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Differential diagnosis of autism and other types of disability.

Keynote Address: Australian Music Therapy Association 17th Annual Conference, Sydney 27-28 September 1991

In Butterworths' Medical Dictionary, Second Edition, the term diagnosis is described as "the art of applying scientific methods to the elucidation of the problems presented by a sick patient. This implies the collection and critical evaluation of all the evidence obtainable from every possible source and by the use of any method necessary". So now, for decades after the introduction of music therapy into the medical and paramedical situations, there is increasing evidence and examples of its application as an assessment procedure as part of the diagnostic process.

It is in fact one of the "methods" this text refers to as a possible source of additional or complimentary information to support or to negate a diagnosis. The text goes on to say "from the facts obtained, combined with a knowledge of basic principles, the concept is formed of the etiology, pathological lesions and disordered functions which constitute the patient's disease. This may enable the disease to be placed in a certain recognised category but, of far greater importance, it also provides a sure basis for the treatment and prognosis of the individual patient" (Butterworths 1978).

In this context therefore, music therapists working individually or alongside other members of a team not only have a role in helping to assess and diagnose the nature of a client's problem, but also to provide a recommendation for treatment. Increasingly in the United Kingdom, there is a requirement for these recommendations to be clear, clinically appropriate and with some evidence of assured outcome. Butterworths also makes reference to "differential diagnosis", and describes it as a process involving "the recognition of a particular condition from amongst those which closely resemble it in certain respects".

This paper concerns the role of music therapy in the process of assessment and diagnosis, and particularly in the process of differential diagnosis. Although it focuses on patients with developmental disability, and in particular communication disorders, the whole process of applying music therapy as a model of assessment and diagnosis can be considered from the methodology which is described in this paper. Application in the field of mental health or general medicine will obviously highlight some differences, but the fundamental principles are the same.

It is the responsibility of the music therapist to examine through the process of music therapy assessment the behaviour, physical status and emotional state of the client referred, and to produce evidence of the nature of that person's difficulty or disorder.

Grant (1991) commented in his paper On music therapy assessment for developmentally disabled clients that "music therapists can not afford to stand aside and wait for other disciplines to do the assessing and programme development, hoping that we can fit in somewhere and make the children happy". His paper on assessment process identifies specific areas in which the music therapist can make a specific contribution in an overall evaluation: sensorimotor; cognitive, especially in the areas of visual and auditory perceptual skills; communication; and social. His paper goes on to describe a detailed process of assessment including a range of practical techniques for evaluating the child's abilities and disabilities. In other situations, the assessment can be quite different. Coming to conclusions through music therapy assessment sessions on the emotional state of the patient, their mood, their relationship with other patients, relationship with people they know, their perception of people they know, and particularly understanding unconscious material and the hidden sides of a person's character and personality will form separate and less measurable aspects of an assessment, but equally important. Assessment of musical output and in particular considering the nature of a patient's music in relation to their problem or disorder is increasingly an explored part of music therapy process. In the Improvisation Assessment Profiles (Bruscia, 1987) the process involves observing a client under various conditions musically, analysing the improvisations using profiles and sub scales provided, and then interpreting the findings according to psychological theory relevant to the nature of a person's disorder. Looking at purely musical material, Sikstrom and Skille (1991) describe a process of a musical skill test, which can be used with normal and handicapped children.

Processes of assessment and diagnostic evaluation require from the therapist a different protocol and procedure than a conventional therapy treatment session, or even a conventional music therapy assessment (Wigram 1990). To be clear about this, one has to look at the purpose of the assessment which is to:

* evaluate with music the nature of the disorder;

* to identify the child's responsiveness;

* to highlight and identify the nature of resistance;

* to look at positive and negative response;

* to identify the appropriate therapeutic approach and evaluate its benefit.

In order to obtain the information that is so vital for a clear understanding of the child's needs, and also essential in determining the value of a therapeutic approach, the therapist has to adopt a number of different approaches to the child during the course of the assessment process. At Harper House (by reason of the fact that the children often come from all over the country) this may have to happen in the course of one day, but often it is more preferable if it can take place over two or three assessments. This paper will look at three individual cases that were referred to the Harper House Children's Service for assessment. Before discussing those cases, it is important to explain the elements that I have considered essential in the assessment process I have developed for differential diagnosis at Harper House. Without categorising these elements in any particular order of importance, I am concerned to explore firstly the child's response to close contact and interaction; secondly, their response to distancing; thirdly, their response to structure or to a free environment; fourthly, their response to intrusive intervention and pressure; and fifthly their response to an imitative and intensive interaction. The investigation also includes looking at the child's response to conventional musical material, e.g. pre-composed music, nursery rhymes, television tunes that may be familiar. Secondly, to investigate their use and response to instruments, particularly their handling and purposeful use of musical instruments. Thirdly, to investigate the child's verbal, vocal and gestural communication skills, and using music as a means of assessing their sociability, appropriate language, comprehension and interactive skills. Fourthly, to assess their responsiveness to sound generally, with consideration to any evidence to hyperacusis pseudohyperacusis sensitivity or preoccupation. And finally, and perhaps most important to assess ways in which the child functions well that are inconsistent with the existing evidence of a disorder or disability.

Differential Diagnosis of Autism

The Harper House Children's Service is a specialist agency which functions as a national assessment and diagnostic service in Great Britain, evaluating the disabilities of children who have come with their parents for help. Because communication disorders within the field of developmental delay is so difficult to diagnose, front-line agencies such as general practitioners or community paediatricians are either reluctant to categorize or label a child, or on the other hand may give an intimation the child has specific features, for example of autism, thus suggesting to the parents that this is the direction in which they should look.

This paper examines the problems by looking at the musical behaviour and the musical responsiveness of children as one means of providing some information to support or not to support a specific diagnosis. The Harper House Children's Service consists of Doctors, Psychologists, Physiotherapists, Social Worker, Music Therapist, Art Therapist and Speech Therapist, and all the professionals play a role as a team in trying to unravel the very confused picture many of the children who are referred present. The late Dr Derek Ricks founded the Service, and the ethos he created within the Team, which still persists, was to put the parents at the centre of what was happening and work all the time with their co-operation. Ricks' own work looked specifically at verbal and pre-verbal communication (Ricks, 1975, 1978). Ricks believed that there were several aspects of diagnosis:

1. Finding out from the parents what they feel to be the matter with their child.

2. Attempting to discover or extending the evidence of his/her actual disability.

3. Presenting this evidence in as coherent a form as possible to the parents in an effort to reconcile what they feel to be wrong with the evidence available.

4. Thereby to equip the parents better to choose among several options available to their child.

Wing, Ricks, Newson and many other clinicians have become well aware of the complexities and diversities of the disorder known as autism (Wing 1976, 1979, 1981). The Autistic Continuum (Wing, 1988) has become a means of sifting out from the evident disability the degree of severity in the child. Many children present with autistic features and it is essential to identify the exact nature of their disability.

In the process of evaluating autistic disability in children for example, one is looking particularly for some impairment of social recognition, impairment of social communication and impairment of social imagination and understanding. At either a severe or mild level, all of these factors must be present for a diagnosis to be made of a disorder within the Autistic Continuum. Many children present the features of autism which are also features of other sorts of disorders and should be treated with some care until an overall survey concludes that there are enough evident features of autistic disability. Children may typically come to the Harper House Service described as isolated, withdrawn, with deviant behaviour and poor language development. Because these features are also compatible with autistic disability, one should not necessarily ignore the fact that the child may have an expressive or receptive dysphasia coupled with a developed behaviour problem which causes them to present as autistic children. Similarly, children I may present with unusual manneristic behaviour, obsessions, and a one-sided response to both their peers and to adults, whereby they may talk without listening.

Within the Autistic Continuum one could identify such children as at the mild end, possibly bright children who have late onset disability. However, they could also be considered as having some of the clinical features of Asperger syndrome (Wing, 1981), which seems to be gaining recognition as a sub-set of autism but with different problems and a different prognosis. Children with dyspraxia can present with very particular behavioural disorders and they make considerable efforts to disguise or cover up the evidence of the features of the problem, which are concurrent with a focal abnormality in the brain, and which makes it so difficult for that individual to perform a contemplated act. Dyspraxia often demonstrates itself as a disorder of a voluntary act.

The differential diagnosis of autism and other handicaps associated with developmental language delay was described by Patricia Howlin (1988) who considered that "the important point to bear in mind is that accurate diagnosis cannot be reached on the basis of one or two isolated symptoms. It is how symptoms cluster together and the patterning of deficits and skills that are the crucial factors for diagnosis ...". Other confusions can arise over bright autistic children who have been confused with maladjusted children, or autistic children who are so disabled, and have so many additional defects, that they have been regarded as a mobile, profoundly retarded child. We are also beginning to find quite a group of children who appear to be quite normal early on, then develop some autistic "tendencies", but subsequently recover some degree of normality although remaining mentally handicapped. Finally, one can encounter children who are frequently described as autistic when they are referred, but in fact have other serious communication handicaps.

Unravelling the mystery of these damaged children is often a confusing and complex process for the professionals who are well skilled and experienced at doing it, so this must be magnified ten-fold for parents. Some parents actively seek a label of autism for their child, either because they are beginning to despair that anybody can clearly identify what is wrong, or because autism may seem to them to be a more acceptable or optimistic diagnosis than mental handicap or retardation. Other parents, when it is first indicated to them that their child may have autistic features, avidly read everything they can find on the subject and subsequently realise that autism is a very disabling disorder, and the prognosis can be extremely bleak. Parents who research the literature in the hope of understanding their children better often find themselves interpreting many of the child's behaviours as "autistic features". One also has to bear in mind that almost all children display autistic features as they grow up i.e. they become very preoccupied with doing one thing over and over again, or for a need for security they like to do things in the same order and can become upset if their order is disrupted. However, for most normal children, or non-autistic children, these features are only transient and they fade as the child grows up and adapts to new situations and new people. With autistic children, however, these features remain and are often exaggerated in their manifestation.

In undertaking assessment work through music therapy, one has to consider a number of factors in terms of the child's general interaction and response, the abnormalities in their behaviour, their music behaviour and their general physical activity. One cannot ignore that in any assessment process in music therapy it is inevitable that one will see features of the disability or the pathology of the disorder in the musical behaviour, and it is important to isolate that and identify it in order to be clear about diagnostic evidence. It is equally important to isolate and identify evidence of normal musical behaviour or normal musical skills that are inconsistent with some diagnostic suggestions that may have been attached to an individual, and to write as accurately and eloquently about the abilities and responsiveness of an individual as one does about their limitations (Wigram, 1989).

The value of music therapy assessment was once described on BBC 2 by the late Dr Hugh jolly, Consultant Psychiatrist and Paediatrician, at the Chafing Cross Child Development Centre. He estimated the value of a music therapy assessment as giving valuable evidence of what a child is able to do, and perhaps more importantly placing the child in a situation where, through the medium of music, they can be more in control, and even "musically direct" the behaviour of an adult. The interactive feature of a music therapy assessment is going to give a clear indication of the child's receptive skills, their expressive skills and non-verbal relationships. But it will also give evidence of behaviour disorder, rituals or routines, lack of creative play and abnormal interaction that people would associate with autism.

More specifically, the assessment work the author has developed in music therapy as part of a multi-disciplinary evaluation where a diagnostic opinion is required, always includes a close look at the way the child responds or behaves under the following four headings:

General Interaction and Response:

Focus

Attention

Diverting behaviour

Body awareness

Response to physical contact

Remoteness

Excessive friendliness

Response to direction

Ability to initiate and direct

Impaired sociability

Lack of awareness of life patterns of normal interaction

Using people as objects.

Abnormal Communication and Behaviour:

Language delay

Excessive dysphasia

Receptive dysphasia

Facial expression

Rigid and inflexible thought process

Resistance to suggestions

Talking without listening

Talking without waiting to answer

No desire to communicate

Using people as objects.

Musical Behaviour:

No concept of rhythm and tempo

No concept of playing with therapist

No concept or limited awareness of turn taking

Using musical equipment inappropriately

Transference of behaviours or features of pathology into musical behaviour

1. Manneristic behaviour (twiddling, fiddling, twirling, plucking, spinning).

2. Obsessive behaviour (sequencing, orienting to specific sounds continuously, perseverating

and organising the therapist to respond in particular ways).

Physical Activity and Behaviour:

Balance and posture

Dexterity

Handling equipment

Handedness

Synchronicity

Deviant ambulation

Clumsiness.

Looking in more detail at some specific cases, one can begin to find evidence in the behaviour of the child in the music therapy session which, together with observed evidence from other therapeutic assessments, adds weight to a clearer diagnosis. Many children who are referred to the Harper House Service (and probably to many other services in the country as well as to the individual practitioners) come with a questionable diagnosis of autistic disability. Because we are beginning to discover the wide variety of disabilities that come within the Autistic Continuum, and are also beginning to take into consideration late onset autism, and the confusion between autism and closely related syndromes such as Asperger, this label can be inappropriately given.

Case Study 1

Allen presented as a child with a withdrawn and isolated manner. He had poor eye contact, poor comprehension and a clear and severe communication disorder which persisted despite progress in other developmental areas. In addition, he had middle ear problems, and it was very difficult to disentangle the nature of his disorder as comprehension, expression and symbolic play appeared to be delayed to roughly the same extent.

In the Art Therapy assessment, Allen did show some communicative intent, particularly at the beginning of the session. He used art materials but did not explore their use for very long and avoided the therapist for much of the time he was in the room. He was cabable of some interaction, marking round a circle that the therapist drew, and imitating the "cleaning" as well as imitating the use of the brush.

In the Music Therapy assessment, Allen wandered around the room, initially ignoring most of the equipment. Attempts to engage him by offering him sticks didn't work, and he discarded them. A game of "Peek-a-Boo" gave us the first clue that Allen's interactive skills were certainly a similar to those one might expect in a child with autistic disabilities. However, he did target on a length of "plastic binding" which he found in the room and he fiddled with this several times during the session, holding it near his ear. Eventually we had to withdraw it and hide it as it was interfering with any attempts to engage him. He didn't object to things being taken away from him, such as this piece of "play material" that he was fixating on.

Musically, there were short periods of interaction when he was playing the drum, and also when he came over to play the piano. He did seem quite interested in the piano, and using two or three fingers of each hand he played "randomly" on the notes for about one and a half to two minutes without having to be encouraged to continue. He did on several occasions respond to instructions, although he rejected quite a lot of suggestions during the course of the session. If I handed him a beater and pointed to an instrument and asked him to hit it, he would do so. He seemed to understand the game of "turn-taking" and responded when I said that it was "his turn to play".

On some occasions I had more success in engaging him in an activity when I contained him in one place (i.e. on a chair) long enough for him to start using the equipment.

His vision appeared normal and he seemed to be able to hear well. However, there were several examples of him putting his hands over his ears, and on one or two occasions he showed a small anxiety of extremely loud sounds. His parents reported that he has a sensitivity to certain sounds, for example the sound the computer makes in the television game "Family Fortunes"; when he hears this he screams and becomes upset until the television is switched off. However, they also commented that he likes some of the other computer sounds in other quiz games on television.

From this, one is beginning to build up a picture of a child whose resistance to activity, resistance to engagement and peculiarities are not consistent or sustained, and although he presented with many of the different features of "funny behaviour" and resistance one might expect in an autistic child, he did not have the complete inaccessibility at a sustained level which one normally encounters.

The main difficulty seemed to be that he was unresponsive and had difficulty in being able to join in and make use of the situation at all. On the very few occasions in this assessment that I explored a therapeutic approach that I would use with him (i.e. containment, structure, etc.), it became apparent that one would need to develop a very structured style of session, and the need to use a fairly intrusive style of work would probably result in much better responses.

Although there was very little speech and he cut himself off from us frequently through the session, refusing to respond to our pleas for him to come and play or do something with us, he was an accepting little boy with whom quite a lot of work was possible. He seemed well able to take a certain amount of pressure and persuasion to be involved in activity and interaction, and this should be capitalised on.

Subsequent visits to Allen's home and Allen's Nursery Group impressed us, and we were able to observe him amongst a normal peer group. He seemed very attached to his Welfare Worker and was co-operative in structured play activities. The Nursery said that they tried to keep a balance between free play and more structured activity, and this seemed to work well for Allen. Whilst he does like to wander off in a rather absent way, he did show signs of beginning to be interested in activities and exploring. When visiting the Opportunity Class, he appeared tired and unwell and yet was able to co-operate in a "functional learning session", albeit with very little enthusiasm or interest. He seemed to be aware of our presence and looked at us watching him, although there were no signs of recognition that we were the two adults he had seen the previous day.

He was more enthusiastic in the home environment and we were able to observe some delightful play between Allen and his father.

The general consensus from the clay assessment was that Allen was fairly difficult to interest and engage in constructive activities. There was no evidence of expressive language in his sessions although some musical interaction had been noted and there were signs of communicative intent in the art session.

To this end, the team had concluded with the parents that they were no longer considering Allen's difficulties in terms of autism, giving a more hopeful prognosis for future development. Allen was three and a half years old at the time of the assessment, and by this age should have identified autistic disability, unless this was a case of late onset autism.

Case Study 2

Simon was a five year old with obvious communicative disabilities, and he was referred to the Service for a second opinion on autistic disability, a diagnosis which had caused varied opinions during the educational statementing process. With Simon, the problems of differential diagnosis presented difficulties particularly in terms of the inevitable overlap between children presenting with autism and those presenting with specific expressive or receptive language disorders. In the final report, the doctor pointed out that Simon's "symptoms" clustered together, and that on the basis of early history, Simon showed clear impairment in social interaction, and in verbal and non-verbal communication and social imagination. Yet in terms of social imagination, he had moved on from rather repetitive lining up of bricks along window sills at 2 to 2.6 years of age, to appropriate use of toys such as bricks, trains, garages and cars, and is now able to play creatively and widely with these but shows more limited pretend or symbolic play with other toys. At Harper House, he tried to give a soft toy dragon a ride on the rocking horse. He is able to copy the symbolic play of others more readily than spontaneously initiating his own.

In the music therapy assessment, he initially became preoccupied with the process of being videoed and put on a performance for the camera. Initially, he appeared indifferent to playing the instruments, and attempts to encourage him to sit on the floor and work from behind resulted in him wriggling away. He did reach out for the drumsticks, and he began to play when I offered him a large tambor. I used the tune "Three Blind Mice", and he smiled and became excited when the music went faster, switching the beater to his right hand and playing vigorously.

He continued to play the drum for five to six minutes, and although I encouraged him to use two beaters, he preferred one. He started a game using his feet and pushing the tambor which I was holding. This resulted in me "falling backwards" which he found very amusing and laughed loudly.

Moving on to the piano, he started three quarters of the way up the instrument and worked carefully down, playing every white note in sequence. He was very careful not to miss one out, and he had to reach right over me to get to the very bottom notes. In fact, he was almost lying across me to reach down to the very end of the piano. He then began to work all the way back up again to the top.

The session continued with Simon reverting to the television, and also resisting using some of the instruments. He found the large toy train in the room and began pushing it around. When using the cymbal, he found that he could balance it with his foot and hit it against the piano. He carried on playing the cymbal in this way, and on occasions he would glance across at me and smile while he was playing. It was, however, difficult a lot of the time to tell whether he was playing with me or just playing by himself.

Finally, he started to withdraw into himself, lounging on the floor. He crawled over to the train again and began to fiddle with the raised lettering on the back of the train which reads "Baptist Church, St Albans, 1983 CWP". He began to work with his thumb around the letters, starting at the bottom and working all the way up a line at a time. He then ignored any effort at communication that we were making, and when he got to the last letter of the top word he simply began to go all the way back again.

It is easy to see from the described behaviours in this session that Simon presents as an unusual little boy who at one moment could be responsive and interactive, smiling and responding to instructions, and at the next moment would either be very resistant and opting out or ignore one completely. Repetitive patterns of self-chosen activity were evident both in this session and in other sessions with other therapists. In terms of language, Simon showed limited skill and quite a lot of echolalic acquisition. He had good memory skills though, and also good fine motor or manipulative skills. The mixed picture we obtained was of a little boy who was most responsive when rigidly or firmly structured and yet who could also show considerable flexibility. Looking at the overall picture presented, in terms, particularly of reciprocity in social encounters, level of symbolic functioning, communicative intent and use of non-verbal forms of communication (gestures, facial expression) in initiating and maintaining social contact, Simon impressed us as an autistic child rather than as a child with specific language disorder.

Case Study 3

Sarah is a ten year old child who came to Harper House for an assessment when she was seven years old. She had previously been assessed in some depth at a Child Assessment Centre where they concluded with a diagnostic opinion that she was an autistic child. She has an older and a younger brother, all three children being delivered by Caesarian section. There were no neo-natal problems and she seemed to develop normally, feeding well and with no adverse reaction to the normal immunizations. Between 15 and 18 months she started to become detached and fretful, showing irritable behaviour, becoming upset (particularly in unfamiliar places) and often screaming. Up to this point she had produced normal babble, and also started to develop a few words, drawing attention to events and interests such as cats or lights.

Her parents began to become worried, particularly as Sarah continued to be fretful, seemed to have no development of vocabulary, and often roamed around randomly in an agitated way. After her second birthday she started to become even more remote and self-contained, sitting passively doing repetitive, pointless activities such as pulling off leaves or handling objects repetitively. Her hearing appears intact, but her listening seems to be selective, and in terms of communicating her needs she tends to pull people towards what she wants and then point out the objects. By the time she came for her assessment at Harper House, she still had quite limited self-held skills and although she was able to feed herself and help with dressing, she was not toilet-trained.

In this case, a music therapy assessment was followed by a series of music therapy sessions which are still continuing. Her general behaviour, and more specifically her musical behaviour and responsiveness, are much more typical of Rett's Syndrome (Rett, 1961; Hagberg, et al, 1983; Ker, A. & Stephenson, J., 1985, 1986) than of Autism. Although many of the disabilities that she appears to suffer from may also be attributed to autism, her ability to make personal contact is much more direct than is typical in autistic children. She is often very quickly stimulated and attracted by musical sounds, and enjoys engaging with the therapist in musical games (Montague, 1988).

In the assessment session and in subsequent music therapy sessions, Sarah did present with typical patterns of hand movements that are characteristic of Rett's Syndrome. She clapped her hands together, occasionally tapping her face with them particularly round the mouth, and she had only limited hand use in the early sessions. She was most adept at picking items up, and depositing them with the therapist. She was not easily encouraged to play anything and when given beaters or sticks to use on the instruments she would quickly discard them. She often reached out to grab things and then pushed them away. Her ability to use her hands constructively was definitely impaired by her continuous plucking, and it has only been over the course of several therapy sessions that we have been able to see some change in this. Initially, by holding one hand apart and insisting that she used the other purposefully, we were able to break through the repetitive plucking movements and give her some structured use of her hands for a specific purpose.

The results of this process have been that she now will hold beaters for quite long periods of time, and use them appropriately.

Sarah has not as yet shown any indications of the atrophy one expects in the lower limbs typical of Rett's Syndrome. She is very agile, moves around quickly and prefers either to stand and move around the room or lie, rather than sit. She makes a variety of different vocal sounds, and it is possible to engage her at purely vocal levels. She will quite often gaze at you and make giggling or cooing sounds in response to similar sounds from a therapist, but she can also make distressed whining sounds when she is upset and is beginning to articulate words. We have definitely heard her use "go" and "bye-bye". She also tries to say "Mum" and other single syllable words. Sustained music therapy sessions over the last few months have resulted in much more positive activity by Sarah. She now uses both her hands, whereas previously she could only be encouraged to use one. Part of the therapy process involved disrupting her repetitive activity and eliminating her habit of discarding objects indiscriminately. She has first been encouraged to pick up any object that she discards and give it to the therapist and this ultimately has resulted in her handing items to the therapist before she discards them. She can now be engaged in musical interaction using various instruments scattered throughout the room for up to ten minutes, and her level of interaction is very much to the therapist's stimulus. The success of this process has partly been due to careful structuring and insistence on the part of the therapist, but also due to the ease with which one can engage Sarah at an interactive level, particularly through the medium of a musical "game". It would have been a very different situation if her disabilities had been primarily autistic.

Conclusion

The therapist is attempting to explore and evaluate the nature of the child's disorder and be clear about his/her level of responsiveness and functioning, and in so doing make comparisons both with an accepted norm and also children with similar disabilities. The process may involve assessing the child's responsiveness to a therapeutic approach and even evaluating and speculating on the nature of a potential therapeutic relationship. However, assessment does not entail or require the therapist to operate with the child in the same way as they would do within a normal therapeutic relationship begun and sustained during a course of therapy sessions. In fact, it is more frequently desirable that the therapist retains an objective and evaluative stance when undertaking the process of diagnostic assessment, even though information may equally be gained from undertaking a more typically music therapy type of session. The reasons for this are that one needs to cover a broad spectrum within an assessment and be concerned with evaluating all aspects of the child's abilities and disabilities. In order to provide information and give an overall picture that can correlate or provide differential evidence to other assessments, the therapists may need to use many different approaches, and explore different facets of the child's character and personality. There is no reason why this cannot be done in a therapeutic and sensitive way but it probably needs to be done without the approach and aims of a therapy session.

In conclusion, these three quite different cases show how, in the process of assessing musical behaviour and musical responsiveness, one can tease out evidence of abilities, skills and characteristics of personality that are atypical of autism. Both Hugh Jolley and Derek Ricks have commented that the value of an assessment through the medium of music, by a music therapist, is enabling a child to demonstrate what they are able to do, much of which may have been hidden in other assessment work.

Language delay or disorder causes communication disabilities that are often confused with similar disabilities of autistic children, and perhaps the main value of the music therapy assessment is in reaching the child at a non-verbal level and enabling them to present their true potential interaction through this medium.

References

Bruscia, K. (1987). Improvisational models of music therapy. Springfield, IL.: Charles C. Thomas Publishers.

Grant, Roy E. (1991). Music therapy assessment for developmentally disabled clients. In Music and the healing process: a handbook of music therapy. Editors Wigram, A., West, R., Saperston, B. (1991). Carden Publications. (In Press)

Hagberg, B., Aicardi, J., Dias, K., & Ramos, O. (1983). A progressive syndrome of autism, dementia, ataxia and loss of purposeful hand use in girls. Rett Syndrome: Report of 35 cases. Annals of Neurology, 14: 471-9.

Howlin, P. (1988). The Differential Diagnosis of Autism and other Handicaps Associated with Developmental Language Delays. Published by The National Autistic Society, 276 Willesden Land, London.

Kerr, A. & Stevenson, J. (1985). Rett Syndrome in the West of Scotland. British Medical Journal, 291: 579-82.

Kerr, A. & Stevenson, J. (1986). A study of the natural history of Rett Syndrome in 23 girls. American Journal of Genetics, 24: 77-8:3.

Montague, J. (1988). Music Therapy and the Treatment of Rett Syndrome. Leaflet published by the UK Rett Syndrome Association, Glasgow, England.

Rett, A. (1966). Uber ein cerebral atropisches Syndrome bei Hyper-ammonamie. Vienna: Bruder Hollinek.

Ricks, D. M. (1978). Making sense to make sensible sounds. In M. Bullowa (Ed.), Before Speech. Cambridge, UK: Cambridge University Press. pp. 245-269.

Ricks, D. M. (1975). Vocal communication in pre-verbal normal and autistic children. In N. O'Connor (ed.), Language Deficits and Retardation. London: Butterworths.

Sikstrom, M. & Skille, O. (1991). "Skille Musical Behaviour Scale and Test as a Tool in the Assessment of Physiological Function and Individual Potential". In Music and the Healing Process, Ed. Wigram, A., West, R., Saperston, B. (1991). Carden Publications. (In Press)

Wigram, A. (1988). Music therapy developments in mental handicap. Psychology of Music: The Journal of the Society for Research in Psychology of Music and Music Education, 16(1): 42- 52.

Wigram, A. (1989). Processo De Diferenciacao Do Autismo E Outras Mentais. (The Significance of Musical Behaviour and Music Responsiveness in the Process of Differential Diagnosis of Autism and Other Handicaps.) Paper presented at the Internal Multidisciplinary Symposium on Music Therapy and the Effects of Sound. Sao Paulo, Brazil.

Wigram, A. (1990). Processes in Assessment and Diagnosis of Handicap in Children through the medium of Music Therapy. Paper presented at the annual conference of the Association for Professional Music Therapists, Severalls Hospital, Colchester, England.

Wing, L. (1979). Differentiation of retardation and autism from specific communication disorders. Child: Care, Health and Development, 5, 57-68.

Wing, L. (1988). The Continum of Autistic Characteristics. In E. Schopler and G. Mesibov (Eds.), Diagnosis and Assessment in Autism. New York: Plenum Publishing Company Limited.

Wing, L. (1981). Asperger Syndrom--A Clinical Account. Journal of Psychiatric Medicine, 1981, 11: 115-29.

Wing, L. (1981). Language, Social and Cognitive Impairments in Autism and Severe Retardation. Journal of Autism and Developmental Disorders, Vol. 11, No. I. Plenum Publishing Corporation.

Wing, L. (1976). Early Childhood Autism, 2nd edition. Pergamon Press.

Tony Wigram, BA(Hons.), LGSM(MT), RMTh. Music Therapist, Harperbury Hospital and Harper House Children's Service Research Psychologist, Royal Holloway and Bedford New College, London University, England
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Author:Wigram, Tony
Publication:Australian Journal of Music Therapy
Date:Jan 1, 1992
Words:6369
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