Music therapy for children with severe and profound multiple disabilities: a review of literature. - Buffalo, NY

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The purpose of this literature review is to identify goals andmethods of music therapy for children with severe and profound multipledisabilities, and to clarify the various orientations used byclinicians. The general goals described have been identified bydifferent music therapists and chosen for their representativeness andbreadth of application. The orientations which clinicians take in theirwork with these children are described according to the practicesoutlined by Bruscia (1989).

While many examples from the literature for adults with severe and
profound multiple disabilities are also relevant for children, they have
not been included in this review because of the school age focus
(approximately 3 to 18 years). As such, this includes the work of Wigram
(1988), Hughes (1995) and Schalkwijk (1994), among others. Further,
while much of the music therapy literature for children with autism shares similarities in orientation, goal(s) and methods, it has also not
been included unless there is a clear indication that the author is
referring to work with children who are severely or profoundly multiply

Identifying the Population

Children who are severely and profoundly multiply disabled have a
combination of physical and intellectual difficulties which, although
caused by similar conditions, create unique qualities and
characteristics. These disabilities generally lead to severe limitations
of movement, communication and socialization. Such children may require
total care and be medically at risk. Epilepsy is common, and often not
completely controlled by medication (Orelove and Sobsey, 1991). These
children may have other impairments, such as hearing and vision loss.
They vary considerably in their ability to understand and communicate
information. Some use simple language or symbolic communication (such as
gestures or picture symbols) while others may be unable to communicate
needs or responses effectively. Their physical abilities also vary
considerably, from well developed fine motor skills such as reaching or
grasping, to a complete lack of independent physical movement. Sometimes
these children will be unable to comprehend or adapt to unfamiliar
environments and events, and this may cause difficulty in transitions,
particularly from familiar to unfamiliar environments. Similarly, these
children may not show recognition of familiar people, including family,
teachers and therapists.

In educational settings, the needs of each child are generallyoutlined in an Individual Educational Program (I.E.P.) wherein goals areset by parents, educators, therapists and care staff. These goals areusually organized in areas such as auditory, visual, tactile,perceptual, sensori-motor, communication, cognitive, social andemotional development, and are then addressed by various disciplines(Boxill, 1989). Alley (1979), Codding (1988) and Jellison (1988) havereviewed various ways in which music therapy interventions haveaddressed the needs of people with disabilities, and this also includeschildren with severe and profound multiple disabilities.

General Music Therapy Goals

A number of interrelated goals have been identified by music
therapists working with these children. These general goals may
singularly, or in combination, provide the focus of a program.

The first and most primary goal is fulfilling the child's
basic needs. For Alvin (1976), this involved creating an emotionally
stable and predictable environment that fostered feelings of security,
love and acceptance along with finding ways of self expression. She felt
that only then could the child relate and develop. For Nordoff and
Robbins (1971, 1977, 1983), fulfilling the child's basic needs
involves 'meeting the child musically', where the therapist
matches the child's inner condition with the music. As Bruscia
(1987 p.46) has indicated, this serves three main functions: to create
an accepting, responsive environment; to make musical contact with the
child; and to build trust and lessen resistiveness.

The second goal found throughout the literature is developing the
child's sense of self. Alvin (1976) discussed this in terms of
"relating self to objects" (Bruscia, 1987 p.91), where the
main aim was to enable the child to develop relationships with
instruments, music, and the therapist. "In order to form these
relationships, developmental growth must take place in the physical,
intellectual, and social-emotional domains" (Bruscia, 1987 p.91).
For Nordoff and Robbins (1971; 1977; 1983), self-image is built by
developing exploration and creativity. This is fostered by supporting
the child's music making, acknowledging, and developing the inner
"music child". Boxill (1985) discusses self image as built
through a cycle or continuum of awareness, where the therapist
approaches treatment with "a view to awakening, heightening, and
expanding [the child's] awareness" (Boxill, 1985, p. 75). Two
main strategies are used: reflection, a mirroring technique; and
identification, a musical representation of the client and therapist.

The third general music therapy goal is establishing orre-establishing interpersonal relationships (1). For Boxill (1985;1989), this meant developing the child's ability to understand andbe understood by others through verbal and non-verbal means, whererelationships may develop between the child, therapist or other person,or child's, therapist's or other person's music.Typically, this is developed through the contact song (Boxill, 1985,p.80), an improvised or composed song which serves to affirm thetherapeutic relationship, and enable interaction. Nordoff and Robbins(1983) felt that developing interpersonal relationships was achieved bydeveloping expressive freedom, where musical options brought aboutincreased possibilities for interaction and the realization that musiccan be "interresponsive". Alvin (1976) discussed this generalgoal as a two fold process: firstly, by establishing a relationship withthe music therapist through self awareness and exploration, andsecondly, by transferring the model of the therapeutic relationship tosignificant relationships in the child's life (for example,parents, siblings, peers) outside the immediate therapy environment.Agrotou (1993) felt that one way interpersonal relationships wereestablished and developed was through ritualized play, the"creative rhythmical formalisation of certain patterns ofinteraction" (Agrotou, 1993 p. 183). The basic qualities of thisplay are as follows: that each player's output is regular in lengthand falls into a predictable regularity of tempo; and that eachplayer's contribution is called a turn and that a pair of turnsconstitutes a round, the building blocks of ritualized play.

Developing specific skills is the fourth general goal. There are
two distinct ways of thinking about this goal area. Firstly, developing
specific skills can be part of the therapy process concerned with
"developing the music child" (Nordoff & Robbins, 1977) or
developing "self awareness" (Boxill, 1985, 1989). In these
orientations, skills are developed in order to increase expressive and
interactive opportunities that foster the child's development and
self esteem. Secondly, developing specific skills tan mean focusing on
the acquisition or development of competencies which enable the child to
function with greater independence. This may include physical,
emotional, cognitive, social or communicative development such as
increasing the quantity, quality or duration of a skill. When this
orientation is taken, the acquisition of the skill often becomes the
central focus of the therapeutic process. For example, skills may
include increasing eye contact (Knout, 1987), using a switch toy
(Holloway, 1980), or reaching for and touching objects (Saperston, Chan,
Morphew & Carsrud, 1980), where musical activities provide a
context, motivation or reinforcement for the development of the skill.

The fifth general goal is dispelling pathological behaviour. For
Nordoff and Robbins (1971; 1983), dispelling pathological behaviour
involves decreasing the incidence of maladjusted or unhealthy behaviour
and developing healthy ways of expressing needs, emotions and responses
to both people and the environment. For Alvin (Bruscia, 1987), this
involves developing a level of awareness that goes beyond sensorimotor experiences in order to resolve conflicts that lead to pathology and
isolation. For Boxill (1985), this involves increasing the child's
self awareness in order to free "misused, misdirected, unused [or]
unoriented energy" (Boxill, 1985, p.73). Agrotou (1993) believes
that fixated and repetitive behavior(s) is a form of communication
associated with grief or loss. Through the establishment of ritualized
patterns of communication and intervention, she provides a reliable and
predictable environment for working through these behaviors. Dispelling
pathological behavior may also include decreasing self-stimulatory
behaviour (Knout, 1987) or cueing other behaviours (Hanser, 1987).

The sixth and final general goal is developing an awareness and
sensitivity to the beauty of music (Pfeifer, 1982). This involves
"cultivating an awareness of, appreciation for, and satisfaction
from beauty through experiential involvement with music" (Pfeifer,
1982, p.5). As Salas (1990, p.5) discussed, this experience may lie in
intramusical structures and relationships, or in music's ability to
connect with human emotion, "giving voice to currents of feelings
far beyond what is expressible in language".

Orientations to Practice

When addressing these goals, music therapists take a number of
orientations to practice. An orientation is defined by a
therapist's stance or theoretical approach to clinical work. This
includes their beliefs about music, their role, and their relationship
to the child. It is represented by the type of goals and methods used in
working with these children and the meaning given to the therapy
experience. Bruscia (1989) describes a number of areas of practice, and
the following orientations are based on his categorization.

These examples are meant to be illustrative and not a comprehensive
categorization of all music therapists working with this client group.
Further, there is no intention to imply that the examples given are the
therapist's only orientation to practice.

Recreational Orientation

When music therapists take a recreational orientation, they are
concerned with providing musical experiences for entertainment,
recreation, diversion and leisure (Bruscia, 1989). These experiences can
include concerts, plays, or special events where children perform music,
perform with music (for example dancing), or where music performance is
a shared experience that unites all members of the event (for example
singing hymns at a church service). In these situations, the music
therapist usually acts as coordinator, either of the musical portions or
the entire event. Sometimes this requires writing or arranging music,
creating a play, or preparing taped music to be used at the event For
example, Shoemark (1988) and Coull and Meadows (1990) created and
produced plays with music as special events in a school setting. In
doing so, they focused on the following: providing performance oriented
opportunities for children to demonstrate skills that they had developed
(Coull & Meadows, 1990; Shoemark, 1988); providing an opportunity
for a school to join together in community (Coull & Meadows, 1990);
providing enjoyment for family and friends (Shoemark, 1988) ; and,
maintaining the dignity of children by involving them appropriately by
age and ability (Shoemark, 1988).

Behavioral Orientation

When music therapists take a behavioral orientation, they are
concerned with "the influence of music (on children] to increase,
decrease, modify, or reinforce carefully designed targeted
behaviors" (Bruscia, 1989 p.114). From the literature reviewed,
music therapists typically place less emphasis on the dynamics of the
therapeutic relationship and are more concerned with changes in the
child's behavior to meet an identified goal(s). As such, programs
are developed with specific goals in mind and structured interventions
formulated to meet these goals. For example, Wolfe (1980) used selected
recorded music attached to a mercury switch to increase the head control
of children with cerebral palsy. Music acted as a reward for these
children, which they were able to hear when keeping their heads in an
upright position. In another study designed to reinforce behavior,
Holloway (1980) used both passive (contingent music listening) and
active (instrument playing) music reinforcers to increase the
pre-academic and motor skills of children in an institutional setting.
Other examples of behavioral interventions include programs designed to
elicit responses such as reaching for and touching objects (Saperston,
Chan, Morphew & Carsrud, 1980), following directions (Dorow, 1975),
and changing activity level (Dorow & Horton, 1982; Kaufman &
Sheckart, 1985; Reardon & Bell, 1970).

Educational Orientation

In adopting an educational orientation, the music therapist
"places an emphasis on curricular or developmental goals ..."
(Bruscia, 1989 p. 70). In the literature reviewed in this discussion,
two distinct orientations can be found. This first, described by Bruscia
(1989) as music therapy in special education, focuses on the use of
music to gain nonmusical skills and knowledge. The second, described as
developmental music therapy, focuses on a broader range of goals that
address delays or obstacles to developmental growth in all areas of the
child's life (e.g. sensory, cognitive, communicative, social,
emotional, affective). Each will be briefly discussed.

When music therapists focus on the use of music to develop
non-musical skills and knowledge, they are typically concerned with
reinforcing and maximizing the educational goals of a child's
I.E.P.. For example, Alley (1977, 1979), Jellison (1977, 1979), Krout
(1987) and Presti (1984) describe the role of the music therapist in an
educational setting as one who provides a systematically structured
program of activities to meet educational/ curricula goals. In meeting
these goals, Jellison (1979) describes how the music therapist should
derive a sequence of short term objectives or behavioral tasks,
determine an acceptable performance criteria for their achievement, and
then implement a series of activities to meet these criteria. As such,
the music therapist takes on an instructional role in the child's
development, focusing on overt behavior and functional adaptation.

Some music therapists take a broader approach to the child's
development, incorporating sensorimotor, communicative, cognitive,
affective, intrapersonal and interpersonal needs in an integrated way.
This approach, which Bruscia (1989) calls developmental music therapy,
"is concerned with autobiographical material, family background,
private emotions, and personality development" (Bruscia, 1989 p.74)
in ways that help children overcome delays and accomplish tasks that
meet their unique needs. Examples of this approach include the work of
Agrotou (1993), Alvin (1976), Boxill (1985, 1989), Howat (1995), Nordoff
and Robbins (1971, 1977, 1983), Shoemark (1991) and Warwick (1995). For
Nordoff and Robbins (1971, 1977, 1983), therapy involves three
interrelated stages: meeting the child musically, where the
therapist's music creates an accepting environment; evoking musical
responses, where the therapist stimulates the child to explore and
create music, both instrumentally and vocally; and developing musical
skills, expressive freedom and interresponsiveness. In this approach,
both recreative and improvisational techniques are used. An increased
emphasis is placed on the dynamics of the therapeutic relationship, and
while sessions may have a structure or plan prior to each session, the
therapist is likely to spontaneously respond to the child, altering the
content of the session accordingly. Further, the therapist places an
emphasis on self inquiry as a way of understanding the therapy process.

Healing Orientation

Music therapists that adopt a healing orientation use "musical
experiences and the relationships that develop through them to heal the
mind, body, spirit, to induce self-healing, or to promote wellness"
(Bruscia, 1989 p.93). In this orientation, primary value is placed on
the music therapist's experiences of the child(ren) as part of
understanding the therapy process, and self inquiry is central to this.
The work of Nordoff and Robbins (1971, 1977, 1983) falls into this
category because the therapeutic experience allows the child to heal and
change from within, activating the child's 'inner
resources'. As Bruscia (1989 p. 94) discusses, Nordoff and Robbins
give the music therapist as healer four main functions: "1) to
accept the [child] with respect and reverence, 2) to work through
various relationships that develop through the music, 3) to create music
that will activate the [child's] inner resources, and 4) to
continually develop one's own musical life".

Major Treatment Methods

When these orientations are taken to meeting the general goals
previously described, music therapists use both active and receptive
treatment methods in individual and group settings. Both of these
methods will be discussed separately.

Active methods refers to the therapy that "takes place within
and through the [child's] efforts to perform, improvise, or create
music, either alone or with others. Here the active experience either
provides therapeutic benefits directly, as the main stimulus for change,
or it leads to a response process that parallels or triggers a
therapeutic change experience" (Bruscia, 1991, p. 65). Active
methods include instrumental activities, improvisation, vocal activities
and movement.

Instrumental Activities

An instrumental activity involves the child manipulating an
instrument in order to produce some kind of sound. Typically,
instruments that are used include hand held percussion, drums, cymbals and xylophones. Sounds can be "organized or unorganized, consist of
random groups of sounds, short series of pulses, intermittent or
prolonged beating, or rhythmic patterns of varying length and
complexity" (Bruscia, 1987, p.48).

Instruments are typically selected according to the child's
ability and interest, and may be adapted to maximize success and
independence. In adapting instruments, the music therapist may position
them for the child's easy access and provide splints and grips in
order to grasp smaller instruments and mallets. Instruments may be
physically altered or other devices, such as levers or frames may be
built. For example, Clark and Chadwick (1980) and Elliott, Macks, Dea
and Matsko (1982) describe a range of adaptations to instruments
designed to maximize the child's access and independence. Music
technology, such as computers and synthesizers, has also been adapted to
utilize the synthesizer's touch sensitivity and potential to
produce a wide variety of sounds using similar movements (Meadows,

Evoking Instrumental Sounds

There are several reasons why music therapists use instrumental
activities. The first of these is to evoke sound or music making
responses from the child. Here, the music therapist helps the child to
produce sounds through the exploration of instrument timbre, texture and
shape (Pfeifer, 1989). Sometimes adapting the instrument or providing
physical assistance is necessary. When the child explores an instrument,
it is a way of stimulating them, making contact, establishing intent and
engaging them in the therapy process. This goal is particularly
important for the child with a physical disability because such
activities physically stimulate them and assist them in understanding
and controlling their bodies.

Nordoff and Robbins.(1971, 1977) evoke musical responses by
engaging the child in music making on instruments through modeling,
verbal encouragement or instruction, and/or physical assistance. Once
the child begins to play, the therapist concentrates on the way the
sound is produced, responding to the dynamics, timbre, melody and level
of organization the child shows. In this way, the therapist begins from
the child's music, and engages the child by imitating, contrasting,
pausing or structuring the musical experience in certain ways. These
techniques apply more readily to children who are physically capable of
using instruments, where the process centers around developing ways to
express feelings, explore, or participate in instrumental activities.

Developing Instrumental Skills

The second goal is to develop instrumental skills. Two types of
skills are emphasized, the first of which is to develop an expressive
musical language. Here the music therapist fosters the child's
ability to express personal feelings, explore and create sounds, and
interact with others through the playing of an instrument(s) (Alvin,
1976; Boxill, 1985, 1989; Nordoff & Robbins, 1971, 1977).

In developing expressive music skills, a common intervention is
improvisation, where the therapist and child spontaneously make music
together. This may comprise the child and/or therapist improvising with
piano, voice, guitar, melodic or percussive instruments, either alone or
in combination. Improvisations can vary in their complexity from simple
sound forms to multi-dimensional compositions. For example, Nordoff and
Robbins (1971; 1977) discuss developing expressive musical skills
through improvisation in terms of 'expressive freedom' and
'inter-responsiveness', where developing a musical language
gives the child new or improved expressive options and choices. Other
examples include the work of Alvin (1971), Boxill (1985), Howat (1995),
Nordoff & Robbins (1971, 1977, 1983), Shoemark (1991) and Wigram

The second area is developing specific music skills, and involves
the child learning and playing an instrumental part in a composition.
Typically, this is structured around recreative activities, where the
child rehearses and performs their part (3). While a number of
therapeutic objectives, such as attending to the task and behaving
appropriately, are implied in this activity, the emphasis remains on
music making. The therapist may write music for specific goals (Levin,
Levin & Safer, 1974; Purvis & Samet, 1976), adapt it from
existing literature (Boxill, 1985, 1989), or write it specifically for
the child, type of activity or goal (Boxill, 1985, 1989; Nordoff &
Robbins, 1971, 1977).

Developing Music-Related Skills

The third goal area is developing music-related skills. Typically,
goals focus on either those non-music skills developed in the process of
music-making, or the non-music skills developed where music is used to
motivate or reinforce specific skills. Bruscia (1991) has outlined a
number of general objectives, which include "developing
sensorimotor skills, learning adaptive behaviours, maintaining reality
orientation, mastering different roles, identifying with the feelings of
others, and working co-operatively toward a common goal" (Bruscia,
1991, p.7). This goal area shares many similarities with the previous
goal (developing instrumental skills). The main difference is in the
emphasis placed by the music therapist. In this particular goal area,
the emphasis is placed on the skills (for example behavior, motor skills
or attention) associated with the instrumental activity. In the previous
goal area, the emphasis was placed on the process of music making.

A wide range of music-related goals have been addressed in the
literature (Alley. 1977; Hanser, 1987; Pfeifer, 1982). These include
developing eye-hand coordination and motor skills such as shaking,
striking and grasping (Pfeifer, 1982; Krout, 1987); imitative behaviour
and turn taking (Boxill, 1985): and following directions (Lathom &
Eagle, 1982). Typically, these goals share a close relationship with the
child's I.E.P., where the music therapist specifically addresses
one or more of these goals in the child's music therapy program.

Vocal Activities

A vocal activity is one which, is focused on the child producing
any sound that can be made orally. Vocal sounds can be "sustained
or unsustained, pitched or unpitched, verbal or non-verbal. They may be
unrelated single tones, short motifs, melodic patterns, or short
phrases" (Bruscia, 1987 p.47). Nordoff and Robbins (1983) and
Boxill (1985) discuss singing as a direct and intimate self extension,
with the potential to integrate perceptual, cognitive and expressive
capacities As with instrumental activities, goals for vocal activities
can be divided into three main areas: evoking vocal responses,
developing vocal skills, and developing music-related skills.

Evoking Vocal Responses

In evoking vocal responses, the music therapist helps the child to
produce any vocal sound in a musical context. This goal is usually most
relevant in three specific situations. Firstly, for children who have
profound disabilities as a way of stimulating a response or fostering
interaction (Boxill, 1985; Cunningham, 1975; Johnson, 1975; Nordoff
& Robbins, 1971, 1977). Secondly, for children with physical
disabilities which impede their ability to produce vocal sounds. And
thirdly, for children who are withdrawn or lack self confidence and need
specific vocal support and encouragement (Nordoff & Robbins, 1971,

Nordoff and Robbins (1977, 1983) use a number of techniques to
elicit vocal responses. These include improvisational techniques such as
a) making vocal sounds while musically reflecting the child's
emotional state, b) singing phrases that describe what the child is
doing, feeling or experiencing, and c) imitating the child's vocal
sounds or words, matching the musical and emotional qualities.
Recreative techniques include a) presenting material the child is able
to copy, add to or develop, b) introducing a familiar song or tune and
encourage the child to sing along, and c) varying the instruments used
in accompaniment. Techniques that can use either method include a)
providing opportunities to complete phrases, add sounds, syllables or
words, and b) combining vocalizing with movement or instrument playing.

Developing Vocal Skills

Developing vocal skills involves the therapist increasing the
range, length, type, accuracy and/or quality of the child's vocal
sounds. Two types of goals are emphasized in the literature: developing
an expressive vocal language, and developing music-related skills.

In developing an expressive vocal language, the music therapist is
primarily concerned with stimulating, supporting and developing the
child's vocal expression(s). These include both verbal and
non-verbal expressions of the child's here-and-now experience with
the therapist, either in group or individual sessions. Boxill (1985)
gives the example of an agitated, hyperactive person, "when
encouraged to hum a melody, may create his or her own sense of calm
through the vibratory effect of the music, as well as the emotional
gratification it affords" (Boxill, 1985, p. 101).

For Nordoff and Robbins (1983), developing an expressive vocal
language involves presenting a variety of songs with different emotional
qualities that gives the child a range of emotional experiences. In so
doing, the child's personality can become integrated in the act of
singing and is functionally organized by the musical structure and
content of the song itself. "Such a variety of emotional experience
is vital to music therapy for it enhances responsiveness ... and
simultaneously fosters the personal development of (the child)"
(Nordoff & Robbins, 1983, p. 32).

Music-related Skills

Developing vocal skills comprises many music-related skills.
Typically, these are either the non-music skills developed in the
process of singing and music making, or the non-music skills developed
where singing is used to motivate or reinforce specific skills. These
include the broad categories of receptive language, expressive language
and academic skills (Pfeifer, 1982). For example, vocal activities can
address the child's ability to attend (Wylie, 1983), turn take,
listen, and make eye contact (Krout, 1987). Songs can reflect a skill or
knowledge that is learnt in the classroom. For example, songs can
describe colours and seasons (Purvis & Samet, 1976), providing a
learning context for the child.


Movement activities focus on the physical well-being and
development of the child. As an active method, movement activities are
those where the child moves their body independently in a musical
context. This includes gross motor activities, basic locomotor activities, structured and free psychomotor movements, and perceptual
motor activities (Boxill, 1985), where the music therapist plays or
selects music which supports and stimulates the child's movements.

In movement activities, two main goals are emphasized: maintaining
or increasing gross and fine motor skills (Robbins & Robbins, 1988);
and educating the child to physically interact with the environment in
ways that help them to learn about themselves, the environment and
others around them (Boxill, 1989). More specific goals include
increasing body awareness (Boxill, 1985), identifying body parts (Levin,
Levin & Safer, 1984), increasing muscle control (Lathom & Eagle,
1982; Robbins, 1988), maintaining range of movement (Robbins &
Robbins, 1988) and integrating movements (Krout, 1987; Levin, Levin
& Safer, 1984).

Typically, movement programs are designed for groups, where
children have similar needs, and may be coordinated with
physiotherapists (Robbins & Robbins, 1988). Live or recorded music
may to used, chosen specifically for the type of activity or experience
undertaken. Live music can be improvised from an established song
repertoire (Robbins & Robbins, 1988; Wigram, 1992). For example,
improvised music can support or imitate the movement(s) undertaken.
Songs can describe the movement (for example stretching), the context of
the movement (for example, identifying body parts), or be a medium by
which the movement occurs (for example, the child spontaneously
responding to the music).

Receptive Methods

The second major area of interventions for children with severe and
profound multiple disabilities are receptive methods. As Bruscia (1989
p.43) describes, receptive methods refer to "the therapy that takes
place when the child listens to, takes in, or receives the music
itself"_ Three main receptive methods can be identified in the
music therapy literature These are sensory stimulation, movement, and
contingent listening.

Sensory Stimulation

Sensory stimulation refers to the therapist's use of musical
and other media to arouse, excite and activate the child: In all
interventions, the emphasis is on engaging the child in any type of
response that will foster activity and awareness of themselves, objects
and others. For example, this can include singing or playing to the
child in order to change affect (e.g. eye contact) or manipulating the
child's arms and hands to explore an instrument, watching for
changes in awareness and activity.

Typically, there are three elements to this type of intervention,
and they can be used separately or' together when working with a
child. The first element is auditory stimulation, or the
therapist's efforts to stimulate the child by improvising (Johnson,
1975), singing songs (Dorow & Horton, 1982; Kaufman & Sheckart,
1985) or playing pre-recorded music (Wigram, 1981). Secondly, this can
involve the use of textures, fabrics and other materials to physically
stimulate the child. For example, fabrics can be gently rubbed over the
child's arms, hands or feet, while textures can be placed in the
child's hand(s) or between fingers. Thirdly, the therapist can
physically stimulate and manipulate the child's body by touching,
massaging or carefully moving body parts. For example, the therapist may
massage the child's arm and hand as a way of making contact or
building trust. Alternatively, the same technique may be used as a
preparation for instrument playing, stimulating the child's body
and then placing the instrument so that the child can explore it, either
independently, or with assistance.


As a receptive method, movement activities refer to the
therapist's caring and purposeful manipulation of the child's
body in a musical context to meet his/her physical well-being and
development. These activities are specifically designed for children who
have little or no voluntary control over their bodies, or lack the
understanding to move in purposeful or controlled ways (Weigall &
Meadows, 1995). These programs are usually designed and run with
physiotherapists because of the high level of expertise required in
understanding the physical makeup of children and limitations to their
movements. Programs are usually run for groups, and there is generally a
very high student staff ratio as children require individualized attention.

The music therapist has two main functions in these programs.
Firstly, to provide the structure of the sessions, or secondly to work
with a child providing physical intervention. Providing the structure to
sessions includes both musical and verbal elements. Musically this
involves selecting songs (both live and recorded) and improvising to
connect, support, and facilitate the child's movement experience.

Verbally, it means acting as a guide to staff members throughout
the session. Providing physical intervention means working with a child
while recorded music is played.

These movement programs have three related elements. The first of
these is to focus on maintaining the child's physical functioning,
including range of movement, muscle tone, and body symmetry (for
example, maintaining posture). Secondly, an emphasis is placed on the
quality of the interactions between therapist and child. As these
children usually receive constant physical handling, care is taken to
make the interaction as positive and sensitive as possible. Thirdly,
while the adult moves the child's body, independent movement is
encouraged and supported at all times.

Contingent Listening

Contingent music listening refers to the therapist's
application of live or recorded music to reinforce or reward appropriate
non-musical behavior. Typically, the music therapist will identify,
shape, reinforce and reward a desired behavior(s), with the music
functioning in the last two elements of the sequence. For example,
contingent listening has been used to reinforce imitative behavior
(Meltzer, 1974), reaching and touching objects (Saperston, Chan,
Morphew, & Carsrud, 1980), head positioning (Wolfe, 1980), motor
skills (Dorow, 1975; Holloway, 1980) and foster positive interactions
and acceptance among students in a mainstream music classroom (Jellison,
Brooks & Huck, 1984).


One way of presenting the music therapy literature for children
with severe and profound multiple disabilities is by goal, orientation
and method. This gives an indication of the ways music therapists work
with these children, showing both the diversity and similarities in
overall approach.

Given the diverse goals of music therapists, there seems to be many
similarities in the methods used. For example, instrumental and vocal
activities were used to meet all the general goals identified in this
review. It appears, therefore, that it is not so much the methods that
are different as the meaning given to the therapy experience. For
example, when a child first plays an instrument independently, it can be
framed in two entirely different ways. From a behavioral orientation, it
may be an example of following directions and playing attention to the
task. From a broader educational perspective (developmental music
therapy) on the other hand, it may be the child's first
communication of intent or interaction.

It follows that the general goals identified earlier in this review
are not really 'general' at all. They reflect an orientation
or orientations to practice by music therapists that value certain types
of goal(s) for these children. For example, the first goal of fulfilling
the child's basic needs reflects a developmental music therapy or
healing orientation that places an emphasis on the quality of the
therapeutic environment and the relationship with the therapist. It has
not been identified as a goal when working from other orientations.

Taking another perspective, the general goal of developing specific
skills means different things in different orientations. From a
behavioral orientation, developing skill; means targeting and
systematically working toward the mastery of a specific skill, task or
behavior that was identified by the therapist to meet adaptive or
educational needs. Typically, music listening is used to reward or
reinforce the child and the music therapist takes on an instructional
role. From a healing orientation, developing skills means fostering,
allowing and encouraging the child to develop his/her own unique ways of
communicating and interacting to become whole. As such, sessions take
place spontaneously and develop in unique and unpredictable ways. A
central focus is placed on the music as a representation of the process,
perhaps without necessity for interpretation or explanation. Further,
the therapist uses his/her own experiences to further understand this

In closing, while music therapist's goals and methods give an
indication of the ways in which therapy is approached with these
children, it is the therapist's orientation to practice which gives
meaning to the experience.


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Tony Meadows *, MMT, RMT

* Tony Meadows is an Australian-trained music therapist currently
enrolled in a doctoral program at Temple University, Philadelphia, USA.


(1) This goal was originally identified by Gaston (1968).

(2) Pfeifer cited Eagle (1978) as the primary source for this goal.
However, as this is acknowledged as a personal communication (Pfeifer,
1982 p.32), Pfeifer is used as the source.

(3) Performance can take place either within the therapy session or
to peers, family and/or others.

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