ANÁLISIS DE LA DEMANDA

Ben was four years old when his music therapy sessions started. Having been allocated to the low-intensity treatment group, he attended 20 individual music therapy sessions in his school over a period of five months. Ben was in the reception class of a special school for children with ASD. A psychologist had assessed him as being of average intelligence. He grew up bilingual and seemed to have good receptive language skills in both English and Polish. When I first met Ben, he used only few words to communicate and tended to repeat them anxiously until an adult echoed his words back to him.

His general presentation in the early music therapy sessions was that of a child driven by a nervous inner energy. He ran around the room, touched every instrument briefly, pushed over chairs and instruments, grabbed beaters and hit everything he could reach with them, including guitars and the wall. Within seconds the room was in a state of chaos and I found myself constantly reacting to prevent harm to the child and damage to the objects. In order to help Ben release his energy and channel it in a more constructive way, I placed a large drum and cymbal in front of him. He immediately hit them loudly and frantically. When I supported his drumming with simple chord progressions, played loudly but steadily from the piano, he beamed at me. Even though Ben was only able to sustain the mutual playing for a few seconds we had experienced a first meaningful musical connection.

It was obvious that Ben enjoyed music making and that he was fascinated by instruments but that he needed lots of support to access them in a safe way. It proved helpful to reduce the amount of distractions in the room by removing all non-essential furniture, and by bringing a big cloth with which I covered up instruments that had been laid out openly before. These rearrangements had an immediate effect and Ben seemed more able to concentrate and to remain focused and involved. Furthermore, it was helpful to structure the sessions

with well-defined activities that had a clear beginning and ending. For example, Ben responded very well to the ritual of saying ‘1-2-3-Finish’ to bring an activity to a close before moving on to the next instrument. I kept the sessions predictable with recurring elements such as a hello and a goodbye song. Ben was fond of this familiar structure and it seemed to help him to relax, concentrate and participate. The following graph shows that Ben’s level of engagement in video excerpts increased as sessions progressed and remained very high from session 10 onwards. Because of technical problems with the recording equipment, no videos from Ben’s first, second and twelfth music therapy session were available. In all the following time-series graphs for Ben, the corresponding data points are left blank.

Figure 53: Ben - Proportion of engagement

After the first few weeks, Ben was more engaged, but he appeared to be very emotional and often tearful during the sessions. Ben's expressive language skills improved immensely during this time. However, what he said in the sessions was often quite concerning. He murmured, for example, “We're not afraid of that” or “We're not crying”. He sometimes repeated “Mummy later” more than 30 times in a session and he often told me that he had a “broken leg”, a “broken arm” or another broken body part. Ben clearly experienced strong feelings and seemed to struggle to make sense of them. I was encouraged that he now felt safe enough to express some of his emotions. I started to incorporate his statements into improvised songs which Ben seemed curious about, and he added varied instrumental accompaniments. This active but playful engagement with his feelings seemed to lessen his anxiety. Ben also increasingly allowed me to calm him with soft music, nursery rhymes and simple musical games commonly used with younger children, at times when he appeared unsettled and anxious. Both his levels of anxiety and his restlessness reduced considerably as can be seen in the following graph. The plot shows Ben’s results for the response variable ‘Difficulty’ which is a combination of the codes ‘Anxiety’ and ‘Fidget’.

Figure 54: Ben - Proportion of difficult behaviour

After a few sessions during which Ben played instruments to accompany the improvised songs, he also started to sing about his feelings and thoughts. He made up little songs about his daily routine and about experiences he had both at home and at school. I felt that matching his verbal, instrumental, facial and physical expressions musically had allowed Ben to listen to himself, to access feelings he had previously masked in constant activity and to express them creatively. Singing and music making seemed to help him to understand and communicate his emotions and to feel heard. Ben’s increased ability to express himself verbally was also reflected by his more varied use of musical parameters. His instrumental playing now had a stronger feeling of pulse, and he experimented freely with rhythms and dynamics. When showing video excerpts from the sessions to his mother, she commented on this development:

P_B: “Yeah, he's definitely different than before where he was like drumming and just making lots of noise. Now he's like exploring different instruments and sounds.”

The quantitative video analysis does not capture this essential qualitative change in Ben’s music making. Nevertheless, the fact that he expressed himself more during the sessions, especially the increase in his singing and vocalising, is represented by the following graphs.

Figure 55: Ben - Proportion of vocalising and of playing

One of the most encouraging developments I could observe in the music therapy sessions was that as Ben became more able to express himself, he also became more interested in interacting with me. He seemed less isolated and more able to engage in mutual improvisations and reciprocal communication. This change was also noticed by his mother and it seemed to be an important aspect determining quality of life of the family:

P_B: “Before was like, he was always on his own, then we catch a moment when he’s, you know, when he’s with us but now it’s different: He’s always with us, then sometimes he’s forgetting about us and he is on his own. It's amazing.”

Ben’s improved relationship skills and especially his increased interest in being, sharing and interacting with other people is reflected by the steep increase of the scores he obtained on the tool assessing the quality of the child-therapist relationship.

Towards the end of therapy, Ben seemed more at ease with himself and the people around him. Consequently, he became more able to try and tolerate new activities and experiences which seemed to result in an overall improved wellbeing and quality of life. In their last parent counselling session, his mother told me:

P_B: “Before when we were singing at home he was like, ‘No, no, stop it’, so we had to stop, but now he don't mind when we're singing. Yeah, he's happy, a very happy boy now. We're doing lots of new things. He's open for new things now”.

This positive change seemed to persist after the end of treatment. In the parent-rated quality-of-life scale, Ben’s score changed dramatically from 67 pre-intervention (0 months) to 90 post-intervention (5 months). At follow-up (12 months), he still received this high score.

Figure 57: Ben - Quality of life

The primary outcome used in TIME-A was the social communication score of the ADOS. Ben was assessed with ADOS Module 1 which is administered with children who have no or very little expressive language. This module was chosen because Ben hardly used verbal language before he started the music therapy treatment. The ADOS was conducted by a blinded psychologist. Higher scores on the ADOS indicate higher symptom severity. At baseline, Ben’s score on the social communication algorithm for social affect was 14. At five months, this score had increased by five points and Ben received a score of 19. If all 29 items of the ADOS are considered, and not only the items relevant for the social affect score, Ben’s overall score amounted to 26 at baseline. At five months, the overall score added up to 30, which is an increase of 4 points compared to the baseline. This result is very disconcerting. The change in ADOS scores does not match the clinical observations of Ben’s development over the course of the music therapy intervention. Furthermore, the ADOS scores stand in stark contrast to the results of the time-sampling video analysis, the ACTR, and the quality-of-life scales.

One of the secondary outcome measures in TIME-A was the parent-rated SRS. In the SRS, Ben obtained a raw score of 103 at baseline, and a raw score of 66 after five months. Whereas the score at baseline falls into the category ‘severe range’, the score after five months corresponds with the ‘mild range’. That means that, according to the SRS, we can see significant improvement in symptom severity after five months. The discrepancy between the results of the primary and the secondary outcome is striking and will be discussed later in this chapter (6.3). The results of the SRS correspond with the feedback of his mother given in parent counselling sessions:

P_B: “I see progress, but it's like big progress right now, on his concentration, on his focus. His speech is--, oh, it's incredible now. It's like, you know, just opened for talking”. Ben’s progress that was noticeable in the music therapy sessions seemed to have generalised across different settings, including home and school. One of his teachers commented at five months that Ben “seems to be happier and more settled after the sessions”, and described his overall development as being “really positive. He’s doing really well.”