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Autism: Family Life - Tactics for Getting Normal Again
Autism continuing education addiction counselor CEUs

Section 14
The Language of Music: Families Working with Children with Autism

CEU Question 14 | CEU Test | Table of Contents | Autism
Psychologist CEs, Social Worker CEUs, Counselor CEUs, MFT CEUs

For some children music is the means of communication and developing a relationship. For others, less severely affected, music can be the medium for enhancing verbal communication. One child I worked with, while having no functional communication, had a storehouse of holiday and children's songs in her head, as I found out one day when I didn't play the last note of a song. Not only did she say the correct word, she sang it at the right pitch. With limited-verbal children of this nature, it is often possible to get them to supply the missing words to a song they know by suddenly stopping the song and accompaniment at points of "maximal tension."² These places of maximal tension (Miller & Eller-Miller, 1989, p. 65, 93) occur during the last few notes of a cadence. An example would be to sing "twinkle, twinkle, little -----" and wait for the child to fill in the missing word "star."

Another person I worked with used facilitated communication (FC). FC depends on another person providing arm or wrist support to someone typing on a keyboard or touching pictures on a communication board. This does raise difficulties in separating the intentions of the person being helped from those of the helper. Be that as it may, when I supported this person's arm to play a piano keyboard, he was able to sing, indeed sing well, old songs he must have heard as a child. This seemed to be the only way that he could sing these songs.

With one particular child with Asperger syndrome, all of my communications are sung. If I mistakenly lapse into a typical conversational tone, he loses focus, engages in self-stimulatory activities, and drifts away. The music helps to organize verbal communication skills that already exist. And by holding the child's interest, I can turn the sessions into fairly typical music lessons.

During the first session with this child, I created a system³ where the child asked me for pieces of paper that had the letter names of the notes. Once this series of events was internalized, I expanded the routine by having him place the notes on the appropriate place on the music staff. This system was expanded further by having him draw a circle on the staff where the note belonged and write in the letter of the note. Then he would give the note to his mother. Fine motor problems were present, and drawing a circle first helped confine where the note should go. Asking him on which space or line the note should go (as opposed to a generic "Where does the note go?") also helped. The system was expanded yet again by having the child guess which note I had in my hand. After guessing correctly he then had to write the note on the staff before receiving the piece of paper. We then took turns as he held the notes, with either his mother or me having to guess which note he had in his hand. When it came time for me to write the note on the staff, I would ask him in a singing voice on which line or space it went.

Other parts of the session were spent in imitative drumming, and later, work on the recorder. I made certain that we took turns in leading the imitation. This was a good activity to do when he seemed to be fading away and losing focus. His mother quickly caught on to our activities; she participated very well in the session, and we all had a pleasurable experience. The child has a lot of musical ability and using the Miller method (Miller & Eller-Miller, 1989; Miller, 2000), he was taught to play the recorder and later the piano, which he now plays well.

With the child that already plays an instrument, I will introduce myself into his world by sharing the instrument via turn taking. When I play the instrument the child accompanies me on percussion. Then we switch roles. The turns start out short and gradually lengthen to where I work on other issues such as verbal skills, writing, and motor control as needed. To establish equality between us, I must also take my turns doing anything I require of him or her. I too, for example, need to ask permission to use the keyboard if the child is already using it.

Music can also be used to organize behavior when working with a group of children, by having them walk or otherwise move to the rhythm of the music. Often I will have them march in a circle as I play music on a keyboard. With the help of aides, I will have the students stop when I stop playing and continue when I resume. When the children understand when to stop and start, I will turn this into a game similar to "musical chairs" where the person who stops last is "out" and has to sit down. Realizing that it is unreasonable to expect these children to sit still with their hands folded while the game plays itself out, I give them a shaker — but not before they ask for it and identify the piece of fruit the shaker represents, if appropriate.

The worst possible thing, which I have too often seen, is children sitting in a circle around a large instrument with nothing to do while they wait to take a turn on the instrument. Typically, the children fall into a disorganized mass of self-stimulatory and challenging behaviors. This situation, caused by failing to engage all the children in a classroom, is entirely preventable.

For the child at the high-functioning end of the autism spectrum, the school band may provide an important avenue for development. The trombone requires a good kinesthetic sense of where one's arm is in order to place the trombone slide in the right place for a note to be in tune. Other instruments, except for the stringed ones, require less ear-to-arm coordination, as the pitches are obtained with the assistance of keys or valves. The French horn, however, demands much coordination of the embouchure.[sup4] Percussion may be another avenue. If complex rhythms present a challenge, the bass drum may be a good choice as the musical patterns are relatively simple. Additionally, the bass drum with its low and relatively simple sound waves is often easier for a person with sound sensitivities to handle. Finally, being at the rear of a potentially cacophonous musical ensemble may be of help, as it is less noisy there.

Location in the ensemble may have to take sensory sensitivities into account. If a student with autism insists on playing a certain instrument and it is clear that there will be problems with sound sensitivities, allowing the child to sit in a different location may be easier than rearranging the ensemble in a nonstandard manner. I skipped many jazz band rehearsals in high school because the director was unwilling to let me sit elsewhere than right in front of the blaring trumpets. In addition to the purely musical benefits, playing in an ensemble is good for working on cooperation with others, coordination, and a sense of accomplishment.

Conclusion
Music has many benefits in working with learners on the autism spectrum. Music provides an alternative means of communication for those who are nonverbal, and for others it can help to organize verbal communication. Music can improve self-esteem, as the child is given an activity he or she can potentially excel in. Finally, playing a musical instrument gives persons with autism a typical means for engaging in social interaction in school and in the community, centered on their strength.
- Shore, Stephen, Screening, The language of music: working with children on the autism spectrum; Journal of Education; 2002; Vol. 183; Issue 2.
The article above contains foundational information. Articles below contain optional updates.

Personal Reflection Exercise #7
The preceding section contained information about using music to work with autistic children.  Write three case study examples regarding how you might use the content of this section in your practice.

Online Continuing Education QUESTION 14
What are the advantages of a child with autism playing music in an ensemble? Record the letter of the correct answer the CEU Test.

 
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Impact of a digital Modified Checklist for Autism in Toddlers–Revised on likelihood and age of autism diagnosis and referral for developmental evaluation
Autism, Ahead of Print.
The present study is a single-site quality improvement project within pediatric primary care involving the implementation of a digital version of the Modified Checklist for Autism in Toddlers–Revised. We evaluated the impact of the digital screener on the likelihood of physician referral for a developmental evaluation or autism diagnosis, and the age of the patients at the time of the event. Patients were children 16–30  months old seen for 18 and 24 months’ well-child visits (1279 encounters), who screened positive for risk for autism spectrum disorder on the Modified Checklist for Autism in Toddlers–Revised without a previously documented autism spectrum disorder diagnosis. Comparisons were made between a cohort of children screened with the paper and pencil version of the Modified Checklist for Autism in Toddlers–Revised before the digital version was implemented and a cohort of children screened during the intervention period. Patients were followed until 48 months and referrals were obtained from electronic health records. Patients screened with the digital Modified Checklist for Autism in Toddlers–Revised were five times more likely to be referred for a developmental evaluation. The automatic scoring, risk assessment, and referral decision support features helped to improve screening outcomes. In this clinic, process change to a digital screening method with automatic guidance for next steps improved adherence to evidence-based clinical care.Lay abstractThis was a project in primary care for young children (1–2 years old). We tested a parent questionnaire on a tablet. This tablet questionnaire asked questions to see whether the child may have autism. We compared the paper and pencil version of the questionnaire to the tablet questionnaire. We read the medical charts for the children until they were 4 years old to see whether they ended up having autism. We found that doctors were more likely to recommend an autism evaluation when a parent used the tablet questionnaire. We think that the tablet’s automatic scoring feature helped the doctors. We also think that the doctors benefited from the advice the tablet gave them.
Implementing early intensive behavioral intervention in community settings
Autism, Ahead of Print.
Although research shows early intensive behavioral intervention is efficacious when delivered in university or private intervention centers, little is known about effectiveness or feasibility of disseminating early intensive behavioral intervention to larger communities. The Michigan State University Early Learning Institute was developed to address gaps in distribution of early intensive behavioral intervention to community settings, with an emphasis of serving children and families on Medicaid. This short report describes the Early Learning Institute’s approach and preliminary utilization data among Medicaid families. Results suggest the model has potential for dissemination within community settings and promote utilization among Medicaid children.Lay abstractAlthough research shows early intensive behavioral intervention can be very beneficial for children with autism spectrum disorder when delivered in university or private intervention centers, little is known about the best way to provide early intensive behavioral intervention within the broader community. The Michigan State University Early Learning Institute was developed to address challenges with providing early intensive behavioral intervention in community settings, with an emphasis on serving children and families on Medicaid. This short report describes the approach taken by the Early Learning Institute and reports data regarding enrollment and utilization among Medicaid families. Results suggest the model has potential to be used within community settings and that children on Medicaid are likely to consistently attend their treatment sessions.
Work, living, and the pursuit of happiness: Vocational and psychosocial outcomes for young adults with autism
Autism, Ahead of Print.
Longitudinal data on the functioning of adults referred for possible autism as children are sparse and possibly different from datasets consisting of adult clinical referrals. A total of 123 young adults, mean age of 26, referred for neurodevelopmental disorders in early childhood were categorized into three outcome groups: autism spectrum disorder (ASD) diagnosis at some point and current intelligence quotient (IQ) ⩾ 70 (Ever ASD-Higher IQ), ever ASD and current IQ < 70 (Ever ASD-Lower IQ), and individuals who never received an ASD diagnosis (Never ASD). Independence and well-being were assessed through direct testing, questionnaires, and interviews. Verbal IQ, beyond intellectual disability status, accounted for group differences in employment; autistic features (Autism Diagnostic Observation Schedule Calibrated Severity Score) were uniquely related to adaptive skills and friendships. In many ways, the Never ASD group had similar outcomes compared to the ASD groups. However, lower well-being and fewer positive emotions were related to ASD diagnosis across IQ. The Ever ASD-Lower IQ group had the highest levels of irritability, hyperactivity, and medications. Families played a major role in supporting adults with and without ASD at all intellectual levels. Realistic ways of increasing independence should be developed through working with adults and their families, while acknowledging the contribution of individual differences in mental health, intelligence, and autism symptoms across neurodevelopmental disorders.Lay abstractIt is important to better understand how adults with autism are functioning in adulthood. Studies that have tracked individuals across the lifespan can help identify developmental factors influence differences in adult outcomes. The present study examines the independence, well-being, and functioning of 123 adults that have been closely followed since early childhood. Autism diagnosis and cognitive assessments were given frequently throughout childhood and during adulthood. We examined differences between adults who had received an autism diagnosis at some point with higher cognitive abilities (Ever ASD-High IQ) and lower cognitive abilities (Ever ASD-Low IQ), as well as adults who never received a diagnosis of autism in the course of the study (Never ASD). We found that autistic features specifically related to adaptive skills and friendships, and verbal intelligence related to work outcomes. In many ways, the Never ASD group had similar outcomes compared to the ASD groups. However, adults with ASD tended to have lower well-being and fewer positive emotions. Families played a major role in supporting adults with and without ASD at all intellectual levels. The findings suggest that realistic ways of increasing independence need to be developed by working with adults and their families, while acknowledging the contribution of individual differences in mental health, intelligence and autism symptoms across neurodevelopmental disorders.
Does implementing a new intervention disrupt use of existing evidence-based autism interventions?
Autism, Ahead of Print.
This study examines how the introduction of TeachTown:Basics, a computer-assisted intervention for students with autism spectrum disorder, influenced teachers’ use of other evidence-based practices. In a randomized controlled trial that enrolled 73 teachers nested within 58 schools, we used three-level hierarchical linear models to evaluate changes in teachers’ use of evidence-based practices across the school year for those who received TeachTown:Basics versus those assigned to control. Both groups received training and implementation support to deliver three well-established evidence-based practices for autism spectrum disorder. Qualitative interviews were conducted with 25 teachers who used TeachTown:Basics to better understand their experience. Compared with teachers in the control group, teachers in the TeachTown:Basics group reported significantly less growth over the 9-month period in their use of evidence-based practices that require one-to-one instruction (ps < 0.05), but no difference in their reported use of evidence-based practices that do not involve one-to-one instruction (p = 0.637). Qualitative interviews indicated that teachers viewed TeachTown:Basics as an effective substitute for one-to-one instruction because it was less burdensome, despite the lack of support for TeachTown:Basics’ effectiveness. Before introducing new practices, education leaders should carefully consider both evidence of effectiveness and the potential impact on the use of other evidence-based practices.Lay abstractInterventions for children with autism spectrum disorder are complex and often are not implemented successfully within schools. When new practices are introduced in schools, they often are layered on top of existing practices, with little attention paid to how introducing new practices affects the use of existing practices. This study evaluated how introducing a computer-assisted intervention, called TeachTown:Basics, affected the use of other evidence-based practices in autism support classrooms. We compared how often teachers reported using a set of evidence-based practices in classrooms that either had access to TeachTown:Basics or did not have the program. We found that teachers who had access to the computer-assisted intervention reported using the other evidence-based practices less often as the school year progressed. Teachers also reported that they liked the computer-assisted intervention, found it easy to use, and that it helped overcome challenges to implementing other evidence-based practices. This is important because the computer-assisted intervention did not improve child outcomes in a previous study and indicates that teachers may use interventions that are appealing and easier to implement, even when they do not have evidence to support their effectiveness. These findings support the idea of interventions’ complexity and how well the intervention fits within the classroom affect how teachers use it and highlight the need to develop school-based interventions that both appeal to the practitioner and improve child outcomes.
Autistic peer-to-peer information transfer is highly effective
Autism, Ahead of Print.
Effective information transfer requires social communication skills. As autism is clinically defined by social communication deficits, it may be expected that information transfer between autistic people would be particularly deficient. However, the Double Empathy theory would suggest that communication difficulties arise from a mismatch in neurotype; and thus information transfer between autistic people may be more successful than information transfer between an autistic and a non-autistic person. We investigate this by examining information transfer between autistic adults, non-autistic adults and mixed autistic-with-non-autistic pairs. Initial participants were told a story which they recounted to a second participant, who recounted the story to a third participant and so on, along a ‘diffusion chain’ of eight participants (n = 72). We found a significantly steeper decline in detail retention in the mixed chains, while autistic chains did not significantly differ from non-autistic chains. Participant rapport ratings revealed significantly lower scores for mixed chains. These results challenge the diagnostic criterion that autistic people lack the skills to interact successfully. Rather, autistic people effectively share information with each other. Information transfer selectively degrades more quickly in mixed pairs, in parallel with a reduction in rapport.Lay abstractSharing information with other people relies on the ability to communicate well. Autism is defined clinically by deficits in social communication. It may therefore be expected that autistic people find it difficult to share information with other people. We wanted to find out whether this was the case, and whether it was different when autistic people were sharing information with other autistic people or with non-autistic people. We recruited nine groups, each with eight people. In three of the groups, everyone was autistic; in three of the groups, everyone was non-autistic; and three of the groups were mixed groups where half the group was autistic and half the group was non-autistic. We told one person in each group a story and asked them to share it with another person, and for that person to share it again and so on, until everyone in the group had heard the story. We then looked at how many details of the story had been shared at each stage. We found that autistic people share information with other autistic people as well as non-autistic people do with other non-autistic people. However, when there are mixed groups of autistic and non-autistic people, much less information is shared. Participants were also asked how they felt they had got on with the other person in the interaction. The people in the mixed groups also experienced lower rapport with the person they were sharing the story with. This finding is important as it shows that autistic people have the skills to share information well with one another and experience good rapport, and that there are selective problems when autistic and non-autistic people are interacting.

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