Imagine They Are Lonely Children

Two years ago, after almost 15 years of treating adults with developmental disabilities, I was asked to consider working with children. Children’s programming represented a new division at my facility in the Midwest, I said yes. After scrubbing my hands I walked through the door of the childcare facility designed to serve the most severely impaired infants, toddlers, and children. Each child was unique, impaired from birth or gut-wrenching child abuse and trauma. Each child lay in a kid cart, or a beanbag sort of bed, or a prison barred safety crib. Buzzers blared warning beeps asserting urgency and need. The children cried out in reflexive utterances responding to the invasive lifesaving medical treatment. Why the need for such a program? Honestly, if the children weren’t at this facility, they would be confined to a hospital or nursing facility.
As a music therapist, I wondered what to do next? Should I pull out my guitar and sing hello? Could I pass out the instruments to allow the children to play along with me? Sadly, I tried that, but unfortunately, it wasn’t effective.

What does the special educator do? Would repetition and reinforcement work to teach basic cognitive concepts?

What does the traditional therapy team do? Well in this case, they completed the assessment to determine if the children qualify for reimbursable authorization. Unfortunately, these children do not generally progress quick enough to warrant 8, 10 or 14 sessions to teach feeding, language, range of motion, or strength training therapy. In other words, prior authorization probably will not be approved.

Most clinicians have experienced these types of challenges from clients or children at some point in their careers leaving them to continue to ask: “What to do next?”

Challenges emerge from the beginning. First I needed to complete the clinical assessment, which turned out to be a major roadblock. The clinical assessment tool required the child identify and vocalize concepts like color and shape as well as demonstrate fine and gross motor skills. This proved impossible given these children were unaware of what they are hearing, seeing, or experiencing. They were unable to move or speak. They each achieved an extremely low score on the test resulting in a prognosis of never or rarely achieving the skill. The truth is that the assessment failed to appropriately identify the problem underlying each child’s disability. More frighteningly, however, the assessment concluded that these children would never acquire the skills allowing them to leave the facility and live an independent life.

The problem of assessment was difficult to untangle. How could anyone assess potential ability locked inside an unresponsive child? The neurologist had already assessed the children in the facility using the Glasgow Coma scale and most scored as a vegetative state (VS) or a minimally conscious state (MCS).

The next problem was the standard treatment options. In the school setting, traditionally a team of experts would develop an individualized education plan (IEP) for the child to develop the skills associated with learning colors, shapes, and fine and gross motor movement. The team would incorporate repetition, reinforcement, and redirection to assist the child in achieving the cognitive and age related goals in the areas of reading, writing, and arithmetic. This model represents current best practices in the academic and clinical worlds. Even in a clinical setting, as in the one I describe, the staff members retain the cognitive goals of reading, writing, and arithmetic, by adapting individualized approaches to achieve the goals for each child. The special education teacher may physically assist the child in a vegetative state to place his or her hand upon an object while verbally speaking the name of the object for the child.

This procedure achieves an age appropriate approach designed to teach the child to learn a concept. Yet, the children I served were diagnosed in a vegetative state usually indicated that the child functioned, unaware of either the teacher or the object, and more importantly, unable to reach the complex cognitive goals.

How can best practices become better? I turned to the field of neuroscience which had transformed a subset of music therapists into Neurologic Music Therapists who believed that a portion of individuals who were unable to respond to the environment, similar to some of the kids I served, were irresponsive because on the neurological level, at the level of the nervous system, they were unable to initiate a response (Guldenmund, Stender, Heine, & Laureys, 2012). Without initiating a response the vegetative child remains motionless. Neurologic Music Therapy (NMT) a Transformational Design Model (TDM) based in neuroscience research, uses a different assessment, treatment, and allow for transition to independence for several of the children I served.

Let’s take the problem of assessment

Briefly the Glasgow Coma Scale accurately and reliably assesses the child’s ability to respond cognitively to the environment. Four children with similar Glasgow Coma Scale scores of vegetative state could and probably do have four different neurological reasons for their disabilities and subsequent lack of response. Assessment requires identifying the unique neurological processes underpinning the individuals’ state.

Diagnostic Differentiation allows the therapist to identify the specific neurologic needs of each individual allowing the professional to identify which neurological processes need to be addressed and which specific neurologic stimulus affects those processes. The Transformational Design Model identifies the disrupted neurological processes and a clinician applies the correct neurological stimulus to affect that process. The Neurologic Music Therapist then builds a treatment protocol including stimulating a neurological sequence designed to drive the nervous system toward health.

Instead of using repetition, reinforcement, and redirection, the treatment involves a rhythmic auditory stimulus in the form of music, which serves to initiate neural activity, sustaining, and inhibiting each neurological sequence or process. In this way, the diagnostic details define the treatment, which may include neurologic music therapists, and depending on the client, a variety of traditional therapists to implement the treatment.