Music Interventions for Neurodevelopmental Disorders

Music Interventions for Neurodevelopmental Disorders

Alessandro Antonietti Barbara Colombo Braelyn R. DeRocher

Music Interventions for Neurodevelopmental Disorders

Alessandro Antonietti · Barbara Colombo Braelyn R. DeRocher

Music Interventions for Neurodevelopmental Disorders

Alessandro Antonietti Department of Psychology Catholic University of the Sacred Heart Milan, Italy

Braelyn R. DeRocher Department of Psychology, Division of Education and Human Studies Champlain College Burlington, VT, USA

Barbara Colombo Department of Psychology, Division of Education and Human Studies Champlain College Burlington, VT, USA

ISBN 978-3-319-97150-6 ISBN 978-3-319-97151-3  (eBook) https://doi.org/10.1007/978-3-319-97151-3 Library of Congress Control Number: 2018949614 © The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer International Publishing AG, part of Springer Nature 2018 This work is subject to copyright. All rights are solely and exclusively licensed by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, express or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. Cover illustration: © Melisa Hasan This Palgrave Pivot imprint is published by the registered company Springer Nature Switzerland AG The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland

Preface

The book aims at informing about what music can do to improve the skills that are impaired in some neurodevelopmental disorders (specifically: ADHD—Attention Deficit-Hyperactivity Disorder, autism, and Rett Syndrome). Rehabilitation interventions based on the use of music (the so-called “music therapy”) are relatively widespread, but only some approaches show empirical support to the alleged benefits they produce. Given these premises, in this volume, the authors try to provide readers with an updated and scientifically grounded perspective, which can explain why music is effective in promoting the acquisition of some basic mental abilities. Research data showing to what extent musical activities can guide children affected by neurodevelopmental disorders to improve those skills will be reported. Also, examples of training programs and exercises addressing the target populations will be described. The purpose is to show that music can be a valid aid in rehabilitation, stressing the difference between evidence-based methods and other approaches, which may be fascinating but not scientifically grounded. Music is certainly not aimed at reaching educational or rehabilitative goals. In human cultures, where music is always present, it is generally linked to the production of sounds with the voice or instruments and people can participate through listening or movement. This production fits other purposes, which can be individual (e.g., expressing one’s mental states, communicating emotions and intentions, inducing

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particular psychophysical conditions, experiencing pleasure) or collective ­(coordinating work and collaborative behaviors, increasing group cohesion, demarcating identity, etc.). Soon, however, it has been discovered that taking part in the creation and fruition of music can help support development and transformation because of the personal and social changes that it triggers. Hence music has been intentionally oriented to acquire skills that are not acquired yet (educational and training use), to enhance existing skills that need to be refined or further developed (empowerment), to favor the recovery of skills that, while previously owned, have been lost or compromised, for example as a result of trauma (rehabilitation use), or which are lacking, for example, because of developmental disorders (habilitation use and therapy). If we try to reconstruct the story—that is partially anecdotal, partially documented—of the attempts to use music for this kind of objectives we face a long and complicated task. Only in recent times, a proper scientific foundation for music therapy can be easily found. The techniques that are often used in music-therapy settings have matured through intense and prolonged personal experiences over time and have also been applied to a broad set of cases. A first step to validate this set of personal experiences consisted of linking those techniques to accredited conceptual frameworks to be able to justify practices through terms and constructs shared by the scientific community. A further step should be taken since many people still mistrust these methods. In fact, the goal should be to be able to present objective evidence of their validity, going beyond the simple “impressions” of effectiveness that derive from music therapists and from subjective feedbacks of benefit that patients provide. Skeptics must be convinced that involving children in activities based on the production of or listening to sounds can be trusted to lead to reliable results. However, even before providing evidence to others, it is a matter of sharing, among professionals, methods that allow monitoring interventions and evaluating the outcomes to become more aware of the specific types of change that are induced in their patients, and thus make practices more and more specifically focused. This book documents different music-based interventions applied to rehabilitation. Each chapter focuses on a different use of music and presents one or more interventions carried out for a specific rehabilitation purpose, the tools used to evaluate the effects produced by the

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interventions, and the results obtained. Beside providing examples of specific interventions, the purpose of the volume is to contribute to the growth of the scientific recognition of music-based therapeutic approaches. This is why we present the tools used to evaluate the changes produced by the interventions: to enable other operators and researchers to apply them. In fact, in addition to using existing validated tools, some of the monitoring and assessment tools that are introduced have been particularly devised to evaluate the very psychological dimension to which each intervention was directed. The volume also intends to give another type of contribution: to enrich the repertoire of existing musical intervention techniques with new activities developed starting from soundly designed experimental studies. These activities are described in a sufficiently analytical way to allow the reader to replicate their application. The reader will understand that the interventions, as well as the procedures used to evaluate their outcomes, derive from different influences and have been implemented in different settings. The different chapters aim at showing how, depending on specific objectives and different contexts, the therapist might choose different approaches. In some cases, a very focused “technical” approach, with an exact definition of the expected changes and with the rational planning of the stages of the intervention, needed to be favored. In other cases, the interventions were conducted flexibly, adapting the activities as a response to the dynamics of the interpersonal relationship between the therapist and the patient, following the state of the moment or responding to the cues offered by the patients. This allows for a procedure that, while not losing sight of a well structured general layout, gives some space to the sensitivity of the operators and to their intuitions. This tension between rigor and freedom, planning and improvisation, technicality and empathy always crosses psychological interventions, which are never either completely pre-determined or open to what emerges during the process. In the first chapter, the reasons why music can be useful in rehabilitation within the field of neurodevelopmental disorders are discussed. A comprehensive theoretical model, supported by experimental findings, is presented. According to this model, music can prompt or enhance the development of mental skills since it elicits mental processing at different levels: motor, visual, and verbal. The three levels, when synchronized, induce synergic effects that act as “scaffolding” tools, facilitating the acquisition of the ability to be trained.

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The second chapter is focused on Attention Deficit-Hyperactivity Disorder (ADHD). Music can play a role in the treatment of children and adolescents with ADHD since it provides patients with a self-regulatory system, which enables them to manage the internal time according to variations in the external time and to synchronize behavior with external stimuli. Thanks to these mechanisms the individuals get control over their impulsive tendencies and can plan their behavior according to the goals they set. The relevant literature about the effects of musical interventions for ADHD patients is reviewed. Some studies aimed at improving self-control in people with ADHD through music intervention programs (consisting of either individual or small-group sessions), as well as different activities included in such programs, are described. Autism Spectrum Disorder (ASD) is the topic of the third chapter. Music treatments targeting individuals with ASD usually aim at enhancing social skills. To do so, musical activities are paired with a series of underlying competencies to be acquired. This chapter focuses on some of these essential competencies, such as the detection of the congruence between the emotional valence of music and the mood states it elicits, the identification of the relationships between the sounds and the motor acts that produced them, the ability to mirror the partner’s mental state through the production of musical acts. Experimental findings supporting the notion that these basic competencies can be acquired or refined by people with autism, as well as the outcomes of musical treatments focused on those skills, are reported in the chapter. In the case of Rett Syndrome, the focus of the fourth chapter, among the variety of possible goals, which can be reached through music interventions (associated to the different pathological manifestations of the syndrome), motor coordination has been chosen as one of the critical deficits characterizing the disorder. Literature supporting the benefits of musical activities when working with Rett Syndrome patients is summarized and reasons highlighting why music might be particularly effective in this fields are explained. An intensive training program implemented with a girl affected by Rett Syndrome is described in detail and several activities carried out during the intervention are exemplified. Finally, some general remarks about why music can be employed in rehabilitation interventions, which can be valid for all the neurodevelopmental disorders considered in the book, are reported. Practical suggestions for parents and rehabilitators, as well as music teachers, are

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proposed so to allow readers to link the outcomes of research to what can be concretely done to promote the enhancement of essential skills in children affected by neurodevelopmental disorders. Milan, Italy Burlington, USA

Alessandro Antonietti Barbara Colombo Braelyn R. DeRocher

Contents

1 The Reasons Supporting the Use of Music in Rehabilitation 1 Three Mental Registers 2 Relationships Within and Between Registers 5 The Motor Register 7 The Iconic Register 9 The Verbal Register 11 Concluding Remarks 13 References 14 2 Enhancing Self-Regulatory Skills in ADHD Through Music 19 Defining ADHD 19 Music Interventions Addressed to ADHD 26 Music and ADHD: Possible Relationships 33 A Single-Case Study Intervention 35 Structure of the Intervention 36 Aims of the Intervention 36 Activities Included in the Intervention 38 Assessment of the Intervention 39 Outcomes of the Intervention 40 Final Comments 41 A Group Intervention for ADHD Children Based on Music 42 Activities Included in the Intervention 43 xi

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Assessment of the Intervention 44 Outcomes of the Intervention 45 Concluding Remarks 45 References 46 3 Enhancing Social Skills in Autism Through Music 51 Defining Autism 51 The Benefits of Using Music with Autism 53 Examples of Assessment Techniques and Training Programs 56 Perception and Discrimination of Musical Rhythm, Intensity, and Speed 57 Perception of Synchronization Between Sounds and Gestures in Music-Based Communication 58 Preferences for Different Aspects of Emotional Music Stimuli 58 Perception of Synchronization of Different Musical Elements in Music-Based Communication 59 Results from the Assessment and Ideas for the Intervention 60 Imitation Interventions Based on Technological Devices 62 Imitation and Autism 62 The Soundbeam Intervention Project 64 Concluding Remarks 67 References 68 4 Stimulating Motor Coordination in Rett Syndrome Through Music 75 Defining Rett Syndrome 75 Music Therapy and Rett Syndrome 77 Music and Rett Syndrome 77 Music Therapy to Promote Emotion Regulation and Emotional Communication 78 Music-Therapy Interventions to Improve Communication and Social Relationships 79 The Use of Music to Promote Motor Skills 81 The Effects of Music Therapy in Rett Syndrome 83 An Intervention to Promote Motor Coordination in Rett Syndrome 83 Patient’s Assessment 84 Structuring of the Intervention 85

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Receptive Phase 86 Interactive Phase 88 Final Comments 90 Concluding Remarks 91 References 91 Conclusions 95

CHAPTER 1

The Reasons Supporting the Use of Music in Rehabilitation

Abstract  This chapter presents and discusses the reasons why music can be useful in rehabilitation in the field of neurodevelopmental disorders. A comprehensive theoretical model, supported by experimental findings, is presented. According to this model, music can prompt or enhance the development of mental skills since it elicits mental processing at different levels: motor, visual, and verbal. The three levels, when synchronized, trigger synergic effects acting as “scaffolding” tools that facilitate the acquisition of the ability to be trained. Keywords  Music · Rehabilitation · Music therapy disorders · Motor system · Imagery · Language

· Neurogenerative

The variety of music-based methods commonly employed for therapeutic purposes is quite extensive (Horden, 2000). On the one hand, music can be used to lead the patient to be in a physical and mental state that is not curative by itself, but that can enhance the effectiveness of other kinds of interventions. For instance, music can be utilized to induce a state of relaxation, to stimulate a positive mood, and to increase the level of self-awareness in the patient (Colombo & Antonietti, 2017), improving successful outcomes of psychotherapy. In this case, music only plays an ancillary role. On the other hand, music can be used to directly trigger changes that allow patients to restore or improve lacking skills (Antonietti & Colombo, 2012). In this case, sounds are effective thanks © The Author(s) 2018 A. Antonietti et al., Music Interventions for Neurodevelopmental Disorders, https://doi.org/10.1007/978-3-319-97151-3_1

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to something that is peculiar to music. Hence, it is crucial to comprehend the reasons why a specific use of music can result in the achievement of specific goals in the field of rehabilitation.

Three Mental Registers A person who is listening to or performing music has a comprehensive experience in which several mind registers are activated simultaneously and synergically so that the coordinated action of multiple mental mechanisms occurs. This characteristic is the foundation for the efficacy of sound-based rehabilitation treatments. The mechanisms can be identified referring to three categories, which correspond to three relevant mental registers available to the human mind: motor, iconic, and verbal. These three registers match an essential distinction within the psychological field that has been acknowledged by different theories and has been effectively systematized by Bruner. He identified three developmental stages. Each of them is matched with a specific system used for mental representation: enactive, iconic, and symbolic (Bruner et al., 1966). First, the child’s motor behavior reveals strategies behind each action, allowing us to assume that mental representations guide movements. These are what Bruner calls enactive representations, constituted by patterns that coordinate the sequence of different acts or segments in order to form a whole movement. Iconic representations are independent of actions, even though they are tied to perception since images or spatial schema are the basis from which iconic representations are generated. They allow representing states, relations, or transformations of events. To perform tasks that require abstract thinking one needs symbolic or verbal representations, which operate through abstract concepts. The tripartition suggested by Bruner can be useful in making our point because it helps us to identify three registers, or lines, along which the mental processes activated by music unfold and to identify along these lines the likely reasons why music-based rehabilitation interventions are successful. As a first point, music activates the motor register because music is naturally connected with the body. A body gesture always initiates music (blowing, beating, etc.). Moreover, often music is composed by thinking of specific actions or movements it is supposed to accompany (dance or military marches, for instance). Some cultures in Africa have no specific word to designate music; They use a single term signifying the

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presence of music and dance at the same time. In various contexts music accompanies working activities: In Ghana, gardeners work more speedily when accompanied by music; In the Hebrides, the activity of textile workers is accompanied by songs that change according to the movements to be performed; Some sailors’ songs also change according to the required maneuvers (DeNora, 2000). Blacking (1973) emphasized the notion of music as being firmly embedded within body movements, a point supported by his long-lasting experience in studying African music. This author thought that adding a physical-motor experience makes the sounds take on a different meaning compared to when we only perceive the sound with our ears. From an ontogenic point of view, the connection between music and movement develops very early. Philips-Silver and Trainor (2005) reported that at 7 months of age infants show the preference for a rhythm associated with a synchronized rocking of the cradle. At 18 months of age children, while they are listening to music, spontaneously perform rhythmical movements synchronized with the sounds (Sloboda, 1985). At a later age, the connection between music and movement does not require the involvement of one’s own body. For example, Boone and Cunnigham (2001) asked 4 and 5-year-olds to make a teddy bear dance according to the emotional features of short musical segments while they were listening to them. Afterward, adults were presented the videotaped performance played by the children without the accompanying music track and were requested to identify the emotion that the body movement intended to express. Results showed that children were successful in moving the teddy bear coherently with the emotional meaning of the associated music. The detailed analysis of how children handled the teddy bear highlighted that upward movement, rotations, shifts, as well as the tempo and the force of the movements, differed significantly according to the expressive meaning of the corresponding music. Secondly, music has an iconic, i.e., a visuospatial, component. Music, at least under some circumstances, seems to translate spontaneously into images. For example, it is proven that musicians, when compared to nonmusicians, have higher capacities of visuospatial memory and their hippocampus—a cerebral structure connected with this kind of memory—is more developed (Sluming et al., 2005). Practicing music develops visual mnestic abilities, probably because of the inherent figural nature of sound patterns. Even people without any musical training think

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about music in spatial terms. In an experiment, Halpern (mentioned in Krumhansl, 1992, p. 202) presented one word, by selecting it from the lyrics of a song, and subsequently another word from the same song. The task of the subjects was to compare the pitch of the notes corresponding to the two words. The reaction time recorded during this task increased as a function of the distance (in terms of the number of bars) between the two words in the song. This suggests that the listeners scanned an image of the melody mentally. Hence, music seems to promote a mental activity similar to the one that happens when we mentally scan visual images. Thirdly, music comes with a verbal component. Similarities between music and verbal language concern mostly the syntax of music. Some authors (for example, Lerdhal & Jackendoff, 1983) identified some broad cognitive principles can be used as the foundations for musical listening. As happens for the syntactic structure of verbal language, music implies abstract structures that meet the laws of generative grammar with a set of recursive analytical rules. However, the verbal dimension of music appears not only at the level of syntactic structures, but involves narrative structures as well. Heinrich Schenker (1954)—an author who anticipated the ideas advocated by Lerdhal and Jackendoff—suggested that the diatonic triad is the Ursatz, that is to say, the basic structure, where the tonic represents the initial balance, the dominant introduces tension, and the return to the tonic reestablishes the balance. It is possible to find a correspondence between this harmonic pattern and the grammar of stories. Fairytales and other narration quite often introduce early on a transition from an initial, calm, situation to a problematic one, to end with the resolution of the conflict or tension. Furthermore, the verbal dimension of music appears at the phonetic-prosodic level, well exemplified by the attempts to reproduce the inflections of the spoken language through musical sounds, and at the pragmatic level, when the dynamic of roles, entrances, and alternations of the interlocutors in the development of the discourse is at play. We can conclude that music activates in the listener and the performer some mental processes in all three registers (motor, iconic, and verbal) and we can find the reasons of its therapeutic-rehabilitative efficacy in the synchronized activation of these registers. In the following paragraphs, we will develop further this last point.

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Relationships Within and Between Registers The motor register is activated at different levels. First we have the neurovegetative responses modulated by sounds (e.g., variations of the heart and breathing rates), then gestural responses (exemplified by the tendency to accompany music by tapping the feet or drumming the fingers), and finally more complex patterns of action (e.g., those implied in the art of dancing). The iconic register is linked to visual synaesthesia: visual, synesthetic-like experiences may be elicited by sounds, which are perceived as dark, shining, and so on. Furthermore, the visual features of music appear in the topological relations that sounds remind us of. For instance, music can be compared to or described as continuous or broken lines, or it can inspire a sense of closure or opening, and so on. Finally, music takes shape in visuospatial isodynamic (it suggests upward or downward jumps, approaching or departing trajectories, etc.). The verbal register is involved at a primary level through the usage of onomatopoeic symbols (e.g., musical sounds can be used to imitate natural or artificial sounds) and at a more sophisticated level through the use of prosodic intonations, that can be achieved by using accelerations and decelerations, variations of rhythm and intensity, or by changing the overall “tone”—solemn, whining, peremptory, friendly, etc.—with which the musical discourse is pronounced. These strategies allow building a discursive structure, better-organized thanks to the distribution of parts, entrances and relative turns, repartition of topics introduced in the discourse, and so on. What relationship exists between the different registers? The registers are interdependent and synchronized. They are activated by the same musical stimulus and mirror the same characteristics of this stimulus, even if with a different emphasis. For example, an aspect of the piece will be better reflected or expressed by the motor register, another within the verbal one. Using different words, we can say that what is processed within a given register is correlated to and presents some analogies to what happens in another register. Let us use a concrete example to describe this isomorphism among different registers. If we imagine a path covered with gravel, we can easily see how some stones will protrude more than others and some depressions will form as well. Let us imagine pressing a piece of cardboard into the ground. Some features of the path—its protrusions and

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depressions, etc.—will be found on the piece of cardboard. For instance, where on the ground there was a sharp stone, on the card there will be a narrow and high protuberance. In some way, the characteristics of the ground have been “re-transcribed” in the shape the card has taken. There are some correspondences between the two surfaces, even if each one is “made” of different things (in this example, stones for the above and cellulose mixture for the latter). If we now imagine pouring some colored paint on the modeled card after it has been pressed into the ground, we can see how the paint will run down along the protrusions of the card and thicken in its depressions, coloring protrusions, and hollows with different intensity. If we flatten the card now, we can still detect the original roughness of the ground that has been impressed on it regarding protrusions and hollows, because the different intensity of the paint has “transcribed” the three-dimensional undulations of the paper. With a different medium (the paint pigment) the characteristics of the ground have been maintained since we can still find the same set of relationships made of hollows and protrusions that are on the ground. We have three different levels and three different materials—stones, paper, and colored pigment. Although different, each of them represents the same system of relations, since the same “print” has been impressed by these different materials. A “transcription” is, therefore, a projection, on a certain mental register, of characteristics emphasized in a different register. The “transcriptions”, i.e., the correspondences that are formed among the different registers (motor, iconic, and verbal), contribute to transforming the mental processing of music into a consistent complex of acts that generates an overall strong impression. The ability to grasp the correspondences among different registers appears quite early. According to Stern (2000), infants show an ability to connect the perceptual information from various senses (sight, hearing, touch). For example, infants capture the relation between the rhythm of a repeated noise and a similar touch-based rhythm (for example a caress) and they associate these rhythms with the on-off switching of a light occurring at the same pace. At 3 weeks after birth infants grasp the relationship between a time matching hearing and visual patterns. When the mother tries to calm her baby by singing or pronouncing some words with rhythmical and prosodic inflections, and she accompanies her voice with a synchronized movement of her hands caressing the child’s body, the baby perceives the correspondence between the two experiences (auditory and tactile).

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Musical cognition is a multimodal form of knowledge that, through the simultaneous activation of different registers, produces a global experience. We will now focus on each one of these registers and on how that can potentially enhance rehabilitation.

The Motor Register On a first level of the motor register, we find how music triggers neurovegetative reactions and affects individuals’ biological rhythms. Within a general tendency to synchronize the internal bio-physiological oscillations with the external rhythms that are heard, we can notice that the musical rhythm induces variations in the cardiovascular and respiratory rates that, in turn, affect other physiological changes. It has been confirmed that lullabies decrease the heartbeat and the respiratory rate by synchronizing them with music (Scherer & Zentner, 2001). It is not only rhythm that has these effects: The emotional quality of music also changes the cardiorespiratory rate (Sloboda & Juslin, 2001). On a different level of the motor register, it is proven that people perceive the expressive tension-release dynamisms in music (Gabrielsson & Lindström, 2001). When subjects were asked to press on a device changing the intensity of the pressure on the basis of the tension perceived in the musical piece they were listening to, the researchers noticed that moments of tension and relaxation alternated. Furthermore, a high tension was recognized in correspondence with sections of fortissimo, when the melody was ascending, the density of notes increased, places of dissonance occurred, rhythmical and harmonic complexity was high, musical segments were repeated, as well as during the pauses and in the parts where some musical ideas were developed. Similar responses can be found at the level of muscular reactions linked to facial expressions. Usually, people respond with subliminal changes in their facial expression while they are listening to music (Molnar-Szakcs & Overy, 2006; Sloboda & Juslin, 2001). These responses tend to be specifically related to the type of music (Scherer & Zentner, 2001): Music with negative emotional meaning tends to produce a greater corrugating muscular activity, whereas music with positive emotional meaning induces zygomatic activity. These associations between music and motor responses appear early: 3–4-year-olds know how to match musical pieces and facial expressions congruently with the emotional character of the music (Sloboda & Juslin, 2001).

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On a more sophisticated level, it has been shown that music generates in the listeners motor responses that allow them to mirror the gestures performed by the interpreter (Leman, 2008). These findings are supported by experiments showing that people can associate to music the corresponding gestures and actions. For instance, only by watching the videotape of a musical performance without any soundtrack, people can successfully guess the artistic intentionality of the piece (Davidson, 1993, 1995). This skill can also be noticed when observing people making sound-producing gestures in the air without playing any particular instrument (Godøy, Haga, & Jensenius, 2006). Similar findings were reported when considering ballet performances: Hearing only the music or seeing only the body movements produced similar judgments about the beginnings and the ends of the internal sections of the performance, as well as about the tension and the emotions conveyed by the stimuli (Krumhansl & Schenck, 1997). The visual experience of a musical performance provides listeners not only with information about the context where it takes place and the alleged personal features of the musician but also with a variety of cues which can emphasize the expressive intention of the executor (Antonietti, Cocomazzi, & Iannello, 2009; Thompson & Russo, 2004). The gestures of the performer help de-codify also some structural aspects of music. In an experiment (Thompson, Graham, & Russo, 2005) a singer was videotaped while performing music intervals varying in range. Subsequently, two samples were presented with only the soundtrack or only the soundless filmed sequence. In both conditions, the judges adequately identified the range of the different intervals. In the visual video cues, such as the facial expression and gestures of the singer, were enough to assess the extent of the performed melodic interval. Many attempts have been made to enhance (Colombo et al., 2013; Gaggioli, Morganti, & Antonietti, 2010) and rehabilitate (Di Nuzzo et al., 2015; Trobia et al., 2009; Trobia, Gaggioli, & Antonietti, 2011) motor functions through music. Nowadays technology enables us to expand the natural link between music and movement or to recover it where physical disabilities have impaired it. For example, Tam and colleagues (2007) devised a computer system, called Movement-ToMusic, which allows children with impaired movements to play and create music, resulting in broader horizons and increased quality of life. Patients with spinal chord injuries were trained to create and play music using an electronic music program: This tool led them to exercise

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upper limbs which were connected to a synthesizer through a computer. Other similar devices are Soundbeam and Wave Rider (Paul & Ramsey, 2000). In all situations when music contributes to restoring motor functions (Thaut, 1988), music can be conceived as an anticipatory and continuous temporal template that facilitates the execution of the movement that has to be rehabilitated thanks to auditory-motor synchronization.

The Iconic Register On a first level of the iconic register, visual representations triggered by music are perceived as scattered chromatic sensations. Through synaesthetic mechanisms, sounds elicit experiences afferent to non-acoustic sensory modes (Bragança, Marques Fonseca, & Caramelli, 2015). On a different level, music can elicit visual images that convey topological relations. First of all, it is clear that the flow of musical notes is inscribed in a sound environment with basic spatial coordinate vectorially oriented from left to right. The Spatial-Musical Association of Response Codes (SMARC) effect (Lidji, Kolinsky, Lochy, & Morais, 2007; Rusconi, Kwan, Giordano, Umiltà, & Butterworth, 2005) can be used as evidence for it. The SMARC effect is a form of stimulus-response compatibility effect. The subject is asked to face a screen where some stimuli appear; They can appear unpredictably either on the left or the right sides of the screen. The task is to push a button as soon as one perceives the appearance of the stimulus. If the position of the stimulus and the button to be pushed are compatible (e.g., the stimulus appears on the left side of the screen, and the button is at the left side of the subjects, so that they use their left hand to push it), the response is quicker than it would be in a situation of incompatibility (the stimulus appears on the left, and the button for the answer is on the right). If the stimuli are musical notes and individuals are asked to determine whether, compared to a standard note, the next stimulus is higher or lower, the SMARC effect occurs. If the button corresponding to the answer “lower” is on the left and the button corresponding to the answer “higher” is on the right, the response is quicker as compared to the condition where the buttons are switched. This happens because in the first condition there is compatibility between the stimulus characteristic (pitch) and the position of the button. The musical notes are therefore mentally represented in a space vectorially oriented from left to right so that low pitches tend to be psychologically “located” on the left and high pitches on the right.

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The iconic power of music is perceived very early. According to Spelke (1976, 1979), 3 and 4-month-olds are capable of detecting when auditory rhythm and visual rhythm are coordinated and when they are uncoordinated. In a series of experiments, infants were shown a visual scene where a puppet representing an animal was making jumps. A sound was produced either when the jumping puppet was landing or a little later. Children preferred to watch the visual scene where jumps and sounds were coordinated rather than the uncoordinated scene (their preference was assessed according to the frequency and duration of visual fixations). Other studies showed that 6–8-month-olds could understand numerical correspondences between sounds and images. For example, given a choice to look at a scene where two objects were presented or a scene with three objects, if the infants heard two sounds, they rather watched the two-object scene, while they turned their gaze to the three-object scene if there were three sounds. The skills highlighted by Wagner and colleagues (1981) in 6–14-month-olds are even more surprising. Children seem to be able to associate characteristics of sounds (such as pitch) and characteristics of sound sequences (ascending or descending sequences, sequences of continuous or intermittent sounds) with similar characteristics of lines. Children prefer to watch a low line, a small circle, and a dark circle in concomitance with low pitch and a high line, a big circle, and a clear circle in correspondence with a high pitch. Moreover, they prefer to turn their attention to an ascending arrow if they are listening to an ascending melodic line and a descending arrow if the melody is descending, or to a continuous line if the sound sequence is continuous and to a broken line if the sound sequence is intermittent. Older children—as documented by Walker (1987)—know how to make even more complex associations, such as matching weak and strong, low and high, long and short notes with, respectively, long and short lines, light and dark lines, low and high lines, empty and full symbols. Fairly early on children understand that specific characteristics of sound stimuli can be represented graphically with a variety of devices (Bamberger, 1991). To summarize, it seems that the figural aspects of musical language can be assigned a role not only in these “peripheral” moments— respectively “incoming” (perceptual organization) and “outgoing” (emotional response)—of the process of listening, but also in the “central” moment of the listening experience, when the formation of meaning of the musical piece happens.

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The visual resonances and spatial analogies activated by music are often used in rehabilitative interventions to induce patients into a state that favors the recovery of their cognitive and emotional resources. To this end, a method called Guided Imagery and Music (GIM) has been devised. It intentionally elicits visual imagery in the patient’s mind starting from music-based stimuli. In addiction, Music-Assisted Relaxation and Imagery, a variant of GIM, has been proven to be more effective in rehabilitation than traditional music therapy (Mandel, Hanser, Secic, & Davis, 2007).

The Verbal Register A first level where correspondences between music and verbal language can be detected is the structural-syntactic level, where discrete elements (notes in the former, words in the latter) are organized into a sequence by respecting some formal rules. It is not surprising, then, that aphasic people with difficulty in understanding the syntactic aspects of language also show difficulty in perceiving syntactical aspects of music related to harmonic relations (Molnar-Szakcs & Overy, 2006). On a different level, the verbal dimension of music appears to be related to how speech is organized. According to Schaffer (1992), music can convey a narrative. The structure of a musical piece describes an implicit event. The way the piece is performed gives shape to this event, enriching it with emotional connotations. The gestures of musical expressiveness would then correspond with the emotional gestures of the implicit main character of the story who participates in or witnesses that event. In other words, the interpretation made by the performer has the function of helping define the character of the protagonist in the narrative script, which is implicitly embedded in the musical structure. The musical elements define the implicit event, i.e., the structure that has a decisive and primary role in determining the range of gestures suitable for that musical piece. The performer, like a storyteller, has to be loyal to the structure of the story and, at the same time, has the freedom to modulate the emotions of the characters. In other words, the performer has the task to create the character to add profound meaning to the literal surface of the musical piece. Schaffer argued that the details of musical expression are more fully understood if regarded as corresponding to the gestures of an implicit main character. Following this line of reasoning, Sloboda (1985) pointed out that people recognize better a melody if, as they are listening to it, they label it with particular titles that hint at its dramatization. This

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is a potential way of using music that Noy (1993) designated as “narrative path,” which leads the listener to identify with the experience of the composer, feeling their emotions as if reliving their own narrative. However, these ideas have to do with either the execution (the musician concretely renders the narrative dimension) or the reception (it is the listener who projects a narrative plot into music). Following Shaffer’s suggestions, how can we identify the narrativity in the structure of music itself? Like in a story, the plot unfolds through premises, the creation of preconditions, anticipations, escalation, dramatic turn of events, sudden resolutions, and so on, and the unfolding of the musical discourse produces similar variations of the arousal levels. The emotional “path” of music would be parallel to that of a story that could overlap it. Music and verbal language share some prosodic inflections. It seems that our nervous system has developed specialized structures and processes to deal with the prosodic aspects of language (Peretz, 2001). The superiority of the right ear (and consequently the left hemisphere) for processing the content of words and the superiority of the left ear (and therefore the right hemisphere) for the perception of the emotional tone of voice has been demonstrated. Hence, brain damages compromise selectively the identification of emotional connotations of the voice as well as the grasping of prosodic variations in exclamations, questions, and assertive sentences. It is not a coincidence that children prefer songs addressed to them rather than songs addressed to adults. Children know how to seize the prosodic inflections of the former and perceive them as adapted to interact with them. It is a fact that in all cultures children are the receivers of songs addressed to them by the adults and that in many cultures these songs are specific for children. Experiments conducted by Trehub and Trainor (1998) showed that, when adults sing for a child, they make higher and slower sounds, in a more loving tone, introducing longer pauses between phrases as compared to when they sing for other listeners. Furthermore, adults seem to use two specific singing styles with children: a lullaby-like mode when they want to quieten and let the child fall asleep and a playful mode aiming to activate the children and draw their attention on exciting aspects of the environment. The continuum existing between the spoken and singing languages explains the prosodic correspondence between texts and sounds in vocal music. However, it is less straightforward to explain the prosodic aspects of instrumental music. Such aspects are grounded on the fact that common traits of music and the human expression of emotions can be found

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in the characteristics of the voice. A voice expressing sadness and music conveying sadness share some features, such as low pitch, a small range of pitch variations, low intensity, trailing sound flow, slowness, pauses, a progressively flat trend of the pitch and the rhythm, etc. The instrumental music tries to mirror these features through nonvocal sounds. The analogies between prosody of verbal language and prosody of music account for the use of singing in rehabilitating the fluency of spoken language. For example, music is beneficial in the treatment of acquired dysarthria following traumatic brain injury or strokes. The intelligibility and the naturalness of speech of dysarthric patients improved as a consequence of a set of sessions where they performed, besides respiratory motor exercises, rhythmic and melodic articulary tasks based on intonation and singing (Tamplin, 2008). Singing is an effective way to rehabilitate aphasia too. It has been proven that patients suffering from severe forms of non-flowing aphasia benefit from the Melodic Intonation Therapy, a rehabilitation technique based on the imitation of singing (Molnar-Szakcs & Overy, 2006). Musical techniques can also be applied to improve the vocal quality, the coordination, rhythm, and timing of speech and pragmatic use of language in children with acquired brain lesions (Kennelly, Hamilton, & Cross, 2001). Also, dyslexic people can be trained through music. Besson and colleagues (2007) found that musical activities were successful in improving pitch processing in speech, an ability that is fundamental in second language learning and that is impaired in dyslexic children, hence suggest­ ing that music can be employed as remediation in dyslexia to improve people’s impaired reading skills. This is in agreement with the observation according to which dyslexic children show some difficulty in the timing in music and, if they attend music classes, they improve their reading skills (Molnar-Szakcs & Overy, 2006). Furthermore, specific rehabilitation programs based on the rhythm of reading have been proved to be beneficial to these patients (Bonacina, Cancer, Lanzi, Lorusso, & Antonietti, 2015; Cancer & Antonietti, 2017; Cancer, Bonacina, Lorusso, Lanzi, & Antonietti, 2016).

Concluding Remarks As we have been discussing in this chapter, if music can trigger representations and processes in different mental registers (motor, iconic, and verbal)—given that sounds carry affordances, forces, vectors which drive specific actions, images, and ways of speaking and that what occurs in the

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various registers is reciprocally synchronized—both the power of music as a spontaneous elicitor of emotions (Allevi, Colombo, & Antonietti, 2011) and as a natural tool of communication (Antonietti & Colombo, 2014) and the deliberate use of music for rehabilitative purposes are justified. Music is intrinsically motor, iconic, and verbal, since gestures, images, and words are not external elements to it. Motor, visuospatial, and verbal elements are already present in the innermost nature of music. The registers that music activates (movements, figures, words) are not “added” to music from the outside. They are deeply embedded in music. It is because of this very embedding that we can argue that music can act with a vicarious function within the rehabilitation context. When the processes of motor planning are impaired, music can provide the sequential and rhythmical patterns required to perform actions that need to be learned, and this is possible because these patterns are embedded in the music itself. When mnestic processes fail in recalling the past, music helps the memory emerge because it suggests colors, shapes, spatial movements that can be found in visual scenes. If the organization of verbal language is impaired, music can assist it, because it contains discursive patterns. In other words, music, thanks to its multimodal nature, offers “scaffolding” on which one can learn to perform movements, carry out cognitive operations, or articulate verbal expressions that need to be rehabilitated.

References Allevi, M., Colombo, B., & Antonietti, A. (2011). Emotions and cognitive processing in musical communication. An experiment on the role of the gaze. In J. Özyurt, A. Anschütz, S. Bernholt, & J. Lenk (Eds.), Interdisciplinary perspectives on cognition, education, and the brain (pp. 153–158). Oldenburg: BIS-Verlag. Antonietti, A., Cocomazzi, D., & Iannello, P. (2009). Looking at the audience improves music appreciation. Journal of Nonverbal Behavior, 33, 89–106. Antonietti, A., & Colombo, B. (2012). Interventi con la musica per il mantenimento e il recupero delle funzioni cognitive nell’anziano [Music interventions to the maintenance and rehabilitation of cognitive functions in the elderly]. Ricerche di Psicologia, 35, 239–255. Antonietti, A., & Colombo, B. (2014). Musical thinking as a kind of creative thinking. In E. Shiu (Ed.), Creativity research: An interdisciplinary and multidisciplinary research handbook (pp. 233–246). New York: Routledge.

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Bamberger, J. (1991). The mind behind the musical hear. How children develop musical intelligence. London: Cambridge University Press. Besson, M., Schön, D., Moreno, S., Santos, A., & Magne, C. (2007). Influence of musical expertise and musical training on pitch processing in music and language. Restorative Neurology and Neuroscience, 25, 399–410. Blacking, J. (1973). How musical is man? Seattle-London: University of Washington Press. Bonacina, S., Cancer, A., Lanzi, P. L., Lorusso, M. L., & Antonietti, A. (2015). Improving reading skills in students with dyslexia: The efficacy of a sublexical training with rhythmic background. Frontiers in Psychology, 6(article 1510), 1–8. https://doi.org/10.3389/fpsyg.2015.01510. Boone, R. T., & Cunningham, J. G. (2001). Children’s expression of emotional meaning in music through expressive body movements. Journal of Nonverbal Behavior, 25, 21–41. Bragança, G. F. F., Marques Fonseca, J. G., & Caramelli, P. (2015). Synesthesia and music perception. Dementia & Neuropsychologia, 9, 16–23. Bruner, J. S., et al. (1966). Studies in cognitive growth. New York: Wiley. Cancer, A., & Antonietti, A. (2017). Remedial interventions for developmental dyslexia: How neuropsychological evidence can inspire and support a rehabilitation training. Neuropsychological Trends, 22, 73–95. https://doi. org/10.7358/neur-2017-022-canc. Cancer, A., Bonacina, S., Lorusso, M. L., Lanzi, P. L., & Antonietti, A. (2016). Rhythmic reading training (RRT): A computer-assisted intervention program for dyslexia. In S. Serino, A. Matic, D. Giakoumis, G. Lopez, & P. Cipresso (Eds.), Pervarsive computing paradigms for mental health (Communications in Computer and Information Science, 604) (pp. 249–258). Cham: Springer. https://doi.org/10.1007/978-3-319-32270-4_25. Colombo, B., & Antonietti, A. (2017). The role of metacognitive strategies in learning music: A multiple case study. British Journal of Music Education, 34, 95–112. https://doi.org/10.1017/s0265051716000267. Colombo, B., Di Nuzzo, C., Missaglia, S., Mordente, A., Antonietti, A., Casolo, F., & Tavian, D. (2013). Exploring the positive involvement of primary motor cortex in observing motor sequences with music: A pilot study with tDCS. Sport Sciences for Health, 9, 89–96. https://doi.org/10.1007/ s11332-013-0149-6. Davidson, J. W. (1993). Visual perception and performance manner in the movements of solo musicians. Psychology of Music, 21, 103–113. Davidson, J. W. (1995). What does the visual information contained in music performances offer the observer? Some preliminary thoughts. In R. Steinberg (Ed.), Music and the mind machine: Psychophysiology and psychopathology of the sense of music (pp. 105–114). Heidelberg: Springer. DeNora, T. (2000). Music in everyday life. Cambridge: Cambridge University Press.

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Paul, S., & Ramsey, D. (2000). Music therapy in physical medicine and rehabilitation. Australian Occupational Therapy Journal, 47, 111–118. Peretz, I. (2001). Listen to the brain: A biological perspective on musical emotions. In P. N. Juslin & J. A. Sloboda (Eds.), Music and emotion (pp. 105– 134). New York: Oxford University Press. Phillips-Silver, J., & Trainor, L. J. (2005). Feeling the beat in music: Movement influences rhythm perception in infants. Science, 308, 1430. Rusconi, E., Kwan, B., Giordano, B., Umiltà, C., & Butterworth, B. (2005). The mental space of pitch height. In G. Avanzini, L. Lopez, S. Koelsch, & M. Mjno (Eds.), The neurosciences and music II. From perception to performance. Annals of the New York Academy of Sciences, 1060, 195–197. Schaffer, L. H. (1992). How to interpret music. In M. R. Jones & S. Holleran (Eds.), Cognitive bases of musical communication (pp. 263–278). Washington: American Psychological Association. Schenker, H. (1954). Harmony. Chicago: University of Chicago Press. Scherer, K. R., & Zentner, M. R. (2001). Emotional effects of music: Production rules. In P. N. Juslin & J. A. Sloboda (Eds.), Music and emotion (pp. 361–392). New York: Oxford University Press. Sloboda, J. A. (1985). The musical mind. Oxford: Clarendon. Sloboda, J. A., & Juslin, P. N. (2001). Psychological perspectives on music and emotion. In P. N. Juslin & J. A. Sloboda (Eds.), Music and emotion (pp. 71–104). New York: Oxford University Press. Sluming, V., Page, D., Downes, J., Denby, C., Mayes, A., & Roberts, N. (2005, 8–10 May). Structural brain correlates of visuospatial memory in musicians. Conference The neurosciences and music II. From perception to performance. Leipzig. Spelke, E. S. (1976). Infants’ intermodal perception of events. Cognitive Psychology, 8, 553–560. Spelke, E. S. (1979). Perceiving bimodally specified events in infancy. Developmental Psychology, 15, 626–636. Stern, D. N. (2000). The interpersonal world of the infant. New York: Basic Books. Tam, C., Schwellnus, H., Eaton, C., Hamdani, Y., Lamont, A., & Chau, T. (2007). Movement-to-music computer technology: A developmental play experience for children with severe physical disabilities. Occupational Therapy International, 14, 99–112. Tamplin, J. (2008). A pilot study into the effect of vocal exercises and singing on dysarthric speech. Neurorehabilitation, 23, 207–216. Thaut, M. H. (1988). Rhythmic intervention techniques in music therapy with gross motor dysfunctions. The Arts in Psychotherapy, 15, 127–137.

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CHAPTER 2

Enhancing Self-Regulatory Skills in ADHD Through Music

Abstract  Music can play a role in the treatment of children and teens with ADHD since it provides patients a self-regulatory system, which enables them to manage the internal time according to variations in the external time and to synchronize behavior with external stimuli. Thanks to these mechanisms the individuals get control over their impulsive tendencies and can plan their behavior according to the goals they set. This chapter presents a review of the relevant literature about the effects of musical interventions in ADHD. Some studies aimed at improving self-control in people with ADHD employing music intervention programs (consisting of either individual or small-group sessions), as well as some activities included in such programs, are also described. Keywords  ADHD Impulse control

· Music · Music therapy · Self-regulation Defining ADHD

Children with Attention Deficit-Hyperactivity Disorder (ADHD) tend to have average or higher than average IQ, yet they cannot focus their attention, are often restless, work in a disorganized and disordered manner, and have considerable difficulties in tasks that require a high and constant level of concentration. At times they are very present, while at other times it seems that their mind is elsewhere and that they do © The Author(s) 2018 A. Antonietti et al., Music Interventions for Neurodevelopmental Disorders, https://doi.org/10.1007/978-3-319-97151-3_2

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not listen to or have not heard what has just been said to them. They disperse, handle carelessly, or damage materials they are managing or using. They frequently switch from one activity to another without finishing any of them. They are easily distracted by irrelevant stimuli. To be more specific, they perceive the stimuli as an “assault” and frequently interrupt the tasks they are carrying out to pay attention to unimportant noises or to events that are usually ignored by others. Children with ADHD also show behaviors that do not have any specific aim (e.g., they might clap their fingers rhythmically, continuously change position on the chair, open and close a zipper or a lid several times). They tend to be always on the move. Sometimes they can appear clumsy in their movements, hitting things or even falling to the ground. They nervously play with objects, tap with hands, and shake their hands and feet too much. They often get up from the table during meals, while watching television, while they are doing their homework. They constantly talk and make noise even when they are involved in calming or relaxing activities. They cannot wait for gratifications when they did something right, and for this reason they immediately demand what they had been promised. They also prefer to have a little gratification immediately rather than to commit time and effort to receive a bigger prize later. The current classification of ADHD deficits includes three subtypes: • the type with predominant inattention: ADHD-I. This subtype describes a child who shows symptoms of inattention and only a few symptoms of hyperactivity-impulsivity, which have persisted for at least 6 months. • the type with predominant hyperactivity-impulsivity: ADHD-H. This subtype describes individuals presenting symptoms of hyperactivity-impulsivity and few symptoms of inattention persisting for at least 6 months. • combined type: ADHD-C. This subtype can be used if children present both symptoms of inattention of hyperactivity-impulsivity for at least 6 months. These different subtypes show different patterns of cognitive and behavioral deficits. In particular, Stanford and Hynd (1994) found that the type with prevalent inattention is more withdrawn socially, more isolated, and children who have this subtype are generally described more

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as “daydreamer”, shy, and less active (slow movements and low energy). On the other hand, children with predominant hyperactivity act before thinking, they often switch activities, have difficulty waiting for their turn and shout in class. The observations of Stanford and Hynd (1994) are consistent with other studies that have highlighted the presence of greater “internalized symptoms” (shyness, cognitive difficulties), problems of academic learning, and deficit in the elaboration of information in subjects with ADHD-I. In contrast, in children with ADHD-H and ADHD-C, there is a higher frequency of “externalized symptoms” (excessive movement, aggression) and adaptation problems. The disorder is much more common in males than in females and the male–female ratio varies from 4:1 to 9:1 depending on the conditions (i.e., general population or hospitalized subjects). Hyperactivity is the dimension that most distinguishes the two genders. It is more present among males and the greater visibility of hyperactive behavior constitutes a factor that can explain, in part, the highest incidence of ADHD among males. In females, the attentional deficit could be underestimated, as it is masked by the absence of hyperactivity (Epstein, Shaywitz, Shaywitz, & Woolston, 1991). Douglas (1983) addressed ADHD by emphasizing above all the cognitive and motivational components and identifying four components in the cognitive functioning of children with ADHD: • the marked tendency to seek immediate gratification and stimulation; • a reduced attentional effort and commitment in complex tasks; • difficulty in inhibiting impulsive responses; • difficulty in modulating the level of excitation. These components, together with secondary deficits, cause the feeling of failure, which, on a circular basis, reinforce the behaviors of inattention and impulsivity typical of this disorder. This creates a vicious circle that progressively increases the symptoms of ADHD which, in turn, will increase the chances of encountering failure, and so on. It is believed that ADHD originates from a self-regulation deficit, namely a general difficulty in the modulation of behavior that includes attentive, motivational, problem-solving aspects. The deficit also involves limited interest in maintained attention, lack of ability to realistically

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assess the solvability of a task, difficulty in committing to invest time and effort; problems in the ability to self-reinforce oneself to maintain the commitment and the right level of emotionality. Children with ADHD cannot use thinking processes to monitor the strategies used to analyze the demands of a task and to control the choice of an appropriate procedure and its application. This situation is mainly due to the lack of internal dialogue. Another model that takes into account experimental data concerning the functioning of the central nervous system is proposed by Stanford and Hynd (1994). These authors found that the level of activation of the central nervous system is significantly lower in subjects with ADHD than in healthy subjects. This hypoactivation would manifest itself through low energy and slow movements. This explains why children with ADHD continuously search for stimulation, a behavior that turns into motor hyperactivity. Sechi, Corcelli, and Vasquez (1998), to explain some components of attention deficit, referred to executive functions (EFs) (Pennington & Ozonoff, 1996). EFs are defined as varied tasks that share the need to use specific strategies to achieve the goal. For example, the inhibition or delay of an answer, the strategic plans of action sequences to achieve a purpose, and the mental representations of the tasks. The primary cognitive element that unites these functions is the selection of specific actions adapted to the context and the consequent inhibition of competitive and less appropriate responses. The domain of EFs overlaps with other concepts such as attention, working memory, and problem solving. Several studies have identified the headquarters of EFs in the frontal areas of the brain. Shallice (1998) discovered that injuries in these areas generate difficulty in carrying out actions with a clear purpose, which require a subject to choose among several competitive responses. The weakening of these functions would hence be linked to the inhibitory processes. The individual understands the task but does not complete it, since two problems occur: perseveration and distractibility. The first refers to the activation of schemas that are unlikely to be replaced, regardless of their effectiveness. The second is the tendency to be sidetracked by irrelevant stimuli of the environment. The hypothesis that a dysfunction of the frontal areas causes ADHD also seems to be confirmed by studies on patients with lesions in these areas that often show hyperactivity, distractibility, and impulsivity (Levin, Eisenberg, & Benton, 1991).

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In conclusion, the three primary symptoms of ADHD (distractibility, impulsivity, hyperactivity) would seem to derive from a deficit of the inhibitory control, considered an EF linked to the frontal areas. Shallice and colleagues (2002) have applied some tests assessing EFs to healthy subjects and individuals with ADHD. These authors identified three domains within the ADHD symptomatology that are connected to three specific areas of the brain. The authors located a center of inattention oriented in the posterior parietal lobe, a center of alert inattention in the right dorsolateral prefrontal cortex, a center of impulsivity-hyperactivity in the anterior cingulate. ADHD would derive from an inadequate functioning of the center of “alert inattention” or the failure of the highlevel effort system. ADHD can hence be seen as the result of the loss of two systems: the right frontal vigilance system evolving into the monitoring center and the top of the high-level effort system. Focusing on the neurological basis of ADHD, Barkley (1997a, 1997b) believes that three brain areas are involved in ADHD dysfunctions: the prefrontal cortex, a part of the cerebellum, and at least two basal ganglia. In confirmation of his hypothesis, it has been shown that the right prefrontal cortex, two basal ganglia, the caudate nucleus, and the cerebellar vermis are significantly less developed in children with ADHD. All of these areas are those most involved in the processes of regulation of attention. It seems, in fact, that the right prefrontal cortex is involved in behavioral programming, distraction resistance, self-awareness, and time processing. The caudate nucleus has the task of inhibiting the automatic responses to allow a more accurate decision and coordination of the various impulses deriving from the cortex. The cerebellar vermis is linked to motivation. However, the inadequate functioning of working memory (ability to hold information about a task while it is being carried out, even if it is no longer in the presence of it) reduces the sense of time, while enhancing the inability to keep events in mind, to perform retrospective evaluations, and to forecast. The internalization of the self-directed speech (together with the self-instructions that the subject silently gives) occurs late in subjects with ADHD causing deficiencies in self-regulated behaviors and reconstruction. Self-regulation of mood, motivation, and attention makes it possible to achieve goals by modifying and delaying immediate reactions. When this system does not work correctly, individuals will exhibit their

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emotions without any censoring and reduce their ability to control motivation and impulses. Reconstruction can be defined as the ability to break down behaviors into their components, to replace and recombine them to make them more functional to achieve the goal. When this function is not adequate, individuals are not able to analyze behaviors to process new ones. Besides, they will have many difficulties in solving problems because they lack flexibility and planning. According to an alternative perspective (Fabio, 2001), higher arousal originates in the organism a very low reception threshold, so that even a mild or neutral stimulus tends to be perceived as significant. The perception of a child with these levels of activation is that of a constant “assault” of stimuli. This burst of stimuli increases the state of tension (it is a process similar to stress in adults). To discharge this tension, children produce behaviors of self-stimulation of both thought and movement. Self-stimulation of thought produces a continuous attention shift, that explains why children with ADHD continually change the focus of their thought. Motor self-stimulation refers to the fact that these children produce unplanned exploration behaviors, as well as micromovement of the hands and the tongue. Self-stimulation lowers the state of internal tension and can generate a self-gratification circle that maintains the symptom. Therefore children with hyperactivated arousal can alternate moments of clarity (ability to receive stimuli) to other moments when they are unable to process stimuli (in the presence of self-stimulation). Hypoactivated arousal produces a low level of activation that generates a very high reception threshold in the organism so that even strong and significant stimuli are perceived as neutral and therefore do not enter the information processing system. In both cases the effect is the same, i.e., the child may be more predisposed to attention deficit. Recently, it has also been recognized that ADHD is a complex and heterogeneous disorder that involves several brain networks regulating cognitive, motivational, and emotional activity. Functional magnetic resonance imaging (fMRI) applied to ADHD children during wakeful rest led researchers to identify atypical patterns of brain activity when no specific task is being undertaken (Castellanos et al., 2008). The focus of fMRI studies was a vast area of the brain that includes different regions functionally connected: posterior cingulate cortex, precuneus, medial prefrontal cortex, and inferior parietal lobes (Castellanos et al., 2008).

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All these regions constitute the so-called default mode network (DMN). DMN is a neural substrate that is involved in introspective cognitive processes such as meditation (Hasenkamp, Wilson-Mendenhall, Duncan, & Barsalou, 2012) and self-related thoughts in the present and the future (Buckner & Carroll, 2007). In children with ADHD, there is a dysfunction of the activity of DMN during rest situation, that may disrupt processes of prospection and undermine effective decision making. On the other side, a lower activation of DMN activity is necessary for goal-oriented tasks, in order to shift effectively from resting to working brain states. It was found that an excessive DMN activity in individuals who were working on processing tasks during fMRI studies is associated with low performance (Sonuga-Barke & Castellanos, 2006). Studies in children with ADHD showed that they fail in suppressing the DMN activity during cognitive tasks (Fassbender et al., 2009). This may explain the patterns of ADHD-related periodic attentional lapses and intra-individual reaction time variability. Furthermore, studies on spontaneous very low-frequency oscillations (VLFO) showed that these are attenuated when individuals are working on attention challenging tasks or waiting for rewards (Hsu, Benikos, & Sonuga-Barke, 2015). Individuals with ADHD display excessive VLFO when engaged in attention tasks. They also have difficulty in waiting for rewards. Researchers underlined the motivational aspect linked with ADHD and described this deficit as depending on hypersensitivity to reward-related delay (Sagvolden, Johansen, Aase, & Russell, 2005). In this case, ADHD is assumed to be characterized by an abnormal sensitivity to reinforcement, including reward, punishment, and response cost. Because of that, children with ADHD are described as “delay averse” rather than “impulsive”. A reconciliation of the two previous accounts, according to which ADHD develops across two separate pathways, has been proposed. The first pathway, the cognitive one, includes executive deficits such as working memory and inhibition. The motivational path is linked to delay sensitivity and aversion (i.e., the tendency to choose a smaller immediate reward rather than wait for a more substantial delayed reward) (Sjowall, Roth, Lindqvist, & Thorell, 2013). As we discussed above, many previous studies in the field of ADHD focused on EFs. They approached EFs as either a unitary construct or conversely as a set of separate and specific abilities (Miyake & Friedman, 2012). The first of these approaches over-assimilate different tasks into a

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single construct, for example deriving assumptions on EF starting from single tasks, which differ from study to study. The second approach, on the other hand, over-splits, treating a long list of tasks—such as decision making, planning, and verbal fluency tasks—as if they were assessing separate abilities rather than a standard set of component processes that support completion of the more complex tasks. Rather than showing only “unity” or “diversity”, the best current evidence indicates that individual differences in EF show both unity and diversity. Following this line of reasoning, a unity/diversity model has been proposed, that focuses on three aspects of EFs: updating working memory, shifting, inhibition, as well as an ordinary EF ability which spans these components. This position is consistent with the view that the ability to be captured by common EFs—actively maintaining task goal and goal-related information and using this piece of information to effectively bias lower-level processing—is the critical requirement of response inhibition. Secondly, common EFs and shifting specific components sometimes show opposed patterns of correlations with other measures, consistently with the hypothesized trade-offs between stability (normal EF) and flexibility (shifting-specific) suggested in the literature (Goschke, 2000).

Music Interventions Addressed to ADHD The treatment of the main symptoms of ADHD through music is still not widespread and only a few studies explored the effectiveness of music-based methods on this disorder (Moore, 2009). Back in the Seventies, Wilson (1976) used rock music in association with the timeout technique as a negative reinforcement to effectively reduce inadequate or destructive behaviors. A few years later, the intervention conducted by Cripe (1986) can be considered as the first attempt to systematically evaluate the effectiveness of music as a therapy for ADHD. Cripe argued that music therapy could be a possible alternative to traditional treatment approaches, mainly because of its “non-invasive” nature, compared, for example, to pharmacological therapies. The underlying assumptions of his study were as follows: 1. The intense and repetitive rhythm of rock music stimulates brain activity of ADHD children, to the point that it can be considered comparable to that of typically developing children.

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2. The very pronounced rhythmic beats of rock music prevail over the distracting elements present in the environment and trigger adequate orientation responses in children with ADHD. As we have discussed above, these children have high levels of distractibility and a limited attention span. Music with a very marked rhythm could reduce the distractibility from the environment, allowing the child to pay attention to a single stimulus for a longer time. 3. Rock music, with its repetitive rhythm, tends to produce a reduction in muscular and skeletal tension that results in less motor activity: Children with this disorder, in fact, show a greater muscular tension. Music manages to reduce this type of tension. As a result of this decrease, involuntary and not finalized motor activity can also be reduced. Cripe started from the hypothesis that when rock music, with an intense rhythm, is introduced as an environmental stimulus, children with ADHD experience a reduction in the level of activity and an increase in attention span. The study was conducted on 8 male children between the ages of 6 and 8 who were asked to listen, using headphones, to some pieces of instrumental rock music. In the meantime, two observers recorded the activities carried out by children using an observation grid. It turned out that rock music had a statistically significant effect on the level of activity. In fact, during the non-musical parts, higher levels of activity were detected. Morton and colleagues (1990) showed that music improves dichotic listening and, consequently, can improve short-term memory while reducing distractibility at the same time. Later Pratt and colleagues (1995) found that background music can reduce hyperactivity and other unwanted behaviors. Montello and Coons (1996) investigated the effects of active music interventions compared to passive ones and found that subjects with serious attention problems benefit more from passive listening interventions since they do not require the internal structuring that is involved in active ones. The use of music was also considered to support learning processes since learning disabilities are often comorbid with ADHD. Jackson (2003) carried out a study on the use of music therapy as a treatment for ADHD with the following goals: to ascertain which music-therapy techniques are most effective with children affected by ADHD; to check

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how much music therapy can be effective for the treatment of this disorder; to evaluate the role that music-therapy interventions play in relation to other forms of therapy. The study was conducted by administering a questionnaire to 268 professional music therapists, who were first asked to identify the methods they used to treat children with a diagnosis of ADHD. Music and movement were the most used techniques with these cases, followed by instrumental improvisation, by playing one or more musical instruments, and by group singing. Each of these methods requires motor involvement and, except for group singing, often activates the movements of both the right and the left sides of the body. The methods used less frequently were relaxation through music, vocal improvisation, the Orff method, body percussion, and vocal instructions. The choice of a specific method depended on the age of the child and the type of setting. Moreover, several specific characteristics of the music played an important role in affecting the results of the ADHD-focused intervention. These include the ability of music to guide structured movement and its impact on the activation of both cerebral hemispheres (Morton et al., 1990), the ability to increase mnemonic functions, and the ability to improve learning (Jackson, 2003), the power of some sounds or tones to influence brainwave production (Plude, 1995). Secondly, music therapists had to indicate which types of objectives they intended to achieve through music therapy when working with subjects with ADHD. It turned out that the most common objectives were mostly behavioral, followed by psycho-social and cognitive ones. Some professionals replied that they intended to achieve two or more types of goals with their treatment. In fact, regardless of the method used, music is simultaneously experimented at multiple levels. According to Jackson, the fact that cognitive objectives are less frequently pursued than behavioral and psycho-social goals merits reflection. The author interprets this finding suggesting that behavioral and psycho-social improvements are easier to record and demonstrate in an “objective and measurable” way compared to cognitive ones; Moreover, most music therapists do not have a thorough preparation on neuro-biological functioning. Finally, therapists were asked to express a preference by choosing between group and individual therapies. Most music therapists responded that they used both modalities, whereas some favored group therapies and a small part led only to individual therapies. Subsequently, the participants involved in this study had to report their perception of

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the effectiveness of music therapy for children with ADHD. In general, they indicated that this type of therapy was effective. Several studies have shown the effectiveness of some music-based activities in improving self-regulation ability in children with ADHD. For example, participation in music groups, composed primarily of peers, requires considerable attention and self-control and there is general agreement that the rhythmic tasks result in an improvement in internal organization and impulse control. The rhythm can also be used to increase body awareness and motor coordination (Moore & Mathenius, 1987). Rickson (2006), however, argued that participation in music groups can further hyper-activate children with ADHD. This result is consistent with the more significant positive response of individuals with this disorder to structured programs with a high level of predictability. As a result, music-therapy interventions should use highly structured rhythm activities to be performed in individual settings or very small groups. Rickson (2006) examined 13 male adolescents (aged 11–16 years) with ADHD to compare the impact of direct and improvisational music-therapy approaches on the level of motor impulsivity. To measure impulsivity, the ability of the boys to maintain a rhythmic beat synchronized with an external stimulus was evaluated. The “directive” session involved the subjects in a hierarchy of activities with the rhythm (from the simplest to the most complex) using percussion instruments, characterized by a strong structuring and repetitiveness, which culminated in the execution of a simple rhythmic composition. Each session ended with a farewell song. The members of the group received direct verbal instructions and advice and feedback following their mistakes and were frequently reinforced for the correct answers or improvements. In the “improvisation” session, through the process of “making music” and the promotion of social skills, the patients had the opportunity to increase confidence, self-esteem, self-awareness, and sensitivity towards the needs of others. Following a greeting song, the boys were asked to choose a style (Country, Rap, Blues, Rock, Jazz), a mood (happiness, sadness, boredom, excitement, anger, tranquility), or a theme (the train, the forest, the beach, the car race, the school) for group improvisation. Each participant was also asked to choose a percussion instrument that in his opinion could express the chosen style/ mood/theme. Each session ended with a farewell song. The role of the

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music therapist was to support and test the subjects musically, so verbal stimuli were reduced to a minimum, and the approach was non-directive. Furthermore, for each session, the music therapists observed the following behaviors: restlessness and agitation, moving through the room, touching the equipment inappropriately, “firing” the answers before the questions were asked, not listening to others, inability to use the instruments quietly or to wait for their turn. This study showed that the directive approach is slightly more effective, compared to the one based on improvisation, in reducing restless and impulsive behaviors. Yet, both methods improved the ability to listen to others and to participate in group work. Borghesi et al. (1995) designed a music-therapy treatment for a 7-year-old boy who had been introduced to him as intelligent, with limited attention and restless behavior. The intervention consisted of 20 sessions of music therapy, twice a week, during which the therapist aimed at influencing the behavioral restlessness. First, an accurate anamnestic interview was carried out through separate meetings with teachers, parents, and the physician. Afterward, the child’s observations were made within the therapeutic setting. The observations highlighted that the patient did not seem to possess spatial limits, seemed not to have a correct perception of the elements in space, and he believed that the only possible way to express dissent and frustration was through an increase in motor activity. Problems in the perception of time also emerged: The child used very approximate and sometimes inadequate words to provide temporal indications. Moreover, two types of motor behaviors have been detected: the first hyperkinetic, chaotic, communicationally dysfunctional; the second relaxed, communicative, with an overall reduction in motor skills. The music-therapy intervention was conducted according to a psychotherapeutic model, based on the creation and maintenance of a stable and meaningful relationship between the therapist and the patient. The therapist assumed the function of promoting the organization and containment of spontaneous expressive behaviors of the child. The setting and the sound-music mediators, on the other hand, have been the modifiable elements of this relationship. Borghesi also created two types of delimitation: 1. “definition of the setting”: progressive delimitation of space and time;

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2. “delimitation of the sound field”, through: • the disincentive of “rough” methods of sound production: When the child used intense methods of approach to the instruments, the therapist refrained from continuing the sound dialogue; • the progressive elimination from the setting of the instruments that the child used forcefully and in a preferential way (“timbric delimitation”); • the decrease in the density of notes produced. At the beginning of the meetings, it was difficult to get the child into a “listening mood”: He was irritated by this type of request; He did not even tolerate the therapist mirroring his musical productions. He only agreed to be left free to move around the room and “to have the attention, the listening, the musical responses of the therapist, who had to be absolutely in line with his expectations”. This approach was modified during the meetings and it was noted that sometimes the child’s sound production was a response to that of the therapist; This dynamic, therefore, involved listening, accepting communication rules and sharing a code. The musical and bodily gratification and the satisfaction of the need of containment carried out through the exposure to soft sounds and hugs led to the discovery of relaxed motor behaviors, characterized by a low level of activity but at the same time a high degree of communicativeness. The child, during the course of the therapy, began to “re-learn his motor skills” and every activity seemed, according to Borghesi, aimed at the evaluation of his body dimensions and the results of his actions. Starting from the twelfth meeting, some activities were introduced that aimed at increasing the child’s skills in measuring time; For example, the child was asked to count aloud the number of his hits on percussion instruments and then to compare that number with the time elapsed or the missing time. During the meetings the child began to measure the limits by himself, evaluating the reaction of others to his infractions; Borghesi interprets this behavior as a way to discover the existence and function of limits. The expression of feelings took on a more communicative and less destructive connotation as the patient was more relaxed from a behavioral point of view. This expression has been made symbolic and met-

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aphorical by the therapist through the use of musical instruments; For example, the child was asked to “dramatize on the drums the beatings received, those given and those he would have liked to give”. During treatment, a relaxed functioning modality in the child was highlighted and promoted, characterized by: • low sensory levels, in concomitance of which the transition to mental processing of stimulations became possible; • a decrease in motor activity and better coordination in the transition to a relaxed mode; • object relationship characterized by a depressive, reflective structure and by readiness to listen, with recognition of the other as a distinct entity. The intervention approach presented by Borghesi is undoubtedly exciting and offers some guidelines from which to take inspiration to design a music-therapy treatment with children affected by ADHD. The idea of structuring and progressive de-structuring the spatial and temporal setting is compatible with the characteristics of the subjects with this disorder. In the first place, Borghesi provided the child with a strongly structured and predictable setting, so that his need for containment from the outside was satisfied by using a regulation that he was not able to give himself from inside; Subsequently, through the process of de-structuring, the external containment gradually faded in, bringing out the child’s self-control capabilities. This allowed him to experiment his limits and to promote his flexibility and adaptability concerning changes and contingencies. The primary objective is that these skills acquired in the therapeutic setting can be transferred and expressed outside the therapeutic settings (e.g., at home and school). It is important to highlight that the author has taken into consideration the definition of “hyperkinetic conduct syndrome” present in the ICD-10 and which has concentrated above all on impulsive and restless behaviors compared to the inattentive ones, despite the child having difficulties in this area. It is also true that the problems of weak attention, probably, have been addressed indirectly. In fact, self-control, especially in the first moments in which it is experienced, implies a subject’s deliberate effort and the activation of the attention and concentration skills both on himself and on the environmental and relational context in

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which he is inserted. Moreover, the very fact of interacting with the therapist and carrying out specific activities following specific prescriptions implies good attention. From these considerations, we can understand how the problems of inattention and those related to hyperactivity are not entirely split and therefore should be treated simultaneously.

Music and ADHD: Possible Relationships As we have seen in Chapter 1, music is a powerful tool that allows achieving multiple therapeutic goals. Moreover, it is very flexible and can undergo structural modifications (e.g., increase or decrease of the reproduction speed, change of the tonality, increase or decrease of the volume) according to the aims to be reached. Firstly, like any other type of therapy that aims to affect psychological dimensions, music-therapy sessions offer a privileged setting where patients can establish a meaningful relationship with the therapist, where they feel recognized, reflected, and accepted as they are. This happens because the therapist does not assume an attitude of prejudice and judgment towards the patient. On the contrary, the starting point is specifically determined by accepting the individual characteristics of a client, even the dysfunctional and pathological ones. Changes are then gradually introduced in those areas that are problematic; Within this process, the music therapist stands as a “model” for the full and free opening of the patient or the introduction of alternative modes of self-expression. Children with ADHD certainly have to satisfy their relational needs because, from this point of view, they are mostly frustrated by peers and adults because of their “disturbing” and inadequate behavior. As a result, within the music-therapy setting, they will be able to experiment working within a “confirmatory” relationship, where the therapist will use their problems as a resource to get to know them better and to promote greater awareness of dysfunctional behaviors in them. For example, the music therapist could imitate the child’s agitation/hyperactivity level by playing it with an instrument. Regarding the hyperactivity and hyper-motility of these subjects, the sound-music mediators could be used with two different objectives. A first type of purpose may be to reduce the level of hyperactivity, i.e., the child may be involved in some psycho-physical relaxation activities, with the help of relaxing melodies, both active (the subject must perform movements following the slow rhythm of the music) and passive

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(the subject will remain relaxed, firm, with eyes closed and will only listen to music and be calmed by it). The music therapist can, in turn, take an active or passive attitude; In the first case, he will facilitate relaxation by suggesting to the person the movements he has to make or images of relaxing landscapes/situations, while in the second case they will limit their intervention to the initial instructions. Clearly, children will initially have difficulty relaxing and will probably prefer active relaxation that involves a certain degree of motor activity. Gradually, then, they will learn to alleviate the states of tension and will succeed in sustaining a passive relaxation. The second type of purpose may be to discharge excess energies. In this case, it will be possible to propose to the subjects to move following a rather fast pace of music or to play percussion instruments using as much energy as they can. A limitation of this strategy, however, is the unpredictability of the outcome. In fact, if on the one hand, it could exhaust excess energies so that the child returns for a specified period to a “normal” level of arousal, on the other hand, it could have an opposite effect and therefore increase hyper-activation, as claimed by Rickson (2006). In fact, it should not be forgotten that these children are attracted to all high-impact stimuli able to increase arousal. The tendency to impulsiveness, on the other hand, can be addressed through activities that will try to increase, for example, the ability to respect one’s turn. The therapist may ask the child to play on a drum a rhythmic sequence, but only after a signal (e.g., only after the facilitator clapped his hands); A variant of this activity consists in asking the child to count aloud up to three before reproducing the rhythmic sequence. This can count as training for self-education; First, the guide will be entirely external, then the child will self-regulate his impulsivity by counting aloud until this behavioral guide will be internalized. Finally, the treatment of attention problems is transversal to that of all other problems. In fact, on a relational level, being careful means being able to listen to the other and to nurture interest in the communication, both verbal and non-verbal; Moreover, it means modulating one’s conduct and self-expression based on the progress of the relational process. As for hyperactivity-impulsivity, attention allows the child to be “sensitive” to contextual variables to control their behavior accordingly; A good attention span is indeed functional for a critical self-regulation ability.

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The activities proposed so far are all good options for the promotion of self-regulation competence. Besides, a music therapist could propose to the child, for example, activities that involve the identification of a sound source or the reproduction of a simple sequence of sounds. To increase the attention span, it is essential to be able to use temporal variables flexibly: At the beginning, the children will be involved in short-term tasks compatible with their sustained attention capacity and, little by little, the therapist will increase the time from devoting to the execution of these activities. In general, to get the collaboration, it is essential that intrinsic motivation is promoted. These children need to be continually involved in exciting and highly stimulating activities, being motivated to participate to eventually achieve gratification. It should be remembered that they are sensation-seekers and that it is critical for them to receive appreciation for what they do, given that their “disruptive” behavior attracts more negative and positive judgments and therefore they live constant frustration. As a result, it will be appropriate to provide positive feedback for every minimum progress they make.

A Single-Case Study Intervention Based on previous research, a music-based intervention project was developed for a child with ADHD (Zugno, 2010b; see also, for another single-case study, Zugno, 2010a). The patient, Simon, is a 7-year-old child. While he was attending preschool, the mother and the teachers observed that Simon seemed to reach the main developmental stages later compared to other children. In particular, he presented difficulties at the motor level and in the acquisition of language. After several years of psychomotor therapy improvements have occurred. The mother reported that around the age of 14 months the child began to perform “strange and repetitive” movements that left the people who cared for him perplexed. A series of neuropsychiatric investigations showed a slight cognitive delay. Because he also had learning difficulties, he was followed by a special-ed teacher while attending kindergarten. When he started primary school learning difficulties were confirmed. Moreover, the child began to show behavioral problems: He used to beat his classmates, was agitated, and could not sit still. He was diagnosed with ADHD and it was recommended that a special-ed teacher supported the child. Besides, he was sent to a center for cognitive training and in the meantime psychomotor sessions continued.

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Structure of the Intervention The child took part in 18 sessions, which were weekly and lasted about half an hour each. The meetings were characterized by a strong spatial and temporal structure, which had the function of organization and containment of spontaneous expressive behaviors of the patient. This strategy is consistent with the hyperactive child’s way of being, which needs predictable and constant situations over time because he does not tolerate changes well. It is crucial, therefore, to provide within the setting a coherent and organized set-up that the child could not otherwise find autonomously and which he strongly needs to feel content and to learn to contain himself. The hope is that the structuring that is offered from the outside is then assimilated. The temporal structuring has been obtained both through a strict respect of the start and end times of the meetings and through the organization of all the sessions in three moments: (a) beginning: welcoming the child and relaxing; (b) performance: involvement of the child in the planned activities; and (c) conclusion: relaxation and farewell. Thanks to this structure, the child got the idea that there is a time for everything and that not all moments are adequate to do what you want. In fact, people with ADHD, taking up the interpretation of this disorder as a “pathology of synchronization between internal time and external time”, have difficulty adapting their behavior based on external time (contextual, environmental, social), and for this reason they tend to follow the rhythms of their own time. Increasing awareness of the existence of an external time means re-educating or re-enabling the child to synchronize with others and with the environment. The spatial structuring, on the other hand, has been obtained by keeping the setting and the arrangement of the objects unchanged; Afterwards, the therapist tried to deconstruct the space by introducing elements of change (e.g., by modifying the arrangement of some objects in the room) or novelties (e.g., by providing the child with new musical instruments). At first, therefore, the poor tolerance towards changes that is typical of people with ADHD was respected, while later the therapist tried to promote and increase the flexibility of the child and his ability to adapt. Aims of the Intervention The general purpose of the intervention was the facilitation of the recovery of some cognitive-behavioral skills through both listening to music and related activities and through music production.

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More precisely, the child’s ability to autonomously manage and regulate the different dimensions connected to the body such as behavior, actions, gestures, movement in space, and contact with objects has been promoted. Secondly, the child has been helped to regain ownership of his body and to become more attentive and sensitive to the signals that the body sends and that precede the occurrence of certain states: For example, perceive the state of agitation that may precede the putting in the act of some hyperactive or impulsive behavior. Finally, activities have been proposed aimed at involving the child gradually in slower and more relaxed rhythms than the fast and frenetic ones he frequently experiences. Starting from the hypothesis that in people with ADHD there may be a dysregulation between the trend of their internal timer and that of the external/environmental time, in the sense that the internal timer of those subjects would have a faster pace than that of healthy people (Rubia et al., 2003; Smith et al., 2002). A re-synchronization between the child’s internal time and the external time has been promoted. In the first place, the therapist tried to make the child acquire the awareness of his impulsiveness and then to provide him with strategies to manage it. In fact, most individuals with ADHD are not able to understand that the impulsive behaviors are inadequate because for them it is normal to behave in this way. The same explanation can be given for hyperkinesis/hyperactivity. It is crucial, therefore, to make the child understand that these behaviors are dystonic with the expectations and rhythms of the external environment and that before taking specific actions or behaviors it is necessary to stop and reflect not only on how to articulate an action for reach a particular goal but also on the consequences that these behaviors can have both on itself and on others. Finally, the therapist tried to teach the child to respect the shifts both during the communication processes and during the activities. The presence of a single person beside him has undoubtedly constituted a facilitating condition to achieve this goal since the child had to consider and respect a single interlocutor. The ability to respect the shifts again implies the ability to exert control over impulsivity, to delay one’s response, waiting for the right moment to express it and to synchronize with the interlocutor at the temporal level.

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Activities Included in the Intervention Particular attention has been given to proposing activities appropriate to the child’s skills and preceded by clear, short, and straightforward instructions. Relaxation, music production, and music reproduction activities have been presented. The pieces used for relaxation remained unchanged for the duration of the treatment so that this activity also contributed to providing structure and predictability to the sessions. Initial and final relaxation took place in the same way and the child could choose to passively or actively participate. Also, the brightness of the room was adjusted by lowering the lights a little. The therapist’s intervention was as discreet as possible and only consisted of giving suggestions to the child about the best way to relax. In addition to relaxation, the following activities have been proposed. The rhythms of the body. With this activity, the therapist tried to make the child understand that different types of rhythms characterize our body and that can be considered in all respects a “sound object”. He tried, therefore, to focus the child on the heartbeat, breathing, speech, and walking. In turn, the rhythms of the body were mirrored by playing a percussion instrument. The mirror. Sequential movements have been proposed (e.g., clapping twice, then tapping the right foot once and then tapping the hands twice) that the child should repeat afterward in the right sequence and the right number. It started with simple sequences to gradually get to more complex sequences. The enchanted forest. The therapist told the story of a child who, during a school trip in the woods, got lost. He could only find the way back if he passed some tests that consisted in reproducing some rhythmic structures with a tambourine or rattles. The magic bag. A small sack was prepared to contain little cards that suggested the child different ways of pronouncing his name (e.g., very slow, very fast, loud, in a low voice, angry, happy). In turn, the therapist and the child extracted a card from the bag and pronounced their names following the card’s indication. The carnival of animals. The child was asked to listen to the different songs from Saint Saens’s “The Carnival of the Animals”; For each of them, he had to say which animal came to his mind and which aspects of music suggested to him to pick that specific animal. He was also asked

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to imitate the movements and behaviors typical of the animal he had thought. Where does the sound come from? Several pieces of the metallophone have been arranged in a large circle; The child was invited to sit with his eyes closed in the center of the circle. The therapist started by placing only two pieces and then gradually increasing the number to increase the level of difficulty. He played the different pieces of the metallophone creating different music sequences and the child, after hearing them, had to open his eyes, get up, and go to play it the same way. Assessment of the Intervention A pre- and post-intervention evaluation was conducted through a series of tests aimed at investigating the following areas: attention, rhythm, and synchronization. Therefore, both the cognitive and the motor-related aspects were taken into consideration. To assess attention skills the Deux Barrage test was employed. The task presents stimulus-target symbols (squares with adjacent segments coming out of them or one of the vertices or one of the sides) within a broad set of stimuli-fillers or distractors (squares with different orientations of the adjacent segments). It is a test of visual search that involves selective attention. Every 4 minutes the point where the child had arrived was marked in the matrix (in this way five-time intervals were obtained: T1-T2-T3-T4-T5). The scoring of the test was carried out by calculating the following indices: 1.  The Incorrectness Index, determined by computing the ratio between the total coding errors (Omissions + Commissions) and the total number of signs examined; 2. The Speed Index expresses the speed in ticking the signs, or the number of signs discriminated in one minute. It was assessed by computing the ratio between the total number of signs examined and the total duration of the test. The Stamback test, consisting of three parts: 1. Spontaneous time: The researcher places a pencil in front of the child and asks him to beat it on the table in the way he prefers, but always with the same rhythm. After 5–6 shots, the researcher

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starts the stopwatch, counts 21 shots, then stops the stopwatch and scores the time the child has used to beat them. Also, he notes any accelerations, delays, irregularities. 2. Reproduction of rhythmic structures: The researcher puts a screen between himself and the child so that the latter does not see the hand with which he will beat the shots. The child is told to listen as well as he beats and then to beat exactly as the researcher did. If the child is wrong, the researcher makes a note and repeats the exercise. 3.  Understanding the symbolism of rhythmic structures and their reproduction: The researcher shows the child the sequences of symbols of the different rhythmic structures and asks him how he thinks they should be beaten. Outcomes of the Intervention In the Deux Barrage Test, there was a decrease in the number of stimuli analyzed. A decrease, comparing the pre- and post-tests, was found in the number of omissions and commissions. The Incorrectness Index was equal to 6% in the pre-test, in which there was a slight progressive decrease in the inaccuracies from T1 to T4 that could reflect gradual learning. In T5, on the other hand, researchers reported an increase in the percentage of inaccuracy, probably due to a lowering of attention for tiredness. During the post-test, there was a decrease in this index, which was equal to 1%. A decrease was also observed in the Speed Index. In fact, while in the pre-test phase this index was equal to 24.15, in the post-test it was equal to 20. In conclusion, slight improvements were noted in the sustained and selective attention span. In the Spontaneous Rhythm test, differences in the frequency of behaviors between the two tests emerged. In both, the child performed more movements of the lower limbs, followed by behaviors aimed at synchronizing with the music and by the better interaction with the therapist. Furthermore, he identified the same number of rhythmic variations (14 out of 20) even if, during the post-test, the synchronous movements were increased and asynchronous ones decreased accordingly. There has therefore been an improvement in the ability to listen and attend to the musical stimulus, accompanied by a higher sensitivity in the perception of rhythmic variations.

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Concerning the Reproduction test of rhythmic structures, during the pre-test the child did not make many mistakes. Specifically, Simon produced more beats (one or two) than those provided by the structure, but at the same time he respected the combination of groups of beats and breaks between one group and another. During the post-test, on the other hand, fewer mistakes were made; In fact, only one rhythmic structure was completely wrong. The result of the post-test, therefore, shows improvements. Final Comments The evaluation and identification of improvements in self-control and attentional behaviors were more straightforward than the ability to synchronize internal and external time. The hypothesis according to which some symptoms such as impulsivity and hyperactivity may be the expression of EFs in charge of the sense of timing has only recently entered the literature. Thanks to the activities built ad hoc for the intervention described above, it was possible to focus on some specific deficits. The use of sound-music mediators has allowed promoting the ability to listen to two sources of communication: the therapist and the musical stimulus. In fact, to perform the activities correctly, the child had to pay selective attention to these sources. In the beginning, considering the deficit in his attentional skill, Simon showed difficulties because he could selectively focus only on one of the two sources. Thanks to the continuous exercise and learning of some strategies, however, the child has started to use his attentive resources more functionally. These improvements were also made evident by the comparison between the results of the pre-test and the post-test. During the intervention, it was also possible to observe a positive evolution concerning self-control and impulsivity. The music itself includes and subtends precise rhythms and times. The work on respecting these rhythms allowed the therapist to promote the ability to inhibit and procrastinate the response at the right time. There are endogenous rhythms “created by consciousness” and exogenous rhythms belonging to the external context; During the intervention, the therapist manipulated exogenous rhythms to regulate endogenous ones.

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If the hypothesis that the environmental rhythms can exert an influence on the subjective ones is valid, then one could also suppose that the incompetence in the deferral of the behavioral output has its origins in the first years of life, that is when, through educational practices, the child is led to follow the environmental rhythms rather than the subjective ones. In other words, concerning children with ADHD, dysfunctional regulation between subjective time and objective time may have occurred early in life.

A Group Intervention for ADHD Children Based on Music The primary objective of this intervention (Bertoni et al., 2014) concerned the improvement of compromised cognitive and behavioral skills in children with ADHD. The general objectives were: 1. To promote the development of skills that are lacking in patients with ADHD. More specific objectives were: increasing the ability to regulate attention, concentration, and listening and improving the ability to respect rules and instructions. 2. To promote the ability to self-control psychomotor behaviors. This goal is articulated in specific objectives, including improving awareness of one’s body, enhancing the sense of control of one’s motor activity, regulating the movements of one’s body in a controlled manner, refining the rhythmic function of one’s body. 3. To promote synchronization between internal and external time. This is linked to other objectives such as increasing awareness of one’s impulsiveness, acquiring the ability to regulate the tendency to perform impulsive actions, learning to modulate the strength of movements, learning to respect the shifts. 4. To promote the improvement of introspection. This is linked to the following specific objectives: to promote self-reflection, to increase awareness of one’s feelings and emotions, to increase the ability to recognize emotions, to increase the ability to manage emotions, and to improve the ability to associate emotions with the sensations experienced. 5. To increase the level of self-esteem. To this end it is necessary to increase the awareness of being able to achieve goals, to increase

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the sense of self-efficacy, to favor a positive self-image, to increase the feeling of satisfaction towards oneself, to diminish the sense of learned impotence, to increase resilience. Activities Included in the Intervention The intervention comprised a total of 10 meetings on a bi-weekly basis (for five continuous weeks). The second and the ninth meetings of the program were devoted respectively to the initial and final phases of the treatment, while in the six central meetings the actual music intervention took place. Each meeting was characterized by a core theme, in particular: rhythmic training, inhibition and self-regulation, attention, self-efficacy, tuning with the other and managing emotions. The children were randomly assigned to one of two small intervention groups. Each session was conducted maintaining a high level of structuring and predictability. The meetings took place in a protected, large, and bright space, where attempts were made to limit the presence of distracting stimuli. As for the individual meetings (each lasting about one hour), they always respected a standard structure for the activities: • moment of welcoming (about 10 minutes); • active relaxation (about 5 minutes); • first activity (from 10 to 15 minutes); • second activity (from 10 to 15 minutes); • reading a story (about 5 minutes); • passive relaxation (about 5 minutes). At the beginning of the session, the children sitting in a circle together with the therapists were prompted to share with the group an experience lived during the week, with the aim of fostering a welcoming atmosphere and mutual exchange. Relaxation was proposed at the beginning and at the end of each meeting with the aim of reducing the level of psychophysiological activation and the state of tension of children. Some authors argue that relaxation activates the child’s resources, promoting activities related to physical functions, but also supporting communication (Caffo & Camerini, 1991). For these reasons relaxation is believed to be particularly useful when it is proposed before a rehabilitative or therapeutic

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activity to facilitate its startup, or in parallel with the treatment. In particular, the “active” relaxation technique used for this program was linked to imagery (body scan), while the passive one exploited the characteristics of audio tracks selected ad hoc. Concerning the rehabilitation activities proposed, these have been developed by a group of psychologists who are ADHD experts. The activities have been conceived by re-elaborating classical techniques of music-therapy treatment and cognitive-behavioral techniques involving musical stimulation and manipulation of musical instruments. Assessment of the Intervention As stated above, the intervention comprised a total of 10 meetings on a bi-weekly basis (for five continuous weeks). A sample of 6 children with ADHD aged between 8 and 12 took part in the intervention. The first and last meeting was dedicated to the cognitive and behavioral evaluation of each child. During these meetings, researchers used assessment tools aimed at assessing attention, evaluation scales for ADHD, tools for the assessment of musical discrimination, and tools for assessing rhythmic ability. In particular, the tools were applied with the aim of investigating the following areas: • sustained attention and selective attention; • hyperactivity; • self-esteem; • life quality; • capacity for musical discrimination; • rhythmic ability. The following is a list of the tools used for the assessment: • Ranette test, taken from the Italian Battery for ADHD, evaluating selective attention, maintained one, and motor inhibition. • TAU (Hearing Supported Attention Test), taken from the Italian Battery for ADHD; • SDAG questionnaire, an evaluation scale for ADHD which aims to investigate the two areas most affected (inattention and hyperactivity/impulsivity).

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• Two questionnaires were also devised to investigate self-esteem and quality of life of children with ADHD. They were administered to both parents and children. • Seashore test, which provides a series of tests aimed at measuring musical attitudes; The ability to discriminate height, intensity, rhythm, duration, timbre is evaluated. For this research, in particular, three parameters were investigated: melody, volume, and intensity. • Three Stamback rhythm tests: The ability to reproduce rhythmic structures is investigated. • Behavioral observation grid: Explicitly built to record the behavior of inattention, hyperactivity, and impulsivity at every meeting and every activity. Outcomes of the Intervention Comparing the results obtained during the initial evaluation phase (pretest) with those obtained from the final evaluation phase (post-test) it can be said that the two groups have responded positively to the proposed musical intervention. The abilities related to ADHD were partially improved as a result of the intervention, in particular, selective and sustained attention, rhythmic abilities, and the level of hyperactivity, while the constructs of self-esteem and quality of life did not change significantly. The results show that the two groups benefited from the intervention and the intervention has strengthened some of the skills compromised in ADHD, in particular, selective and sustained attention and control of hyperactivity. The objectives of improving attention span, psychomotor self-control, and synchronization between external time and internal time were also met. The objectives related to introspective skills and increased self-esteem were only partially achieved. The short duration of the intervention is one of the factors that determined the weaker effects in the areas as mentioned earlier (self-esteem, introspective abilities, quality of life), which generally require longer times for changes to take place.

Concluding Remarks ADHD is a widespread disorder that affects children and adolescents; Therefore, the need arises to look for alternative therapeutic approaches to traditional pharmacological therapy. On the one

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hand, psychopharmacological treatment can be considered as the least expensive route both in terms of costs and commitment, as it allows immediate positive results to be achieved; On the other hand, research has shown that the duration of these results is short-term and that the symptoms tend to re-emerge as soon as the drug is stopped. The real challenge, therefore, is not the suppression of symptoms, but to find strategies to make these children acquire a level of awareness with respect to their dystonic behaviors, to reduce them within the limits of the possibility of that particular individual, to bring out the alternative resources that are undoubtedly present in each individual and to help the person to live with their symptoms and to develop a reasonable level of adaptation. Music interventions can help achieving these goals since activities based on sounds and rhythms foster basic mental processes which are impaired in ADHD, so leading children to master them in order to self-regulate their behavior efficiently.

References Barkley, R. A. (1997a). ADHD and the nature of self-control. New York: Guilford Press. Barkley, R. A. (1997b). Behavioural inhibition, sustained attention and executive functions: Constructing a unifying theory of ADHD. Psychological Bulletin, 121, 65–94. Bertoni, S., Cancer, A., Zugno, E., Zanaboni, C., Allevi, M., & Antonietti, A. (2014). Training musicale per bambini con disturb da deficit di attenzione e iperattività (ADHD): l’efficacia di un intervento in piccolo gruppo [Musical training for children with attention-deficit/hyperactivity disorder (ADHD): The efficacy of a small-group intervention]. Abilitazione e Riabilitazione, 23(2), 37–47. Borghesi, M., et al. (1995). Linee generali del trattamento musicoterapico di un caso di “Sindrome del Bambino Ipercinetico” [Outline of the music-therapy treatment of a case of “Syndrome of Hyperkinetic Child”]. Musica & Terapia, 3, 27–30. Buckner, R. L., & Carroll, D. C. (2007). Self-projection and the brain. Trends in Cognitive Sciences, 11, 49–57. Caffo, & Camerini. (1991). Clinica della psicomotricità e del rilassamento. Dall’osservazione all’intervento nei disturbi dello sviluppo in età evolutiva [Clinical approach to psycomotricty and relaxation. From observation to intervention in developmental disorders]. Milan: Guerini Studio. Castellanos, F. X., Margulies, D. S., Kelly, C., Uddin, L. Q., Ghaffari, M., & Kirsch, A. (2008). Cingulate-precuneus interactions: A new locus of dysfunction in adult attention-deficit/hyperactivity disorder. Biological Psychiatry, 63, 332–337.

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Cripe, F. F. (1986). Rock music as therapy for children with attention deficit disorder: An exploratory study. Journal of Music Therapy, 23, 30–37. Douglas, V. I. (1983). Attentional and cognitive problems. In M. Rutter (Ed.), Developmental neuropsychiatry (pp. 280–328). New York: Guilford Press. Epstein, M. A., Shaywitz, S. E., Shaywitz, B. A., & Woolston, J. L. (1991). The boundaries of attention deficit disorder. Journal of Learning Disabilities, 24, 78–86. Fabio, R. A. (2001). L’attenzione. Fisiologia, patologie e interventi riabilitativi [Attention. Physiology, pathology, and rehabilitation interventions]. Milano: Franco Angeli. Fassbender, C., Hester, R., Murphy, K., Foxe, J. J., Foxe, D. M., & Garavan, H. (2009). Prefrontal and midline interactions mediating behavioural control. European Journal of Neurosciences, 29, 181–187. Goschke, T. (2000). Involuntary persistence and intentional reconfiguration in task-set switching. In S. Monsell & J. Driver (Eds.), Control of cognitive processes (pp. 331–355). Boston: MIT Press. Hasenkamp, W., Wilson-Mendenhall, C. D., Duncan, E., & Barsalou, L. W. (2012). Mind wandering and attention during focused meditation: A finegrained temporal analysis of fluctuating cognitive states. Neuroimage, 59, 750–760. Hsu, C. F., Benikos, N., & Sonuga-Barke, E. J. S. (2015). Spontaneous activity in the waiting brain: A marker of impulsive choice in attention-deficit/hyperactivity disorder. Developmental Cognitive Neuroscience, 12, 114–122. Jackson, N. A. (2003). A survey of music therapy methods and their role in the treatment of early elementary school children with ADHD. Journal of Music Therapy, 40, 302–323. Levin, H. S., Eisenberg, H. M., & Benton, A. L. (1991). Frontal lobe function and dysfunction. New York: Oxford University Press. Miyake, A., & Friedman, N. P. (2012). The nature and organization of individual differences in executive functions: Four general conclusions. Current Directions in Psychological Science, 21, 8–14. Montello, L., & Coons, E. E. (1996). Effects of active versus passive group music therapy on preadolescents with emotional, learning and behavioural disorders. Journal of Music Therapy, 35, 49–67. Moore, P. (2009). Confronting ADHD in the music classroom. Teaching Music, 17(1), 57. Moore, R., & Mathenius, L. (1987). The effects of modeling, reinforcement, and tempo on imitative rhythmic responses of moderately retarded adolescents. Journal of Music Therapy, 24, 160–169. Morton, L. L., Kershner, J. R., & Siegel, L. S. (1990). The potential for therapeutic applications of music on problems related to memory and attention. Journal of Music Therapy, 27, 195–206.

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Pennington, B. F., & Ozonoff, S. (1996). Executive functions and developmental psychopathology. Journal of Child Psychology and Psychiatry, 37, 51–87. Plude, D. B. (1995). New technology: A biological understanding of attention deficit-hyperactivity disorder and its treatment. Journal of Neurotherapy, 1, 1–3. Pratt, R. R., Abel, H. H., & Skidmore, J. (1995). The effects of neurofeedback training with background music on EEG patterns of ADD and ADHD children. International Journal of Arts Medicine, 4, 24–31. Rickson, D. J. (2006). Instructional and improvisational models of music therapy with adolescents who have attention deficit hyperactivity disorder (ADHD). A comparison of the effects on motor impulsivity. Journal of Music Therapy, 43, 39–62. Rubia, K., Noorloos, J., et al. (2003). Motor timing deficits in community and clinical boys with hyperactive behaviour. The effect of methylphenidate on motor timing. Journal of Abnormal Child Psychology, 31, 301–313. Sagvolden, T., Johansen, E. B., Aase, H., & Russell, V. A. (2005). A dynamic developmental theory of attention-deficit/hyperactivity disorder (ADHD) predominantly hyperactive/impulsive and combined subtypes. Behavioral and Brain Sciences, 28, 397–419. Sechi, E., Corcelli, A., & Vasquez, P. (1998). Difficoltà esecutive e problemi di programmazione prassica dei bambini con Disturbi da Deficit dell’Attenzione con Iperattività [Executive dysfunctions and praxic planning deficits in children with ADHD]. Psichiatria dell’Infanzia e dell’Adolescenza, 65, 187–195. Shallice, T. (1988). From neuropsychology to mental structure. Cambridge, MA: Cambridge University Press. Shallice, T., Marzocchi, G. M., Coser, S., Del Savio, M., Meuter, R. F., & Rumiati, R. I. (2002). Executive function profile of children with attention deficit hyperactivity disorder. Developmental Neuropsychology, 21(1), 43–71. Sjowall, D., Roth, L., Lindqvist, S., & Thorell, L. B. (2013). Multiple deficits in ADHD: Executive dysfunction, delay aversion, reaction time variability, and emotional deficits. Journal of Child Psychology and Psychiatry, 54, 619–627. Smith, A., et al. (2002). Evidence for a pure time perception deficit in children with ADHD. Journal of Child and Adolescent Psychiatry, 43, 529–542. Sonuga-Barke, E. J. S., & Castellano, F. X. (2006). Spontaneous attentional fluctuations in impaired states and pathological conditions: A neurobiological hypothesis. Neuroscience and Biobehavioural Reviews, 31, 977–986. Stanford, L. D., & Hynd, G. E. (1994). Congruence of behavioral symptomatology in children with ADD/H, ADD/WO and learning disabilities. Journal of Learning Disabilities, 27, 243–253. Wilson, C. V. (1976). The use of rock music as a reward in behavior therapy with children. Journal of Music Therapy, 13, 39–48.

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Zugno, E. (2010a). La musica nel Disturbo da Deficit dell’Attenzione e Iperattività (ADHD) [Music and attention deficit-hyperactivity disorder (ADHD)]. In A. Antonietti & B. Colombo (Eds.), Musica che educa, musica che cura [Educating music, healing music] (pp. 193–217). Roma: Aracne. Zugno, E. (2010b). Musicoterapia e disturbo da deficit dell’attenzione e iperattività (ADHD): Un incontro possibile? [Music therapy and attention deficit-hyperactivity disorder (ADHD): A possible match?] Disturbi di Attenzione e Iperattività, 5, 199–212.

CHAPTER 3

Enhancing Social Skills in Autism Through Music

Abstract  Music treatments addressed to individuals with autism are usually aimed at enhancing social skills. To do so, musical activities are paired with a series of underlying competencies to be acquired. This chapter focuses on some of these basic competencies, such as the detection of the congruence between the emotional valence of music and the mood states it elicits, the identification of the relationships between the sounds (hearing) and the motor acts (vision) which produced them, the ability to mirror the partner’s mental state through the production of musical acts. Experimental findings supporting the notion that these basic competencies can be acquired or refined by people with autism, as well as the outcomes of music treatments focused on those skills, are reported and discussed in the chapter. Keywords  Autism · Music therapy Assessment · Intervention

· Social skills · Emotions

Defining Autism Autism Spectrum Disorder (ASD) is a pervasive disorder whose causes have not been understood fully. Many studies will suggest that it is probably due to genetic inheritance (Faras, Ateeqi, & Tidmarsh, 2010). People with ASD have communication challenges and typically struggle with deficits in social-emotional reciprocity, lack of understanding and © The Author(s) 2018 A. Antonietti et al., Music Interventions for Neurodevelopmental Disorders, https://doi.org/10.1007/978-3-319-97151-3_3

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expressing nonverbal and verbal communication, and show difficulties in developing and/or maintaining and understanding personal relationships. Another challenge that is often faced with ASD is behavioral. This disorder includes repetitive motor movements, use of objects, or speech, insistence on inflexibility or sameness, adherence to routine, ritual patterns of verbal or nonverbal behaviors, and fixated interests that are abnormal in intensity or focus (American Psychiatric Association, 2013). As human beings, we require the abilities of empathy and emotional recognition in our daily life to maintain relations with others around us. ASD is a condition in which social-communication, confined obsessions, and the ability to understand emotions of others are deficient. Empathy enables people to understand emotions of others surrounding them and to share their feelings. We come to articulate these feelings in joint effort through emotion recognition—which is essentially the process where humans identify other human beings’ emotions through facial, verbal, and bodily expressions (Sucksmith, Allison, Baron-Cohen, Chakrabarti, & Hoekstra, 2013). Unfortunately, children who suffer from ASD commonly have these impaired abilities to match empathy and emotional recognition (Stephenson, Quintin, & South, 2015). Empathy has become one of the greatest hallmark traits of those with ASD. However, research has gone into whether or not people who have ASD can truly empathize with others. Empathy towards others requires the ability to resonate with others’ feelings while maintaining a healthy understanding of one’s own and to identify what others are thinking without resonating with that state of being. Essentially to understand the facial expression, body language, and vocal tone is the key to empathy (Jones, Happé, Gilbert, Burnett, & Viding, 2010). Processing emotional recognition difficulties within ASD stems from attentional and perceptual activity. In other words, those with ASD analyze face differently, resulting in lower attention to expression (Dawson et al., 2004; Klin et al., 2002). Studies have shown that this may be due to surrounding information that is received by the eyes (Baron-Cohen et al., 1995). The struggle for people with ASD is to understand what people think. A typical developing individual learns how to appropriately express words and body language through empathy. For example, if a child sees a person get injured they may run up to that person and kiss the area that was hurt because that is what they were taught to be an appropriate response to someone else’s pain. However, people with ASD,

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because of their lack of recognizing body language, fail to express empathy for that individual. This is a result of the precise skills that are compromised by the disorder (Montgomery et al., 2016). Society is prompted to scrutinize and validate each other’s emotions through emotion recognition. Fortunately, there are many forms of therapy that can assist in the enhancement of the quality of life in individuals with ASD. According to the American Music Therapy Association (2012), one form of therapy that has proven to adjust bodily regulation, create personal connections, relaxation, personal expression and pursue long-term goals is music therapy. As trained professionals, music therapists are capable of producing significant interventions for their clients with ASD. The diverse applications of music therapy have proven to assist children with ASD to excel in their interpersonal and social lives. In order to adequately serve such a purpose, it is important to understand how patients’ emotion recognition and empathy operate within an emotional and cognitive standpoint. Once a relationship is implemented between the music therapist and the client, they can begin to work on music making of rhythmic notes, pitch, temporal beats, and so on, that will enable a better dynamic between them. With this relationship in place and the musical engagement, the individual on the ASD can begin working on self-expression, social interaction, and interpersonal emotions.

The Benefits of Using Music with Autism Some of the characteristics of music appear to promote or trigger specific positive responses in individuals on the ASD, both from a cognitive and an emotional stance. From a cognitive standpoint, the fact that individuals with ASD are so focused on the details allows them to develop a better “relative pitch”, that is, the ability to identify a musical note within a melody by comparing it to a reference note and being aware of the interval between them. This allows them to recognize and categorize musical excerpts more easily (Baron-Cohen, 2002; Mottron, Dawson, & Soulières, 2009). Yet they do not show any difficulty, when compared to neurotypical individuals, in the global elaboration of music (Heaton, 2005; Heaton, Pring, & Hermelin, 2001) and that supports the fact that using music-therapy inspired approaches can be very effective when working with patients with ASD.

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From an emotional standpoint, music appears to benefit individuals with ASD from several points of view. Examining the neurophysiological effects caused by listening to music, studies have reported increased relaxation, mainly considering muscle tension (Skille & Wigram, 2013). In children who have impaired basic communication skills because of ASD, music can be a catalyst for mutual interaction and mitigate the lack of flexible behaviors and social patterns. This form of active music advocates and motivates the individuals with ASD and draws shared engagement and attention (De Marchi, Benatti, Traficante, & Antonietti, 2009; Wigram & Gold, 2006). As these social and behavioral patterns begin to diminish, music can also improve the functions of the autonomic nervous system (Hirstein, Iversen, & Ramachandran, 2001; Lundqvist, Andersson, & Viding, 2009) and reduce anxiety (Wigram & Gold, 2006) and stereotyped behaviors (Rapp, 2007) as well. In addition, music can be effectively used by individuals with ASD as a self-regulation strategy, as can be derived from the internally focused language that they use when describing the effects of music on their mood, a type of language that is not used by neurotypical individuals (Allen, Hill, & Heaton, 2009). This is linked to an overall better processing of main emotions (Heaton, Allen, Williams, Cummins, & Happé, 2008; Heaton, Hermelin, & Pring, 1999). There are many forms of music therapy that are widely used, but one in particular—improvisational music therapy—has become a rapidly growing intervention treatment for children with ASD. Improvisational music therapy is an effective treatment intervention that focuses on the spontaneous communication, expressions of self, and how to engage in social constructs. As other therapeutic interventions using music as a backdrop to engage a client, in improvisational music therapy the therapist and client use interactive live music within the session to meet therapeutic needs (Gold et al., 2006; Trevarthen, 2001). Studies supported the importance of the emotional role that interpersonal relationships play in children with ASD. It has been proven that improvisational therapy helps shape interpersonal relationships, goal incentives, emotional engagement, and responsiveness in children with ASD (Wigram & Gold, 2006). Which specific aspects of music seem to promote these positive effects? First of all people on ASD seem to appreciate the physical aspects of sounds as well as their resonance, elements that help them focusing

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their attention. The fact that music shares many similarities with verbal language and can be used to create a well-structured (and, hence, reassuring) symbolic system that can, if needed, overcome the semantic aspects of communication that could be problematic for individuals on the ASD. The similarities between music and language also include the similarities between the elements of musicality embedded in every language, which characterize language as a multimodal experience (Besson & Schön, 2001; Jackendoff, 2009). In a study conducted by Kim, Wigram, and Gold (2009) the music therapist identified elements in the child’s musical and non-musical behavior and provided the child with empathic, supportive musical structure in an attempt to engage the child. The elements identified included rhythmic patterns, dynamics of expression, pitch range, temporal beat, and melodic contour. The supportive musical structure, also known as musical attunement, used by the therapist included vocal and instrumental exchange, eye contact, movement and gestures, and facial expressions. This study also indicated a significant difference in the effects of improvisational music therapy and toy play sessions. This was especially evident regarding social-motivational aspects. Improvisational music therapy elicited joy and emotional synchronicity more frequently and for longer durations than the toy play sessions did. Because of the elements mentioned above, music can trigger the activation of the mirror system while playing or listening to music (Lahav, Saltzman, & Schlaug, 2007). Moreover, the activation of the mirror system can be enhanced with music practice (Bangert et al., 2006). Another element that can explain the multiple benefits of using musicbased intervention when working with individuals with ASD is rhythm. Internal rhythm is fundamental to promote baby’s development and healthy interaction since the first days of life (Malloch & Trevarthen, 2009). Moreover, rhythm helps organizing life and work activities. Since this kind of organization helps these individuals deal with anxiety, providing addition rhythm-based support can be seen as another effective use of music. Several studies have shown that people with ASD have a preference for auditory stimuli in the formation of music over other sources of stimuli. It was also found that people with ASD engage with music as a stimulus for longer periods of time in comparison to other children without ASD. In regard to responsiveness to music improvisations, it was found that children with ASD had no significant difference in rhythm,

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restriction, or originality compared to their same-aged peers without ASD. This indicated that the music responsiveness was intact within the ASD group (Simpson & Keen, 2011). In a study conducted by MolnarSzakacs and Heaton (2012), children responded to sounds and were coded for vocalization, orientation-coordination, anticipation-increased focus, and positive affect. They found that children with ASD were more responsive to all stimuli compared with the neurotypical children. It was argued that this is an indicator of sensory or attention difficulties. It was also found that the children with ASD presented a significant increase in response to music compared to speech or environmental noise. This was suggestive of music eliciting special attention in children with ASD.

Examples of Assessment Techniques and Training Programs In the previous paragraph, we examined the strong links between different music elements and the autistic mind and we discussed different possible music-therapy inspired approaches that rely on these links to promote emotional and cognitive well-being in an individual with ASD. Music-therapy interventions, as we have just seen, use the “musical language” as a privileged communication channel to trigger a multimodal connection among movement, emotions, and cognition. Effectiveness of the music-therapy intervention described above supports the benefits of this approach. Yet, to be able to better design targeted interventions it is important for professionals to be able to assess individuals’ ability to understand and appreciate a congruent connection between music and gestures (a fundamental prerequisite for the work on the activation of the mirror system and the connection between music and language/ expression). Having good assessment strategies that can be used to evaluate this competency in a population with ASD can help specifically to evaluate individuals who are considering a music-therapy inspired intervention in order: 1. To know how music can facilitate global perception against the tendency of individuals on the ASD to focus mainly or exclusively on the details;

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2. To explore the relationship between individuals’ motivation and interest in musical language and music specific intermodal motor components. To be more specific, to assess the specific role of speed, intensity, and rhythm (the three main dynamic components that are the foundation of the link between music and movement) to promote a multimodal perception of gestures and movement and their synchronicity; 3. To collect enough reliable information to assess if there is evidence to support the possibility from people with ASD of using the recognition of synchronicity between gestures and music to promote an emotional synchronization within a therapeutic setting; 4. To identify which out of the aforementioned communication dimensions (intensity, speed, and rhythm) would be the most relevant to target in order to promote the most effective therapeutic session when working with high functioning individuals on the ASD. To reach these goals, Dirito and Stevens (2010) developed four specific assessment tasks, which they tested on a sample of 103 participants, both children and adults. Half of the sample consisted of individuals with ASD and the other half was a control group of neurotypical individuals. Information derived from this set of tasks can help in identifying specific preferences of individuals with ASD, considering their different level of functioning, and this specific information can be used to plan more effective music-therapy interventions. Perception and Discrimination of Musical Rhythm, Intensity, and Speed The first assessment task aims at assessing the perception of the three main structural variables of music language (rhythm, intensity, and speed). This task allows therapists to specifically assess if individuals are or are not able to detect congruence and incongruence in music elements produced by two different players hitting drums at the same time. Individuals are shown a video of a musical dialogue presenting the two players beating the drums, where Player B would respond to Player A by imitating what Player A has just played. Respondents are then asked to assess how adequate Player’s B imitation was, with reference to intensity, speed, and rhythm. Research evidence (e.g. Accordino, Comer, & Heller, 2007) shows that rhythm is the most significant interactive

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element within a music-therapy section with individuals with ASD when it comes to build a music dialogue that fosters a feeling of a safe sense of “be together”. Perception of Synchronization Between Sounds and Gestures in MusicBased Communication The main aim of this second assessment task is to test if individuals with ASD can recognize synchronization between gestures and sounds during a music-based communication. In order to be able to focus mainly to this specific skill, the emotional and expressive components of music communication have been reduced as much as possible. As is the case of the task described in the previous paragraph, each video clip is quite short (37 seconds each) to allow testers examining immediate perception. We know from the literature (Schutz & Lipscomb, 2007) that neurotypical individuals tend to be more influenced by visual than by auditory perception. For this reason, they should perceived a musical gesture as synchronized with music even when it is not, because they perceive gesture and music as a whole. Preferences for Different Aspects of Emotional Music Stimuli This task is divided into two subtests: “Pingu at the disco” and “The Ballerina”. “Pingu at the disco” is based on a video clip (1 minute and 37 seconds length) derived from the popular Cartoon Pingu, which appears to be a favorite of children with ASD. The target video clip shows Pingu and his friends dancing to a very upbeat music. Music and dance music are well synchronized. Emotions are expressed by using nonverbal elements linked to movements and gesture. In the second version of the video clip, the same visual elements are presented, but the soundtrack is replaced by classical music piece (a waltz by Strauss) that conveys the same emotion but with a more moderate rhythm. Moreover, in this second version, the music is not synchronized with the characters’ movements. This task is similar to the first one but in this case the emotional and semantic aspects of the music-based communication are not present. Comparing these two video clips is interesting for a few reasons. First of all because the cartoon Pingu, having animals as main characters, does not involve human body. This allows testers to focus exclusively onto the

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congruence between gesture and music, without the possible interference of other variables, like the different levels of activation of the mirror system. Because of the preference of high functional subjects with ASD for nonhuman stimuli like objects, cartoons, and animals, this cartoon appears to be adequate to be used with this specific population. As mentioned above, individuals with ASD tend to like this cartoon and this increases their attention to any stimulus related to it. The second subtest (the Ballerina task) is structured the same way as the previous one, but a human element is added. Hence, this can be considered a higher-level task to assess similar skills in high function individuals with ASD. It can be matched to the previous task to assess the effect of processing human elements (in this case a ballerina) when evaluating musical stimuli and the congruency between gesture and music. This task also controls for music preference because, in this case, a classical music piece is the one that is perfectly synchronized with the ballerina movements, while the more modern upbeat music is not synchronized (the opposite was true for the Pingu task). An interesting characteristic of these tasks is linked to the fact that these videos are longer than the ones used for the previous tasks so to allow testers to better analyze individuals’ perception on a longer time span. These two subtests, taken together or separately, specifically allow to explore the preference of individuals with ASD for video clips with upbeat music, detection of congruence between music and images, and level of appreciation for this coherence. Again the preference for a global elaboration or for processing single details can help to plan more effective music-therapy interventions. Perception of Synchronization of Different Musical Elements in Music-Based Communication This task aims at assessing how well individuals with ASD process three different aspects of the music communication: speed, intensity, and rhythm. The video clips used for this assessment show a musician playing a djembè and participants are asked to assess if the musicians’ movements were synchronized with the music. Using a percussion instrument, like the djembe, allows to control for the influence of pitch that could affect responses.

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To be more specific, this task allows to assess the role of each of the three aforementioned elements, as well as to highlight any preference for one of them. It allows to assess if high functioning individuals with ASD tend to consider, at least to some extent, all these elements when evaluating the congruence of a musical communication or focus only on one or two of them. Individuals are asked to rate the congruency between music and movements of 12 videos. Each video lasts 30 seconds. Six videos are synchronized while the other 6 are not. The videos are matched either for speed (low and high), intensity (low and high), and rhythm (simple and complicated) and could be either matched or not matched with the congruent soundtrack. The videos show only the instruments and the hands of the player in order to exclude the possible interference by emotional expressions derived by the presence of a human face. Results from the Assessment and Ideas for the Intervention The tasks described in the previous paragraphs have been tested (Dirito & Stevens, 2010) on a sample of 103 individuals, half with ASD and half neurotypical. Data confirmed the validity of the assessment tasks in highlighting differences between individuals with ASD and neurotypical ones. Interesting differences that can be used to effectively plan music-therapy based interventions emerged. High-functioning individuals with ASD perform better than neurotypical individuals of the same age group in recognizing when music and gestures are not synchronous, being less affected by the illusion of a global coherence between music and gesture. The same is true when congruence between intensity of gesture and intensity of music is lacking: Individuals with ASD point out discrepancy between low-intensity movements and high-intensity music more often. Individuals with ASD tend to prefer upbeat music, making them overlook incongruences more when upbeat music is played. Individuals who are in the middle of the spectrum tend to prefer upbeat music, while this is not true for high functioning individuals with ASD. High functioning individuals tend to prefer intense upbeat music, regardless of the possible coherence between music and the communication behind it, thus showing more difficulties in recognizing and responding to rhythm.

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How can we read these data and how can this information help planning more effective music-based interventions? The fact that individuals with ASD perform better in recognition tasks can be explained by their preference for an elaboration focused on details and not on the global stimulus. As reported in the literature, both children and young adults with ASD are better than neurotypical individuals in isolating single elements in music and body-based communication (Baron-Cohen, 2002; Bishop, 2008; Spencer et al., 2000). To be more specific, the responses to the assessment tasks described above confirmed results derived from similar samples regarding lower susceptibility to visual illusions (Happè, 1995; Ropar & Mitchell, 1999, 2001), higher discrimination ability when evaluating highly confounding visual and auditory patterns (Plaisted, O’Riordan, & Baron-Cohen, 1998), high ability in globally processing music stimuli (Heaton, 2003; Mottron, Peretz, & Menard, 2000), even if the perception of coherence within gestures used as communication tools can be lacking in high functioning individuals with ASD (Bertone, Mottron, Jelenic, & Faubert, 2003; Milne et al., 2002; Spencer et al., 2000). Individuals who are in the middle of the spectrum do not need or look for upbeat music. This happens because of the problems they have in regulating emotions. In this case, an intense, upbeat music does not coach them to better regulate emotions, but would only increase their anxiety. This would also be increased by their high sensitivity to perceptual stimuli. For these individuals music-based interventions should start with more relaxing, low-intensity music, that would guide them toward a better emotional regulation. The intervention could introduce progressively more intense or upbeat music. The same principle should guide the choices of gestures or tunes to accompany music: The therapist should avoid anything that is too intense in order not to over-stimulate the patient and trigger an even lower level of self-regulation. Following this line of reasoning, an intervention should be planned so that patients start by learning to cope with emotions elicited by low intensity relaxing music, by the way of using soothing properties of music to enhance this effect. This kind of music will also promote a better and more coherent perceptual organization, which will eventually lead to the possibility of using more upbeat music and work on the higher level of emotion regulation. When working with high functioning individuals with ASD, their difficulties in recognizing and processing rhythm might be the first

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ones to be addressed. Starting by utilizing music that presents a clear, simple, and repetitive pattern could be useful. Good examples are lullabies or metal music, which are both favorite of individuals with ASD. The ideal starting point for each patient could be easily assessed by using tasks similar to the ones described above. Progressively, the complexity of the rhythm could be increased and variations could be introduced. An improvisational music therapy could be the most effective, given the way it is structured, to help manage social, communication-based interactions.

Imitation Interventions Based on Technological Devices Imitation and Autism As seen in the previous paragraphs and as it is discussed in the literature (Williams, Whiten, & Singh, 2004), imitation difficulties are common in children with ASD. The capability of imitating others is thought to be critical for the development of social skills and language (Rizzolatti & Arbib, 1998, 1999; Tettamanti et al., 2005; Tomasello, SavageRumbaugh, & Kruger, 1993), which, as we have seen, are impaired in ASD. Specific interventions aimed at addressing these issues have been designed. Relying on what we have been discussing earlier in the chapter, it will be evident that these interventions can be beneficial, especially if they are music-based, because they address a primary symptom of the disorder and, at the same time, they indirectly positively affect social skills (Rogers, Hepburn, Stackhouse, & Wehner, 2003; Small, Buccino, & Solodkin, 2012) through the possible activation of the mirror system (Iacoboni et al., 1999). Mirror neurons are activated when imitation is involved (Fadiga, Fogassi, Pavesi, & Rizzolatti, 1995; Grèzes, Armony, Rowe, & Passingham, 2003; Iacoboni et al., 2001; Mashal, Solodkin, Dick, Chen, & Small, 2012) and, since they allow individuals to assimilate other people’s actions into their own motor schemas (Iacoboni et al., 2001; Oberman et al., 2005), they are hypothesised to represent one of the bases of an effective communication (Iacoboni et al., 2001; Rizzolatti & Arbib, 1999). A large body of evidence confirmed dysfunctions in the mirror function in patients with ASD (Hadjikhani, Joseph, Snyder, & Tager-Flusberg, 2007; Martineau, Andersson, Barthélémy,

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Cottier, & Destrieux, 2010; Oberman, Ramachandran, & Pineda, 2008). They correlate with the severity of the symptoms (Dapretto et al., 2006) and have been related to social and imitation deficits in these patients (Iacoboni, 2009; Kolb & Gibb, 2011). Building interventions to address these issues are justified by the fact that experience can lead existing neurons to change their synaptic connectivity (Kolb & Gibb, 2011). Hence, the functioning of the mirror network might be improved by activities based on the imitation. Imitation, in fact, can be seen as the mirror exercise by definition and—by eliciting the visual, auditory, and proprioceptive canals together (Iacoboni et al., 1999)—may maximize the activation of the mirror neuron network. Imitation indeed can assume several shapes: oral-facial imitation, actions (with or without objects), and gestures (symbolic or meaningless). The question of whether such abilities are moderately separated and unrelated or, rather, depend on a unitary general imitation ability is still controversial. However, meaningless gestures are particularly difficult to be trained in imitation, in particular with children with ASD, given their difficulties in sustained social attention. These gestures produce neither physical effects that may act as feedback for imitation, nor semantic effects that may help to sustain attention. For this reason, when designing a music-based intervention, it is worth reminding that is the imitation of meaningless body gestures that seems universally impaired in children with autism. On the other hand, the imitation of meaningful gestures is impaired only in low functioning autism (Vanvuchelen, Roeyers, & De Weerdt, 2007). This suggests that different forms of imitation (e.g., object, gesture, vocal) may represent independent dimensions as there is evidence that children with ASD only generalise within the imitation category they have been trained to (Stone, Ousley, & Littleford, 1997), although Rogers and colleagues (2003) and Ingersoll, Meyer, Bonter, and Jelinek (2012) reported correlations between different imitative behaviors (even if meaningless gestures were not considered or largely underrepresented in these studies). A specific imitation intervention for autism has been developed by Ingersoll and her colleagues (Ingersoll, 2010, 2012; Ingersoll & Gergans, 2007; Ingersoll & Lalonde, 2010; Ingersoll, Lewis, & Kroman 2007; Ingersoll & Schreibman, 2006), based on the object-related actions and meaningful gestures, which appeared to be effective in increasing the quality of both spontaneous and elicited imitation. However, children with

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ASD may be facilitated by adding meaning to the gestures (in contrast with normally developing children: Rogers, Bennetto, McEvoy, & Pennington, 1996). On the other hand, children with ASD show unusual difficulties in imitating meaningless body gestures (DeMyer et al., 1972; Stone et al., 1997; Vanvuchelen, Roeyers, & De Weerdt, 2007). If the assumption of independent imitation dimensions is true, only an intervention grounded on the imitation of meaningless body gestures may address the core difficulty of patients with ASD (Wild, Poliakoff, Jerrison, & Gowen, 2010). However, achieving this goal is extremely problematic for children with ASD, given the paucity of social interaction and their reduced sustained attention. Imitating meaningless movements has no effects on the physical world and the lack of such feedback makes this kind of imitation particularly demanding. In addition, the lack of relation with a semantic/social meaning of the action prevents to sustain attention during training. Technological devices allowing individuals to receive feedbacks to their meaningless actions might enable trainers to overcome such limits. The Soundbeam Intervention Project Forti and colleagues (2012) designed a music-based intervention for children with ASD, the Soundbeam Imitation Intervention (SII). In SII imitation is trained for meaningless gestures by coupling movements with sounds through Soundbeam5® ultrasound-to-midi converter. When two Soundbeam5®s are used in a child-model imitation setting and generated sounds are sequenced in a melody, they represent direct feedback for the accuracy of imitation and engage children’s attention. SII is designed as an individual intensive intervention in a progression of imitation exercises: synchronous/one arm imitation, synchronous/ two arms imitation, and delayed imitation. Exercises are based on the repeated movements-melodies associations of increasing difficulty. The sequencing of sounds enables the actor to generate melodies and it has been documented that music represents an attractive and motivating stimulus for children with ASD (Molnar-Szakacs & Heaton, 2012; Reschke-Hernández, 2011). Thus, musical feedback can make an intervention grounded on the imitation of meaningless body gestures possible for these patients. The intervention is designed as 12 individual SII sessions of 30 minutes each, run biweekly over a 6 weeks period.

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Assessment To check for actual efficacy of the program, imitation and social attention assessment took place one week before and one week after completion of the SII programme. Both motor imitation and social attention were assessed in a synchronous video-modeling task, similar to the ones described in the previous paragraph. In this specific assessment task, participants were required to play a drum copying a model shown on a video. They sat on a child sit in front of a bongo drum. Behind the drum, the video was played on a 15″ laptop PC placed on a height-adjustable desk. The video started with an initial “beep” to grab participants’ attention. For the first 10 seconds, they were asked to watch the video, where the model was shown while playing the same kind of drum, two strokes with the left hand and one stroke with the right hand, at a slow rhythm. After the second “beep,” participants were asked to copy the model on their drum while keep watching the video where the model was still hitting the drum. They were encouraged to carry on playing for 60 seconds. Through motion capture, motor imitation was precisely measured regarding accuracy. Sustained social attention was measured through the analysis of video recordings: The amount of time during which participants were looking at the video returned an indicator of sustained social attention. Intervention SII is designed as training for synchronous imitation of up and down arm movements of a model standing in front of the child. Soundbeam5® (Soundbeam project, UK), shaped like a red plastic microphone, allows returning a sound each time one’s hand is moved in front of the sensor. The sequence of generated sounds can be preprogrammed. Thus, repeated movements make it possible to play a predefined melody. Two Soundbeam5®s were used in SII: one for the participant and one for the trainer. Although they were programmed on the same melody, different tunes were used to make it possible to identify the sound generated by one’s movement. SII sessions were designed as a series of steps whose progression is individualized and regulated by the acquisition of competencies measured as two consecutive trials on the same exercise with no mistake. In the first two exercises, participants are asked to play the melody with Soundbeam5® by moving hands together with the trainer (synchronous

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imitation): Exercise 1 concerns the right arm; Exercise 2 concerns both arms, although they are moved one at a time in a randomized order. The trainer regulates the movement-melody rhythm on the basis of the child’s promptness to imitate. If one movement is not copied, the trainer sings to grab the child’s attention and solicits the movement. In Exercise 3, participants are asked to play the melody alone, immediately after the demonstration by the trainer (delayed imitation) using their dominant hand. Once the three exercises are learned for a melody, they are repeated with a more difficult melody. Difficulty is manipulated both regarding familiarity and regarding rhythm complexity. The progression of melodies is as follows: (i) familiar children song/rhythmically easy: “Frère Jacques”; (ii) familiar children song/rhythmically difficult: “Happy birthday”; (iii) unfamiliar rhythm/rhythmically easy: “We will rock you” chorus by The Queen; (iv) unfamiliar melody/rhythmically difficult (purposely composed). Outcomes The study designed by Forti and colleagues to test their intervention involved 14 children with ASD and lasted 6 weeks. The effectiveness of the intervention has been evaluated for imitation accuracy and sustained attention, both assessed at a video-modeling task. In that procedure, participants were required to imitate a model shown at a video while playing the drum. After SII, imitation increased considerably. Social attention was measured as the time interval children attended the video. After SII intervention, attention improved from 68 to 97% of total time. Older children made a quicker progression in SII exercises and participants with higher IQ were somewhat facilitated. A positive relationship between developmental skills and growth during treatment has been previously suggested (e.g., Kraemer & Kupfer, 2006; Sallows & Graupner, 2005). Despite such relationship, in this study gains in imitation and attention skills were similar for all children. For this reason, SII might represent a valid intervention for children with autism between 5-and 9-years-old. Also, SII might be a potentially viable intervention for children with ASD with severe intellectual disability and indeed one of the few for nonverbal patients. SII is not only focused on the meaningless gestures, but also on simultaneous, rather than delayed, imitation. Thus, SII might address a specific timing and coordination deficit of children with ASD, evident

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both in imitation settings (Trevarthen & Daniel, 2005) and in other areas, such as gait (Nobile et al., 2011). As Small and colleagues (2012) suggested, the selection of appropriate therapy for autism should ultimately depend on knowledge of the underlying biology. The approach described above is based on the hypothesis that mirror-neurons deficit may represent the cause for the incomplete development of social functioning in children with ASD and that a systematic activation of such system through the simultaneous observation-execution of meaningless body gestures may affect functional changes of mirror-related functions. According to Rizzolatti and collaborators (Rizzolatti & Arbib, 1998, 1999; Tettamanti et al., 2005), movements represent the basis for interindividual communication and the development of speech. In fact, neural interactions between movement and language have been discovered (Rizzolatti & Arbib, 1999; Tettamanti et al., 2005), there is high comorbidity for movement and language deficits (Kimura & Archibald, 1974; Nobile et al., 2011; Rizzolatti & Arbib, 1999), and imitation abilities of patients with ASD are strictly related to language skills (Arbib, 2008).

Concluding Remarks In this chapter, we introduced and explained the benefits of using a music-therapy-based approach to help individuals with ASD and presented different ways of assessing individuals’ responses to the different components of music, as well as a possible way of planning and implementing a music-based intervention that could benefit patients on the spectrum. Research data have been discussed to highlight the relevance of using music therapy with patients with ASD, as well as the need to create a music-therapy program that can meet the individual characteristics of each patient on the spectrum. Depending on where on the spectrum a patient is, they will not only have a different therapeutic need but will also respond differently to a different type of music. If used correctly, music proves to be extremely beneficial in supporting patients on ASD in interactive in a more effective way with their surroundings, by way of improving emotion regulation and enhancing the quality of social interaction by promoting a better understanding of rhythm in conversation and triggering the activation of the mirror system.

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CHAPTER 4

Stimulating Motor Coordination in Rett Syndrome Through Music

Abstract  In the case of Rett syndrome, among the variety of possible goals that can be reached thanks to music-based interventions (associated to the different pathological manifestations of the syndrome), motor coordination has been chosen as one of the critical deficits characterizing the disorder. Literature supporting the benefits of musical activities when working with Rett syndrome patients are summarized and reasons highlighting why music might be particularly effective in this fields are discussed. An intensive training program implemented with a girl affected by Rett syndrome is described in detail and some activities carried out during the intervention are also exemplified. Keywords  Rett syndrome Motor skills

· Music therapy · Intervention

Defining Rett Syndrome Rett Syndrome (RTT) is a rare neurodevelopmental disorder that affects one in 10,000–15,000 girls and it is due to a mutation in a MECP2 gene (Elefant & Lotan, 2011; Fabio et al., 2014). This syndrome causes an increasing loss of intellectual and cognitive abilities, as well as motor and communication skills. Girls with RTT develop normally for the first 6 months of their life when the regression starts. The most pronounced

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changes generally occur at 12–18 months of age, suddenly or over a period of weeks or months. Eventually RTT will cause symptoms that include, but are not limited to: slowed growth of brain and, later on, of other parts of the body; loss of movement and coordination, which usually starts with reduced hand control; loss of communication abilities, that include not only speaking but also the ability to make eye contact and communicate in other ways; abnormal hand movements that include repetitive and purposeless movements like hand clapping, tapping, or rubbing; breathing problems during waking hours, like hyperventilation or breath-holding; emotion regulation problems that leads to agitation and irritability; cognitive disabilities; seizures; scoliosis; irregular heartbeat, which is a life threating problems for individuals affected by RTT. The regression follows four defined stages: early onset, rapid destruction, plateau, and late motor deterioration. Stage I (early onset) generally starts between 6 and 18 months and its duration varies between a few months and one year. Babies start to lose interest in their surroundings and avoid eye contact, they might also show some delays in motor developments milestones, like sitting or crawling. When the babies are between 1 and 4 years of age, they go through Stage II (rapid destruction): They more or less gradually loose ability that they have previously acquired. During this stage, other common symptoms of RTT, like slowed head growth, abnormal hand movements, hyperventilation, loss of emotion regulation and social interaction, and problems with motor coordination. The Stage III (plateau) can begin anytime between age 2 and 10 and usually lasts for several years. Children can experience some improvements during this phase. These improvements can be related to emotion regulation, communication, and hand use. Motor coordination tends not to improve. Some children start experiencing seizures during Stage III. Stage IV (late motor deterioration) happens after the age of 10 and lasts up to decades. It brings reduced mobility, associated with muscle weakness and scoliosis. Other symptoms are usually stable and seizures occur less often. People affected by RTT tend to have a strong desire for human contact and interaction, but they are unable to express themselves in a conventional way. For some people it is hard to interpret nonverbal messages that are communicated from people with RTT. Generally, patients express pleasure and displeasure through facial expressions and body

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language. Their physical activity appears to be exclusively focused on hands, engaged in either simple or complicated stereotypical movements that basically last all day (Elefant & Lotan, 2004).

Music Therapy and Rett Syndrome Different therapeutic approaches are used to help patients deal with RTT, the most common being pharmacotherapy, physiotherapy, hydrotherapy, horse therapy, occupational therapy. Music therapy is also used with positive results. Interestingly enough, it was Rett himself—who first described the syndrome—to recommend music as an helpful approach to support girls with RTT (Rett, 1982). Music appears to be beneficial because it promotes the patients’ desire to interact and to communicate with their surroundings as well as in developing their cognitive, affective, sensory-motor, and physical abilities (Elefant, 2002, 2005, 2009; Hill, 1997; Merker, Bergström-Isacsson, & Engerström, 2001). Music and Rett Syndrome The first question that should be addressed is if girls with RTT do like music. To achieve this goal, Merker and colleagues (2001) distributed questionnaires to parents of girls with RTT that contained questions regarding music and the patients’ responses to it. Results indicated that music is a significant aspect of the patients’ everyday life experience. This affirmation was supported not only by the 90% of the parents’ positive responses to the first question (that asks if their daughter is interested in music), but also by the specificity and richness of the answers relative to music preferences. Data from Merker and colleagues’ study also highlighted that all of the girls were exposed to music many hours a week. They tend to have a preference for children’s songs and this preference remains constant in adult life. Considering all the characteristics of music that can promote emotional regulation, increase cognitive abilities, and strengthen coordination, the fact that music is such an important part of the RTT girls’ life supports the inclusion of music when planning interventions that aim to enrich the quality of their lives.

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Music Therapy to Promote Emotion Regulation and Emotional Communication Girls with RTT experience problems when trying to express and communicate their emotions and feelings. As we have seen, RTT causes the loss of communication abilities that affect not only language but also other form of communication. For this reason patients can use loud sounds or screaming to express both happiness or pain or can easily barrier themselves behind a blank expression to communicate discomfort (Bergström-Isacsson, Lagerkvist, Holck, & Gold, 2012). Music can be used in a therapeutic setting to reflect and support these expressions. This music-based mirroring helps creating a safe and enabling environment, helping to broaden and to increase the girls’ communication. The same concept is also supported by Wigram (2007), who reported that all the RTT patients he examined responded positively to music therapy. Music-based interventions were particularly helpful in improving attention and general motivation, fine motor skills, nonverbal interaction and communication skills, as well as emotional expression and relaxation. According to Wigram (2007), people with RTT are often unhappy, frustrated, anxious, and hypertensive. Making music and the ability to vocalize and create simple sounds with the instruments allow patients to express their emotions and improving their overall mood at the same time. Musical interactions can also be read the other way. The therapist can use them to become more familiar with the way each child expresses her feelings. In turn, this might foster the creation of a closer and hence more therapeutically effective interaction (Elefant & Lotan, 2004). (Elefant & Lotan, 2004) believes that music can certainly trigger emotions, but it is necessary to have someone who recognizes those feelings and is able to contain the emotions provoked by music, for it to make sense. It is therefore essential to have a significant and structured interaction as foundation. Following this line of thought, Garred (2001) claimed that reciprocity is one of the more important variables of music therapy: A one-way mechanical relationship between the music and patient would most likely have no effect; On the other hand, when the therapist, the patient, and music are mutually interconnected in a dynamic relationship the intervention can be effective. Wigram, Cass, Riley, Wisbeach, and Weekes (1994), while working at the Harper House Children’s Service of Hertfordshire, practiced

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improvisation music therapy combined with vibroacustic therapy. Vibroacustic therapy, or VAT, is a form of sound therapy that uses sound to produce vibrations that are applied directly to the body. Wigram used a combination of these two approaches to promote relaxation, reduce hyperventilation, decrease the stereotypy, increase awareness, attention, and concentration, develop voluntary movements. As an example, the therapist discussed a case study (Claire). During the initial sessions the girl would sit on the physiotherapist’s lap while the music therapist played the piano in front of her. Slowly she started putting her hands on the instrument and began playing with her right hand. Whenever the rhythm became faster and stimulating, Claire started playing. During this part of the intervention the girl never twisted her fingers. The next instrument was the drum. Initially played by the therapist, who, in the meantime, tried to keep Claire’s hand on it. He hit the drum with an open palm and sometimes he lifted the patient’s hands to help her play. This procedure helped focusing Claire’s attention. After a while she started playing the instrument with both hands, while at the beginning of the intervention she would only use her left hand. Finally the therapist encouraged the girl to hold the drumstick with her right hand. She took the stick and twice she hit the drum. The third time she took the stick and she held it for several seconds. During this intervention she didn’t show any stereotype. Wigram concluded that music therapy was clearly a very positive experience for this patient. Claire was able to express her emotions and she did it through the sounds and the music she created. Music-Therapy Interventions to Improve Communication and Social Relationships Based on results from case studies similar to the one presented above, Wigram (2007) sustained that music can act as a language and the development of vocalization and a wider range of expression skills through sounds are more important for a child who has limited possibilities of communication, as it is the case for patients with RTT. Several other case studies reported in literature support the efficacy of different types of music therapy to improve communication skills in girls with RTT. For example, Wigram (1991) discussed the case of an 11-year-old girl, Helen, who attended music-therapy sessions over a period of 22 months. The therapist started with a structured, directive approach and progressed with the intervention until he guided

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the patient to interact within a more unstructured session based on free interaction. The initial assessment showed that the girl’s principal areas of difficulty were in the constructive use of the hands, attention, and communication abilities. It was also clear that she liked music, but she could not create it or even understand what she could do with the instruments. After the first assessment, Helen started a 2-phase therapy period. The first phase consisted of 25 weekly sessions of 45 minutes. Each session comprised the same activities, which were always performed in the same sequence. Progress was slow at the beginning. Each time the therapist handed something to Helen, she just let it slip on the floor. After 4 weeks, she started interacting with some of the percussion instruments. During this period important milestones were achieved: She learned to hold the instruments and the sticks and she became more focused. Although she still exhibited stereotyped movements during the sessions, there were longer intervals during which she used her hands voluntarily with purpose. She even started to use her right hand, to the point that her mother reported the generalization of this ability at home. Toward the end of this phase she began to acquire the ability to express herself through music. She was able to communicate her mood and her emotions both by producing sounds and by coherently using body language. Similar results are reported by Hill (1997), when discussing Lisa’s case, a 12-year-old girl with RTT. Hill and Lisa met for 12 times, in weekly half-hour sessions. One of the goals was to improve vocalization. Lisa was very responsive to the voice and tone changes, but could not use them to communicate. The therapist realized that by using Lisa’s name as part of vocalization exercises, producing different variations with tones and sounds, triggered stronger and more dynamic vocal responses from the patient. More important, this kind of interaction allowed Lisa to produce meaningful vocalizations, so that she began to be able to express her needs to others. Sometimes music appears not only to foster communication per se, but also to promote understanding of what a meaningful communication is. This, in turn, helps promoting a better emotion regulation within meaningful social interaction. A good example is reported by Garred (2001), when describing the case of Anne, a 14-year-old girl with RTT. The purpose of the intervention was to try engaging the patient in significant activities. She was very introvert and presented incessant stereotypy. During their first session

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together, when the therapist gently took a hand, “preventing” her from rubbing it continuously against the other, Anne did not protest but the other hand continued to make automatic movements. Following up on this, the therapist held a tambourine next to her moving hand and when she accidentally touched it she was positively surprised and continued doing so. Garred, following an improvisational music-therapy approach, began intoning a song that adapted to the same rhythm she was making hitting the instrument. Session after session, Anne became more involved and started to recognize the song and the actions of the therapist. Even though at first the beats she was giving the tambourine were automatic, over time she started to follow the rhythm of the song. The patient seemed to be having fun and she seemed to understand this uncommon conversation. The author suggested that what really appeared to elicit Anne’s amusement and awareness of the meaning of the shared activity was her realization that each action she performed had an effect on the other person. The communicative exchange took place through music and the specific qualities of the “medium” favored it. Without it, Garred claimed, he would not have been able to reach Anne and it is really because of music that has been able to establish a contact with the therapist. This patient could not use verbal language. Therefore it was important for her to express herself by doing something meaningful so that it was recognized by the other for what it really was. The Use of Music to Promote Motor Skills As we have seen so far, music promotes many positive outcomes, which affect different aspects of life of RTT patients. We have seen that in many cases, even if the main focus of the intervention is on some other symptom (like, e.g., emotion regulation and expression or communication), the tactile and auditory stimulations provided by musical instruments appear to be beneficial in motivating the patients and engaging their hands in meaningful activities. Following this line of reasoning, the purpose of Wylie’s (1996) study was to investigate the use of various rhythm instruments and noninstrumental objects accompanied by songs to allow two girls affected by RTT to touch, grasp, and restrain in a coordinated and voluntary way. The research aimed at assessing possible differences between a pre-test and a post-test evaluation in the number of times the patients hit or touched the musical instruments or the objects

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following vocal suggestion. They also measured the number of seconds the girls restrained or put their hands on the percussion instruments that were available during the sessions. Each child was observed individually once a week for 30 minutes during their music-therapy sessions. The therapist sang simple children’s melodies to accompany their use of the instruments. With each song, the child was encouraged to briefly touch an instrument, then to touch it for the entire duration of the song, and then grab, restrain, or actually play an instrument. There was an increase from the pre-test to the post-test of the number of times when both girls played or touched percussion instruments following verbal encouragement. They also spent significantly more time holding the instrument or just restraining their hands on them. These results highlight that music therapy can encourage a more functional use of the hands in girls with RTT. These results are consistent with those documented in other studies that have used music therapy to improve the use of hands in girls with RTT (Hadsell & Coleman, 1988; Wigram, 1991). More recently, Yashuara and Sugiyama (2001) used an active music therapy in individual sessions with RTT patients to evaluate, in particular, the effects of music in increasing functional use of hands and communication skills as well as mental and physical development. Each session, on a weekly basis, lasted 30 minutes. The girls were initially evaluated based on their ability to: listen, play musical instruments, sing, perform fine motor tasks, use language, and demonstrate an appropriate relational behavior. Regarding the use of hands, they were evaluated based on the duration and frequency with which they held the sticks and also the number of times the girls would grab them. After a few sessions, the patients began to indicate their favorite instrument by pointing with their hand. They were able to choose between 2 instruments being shown to them and they attempted playing the piano, taking turns with the therapist. After some more sessions, they started making sounds that meant “yes.” At the end of the intervention, they were able to hold sticks in their hands for a long interval of time, with a good hand–eye coordination, to recognize short melodies and they demonstrated a significant cognitive improvement. The therapists reported that the activity that picked their interest the most was allowing them to freely play the instruments by themselves, and that led to an improved and more functional use of their hands. Improvement in language comprehension had also been observed.

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The Effects of Music Therapy in Rett Syndrome From what we have been discussing in this chapter, it looks like music therapy plays more than a simple motivation role when used with girls with RTT. It is evident that it can improve the relationship between the therapist and the patient. Both can communicate through a speech that is more attainable to these children, because it is not based on words. Moreover, these kinds of interventions appear the affect the patients’ overall development. After a period of music therapy, children’s self-esteem is improved, as well as physical abilities, and there is a decrease in stereotypes and they are able to use their body and voice to produce musical sounds. If it is clear that musical therapy can develop communicative, motor, cognitive, and affective skills, it is also important to stress that the most important aspects in music therapy is the construction of a musical relationship with the patients and, through it, find a way to match and share their needs. These results have been achieved thanks to repetitive and structured activities that give the girls the opportunity, space, and time to express themselves and interact. To support this idea, we can notice that what all the interventions presented above have in common is building a relationship, so to give the patients a sense of security and acceptance and to validate every gesture/action that they bring to the sessions. Music therapy can certainly help girls with RTT to have a more fulfilling emotional and interactive life and this, for them, is of fundamental importance.

An Intervention to Promote Motor Coordination in Rett Syndrome As we have seen above, one of the main characteristics of RTT is the severe expressive and receptive communication impairment. Consequently, the ability to communicate has continuously been seen as a priority in the primary educational interventions with this population (Sigafoos & Woodyatt, 1996). The first studies focused mainly on the improvement and development of speech. Later, however, there has been an emphasis on enhancing multiple processes of communication (Stasolla et al., 2014; Wandin, Lindberg, & Sonnander, 2015). Following this perspective, Sigafoos and colleagues (2000) suggested to

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look for and try to promote the Potential Communicative Acts in children with communication impairments. Potential Communicative Acts are defined as idiosyncratic and informal behaviors of communication. As detailed above, music therapy is effective in promoting this kind of nonconventional communication, on top of being a substantial motivating factor. When RTT patients find themselves in an exciting, safe, and motivating context, such as music therapy, they become active, engaged, and more willing to learn. Starting from these assumptions, Cardani and colleagues (2009) designed a music-therapy intervention that was tested working with Stella, a 20-year-old girl with RTT. The main objective was to analyze her expressive and communicative skills during the sessions, hypothesizing that music could act as a medium between her and the surrounding environment and that this could, in turn, trigger her desire to express herself and eventually improve her expressive abilities. A second goal of the intervention was to analyze her specific stereotyped behaviors and promote a more functional use of the hands thanks to instruments and mallets that could be grasped or restrained, thus improving her ability to use pressure, which has been severely compromised since she was 2. Patient’s Assessment From the first assessment it clearly emerged that the most evident clinical aspects of Stella were: the inability to use verbal and nonverbal language, stereotypy (hand twisting and finger rubbing), bringing her hands in her mouth, inability to use pressure, cognitive and relational difficulties, inability to feed, dress, and wash herself, incapability to communicate any kind of need and to choose or express preferences. Stella was able to walk and sit upright without support (while she needed help in going up and down the stairs). She did not have any respiratory crisis or hyperventilation, no records of epileptic attacks for 3 years, no severe scoliosis problems, and no signs of any form of self-harm. She tended to express strong vitality and energy, especially while playing with her toys and listening to music. She was a happy child, with deep, expressive eyes, whose attention was captured mostly by people’s face and eyes. She was reported to be friendly to everyone, even with strangers, and she continuously needed physical contact.

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Structuring of the Intervention The intervention took place over a 6 months period, with weekly 2-hour sessions. During the sessions the patient would first have snacks and play with her favorite games. After that, she would engage in music-based activities, usually for a period of 40–50 minutes. The music-therapy sessions were divided into two phases: • Receptive Phase: took the first 20–30 minutes, when the therapist and Stella would listen to recorded music. This phase was further divided into: – Passive Listening: the therapist and the patient would listen to Stella’s favorite and non-favorite songs; – Active Listening: they listened to the same songs a second time, but this time the therapist would mimic the songs and sing along with them. • Interactive Phase: this part consisted of music improvisation using different rhythmic and percussion instruments. The therapist would work to include Stella more and more into active co-playing progressively. The first phase had the main goal of analyzing Stella’s expressive capability while listening songs that she liked (favorite) and the ones that she did not like (non-favorite), comparing at the same times responses during active and passive listening. The idea was that Stella would have been able to communicate—using gestures, facial expressions, and stereotypy behaviors—her like or dislike for a song, thus expressing a preference. Having two listening phases (active, with no interaction, vs. passive, where singing along and mimicking were added) helped the therapist to better understand Stella’s responses to music with and without human interaction. The second phase (interactive phase) had the primary aim of promoting a more functional use of the hands. Stella could not grab anything since she was 2 years old. The hypothesis behind this specific part of the intervention was that, by using music and interaction with musical instruments, she would be motivated to grab, manipulate, and play them, starting to improve both gross and fine motor skills. Each session was video-recorded after obtaining the consent by Stella’s parents. At the end of each session the therapist wrote a short report

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focused on the events of the music-therapy session and how Stella was feeling and behaving. Receptive Phase The first 20 minutes of the music-therapy session were devoted to music listening. The therapist had compiled a playlist with approximately 20 songs. Half of these songs were picked from Stella’s favorites (mostly cartoons songs or songs for children), whereas the other half were songs that she had never heard before, randomly chosen from an Italian music book for children (Ciurleo, 2005). In each session the therapist would listen with Stella to 4 different songs, always pairing a favorite one with a non-favorite one, to be able to analyze differences in her reactions and to investigate her potential to communicate her preferences or emotions. To assess Stella’s reaction to different kind of songs (favorite vs. non-favorite) during different ways of listening to them (interactive vs. noninteractive), recordings and note from two sessions that happened at the beginning of the intervention and of two from two sessions that happened toward the end of the intervention have been analyzed. Stella’s reactions to her favorite songs were similar both during interactive and noninteractive listening, even some differences emerged. During passive listening of her favorite songs, Stella smiled and produced minor vocalizations and a few stereotypy behaviors. She tried to reach out for eye contact (but soon she moved her gaze toward the stereo), looking for physical contact by leaning against the therapist through the duration of the song. No loud vocalizations, proto-words, or body movements appeared during passive listening. While actively listening to her favorite songs, Stella smiled continously (smiles were broader in this case) and from time to time she laughed. Stereotyped behaviors were continuous: She would rub her fingers and gently tap on the part of one hand with the other hand. Her facial expression was focused, and yet happy. She looked constantly at the therapist and rarely to the stereo. Physical contact was also constant. There were more vocalizations but no proto-words. Reactions when listening to non-favorite songs are interesting as well. During passive listening body movements, as throwing herself back on the couch or letting her arms fall heavily next to her body, occurred, whereas they were absent during the listening to the favorite songs. As a consequence, there were not any stereotypes, because her hands were

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separate almost all the time and, when they were joined together, they would remain still. Stella would not smile or laugh all the time. There was no attempt to make eye contact. Her expression was bored, at the moment even annoyed, and the few vocalizations she produced were weak moans. The physical contact was less constant as well: She tended to lie down, as if trying to go to sleep, instead of that against the therapist. No proto-words or loud vocalizations were recorded. During the active listening of non-favorite songs, Stella produced few, rare, and weak smiles. Her hands remained or next to her body, separated, or joint together. She would rub her fingers from time to time. The eye contact was almost absent: She looked at the therapist because her attention was captured by the mimic gestures, but she diverted her gaze quickly. She sat close to the therapist during all song, but sometimes she distanced herself. No vocalizations or proto-words were recorded. According to Elefant & Lotan (2004), girls with RTT do not smile or assume an annoyed expression when they are experiencing something they do not like. These expressions are usually matched with the other coping mechanisms that these patients use to avoid unpleasant situations, like avoiding eye contact and not producing any vocalization. Results reported by Cardani and colleagues (2009) are coherent with Elefant’s remarks, showing that Stella would smile only while listening to music she liked and frowned and avoided eye contact while listening to unfamiliar music. Both Sigafoos and colleagues and Elefant & Lotan (2004) reported that girls with RTT look for eye contact and manifest stereotyped behaviors only when a music-therapy session includes music and the therapist is active. Again, results reported by Cardani and colleagues (2009) confirm these data, since stereotyped behaviors were recorded mainly during active listening and only when Stella was listening to her favorite songs. This is interesting mainly because several researchers suggest that hand stereotypy movements can be read as Potential Communicative Acts used by girls with RTT (Hunter, 1999; Lindberg, 1991), mirroring their feelings. So we can read Stella’s motor activation as her way of communicating her excitement in response to a pleasant situation. Following this line of reasoning, Kerr (1992) suggested that there could be a link between the stereotypy behaviors and the cerebral activity of girls with RTT and that these movements could be an auto-stimulation used to expresses they excitement. Even if they are considered pathological behaviors—and

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to some extent they prevent to use the hands in more functional ways, interfere with other movements, and might cause tissue injuries—there still is not a consent about possible methodologies to containing these stereotypy movements, and if these strategies could actually be useful (Fabio, Giannatiempo, Antonietti, & Budden, 2009). Girls with RTT do not have many other ways to express their emotions: Preventing them from moving their hands would mean depriving them of one of most powerful methods of communication they can use to interact with the external environment. Stella appeared to be able to use other strategies, like body movements, eye contact, and physical contact, to communicate her preferences. She would also vocalize more while listening to her favorite songs. Her communication strategies were apparent, with her being able to show a clear preference or to protest against something she did not like. In conclusion, analyzing this first part of the training, we can conclude that Stella was able to communicate emotions, feelings, and level of excitement through unconventional communicative acts, as eye and physical contact, facial expressions, stereotypies, vocalizations, smiles, and body movements. These Potential Communicative Acts are coherent and adequate to the external situation that triggers them, demonstrating that the patient could discriminate different contexts and behave accordingly, showing her preference for a situation over another one. Interactive Phase During the interactive phase, Stella and the therapist would improvise together using percussion instruments (e.g., marimbas, drums, bongos, rattles, etc.). This second part of the music-therapy session would usually last between 15 and 20 minutes. The primary aim of this part of the intervention was to improve Stella’s way of using her hands, by way of the coproduction of music as a way of foster better use of her hands by learning how to grab and manipulate different objects. Stella appeared to favor the marimba and the bongos above the other available instruments. The therapist focused her analysis on Stella’s interaction with these two instruments, by counting the number of grabs and their duration, as well as the number of hits over the bongos, during seven sessions over the overall 6-month intervention. Concerning Stella’s interaction with the marimba specifically, the therapist analyzed the number of times the patients grabbed the mallets and

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the total time Stella has been holding them during the sessions. Both indexes increased significantly when comparing the beginning to the end of the intervention. This mirrors her improvement in overall fine motor abilities. Over the 6-month time, she learned to grab the mallets and hold them with ease for several seconds without dropping them. From a more qualitative standpoint, Cardani and colleagues (2009) reported that the marimba was Stella’s most favorite instrument. She started laughing and producing vocalizations as soon as she saw it. She also moved immediately closer to the instruments and started playing it. At the beginning of the intervention, when she was not able to grab and hold the mallets, she still attempted to play the instrument just using her hands. Then she transitioned into trying to use the therapist’s arms to have her play the marimba and produce the well-defined notes she could not produce just using her hands. These interactions with the marimba made Stella extremely happy: She vocalized a lot and even used several proto-words (which never emerged, as noted above, during the receptive phase). This emotionally positive interaction led Stella to be more self-confident while interacting with the marimba, so that she started to try taking the mallets from the therapist’s hand and imitate her way of holding them. During the final meetings Stella was able to effectively hold the mallets and use them to play the marimba. This is a significant result because RTT leads the girls to be unable to grab and hold an object after they are 2 years old: This was the first time Stella was able to perform this action in years. Stella was also very interested in the bongos, mainly because it was effortless for her to play them, just by hitting them with her open hands. The therapist analyzed Stella’s interaction with the bongos over six different music-therapy sessions overall 6 months of the intervention. Stella’s interaction did not change drastically per se: The number of hits remained almost constant since the second meeting when she understood how easy it was to play them. This is not surprising, given the fact that RTT does not affect gross-motor abilities, such as those required to play the bongos. These data confirmed that Stella had good gross-motor abilities, good eye-hand coordination, and a good understanding of the cause-effect relationship: She was able to understand from the very beginning that she needed a specific amount of strength to obtain the desired sound. An impressive result that emerged from the analysis of the video recording is that Stella slowly started to use the right hand too when

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playing the bongo. This is remarkable given the fact that Stella has not been using the right hand at all during the first sessions. The interactive phase showed that the intervention was successful not only at a motor level but also in motivating Stella in wanting to learn new skills (like playing the marimba). Cardani and colleagues (2009) suggested that this can be read as an improvement at the cognitive level too: Stella improved her observation skills and her ability to mime the therapist’s movements, by reproducing the position of her hands while holding and using the mallets. The same could be said about her introducing the use of her right hand while playing the bongos, possibly in response to the fact that the therapist has been continuously playing that instrument using both hands. To be able to achieve these goals Stella needed to be able to carefully observe the therapist’s movements, recognize the patterns of actions, and memorize them and repeat them in a finalized and appropriate way. Final Comments The intervention designed and applied by Cardani and colleagues (2009) allowed deriving some relevant information that could be effectively used when planning music-based interventions targeting girls with RTT. First of all, vocalization appears to be remarkably different when using active or passive music-therapy approach. Active music therapy seems to trigger more continuous and intense vocalizations, which were often associated with smiles and laughers. When playing her favorite instruments, Stella also produced some proto-words, which were absent in the receptive, passive phase. What caused this difference is most likely the fact that during the active parts of the sessions Stella had more space, time, and freedom to express herself. This allowed the girl to interact more directly with the therapist, using the instrument to promote a more complex form of emotional communication than during the receptive phase. The interactive intervention promoted what Garred (2001) defined as a triangular relationship among Stella, the therapist, and the music, which is supposed to be the ground of a successful music-based intervention. Music constitutes a positive experience for almost all patients with RTT, but the structured interaction with a trained therapist is the critical factor that can promote social interaction, emotion regulation, and motivation and eventually lead to the cognitive, emotional, and motor improvements described above.

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It is also important to report that what Stella learned during the music-therapy intervention was then transferred to her everyday life. A few weeks after the conclusion of the music-therapy intervention, Stella’s mother reported that the girl has begun to use both hands in a way that she never did before: She was able to grab different objects and bring them to another place in the house.

Concluding Remarks The current way of considering RTT leads researchers and practitioners to believe that some improvements can be induced in the behavioral repertoire of girls affected by this syndrome (Fabio, Antonietti, Marchetti, & Castelli, 2009). The several studies and interventions reported and discussed in this chapter showed that music therapy can be used as a practical approach when working with patients with RTT. Music-based interventions appear to be effective in promoting communication, fostering emotion regulation, and even recovering some of the motor abilities lost due to the progression of the syndrome. Grabbing is a good example, giving the fact that this skill is fundamental for the patients’ autonomy and for their self-esteem and self-efficacy. Music can also lead to better communication between patient and their therapist or caregivers, allowing them to identify the emotional reactions and the different behaviors that can be identified as patients’ attempts to communicate. Music therapy can hence be considered a base for the development and growth of the patients with RTT and it is crucial that the future researchers explore and continue to investigate the potentiality that music can have on these patients and, vice versa, the signs of progress that these patients can reach thanks and through music.

References Bergström-Isacsson, M., Lagerkvist, B., Holck, U., & Gold, C. (2012). How facial expressions in a Rett syndrome population are recognised and interpreted by those around them as conveying emotions. Research in Developmental Disabilities, 34, 788–794. Cardani, F., & Antonietti, A. (2009, 4–6 June). Music therapy in Rett Syndrome: An intervention aimed at enhancing communicative skills in a Rett

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syndrome girl. In Proceedings of the 1st European Congress on Rett Syndrome From Research to Treatment: New Perspectives in Rett Syndromee. Milan. Ciurleo, M. A. (2005). Canzoni, filastrocche e danze [Songs, nursery rimes, and dances]. Milano: Rugginenti. Elefant, C. (2002). Enhancing communication in girls with Rett syndrome through songs in music therapy (Doctoral dissertation). Aalborg University. Elefant, C. (2005). The use of single case designs in testing a specific hypothesis. In D. Aldridge (Ed.), Case study designs in music therapy (pp. 145–162). London: Jessica Kingsley Publishers. Elefant, C. (2009). Music therapy for individuals with Rett syndrome. International Journal on Disability and Human Development, 8(4), 359–368. Elefant, C., & Lotan, M. (2004). Rett syndrome: Dual intervention—Music and physical therapy. Nordic Journal of Music Therapy, 13, 172–182. Elefant, C., & Lotan, M. (2011). Organizing the Sensory System of Individuals with Rett Syndrome through Music. Functional Neurology, Rehabilitation, and Ergonomics, 1(4), 561. Fabio, R. A., Antonietti, A., Marchetti, A., & Castelli, I. (2009). Attention and communication in Rett syndrome. Research in Autism Spectrum Disorders, 3, 329–335. Fabio, R. A., Giannatiempo, S., Antonietti, A., & Budden, S. (2009). The role of stereotypies in overselectivity process in Rett syndrome. Research in Developmental Disabilities, 30, 136–145. Fabio, R. A., Colombo, B., Russo, S., Cogliati, F., Masciadri, M., Foglia, S., et al. (2014). Recent insights into genotype-phenotype relationships in patients with Rett syndrome using a fine grain scale. Research in Developmental Disabilities, 35, 2976–2986. Garred, R. (2001). The ontology of music in music therapy. Voices, 1(3), https://doi.org/10.15845/voices.v1i3.63. Hadsell, N. A., & Coleman, K. A. (1988). Rett syndrome: A challenge for music therapists. Music Therapy Perspectives, 5, 52–56. Hill, S. A. (1997). Focus on practice: The relevance and value of music therapy for children with Rett syndrome. British Journal of Special Education, 24, 124–128. Hunter, K. (1999). The Rett syndrome handbook. Clinton, MD: International Rett Syndrome Association. Kerr, A. (1992). Communication in Rett syndrome. London: Rett Syndrome Association, UK. Lindberg, B. (1991). Understanding Rett syndrome. New York: Hogrefe & Huber. Merker, B., Bergström-Isacsson, M., & Engerström, I. W. (2001). Music and the Rett disorder: The Swedish Rett center survey. Nordic Journal of Music Therapy, 10(1), 42–43.

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Rett, A. (1982). Grundlagen der Musiktherapie und Music-Psychologie. In H. G. Harrer (Ed.), 2. Stuttgart: Neubearbeitete Auflage, Fischer. Sigafoos, J., & Woodyatt, G. (1996). Educational implications of Rett syndrome. European Journal of Mental Disability, 3, 19–28. Sigafoos, J., Woodyatt, G., Keen, D., Tait, K., Tucker, M., Roberts-Pennell, D., & Pittendreigh, N. (2000). Identifying potential communicative acts in children with developmental and physical disabilities. Communication Disorders Quarterly, 21(2), 77–86. Stasolla, F., De Pace, C., Damiani, R., Di Leone, A., Albano, V., & Perilli, V. (2014). Comparing PECS and VOCA to promote communication opportunities and to reduce stereotyped behaviors by three girls with Rett syndrome. Research in Autism Spectrum Disorders, 8, 1269–1278. Wandin, H., Lindberg, P., & Sonnander, K. (2015). Communication intervention in Rett syndrome: A survey of speech language pathologists in Swedish health services. Disability and Rehabilitation, 37, 1324–1333. Wigram, T. (1991). Music therapy for a girl with Rett’s syndrome: Balancing structure and freedom. In K. Bruscia (Ed.), Case studies in music therapy (pp. 39–55). Barcelona: Gilsum, NH. Wigram, T. (2007). The importance of music therapy for people with Rett syndrome. London: Rett Syndrome Association, UK. Wigram, T., Cass, H., Riley, S., Wisbeach, A., & Weekes, L. (1994). The process of a therapy clinic for children and adults with Rett syndrome. Paper presented at the 1994, UK, Rett Syndrome Conference, Coventry. Wylie, M. (1996). A case study to promote hand use in children with Rett syndrome. Music Therapy Perspective, 14, 83–86. Yasuhara, A., & Sugiyama, Y. (2001). Music therapy for children with Rett syndrome. Brain and Development, 23, S82–S844.

Conclusions

Abstract  Some general remarks about why music can be employed in rehabilitation interventions, which can be valid for all the neurodevelopmental disorders considered in the book, are reported. Future directions of research are outlined. Practical suggestions for parents and rehabilitators, as well as music teachers, are also discussed. Keywords  Music  · Music therapy · Rehabilitation This book presented a picture of studies, theories, and techniques supporting the notion that music can be used to improve different skills that are affected by neurodevelopmental disorders. The book, after presenting a general overview about why and how music can be used within therapeutic settings, focused on specific interventions for ADHD, ASD, and Rett Syndrome. The book tried to guide readers to understand the empirical bases that stand behind some music-based intervention, while describing examples of interventions and their expected results. Given how widespread ADHD is among children and teenagers, and how invasive pharmacological interventions might be, finding alternative approaches that could help children and teenagers to deal with their symptoms even when they are off their medication is relevant and timely. © The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer International Publishing AG, part of Springer Nature 2018 A. Antonietti et al., Music Interventions for Neurodevelopmental Disorders, https://doi.org/10.1007/978-3-319-97151-3

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From what we discussed in Chapter 2, music seems to be a good candidate to address this need. Music can be used to address symptoms at many different levels. To be more precise, from what we discussed in the chapter, music can help at an emotional, behavioral, and cognitive level. At an emotional level, music can be used as a basis to build a safe space where the patient can experiment confirmatory relationship, which will support any other growth process they might go trough during music-therapy sessions. At a behavioral level, music can help to promote relaxation and foster more awareness about what can cause hyperactivity and suggest spontaneous strategies that could be subsequently spontaneously used by children outside the therapeutic sessions. The rhythm components of music can also be used effectively to enhance children’s control and manage more effectively their impulsiveness, by the way of learning how to respect turns and listen to others, while being aware of different context-related variables. This promotes better overall cognitive performance even in structured learning tasks. Working with ADHD patients, music will not aim at suppressing the symptoms: It will foster a deeper awareness regarding the patients’ specific behaviors, and this awareness will be functionally used by the therapist to reduce the symptoms always respecting the individual possibilities of each person. Using the same approach, music will also trigger compensatory resources that each child can use to improve the quality of interaction with their environment. A similar approach, using music to work both an emotional and a cognitive level, can be applied when working with individuals with ASD. Music can be employed to assess individuals’ responses to different cognitive and emotional stimuli, as well as a base for interventions that could specifically benefit patients on the spectrum. The research data discussed in Chapter 3 stressed the relevance of using music therapy with patients with ASD, as well as the need to create music-therapy programs that can meet the individual needs of each patient on the spectrum. Depending on where on the spectrum patients are, they will not only have a different therapeutic need but will also respond differently to a different type of music. If approached correctly, music proves to be extremely beneficial in supporting patients on the spectrum in interacting in a more effective way with their surroundings, by way of improving emotion regulation and enhancing the quality of social interaction and by promoting a better understanding of rhythm in conversation and triggering the activation of the mirror system.

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The several studies and interventions reported and discussed in Chapter 4 showed that music therapy can also be used as a practical approach when approaching patients with Rett Syndrome (RTT). As it was the case for the other neurodevelopmental disorders discussed above, music-based interventions addressed to RTT patients appear to be effective in promoting communication, fostering emotion regulation, and even recovering some of the motor abilities lost due to the progression of the syndrome. Grabbing is a good example, giving the fact that this skill is fundamental for the patients’ autonomy, as well as for their self-esteem and self-efficacy. Music can also lead to better communication between patient and their therapist or caregivers, allowing them to recognize the emotional reactions and the different behaviors that can be identified as patients’ attempts to communicate. Music therapy can hence be considered a base for the development and growth of the patients with RTT and it is crucial that the future researchers explore and continue to investigate the potentiality that music can have on these patients and, vice versa, the signs of progress that these patients can reach thanks and through music. What can we derive from the role that music can play in helping and supporting patients with different neurodegenerative disorders? Music appears to promote benefits at emotional, behavioural, and cognitive levels. This happens because sounds can be used to trigger the activation of different mental registers: motor, iconic, and verbal. These registers are naturally synchronized and foster emotions understanding and regulation while promoting better communication. Motor, visuospatial, and verbal elements are already part of the very nature of music, and hence deeply embedded in any form of music communication. As an example, music can provide support to foster a better motor planning, thanks to the motor register associated with rhythm elements embedded in any music-based communication. Rhythm can also promote a better emotion regulation, because of the intrinsic organization of emotional elements that are associated with its nature. The visual register can enhance mnestic processes, thanks to the visual images and synesthetic elements that music spontaneously elicits. The discursive patterns that are the base of each music sentence can finally support language organization, reading and, to some extent, language production. In conclusion, this book guided the reader to the discovery of how music, thanks to its multimodal nature, offers “scaffolding” to foster learning of movements, carry out cognitive operations, or articulate

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verbal expressions that need to be rehabilitated, as well as supporting emotion understanding and control. What also emerged from the analysis and discussion of the studies described in the book is that music alone will not produce the desired effect: It is critical that its use or production is associated with well-designed assessment aimed at evaluating the individual needs of each patient. Moreover, building a safe and interactive relationship between the therapist and the patient is also a crucial ­element that can predict the success of any music-based intervention.