EvidenceEvidence--based guidelines based guidelines Music Music therapy for CSHCNtherapy for CSHCN

Dr Dr SuvarnaSuvarna NalapatNalapat

A new project A new project

•• No No side effectsside effects•• CCost ost effectiveeffective•• RResultesult--oriented, clientoriented, client--orientedoriented•• community community orientedoriented•• BBasic asic scientific principles on which it scientific principles on which it workwork

& Practical & Practical methods for executing it methods for executing it

Integrated Integrated interdisciplineryinterdisciplinery

•• NaadaNaada, , layalaya, yoga, yoga--——YogaYoga terminologyterminology•• swaraswara, , sruthisruthi, , thaalamthaalam, , raagamraagam-- MusicMusic

terminologyterminology•• SaamkhyaSaamkhya thridhoshathridhosha--thrigunathriguna balancingbalancing--

AyurvedaAyurveda•• PanchabhoothaPanchabhootha have have three three gunaguna•• Balance Balance ––organisedorganised ,integrated function of the ,integrated function of the

panchendriyapanchendriya of senses and of senses and panchendriyapanchendriya of of karmakarma--sensorimotorsensorimotor –– Indian Philosophy Indian Philosophy

Physics of sound and hearingPhysics of sound and hearingAakaasaAakaasa

•• ATHATH absolute threshold of hearing in absolute threshold of hearing in decibeldecibel

•• SPLSPL sound pressure levelsound pressure level

•• Together expressed Together expressed dBSPLdBSPL

8080--85 85 dBSPLdBSPLabove pollution levelabove pollution level•• 90 heavy truck ,loud factory 1 m away90 heavy truck ,loud factory 1 m away•• 100 pneumatic 100 pneumatic hammer,insidehammer,inside disco 2 mdisco 2 m•• 110 accelerated motor bike 5 m 110 accelerated motor bike 5 m •• 120 jet engine 100m ,and a rock concert120 jet engine 100m ,and a rock concert•• 130 pain threshold exceeded130 pain threshold exceeded•• 130 jet engine 30 m130 jet engine 30 m•• 180 rocket engine 30 m180 rocket engine 30 m

6060--80 range of instrumental 80 range of instrumental musicmusic•• 80 80 vacumvacum cleaner,heavycleaner,heavy traffic 1mtraffic 1m•• 7575--80 very loud harsh angry voices80 very loud harsh angry voices•• 70 heavy traffic 5 m70 heavy traffic 5 m•• 60 60 office,busyoffice,busy restaurant ,instrumental music restaurant ,instrumental music

•• JaagradJaagrad waves waves betabeta..

Vocal music alone 20Vocal music alone 20--3030

•• 20 forest with only the rustle of leaves20 forest with only the rustle of leaves•• 30 silent house with mothers lullaby or her voice alone30 silent house with mothers lullaby or her voice alone•• 40 night in a residential area40 night in a residential area•• 50 inside a quiet restaurant50 inside a quiet restaurant

•• JagrathJagrath waves waves . 35. 35--40 40 intrauterine intrauterine audiophonicaudiophonic state state FamiliarFamiliar. . The The maximum is 80 maximum is 80 . Beyond . Beyond that human brain that human brain do not tolerate.do not tolerate.

88--13.9 Hz 13.9 Hz dhaaranadhaarana alpha alpha waveswaves•• 0 the threshold with max hearing capacity .can 0 the threshold with max hearing capacity .can

hear voices of silencehear voices of silence•• 10 10 breathsoundsbreathsounds alone at 3 m alone at 3 m ––praanaayaamapraanaayaama

•• Serotonin,norepinephrineSerotonin,norepinephrine increase increase .parasympathetic stage.parasympathetic stage

•• 1414--100 100 jaagradjaagrad sympathetic.betasympathetic.beta waveswaves

Comparison Comparison

44--7.9 7.9 REM REM Theta Theta DhyaanDhyaan.meditation.Integration.meditation.Integrationof emotional change by of emotional change by imagination,dreamsimagination,dreams

0.10.1--3.9 3.9 samadhisamadhi rejuvenation rejuvenation

YogaYoga, EEG , EEG waveswaves, Vocal/instrumental , Vocal/instrumental music for music for music therapy purposes music therapy purposes

Emotional contentEmotional content

•• VaatsalyaVaatsalya•• MaadhuryaMaadhurya•• BhakthiBhakthi•• 3 private languages 3 private languages . Direct . Direct communicationcommunication, ,

touch touch heart and soft feelingsheart and soft feelings•• Each has voiceprint Each has voiceprint . . MathrubhaashaMathrubhaasha..•• Use of Use of swaraswara, , vyanjanavyanjana as soul and as soul and body (body (UyirUyir

MeyMey in Tamil )in Tamil )

Chimp and human 99 Chimp and human 99 % same % same genegene•• 21 genes only in humans21 genes only in humans--for learningfor learning, talking , talking

and singingand singing

•• Through singing learn and talkThrough singing learn and talk•• To train this natural for all mothersTo train this natural for all mothers, all , all

languageslanguages, even , even birdsbirds, animals, animals•• Most natural Most natural •• Story of Story of BambaathaBambaatha in South Africain South Africa

Human /mother’s voiceHuman /mother’s voice

•• PitchPitch, rhythm, tempo, length , rhythm, tempo, length of of swaraswara, the , the stressed stressed vyanjanavyanjana at the end of a wordat the end of a word, cyclical , cyclical repetitionsrepetitions, the , the place of stops place of stops

•• The rocking movements of mother The rocking movements of mother •• Security Security •• ChanjaadunnniChanjaadunnni•• ThappoThappo thappothappo•• AkkaamAkkaam pukkaampukkaam•• UrumbeUrumbe urumbeurumbe•• Asking Asking ponnumonponnumon evideeeeeeevideeeeee? Child communicates? Child communicates

Musical languageMusical language

•• SruthiSruthi ––raise one octave raise one octave , slowly , with , slowly , with stopsstops, repeat , repeat the the same in small words.same in small words.

•• Hide and Hide and seek , seek , kaaakaaa--kkkakkka, , pooopooo--chhachha etcetc•• KaaakkkaiiKaaakkkaii to to make a crow fly with make a crow fly with kaimudrakaimudra ––eye eye

contact with the object contact with the object , identify , identify the objectthe object•• SaaSaa saasaa saasaa ––flatflat•• SaaSaa niinii N3N3•• SaaSaa paapaa saaasaaa

Film songs/devotionalsFilm songs/devotionals

•• Kizhakku kizhakoraanaaKizhakku kizhakoraanaa•• Thumbee thumbee vaa vaaaThumbee thumbee vaa vaaa•• Kaakkakkum poochaakkm kalyaanam Kaakkakkum poochaakkm kalyaanam •• Panchathanthram kathayile Panchathanthram kathayile •• Oonjaalaa oonjaalaa Oonjaalaa oonjaalaa •• Ayigiri nandiniAyigiri nandini•• Achutham kesavamAchutham kesavam•• Govinda raama raama Govinda raama raama •• Kannanaam unniye Kannanaam unniye •• Ambadi thannilorunniyundanganeAmbadi thannilorunniyundangane•• AnjanasreedharaAnjanasreedhara•• Adharam madhuramAdharam madhuram•• Neelakkarmukil varnananneram raadha ennoru Neelakkarmukil varnananneram raadha ennoru

Musical drama playsMusical drama plays•• Common stories Common stories . Tell . Tell themthem, sing to them , sing to them and and

enact enact to them to them as action songsas action songs•• Improvise according to Improvise according to child’s child’s needsneeds•• Not according to what we Not according to what we expect expect them to dothem to do•• Imitate the Imitate the childschilds voice voice / manners / manners of expression of expression

to make them understandto make them understand•• Less of spoken instructions Less of spoken instructions . More . More of singof sing, play , play

and natural and natural undersatandingundersatanding

First Guru, First Guru, AmarakosaAmarakosa, healer , healer for a child for a child •• AmmaAmma•• 11stst psychic experience in psychic experience in uteroutero•• The first The first mahaamanthramahaamanthra her her vaalsalyanaadavaalsalyanaada•• Music therapy for children facilitates this natural healing Music therapy for children facilitates this natural healing

––creative therapy.creative therapy.•• Both for normal and CSHCN. The difference is only in Both for normal and CSHCN. The difference is only in

time taken and more understanding needed from adults.time taken and more understanding needed from adults.

CSHCNCSHCNgeneral goals /specific objectives general goals /specific objectives •• Developing responseDeveloping response•• Initiation of communication/verbal or nonverbalInitiation of communication/verbal or nonverbal•• Turntaking,socialTurntaking,social skillskill•• Body awarenessBody awareness•• Physical rehabilitationPhysical rehabilitation•• Memory Memory •• Depend on each individual child as a unique Depend on each individual child as a unique

person.person.•• ChollumChollum vannillavannilla pallumpallum vannillavannilla nammudenammude

unnikannanuunnikannanu

Role of therapistRole of therapist

•• Care of individual child as a unique personCare of individual child as a unique person•• Care of stress of familyCare of stress of family•• Development of systems of care at Development of systems of care at

community levelcommunity level•• CoCo--operative effort as a member of a operative effort as a member of a

team for common welfare of communityteam for common welfare of community

Guidelines Guidelines

•• PlanPlan, study, act. The , study, act. The small cycle of improvement small cycle of improvement model.model.

•• Longitudinal continuity of care Longitudinal continuity of care . . FFollow ollow up up , long , long term relationship with therapistterm relationship with therapist

•• Orderly transfer of care from the therapist to Orderly transfer of care from the therapist to assistantsassistants

•• Family centered supporting the entire family and Family centered supporting the entire family and its stressits stress

The The broad planbroad plan

•• 11stst most basicmost basic. Diagnosis . Diagnosis by a PCPby a PCP. And . And get all details of child from get all details of child from doctordoctor, teacher, parent , teacher, parent

•• Prepare how to work with a Prepare how to work with a multidisciplinerymultidisciplinery teamteam•• Verbal and written communication between team members and Verbal and written communication between team members and

familyfamily. Keep . Keep a diary with the child a diary with the child . Every . Every member of the team can member of the team can assess the work and improvement of other team membersassess the work and improvement of other team members

•• Both pretest and posttest conditions are thus transparentBoth pretest and posttest conditions are thus transparent•• Parents/teachers/therapists/PCP coParents/teachers/therapists/PCP co--operationoperation

From the pretest condition From the pretest condition --start start planningplanning•• Group/individual/bothGroup/individual/both•• Grouping children Grouping children •• Infant/toddlerInfant/toddler, preschool, , preschool,

school/adolescentschool/adolescent•• Or on class basisOr on class basis•• Whichever is convenientWhichever is convenient

Each Group with parents/music Each Group with parents/music therapists/teachers therapists/teachers •• 11stst 15 days with sruthipetty/thamburu /or keyboard 15 days with sruthipetty/thamburu /or keyboard

whichever availablewhichever available•• Mandram,madhyam.athitaaram Mandram,madhyam.athitaaram •• Two different notes of recognisable difference Two different notes of recognisable difference •• Esp useful for children with no language/monosyllablesEsp useful for children with no language/monosyllables•• See whether they are trying to make sounds.dont worry See whether they are trying to make sounds.dont worry

about the pitch .need not be perfect.but just making about the pitch .need not be perfect.but just making sounds would be a good beginingsounds would be a good begining

Turn takingTurn taking

•• Some silent for 2Some silent for 2--3 days3 days, even , even weeks/months then start weeks/months then start making soundsmaking sounds

•• Hence 15 days minimum trial givenHence 15 days minimum trial given•• Note down in diary each day/each time the child Note down in diary each day/each time the child

makes/try to make sounds/improvementsmakes/try to make sounds/improvements•• Tolerance 30 Tolerance 30 mtsmts . Max . Max 45 45 mtsmts initiallyinitially. Later . Later they they

tolerate moretolerate more•• At home in privacy they may try to At home in privacy they may try to vocalisevocalise . with . with

selfconfidenceselfconfidence start start vocalisingvocalising in group alsoin group also. give . give time time for thatfor that. .

•• do do not rush the child.not rush the child.

Already singing vocalising Already singing vocalising childrenchildren•• RaagaRaaga with low frequency at random from a with low frequency at random from a

music source with music source with sruthipettysruthipetty alonealone•• Film/light/action/classical Film/light/action/classical . Reduce . Reduce BGM sounds BGM sounds

because it distract because it distract childschilds attentionattention, and , and disturbs disturbs his cognition.his cognition.

•• Value of play/musical drama Value of play/musical drama . The . The triad of triad of competence competence . communication, sensitivity . communication, sensitivity and and creativity needed in all areas of life.creativity needed in all areas of life.

Examples of role play/dramaExamples of role play/drama

•• Mother playMother play•• Krishna playKrishna play•• Doctor play Doctor play •• Engine driver playEngine driver play•• Elephant play /animal /Elephant play /animal /panchathanthrapanchathanthra musical drama musical drama •• By imitationBy imitation, purposeful , purposeful activities doneactivities done•• Musical play session tolerate for 40Musical play session tolerate for 40--45 seconds 45 seconds . act . act with with

childrenchildren, changing , changing the rolesthe roles, act , act with siblingswith siblings, parents, , parents, teachers teachers as a playtime action not as a learning action.as a playtime action not as a learning action.

•• They should enjoy it They should enjoy it . It . It should be flexible for individual should be flexible for individual child.child.

Neurophysiology of Neurophysiology of actionplayactionplaysradhaavaansradhaavaan labhathelabhathe gnaanamgnaanam..•• Acetylcholine increase when child plays.Acetylcholine increase when child plays.•• Concentration in the play facilitate free association Concentration in the play facilitate free association

thinkingthinking•• ImaginationImagination--actingacting--music and the sharing of it with music and the sharing of it with

others.Socialothers.Social competence and cocompetence and co--operationoperation•• TurntakingTurntaking when the children enact a rolewhen the children enact a role--they they

listen,watchlisten,watch have have eyecontacteyecontact with other actors in the with other actors in the play (play (other childrenother children), imitate ), imitate other children other children , imitate , imitate emotionsemotions. A . A balanced musical dialoguebalanced musical dialogue

Musical chairsMusical chairs

•• Keep a hat on head of 1Keep a hat on head of 1stst child or something in his hand child or something in his hand to pass on to pass on

•• Sing two lines Sing two lines . All . All repeating /or teacher alonerepeating /or teacher alone•• When last word said the child pass on hat to next When last word said the child pass on hat to next childschilds

head/handshead/hands•• RepeatRepeat•• TurntakingTurntaking learntlearnt. Assess . Assess which object each child loves which object each child loves

best best . What . What music is loved by each child in a natural music is loved by each child in a natural wayway. (By observation .Not by questioning the child ). (By observation .Not by questioning the child )

•• Informal way of finding out through play .Informal way of finding out through play .•• Small group teaching/play /singing Small group teaching/play /singing

Other research methodsOther research methods

•• Shadow a child whole day observing Shadow a child whole day observing •• 10 10 mtmt videotape on each childvideotape on each child•• Interviews with Interviews with PCP,SpeechPCP,Speech therapists,parentstherapists,parents and teachers of each child and teachers of each child •• HomebasedHomebased evaluationsevaluations•• QuestionnaireQuestionnaire•• Pre and post test assessment of Pre and post test assessment of behaviouralbehavioural improvements improvements ––behavioral psychologistbehavioral psychologist•• Speech improvement Speech improvement ––speech therapistsspeech therapists•• Day to day satisfactory improvement Day to day satisfactory improvement ––parents parents •• Analysis of entire data with music /type of method employed/Analysis of entire data with music /type of method employed/raagaraaga//swaraswara by music by music

therapisttherapist•• Comprehensive integrated analysis of all the data to arrive at a conclusionComprehensive integrated analysis of all the data to arrive at a conclusion•• Communication of results by the final analyst to the group members and planning Communication of results by the final analyst to the group members and planning

further action.further action.

Different checklists Different checklists

•• Ratings Ratings •• StatisticsStatistics•• Value of EEG and Brain mapping Value of EEG and Brain mapping fMRIfMRI•• Fear Fear ––amygdalaamygdala stimulationstimulation•• On volunteers/parents of children with autismOn volunteers/parents of children with autism•• Family and autistic children known to the Family and autistic children known to the

researcher for long time the fear complex will be researcher for long time the fear complex will be less. less.

Reasons Reasons

•• Toddler should be able to sleep in the scanner Toddler should be able to sleep in the scanner for imaging to take place in sleep .for imaging to take place in sleep .sleepscansleepscandone on done on weeknights.Itweeknights.It should be done between should be done between 2727--32 months age32 months age

•• Repeated at 30Repeated at 30--42 months age42 months age•• Normal controls between 15Normal controls between 15--20 months and 20 months and

between 18between 18--30 months30 months

fMRIfMRI

•• Has to hold controller and lie down quietly and Has to hold controller and lie down quietly and do play and watch overhead screen for 20do play and watch overhead screen for 20--30 30 mtsmts

•• Autism children have less activation of deeper Autism children have less activation of deeper part of brain responsible for execution function part of brain responsible for execution function --attentionattention, reasoning, problem , reasoning, problem solving.solving.

Empathy Empathy

•• They have psychic ability to sense They have psychic ability to sense emotions . Are unable to understand emotions . Are unable to understand thoughts of othersthoughts of others

•• Telepathy.Telepathy.•• Music is empathy Music is empathy . It . It touch the heart.touch the heart.•• Through empathy and not by analysis or Through empathy and not by analysis or

logic they learn .logic they learn .

YamunaYamunavrindavanavrindavana ThulsiThulsiMelakarthaMelakartha

AmygdalaAmygdala/social score inverse/social score inverseRtRt InfrInfr F F gyrusgyrus/s score direct same /s score direct same in control.in control.

Communication interaction Communication interaction research in autism UK research in autism UK

•• CIRA UK (pronounce keera)CIRA UK (pronounce keera)

Echolalic child 6 yrsEcholalic child 6 yrselementary repetitive songelementary repetitive song

•• RAS rhythmic auditory stimulusRAS rhythmic auditory stimulus•• Do you eat an appleDo you eat an apple? Yes , yes, yes? Yes , yes, yes•• Do you eat a pencil ?noDo you eat a pencil ?no, no, no , no, no •• Repetitive Repetitive swaraswara, pitch , pitch as as saabdikabheshajasaabdikabheshaja

(sound as medicine).(sound as medicine).

BerardBerard, , TomatisTomatis,,Mozart Mozart effect ?effect ?•• BerardBerard approach 10approach 10--12 days 12 days . select . select high and low high and low

frequencies from a music frequencies from a music . send . send via via headphones. headphones. Modulated Modulated throughout the 10 hrs of trainingthroughout the 10 hrs of training. . safe,butsafe,butexpensive.expensive.

•• TomatisTomatis approach approach 66--12 months(Mozart) for right ear 12 months(Mozart) for right ear dominancedominance..

•• MOZART Effect MOZART Effect TomatisTomatis method method did not help in did not help in developing language skills. developing language skills.

•• KrishnaKrishna--MeeraMeera--MSS Effect MSS Effect •• RamaRama--TyagarajaTyagaraja--JesudasJesudas Effect Effect •• Suvarna’sSuvarna’s approach approach / Method / Method •• Name tags Name tags ?.?.

Thank you .Thank you .