The International Journal of Psychosocial Rehabilitation

Rehabilitation for Children with Cerebral Palsy:

Seeing Through the Looking Glass

Enhancing Participation and Restoring Self-Image through the Virtual Music Instrument

 

Heidi Ahonen-Eerikäinen[1], Ph.D., MTA,

Andrea Lamont[2], MMT, MTA,

Roger Knox[3], Ph.D.

 


Citation:
Ahonen-Eerikäinen H, Lamont A & Knox R. (2008). Rehabilitation for Children with Cerebral Palsy:Seeing Through the Looking Glass
--Enhancing Participation and Restoring Self-Image through the Virtual Music Instrument International Journal of Psychosocial Rehabilitation. 12 (2), 41-66




Abstract
This paper presents the results of a qualitative pilot study conducted on an innovative psychosocial rehabilitation technology developed and applied at Bloorview Kids Rehab, Toronto, Ontario, Canada.  The Virtual Music Instrument (VMI) developed by Dr. Tom Chau is a video-capture software program that increases music-making opportunities for children and youth and allows children with disabilities to play musical sounds and melodies using gestures. The qualitative study was conducted to identify suitable music therapy interventions and techniques using the VMI with children with cerebral palsy (CP), to categorize areas of benefit that are made possible by the VMI, and to build theory on the role and significance of the VMI in music therapy. The research questions included: (1) What interventions and techniques are best used by the music therapist to promote the therapeutic relationship in application of the VMI?[4] (2) In which domains is there benefit, both during sessions and over the time period of the study, from the use of this instrument within music therapy?[5] Six participants aged 5.5 to 10 were recruited on a cross-disability basis. Each participant received ½-hour individual music therapy sessions, twice per week over 10 weeks, using the VMI. The Music Therapist employed a variety of techniques, including both clinical improvisation and task-oriented activities. The sessions were videotaped, transcribed and reviewed by a multi-disciplinary team. The clinician notes were also transcribed. Using a multiple case study qualitative methodology and grounded theory techniques, the transcribed material was coded and analyzed according to emerged themes using the QSR N6 software program. The results bring better understanding of using the VMI for optimum benefit, and also lead to theoretical and practical advances in the use of gesture recognition technology on music therapy and psychosocial rehabilitation among children with cerebral palsy.[6]
Keywords: Cerebral Palsy, psychosocial rehabilitation, Music Therapy, Virtual Music Instrument, Qualitative Research


Introduction
Children with significant physical challenges such as cerebral palsy (CP) are at risk for developing passivity and learned helplessness. They may feel socially isolated (Blum et al., 1991; LaGreca, 1990; Anderson & Clarke, 1982; Cadman et al., 1987; Law & Dunn, 1993).  A lack of participation is ubiquitously reported in the literature for children with special needs.  Patterns of social restriction and isolation begin early in life, indicating a need for timely intervention (Blake, 1995; Brown & Gordon, 1987).  Preschoolers with disabilities are unable to explore the world around them (Rosenberg et al., 1989) and spend more time passively non-engaged, compared with developmentally age-mated peers (McWilliamet al., 1995).  By school age, social contact is diminished (Romer & Haring, 1994), with the majority of free-play time focused on non-play or manipulative activities (Kontos et al., 1998). Observational studies (e.g. Magill & Hurlbut, 1986) note that adolescents with physical disabilities also have a smaller peer network and fewer peer-interactions. Adolescents with physical disabilities experience more emphasis on activities planned by adults than on spontaneous activities with peers (Margalit, 1981). Studies also show that the participation of children and youth with disabilities decreases as they grow up. As adults the participation may be strictly limited (i.e. Pollock & Stewart, 1990; Crapps et al., 1985; Dempsey, 1991). A lack of participation can lead to the development of physical, medical, cognitive, emotional, or psychosocial secondary conditions with adverse outcomes in health, wellness, and quality of life (Hough, 1999). Contributing to the enhanced accessibility of current media and technology is a key aspect of independence, full participation, and achievement of long-range goals. Throughout history, music has been a significant component of health care (Davis et al., 1992).  Particularly, in the last decade, effective therapeutic applications of music in many health-related domains of participation have been documented.  For example, improvisational music therapy was found to increase communicative behaviours in eleven children with autism (Edgerton, 1994).  Similarly, using creative music therapy as a treatment form, Aldridge et al. (1996) reported improvements in hand-eye coordination, personal-social relationships, and hearing and speech tasks in eight children with developmental delay.  In studying the impact of music therapy on children with visual impairments, Gourgey (1998) reported increased exploration of the environment, heightened social awareness and interaction with peers.  Subsequent studies have recounted therapeutic benefits of music such as enhanced participation, interaction and relationship development in school children (Camilleri, 2000), and acquisition of appropriate social skills among adolescents with behavioural problems (DeCarlo, 2001).  Yasuhara & Sugiyama (2001) studied the impact of music therapy on children with Rett Syndrome.  They found significant improvements in sustained hand grasp duration and frequency, socialization, language and participation in music activities.  In a study of hospitalized pediatric oncology patients, Robb (2000) concluded that the therapeutic music interventions elicited significantly more engaging behaviours from the children than any other hospital activity. Contrary to other therapeutic techniques, engagement in musical tasks does not have physical, cognitive or sensory prerequisites for participation.  However, in traditional music therapy practice, acoustic instruments are used to elicit active participation, leaving out some children with special needs due to access issues based on limited fine motor control, co-ordination, strength and endurance.  This limits the level of participation and therefore the extent to which they can effect their environment.
 

Bloorview Research Institute has been at the forefront in developing and applying psychosocial rehabilitation technology. In the music technology area, the Institute has developed four original technologies, and tested a number of other devices and software programs that involve young people with disabilities in new and different ways (Knox, 2004). One of these developments was ListenUp! (Assistivex, 2003), a music software program for remediation of attention deficits of clients with acquired brain injuries. Musical engagement has been encouraged through active participation, enabled by a variety of adaptive technologies such as the MIDImate switch access system (Assistivex, 2003), and automatic movement technologies that convert movement to music are used, such as the Soundbeam (Soundbeam Project, 2003; Swingler, 2003), and the Virtual Musical Instrument (VMI) developed at Bloorview Kid’s Rehab by Biomedical Engineer Tom Chau (Lamont et al., 2002).  The use of these adaptive technologies has created a paradigm shift in which access to a musical instrument no longer requires physical strength, endurance and fine motor abilities (Ellis, 1995).  As a result, participation in musical tasks and the subsequent emotional, psychosocial and therapeutic rewards is no longer restricted by physical barriers (Schwellnus et al., 2002).

 
The Virtual Music Instrument (VMI) is an instrument that uses a computer and web-camera to capture and display the image of the child on the screen and allows the user to designate musical areas that are outline on the screen by different coloured icons (Chau et al., 2003).  The child interacts with the instrument producing pre-determined musical tones or events by moving his or her body into the physical space represented by the icons on the screen (Chau et al., 2002).  The VMI has been used extensively in individualized settings and the newer versions of VMI software have proven highly valuable in past years. Usability studies involving the VMI suggest a positive impact on precursors to participation, including learning cause and effect (Chau et al., 2002), and the technology is more engaging for children with more complex physical disabilities (Lamont, et al., 2003).  The versatility and ease of use inherent in the VMI system, makes it an ideal music environment in which to assess a children’s ability to participate. However, in addition to development and usability study of the VMI system, research on its efficacy within music therapy practice was needed.  A qualitative study was required to build a knowledge base as to the potential techniques and varied use of the system for practical use in the music therapy, and to better understand areas of benefit resulting from use of this adaptive technology as a tool within the music therapy environment.

 

Figure 1: The Virtual Musical Instrument (VMI)

1. Research Methodology

 

The objectives of this qualitative pilot study were to identify music therapy interventions and techniques using the VMI that are suitable for young people with disabilities, to categorize areas of benefit over time that are made possible through enhanced participation using the VMI, to build theory on the role and significance of the VMI in music therapy, and to add to the existing literature and practice of music therapy, with the ultimate goal of client self-actualization through active participation.

The research questions included: 

1.   What interventions and techniques are best used by the music therapist to promote the therapeutic relationship in application of the VMI?[7]

2.   In which domains is there benefit, both during sessions and over the time period of the study, from the use of this instrument within music therapy?

 

Participants
The trials were carried out with six study participants of either sex (between 5.5 and 10 years of age).  From previous experience, it was found that the VMI is most effective and of most benefit to lower-functioning children with significant physical challenges including spinal muscular atrophy, cerebral palsy, and chromosomal abnormalities such as Rett Syndrome.  The inclusion criteria were that the child: have at least one independent movement that is self-controlled; not knowingly possess any adverse sensory reactions to music (e.g. seizure activity onset by particular frequencies); might be non-speaking but must have identifiable responses to auditory stimuli, specifically musical tones of mid-range frequency; must be able to remain positioned on the floor, in a chair, or in wheelchair for the majority of the session time. Participants were recruited by advertisements and were selected on a cross-disability basis according to inclusion criteria and interest. All sessions took place at the Bloorview site of Bloorview Kids Rehab.  They were held in a moderately sized, multi-use clinical space that houses musical instruments (including a piano, several guitars, percussion equipment, and small hand percussion equipment), audio equipment, a computer installed with the VMI system, a webcam, and a large screen television.  All children were seen individually. Music therapy sessions were ½ hour in length and were scheduled 2 times per week for 10 weeks, within each of the study’s time periods. The child was invited to take his or her place in front of the camera of the VMI.  The music therapist made camera adjustments to center the child’s image in the television screen.  If applicable, the child was encouraged to recognize his/her image in the television screen.  From the computer, the music therapist placed circles and/or squares of various colours with corresponding tones around or on the child’s image according to each child’s physical abilities. The child was then engaged in a music therapy session employing a variety of music therapy techniques including clinical improvisation and task-oriented activities to encourage active participation on the VMI.  Verbal, gestural, and physical prompting (hand over hand) was employed in sessions to ensure comprehension and appropriate access of the system.  The therapist monitored the child’s fatigue (physical and emotional) through observation and verbal inquiry to ensure participant safety.

Research Design
The research was based on the qualitative paradigm (Denzin & Lincoln, 2000; Coffey & Atkinson, 1996) and its nature was abductive
(Peirce, 1839-1914) and descriptive[8] (Bruscia, 2005, p. 81). The study employed a multiple case study paradigm, one of the five key methods in qualitative research (Creswell, 1998), grounded theory[9] (Corbin & Strauss, 1998; Glaser & Strauss, 1967/1999; Strauss & Corbin, 1990, 1997, 1998; Glaser, 1998), and narrative inquiry (Ceglowski, 1997; Glesne, 1997; Hollway & Jefferson, 1997; Frank, 1995.)[10]  The aim was to look deeply into the characteristics and processes of six children in their music therapy sessions. The study was designed to characterise the individual; however, cases often show precedence and build up a body of evidence on which to build theory. In this study we also took a comparative approach to examining the six children’s case data.


Qualitative Data Collection
Two types of data were collected: (1) Field notes (indexed session notes, case studies, and reflections) on all sessions from the therapist’s observations,[11] and (2) video observation notes on all sessions.[12] All sessions were videotaped and reviewed by two music therapists but only meaningful moments (Amir, 1996) chosen by them were analysed by the occupational therapist[13]. Reviewers justified their selections by saying why the examples illustrate what they say they do.  Those moments were first described as narratives and transcribed, followed by further reflection. The field notes then combined with the video narratives (see Table 1).


During the research process there was a cycle of observing-describing-interpreting completed several times; not always followed in a linear fashion (Ansdell & Pavlicevic, 2001). Sometimes the different stages of the cycle interacted and circled back on each other. The task was to get the material into a form where closer analysis was possible, in view of the research questions. Once field notes of the therapist and videotape notes had been transcribed, the two researchers[14] coded data into themes for content analysis using QSR N6 software. The aspects or events that were relevant to the research questions were labelled, while not excluding the possibility of unveiling new questions. The material was then organized into categories and subcategories. The robustness of the categories was tested in addressing the research questions, and the researchers firmed up boundaries by looking for overlaps and discarding weak categories.

One of the chief characteristics of this qualitative inquiry was the evolving nature of the design, methods and analytic procedures used.  The theory evolved as the data was being analyzed and the descriptive categories were formed. It was not straightforward to separate out description from interpretation.  The research process included a series of dialogues; with the data, with the ideas, with colleagues and with oneself. All of those interactions led to reflections and different decisions. The results developed through these various transactions (Coffey and Atkinson, 1996).

 

Results: Therapeutic Benefits

The therapeutic benefits of the VMI are introduced in the form of the following descriptive categories (Table 1). The core category — the grounded theory — is articulated as: “Enhancing Participation and Restoring Self-Image Through the Virtual Musical Instrument — Seeing Through the Looking Glass.” The main category growing out of the core category is: “Knowing through creative musical expression.” The four sub-categories include: To see and to be seen through reflective mirroring,” “Learning and building concepts through a musical framework,” “Enhancing full body participation through multi-sensory musical expression,” and “Restoring self-image and expressing feelings through containing musical experience.”(In the following, participants’ names have been changed to maintain confidentiality.)

  
Table 1: Seeing Through the Looking Glass
Enhancing participation and Restoring Self-mage through the Virtual Musical Instrument

 

 1

Visual Awareness

 

2

Auditory Awareness

 

3

 Kinesthetic Awareness

 

4

Self Awareness

 

I can see me

I can see you

I can see us

I can see it

 

 

 

I can hear it

I can hear you

I can hear myself

I can hear us

 

I can touch it

I can play it

I can control it

I am good at it!

 

I can understand

I can feel it

I know

I like it

I did it!

I can cope

I can choose

I believe

 

To see and to be seen through reflective mirroring

experience

 

 Learning

and building concepts through musical framework

 

 

Enhancing

full body participation through multi-sensory musical expression

 

Restoring

self-image

and expressing feelings through containing musical experience

 

 

Knowing through creative musical expression

 

 

Enhancing Participation and Restoring Self- Image Through the Virtual Musical Instrument

     Seeing Through the Looking Glass

 

 
[1] Dr. H. Ahonen-Eerikäinen and A. Lamont

 

Category 1 — “To see and to be seen through reflective mirroring experience”

 

I can see me

I can see you

I can see us

I can see it

 

According to Hobson, (1987) “The face is the mirror of the emotions and the eyes are the windows of the soul. In a simultaneous expression and communication, we give and receive, as our eyes convey and register the emotions of joy, interest, curiosity, anger, fear, and many complex combinations of these and other affects.” (p. 123).

We all need to belong. We need a sense of self, other and belonging (Stern, 1985). “The sense of community and belonging can be related to empathy itself” (Shapiro, 1998, p. 52). “The earlier in life an individual experiences that the need for a relationship is not being met, and the more consistent that experience is, the greater and more disruptive its effects…” (Erskine, Moursund & Trautmann, 1999, p. 11). There is only one thing that can cure isolation. “Contact… is the key. Contact, contact, and more contact (Erskine, Moursund, & Trautmann, 1999, p. 12). An infant can feel what her mother is feeling if she is imitating her mother’s facial expression (Lee and Martin, 1991). “Without the dance that takes place between mother and child, growth and development are constricted” (Shapiro, 1998, p. 51). 

 

“The visual feedback of her own image in the VMI allowed X to make eye contact with herself and with the music therapist on a regular basis… Also, the visual feedback permitted X the opportunity to play “dress-up” as the diva (bowing in front of the camera and saying “thank you, thank you!”), or as the leapfrog.  When the camera was not focused on her face, X could become confused, occasionally moving to the floor to see her face in the television if working on a “dancing” screen.”

 
According to the research results VMI provides a sense of relationship. Participating in VMI as a form of creativity and play is a benefit in and of itself.  Play is one of the main occupations of children and play for play itself is satisfying.  It also gives the opportunity for empowerment, to control objects in their environment, which children with CP may not have in other typical play activities. VMI sessions were full of feelings and laughter. According to Chain-West (1998, p. 101) playfulness spreads within a developing therapeutic process and laughter is therapeutic. It reduces tension and anxiety and establishes cohesiveness as an outcome from shared experiences. Winnicott (1971a) explains that if the therapist cannot be playful he/she will not be capable of doing successful therapy. Stern (1985) noticed that only a securely attached baby plays, and only a very secure baby can tease. Chain-West (1998) compared play with therapy and found the level of comfort and security of the clients was reflected in their playfulness within the psychotherapeutic process.  “If the therapist can be teased, in a benevolent way, he is less likely to be either feared or defensively idealized and is experienced as more human and, thereby, more understanding of his patients and compassionate towards them” (Chain-West, 1998, p. 101).

 

Category 2 — “Learning and building concepts through musical framework”

I can hear it

I can hear you

I can hear myself

I can hear us

 

Cognitive behavioural therapy focuses on correcting a vicious cycle of thought distortions, negative emotional responses to these thoughts, and the resultant maladaptive behaviour (Beck, 1975).  In the context of this study, challenges faced by children in previous music experiences, such as unsuccessful traditional music lessons or a lack of physical strength and/or dexterity, left a sense of failure.  This can leave the child with little motivation to embrace music-making and distort a sense of musicianship. The use of VMI seemed to motivate children:

 

“The use of the pentatonic scale, specifically, appeared to be a motivator for Bill  to move his body.  As this scale was used in previous therapy, it was easily recognizable to Bill  evidenced by the immediate use of his voice and engagement with the VMI system...  No matter what icon was fired, Bill  could be assured that his music would sound correct and sonorous.”

 

Bill’s tune contained within the pentatonic scale provided a secure base from which he could explore musically in a safe manner. Success-oriented client experiences in the music making can work to challenge thought distortions.  This is encouraged through the music therapist’s ability to establish a therapeutic relationship with the client through the provision of an appropriate music aesthetic (Lee, 2003) within communication accentuated music therapy practice (Ahonen-Eerikäinen, 1999) in which child can then hear his or her successful communication in the music making.

 The results show the VMI, as a music therapy tool, offers the potential for positive, reinforcing musical experiences.  The use of the VMI provides a new learning experience and one that focuses on the ability of the child versus the child’s inadequacy. The music therapist has the opportunity to design screens that focus on accessible modes such as the pentatonic.  The pentatonic offers a developmentally-appropriate, comforting and stable aesthetic that ensures no harmonic mistakes can be made by the child, allowing the child a success-oriented musical experience.  This resembles communication accentuated music therapy as an upper level of all music therapy approaches (Ahonen-Eerikäinen, 1999).  Communication must be encouraged within a safe musical atmosphere before an issue may be “worked through” (Ibid).

Once this is achieved, learning a theoretically accentuated music therapy approach in which “music conditions and works on behaviour or stimulates learning” (Ibid, p.159) is possible.  In this approach, positive reinforcement through song lyrics and/or social praise confronts previous emotional responses.  Maladaptive behaviours in response to initial distorted musical experiences can then be reshaped into more productive music making, thereby reinforcing the new thought process. 

 

“In the final period, Bill demonstrated a different child; one that could “play” in the music with the more subtle awareness evident in the ability to top his own music, explore silence with another person, and to express a complex musical thought understanding that he would hear another and would be heard in his place.”

The use of imitation is crucial to the process of reshaping associated feelings and behaviours.  The child begins to understand his/her music through the auditory recognition of his/her movements causing the effect of music (“I can hear it”), of his/her music played on the VMI or imitated by the therapist (“I can hear myself”), imitation of the music therapist’s music (“I can hear you”) and musical interplay (“I can hear us”).  This, of course, then feeds back to reinforce the formerly distorted thought regarding musicianship and leads to potential success in other areas:

 

“…may develop physical skills to access an augmentative communication device.  The VMI could be a motivating method to practice physical and perceptual motor skills.”

 

Category 3— “Enhancing full body participation through multi-sensory musical expression”

 

I can touch it

I can play it

I can control it

I am good at it!

 

Sensory integration refers to the body’s ability to receive input from the senses, integrate this information to what is already known by means of sorting and screening, and interpret this information with respect to the individual’s experiences and understanding of the world (Hatch-Rasmussen, 1995).  It is known that sensory modulation, an aspect of sensory integrative dysfunction, is often a critical issue within developmental disability (Riesman, 1993).  This refers to the nervous system’s over-efficiency or lack thereof when processing information from the senses resulting in hypo-reactivity or hyper-reactivity to the stimulus (Stephens, 1997).  In the practice of sensory integration therapy, as developed by Ayrs (Spitzer et al. 1996), the occupational therapist strives to provide the client with a stimulating environment with physical activity (both gross and fine motor) that is reasonable in expectation (known as the “Just Right Challenge”), promotes adaptive behavioural responses to tasks presented, allows the child to be active in participation, and is client-directed or centered (Dabrowski, K., 1967).

In recent literature, it has been suggested that there is a link between the practice of sensory integration therapy and music therapy (Hooper et al., 2004).  Music therapy provides a context in which a client can interact with his/her environment in a variety of ways with purpose and success (Berger as cited in Hooper, 2004).  Specific techniques involving the pairing of movement with music (pre-composed and improvised) are of particular interest for the integration of the auditory sense to the vestibular (information from the head in relation to gravity and the inner ear) and proprioceptive (as sense of self in space) systems (Ibid).  This dovetails well with the idea of neuropsychologically accentuated music therapy in which “music serves as multisensory experience, contributes to the automatisation of working, [and] initiates association and memory functions and stimulates verbalization” (Ahonen-Eerikäinen, 1999, p. 159).

 

“The VMI provided the opportunity for full body musical expression.  This emphasis on gross motor skills may have better spoken to Bill’s abilities rather than his inability to correctly grasp or articulate his fine motor movement.  This instrument also addressed Bill’s energy and attention span.  It did not require compliance to sit or maintain a specific posture, but could be adapted to Bill’s unique movement.”

 

The results of this study show how the use of the VMI provides a number of opportunities for sensory integration within the music therapy environment.  Specifically, it meets all criterion listed above for successful practice with an added dimension of potentially positive visual feedback. 

Adequate stimulation within the environment is clear:

 

“The VMI may be a good way to promote movement, physical fitness and exercise.  For example, it may help to increase strength, coordination and balance.  Large movements of the body may help to stimulate muscle tone of the trunk and increase her ability to sit in a stable position for activities that require more precise motor control of the arms.”

 

“Most outstanding was motivation the VMI provided X to move both in novel ways and clearly outside of her normal ranges.  She was rewarded both musically and visually in the jumping tasks.  With the success of tasks such as jumping out the tune of “Twinkle, Twinkle Little Star”, it suggests that music education could be conceived as a full body experience promoting not only musical skills but also physical fitness and gross motor strength and agility.”

 

Physical activity was promoted:

 

“Used right hand to access VMI icons most frequently and was observed to cross midline.  Was able to target and activate specific icons when asked.”

“The physical nature of the VMI may improve joint range of motion, muscle strength, eye-hand coordination and body awareness.  These skills may transfer to other activities in her daily life such as participating in dressing, bathing, etc.  It may make it easier to move her body and rely less on caregivers to move/stretch her body parts”

 

“X  demonstrated twisting at his waist and clapping to the side and overhead”

 

“For the masking tape activity, he worked on directionality, front/back, side to side”

 

“The VMI could be used to introduce new movements, therefore increasing strength, coordination and balance.”

 

As a result of this study….“X increased the number of times he crossed his midline with both arms…increased his ability to target specific icons to make musical sounds and phrases”

 

Activity was reasonable in its expectation, fitting the “Just Right Challenge”: 

 

“X could alternate hand movements on the drum.  Holding the drumsticks may give him a tactile, concrete clue to improve his accuracy to activating the icons (tactile feedback to his hand that guides movement).”

“X improved bilateral hand skills.  He increased the use of a hand that he does not normally use.”

 

“X increased ability to dissociate body movements i.e. he will be able to move his arm without his whole trunk moving”

 

Adaptive behaviour was promoted:

 

“X may develop physical skills to access an augmentative communication device.  The VMI could be a motivating method to practice and develop physical and perceptual motor skills.”

“X demonstrated the ability to separate movements i.e. he could play the drum and VMI together and separately (demonstrated bilateral hand skills)

 

“X created new movements on his own such as twirling, walking on all 4’s, and taking little steps.  Jumping seemed challenging for him.”

 

Active participation was clear:

 

“X developed a ‘boxing’ move to activate icons and said it was like getting exercise on a bike.”

 

“X appeared to increase her repertoire of movements from session 2.  This could be used to improve her balance, coordination, physical stamina and endurance, and body and spatial awareness.  She was able to explore different body movements to activate the VMI icons i.e. jump like a frog, flap like a bird.”

 

“X was able to follow a simple beat.  Following the music beats may improve the fluidity & quality of his movements.  He was able to respond to increased speed of beats with increased speed of movements.”

 

“X demonstrated cause & effect by crouching on the ground to stop the music, then popped up to activate the icons.”

Music making was client-directed:


”The activation of his voice also appeared to be influenced by the whole tone scale, although this could not be confirmed with so few sessions.  It would suggest that the stretching nature of the scale could be influencing the end points of his vocal range.  In this case, there is very much a safe base for the whole tone, but it is elongated vertically, not laterally which may encourage a smaller voice like Bills to slide slightly higher or lower than normally would be seen.” 

 

“During the dancing/making bird sounds activity, X initiated jumping, flapping arms like a bird, moved right arm to hit icon”


Category 4 —“Restoring self-image and expressing feelings through containing musical experience”

 

I can understand

I can feel it

I know

I like it

I did it!

I can cope

I can choose

I believe

 

It was Donald Winnicott (1971) who first asked “What does the new born baby see when he or she looks at the mother’s face?”  Mother is looking at the baby, and how she looks at the baby is somehow related to what the baby sees in her. If the mother “looks with love and with tenderness, the baby experiences him or herself as joyfully alive. If, however, she is depressed and unsmiling, even more so if she does not look back and cannot maintain the reciprocity of looking, the baby experiences him-or herself as joyless, unlikely, even absent”  (Pines, 1998, p. 47). Winnicott (1947/1964) discovered how the baby begins to see him- or herself in the mother’s look, and how babies begin their lifetime search of “creating a sense of self. That sense of self could, for example be: ‘I am good or bad to see and/or to hold.’ Or the response could be empty of feeling” (Pines, 1998, p. 144–145). Can the cerebral palsy experience be an “empty mirror” for the baby or toddler, who may adopt a non-reflective image and incompetence and bad self-esteem through to the core of the self?

VMI could be compared to a hall of mirrors where each client is confronted with aspects of his or her psychological, social or body image (Foulkes and Anthony, 1990, p. 150–51). Children discover themselves, seeing who they are in a new light through their experiences in the VMI screen. For many children with CP this is crucial as their environments may not have provided that “magical” or good mirror all human beings need to see themselves in a healthy light. These children may have been seeing themselves only through distorting mirrors that have been reflecting only ugly images or freezing images (Behr, 2000, p. 175–76).

 

“Period 3 is a time in which X is able to process many of his feelings around strong emotions such as violence and sadness.  It is in the acknowledgement of sadness that X opens up emotions forbidden in the past.  Like other children with disabilities, X is not denying his own capacity or understanding of sadness, but is sensitive to exposing others to what might be additional sadness or worry; especially his parents.”

    

“Creating music and incorporating emotional content may help him to express his own feelings and explore emotional expression…”

 

The results show that through the VMI the children with CP find their new identity. It is like the voiding a spell of an old distorted image: something that made them freeze, did not allow them to be visible, audible, livable, motorically talented, musical, or competent. It gives them permission to feel equal. It gives them permission to show their true self, instead of a false self, to become visible and audible. In VMI children with CP have different ways of dealing with their issues, and expressing their feelings. It becomes acceptable to be different, “to be one’s own person” (Chazan, 2001, p. 55), to be individual.

The use of song-writing appeared to contain feelings in a more effective way than improvisations with instruments on the subject of anger.  The inclusion of text may have helped to contain and address the topic in a more concrete and therefore satisfying manner.
 

“X was able to explore emotions by matching sounds to the emotions.  He

followed the verbal cue of ‘sad’ in the song to change instruments.”

 

“Repetition of key words such as yes or no allowed the song to be

accessible to X.  These were words that were well practiced and

easily understood in his vocabulary allowing to express some of

these feelings, in some ways, to the “empty chair” containing different

family members.”

 

The holding environment (Winnicott, 1965) is a further idea that describes VMI experience and the container (Bion, 1959) is another. A VMI is a safe container and holding environment. It holds feelings of anger or pain. It holds feelings children were not able to express without music. If the music can contain those feelings, if the music can hold the child, it will be a corrective and compensative — something that perhaps was missing during their formative years. Having cerebral palsy may be quite traumatizing experience. The VMI is often the container for hurting feelings, anger, depression and anxiety.

 

Main Category —“Mastery of knowing through creative musical expression”


“It was often noted that Luke appeared to be watching himself in the television or computer screen.  This seemed to be a point of investigation or reflection as he played.  … a sense of musical mastery was achieved and Luke enjoyed viewing the results of his hard work.”
 

“This therapeutic relationship developed in the music seemed to permit X to not only learn to praise herself, but to explore the limits of her social, communication, and motor boundaries through active participation in the music.”

 

Results show that VMI engages the children with CP in the occupation of play, which is a normal activity for their age.  VMI also gives them the opportunity to be an active participant and indicator of play rather than having less control as a passive recipient.  This could benefit feelings of competence, confidence and self-esteem. Engaging in cooperative song writing and improvisations may provide feelings of pride or mastery, which is positive for building sense of competence and self-esteem i.e. “look what I can do!”  This may help build confidence in self and in interactions with others. Children know they can succeed at VMI. “I like it because I know I can do it.  For example, Jennifer verbalized her own positive reinforcement by saying “I did a good thing” and “I did it” after each stop during VMI play.
 

“X demonstrated increased competence in making something happen (making musical sounds)…He seemed to have increased confidence that he could produce/create music.  He was doing something that made him feel good.”

 

“A smile on his face indicated enjoyment of making music.  He appeared to be proud of himself in completing the whole song and said “I may have a little party when I come home.”

 

The search for competence and mastery is basic motivation for behavior (Basch, 1988, p. 25).  The following lower level categories illustrate that in VMI, children with CP find enjoyment with music and the multi-sensory stimulation it provides. They find mastery in various areas when playing music with the VMI.  They begin to communicate, build concepts, enhance full body participation, restore self-images and express feelings. They begin to share their stories through improvisations and song-writing. It is remarkable that if people feel they cannot share their stories, they feel isolated, invisible, lonely, unimportant and incompetent. Only after their stories have been heard, shared, and witnessed do they begin feeling validated.
 

Core Category: Seeing Through the Looking Glass
—Enhancing participation and Restoring Self-Image through the Virtual Musical Instrument

 

“How would you like to live in Looking-glass House, Kitty?

I wonder if they'd give you milk in there?

Perhaps Looking-glass milk isn't good to drink -- But oh, Kitty!

Now we come to the passage.

You can just see a little peep of the passage in Looking-glass House,

 if you leave the door of our drawing-room wide open:

and it's very like our passage as far as you can see,

 only you know it may be quite different on beyond.

Oh, Kitty! how nice it would be if we could only get through into Looking-glass House!

 I'm sure it's got, oh! such beautiful things in it!

 Let's pretend there's a way of getting through into it, somehow, Kitty.

Let's pretend the glass has got all soft like gauze, so that we can get through.

Why, it's turning into a sort of mist now, I declare!

 It'll be easy enough to get through –

 ' She was up on the chimney-piece while she said this,

Though she hardly knew how she had got there.

And certainly the glass was beginning to melt away, just like a bright silvery mist.“

The multiple case studies included 6 children with a diagnosis of cerebral palsy who restored their self-image and found and owned a new identity during the VMI Therapy experience. During the narrative case study analysis (Ceglowski, 1997; Glesne, 1997; Hollway & Jefferson, 1997; Frank, 1995) the following titles became apparent. Matthew became The Boxer. Jennifer became The Performer. Bill  became The Conductor.    Steven became The Acrobat.   Maddie became The Scout.    Luke became The Rebel[15]

 

MATTHEW—The Boxer

 

Matthew is looking through the glass but he can’t see himself —he only sees his disability. He feels sadness and anger but locks the forbidden emotions inside. He doesn’t want to upset anybody as they’ve been through enough…  Gradually, music opens the door for Matthew to reach out and explore an extreme character. He becomes a boxer, rapper, a crocodile hunter… He expresses anger, sadness, frustration, violence… Multi-sensory combination of music and the physical manipulation of the mirroring experience make the self-process and new identity possible. He declares he will have a little party for himself!

 

THE BOXER

Song composed

by Matthew

 

There was a boxer - there was a boxer

There was a boxer who wasn’t in the ring

So he boxed - and he boxed

And he boxed the television in

BOXING ACTIONS & INSTRUMENTAL CHORUS

First he gave it the left hook

Then he gave it the right hook

And then he gave it the noggin

And the TV fell down

BOXING ACTIONS & INSTRUMENTAL CHORUS

There was a boxer – there was a boxer

There was a boxer who wasn’t in the ring

So one day he boxed the TV

And his parents came in

BOXING ACTIONS & INSTRUMENTAL CHORUS

 

The Long Way Home

Song composed

by Matthew

 

There were two crocks that liked to eat humans

[3x djembe, tom drum right hand then left]

But I’m already too far into the story.  Let me go back

[chime]

One day a man goes for a walkabout and becomes very, very hot

[bongos]

So he decides to go for a swim in the lake

[2 black, one red, one green icon on VMI]

But he doesn’t know that there are 2 crocks in the lake.

[2 black VMI icons and cymbal]

So he tries to throw a fish to trick them

[VMI icon arch]

But then they fought

[VMI/piano fighting music with arch ending in an accelerando]

And fought – but then the man died

[bell tree music with Aeolian scale on piano]

There was a funeral for the man.  Everyone was sad, but especially his cousin.  His cousin was very sad

[improvisation con’t]

He went from being sad to being mad

[Improvisation with snare drum and piano in dual tonality]

To being angry

[improvisation con’t]

And he went from angry back to being sad again

[Snare changes to bell tree, piano changes to Aeolian mode]

He couldn’t get over it.  He began to have feeling about the crocks.  He started to think about how he wanted to shoot them

[black square VMI icon]

Then he thought no, he wanted to poison them

[blue circle icon]

Then he thought he wanted to club them

[black circle icon]

Then he thought, “That’s even too good – I’m going to leave them in the water.”

[silence]

One day the cousin discovers that music helps to fill the hole in his heart.  While he was playing, he realized something about life.  He began to sing: “Live Your Life”

and he lived happily ever after

[Guitar with vocal line “live your life”]

 

 

JENNIFER—The Performer

 

Jennifer is looking through the glass and only sees herself.  Me, me, ME!!!! MY MUSIC! She’s afraid of the mist because she can’t see anyone else… she can’t find them.  She’s there by herself.  It’s a lonely place to be, filled with anxiety.  It’s like she’s desperately trying to control her environment but she can never see very far ahead. New sound, new person, new demands would break down her safety. Music clears the mist.  Jennifer first recognizes connections in music and gradually with another human being.  She integrates the “we-ness”, dance between two people.  She learns to dialogue. She becomes brave—exploring novel movements, crossing her physical comfort level. 

 

 

Level of independence:  5=Independent     4=verbal prompting required     3=gestural prompting required      2=physical prompting required     1=no performance

 

 

BILL—The Conductor

 

Bill is looking through the glass and only sees the glass, its beauty, its colours, its shapes, its music…its chaos. He does not see himself. He does not see another person. He’s thrilled, however, like being inside a kaleidoscope. Every turn produces beautiful sounds. He controls them. He owns them.  There’s empowerment but music stretches him … his body, his voice, his abilities.  Music helps him to differentiate himself from the chaos and have intentional communication with another person. And certainly the chaos was beginning to melt away, just like a bright silvery mist.

 

 

 

MADDIE—The Scout

 

Maddie is looking through the glass but doesn’t like what she sees.  She turns away. She’s resistant. She tries to control but there’s too many things going on…  She tries to trust but why bother as she may not come back next week. [16]  Music gave her a glimpse of an old Megan, the playful one, without so many worries…  Although she has explored before through the looking glass her footing was no longer secure.  It’s like she’s looking at the frame and not the mirror… and taking glimpses of herself when she can. Let's pretend there's a way of getting through into it, somehow, Kitty…

 

STEVEN—The Acrobat

 

Steven is looking through the glass and is looking for something particular…to be excited.  There are many fascinating things in the glass but he only plays with his favourites. You can just see a little peep of him in Looking-glass House, even if you leave the door wide open and offer him all the possible opportunities.  He’s caught and knows only a few ways to get out.  Music helps him to expand his musical expression.  Enticing music brought him to life.

 

 

LUKE—The Rebel

 

Luke is looking through the glass and sees everything taking away from him. He sees an angry boy! He’s blaming his disability. He’s blaming his family. He feels his life is unfair. He feels nobody’s listening. He’s beating himself on a glass. Music allows constructive expression and control over the feelings.  The song is empowering. It validates his opinions and feelings about his life. Music gives him a voice. It allows him to be articulate, respected. It gives permission to rebel. Music restores his self-image, re-constructs his identity.

The following song was composed

1.

Your Mom or Dad says: “No more TV!” but you want it…so you sing:

YA, YA, YA, YA! I want TV!

YA, YA, YA, YA! I want TV!

2.

Your Mom or Dad says: “It’s time to get in the car to go for an appointment far, far away!” but you don’t want to go…so you sing:

NO, NO, NO, NO! I don’t want to go!

NO, NO, NO, NO! I don’t want to go!

3.

Your Mom or Dad says: “It’s time to go to school” but you don’t want to go…so you sing:

NO, NO, NO, NO! I don’t want to go!

NO, NO, NO, NO! I don’t want to go!

                         4.

Your Mom or Dad says: “It’s time to go to bed!” but you don’t want to go…so you sing:

NO, NO, NO, NO! I don’t want to go!

NO, NO, NO, NO! I don’t want to go!

                                                                         5.

Your brother comes and takes your piano and says: “NO! MINE!”

but it belongs to you…so you sing:

YA, YA, YA, YA!  That’s my piano!

YA, YA, YA, YA!  That’s my piano!

 

These multiple case studies and narratives characterize the school aged child with cerebral palsy— their daily life challenges, joys and sorrows, preferences, motivations, inner realities and main obstacles, and psychosocial therapeutic needs.  The categories presented as results of this study represent the multi-sensory benefits of VMI in the therapeutic setting with these children.  The results show clearly that music is a motivator for participation in life.  This will decrease the learned helplessness and restore the damaged self-image.

Conclusion
Participation is "the nature and extent of a person's involvement in life situations" (WHO, 1997). Participation “includes the activities of personal maintenance, mobility, social relationships, education, leisure, spirituality, and community life.” (King, Law,  King, Rosenbaum,  Kertoy, & Young,  1999).


One of the main aims of psychosocial rehabilitation of children with CP is to help them to promote participation. Active participation is the key. Through participation children develop various skills and competencies, reach psychological and physiological challenges, accomplish mental and physical health, express themselves, and establish their own purpose in life. Participation is associated to better social and intellectual capability and to resilience (Werner, 1989).  Contentment with various activities is a central interpreter of life happiness among adults with various physical disabilities and is linked with adjustment and over all well-being (Kinney & Coyle, 1992; Lyons, 1993; Brown & Gordon, 1987).

King, Law, King, Rosenbaum, Kertoy & Young  (1999, 2005) and other literature (i.e. Anderson,  & Clarke, 1982; Blum, Resnick, Nelson, & Germaine, 1991; Brown & Gordon, 1987;  Cadman, Boyle, Szatmari, & Offord, 1987; Dempsey, 1991; LaGreca, 1990; Law,  & Dunn, 1993;Lyons,1993) indicate that some of the most important factors to enhance participation may be to enhance children’s feelings of competence,  to enhance their physical, cognitive, communicative, emotional, behavioral, and social functioning.

The results of this research project addressed the whole child with CP, not only their disability—offering new knowledge to rehabilitation teams, families, challenging social and musical barriers, and allowing ample opportunity for the child’s participation and creative development.  The results show that the VMI enhances children’s feelings of competence. It also enhances their physical, cognitive, communicative, emotional, behavioral, and social functioning. It helped children with CP to see beyond their disabilities.

Keeping in mind the whole child, in music therapy it is standard to consider more than one area of benefit, both when assessing areas of need (Boxill, 1985), and designing music therapy programs (Davis, 1992; Bunt & Hoskyns, 2002; Wigram,  Nygard, Pedersen & Bonde, 2002). This consideration is well suited to the clientele of Bloorview Kids Rehab, where the mandate includes addressing the unique individual in a family context. This study considered the following areas of potential benefit from music therapy: The VMI experience enhances participation and restores self-image of the child with Cerebral Palsy.  Visual, auditory, kinesthetic, and self-awareness is developed and increased during the therapeutic process.

According to research results the VMI creates an environment that is developmentally appropriate and fosters active exploration and engagement, which is key to facilitating social-communicative skills, motor skills and kinesthetic abilities, cognitive development and socio-emotional growth. According to the child’s therapeutic needs the VMI can be used as a tool of music therapy but also as a tool of physiotherapy, occupational therapy, speech therapy and psychotherapy when working with the psychosocial and physiological rehabilitation needs of children with CP.  Various theories, such as sensory integration theory, cognitive-behavioural theory, Winnicot’s psychotherapeutic approach, or Stern’s mother-baby interaction findings, can be applied as eclectic theoretical foundations of VMI rehabilitation.  


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[1] Dr. Heidi Ahonen-Eerikäinen, Associate Professor of Music Therapy, and Director of the Laurier Centre for Music Therapy Research, Wilfrid Laurier University, Waterloo, Ontario, Canada, was responsible for planning the qualitative research project.  She contributed in qualitative data analysis, video reviews, and preparation of reports.

[2] Andrea Lamont, MMT, MTA, Bloorview Kids Rehab, Toronto, Ontario, Canada, was the study’s Music Therapist and was responsible for data collection.  She contributed to qualitative data analysis, video reviews and preparation of reports.

[3] Dr. Roger Knox, Music Research Coordinator, Bloorview Kids Rehab, contributed to the preparation of the grant proposal and coordination of the budget.

[4] This article explores the findings from the second research question only.

[5] This article focuses on results generated on the second research question only.

[6] This research is a project of the Bloorview Research Institute and generously funded by the Bloorview Foundation. We are grateful to Dr. Tom Chau, Biomedical Engineer, Bloorview Kids Rehab for continuous system development and support, and to Yani Hamdani, Occupational Therapist, Bloorview Kids Rehab for insightful video review.

[7]  Results generated from the first research question discuss musical interventions in the following non-musical goal areas:  (1.) Motor and physical Skills (1.1 Instructional Lyrics: Identification and/or emphasis of specific targets; 1.2 Enhancement of Physical Experience: Utilization of parallel musical elements such as up/down; 1.3 Theme Creation/Improvisation: Distillation of the whole person: creation of themes using various elements of music; 1.4 Repetition and/or Fragmentation of Music: Establishment or re-establishment of structure & Complimentary music to movement; 1..5 Pre-Composed Music: Relaxation & Encouragement of specific movement; 1.6 Hide & Seek: Imitation of contrasting elements, Motivation & Mastery; 1.7 Combination of “real” instruments and VMI: Enhancement of drum set & Use of jingle bells/egg shaker for grasp) (2.) Communication, Speech, and Cognitive Skills (2.1 Receptive Communication: 2.1.1 Instructional lyrics: Directions; 2.1.2 Musical interaction/conversation: “Is the child imitating what he is hearing?” “Does he understand me?”; 2.1.3 Pre-composed music: target actions; 2.2 Expressive Communication; 2.2.1 Enhancement of communication: reinforcement of expression or tone; 2.2.2 Musical Reflection: observation of client’s actions/behaviour (therapist is saying “I see, hear, and accept you); 2.2.3 Theme Creation/Improvisation: distillation of the whole person: creation of themes using various elements of music,  Repetition/fragmentation: can include vocal themes to distil anxiety, reference earlier material for integration or anticipation, or re-establishment of structure, Pre-composed music: for familiarity, trust, and relaxation, Hide & Seek: to establish non-verbal, humorous musical exchanges (mother/baby) & Character Development.) (3.) Sensory and Auditory Skills (3.1 Instructional Lyrics: Identifies specific target with emphasis, repetition, and lengthening of words; 3.2 Enhancement of Sensory/Auditory Skills: Utilization of Musical Element; 3.3 Theme Creation/Improvisation: Distillation of the moment of the whole person; 3.4 Repetition/Fragmentation:  Re-establishing structure & Modelling target consonants/vowels; 3.5 Pre-composed Music: Sense of structure; 3.6 Hide & Seek: Mastery & Cause & effect; 3.7 Combination of “real” instruments & VMI: orientation.) (4.) Socialization Skills (4.1 Instructional Lyrics: Target action emphasized,Orientation to social structure, Sequencing events, transitions, turn taking & Leadership initiation; 4.2 Enhancement of socialization: Use of musical elements to emphasize social structure, direction, etc.; 4.3 Musical Conversation: Musical interactions that are based on client’s expression building to a more complex musical environment; 4.4 Theme Creation: Distillation of the moment of the whole person; 4.5 Repetition/Fragmentation: Re-establishment of the structure; 4.6 Pre-composed Music: Familiarity, Trust & Structure; 4.7 Hide & Seek: Establishing non-verbal, humorous musical exchange (mother-baby).) (5.) Psycho-Social and Emotional Skills (5.1  Enhancement: Spotlight on the experience, Establishment of tone & Acknowledgement of feelings;  5.2 Musical Reflection: observation of client’s actions/behaviour (therapist is saying “I see, hear, and accept you); 5.3 Musical Conversation: Reflection of child’s feelings & Reflection of child’s verbalizations in song writing, etc.; 5.4 Theme Creation/Improvisation: Distillation of the moment of the whole person; 5.5 Pre-composed Music: Exploration of feelings, Familiarity, Trust & Relaxation; 5.6 Hide & Seek: Establishing non-verbal, humorous musical exchange (mother-baby); 5.7 Empowerment or “being the boss”; 5.8 Character Development: Song writing, Improvisation, development of themes & Development of alternate personalities (the boxer, rock star, etc.): Song Writing: Original compositions, Song arrangements, Lyric replacement & Improvised song.) This article does not, however, explore these findings further but concentrates the results generated from the second research question.

 
[8] This kind of holistic description “gives the what, when, where, and how, without the whys. It is concerned with discerning what constitutes the phenomenon”(Bruscia, 2005, p. 89).

[9] Grounded theory “is a general approach of comparative analysis linked with data collection that uses a systematically applied set of methods to generate an inductive theory about a substantive area. It’s purpose is to discover theory from data (Glaser & Strauss, 1967, p. 1). The researcher focuses on one area of study, gathers data from a variety of sources such as interviews and field observations, and analyzes the data using coding and theoretical sampling procedures. (Glaser & Strauss,1967, pp. 22-23)” (Amir, 2005, p. 365)

[10] Narrative Inquiry “creates an intersubjective space that reflects a dynamic relationship between researcher, the context of research, and the reader.” (Bruner, 1986 cited in Kenny, 2005, p. 416).  It “… is hermeneutic in nature because it is contingent upon the perception and interpretation of the researcher. The writer/researcher selects aspects of a narrative to highlight elements of a research context in order to portray a holistic picture of research participants, issues, and settings. “ (Kenny, 2005, p. 416). The narrative inquiry was used to capture the essence of multiple case studies and the core category and illustrate it in the form of narrative.

[11] The field notes included reactions, thoughts, and analyses either during or after the sessions, and were transcribed.

[12] The ethical review was accepted both by the Wilfrid Laurier Ethics Committee and the Bloorview  Research Institute Ethical review board.

[13] The Occupational Therapist was issued an instruction sheet directing her to read a case study, and then observe selected video excerpts for each participant.  The Occupational Therapist was then asked to describe beneficial outcome areas of the VMI in the music therapy setting.  Any additional comments were welcomed.  There were no restrictions for video and/or case study access.

[14] Dr. H. Ahonen-Eerikäinen and A. Lamont

[15] The names assigned are pseudonyms.

[16] For various reasons Maddie attended only 50% of the scheduled session.





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