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

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).

 

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.

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?

 

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.)

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

 

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.”

 

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. 

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…”

 

“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.”

 

 

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

 

“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.”

 

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.  

Ahonen-Eerikäinen, H. (1999). Different forms of music therapy and working styles of music therapists – a qualitative study. Nordic Journal of Music Therapy, 8(2), 156-167.

Aldridge, D. (1996). Music Therapy Research and Practice in Medicin:From Out of the Silence. London: Jessica Kingsley Publishers.

Amir, D. (1996). Experiencing music therapy: Meaningful moments in the music therapy process. In M. Langenberg, K. Aigen, & J. Frommer (Eds.), Qualitative Music Therapy Research—Beginning Dialogues (pp.109–132). Gilsum, NH: Barcelona Publishers.

Amir, D. (2005). Grounded theory. In B. Wheeler (Ed.), Music Therapy Research (2^nd edition), pp. 365-378. Gilsum, NH: Barcelona..

Anderson, E. M., & Clarke, L. (Eds.). (1982). Disability and Adolescence. New York: Methuen.

Ansdell, G. & Pavlicevic, M. (2001). Music Therapy Research. London: Jessica Kingsley.

Assistivex (2003). Web link:  www.assistivex.com/Public/category

Basch, M. (1988). Understanding Psychotherapy: The Science Behind the Art. New York: Basic Books.

Beck, A. T. (1975). Cognitive Therapy and the Emotional Disorders. International Universities Press.

Berger, D.S. (2002).  Music Therapy, Sensory Integration and the Autistic Child. London: Jessica Kingsley.

Behr, H. (2000). Families and group analysis. In D. Brown & L. Zinkin (Eds.), The Psyche and the Social Worl: Developments in Group-Analytic Theory (pp. 163-179). London: Jessica Kingsley.

Blake, K. (1995). The social isolation of young men with quadriplegia. Rehabilitation Nursing, 20(1), 17-22.

Blum, R. W., Resnick, M. D., Nelson, R., & St. Germaine, A. (1991). Family and peer issues among adolescents with spina bifida and cerebral palsy. Pediatrics, 88(22), 280-285.

Bion, W. R. (1959). Experiences in Groups and Other Papers. New York: Basic Books.

Boxill, E. (1985). Music Therapy for the Developmentally Disabled. PRO-ED, Inc., p.23.

Blake, K. (1995). The social isolation of young men with quadriplegia. Rehabilitation Nursing, 20(1), 17-22.

Brown, M., & Gordon, W. (1987). Impact of impairment on activity patterns of children. Archives of Physical Medicine and Rehabilitation, 68, 828-832.

Bruscia, K. (2005). Research topics and questions in music therapy. In B. Wheeler (Ed.), Music Therapy Research (2^nd edition), (pp. 81-93). Gilsum, NH: Barcelona.

Bunt, L.& Hoskyns, S. (2002). The Handbook of Music Therapy. London: Brunner-Routledge.

Cadman, D., Boyle, M., Szatmari, P., & Offord, D. R. (1987). Chronic illness, disability, and mental and social well-being: Findings of the Ontario Child Health Study. Pediatrics, 79, 805-813.

Camilleri, V. (2000). Music therapy groups: A path to social-emotional growth and academic success. Educational Horizons, 78(4), 184-189.

Crapps, J., Langone, J., & Swaim, S. (1985). Quality and quantity of participation in community environments by mentally retarded adults. Mental Retardation, 20, 123-9.

Ceglowski, D. (1997). That’s a good story, but is it really research? Qualitative Inquiry, 3(2), 188-201.

Chain-West, J. (1998). Infant research and intersubjective responsiveness in group therapy. In I. N. H. Harwood & M. Pines (Eds.), Self-Experiences in Group: Intersubjective and Self-Psychological Pathways to Human Understanding (pp. 99–109). London: Jessica Kingsley..

Chau T., Schwellnus H., Hamdani Y., Lamont A., Eaton C., Tam C., Knox R., & Johnson P. (2002). Usability of movement-to-music technology for children with physical disabilities. In Proceedings of the 27^th Canadian Medical and Biological Engineering Conference. Ottawa, ON.

Chau, T., Eaton, C., Tam, C., Schwellnus, H., Hamdani, Y.Lamont, A., Knox, R., & Johnson, P. (2003). Design and usability of a movement-to-music system for the rehabilitation of children with cerebral palsy.  Developmental Medicine and Child Neurology (Supplement 94, vol. 45), 50.

Chazan, R. (2000).The Group as Therapist. International Library of Group Analysis (Vol. 14). London: Jessica Kingsley.

Coffey, A., & Atkinson, P. (1996). Making Sense of Qualitative Data, p. 196. Thousand Oaks, CA: Sage.

Conroy, M., & Brown, W. (2001). Employing an ecological perspective for planning interventions. In Goldstein, H., Kaczmareck, & English, K. (Eds.). Promoting Social Communication: Children with Developmental Disabilities from Birth to Adolescence, Baltimore, MD: Brookes.

Corbin, J., & Strauss, A. (1998). Basics of Qualitative Research: Techniques and Procedures for Developing Grounded Theory. Thousand Oaks, CA: Sage..

Creswell, J. (1998). Qualitative Inquiry and Research Design: Choosing Among Five Traditions. Thousand Oaks, CA: Sage.

Dabrowski, K. (1967). Personality Shaping Through Positive Disintegration. Boston, Mass.: Little Brown.

Davis, W., Gfeller, K, & Thaut, M. (1992). An Introduction to Music Therapy: Theory and Practice, Dubuque, IA: Wm. C. Brown..

DeCarlo, A. (2001). Rap therapy? An innovative approach to groupwork with urban adolescents. Journal of Intergroup Relations, 27(4), 40-48.

Dempsey, I. (1991). Parental roles in the post-school adjustment of their sons and daughters with a disability. Australia and New Zealand Journal of Developmental Disabilities, 17(3), 313-320.

Denzin, N. & Lincoln, Y. (2000). Handbook of Qualitative Research (2nd. edition). London: Sage..

Edgerton, J. E. (1994). American Psychiatric Glossary (7th ed.). Washington, DC: American Psychiatric Press.

Ellis, P. (1995). Incidental music: A case study in the development of sound therapy. British Journal of Music Education, 12, 59-70.

Emde, R.N. (1991). Positive emotions for psychoanalytic theory: surprises from infancy research and new directions. Journal of the American Psychoanalytic Association, 39 (Supplement), 5–44.

Emde, R.N. & Shapiro (Eds.), (1993). Affect: Psychoanalytic Perspectives. Madison, CT: International Universities Press.

Erskine, R. G., Moursund, J. P., & Trautmann, R. I. (1999). Beyond Empathy. A Therapy of Contact-in-Relationship. London: Brunner & Mazel.

Frank, A. (1995). The Wounded Storyteller. Chicago: University of Chicago Press.

Foulkes, S.H. & Anthony, E.J. (1957/1984/1990). Group Psychotherapy—The Psychoanalytic Approach. London: Karnac.

Glaser, B. (1998). Doing Grounded Theory: Issues and Discussions. Mill Valley, CA: Sociology Press.

Glaser, B & Strauss, A. (1999/1967). The Discovery of Grounded Theory: Strategies for Qualitative Research. Aldine De Gruyter: New York.

Glesne, C. (1997). That rare feeling: Re-presenting research through poetic transcription. Qualitative Inquiry, 2(2), 53-70

Gourgey, C. (1998). Music therapy in the treatment of social isolation in visually impaired children. Review (Washington,. 29(4), 157-162.

Hatch-Rasmussen, C. (1995). Sensory Integration. Retrieved 01:55, November 13, 2007, from http://www.autism.org/si.html

Hobson, R. F. (1985). Forms of Feeling: The Heart of Psychotherapy. London: Tavistock.

Hollway, W., & Jefferson, T. (1997). Eliciting narrative through the in-depth interview. Qualitative Inquiry, 3(1), 53-70.

Hooper, J., McManus, A., & McIntyre, A. (2004). Exploring the link between music therapy and sensory integration: an individual case study. British Journal of Music Therapy, 18(1), 15-23.

Hough, J. (1999). Disability and health: A national public health agenda. In Simeonsson, R.J. & McDevitt, L.N. (Eds.), Issues in disability & health: The role of secondary conditions & quality of life. Chapel Hill: North Carolina Office on Disability and Health, pp.161-203.

Kenny, C. (2005).  In B. Wheeler (Ed.), Music Therapy Research (2^nd edition), (pp. 416-428-378). Gilsum, NH: Barcelona..

King, G., Law, M., King, S., Rosenbaum, P., Kertoy, M., & Young, N. (1999). CanChild Centre for Childhood Disability Research. MacMaster University. www.canchild.ca

Kinney, V. B., & Coyle, C. P. (1992). Predicting life satisfaction among adults with physical disabilities. Archives of Physical Medicine and Rehabilitation, 73, 863-869.

Knox, R. (2004). Adapted music as community music. International Journal of Community Music, Vol. 1. Web link: www.nyu.edu.education/music/meducation/ijcm/

Knox, R., Yokota-Adachi, H., Kershner, J., & Jutai, J. (2003). Musical Attention Training Program and alternating attention in brain injury: An initial report. Music Therapy Perspectives, 21(2):99-104.

Knox, R., Lamont, A., Chau, T., Hamdani, Y., Schwellnus, H., Eaton, C., Tam, C., & Johnson, P. (2003). Movement-to-music: Designing and implementing a Virtual Music Instrument for young people with physical disabilities. International Journal of Community Music, vol. 2. Web link: www.nyu.edu.education/music/meducation/ijcm/

Kontos, S., Moore, D., Giorgetti, K., (1998). The ecology of inclusion. Topics in Early Childhood Special Education, 18(1), 38-48.

LaGreca, A. M. (1990). Social consequences of pediatric conditions: Fertile area for future investigation and intervention? Journal of Pediatric Psychology, 15, 285-307.

Lamont, A., Knox, R., Chau, T., Hamdani, Y., Schwellnus, H., Tam, C., & Johnson, P. (2002).

Converting movements to music: New musical exploration opportunities for children in rehabilitation.  In N. Oddy (Ed.), Proceedings of the 29^th Annual Conference of the Canadian Association for Music Therapy (pp. 26-31). Waterloo, ON: Canadian Association for Music Therapy.

Law, M., & Dunn, W. (1993). Perspectives on understanding and changing the environments of children with disabilities. Physical and Occupational Therapy in Pediatrics, 13(3), 1-17.

Lee, C. (2003). The Architecture of Aesthetic Music Therapy. Gilsum, NH: Barcelona

Lee, R. R., & Martin, J. C. (1991). Psychotherapy After Kohut: A Textbook of Self-Psychology. Hillsdale, NJ: Analytic Press.

Lyons, R. F. (1993). Meaningful activity and disability: Capitalizing upon the potential of outreach recreation networks in Canada. Canadian Journal of Rehabilitation, 6(4), 256-265.

Magill, J. & Hurlbut, N. (1986). The self-esteem of adolescents with cerebral palsy. American Journal of Occupational Therapy, 40(6),402-407.

Margalit, M. (1981). Leisure activities of cerebral palsied children. Israeli Journal of Psychiatry and Related Sciences, 18(3), 209-214.

McWilliam, R., Bailey, D. (1995). Effects of classroom social structure and disability on engagement. Topics in Early Childhood Special Education, 15(2), 123-147.

Pines, M. (1998). The self as a group: The group as a self. In I. N. H Harwood & M. Pines (Eds.), Self Experiences in Grou: Intersubjective and Self Psychological Pathways to Human Understanding (pp. 24–29). London: Jessica Kingsley..

Pines, M. (1998). Circular Reflections: Selected Papers on Group Analysis and Psychoanalysis. London: Jessica Kingsley..

Pollock, N., & Stewart, D. (1990). A survey of activity patterns and vocational readiness of young adults with physical disabilities. Canadian Journal of Rehabilitation, 4(1), 17-26.

Reisman, J. (1993). Using a sensory integrative approach to treat self-injurious behaviour in an adult with profound mental retardation. American Journal of Occupational Therapy, 47, 403-411.

Robb, S.L. (2000). The effect of therapeutic music interventions on the behaviour of hospitalized children in isolation: Developing a contextual support model of music therapy. Journal of Music Therapy, 37(2), 118-146.

Romer, L., & Haring, N. (1994). The social participation of students with deaf-blindness in educational settings. Education & Training in Mental Retardation & Developmental Disabilities, 29(2), 134-144.

Rosenberg, S., Clark, M., Finkler, D., Filer, J., & Robinson, C. (1989). Project Participate Final Repor.. Winthrop University Project Description, University of Nebraska at Omaha.

Schwellnus, H., Tam, C., Chau, T., Knox R., Johnson, P., & Hamdani, Y. (2002). Using movement to music technology to facilitate play in children with special needs. Occupational Therapy Now, 4(6), 11-13.

Shapiro, E. (1998). Intersubjectivity in archaic and mature twinship in group psychotherapy. In I. N. H. Harwood & M. Pines (Eds.), Self-Experiences in Group: Intersubjective and Self-Psychological Pathways to Human Understanding (pp. 47–57). London: Jessica Kingsley..

Singer, P. (1983) Hegel. Oxford: Oxford University Press.

Spitzer, S., Roley, S.S. et al. (1996). Sensory integration: current trends in the United States. Scandinavian Journal of Occupational Therapy, 3, 123-138.

Strauss, A. & Corbin, J. (1997).  Grounded Theory in Practice. Thousand Oaks, CA: Sage..

Strauss, A. & Corbin, J. (1998). Grounded theory methodology: An overview. In Denzin & Lincoln (Eds.), Strategies of Qualitative Inquiry (pp. 158-183). London: Sage.

Stephens, L. (1997). Sensory integrative dysfunction in young children. Retrieved November 13,

2007 from SEE/HEAR Newsletter. Website: http://www.tsbvi.edu/Outreach/seehear/fall97/sensory.htm

Soundbeam Project (2003.) Soundbeam 2®. Web link: www.soundbeam.co.uk/

Swingler, T. (2003). Electronic music interfaces for people with disabilities: Do they lead anywhere? In G. Craddock et al. (Eds.), Proceedings of the AAATE Conference: Assistive Technology - Shaping the Future (pp. 247-252). Dublin: IOS Press.

Yasuhara, A., & Sugiyama, Y. (2001). Music therapy for children with Rett syndrome. Brain and Development, Suppl. 1, 82-84.

Werner, E. E. (1989). High-risk children in young adulthood: A longitudinal study from birth to 32 years. American Journal of Orthopsychiatry, 59, 72-81.

Wigram, T., Nygard, Pedersen, I., & Bonde, L. (2002). A Comprehensive Guide to Music Therapy. London: Jessica Kingsley..

Winnicott, D. (1965) ‘Ego distortion in terms of the true and false self’. In D. W. Winnicott (Ed.), The Maturational Processes and the Facilitating Environment. New York: International Universities Press.

Winnicott, D. W. (1971). Mirror role of mother and family in child development. In D. Winnicott, Playing and Reality (pp. 111–118). London: Routledge.

World Health Organization. (1997). International classification of impairments, activities and participation: ICIDH-2 Beta Draft. Geneva: World Health Organization.