Autism Spectrum Disorder, Gestalt Language Processing & Music Therapy

When a young child is greeted with your appreciative gesture of saying “Thank you”, they will most likely reply with, “You’re welcome” because they have heard it relayed time and time again by their surrounding adults and peers. In actuality, how long does it take in a child’s development to realize the building blocks of their reply? “You. Are. Welcome.” The shortened response is a script, or a gestalt, being an organized whole different from the summation of its parts (Merriam-Webster). The building blocks of language consist of single words, but for gestalt language processors, chunks of words are used instead. As stated before, many young children use these chunks in communication, as gestalt language processing is a normal part of human language development. However, this is seen more frequently in later years in children with Autism Spectrum Disorder (ASD) (Konyn, 2022).

Social communication with a focus in speech and language impairment is the one criterion of diagnosis in those with ASD (American Psychiatric Association, 2013) that has not changed since Dr. Leo Kanner first created the description of infantile autism in 1943 (Lim, H. A., 2010). Over the years, researchers have suggested that the capacity for pattern perception and production based on the “Gestalt style of language acquisition” has greatly influenced the language development of children with ASD (Prizant, 1987; Prizant et al., 1997). With these deficits in social communication, therapists have long searched for a form of treatment to bypass the gestalt form of language processing to a more analytic form of language processing. From a study conducted in 2010 by Hayoung A. Lim, PhD, MT-BC, NMT, both music therapy and speech therapy share nearly equal benefits when it comes to addressing a child’s language processing and verbal production.

The results of Dr. Lim’s study (2010) showed that the improvements in language processing brought on by music therapy versus speech therapy were not significant, meaning that the findings of both therapies showed similar outcomes. After being scored on the Verbal Production Evaluation Scale (VPES), 50 participants diagnosed with ASD aged 3-5 were separated into three groups: speech training, music training, and no training. After 3 days of training, the VPES posttest was administered, and it was shown that the speech and music training groups had great effects on speech production compared to the no training group. Although Dr. Hayoung listed the difference between music therapy and speech therapy, her study showed that those with music training had a 12.14 point advantage over those who were assigned speech training. A reason for this advantage towards music is a music therapy technique called developmental speech and language training through music (DSLM) that uses rhythmic cueing and pausing in order to facilitate speech through emphasizing target words. Dr. Lim explained another possible reason for the advantage of music in her earlier published article from the Music Therapy Perspectives journal (2009), stating that children with ASD are able to identify and reproduce rhythmic and melodic patterns. Through using these available strengths, music can facilitate speech and language development through DSLM, or developmental speech and language training through music.

The following case study demonstrates the effect of rhythmic emphasis on language in practice:

Patient O is an individual with ASD and is a Gestalt Language Processor receiving music therapy treatment. O has a tendency to break into long periods that he scripts that sometimes have social implications. This is seen for instance, when we sing our goodbye song. After singing, he shows the behavior of scripting, using large chunks of unanalyzed and unorganized language for around 30 seconds, listing different ways to say goodbye. To address his gestalt scripting, we used boom whackers (colored tubes that emit different notes when struck) to separate each syllable in conversational sentences. Prior to the intervention, O took 10 to 15 seconds to commit to an activity, but with the rhythmic cueing offered by the boom whackers and the music therapy intern, he was able to attain his focus and direct his attention solely to the cues, the pitches of the instruments, and the individual parts of the sentences. He was able to read 4 different sentences within 20 seconds, greatly reducing the time that O spent scripting.

-Jackson Arnold, Music Therapy Internn

Works Cited

Konyn, L. (2022, February 8). Gestalt language processing and AAC. AssistiveWare. Retrieved August 22, 2022, from https://www.assistiveware.com/blog/gestalt-language-processing-aac

Lim, H. A. (2010). Effect of "developmental speech and language training through music" on speech production in children with autism spectrum disorders. Journal of Music Therapy, 47(1), 2–26. https://doi.org/10.1093/jmt/47.1.2 

Lim, H. A. (2009). Use of music to improve speech production in children with autism spectrum disorders: Theoretical orientation. Music Therapy Perspectives, 27(2), 103–114. https://doi.org/10.1093/mtp/27.2.103

Merriam-Webster. (n.d.). Gestalt. In Merriam-Webster.com dictionary. Retrieved August 22, 2022, from https://www.merriam-webster.com/dictionary/gestalt

Prizant, B. M., 8chuler, A. L., Wetherby, A. M., & Rydell, P. (1997). Enhancing language and communication development: Language approaches. In D. Cohen & F. Volkmar (Eds.), Handbook of autism and pervasive developmental disorders (pp. 572-605). New York: John Wiley & Sons, Inc.

Prizant, B. M. (1987). Clinical implications of echolalic behavior in autism. In T. Layton (Ed.), Language and treatment of autistic and developmentally disordered children. Springfield, IL: Charles Thomas.

Music Therapy Strategies for Patients with Obsessive Compulsive Disorder (OCD)

As research develops regarding music therapy and mental health, the types of conditions that music interventions can assist with have increased. Obsessive Compulsive Disorder (OCD) is identified in The Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM–5) as having obsessions, compulsions, or both that are time consuming and not attributed to the effects of a substance, medical condition, or another mental disorder. These obsessions, defined as “recurrent thoughts, urges, or images,” and compulsions, defined as “repetitive behaviors or mental acts” such as counting, creating symmetry, cleaning, etc., can impede activities of daily living and cause other mental health conditions such as anxiety or depression (American Psychiatric Association, 2013). While there is not an abundance of research with music therapy and patients with OCD, some strategies have been effective in helping the effects of OCD in individuals. 

In order to address music therapy techniques for patients with OCD, the foundations of general counseling and therapeutic techniques must be considered. Some widely-used treatments for patients with OCD include medication such as Selective-Serotonin Reuptake Inhibitors (SSRIs) and exposure-response prevention, a method of desensitization (Abdulah, et al., 2018). However, other approaches are more applicable to the function of a music therapy session such as the cognitive-behavioral approach of restructuring thoughts to normalize the patient’s view of their condition (Salkovskis, 1999). Instead of invalidating and minimizing the client’s obsessions and compulsions, the therapist should lead the client in the “identification of key distorted beliefs and the collaborative construction of a non-threatening alternative account of their obsessional experience and preoccupations” (Salkovskis, 1999, p. 36). Cognitive-behavioral approaches have been effective in talk-therapy settings, so similar affirming and normalizing counseling techniques should be used to approach music therapy sessions with people with OCD. 

As far as specific techniques, receptive music listening has been a commonality across multiple studies with patients with OCD. Studies have found that “receptive music therapy helped reduce obsessive symptoms with comorbid anxiety and depression” (Truong, et al., 2021, p. 3). The receptive music interventions in these studies took the form of independent listening, lyric analysis, or music relaxation, and classical music was found to be the most effective genre for these types of interventions. The lyric analysis was structured by recalling obsessional thoughts, relating the lyrics to the feelings about their obsessions, and guided-imagery relaxation followed by therapeutic reflection discussion (Shirani Bidabadi, 2015). One study showed a reduction in the severity of overall OCD symptoms in individuals who listened to classical and sleep music for 50 minutes every day independently (Abdulah, et al., 2018). All of these treatments were used as adjuncts to other therapy and medication approaches. However, implementing them into sessions with patients with OCD, even if their primary goal is not related to this diagnosis, can help regulate the client so they can achieve their other goals.

Receptive music therapy approaches have been more researched with this population; however, active interventions such as “improvisational music therapy might also alleviate symptoms in OCD patients” (Truong, et al., 2021, p. 3). Allowing music improvisation within a session when someone is expressing obsessions, exhibiting compulsions, or experiencing anxiety or distress can potentially improve the outcome of the session and achievement of session goals. Providing support for patients with OCD through music therapy interventions can reduce the impact of the symptoms so the patient can resume daily and social activities more easily (Abdulah, et al., 2018). While the established techniques to implement with clients with OCD are limited due to the scarcity of research, music has a definitive impact on the symptoms related to OCD and can be implemented to improve the effectiveness of treatment. 

-Tess Vreeland, Music Therapy Intern

References

American Psychiatric Association. (2013). Obsessive-Compulsive and Related Disorders. In Diagnostic and Statistical Manual of Mental Disorders (5th ed.). 

Abdulah, D. M., Miho Alhakem, S. S., & Piro, R. S. (2018). Effects of music as an adjunctive therapy on severity of symptoms in patients with obsessive-compulsive disorder: Randomized controlled trial. Nordic Journal of Music Therapy, 28(1), 27–40. https://doi.org/10.1080/08098131.2018.1546222 

Salkovskis, P. M. (1999). Understanding and treating obsessive—compulsive disorder. Behaviour Research and Therapy, 37, 29-52.

Shirani Bidabadi, S., & Mehryar, A. (2015). Music therapy as an adjunct to standard treatment for obsessive compulsive disorder and co-morbid anxiety and depression: A randomized clinical trial. Journal of Affective Disorders, 184, 13–17. https://doi.org/10.1016/j.jad.2015.04.011 

Truong, T. P., Applewhite, B., Heiderscheit, A., & Himmerich, H. (2021). A systematic review of scientific studies and case reports on music and obsessive-compulsive disorder. International Journal of Environmental Research and Public Health, 18(22), 1-23. https://doi.org/10.3390/ijerph182211799

Music Therapy for Emotional Perception & Expression with ASD

While many goals are addressed and specific to the individual person in a music therapy session, social skills are one of the primary goal domains for people with Autism Spectrum Disorder. The Diagnostic Statistical Manual of Mental Disorders (5th ed.; DSM–5; American Psychiatric Association, 2013) lists the first diagnostic criteria as deficits in social-emotional reciprocity “ranging, for example, from abnormal social approach and failure of normal back-and-forth conversation; to reduced sharing of interests, emotions, or affect; to failure to initiate or respond to social interactions.” Within this social skills goal domain, emotional perception and expression are more specific goals that assist with socialization with peers. Research shows that music therapy is beneficial in addressing  nonverbal emotional skills, appropriate expression, and other skills within this social-emotional domain (Reschke-Hernandez, 2011).

The types of interventions to address the emotional aspect of social skills with people with ASD has shifted and expanded throughout the years with more research and practical application. Music is often used as a carrier of nonmusical information that is more engaging than spoken word. Because individuals with autism “respond more frequently and appropriately to music than to other auditory stimuli,” important social cues are more easily perceived through this mode of communication (Bownell, 2002, p. 123). This increased responsivity supports the use of music accompanying social stories to directly teach appropriate perception of emotions in relatable scenarios. Social stories have also been found to be effective in shifting behavior to prompt appropriate responses. A social story is a short, individualized text that describes an event or social situation in detail using images, printed words, and verbal explanations to provide instructions on how to appropriately respond to that situation (Brownell, 2002). The use of music to accompany these stories aids in retention of the concepts discussed because “the ability for musical recall may provide another avenue by which these students may remember and incorporate vital information” (Brownell, 2002, p. 141). 

Nonverbal communication, whether it is in the timing, facial expressions, or body language, can be an area of difficulty for people with ASD (Katagiri, 2009). Interventions that emphasize these nonverbal aspects of communication can improve the overall perception of emotions in a reciprocal conversation. The use of visual aids, flash cards of moods and facial expressions, and photographs has been found to assist with this direct explanation of the more indirect nuances of communication (Reschke-Hernandez, 2011). Drawing attention to and discussing the images and facial features associated with specific emotions can create connections and help recognize patterns for social interaction.

Researchers have also seen improvements in emotional perception through the use of correlated background music when discussing emotions or social stories attached (Katagiri, 2009). The auditory cues in the music such as tempo, dynamics, and instrumentation contribute to the understanding of the emotion being discussed. The musical delivery of the lyrics also improves the perception of the emotional meaning due to the engaging and multisensory qualities. Specifically negatively associated emotions such as anger and sadness were found to be perceived the most strongly through the use of background music interventions (Brown, 2016). 

Music has proven to be a successful method of improving emotional perception and expression in people with Autism Spectrum Disorder. Having this emotional reciprocity is important to daily living and interactions with others. Whether this is in casual social interactions with family or friends, or it is in a more formal educational or employment setting, fostering connections with others and being able to more easily express oneself benefits all people involved. Music therapists are integrating different interventions into their sessions with people working on these specific goals, and the research is growing to expand on the possibilities for finding more effective methods of connection through the medium of music.

References

American Psychiatric Association. (2013). Autism Spectrum Disorder. In Diagnostic and statistical manual of mental disorders (5th ed.). 

Brown, L. S. (2016). The influence of music on facial emotion recognition in children with autism spectrum disorder and neurotypical children. Journal of Music Therapy, 54(1), 55-79. https://doi.org/10.1093/jmt/thw017 

Brownell, M. D. (2002). Musically adapted social stories to modify behaviors in students with autism: Four case studies. Journal of Music Therapy, 39(2), 117–144. https://doi.org/10.1093/jmt/39.2.117 

Katagiri, J. (2009). The effect of background music and song texts on the emotional understanding of children with autism. Journal of Music Therapy, 46(1), 15–31. https://doi.org/10.1093/jmt/46.1.15 

Reschke-Hernandez, A. E. (2011). History of music therapy treatment interventions for children with autism. Journal of Music Therapy, 48(2), 169–207. https://doi.org/10.1093/jmt/48.2.169

Meet Laura!

Hello everyone! I’m Laura Sidwell, one of the new music therapy interns with Therabeat, Inc. I am beyond thrilled to be learning alongside this incredibly talented team of music therapists, and to be a part of the phenomenal experiences created within In Harmony Pediatric Therapy. I am currently in my last step of completing my Bachelors Degree in Music Therapy at Berklee College of Music where I have spent the last four years in Boston, though I grew up right here in the North Atlanta suburbs. I am excited to be back in my hometown following a career path of which I am so passionate, at such an amazing facility. My main instrument is voice, and I also play piano, guitar, ukulele, and percussion. Other than playing music, I enjoy creating arts and crafts, practicing yoga, dancing, and spending time with family and friends.

I have always loved music and have been singing in the car for as long as I can remember. I grew up playing piano from a young age, and eventually started singing lessons as I fell into a love for musical theater and performing. My life has always oriented around a love for playing music and it has always kept me going through any up or down. I also have a very compassionate heart, and love being able to help others. I always knew I wanted to work in a field that involves helping people, but another part of me always wanted to keep music in my life. It wasn’t until I was in high school that I discovered the field of music therapy, and it took less than an instant for me to realize that it’s what I’m meant to do. I love being able to share my passion for music in a way that is able to help others in so many therapeutic goal areas, and I am so looking forward to expanding my knowledge and experience over the next six months.

So far my experiences with Therabeat, Inc. have been nothing short of wonderful. Being introduced to so many gifted students and staff members over the first couple weeks has been overwhelmingly exciting! My highlights so far have included helping with last week’s summer camp, meeting so many new people, and observing music therapy sessions as well as other therapies. I feel so lucky to be working in such a well-rounded therapeutic center that includes so many different modes of therapy treatments. I have loved observing the way therapies connect and use their different modalities to work together on achieving a child’s goals from different angles, and I am looking forward to opportunities to observe co-treatment sessions. I can't wait to continue to expand and strengthen my clinical musicianship, and gain more hands-on experience throughout this incredible internship opportunity!

MEET JACKSON!

Hello! 

My name is Jackson Arnold and I am one of the new music therapy interns at Therabeat, Inc.! I am so excited and grateful to start my journey here at the In Harmony Pediatric Therapy offices, and if these first two weeks are any indication of how great the next six months will be, we are all in for an informative and inspirational adventure for sure!

Although I was not aware that Music Therapy was a career option when I was young, you could easily say that I have been preparing for this career my entire life, starting with my love for music. Growing up, our house was always filled with music, and usually filled with my family singing or dancing along to the music! From there it was singing in church, and school, and then band, then elementary choir, then musicals, then marching band, then college choirs, then opera, then piano, then guitar…and even to this day, I am still learning and soaking up all the music my heart and soul can hold! 

Early in my senior year of high school, I was introduced to a very special person that opened the most amazing door to the path that would allow me to follow my passion (music) and my purpose (caring for others) as a career in music therapy! While researching the educational path for a music therapist, I was simultaneously learning to navigate a (then) recent diagnosis of Type 1 Diabetes. After being accepted to multiple universities, I decided with the support of my family to stay close to home and attend Kennesaw State University for the initial two years of college while I acclimated to the diabetic lifestyle. During my time at KSU, I immersed myself in their choral music education program, participating in multiple vocal education studies, chorus groups, and one of my favorite experiences–opera. When my second year was underway, I knew that it was time to start making preparations to transfer into a music therapy program, which was not offered at Kennesaw State. Forever grateful for my experience at KSU (Hooty-Hoo!), in the fall of 2020 I transferred to begin my coursework and clinical experience in music therapy, officially making me a Georgia Bulldog (Go Dawgs!).

As I continued my education at UGA, I began my clinicals and participated in additional music therapy opportunities, I was further convinced that music therapy was the perfect fit for me. Every opportunity to engage with another individual or group through music continues to solidify what I know to be true, that music reveals (memories, skills, stories), heals (pain, trauma, hurdles), and gives us ALL the feels (so many emotions)! And quite simply–music makes the world go round!

So now my coursework at UGA is complete, I have walked across the stage during graduation, and now all that is left to complete my formal UGA Music Therapy degree is a six month internship with Therabeat. My experiences so far have been incredible, participating with some amazing people in music camp. In addition to this, I was able to observe not just the wonderful music therapists, but some of the amazing interdisciplinary teams as well, including physical therapists, occupational therapists, and speech therapists! The amount of skill and dedication in this team of many talents is truly astonishing and I am so lucky to say that I am a part of the Therabeat and IHPT teams!

Can’t wait to see you at Therabeat!

~Jackson Arnold