetop




Up on the housetop the reindeer pause
Out jumps good old Santa Claus
Down through the chimney
With lots of toys
All for the little ones Christmas joys.

Ho, ho, ho! Who wouldn't go,
Ho, ho, ho! Who wouldn't go
Up on the housetop
Click, click, click
Down through the chimney
With good Saint Nick.

This song is great for teachers and parents alike as it is flexible for a variety of musical settings and ability levels. The song naturally provides several instances for using instrument sounds to compliment the story. I use bells for the reindeer, a rain-stick for Santa going down the chimney and rhythm sticks or sand blocks for the, "click, click, click." My adaptations include using a Bigmack switch to record the, "Ho, ho, ho," for non-verbal participants and using body percussion such as patting or snapping for the, "Click, click, click."

Adding instrument sounds to go along with parts of a story in a song can be used to address many different educational objectives:

1. Sequencing skills. I have used a story board approach to see if students can arrange pictures into the correct order after singing the song. Instrument sounds can be used for non-verbal cues to help in the sequencing process.

2. Focus of attention and waiting skills. Individual students in a small group setting must practice taking turns and waiting for the appropriate times to play their instruments.

3. Problem solving. Students with more advanced skills may be able to choose instruments they feel will compliment the parts of the story. I facilitate this by providing a variety of appropriate instruments to choose from.

These are just a few of the ways I have used this song to help clients this year. Christmas and other holiday songs are very effective music choices for therapy since they are usually familiar and many of them have simple melodies. The song, "Up on the Housetop" has been very successful in groups of children who have autism or groups with children who have a mixture of different disabilities.

Ho, ho, ho!

Monday, December 17, 2007

Pain - Forget About It! Using Music Effectively to Manage Pain.

Everyone dreads the dentist chair when they know they have a cavity. Sometimes even a sound that reminds you of a dentist's drill can cause perceived pain! I have worked with clients at the doctor's office, in hospital rooms, and at home to help them with pain management. These patients have been dealing with everything from needle sticks to chronic pain from disease and in many cases using music to help them relax and ignore the pain has been very effective.

The main theory behind using music to help with pain management is centered around the "Gate Control Theory of Pain." This theory establishes that a person cannot actively think about two different information streams at the same time. Pain is a perceived idea in our cognitive thought process. Without cognitively focusing on the pain, the sensation can be greatly diminished. The Gate Control Theory is useful in that it promotes using focus of attention to distract from pain. Active music listening or music used for relaxation are very effective ways to focus attention.

Music provides a preferred and pleasant stimulus for focus of attention. The sound of music can mask unwanted environmental sounds such as medical staff talking about procedures or the clanking of surgical equipment. Music may also act as a trigger for positive memories and associations. The choice of music, therefore, is key to successfully utilizing it as a tool for distraction from pain. In order to further enhance the success of using music to distract from pain, a person may also choose whether they want to use upbeat and highly preferred music or sedative music to use for pain management.

Upbeat or stylized music may be a better choice for masking environmental sounds and promoting active listening. Familiar lyrics and memories associated with favorite songs may more easily hold active thought patterns and form "trains of thought" to other memories. Sedative music may be recommended for highly stressful situations where anxiety and tension are contributors to pain. In most cases, muscle tension will increase pain sensations by heightening physical awareness and pulling the thought pattern towards thinking about environmental sensations. Tightening the muscle fibers can also cause more painful procedures such as needle sticks or shots into the muscle tissue. Music facilitated relaxation provides a distraction as well as helping to relax the muscles.

I suggest using music listening during dental procedures, blood draws and before surgery to help with a variety of issues, including pain management. All of these settings easily accommodate headphones and family, friends or a therapist who can be there to help.

Friday, December 14, 2007

The Importance of Using Music as Part of the Lifestyle Change After a Heart Attack or Serious Cardiac Event

Research has recently begun catching up with the conventional wisdom that mental stress after having a heart attack can greatly increase the chances for future cardiovascular problems and incidents. The emotional strain and life altering consequences after having a heart attack or cardiac related surgery are only the first challenges. Daily events produce additional physical, emotional and mental stressors that are documented to lengthen recovery times.

I have developed a workshop called, Music for the Heart, that seeks to address the specific stress-inducing events that surround cardiovascular health problems. Recent research has emphasized the need for a holistic approach to health after heart attacks and cardiovascular surgery. I present tools and guidance in the workshop to help patients elevate their mood, learn to relax and introduce music as a leisure-time tool to help them make the post-cardiac event lifestyle change. Dr. Barry Bittman, MD, and the developer of the Health Rhythms program said, “Recreational music-making provides an extraordinary opportunity for people to regain a sense of balance and wholeness conducive to improved well-being.” (San Francisco Chronicle, September 28, 2001, Rhythm of Life: Pleasant Hill drum circle participants say monthly playing is therapeutic.)

I have had the opportunity to present the Music for the Heart program to several cardiologists and surgeons. There are several recent research studies that I point to in my discussions with the doctors about the potential for using music to facilitate the lifestyle changes for their patients. John C. Barefoot, PhD and Marianne Schroll, MD, DMSc conducted a study, "Symptoms of Depression, Acute Myocardial Infarction, and Total Mortality in a Community Sample," which concluded that high levels of depression are associated with greater chances for heart attack and mortality. This study was conducted over twenty-seven years with a large sample size of over seven hundred participants. Depression and negative mood are often the result of mental stress.

Two other studies have indicated that mental stress indicates a greater chance for myocardial ischemia and mortality after someone has already had a heart attack. One of these studies is, "Mental Stress-Induced Myocardial Ischemia and Cardiac Events." In this study more than one hundred patients with coronary artery disease were followed for up to five years. The researchers concluded that the presence of mental-stress induced ischemia is associated with significantly higher rates of later fatal and non-fatal cardiac events. Another study, "Mental Stress-Induced Ischemia and All-Cause Mortality in Patients With Coronary Artery Disease," found that patients with ischemia had a greater risk of dying when they were having mental-induced stress.

The evidence is clear that a patient's lifestyle is extremely important after a cardiac event. Cardiac rehabilitation programs encourage lifestyle changes that include stress-management strategies. I believe that music facilitated relaxation is a powerful tool to help people with managing stress. Music of some type is enjoyed by almost everyone and is an easy and appropriate way to help manage stress and elevate mood states. Related articles for using music in relaxation may be found in the
Most Popular Posts links and in the following articles:

A Guide for Home Relaxation
Kevin Kern Relaxation CD
Suggestions for Relaxation Music

Tuesday, December 11, 2007

Henry Sings For Success: A Schoolhouse Story About Singing and Stimming Behaviors

Henry is a delightful boy in the second grade. He has recently been labeled as having an autism spectrum disorder and his behaviors are consistent with many of the common characteristics of autism. One of these characteristics is his desire for self-stimulation through hand flapping, visual and verbal perseveration, muscle flexing and in Henry's case, singing. For the purpose of this article, I will refer to these behaviors by the more official term, stereotypy, since "stimming" is not a word currently listed in the dictionary.

Henry has been observed to sing to himself almost all the time. He is a very good singer with excellent pitch accuracy and the ability to remember many lyric phrases. His teachers have been working with Henry to have him sing more quietly outside of the classroom or at times when he should be quiet. His teachers have noticed that when Henry is working with his hands on tasks that involve objects with significant tactile stimulation, he stops singing. He will stop singing, for example, when he is putting his hands in shaving cream or trying to button a sweater. He also decreases his stereotypic singing when he is on a therapy ball during physical therapy or adapted PE.

I have worked with Henry during music therapy sessions and observed his eager participation in the activities. He seems to crave the sensory input provided by the music stimuli. Fortunately, Henry is able to participate in music activities in more significant ways than only absorbing it as sensory stimulation. Henry has demonstrated that he can follow sung directions during movement to music activities and can start and stop singing or playing instruments as part of group activities and highly structured musical activities. In general, Henry stops his stereotypic singing for the duration of music therapy groups, approximately thirty minutes. He has also been observed to be less restless and stay in his seat better during the music therapy sessions. His teacher said that Henry has the best waiting skills during music therapy than any other time or activity of the day.

Recently, I observed Henry working in the classroom in order to obtain data about his behavior and skills outside of music therapy. I was able to see how Henry worked on writing skills, matching words and quantities and following directions. Henry was guided by picture schedules to help him stay on task, but also to allow choices and provide rewards for work completed. One of his work tasks was to match word strips to pictures. He seemed to know how to match correctly, but he took a long time because he was singing to himself throughout the entire work activity.

I had noticed that Henry preferred familiar children's songs with attractive melodies rather than chants or repetitive melodies with little variance in pitch. I composed an original melody, ad lib, that was reminiscent of songs like, "The Itsy, Bitsy Spider," or "Oh Where, Oh Where Has My Little Doggie Gone." I wanted to use this song to help him with his word to picture matching activity. Henry quickly began singing the song with me after only one example and we began matching his words to pictures. Henry stopped singing to himself and immediately switched to the song I had composed and sang along with me. I sang with Henry for several word matches and then gradually stopped singing with him. He was able to continue singing the new melody with each new word and finished the matching exercise with amazing speed. Before I introduced the song, he had been sitting with his work folder for five minutes just moving the word strips around without actively matching. In Henry's case, I was able to combine his need for sensory input with active learning. His singing stopped being an impediment to his productive use of time, and instead, accelerated his work.

Tuesday, December 4, 2007

Schoolhouse Story: William Learns to Walk Like a Man

I am fortunate that many behavior problems disappear during music therapy activities. The teachers I work with often joke that I remain around longer so that their students continue to pay attention and remain sitting appropriately. These students do not have bad teachers, but the power of the music activities is often strong enough to maintain order during the music therapy session without many of the behavioral interventions that are necessary during regular classroom activities.

William is a student in second grade who I have often observed demonstrating defiant and oppositional behavior in the classroom. William has a rare brain disorder that affects his gross motor skills, but he is fully capable of walking. His teacher reported, however, that William was having great difficulty walking to the bus. William frequently decided to practice the safety protocol for when you are on fire and, "stop, drop and roll," in the hallway on the way to the bus!

William did not respond to music activities immediately when school started in the Fall, but he seemed to be listening and demonstrating good eye gaze toward the music therapist and the activities. Approximately half way through the school-year, William suddenly began performing all the movement to music activities that were part of the general music therapy session routine. He did not require prompts and seemed excited to participate. In light of this behavior, I adapted the lyrics to the song by Frankie Valli, "Walk Like a Man," in an effort to teach him more appropriate behavior. The song went something like, "Walk like a man, fast as you can, walk like a man my friend... stand straight and tall, walk never fall, walk like a man, William!"

I began using this song as one of the movement to music activities during the weekly music therapy sessions. William was very excited to practice walking around the room and did not demonstrate any inappropriate behaviors. I recorded the song with guitar accompaniment onto a tape so that the teachers could use the recording for William after school. The tape worked beautifully and William seemed to forget that he had ever had any problem going to the bus. This strategy continued to be successful more often than not for the remainder of the school year.

One of the advantages of using music is that it is "moveable." In the case with William, the sound of the guitar and upbeat accompaniment was a key to the successful result. Sometimes, simply singing a song and clapping along is all that is necessary to use music successfully as a therapuetic strategy. Many children will respond in a unique and significant ways to music stimuli and familiar songs with corresponding actions can effectively be used across settings. Social stories are often used with children who have autism, for example, to help them practice appropriate social skills. Sometimes adding a melody to a social story can be even more effective. This social story can then be sung anywhere, at any time to help encourage desired behaviors.

Monday, December 3, 2007

Schoolhouse Story: Wendy and the Power of Melody

I am often called upon to conduct assessments to see if a student will qualify for music therapy as a related service. "Wendy" was referred for a music therapy assessment after her teacher observed that Wendy significantly increased her focus of attention during songs at circle time activities. Wendy has mild to moderate mental retardation and speech impairments. As part of the music therapy assessment process I observed Wendy working in the classroom during various group activities as well as some individual work.

Wendy was observed to provide very short attention to her teacher unless given direct verbal prompts. When she was prompted, she was able to maintain her eye gaze focus to the teacher or task for less than one minute for most tasks. I watched Wendy become very focused, however, during familiar songs that employed accompanying gross motor movements. Wendy began singing the songs and performing all the motions without prompts. Wendy had not verbalized any other words throughout the activities until the singing activity except for saying some numbers during a counting exercise. One of the songs the group sang used the melody from Skip to my Lou. Wendy performed motions in the air as if she was drawing each number from one through four. The lyrics to the song described the motions for the number four as, "down, across, one more down...that is the numeral four."

After the group activities, Wendy was tracing the numeral 4 with a pencil for one of her assignments. Her teacher used hand over hand prompts to help Wendy focus her attention and trace the numbers. Wendy's teacher was verbalizing the same instructions as repeated in the lyrics of the song, but Wendy was not paying attention to the verbal instructions. I suggested that the teacher try to sing the melody along with the instructions. The teacher tried this and immediately gained Wendy's attention to the task, although she was still required to provide hand over hand guidance for Wendy's tracing.

I wanted to build on the progress that the teacher made simply by adding the melody back to the instructions for writing the number four. I had observed that Wendy was successful with larger gross motor movements and so suggested that we use a white board to write the number as we sang the song. Wendy was able to sing and draw the number 4 several times on the white board as I sang along with her. Her numbers were messy since she did not have reference points to trace over, but she clearly drew the number 4 without assistance and was fully engaged in the activity.

In Wendy's case, melody and scale were the key elements to enabling her success. She had been observed to respond to some elements of rhythm during chanting and counting activities in group activities, but she was unable to resist singing and moving to music when the melody was added during songs. I believe that by starting out with her drawing large numbers and gradually decreasing the size of her motions to write smaller characters that she will be successful in writing numbers with her pencil on paper. Singing may further enhance this process if the singing is louder for the large drawing on the white board and gradually softer for writing smaller characters.

Sing...sing...sing for success!

Sunday, December 2, 2007

FAQ: Suggestions for Sedative Relaxation Music

I am frequently asked about how to use music for relaxation. One of the most effective types of music for relaxation is classified as sedative. Sedative music is defined in part by having a fairly slow underlying tempo or pulse, around or below 80 beats per minute. The melody should be free of sudden jumps in pitch and without extreme high or low notes. The overall effect of the song should not be distracting, but still have aesthetic value.

Sedative music can be difficult to find on one album or in a single collection of songs. The proliferation of digital music, however, has made it much easier to separate sedative music from a collection and place it with other music for the purpose of relaxing. I have compiled a list of some music that can be considered sedative. The music can be used in any order and it is important that any music that will be used for relaxation be something related to personal preference. This list is not all inclusive and is limited in genre. There is much music available that can be effectively used for relaxation and the following examples may prove helpful.

Classical:

  1. Nicamer Zabaleta: Concerto for the Harp and Orchestra in G major
  2. Mozart: Adagio, Sonata in E-flat
  3. Henry Purcell: Adagio from the Fairy Queen
  4. Mozart: Andante K. 525
  5. JS Bach: Air on a G String
  6. Mozart: Concerto for Clarinet and Orchestra in A
  7. Brahms: Lullaby, Cradle Song, Opus 49
  8. JS Bach: Arioso in F
  9. JS Bach: Concerto in D minor, Siciliano
  10. Schumann: Scenes from Childhood, Foreign Lands and People

New Age:

  1. Seasons: Sisters of Paradise, Guitar and Chamber Nouveau, Steven Pasero
  2. Seasons: Silhouettes of Dawn
  3. Rocky Mountain High: John Denver, Winter – Spring
  4. Watermark: Enya, Watermark
  5. Picture This: Jim Brickman, Sweet Dreams
  6. Forest: George Winston, Walking on Air
  7. Winter Solstice: Snow in the Prairies
  8. Red River Crossing: Marshall Styler, Red River Crossing
  9. Red River Crossing: Marshall Styler, Ballad of Brenham Road
  10. Reflections of Passion: Yanni, A Word in Private

Friday, November 30, 2007

Schoolhouse Strategy: Drum Circles for the Special Needs Classroom


Drum circles offer a sense of independence within a community situation. A typical drum circle usually involves a variety of instrument sounds including different sized drums, shakers and bells. The participants play their instruments, dance and even sing around a central drum facilitator. Sometimes a large drum may provide a steady underlying pulse for the group to build upon, but other times the group plays to whatever rhythm develops, changing as the drumming continues.

A drum circle depends on the ability of the participants to play a steady beat or respond to the musical dynamic with a part that fits into the musical experience. A few people off the beat or not able to follow the directions of the leader will not disrupt the cohesion of the musical product. In a classroom with children with special needs it is still possible, however, to use a drum circle effectively for a group activity. The following strategies may be helpful for successful drumming with children who have disabilities.

1. Establish a strong beat. You may want to use an audio recording in the background to provide a steady pulse and supportive drum circle atmosphere. It is important to have a pleasing musical product in order to encourage participation by the children. Some good recordings are found on Christine Stevens, The Healing Drum Kit or Sweet Honey In the Rock, Still the Same Me. Christine Stevens has recorded drum circle tracks specifically to be played as a background for an individual or small group drumming experience. The CD from Sweet Honey In the Rock has recordings of traditional African drumming. Another way to establish a pulse for the drum circle is to use a large paddle drum or gathering drum to play a steady, consistent beat that is solid enough to be heard and felt during the group drumming.

2. Vary the instrumentation. A drum circle does not require a majority of drums. The circle activity will become too loud and lack variety. Use at least three different timbres in the drum circle. Different instruments will appeal to individual children and the drum circle facilitator will have flexibility in having different timbre groups play.

3. Have a drum circle facilitator. The facilitator is key to the successful drum circle. Children with disabilities can learn to start and stop a drum circle using gestures. A four count start or stop is a good way to practice this. They can also direct the group to get louder and softer or have selected groups of instruments play. Adaptations can be made to help the children be facilitators by giving them adaptive technology such as "Big Mac" switches for verbal commands to start and stop. The drum circle facilitator may also be the "DJ" and operate the audio recording to guide the drumming experience.

The drum circle allows for much creativity and exploration. Concentrate on non-verbal communication skills that go along with objectives from Individual Education Plans. Focus of attention, imitation and following directions are all skills that will naturally occur during group drumming. Encourage the drumming to continue for several minutes at a time before doing starts and stops. This will allow the players to entrain their playing with the beat of the pulse. The entrainment effect happens naturally over time as a steady beat is played.

1..2..3...Drum!

Wednesday, November 28, 2007

Relaxation Strategies for Pre-operative Settings

Surgery pre-op. Blank walls, metal and tubes. Bright lights and cold air. People come and go with the urgency of holiday shopping, providing cursory nods and perfunctory statements to the people on beds blocking their way. Certainly it is not always like this, but in general, the pre-surgery holding area is very lonely, with different professionals visiting you intermittently to take vital signs, blood or signatures. The environment is well formed for nurturing anxiety.

The prospect of surgery usually presents patients with an array of feelings and worries. These anxieties are counterproductive to maintaining the calm and positive state of mind that is beneficial for successful recovery after an operation. I have had the opportunity to assist patients in several different pre-operative settings to help them cope with the stress of their situation. Through these experiences, I have discovered some simple strategies that can be used by patients and their caregivers to help them relax directly before surgery.

1. Pre-op partner - Obtain permission for someone to stay with you in the pre-op area and, if possible, all the way into the operating room. This partner can offer silent companionship or conversation depending on how you feel. In my experience, some people become very talkative as they are nervous while there are others who just wish for me to hold their hand. A pre-op partner can be very helpful in distracting you from the sights and sounds of the pre-op area and focusing your attention on other subjects. A partner can also be helpful in facilitating deep breathing or relaxation routines. If the partner is allowed to go into the operating room, he or she can be responsible for collecting music recordings or personal effects that were helpful during relaxing in the pre-op area. On many occasions I have been able to stay with a patient until they are fully under anesthesia in the operating room. Family members are usually not allowed in pre-op after a certain time. Suggested candidates for a pre-op partner are a music therapist, clergy or patient services representative that work at the medical facility. The best way to obtain permission for someone to be with you is to ask the surgeon. The surgeons usually have authority over the operating room procedures and can smooth the way for you to talk with nursing staff about the possibilities.

2. Music - Bring an MP3 or CD player and your favorite music. Music may be used to distract you from the activity in the pre-op room. The music will serve to mask environmental noises and help you focus your attention on something other than needle sticks and blood pressure monitors. Consider using your preferred music, whether you are trying to facilitate relaxation or provide distraction. Preferred music will hold your attention better than trying to use music that you have never heard or that is unappealing. The advantage to using an MP3 player is that you can bring both sedative and preferred upbeat music. I have found that many people cannot start out with sedative music right away. It takes time to adjust your mood and stress level. I recommend that you start with preferred music with a moderate beat and intensity and then gradually change to more relaxing music. In this way you will be able to help yourself move in the preferred direction to a less anxious state.

3. Relaxation methods - Use breathing to induce a more relaxed state. Close your eyes and allow yourself to breathe normally, focusing on breathing in through your nose and out through your mouth. After your breathing has fallen into a natural rhythm, begin elongating the cycle by counting slowly to four on each inhale and exhale. Gradually count to higher numbers so that you have a deep breath happening on eight counts in and eight counts out. Once your breathing has slowed, begin relaxing muscle groups from your head to your feet by tensing and releasing one by one. Begin with your facial muscles by scrunching them up, holding for a moment, and then releasing. Feel the tension melt away and notice the difference in feeling between tense and relaxed states. As you work your way through a progressive muscle relaxation, be sure to drop your jaw so that it hangs loose and your tongue feels heavy and relaxed. If you are able to have a music therapist with you as a pre-op partner, then consider allowing the therapist to facilitate guided imagery to your music listening. Even without a music therapist you can imagine a peaceful place with pleasant scents and attractive sights and sounds.

Monday, November 26, 2007

Schoolhouse Rock: Ten Great Ways to Use a Gathering Drum



My Remo gathering drum almost always travels with me from school to school as I see clients for music therapy. The gathering drum is a wonderful tool that can be used as an instrument, but also in many non-traditional ways. A small gathering drum about 8 inches tall and 22 inches in diameter is a good size for working with an individual student or a small group of younger children. Remo gathering drums are made of synthetic materials which are less affected by changes in weather. My Remo gathering drum has proven to be very resilient and continues to make a nice drum sound after seven years of heavy use. Here are my top 10 recommendations, in no particular order, for using a gathering drum:

1. Thunderstorm - Create a rainstorm that comes and goes using soft body percussion such as snapping and clapping. As the rainstorm moves closer the gathering drum can be played with fingertips and then gradually played with the entire hand to create heavy rain and thunder sounds. I add even greater thunder effect by using a Thunder Tube, also made by Remo.

2. Fishing - Turn the gathering drum over so that it creates a "pond" for paper or toy fish. I use the pond to fish for songs, numbers or alphabet letters. You can sing the song, "You Get a Line, I'll Get a Pole," and provide water sounds with an Ocean Drum.

3. Group drumming - Gather up to 4 children around the drum for songs such as, "The Ants Go Marching In." Use the surface of the drum to facilitate learning about personal space, sharing, taking turns and cooperation.

4. Reward - The gathering drum is visually impressive. I have found that many children will pay attention to the sound and sight of the gathering drum in significant ways. The drum can be used as a reward object earned throughout the day or as a positive reinforcer for demonstrating waiting and focus of attention skills.

5. Big and little - The gathering drum naturally fills the requirement for being large. Other smaller drums can be used to illustrate opposites for size or sound.

6. Heartbeat - Play a steady beat on the drum and use it to set the pulse for a group drum circle with the other children playing smaller drums, shakers and bells.

7. Create a circle - I have often used the gathering drum to help small groups create a circle. Circles are sometimes difficult for kids to establish and maintain, even with something drawn on the floor. The drum acts as a natural obstacle for dancing or marching around it in a circle. I like to use songs like Hap Palmer's, "Marching Around the Alphabet," and place letters of the alphabet on the drum head for the children to pick up when they come to a stop.

8. Sensory integration - The gathering drum can be very appealing to children who are sensory defensive. These children may not actively drum, but they will often place their hands on the surface of the drum to feel the vibrations. For some children, the desire to feel the vibrations may outweigh defensiveness about the smooth texture of the drum head.

9. Attention - Use drum mallets to play the drum and immediately obtain attention. This will work very well if you also play the drum with a recognizable two-beat rhythm. Teachers commonly do this by clapping a rhythm and having the class clap a simple response. The gathering drum offers a unique timbre as well as volume in order to naturally draw attention.

10. Umbrella - This may be the most unique use for the gathering drum, but there have been times when I have been thankful for the large covering surface as I go to and from my car in bad weather. The advantage to using a Remo gathering drum for this purpose is that it is virtually unaffected by rain, snow, heat or cold!

Ready...set...drum!

Sunday, November 18, 2007

Schoolhouse Story: Bobby and the Ladybug

I never cease to be amazed at the power of music to reach out and communicate with children with disabilities. Recently I conducted a music therapy assessment with a second grade student with autism who I will refer to as "Bobby" for the purpose of this article. Bobby had received music therapy before, but was withdrawn from services in order to spend more time in the general education classroom. As he moved into the second grade this year, his stereotypic behaviors (i.e., hand flapping, rocking and perseverative vocalizations) increased and diminished his ability to participate and keep pace with his peers. One of Bobby's teachers noticed that Bobby reduced his stereotypic behaviors and provided better eye contact during songs and activities used in routine group instruction times. A music therapy assessment was requested to evaluate the possibility of developing specialized music activities to help Bobby make progress on his Individual Education Plan objectives.

I observed Bobby working in the classroom during his regular work tasks such as writing, coloring and cutting. He required one to one supervision by the teacher in order to perform his work. He was not providing eye contact to the teacher and only spent a few seconds at a time doing his work even when prompted continually by his teacher. She used verbal prompts, gestural cues and some hand over hand help to encourage and guide Bobby in his work. Bobby often became agitated and upset as demonstrated by his yelling, hitting himself or stabbing the wall with a pencil.

I began the music session with a familiar "Hello" song that Bobby immediately seemed to remember from over one and a half years ago. He had actually started singing the song to me before I had even taken my guitar out of the case. He sang the melody and used my name in the song. He was also able to calm his hand flapping and provide direct eye gaze focus to me and the guitar I was using. As long as the music stimuli continued Bobby did not exhibit his hand flapping and rocking behaviors. He also remained focused on the activities without verbal prompts or physical redirection.

One of the most impressive moments was when Bobby used a song to point to and count spots on a picture of a ladybug. Bobby had not been willing to count the spots before the song was introduced, even with hand over hand prompts. He was not focusing his attention and was actively engaged in hand flapping. Bobby calmed his behaviors as I began singing the song and he was able to pat his knees in rhythm to the music by the time two spots had been added to the picture of the ladybug. The Ladybug song repeats as a new spot is added each time for up to ten spots. Bobby learned the song very quickly so that after only two spots he was adding spots and counting them independently! As each spot was added, Bobby counted the spots by singing up a major scale, one note for each number counted.

Bobby's responses may seem miraculous, but there are reasons behind his success. The music provided stimuli and structure that helped him to calm his stereotypic behaviors and engage his cognitive functioning. I believe that in many cases, the music serves as an auditory stimuli to replace the need for hand flapping, rocking and other behaviors. Fortunately, music is an appropriate stimulus when used in a controlled setting. Once Bobby was focused on the music, he was able to respond to the rhythm and melody of the song to help him maintain interaction through the activity. The melody, rhythms and harmonic structure in the song helped him to provide verbal and physical responses in a predictable sequence. As he was counting, for example, the steady beat of the music helped Bobby to point to each spot without going too fast or slow. The ascending melodic scale provided direction and harmonic urgency to move to each successive note in the scale while he was singing and counting.

Children with autism often have the desire to make sure that events, verbal phrases and in this case, music, are complete and not open-ended. Once the repeating lyric and melodic lines of a song are established, the child with autism may be compelled to continue an activity to its completion. In this case, the visual representation of the ladybug was also incomplete with only a few spots. Bobby was likely compelled to follow through with placing all of the spots so that the picture could be finished.

The song was intrinsically ordered with a beginning and end and repeating lyric refrain. The only new words for each verse of the song were new numbers as Bobby counted more spots each time. As he sang more numbers each time through the song he also ended up on a different note in the musical scale. Many of the notes in a musical scale may feel less satisfactory to end up on without moving on to a more harmonically stable note in the scale. In this way, a singer is compelled to a sense of forward motion. This motivation may have appealed to Bobby and helped his desire to move on to each successive verse in the song. Bobby was ultimately able to count up to nine spots without help during the Ladybug song.

Bobby continued through the assessment to demonstrate behaviors that illustrated the power of music to help him interact with the world around him. He beautifully provided another example of a situation where music makes sense.

Friday, November 16, 2007

FAQ: What happens in a music therapy assessment?

I am often asked this question several times a month by teachers and parents. They have children in school with disabilities who have been recommended for a music therapy evaluation, but many of them have not been exposed to music therapy and sometimes do not even know that it exists, especially in their school district. I have always been happy to give them a brief description of what I do when I come to see their child for the music therapy assessment.

Music therapy assessments take many different forms and may include different elements depending on the therapeutic setting. Music therapy in the public schools, for example, is partially governed by state and federal guidelines. It is considered a related service and a music therapist is part of a team of teachers and therapists who work with a student according to an Individual Education Plan (IEP). An Admission, Review, and Dismissal (ARD) committee must obtain consent from the parent or guardian to ask for a music therapy assessment in order to begin the process.

Music therapy assessment procedures will vary between types of client populations, but there are several key areas that should be considered when conducting any music therapy assessment. An assessment should include a review of the client history, including origin of disabilities, medical or psychosocial issues, current therapeutic strategies and existing goals. The assessment will also gather remarks and observations from teachers, staff, and parents about how they have seen the student respond to music at school or at home. The majority of an assessment should be comprised of a comparison between client responses during music and during regular activities that do not normally include music.

Music therapy assessments in the public school setting require that the evaluator look for significant or unique differences in client performance on specific objectives as described in their IEP. I explain to teachers and parents that the assessment should take place in the client's main classroom or wherever therapy would be conducted. The assessment process including consulting with staff, observation of the client in the classroom, and music activities usually takes from one to two hours. In order to accurately assess a client's responses to the specially developed music activities, the therapist will choose several specific areas of need as described by teachers, parents and the IEP objectives to address during the assessment.

The music therapist should try and observe the client working in the classroom through several different activities. During this time, the therapist can obtain an overall sense of how the client participates with peers and interacts with teachers and work tasks. The therapist will be looking for patterns in expressive and receptive communication, general ability to focus attention and follow directions, and some indication of academic abilities. The client should also be observed working on specific IEP objectives so that data may be collected and used for comparison with data gathered from work during music therapy activities.

The music therapist will conduct a music therapy session with the client that will last twenty to thirty minutes. During this time, the therapist will typically use an acoustic guitar as the primary accompaniment instrument unless a piano or other client preferred instrument are available and more appropriate. Other instruments such as hand drums, shakers, and bells are used throughout the session as both accompaniment and for active engagement with the client. Age appropriate songs and music activities with supportive visual aids will be used to address specific IEP objectives. The music therapy session may be structured similarly to other music therapy sessions which include an opening and closing song along with the specific music activities that were chosen to address the student's IEP objectives. A comparison will be made between the student's behavior and performance in the non-musical setting and the structured music activities. The comparison of data will then determine the significance and/or uniqueness of music strategies in helping the student to make progress on targeted IEP objectives.

This outlines a music therapy assessment process for a child in the public school. The conclusion of the assessment will result in an official recommendation to the ARD committee explaining how the client does or does not require music therapy services in order to make adequate progress on IEP objectives. The ARD committee must take the recommendation under consideration and decide upon the implementation of services and, if approving music therapy, determine the amount of time the student will receive therapy.

Tuesday, November 13, 2007

Book Review: Therapeutic Uses of Music with Older Adults, by Alicia Ann Clair

Alicia Ann Clair, Ph.D., MT-BC wrote this foundational book while she was a professor at the University of Kansas. I have always valued this book as a good source for non music therapists who want to use music in their lives or for those they care for. Although the setting for Dr. Clair's discussion is based around using music therapeutically with older adults, the principles of music she outlines can be applied in many other settings.

The first chapter of the book outlines the elements of music that are useful for therapeutic intervention. Dr. Clair identifies concepts such as music used for a focus of attention and music used to structure events and activities over time. She expertly defines the ways in which music can facilitate therapy without becoming overly technical.

For those not working with older adults, a highlight of the book is the chapter discussing stress-management. Dr. Clair discusses strategies for relaxation, including progressive muscle relaxation, jaw-drop technique and guided imagery. She adeptly explains how music may be used to facilitate these techniques as well as the elements of music that are useful in relaxation protocols.

I highly recommend this book to everyone interested in how music works in our lives. We all have an idea about how music effects our lives, but Dr. Clair breaks down the parts of music in a well thought out discussion using descriptions that are easy to read and understand. This book is an excellent example of how "music makes sense" in our lives and in our world.

(Amazon.com: Therapeutic Uses of Music with Older Adults)

Monday, November 12, 2007

Nuts and Bolts: How Music Works for Relaxation

Most people intuitively understand that music can play a powerful role in helping set the mood or reflecting our current state of feeling. Understanding some of the ways music accomplishes this will enable us to use music as a tool. Music as a tool to facilitate relaxation is effective for several definable reasons. I would like to outline some of these basic properties and functions of music as it is used to aid in relaxation.

In our fast-paced world finding time for relaxing has become a major priority. Sometimes we only have a small window of opportunity to try and wind down or take a short break. Music can help by facilitating induction to relaxation. Just as our attention is immediately turned towards finding the flag when we hear the National Anthem being played, selected music can shift our attention of focus away from the hustle and bustle and towards the purpose of relaxing. As our focus changes to listen to the music, the rhythm of the music begins to establish parameters for our breathing. Breathing is a major component for any relaxation protocol and one of the first things that we can control in trying to begin relaxing. Music may also begin to effect changes in the autonomic body systems including heart rate and blood pressure. Over time and practice, selected music can become a cue for relaxation, a conditioned stimulus that sets the mind and body onto a course for relaxation.

Once the direction has been established in inducing relaxation, music has an important role in maintaining the setting for relaxation to continue. The music holds the focus of attention and may mask unwanted environmental sounds. Appropriate music selections will assist in slowing breathing and taking deep breaths. The rhythm and constant underlying pulse of sedative music selections are mental guidelines for breathing and progressively relaxing each part of the body. Heart rate and other indicators should remain steady and at a reduced count, especially as repeated practice with the same or similar music has established a conditioned response. The music, especially a well chosen melody, may also lead to positive emotional associations and allow for feelings of self-worth and affirmations.

Music to help in relaxation is best used when combined with other relaxation methods and protocols. As previously outlined, music is a good cue for relaxation and framework for maintaining a relaxed state for a defined period of time. Techniques such as progressive muscle relaxation, deep breathing, circular breathing, imagery or biofeedback are extremely effective when used in conjunction with music. Experiment with different tempos, rhythms and melodies to gain the full advantage of using music to help structure the relaxation experience. An ascending and then descending melodic scale may lend itself to deep breathing, for example. Some melodies and instrumental arrangements can help set the stage for painting a mental picture of a beautiful nature scene where worries and stress can melt away.

Practice makes perfect!

Thursday, November 8, 2007

Rock-a-bye Baby...A Guide to Sedative Music

Confusion abounds about what kind of music to use to aid in relaxation! I generally suggest using your preferred, sedative music. Finding your preferred music is not difficult, but finding sedative music that you like and music that is truly sedative will take some consideration. Relaxation will be much easier with a combination of sedative music that you enjoy.

Truly sedative music can be found by examining the rhythm, tempo, melody and dynamics in a given selection. Although these elements may change throughout a musical piece, the overall impression of each element should be similar, without abrupt changes or dramatic differences across the whole song. The tempo for sedative music is generally agreed upon to be between 60 to 80 beats per minute. The underlying rhythm and pulse at this tempo should be constant, without speeding up or slowing down. A repeating melodic pattern over this foundation is another key element. The melody can vary some for beauty and taste, but it should not contain unusually high or low notes and sudden changes in articulation, syncopation or untraditional leaps in pitch. The dynamics throughout the musical selection should be gently rising and falling, without dramatic swells or significantly soft or loud passages.

Beautiful music does exist within these parameters. Although music with these characteristics is usually a smaller section of a larger work or perhaps one song from an album of other selections that do not fit the requirements to be sedative music. The advent of Windows Media and other music file players has made things much easier in collecting an appropriate assortment of sedative music selections to use effectively in facilitating relaxation. While an entire symphony may not be a good choice, it is now possible to extract an appropriate Adagio section from a symphony and pair it with other sedative music selections in preparation for relaxing. Special care should be taken when using Adagio sections from symphonies since they are often written in minor keys with a melancholy mood. I suggest that the sedative music be chosen for its ability to uplift the spirit and create a sense of light and beauty. Two Adagio sections that work well are from Mozart's Sonata in E-flat and Henry Purcell's Adagio from the Fairy Queen. New Age artists such as Enya, Jim Brickman, George Winston and Yanni also have a variety of songs that fit into the category of sedative music.

So, find some sedative music that you like, turn off the phone, find a comfortable place to recline and take a deep breath...exhale slowly...

Wednesday, November 7, 2007

Schoolhouse Strategy: Picture schedules

I work in many classrooms where picture schedules are used to help the students transition between activities throughout the day. Picture schedules are especially effective in helping students with autism spectrum disorders. I was talking with a teacher today, however, who was unsuccessful in convincing a regular education teacher to implement a picture schedule for a student during "inclusion" time in her class. Although most teachers in special education understand the value of using picture schedules when appropriate, I have been surprised in my visits to literally hundreds of different classrooms that picture schedules are not used more frequently to help small group activities run more smoothly.

As a music therapist I depend on the power of songs and music activities to structure events and actions across time. Typical songs have a beginning and end that act as placeholders in time, while the rhythm and tempo of a song may be considered the ticking of time as it passes. Familiar songs can therefore provide a predictable framework that helps students with disabilities to pace themselves. Students with autism, for example, can better understand what is expected through these musical cues so that they can focus their attention and manage their behaviors for a predictable amount of time.

The intrinsic power of songs and music activities to provide structure minimizes the amount of undesirable behavior that occurs during a music therapy session. I have found, however, that using a picture schedule in certain instances has helped tremendously during transitions between songs as well as providing visual cues for appropriate behavior during songs and activities. I often employ a picture schedule comprised of seven to ten pictures that represent each song or activity in the session. In my experience, the clients are able to learn the schedule after only a few sessions. Although some of the songs change from week to week, the pictures remain the same, so the students know at any given time where they are in the session time line and what is expected of them. As a supervisor, I have frequently suggested to my therapists that they begin using a picture schedule to help some of their sessions run more smoothly. They have often been amazed at how effective such a simple tool can be.

One final note on the subject would be that I advise using pictures with word labels. Social stories, for example, are often very effective in helping children with autism to pattern a behavior. There is power in reading a word. The word-picture combination is a more effective format for the picture schedule.

Monday, November 5, 2007

Music for the Heart: Instructions for self-guided relaxation


I have developed a program that I call, Music for the Heart. This program is centered around helping people who have had heart trouble or other cardiac related problems. The participants learn to use music as one of the tools to change their lifestyle in order to avoid future medical problems.

There is much new research about the role of mood and stress as it relates to recurrent heart attacks. Music is one tool that may help heart patients to manage stress and elevate their mood. I use a very simple set of instructions that I send home with clients after practicing relaxation techniques. There are many ways to use music to facilitate relaxation and this is just one example:




1. Find a place free of distraction from family, phones, etc.

2. Lie in bed or sit in a comfortable chair

3. Dim the lights and turn off the television

4. Turn on your preferred, soothing music

As you lie or sit quietly, begin to focus on your breathing. Naturally, your breath will slow down as you begin to focus on your exhales. As your breath slows down, let the weight of your body sink into the chair or bed. As you begin to feel more relaxed, imagine that you are riding down an escalator. At the bottom of the escalator is one of your favorite places in nature.

Imagine that you are walking around in this favorite place and notice all of the colors, sounds, and smells of your surroundings. Enjoy this place and the feelings of relaxation it brings you. You are moving freely and breathing easy in this place. Continue to relax and enjoy the music for a time. It is okay if you fall asleep. In fact, you may use this technique to help you fall asleep. When you are ready to return from this imagined place, slowly move your fingers and toes and return to an upright position.


Shoptalk: Assessment of Music Skills and Responses

The process for music therapy assessments has not been standardized, although it includes certain basic elements. One of the basic elements in a music therapy assessment is to try and ascertain if a client has certain unprompted responses to musical elements. Some assessment procedures also include levels of response to music based on the number and type of verbal, visual and physical prompts. This information is helpful since many clients do not have many unprompted behaviors and so may qualify for music therapy services based on a difference in the number of prompts or self-initiated behaviors between music activities and non-music activities. I feel that it is important, however, to evaluate the power of music without prompts so that it can be argued very clearly that music stimuli alone is having an effect.

Music therapy in the public school setting, for example, requires that in order for a client to receive music therapy there must be a demonstrated effect of music to help the client achieve educational objectives. Over time, I have adapted from other assessment templates some groupings of music that I consider when evaluating a client for music therapy services. For each song or activity, I record my observations with a simple "yes" or "no" if the client exhibited responses without non-musical prompts.

Song/Activity:

Code


Code

Singing

Vocalizes by:


Listening


Humming


Alerts to sound


Whispering


Attends to sound


Speaking


Responds/differentiates to dynamics


Singing on Sounds/Syllables


Responds/differentiates to timbres


Imitates


Follows one step lyric directions


Sings on Pitch


Follows two step lyric directions


Sings off pitch, but follows melodic

pitch contour.


Responses to Musical Structure


Sings 2(+) note melodic phrases


Takes turns in call and response

exchanges


Indicates song preferences


Responds to pauses in songs


Melody


Uses rhyming words


Motivated to complete melody


Motivated to complete chord/rhythmic

cadence


Sings up/down a musical scale


Starts and stops to sound cues


Remembers lyrics with melody


Responds to 7th chords, suspensions to

resolutions


Rhythm


Supplies sequential information


Maintains basic beat


Social Skills


Imitates 2 beat rhythm


Engages with adult during musical play


Responds to changes in tempo


Engages with peers during musical play


Moves body to rhythm


Maintains appropriate eye contact


Completes rhythmic sequence


Imitates gestures


Instrument Playing




Indicates instrument preference




Plays instruments appropriately




Plays instruments in rhythm with accompaniment





After each activity is scored, the data may be compiled for all the activities to give an idea of what music elements are most effective. The more unprompted responses, the greater likelihood that the client will respond to specially developed music activities. The unprompted responses also indicate that certain music stimuli are unique in aiding the function of the client. My template is still a work in progress, but I invite other therapists to comment about the idea.

Sunday, November 4, 2007

Research: Review: Effect of Music on State Anxiety Scores in Patients Undergoing Fiberoptic Bronchoscopy

I recently read the following article as I was looking through research, "Effect of Music on State Anxiety Scores in Patients Undergoing Fiberoptic Bronchoscopy," by Henri G. Colt, MD, FCCP; Anne Powers, NP and Thomas G. Shanks, MPH. I think that the research study was well organized and the researchers earnest in their attempt to discover the effects of music on anxiety, but they did not consider the power of preferred music in their development of the study.

The researchers looked at sixty patients divided into two equal groups. Each patient wore headphones that played music or nothing at all during a bronchoscopy procedure. The study did not find a statistically significant difference in pre and post STAI anxiety scores between the experimental and control group. This is not surprising since the research protocol did not use any method to deliver preferred music styles to each patient and limited the music to piano music from one recording. Although the music used was slow in tempo, sixty beats per minute, there was no other attempt to classify and present "sedative" music.

The researchers admitted that they did not use preferred music and stated that it would have required a much larger population sample in order to add preferred music as a variable. They erroneously wrote that using preferred music, "...
could have changed the focus of the trial to addressing what type of music is effective, rather than answering the more straightforward question of whether or not music reduces FFB-related state anxiety." They continued their argument that further studies would be unnecessary and concluded that music would primarily be beneficial in waiting rooms and procedure suites as a way to "soften" the atmosphere.

I think it is unfortunate that so much time and effort, as well as professional prestige were used for this study since it sends the incorrect message that music is not effective in helping patients cope with anxiety during surgeries and painful procedures. Preferred music is a key element in using relaxation to reduce anxiety. Sometimes the music does not even need to be "sedative" in nature if the preferred music is effective in distracting the patient from pain or environmental factors. Music alone is not a proven aid to helping reduce anxiety, but combined with other relaxation techniques such as progressive muscle relaxation or imagery it can be very powerful. I urge medical professionals and music therapists to continue the research in using music to help alleviate anxiety with the hope that larger studies can be developed to address all the variables.

Saturday, November 3, 2007

Shoptalk: Staying in Tune

Music therapists working in the public school setting often see up to eight individuals or groups in one day. This type of schedule requires therapists to build up their physical and vocal stamina and use some tips to help them reduce the the physical strain, especially on their voices. I have a list of strategies that I share with the music therapists I supervise to help them maintain vocal and physical health. These tips are not new, but are easily forgotten in the day to day routine without reminders:

1. Maintain good posture: Try not to hunch over the guitar or lean on it for support. If you are standing up and wearing a guitar strap be very careful to stand up straight.
2. Practice good breath support: Activities during a music therapy session can move very fast and you need to take time to breathe.
3. Sing in the middle to higher part of your vocal range: For example, I am a tenor, so I usually capo up three frets on the guitar if I am playing in the key of D. Please stay aware, however, of the vocal range of your clients and try to find a happy medium so that you are all able to sing comfortably.
4. Use folder activities while singing a cappella: This provides some nice variety in a session and allows your hands to be free to help clients or perform actions to music. You can do clapping, snapping or other body percussion to jazz up the songs. Folder activities help you to vary your seating position since you can put the guitar down and stretch or stand up and move around.
5. Use your fingers to strum or pick the guitar. I suggest not using a guitar pick to help reduce the chance of vocal strain from trying to sing over a loud guitar sound.
6. Talk using a light voice with varying pitch. Do not talk in a monotone voice or in a low range with a "gravelly" tone. My voice teacher advised me to try and talk with a raised soft pallet, a little like the secretary on the Beverly Hillbillies. It is not necessary to sound silly, but talking can be very stressful on the vocal chords without proper attention to how you talk throughout the day.
7. Employ strategic group management. If you have 7-8 clients ins a group, do not try and talk over them if they are all playing instruments. I suggest providing instrument choices from quieter instruments or controlling the group as much as possible through gestures or other non-verbal cues.
8. Warm up! Use time in the car to sing and do your favorite vocal exercises. This can be especially helpful in the morning before the first music therapy session.
9. Drink plenty of water throughout the day!

Friday, November 2, 2007

Research: Title Page: The Effect of Preferred Sedative Music on the Anxiety of Patients During Pacemaker Implant Surgery and Heart Catheterization

The Effect of Preferred Sedative Music on the Anxiety of Patients During Pacemaker Implant Surgery and Heart Catheterization

by

Daniel B. Tague

B. A., Texas Tech University, 1994

Submitted to the Department of Music and Dance

and the Faculty of the Graduate School

of the University of Kansas

in partial fulfillment of the requirements for the degree of Master of Music Education (Music Therapy)

Thesis Committee:

_________________________

Chair

_________________________

_________________________

May, 2000

Date Defended

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