Design of research clinical trials

As previously mentioned (section 3.1), each child received a total of eight music therapy sessions (four sessions in both ‘B’ stages of the A-B-A-B or B-A-B-A design) and the same number of play sessions with a corresponding pattern of presentation. In order to compare results between subjects and between conditions, as well as for future replication with other samples or in other settings, it was necessary to establish consistent and systematic procedures during the sessions. Therefore, a protocol was written, which offered a clear procedure, accompanied by guidelines and specific techniques for use in both music therapy and play. The protocol offered structured procedures for the therapist during the directed part of the sessions but at the same time was relatively flexible to adapt to the child’s individual needs and ability.

3.8.2.1.1 General principles and procedures

As mentioned in section 3.9.2.1, the researcher wrote a flexible protocol for the music therapy and the play sessions. This protocol is presented in detail in Appendix A.

Wigram (2007) states that “studies where music therapy is being compared with a placebo intervention can particularly benefit from a structured procedure that is consistent enough to be reliable, but flexible enough to allow the clinician researcher to respond to the client’s evident therapeutic needs, rather than the client being required to respond to the procedure” (p. 91).

This section will present only a brief outline of the general procedures and principles that were common to both music therapy and play sessions³⁶:

36 The reader may refer to section 3.1 for the different reasons for a specific procedure administered during the research trials.

• The sessions³⁷ were implemented once a week, usually on the same day and at the same time during the morning, except in the case of unusual circumstances.

• The researcher was also the therapist (reasons for this dual role appear in section 3.1).

• Each session lasted for 20 minutes and was divided into two parts: ten minutes of a directed part, which was therapist-led (i.e., initiated, guided, and structured by the therapist), and ten minutes of an undirected part, which was child-led (definitions of these two parts were given in section 3.7).

• The point of moving from the directed part of a session to the undirected one (or vice versa) was signaled by a digital timer.

• Each session took place in the same room, except in the case of unusual circumstances.

• The first session in each stage (music therapy or play) always began with the directed part, in order to provide these young children with supportive modeling and ease their transition from one condition to the next. To minimize order effects, subsequent sessions alternated the order of the undirected and directed parts.

• The number and variety of objects that could be utilized for expression, play and manipulation was similar in the music therapy condition and the play condition.

• The same musical instruments or toys and games were used in the directed part of the session as in the undirected part.

• To prevent novelty effect during the research trials, no new musical instruments or new toys and games were introduced to the child besides those that had been presented in the first session. No sound games/toys were available to the child during the play sessions.

• Every session always opened with a greeting ritual (‘hello’ song in music therapy; verbal greeting, in play), and closed with a bye ritual (a good-bye song in music therapy; verbal good-good-bye in play).

37 The word ‘session’ throughout this section will refer to either a music therapy session or a play session.

• Mother attendance during all sessions was recommended if possible.

• All sessions were video taped by two video cameras.

The above procedures and principles provided these young children with the permanency and predictability that are necessary for developing feelings of security.

There are some commonalities of the music therapy and the play condition in this study with the speech and language approaches mentioned in section 2.1.2.4. During the music and play activities the therapist used only oral communication. Neither signs nor lip-reading cues were added. The sentences in both conditions were short and simple, and appropriate to the developmental hearing stage of the children.

Sometimes the therapist repeated the sounds, words, or the short sentences, as with the oral approach. Two of the songs sung in the music therapy sessions included the word for the object itself and sounds that were associated with them, and one song was only the sound itself-“la la la”- to demonstrate the girl’s singing (see Appendix N). This is in keeping with the recommended list of sounds suggested by the auditory-verbal approach (Sternberg, 1998), where in the first stage, each word for each object is accompanied with its sounds i.e., a cow- moo, a cat- meow. The different sounds in the list include extensive acoustic information, which is rich in its contrasts. Thus, it is easier for the children to discriminate between the sounds and to be able to say them out loud, rather than saying the words themselves.

In the natural language acquisition program (Dromi & Ringwald-Frimerman, 1996), based on normal developmental processes in language acquisition and developing communication as the main goal in the interventions, some general interventions are suggested as well as more specific ones, for example those which are within the dialogue level. These are consistently implemented during the speech and language sessions. Some of the more general ones which were also implemented in the music therapy and play session in this study are:

• Response to child’s initiations and encouraging him/her to respond (the latter obviously could not be applied in the undirected (child-led) part of the session);

• Mediating: Acts done by the therapist in order to interpret the environment for the child and enable him/her to create more meaningful relations with people and objects in the environment. This can be done by demonstrating, giving

cues (by pointing, gestures, verbalization, presenting an object, etc.), questioning, and explaining;

• Observation: Observing the child enables the therapist to identify the child’s areas of interest, his/her communicative intentions and the ways used to express them, and his/her relations with objects in the environment as well as spontaneous activity with these objects without the therapist’s support.

Observation enables setting goals and ideas in regards to the interventions needed.

Interventions within the dialogue level:

• Interpreting the child’s communicative intentions: The therapist talks instead of the child, e. g., The child looks at a house that he/she built out of Duplo blocks and knocked it down, laughs, and the therapist says: Oye, the house was knocked down. Are you happy?

• Expanding, e.g., the child says ‘ah’, points to a ball and the therapist says- A ball? Is it a ball? Would you like the ball?

• Different types of imitation made by the child (see section 2.2.4.1); In addition to these, the therapist may repeat the child’s vocalizations/verbalizations and later- repeat the sound/word in the correct way.

• Encouraging the child to speak: The therapist may point to an object and starts to say the first syllable of a word that is easy to produce and waits for the child to complete it.

• Verbal description, e.g., the child ‘cuts’ a plastic orange and the therapist says:

It is an orange. You cut the orange.

• Waiting time- Timing is of paramount importance during communication with the child, e.g., the therapist directs the child’s attention to an object in the room, waits until the child terminates looking at the object and only when the child looks again into the therapist’s eyes, the therapist asks /says something about this object.

The speech and language approaches, as with every other intervention program for children, encourage strong parental involvement. In this study, each mother’s attendance during all sessions was recommended if possible (fathers were not available). For those who attended the sessions, new avenues to relate and

communicate with the child were opened up.

With regard to the music therapy sessions, as mentioned in section 1.2, the music therapist may actually reinforce the speech and language therapist’s work with the child since listening is inherent to music and the musical parameters are also components of language (see also Appendix A).

3.8.2.1.2 Therapeutic approach

The researcher, who was also the therapist, employed many of the tenets of Carl Rogers’ (1951) client-centered approach in both the music therapy and the play conditions in this study. In keeping with his humanistic approach, Rogers is concerned with the holistic understanding of the person. His assumption is that each person has the capacity and the motivation to change. A therapist who adopts a Rogerian approach should function in a non-directive manner, providing a permissive atmosphere of warmth, empathy, understanding, and ‘unconditional positive regard’.

To build a trusting relationship with the client, the therapist needs to be open and honest. The child is allowed to set the pace and to reveal his/her personal view of the world. The child does not feel threatened since the therapist fosters and appreciates the child’s open expression of all different possible feelings. The therapy can then become a socializing experience because the child learns that there are acceptable outlets for such feelings and that they do not need to be denied. Because the child feels that he/she is accepted, rather than being judged and evaluated, he/she does not need to respond defensively and finds the courage to explore new ways of feeling and behaving.

Rogers states that “Once the child has undergone some personal change, however slight, his environmental situation is no longer the same” (p. 239). The therapy session provides freedom within clearly defined limits. First of all, the therapy is held at the same time and in the same place. Destruction of objects in the therapy room, or physically attacking the therapist is unacceptable behavior. The therapist enforces these limits consistently and in doing so, reduces the build-up of the child’s anxiety. Even as the therapist enforces the limits, he/she accepts the child’s desire to break them.

In this study, Rogers’ non-directive approach was primarily employed, with a further development to a more guided and directed style of work in half of each session that would also be considered a natural progression of the therapist’s

responsibility within a client-centered approach. The therapist encouraged the children through initiating and structuring activities more in that half of the session, building on the child’s own initiative and interests. The child could exert control over the session by choosing his/her way to participate, or by declining to participate in any way. The therapist could then try again after a while and the child could choose again whether to follow or not. As in the undirected part of the session, the child felt respected and accepted for whatever he/she did, and his/her experience was one of control, which was so important to these children. The therapist made every effort to follow Rogers’ approach in the directed part of the session as well, while still keeping with the procedures in the protocol.

This therapeutic approach enhances the activation of the ‘music child’. This key concept was defined by Nordoff and Robbins (1977) as “that entity in every child which responds to musical experience, finds it meaningful and engaging, remembers music and enjoys some form of musical expression” (p. 1), no matter how disabled he/she is. It is the “individualized musicality inborn in each child” (p. 1). “The term has reference to the universality of musical sensitivity- the heritage of complex sensitivity to the ordering and relationship of tonal and rhythmic movement; it also points to the distinctly personal significance of each child’s musical responsiveness”

(p. 1). In order for the music child to function, the child has to be open to experiencing himself/herself, others and the world around him/her, since the ‘music child’ represents the “organization of receptive, cognitive, and expressive capabilities” (p. 1) As the child becomes deeply, personally involved, “he becomes emotionally involved not only in the particular music itself or in his activity in it, but also in his own self-realization and self-integration within all the therapy situation holds for him” (p. 2). The Rogerian approach permits this process to happen.