Music Therapists’ Perceptions of the Therapeutic Potentials Using Music When Working With Verbal Children on the Autism Spectrum: A Qualitative Analysis

Abstract

While there are numerous descriptions of the use of music and its therapeutic potential by music therapists working with nonverbal children on the autism spectrum, only limited literature focuses on exploring how music therapists use music and perceive its therapeutic potential when working with children on the spectrum who have verbal skills. This qualitative study aimed to explore music therapists’ descriptions of the use of music and its therapeutic potential in their work with children on the autism spectrum who have verbal skills. Semi-structured interviews were conducted with six qualified music therapists from Israel and then analyzed according to the principles of interpretative phenomenological analysis (IPA). Three main themes were identified: (a) musical infrastructure, which describes how the music therapists facilitated musical experiences to support the children’s ability to regulate their arousal, attention and emotions; (b) the meeting point between musical and verbal playfulness, which reflects the music therapists’ beliefs about how musical experiences add vitality and support the development of both verbal and nonverbal imaginative play; and (c) musical responses, which describes the different ways music therapists use their voice and songs to interact musically with verbal children. The experiences described by the participants emphasize the importance of the therapist musically attuning to the child’s emotional, physiological, creative, and playful qualities, even when the child has verbal skills. These musical interactions help to create a shared experience between the child and therapist that are perceived to help the child’s different forms of regulation, continuity, and vitality within the play.

This qualitative study explored music therapists’ descriptions of use of music and its therapeutic potential in their work with children on the autism spectrum with verbal language skills. Although the term “high functioning autism” (HFA) is widely used, its accurate definition is elusive and often unclarified. There is scarce music therapy literature describing clinical practice with children on the autism spectrum who are verbal; however, the first author’s clinical experience suggests that some music therapists are seeking more knowledge to inform their use of music and its therapeutic potential with this population.

Prior to the publication of the DSM-5 (American Psychiatric Association, 2013), the term HFA was often used to refer to children diagnosed with autism spectrum disorder (ASD) showing language skills and intelligence within the typical range (Critchley et al., 2000; Lincoln, Courchesne, Kilman, Elmasian, & Allen, 1988; Rao, Beidel, & Murray, 2008). In the DSM-IV (American Psychiatric Association, 2000), a high functioning autism diagnosis may also have been attributed to individuals that met some but not all of the criteria for autism. Alternatively, the diagnosis PDD-NOS (pervasive developmental disorder not otherwise specified) was sometimes used for these individuals, while at other times they may be diagnosed with Asperger’s Syndrome. Some of the major changes presented in the DSM-5 (American Psychiatric Association, 2013) were the removal of these clinical subtypes and instead creating the umbrella category of ASD. Rather than describing levels of functioning, the DSM-5 categorizes individuals according to the level of support required. While “Level 1” describes individuals who can engage in verbal communication and therefore require the lowest level of support, no specific attributes are described, such as intelligence and language skills, pointing to the large diversity of these skills in individuals on the spectrum (Grzadzinski, Huerta, & Lord, 2013). Although individuals requiring the lowest level of support are likely to have an IQ and language skills in the typical range, they may still face challenges with social interaction which in turn affects their emotional and social development. In addition, their relationships and interactions with family and peers are often impacted, as well as their academic skills (Rao et al., 2008).

Music Therapy for Children on the Autism Spectrum

Infant research has shown that reciprocal communication between infants and caregivers contains many musical features, such as timing, form, and intensity (Malloch & Trevarthen, 2009; Stern, 2010). These innate nonverbal interactions are described by the theory of “communicative musicality” (Malloch & Trevarthen, 2009) as supporting the infant to acquire self-regulation and reinforcing social communication development. For young children on the autism spectrum, promoting the regulation and organization of sensory experiences may be seen as a precondition to supporting further development in relational skills (Mössler et al., 2017).

While a recent RCT comparing music therapy to standard care showed no improvement in the children’s symptom severity (Bieleninik et al., 2017), music therapy has been shown to promote the development of various functional skills in young children with autism. A range of music therapy methods and techniques have positively supported children with autism to develop verbal and nonverbal communicative skills, motivate social engagement, and foster closer interpersonal relationships (Carpente, 2016; Gold, Wigram, & Elefant, 2006; Kim, Wigram, & Gold, 2009; Pasiali, 2004; Simpson & Keen, 2011; Thompson, McFerran, & Gold, 2014). A recent video microanalysis exploring how music therapists use their voice in sessions with both nonverbal and verbal children on the autism spectrum showed that the children’s range of vocal expressions increased and became more communicative (Salomon-Gimmon & Elefant, 2018). While the data (in Salomon-Gimmon & Elefant’s study) were based on a small sample size of 2 therapists and 4 children, the results identified 16 vocal interventions that were commonly used. These interventions included: (a) “vocal resonance with changes” (p. 13), which was described as the therapist repeats the musical and nonmusical characteristics of the client’s vocalization while introducing subtle changes; (b) “vocal cross modality” (p. 14), where the therapists’ vocalizations reflect the client’s nonvocal actions; and (c) “changes in vocal intensity” (p.14), described as the therapist changing the intensity of his voice in a playful manner.

Whether through vocal or instrumental techniques, music therapists often use spontaneous, live, improvised music making to facilitate reciprocal communication through musical interactions that incorporate expected musical structures as well as elements of anticipation and surprise (Carpente, 2016; Simpson & Keen, 2011). These techniques arrange the harmony, melody, rhythm, and dynamics into shareable structures between dyads or groups. Music-making creates the potential for a shared and reciprocal experience that aims to encourage greater responsiveness from the child (Geretsegger et al., 2015; Josephson, 2016; Wigram & Elefant, 2009). Music therapists more generally describe how they respond to the clients’ expressions and behaviors through cross-modal musical forms as a means to build the therapeutic relationship (Trondalen, 2016). When working with children on the autism spectrum, music therapists have also described ways they attune and respond to the child’s behavior, emotions, and movements through empathic and supportive musical structures (Brown, 1994; Geretsegger et al., 2015; Wigram & Elefant, 2009). In this way, use of music helps to motivate interaction and supports regulation of sensorimotor experiences (Moessler et al., 2017), affect and emotions (Schumacher & Calvet, 2007b; Josephson, 2016).

Baker, Wigram, Stott, and McFerran (2009) conducted a survey of music therapists to examine their preferences for using songwriting and pre-composed songs when working with people across various populations. According to their findings, most music therapists working with people on the autism spectrum use improvised music within their song writing approach in order to respond to the client’s spontaneous verbal expressions. Baker et al. (2009) also describe how pre-composed songs or song frameworks are frequently used as a starting point to facilitate further improvisation and song writing in the session. In a similar way, a technique described as “spontaneous structured story telling” (p. 42) was prevalent with this population, where the client’s verbal story line as well as nonverbal gestures are incorporated into an improvised song-story.

Despite detailed descriptions of using music and its therapeutic potential with this population (Geretsegger et al., 2015), and several studies showing positive developmental outcomes for children on the autism spectrum receiving music therapy (Carpente, 2016; Geretsegger et al., 2015; Gold et al., 2006; Kim et al., 2009; Pasiali, 2004; Simpson & Keen, 2011; Thompson et al., 2014), only limited literature specifically focused on children with verbal skills exists. In a recent publication, Thompson (2018) described her work with a 6-year-old child who had excellent verbal skills. Thompson responded to the child’s verbal story-telling and dramatic movements by musically interpreting the child’s actions and the emotional content of their story. The case study analysis revealed an increase in the child’s use of spontaneous real-life events within their story-telling, instead of relying solely on previously learnt scripts based on movies and television programs. Thompson described the importance of conveying to the child that his actions and invitations to play were meaningful to her and striving to understand his communicative initiations. She described their relationship, although containing verbal dialogues and dramatic role-play, as based mainly on their ability to affectively attune to each other.

Despite the positive outcomes described broadly in the music therapy literature for children on the autism spectrum, there is a scarcity of literature exploring how music therapists use music when working with verbal children. Since children on the autism spectrum are all unique, have a variety of strengths and face individualized challenges, this research seeks to understand more about how music therapists perceive the role of music and the ways they use it in their clinical practice with verbal children.

Research Objectives

This research aimed to explore the way experienced music therapists use music and perceive its therapeutic potential when working with children with verbal skills. Since the term HFA was commonly used and understood by the therapists recruited for this study, the main research questions were: (a) What are the music therapists’ perception of the role of music when working with children with HFA?, (b) how do music therapists use music in their work with these children?, and (c) how do music therapists use music when a child initiates verbal interactions?

Method

This qualitative study was based on semi-structured in-depth interviews (Kvale, 2007) with qualified music therapists working with children on the autism spectrum with verbal skills in Israel. The constructive–qualitative method ascribed to the interpretative phenomenological analysis (IPA) (Smith, Flowers, & Larkin, 2009) was chosen due to its focus on participants’ perceptions and understandings of the topic. IPA allows researchers to create links and connections between data from individual participants, and therefore aims to uncover a broader understanding of their joint experience that is gathered into a common theme, while maintaining differentiation between the individual voices.

The research was approved by the ethics committee for the Evaluation of Research with Human Subjects of the Faculty of Social Welfare and Health Sciences, University of Haifa, Israel.

Participants

Purposeful sampling (Smith et al., 2009) was selected for this study, which is a deliberate process of selecting respondents based on their ability to provide the required information. The first author contacted several educational administrators who work in programs for children with autism who recommended six female music therapists working in different locations in Israel who could confirm they have worked with verbal children for at least 3 years (Table 1). Only therapists from Israel were approached since Hebrew is the first author’s primary language. Due to the practicalities of completing a graduate research project, and a preference for face-to-face interviews, the sample was limited to one country. All selected participants confirmed they had been working with children on the autism spectrum.

The participants were initially contacted by the first author via phone. The aims of the study, the nature of the interview, and the types of questions they would be invited to respond to was explained. In addition, the first author clarified the definition for children with HFA based on Rao et al.’s (2008) research, which describes children diagnosed with ASD with intelligence and language skills within the typical range. Participants first gave signed consent and were then interviewed individually by the first author for 60–90 min. Interviews were held in a convenient location for the participant and audio recorded.

Authors’ Lens

The first author is a music therapist who works with children on the autism spectrum, and therefore had previously formed her own view of the challenges and joys of working in this field. In this way, her dual role was seen as a possible advantage in gaining a deeper understanding of the participants’ experiences. However, this dual role also calls for sincere and deep reflexivity (Kvale, 2007; Stige, Malterud, & Midtgarden, 2009; Tong, Sainsbury, & Craig, 2008) throughout the project. The use of a reflective diary as well as regular conversations with the research supervisor (second author) were important in this process, during which feelings and possible judgments were exposed and processed. Both second and third authors have many years of experience with verbal children with autism (Salomon-Gimmon & Elefant, 2018; Thompson, 2018; Thompson & Elefant, 2019; Thompson et al., 2014; Wigram & Elefant, 2009). The third author served as a consultant during the analysis and discussion processes. Further detail about the researchers’ approach to reflexivity is provided in the reflectivity section.

Semi-structured Interviews

Different from a structured interview that has a formalized, limited set of questions, a semi-structured interview is flexible, allowing new questions to be brought up during the interview as a result of the interviewee responses (Kvale, 2007). The interview guide (Table 2) was designed to explore the participants’ experience of the therapeutic potentials using music when working with verbal children on the autism spectrum.

Data Analysis

The interview data were divided and deconstructed into units of meaning according to IPA guidelines that outline several iterative stages (Smith et al., 2009; Smith & Osborn, 2008). In the first stage, the interviews were transcribed by the first author and read several times in full. In the second stage, the analysis occurred through the following steps: (a) each interview was divided into identified units of meaning; (b) comparative analysis between the interviews was completed in order to find similar units and form concept groups; (c) categories were chosen and labeled, containing larger groups of concepts; (d) through finding connections between the categories, the main research themes were identified and created. The themes were supported by the examples and quotations provided in the interviews.

Throughout the process of analysis by author 1, intersubjectivity was promoted through regular consultation and mentoring with the second author. The process of creating the themes and connecting them to existing literature was mentored by the third author, in order to reflect on the themes and quality of analysis.

Reflectivity

Since qualitative researchers engage closely with the research process and the participants, it is highly important for the researcher to reflect upon their identity, training, occupation, and observations to increase the trustworthiness of the findings (Stige et al., 2009; Tong et al., 2008). The following is a description made by the first author who completed the main analysis as part of her master’s thesis research study. Therefore, the reflection will use first person pronouns to highlight the personal nature of the engaging in reflexivity.

Professional Background.

At the time of conducting this research, I had been working for more than 5 years with young children on the autism spectrum individually and in group settings in a psychiatric day center. A large part of the work in the day center was dedicated to team work and collaborations about mutual clients. I felt that when working with children who had limited language skills, it was easier to understand how to use music, however with verbal children I experienced confusion about the role of music in my work. At times when I responded to the children’s verbal communications only, I felt distant from them and experienced a sense that the therapy was stuck. Furthermore, these children often rejected my suggestions for using music and I had to be very creative in my choice of musical applications. Through my work and supervision, I started to acknowledge that music did in fact exist in these sessions, however its appearance was often quite subtle, and it required a change in the way I listened to my clients’ verbal expressions by concentrating on how they presented their words and gestures.

Personal Views Affecting the Research.

My experiences and assumptions impacted the questions I chose for the interview guide, as well as the way I probed for information during the interviews. I particularly guided the participants to specifically reflect on their reactions to the children’s verbal expressions, and encouraged them to describe what was “working” and how they used music. Questions such as “what did not work” were drawn directly from my personal experience, as well as questions such as how central music was in your work, revealing my own experiences as a music therapist. My observation that there was a difference between working with verbal and nonverbal children on the autism spectrum was central in forming the research questions. These pre-assumptions were managed through the analysis process by consulting with my supervisor (second author).

Results

Three main themes were identified through the IPA analysis described above. These themes are listed as a summary first and then described in full accompanied by supporting examples of the data from the interviews.

• Theme 1: musical infrastructure, which describes how the music therapists use music and perceive its therapeutic potential to facilitate musical experiences to support the child’s different forms of self-regulation;

• Theme 2: the meeting point between musical and verbal playfulness, which reflects the music therapists’ perception of music’s therapeutic potential in musical experiences adding vitality and supporting the development of both verbal and nonverbal imaginative play; and

• Theme 3: musical responses, which describe the different ways the music therapists use their voice and songs to interact musically with verbal children.

Theme 1: Musical Infrastructure

All participants indicated that the way they used music to facilitate music experiences added much needed nonverbal qualities to the therapist–child play interactions in two different ways: supporting the child’s different forms of self-regulation; and increasing the sense of continuity within activities and between sessions. These two sub-themes are described below, with the common factor being the way the musical infrastructure provided by the music therapist supported these foundational qualities for later development in the child’s play and communication.

Regulation.

All of the participants gave examples for different forms of self-regulation achieved through the musical interactions. Wilma (pseudonym(explained how she intentionally used various musical elements to promote the child’s regulation of attention:

This part of the song is relatively slow and continuous, and he is used to walking in the room until I stop on the Dominant ‘and…. [Wilma sings the G tone, which is the dominant function in C scale] ‘[Return] the guitar into its place, puff!,’ [sings a dominant downwards] and then he rushes to take the guitar and returns it to its place.

In this example, Wilma used the dominant chord, which contains the leading tone of the scale to create tension. The leading tone and the connection between melody, harmony, text, dynamics, and the pause at the peak of tension, create anticipation for resolution to the scale’s tonic. This opportunity may help the child to regulate his attention, manifested in his ability to organize the therapy room.

Sara described how one child used music independently to regulate their arousal level:

Sometimes he needs a pause [from the therapist], where he goes to play the drums or the piano and uses it to organize himself... During the earlier sessions, he would often play the drums in a very chaotic way… Gradually it became organized.

In this example, the child’s organized drum playing demonstrates his ability to regulate his arousal state. Three more participants referred to the way they used music to support other forms of regulation: The first described how musical interaction could reduce anxiety, while two others described how it could engender a sense of security and calmness.

Sense of Continuity.

Five out of six participants referred to their observations of how music promoted a sense of continuity. Three different types of continuity were mentioned including (a) intra-personal; the ability to experience the self as continuing; (b) inter-session; where the children seemed to rely on previous musical materials to connect prior events and experiences shared in the music therapy room; and (c) intra-play; where the music therapist attempts to form a narrative during the child’s play. Pearl explained: “The [psycho] dynamic part of it is to calm down, creating a holding environment, a sense of two [people], and a sense of [interpersonal] continuity.”

Donna described an example of inter-session continuity with a child who would remember musical moments from previous sessions and ask the therapist to repeat them in the next session. Donna considers that the child was building for himself a sense of continuity in their relationship and the play: “He asked, he remembered, he said: ‘Sing with the guitar’.”

All of the participants described their sense that the child’s play often lacked coherence and sequence. Wilma explained about a child’s play narrative: “The play [narrative] is often fragmented, and things suddenly occur without my understanding why. For example, suddenly a ball of fire arrives. Who sent it? [she asks the child] The mouse? The mouse was not part of the play!” Wilma further explained the result of her musical intervention in this instance, creating an intra-play continuity by musically connecting different parts of the plot together: “it makes a sequence of what we did and it can be repeated and suddenly there’s a narrative.”

Theme 2: The Meeting Point Between Musical and Verbal Playfulness

This theme describes the participants’ understanding of how music experiences create a playful environment in their work with children with verbal skills. The music therapists perceived that the musical interactions helped to expand the children’s play and verbal expression and to form meaning. The sub-themes were as follows:

Music Adds Vitality.

All participants described how they used music to add vitality to the child’s verbal initiatives and play. Veronica explained: “When there is an imaginative play with words, the words enter the music [that I improvise]. Through the music I can use [for example] elements of fear. In this way the music increases the drama [in the non-musical play].”

All participants described how at different times and stages of the child’s play, they sensed that something was missing. Four of the participants described this missing essence as playfulness, while two others emphasized a lack of emotional expression, joy and arousal. Pearl described it in the following way: “He was a very smart boy, and my role was to add the color, the emotion, the humor [to the play].” Zina stated: “There are some parts [of the child’s capabilities] that developed extremely fast. These parts are cognitive [and] verbal, [for example] the ability to allegedly explain what I’m going through but without actually feeling it. There is a disconnection [between the different capabilities] there.”

Music Fosters Verbal Expression and Imaginative Play.

All of the participants described how musical interactions fostered the socio-dramatic or imaginative play of the child. The participants described situations where they could not make sense of the activity occupying the child. In these situations, they felt that music enabled them to create content and meaning that later might form an experience that can be shared. Sara described how the music helped to create meaning: “Suddenly this connection occurs, and it becomes a connection of meaning. It is as if what occurs in the [child’s] internal world… suddenly we both understand what is happening.”

In other cases, the participants described how they used a deliberate intervention where they added words and content through the music as a way to express the story line in the child’s play:

He took the truck and there were many dolls on it, and the truck fell, and the [dolls] fell too. So, I added words [to the music I played], such as ‘wait for us, we’re not keeping up,’ something that the children that were left [behind might say] (Veronica).

Theme 3: Musical Responses

This theme captured descriptions of different ways music therapists used music to respond to the child’s verbal and musical initiations. The participants described two main forms of musical responses: vocalizations that focus on the proto-musical features of the child’s expressions; and making creative adaptations of pre-composed songs and improvised songs to accompany the child’s play and behaviors.

Vocalizations to Respond to Proto-musical Features of the Child’s Expressions.

The music therapists’ descriptions of using basic musical qualities, such as pitch, timbre, pulse, and more, suggests that they prioritized responding to the proto-musical aspects of the child’s play and behavior. For example, if a child talked about a spaceship or used gestures to make the spaceship “fly,” the therapist musically matched or interpreted the child’s actions/intensity of the play with their voice. Within the interviews, all participants described various uses of proto-musicality in the sessions, such as character changes, changing voice dynamics, and intonation; matching and mirroring, and creating tension and release. Five of the participants emphasized the essential presence of their vocalizations in the therapy sessions with verbal children with autism. Zina explained: “Out of all the different musical uses, this [vocalization] is the one thing I use the most, this is the most accessible, immediate [tool] and also the thing that works best in my opinion.” Within this sub-theme, the following topics were identified:

Musical attunement.

Musical attunement was referred to by all of the participants as their main approach, meaning they would adjust their musical responses to the child’s presentation in the “here and now.” Zina elaborated: “By musically attuning, I’m attuning to the emotional state, not to the cognitive place of what he [the child] is doing or what he is saying, but rather the feeling that is capsulated inside this [behavior]… The music relates directly to this aspect.”

Character changes.

Four participants explained how they use their voice in playful and expressive ways, such as pretending to be characters in the child’s imaginative play. An example of the impact of using playful vocal expression was given by Wilma: “He looks fascinated when I play with funny voices, and anything I do that is exaggerated, it feels like he is becoming more alert by it.”

Changing voice dynamics and intonation.

Four participants described various ways that they exaggerated their vocalizations when working with verbal children. Zina demonstrated cross-modally matching a child’s drumming through changes in her vocal intonation: “When a child plays [the percussion instruments]… I would do ‘Boom, Boom, Boom, UHHHH Wah!’ [says in an increased and decreased tone].”

Matching and mirroring.

Mirroring was described by five participants as an exact imitation performed on the same instrument, or as Wilma explains, by vocally mirroring certain features in the child’s music, such as dynamics, tempo, or pitch.

We had some vocal games, such as imitations or joint singing, when he played a melody on the electric keyboard and I would respond with my voice accordingly. When he would play a fast melody, I would respond accordingly with fast vocalization.

Donna described a similar use of musical matching response: “My musical response is matched to the child in the intonation, level of singing, and also by sometimes pausing and allowing him a break.”

Tension and release.

Creating tension and release was described by three participants as a key therapeutic use of music that promoted the child’s flexibility, enjoyment and interaction in the play, particularly when the music therapist perceived that the child’s play was becoming repetitive. Wilma explained how she practiced the principle of tension and release with the child by using a musical movement game involving starting and pausing: “Each time the music stops, one of the animals falls until the last one is left.” Donna demonstrated the use of rhyming words and musical pauses as a means to create tension and anticipation to engage the child and support them in experiencing a sense of release: “So I have this song and he completes it: ‘The play-dough, you know, you roll and you roll until it becomes a…. Ball!’ I made this song up, he can’t say all these words but he can complete the end of the sentence.”

Creative Use of Songs.

All participants described their creative use of songs in their work with verbal children. Songs were predominantly described in two ways: adapting familiar pre-composed songs; and improvising or writing new songs. In all cases, the songs were used dynamically in the session, and included improvisational elements, such as changes and variations.

Adapting familiar songs.

Four participants described their use of familiar songs as a means to create variations and playfulness. They described spontaneously selecting popular songs that burst in their minds during the session and using them to promote interaction with the child. Zina explained the therapeutic potential of improvising with familiar songs to promote playfulness:

I sang [sings a familiar song about a ship] and then we changed it, we sang about the tractor, and then he asked to sing about the helicopter, so we did [it] using the same tune... he knew that when we’ll sing about the helicopter it would always sound this way, and also when we would sing about the tractor, so in a deeper level, it gave him an easier basis to improvise upon later.

Improvising and song-writing.

All of participants gave examples of how they use spontaneous song-writing and its benefits: “I can invent the song by myself or I begin a song and let the child complete it, complete a certain word” (Donna). While sometimes the therapist would initiate the song-writing, at other times the child was the one initiating: “He would start singing something and I would join him and turn it into a short song we would repeat” (Sara). The songs were used to expand the play and verbal communication of the child:

He had a [game] where he put the dolls to bed and told them “good night”, so I made up a song about it, and ever since then he asks me to repeat it whenever he played this game. Later on [in the therapy process] he invited me to join him in the play and go to sleep with him (Wilma).

At other time the songs were used as an invitation from the child to improvise imaginative play: “He told me which content to add, he said ‘Now let’s sing about the plane, he is a friend of the tractor and together they do this and that’” (Zina).

Discussion

This study aimed to explore music therapists’ use of music and perception of its therapeutic potential in their work with children on the autism spectrum who have verbal skills. The main qualitative themes from the interviews emphasize how the music therapists used the music in different ways in order to musically attune to the child’s emotional, physiological, creative, and playful qualities. These musical interactions were perceived as helping to create a shared experience between the child and therapist that supports the child’s regulation, continuity, organization, and vitality within the play. The main themes will now be discussed in relation to the existing literature.

Theme 1: Musical Infrastructure

There was a great deal of similarity in the way the participants described how they used music to facilitate important foundational qualities to support social interactions, despite the fact that the children had language skills. These foundational qualities were organized into two sub-themes: regulation, and a sense of continuity.

Regulation.

The unique developmental trajectory of children with autism has been well described, with some stages occurring in a different sequence to typically developing children, while others are more or under developed (Marco, Hinkley, Hill, & Nagarajan, 2011). For example, while intellectual and language skills may be well developed, different forms of self-regulation may require support (Greenspan & Wieder, 2006; Grzadzinski et al., 2013).

According to Stern’s (2000) theory, the early experience of inter-subjectivity is comprised of the ability to experience the other (e.g., a care giver) as self-regulating. Stern described in detail different forms of regulation achieved early in life through the relationship with the other: Attachment regulation, arousal regulation, attention regulation, pleasure and displeasure regulation, self-esteem regulation, affect regulation, and more. Schumacher and Calvet (2007a) have based their work with children on the autistic spectrum on this notion, emphasizing that in order to form inter personal relationships, one must first be able to achieve emotional regulation through the other person. Trondalen (2016) more broadly explained that even when language emerges and symbolic thinking is possible, regulation remains a critical basis for verbal dialogues. These positions are reflected in the descriptions offered by the participants in this study, who perceived that music often supported different forms of regulation in verbal children with autism. The participants gave examples of attention regulation, arousal regulation and affect regulation, and described how the predictable elements and structures in the music promoted the children’s ability to self-regulate and to build a trusting relationship with the music therapist (Wigram & Elefant, 2009).

Sense of Continuity.

Participants explained their perception of how their use of music supported the child to link previous experiences and create a line that connects past, present, and future. Similarly, Maiello’s (2001) psychoanalytic theory explained that in order to tolerate surprises and lack of continuity and synchronicity, the child must have an established infrastructure of intersubjective continuity and stability, which is formed through foundational interactive rhythmic experiences.

Continuity was described by the participants in three different ways. The first is the intra-personal, where the music therapist used the music to support the child’s ability to experience the self as continuing. Secondly, the participants described ways they used music to promote inter-session continuity. The concept of inter-session continuity aligns with Geretsegger and colleagues findings (2015), in which they defined “tapping into the shared history of musical interaction” (p. 272) as a unique and essential principle in improvisational music therapy with children with ASD. This shared musical repertoire is created over the course of therapy and then can be used by the child or therapist to provide a sense of predictability, familiarity, and anticipation (Geretsegger et al., 2015). Thirdly, participants described moments where their musical responses to the child helped create a continuous narrative in the child’s creative verbal or dramatic play-plots, which is similar to descriptions from previous case studies with verbal children (Oldfield & Franke, 2005; Thompson, 2018).

While many of the musical responses described by participants in their work with verbal children have similarities to previous descriptions of the use of music with nonverbal children, the importance of supporting a continuing verbal narrative is a distinct finding. These participants described how verbal children with autism often bring imaginative stories and thoughts to the therapy room, compared with nonverbal children. However, the participants considered that these verbal play-narratives were often difficult to understand and appeared disorganized and nonlinear. The musical infrastructure provided by the music therapists was perceived as providing a platform for interaction that both therapist and child could access and therefore co-create a more coherent play narrative.

Theme 2: The Meeting Point Between Musical and Verbal Playfulness

When working with children with verbal skills, the participants emphasized that they often chose to introduce foundational musical aspects to the child’s imaginative play, such as vitality, arousal, emotional expression, and joy. They also introduced various uses of music to foster the child’s play and verbal expression.

From Words to Music: Adding Vitality.

The participants expressed that they used cross-modal musical/vocal motives to add vitality to the children’s play, as a means to expand the child’s play and expression. Stern (2010) emphasizes the developmental importance of vitality as a basic human experience that is felt and shared in every action and interaction in early childhood. However, Stern also proposes that vitality continues to be important throughout life to support interpersonal relationships and complex communication through expressive forms that can be described in musical terms such as fading away, crescendo, accelerando and more (Stern, 2010). Similar to the ways that parents attempt to increase the infant’s range of experience (Ammaniti & Ferrari, 2013), the participants explained how they often used exaggerated vocal sound effects, such as explosions, fading and whispering to add a sense of expanded vitality to the play.

From Music to Words: Music Fosters Verbal Expression and Imaginative Play.

Most of the participants described how musical experiences fostered the socio-dramatic or imaginative play of the child. They considered that the music helped to add meaning to the play in various ways, such as by sparking ideas for narratives/actions in the child’s play or inspiring the child to expand on their story and the progression of the play. The participants referred to ways they provided a musical infrastructure for the child, suggesting that it might later serve as the grounds for the expanded development of imaginative play. Similar to the notion of musical scaffolding proposed by Geretsegger et al. (2015), the music therapists described various ways they used scaffolding in the child’s verbal interactions and play with music.

Many participants perceived that the musical experiences promoted development in the child’s spontaneous play ideas. At times when the child was involved in activities that did not make sense to the therapist, using songs and improvisation allowed the therapist to add content and meaning so that the play could be shared as a joint experience. These findings differ from previous literature focused on children with more severe symptoms of autism, where the music therapist often musically synchronizes with the child’s movements and actions, creating a sense of organization and meaning (Schumacher and Calvet, 2008). The results from this study suggest that when working with verbal children with autism, rather than simply synchronizing to the child’s verbal expressions, music therapists might look deeper into the apparent play and attempt to match the sometimes small and unexpected emotional states and expressions occurring in the play. By joining the children’s nonmusical play using musical forms, the interactions may be turned into new sharable and meaningful interactions.

Theme 3: Musical Responses

The participants described two main forms of musical responses to the child: vocalizations that focus on the proto-musical features of the child’s expressions; and creative use of songs to accompany the child’s play and behaviors. In each form, the music therapists described instances when they were highly musically attuned to the child.

Musical Attunement.

Similar to definitions in the music therapy literature, participants described musical attunement as adjusting their musical responses to the child’s behavior and/or emotional state (Carpente, 2016; Geretsegger et al., 2015, Kim et al., 2009; Schumacher & Calvet, 2007b; Wigram & Elefant, 2009). They described moments where their own musical initiations “didn’t work” to engage the child, driving them to attune better to the child’s initiations. The participants described striving to musically attune to what the child brings, or more accurately how the child brings it. According to Stern (2000), adults striving to attune to the child will lead to a state where the child feels understood, and for communication to be possible. The participants’ musical responses to the child’s verbal interactions suggest that attuning to the child’s perceived emotional state is paramount even when the child has verbal skills. Through striving to attune to the child, the therapist may create a musical infrastructure that allows for future sharing of experiences and social reciprocity.

Vocalizations to Respond to Proto-musical Features of the Child’s Expressions.

The participants described various ways they use proto-musicality within their music therapy sessions, and emphasized the importance of using their voice. The voice constitutes the primary medium of supporting early parent–child relationships and human communication (Malloch & Trevarthen, 2009; Stern, 2000). The participants described different uses of their voice, such as changes in intonation, dynamics and taking on different characters in role-playing. They responded to the child’s expression by replying with an augmented and exaggerated vocal response. In this way, they considered that they helped increase the range of the child’s expression, adding a quality of vitality to the speech or play. They described creating a vocal response that fascinated the child and called for his attention, promoting mutual enjoyment and communication. The participants’ descriptions support Salomon-Gimmon and Elefant’s (2018) findings from a video microanalysis proposing that the vocal techniques used by music therapists may promote social communication development in children with ASD.

Creative Use of Songs.

All participants described using pre-composed or improvised songs as a means to create variations and playfulness. Through adapting familiar songs, the therapist can add variations and surprises, and therefore provide opportunities to experience changes and interruptions (Wigram & Elefant, 2009). The participants also described how they improvised based on the child’s story or play, while at other times, the child would be the initiator and the therapist would continue and build the remaining song structure. All participants described using songs as a means to expand the child’s play, improvisational skills and verbal communication. These findings align with Oldfield and Franke’s (2005) work revealing that using song improvisation for story telling allowed the therapist to observe the emotional responsiveness in the child in a different manner than non-musical interactions, often shedding light on their inner emotional world. They found that the music-making accompanying the story telling appealed to children and served as a motivator for their continued creativity. The improvised songs helped the children relax into the interaction, offering them a predictable structure, an equal communication with the therapist and a playful environment.

Limitations of the Research

Due to the illusive definition of the research population, that is, children with high functioning autism or verbal children with autism, a potential limitation concerns the interpretation of these terms made by the participants in selecting clients to reflect upon in their interviews. Every effort was made to highlight that the focus of the interview questions was on those clients with verbal ability, however the participants were free to reflect on their work with clients in a broad way. Furthermore, these therapists were all from the same country and are likely to have received similar training in music therapy. The results may therefore be influenced by the cultural and training lens of the participants. Similarly, the author’s lens as elaborated above has influenced the explication of the themes within the interviews.

Conclusion

This research examined six music therapists’ perceptions of their musical facilitation when working with verbal children with autism. The findings highlight how these music therapists actively initiated the use of music in the sessions, particularly the use of vocalizations and songs, in order to engage the child in mutual play and expand on their play routines. They explained how they endeavor to acknowledge and utilize the child’s intellectual and language skills in order to enhance musical and communicative interactions. These findings suggest that even when working with verbal children, music therapists strive to musically attune to the child’s emotional, physiological, creative and playful qualities, in order to support and expand shared experiences within the play. When verbal children on the autism spectrum are involved in dramatic play or storytelling, the music therapist has an important role to play in addressing more foundational qualities, such as supporting emotional, arousal, and attention regulation, a sense of continuity, and vitality. Vocal responses and the creative use of songs were used by participants in this study as the primary way to support musical and emotional attunement to the child. These findings might serve music therapists as a preliminary suggestion for applying music while meeting children with autism who are verbal. Further research is needed to explore these findings with music therapists from different cultural and training backgrounds.

Notes on Contributors

Shulamit Epstein is trained as a music therapist from the Levinsky College of Education and currently is a PhD student at the University of Haifa, Israel. She holds a position as a music therapist at the Sheba medical center, working with children with ASD. The current study was part of Shulamit’s MA research completed in 2017 and supervised by Cochavit Elefant.

Cochavit Elefant is an Associate Professor in music therapy at the University of Haifa. She has practiced for many years as a music therapist with children with autism and other disabilities and their families, and published on topics of Autism, Rett Syndrome as well as Community Music Therapy. She holds a PhD from Aalborg University, Denmark with a dissertation on Communication in girls with Rett syndrome.

Grace Thompson is a Senior Lecturer in music therapy at the University of Melbourne, Australia. She has 25 years of clinical experience as a music therapist, working with children with autism and other disabilities and their families. She holds a PhD from the University of Melbourne, Australia, with a dissertation exploring family-centered music therapy with children on the autism spectrum.

This study was completed in partial fulfillment of the first author’s degree of MA in Music Therapy at the University of Haifa, Israel.

Conflict of interest: None declared.

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