Antonietti2018 Book MusicInterventionsForNeurodeve

Music Interventions
for Neurodevelopmental
Disorders
Alessandro Antonietti
Barbara Colombo
Braelyn R. DeRocher
Music Interventions for Neurodevelopmental
Disorders
Alessandro Antonietti · Barbara Colombo
Braelyn R. DeRocher
Music
Interventions for
Neurodevelopmental
Disorders
Alessandro Antonietti Braelyn R. DeRocher
Department of Psychology Department of Psychology, Division
Catholic University of the Sacred of Education and Human Studies
Heart Champlain College
Milan, Italy Burlington, VT, USA
Barbara Colombo
Department of Psychology, Division
of Education and Human Studies
Champlain College
Burlington, VT, USA
ISBN 978-3-319-97150-6 ISBN 978-3-319-97151-3 (eBook)

https://doi.org/10.1007/978-3-319-97151-3
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Preface
The book aims at informing about what music can do to improve the
skills that are impaired in some neurodevelopmental disorders (specifi-
cally: ADHD—Attention Deficit-Hyperactivity Disorder, autism, and
Rett Syndrome). Rehabilitation interventions based on the use of music
(the so-called “music therapy”) are relatively widespread, but only some
approaches show empirical support to the alleged benefits they produce.
Given these premises, in this volume, the authors try to provide read-
ers with an updated and scientifically grounded perspective, which can
explain why music is effective in promoting the acquisition of some basic
mental abilities. Research data showing to what extent musical activities
can guide children affected by neurodevelopmental disorders to improve
those skills will be reported. Also, examples of training programs and
exercises addressing the target populations will be described. The pur-
pose is to show that music can be a valid aid in rehabilitation, stressing
the difference between evidence-based methods and other approaches,
which may be fascinating but not scientifically grounded.
Music is certainly not aimed at reaching educational or rehabilita-
tive goals. In human cultures, where music is always present, it is gen-
erally linked to the production of sounds with the voice or instruments
and people can participate through listening or movement. This pro-
duction fits other purposes, which can be individual (e.g., expressing
one’s mental states, communicating emotions and intentions, inducing
v
vi Preface
particular psychophysical conditions, experiencing pleasure) or collective

(coordinating work and collaborative behaviors, increasing group cohe-
sion, demarcating identity, etc.).
Soon, however, it has been discovered that taking part in the creation
and fruition of music can help support development and transformation
because of the personal and social changes that it triggers. Hence music
has been intentionally oriented to acquire skills that are not acquired yet
(educational and training use), to enhance existing skills that need to be
refined or further developed (empowerment), to favor the recovery of
skills that, while previously owned, have been lost or compromised, for
example as a result of trauma (rehabilitation use), or which are lacking,
for example, because of developmental disorders (habilitation use and
therapy).
If we try to reconstruct the story—that is partially anecdotal, partially
documented—of the attempts to use music for this kind of objectives we
face a long and complicated task. Only in recent times, a proper scientific
foundation for music therapy can be easily found.
The techniques that are often used in music-therapy settings have
matured through intense and prolonged personal experiences over time
and have also been applied to a broad set of cases. A first step to validate
this set of personal experiences consisted of linking those techniques to
accredited conceptual frameworks to be able to justify practices through
terms and constructs shared by the scientific community.
A further step should be taken since many people still mistrust these
methods. In fact, the goal should be to be able to present objective evi-
dence of their validity, going beyond the simple “impressions” of effec-
tiveness that derive from music therapists and from subjective feedbacks
of benefit that patients provide. Skeptics must be convinced that involv-
ing children in activities based on the production of or listening to
sounds can be trusted to lead to reliable results. However, even before
providing evidence to others, it is a matter of sharing, among profes-
sionals, methods that allow monitoring interventions and evaluating the
outcomes to become more aware of the specific types of change that are
induced in their patients, and thus make practices more and more specif-
ically focused.
This book documents different music-based interventions applied
to rehabilitation. Each chapter focuses on a different use of music and
presents one or more interventions carried out for a specific rehabili-
tation purpose, the tools used to evaluate the effects produced by the
Preface vii
interventions, and the results obtained. Beside providing examples

of specific interventions, the purpose of the volume is to contribute
to the growth of the scientific recognition of music-based therapeu-
tic approaches. This is why we present the tools used to evaluate the
changes produced by the interventions: to enable other operators and
researchers to apply them. In fact, in addition to using existing validated
tools, some of the monitoring and assessment tools that are introduced
have been particularly devised to evaluate the very psychological dimen-
sion to which each intervention was directed.
The volume also intends to give another type of contribution: to
enrich the repertoire of existing musical intervention techniques with
new activities developed starting from soundly designed experimental
studies. These activities are described in a sufficiently analytical way to
allow the reader to replicate their application.
The reader will understand that the interventions, as well as the pro-
cedures used to evaluate their outcomes, derive from different influences
and have been implemented in different settings. The different chap-
ters aim at showing how, depending on specific objectives and differ-
ent contexts, the therapist might choose different approaches. In some
cases, a very focused “technical” approach, with an exact definition of
the expected changes and with the rational planning of the stages of
the intervention, needed to be favored. In other cases, the interven-
tions were conducted flexibly, adapting the activities as a response to
the dynamics of the interpersonal relationship between the therapist
and the patient, following the state of the moment or responding to the
cues offered by the patients. This allows for a procedure that, while not
losing sight of a well structured general layout, gives some space to the
sensitivity of the operators and to their intuitions. This tension between
rigor and freedom, planning and improvisation, technicality and empathy
always crosses psychological interventions, which are never either com-
pletely pre-determined or open to what emerges during the process.
In the first chapter, the reasons why music can be useful in rehabili-
tation within the field of neurodevelopmental disorders are discussed. A
comprehensive theoretical model, supported by experimental findings, is
presented. According to this model, music can prompt or enhance the
development of mental skills since it elicits mental processing at different
levels: motor, visual, and verbal. The three levels, when synchronized,
induce synergic effects that act as “scaffolding” tools, facilitating the
acquisition of the ability to be trained.
viii Preface
The second chapter is focused on Attention Deficit-Hyperactivity

Disorder (ADHD). Music can play a role in the treatment of children
and adolescents with ADHD since it provides patients with a self-regu-
latory system, which enables them to manage the internal time accord-
ing to variations in the external time and to synchronize behavior with
external stimuli. Thanks to these mechanisms the individuals get control
over their impulsive tendencies and can plan their behavior according
to the goals they set. The relevant literature about the effects of musi-
cal interventions for ADHD patients is reviewed. Some studies aimed at
improving self-control in people with ADHD through music interven-
tion programs (consisting of either individual or small-group sessions), as
well as different activities included in such programs, are described.
Autism Spectrum Disorder (ASD) is the topic of the third chapter.
Music treatments targeting individuals with ASD usually aim at enhanc-
ing social skills. To do so, musical activities are paired with a series of
underlying competencies to be acquired. This chapter focuses on some
of these essential competencies, such as the detection of the congruence
between the emotional valence of music and the mood states it elicits,
the identification of the relationships between the sounds and the motor
acts that produced them, the ability to mirror the partner’s mental state
through the production of musical acts. Experimental findings support-
ing the notion that these basic competencies can be acquired or refined
by people with autism, as well as the outcomes of musical treatments
focused on those skills, are reported in the chapter.
In the case of Rett Syndrome, the focus of the fourth chapter, among
the variety of possible goals, which can be reached through music inter-
ventions (associated to the different pathological manifestations of the
syndrome), motor coordination has been chosen as one of the critical
deficits characterizing the disorder. Literature supporting the benefits of
musical activities when working with Rett Syndrome patients is summa-
rized and reasons highlighting why music might be particularly effective
in this fields are explained. An intensive training program implemented
with a girl affected by Rett Syndrome is described in detail and several
activities carried out during the intervention are exemplified.
Finally, some general remarks about why music can be employed
in rehabilitation interventions, which can be valid for all the neurode-
velopmental disorders considered in the book, are reported. Practical
suggestions for parents and rehabilitators, as well as music teachers, are
Preface ix
proposed so to allow readers to link the outcomes of research to what

can be concretely done to promote the enhancement of essential skills in
children affected by neurodevelopmental disorders.
Milan, Italy Alessandro Antonietti

Burlington, USA Barbara Colombo
Braelyn R. DeRocher
Contents
1 The Reasons Supporting the Use of Music

in Rehabilitation 1
Three Mental Registers 2
Relationships Within and Between Registers 5
The Motor Register 7
The Iconic Register 9
The Verbal Register 11
Concluding Remarks 13
References 14
2 Enhancing Self-Regulatory Skills in ADHD Through

Music 19
Defining ADHD 19
Music Interventions Addressed to ADHD 26
Music and ADHD: Possible Relationships 33
A Single-Case Study Intervention 35
Structure of the Intervention 36
Aims of the Intervention 36
Activities Included in the Intervention 38
Assessment of the Intervention 39
Outcomes of the Intervention 40
Final Comments 41
A Group Intervention for ADHD Children Based on Music 42
Activities Included in the Intervention 43
xi
xii Contents
Assessment of the Intervention 44

Outcomes of the Intervention 45
References 46
3 Enhancing Social Skills in Autism Through Music 51

Defining Autism 51
The Benefits of Using Music with Autism 53
Examples of Assessment Techniques and Training Programs 56
Perception and Discrimination of Musical Rhythm, Intensity,
and Speed 57
Perception of Synchronization Between Sounds and Gestures
in Music-Based Communication 58
Preferences for Different Aspects of Emotional Music Stimuli 58
Perception of Synchronization of Different Musical Elements
in Music-Based Communication 59
Results from the Assessment and Ideas for the Intervention 60
Imitation Interventions Based on Technological Devices 62
Imitation and Autism 62
The Soundbeam Intervention Project 64
References 68
4 Stimulating Motor Coordination in Rett Syndrome

Through Music 75
Defining Rett Syndrome 75
Music Therapy and Rett Syndrome 77
Music and Rett Syndrome 77
Music Therapy to Promote Emotion Regulation
and Emotional Communication 78
Music-Therapy Interventions to Improve Communication
and Social Relationships 79
The Use of Music to Promote Motor Skills 81
The Effects of Music Therapy in Rett Syndrome 83
An Intervention to Promote Motor Coordination in Rett
Syndrome 83
Patient’s Assessment 84
Structuring of the Intervention 85
Contents xiii
Receptive Phase 86
Interactive Phase 88
Final Comments 90
References 91
Conclusions 95
CHAPTER 1
The Reasons Supporting the Use of Music

in Rehabilitation
Abstract  This chapter presents and discusses the reasons why music can
be useful in rehabilitation in the field of neurodevelopmental disorders.
A comprehensive theoretical model, supported by experimental findings,
is presented. According to this model, music can prompt or enhance the
development of mental skills since it elicits mental processing at different
levels: motor, visual, and verbal. The three levels, when synchronized,
trigger synergic effects acting as “scaffolding” tools that facilitate the
acquisition of the ability to be trained.
Keywords  Music · Rehabilitation · Music therapy · Neurogenerative

disorders · Motor system · Imagery · Language
The variety of music-based methods commonly employed for therapeu-

tic purposes is quite extensive (Horden, 2000). On the one hand, music
can be used to lead the patient to be in a physical and mental state that
is not curative by itself, but that can enhance the effectiveness of other
kinds of interventions. For instance, music can be utilized to induce
a state of relaxation, to stimulate a positive mood, and to increase the
level of self-awareness in the patient (Colombo & Antonietti, 2017),
improving successful outcomes of psychotherapy. In this case, music only
plays an ancillary role. On the other hand, music can be used to directly
trigger changes that allow patients to restore or improve lacking skills
(Antonietti & Colombo, 2012). In this case, sounds are effective thanks
© The Author(s) 2018 1

A. Antonietti et al., Music Interventions for Neurodevelopmental Disorders,
https://doi.org/10.1007/978-3-319-97151-3_1
2 A. ANTONIETTI ET AL.
to something that is peculiar to music. Hence, it is crucial to compre-

hend the reasons why a specific use of music can result in the achieve-
ment of specific goals in the field of rehabilitation.
Three Mental Registers

A person who is listening to or performing music has a comprehensive
experience in which several mind registers are activated simultaneously
and synergically so that the coordinated action of multiple mental mech-
anisms occurs. This characteristic is the foundation for the efficacy of
sound-based rehabilitation treatments. The mechanisms can be identified
referring to three categories, which correspond to three relevant mental
registers available to the human mind: motor, iconic, and verbal.
These three registers match an essential distinction within the psycho-
logical field that has been acknowledged by different theories and has
been effectively systematized by Bruner. He identified three developmen-
tal stages. Each of them is matched with a specific system used for men-
tal representation: enactive, iconic, and symbolic (Bruner et al., 1966).
First, the child’s motor behavior reveals strategies behind each action,
allowing us to assume that mental representations guide movements.
These are what Bruner calls enactive representations, constituted by pat-
terns that coordinate the sequence of different acts or segments in order
to form a whole movement. Iconic representations are independent of
actions, even though they are tied to perception since images or spatial
schema are the basis from which iconic representations are generated.
They allow representing states, relations, or transformations of events.
To perform tasks that require abstract thinking one needs symbolic or
verbal representations, which operate through abstract concepts.
The tripartition suggested by Bruner can be useful in making our
point because it helps us to identify three registers, or lines, along which
the mental processes activated by music unfold and to identify along
these lines the likely reasons why music-based rehabilitation interven-
tions are successful.
As a first point, music activates the motor register because music is
naturally connected with the body. A body gesture always initiates music
(blowing, beating, etc.). Moreover, often music is composed by think-
ing of specific actions or movements it is supposed to accompany (dance
or military marches, for instance). Some cultures in Africa have no
specific word to designate music; They use a single term signifying the
1 THE REASONS SUPPORTING THE USE OF MUSIC IN REHABILITATION 3
presence of music and dance at the same time. In various contexts music
accompanies working activities: In Ghana, gardeners work more speed-
ily when accompanied by music; In the Hebrides, the activity of textile
workers is accompanied by songs that change according to the move-
ments to be performed; Some sailors’ songs also change according to the
required maneuvers (DeNora, 2000). Blacking (1973) emphasized the
notion of music as being firmly embedded within body movements, a
point supported by his long-lasting experience in studying African music.
This author thought that adding a physical-motor experience makes the
sounds take on a different meaning compared to when we only perceive
the sound with our ears.
From an ontogenic point of view, the connection between music
and movement develops very early. Philips-Silver and Trainor (2005)
reported that at 7 months of age infants show the preference for
a rhythm associated with a synchronized rocking of the cradle. At
18 months of age children, while they are listening to music, sponta-
neously perform rhythmical movements synchronized with the sounds
(Sloboda, 1985). At a later age, the connection between music and
movement does not require the involvement of one’s own body. For
example, Boone and Cunnigham (2001) asked 4 and 5-year-olds to make
a teddy bear dance according to the emotional features of short musi-
cal segments while they were listening to them. Afterward, adults were
presented the videotaped performance played by the children without
the accompanying music track and were requested to identify the emo-
tion that the body movement intended to express. Results showed that
children were successful in moving the teddy bear coherently with the
emotional meaning of the associated music. The detailed analysis of how
children handled the teddy bear highlighted that upward movement,
rotations, shifts, as well as the tempo and the force of the movements,
differed significantly according to the expressive meaning of the corre-
sponding music.
Secondly, music has an iconic, i.e., a visuospatial, component. Music,
at least under some circumstances, seems to translate spontaneously into
images. For example, it is proven that musicians, when compared to
nonmusicians, have higher capacities of visuospatial memory and their
hippocampus—a cerebral structure connected with this kind of mem-
ory—is more developed (Sluming et al., 2005). Practicing music devel-
ops visual mnestic abilities, probably because of the inherent figural
nature of sound patterns. Even people without any musical training think
about music in spatial terms. In an experiment, Halpern (mentioned in

Krumhansl, 1992, p. 202) presented one word, by selecting it from the
lyrics of a song, and subsequently another word from the same song. The
task of the subjects was to compare the pitch of the notes corresponding
to the two words. The reaction time recorded during this task increased
as a function of the distance (in terms of the number of bars) between
the two words in the song. This suggests that the listeners scanned an
image of the melody mentally. Hence, music seems to promote a mental
activity similar to the one that happens when we mentally scan visual
images.
Thirdly, music comes with a verbal component. Similarities between
music and verbal language concern mostly the syntax of music.
Some authors (for example, Lerdhal & Jackendoff, 1983) identi-
fied some broad cognitive principles can be used as the foundations
for musical listening. As happens for the syntactic structure of ver-
bal language, music implies abstract structures that meet the laws of
generative grammar with a set of recursive analytical rules. However,
the verbal dimension of music appears not only at the level of syntactic
structures, but involves narrative structures as well. Heinrich Schenker
(1954)—an author who anticipated the ideas advocated by Lerdhal and
Jackendoff—suggested that the diatonic triad is the Ursatz, that is to say,
the basic structure, where the tonic represents the initial balance, the
dominant introduces tension, and the return to the tonic reestablishes
the balance. It is possible to find a correspondence between this har-
monic pattern and the grammar of stories. Fairytales and other narra-
tion quite often introduce early on a transition from an initial, calm,
situation to a problematic one, to end with the resolution of the conflict
or tension.
Furthermore, the verbal dimension of music appears at the phonet-
ic-prosodic level, well exemplified by the attempts to reproduce the
inflections of the spoken language through musical sounds, and at the
pragmatic level, when the dynamic of roles, entrances, and alternations
of the interlocutors in the development of the discourse is at play.
We can conclude that music activates in the listener and the performer
some mental processes in all three registers (motor, iconic, and verbal)
and we can find the reasons of its therapeutic-rehabilitative efficacy in the
synchronized activation of these registers. In the following paragraphs,
we will develop further this last point.
Relationships Within and Between Registers

The motor register is activated at different levels. First we have the neu-
rovegetative responses modulated by sounds (e.g., variations of the heart
and breathing rates), then gestural responses (exemplified by the ten-
dency to accompany music by tapping the feet or drumming the fingers),
and finally more complex patterns of action (e.g., those implied in the art
of dancing).
The iconic register is linked to visual synaesthesia: visual, synesthet-
ic-like experiences may be elicited by sounds, which are perceived
as dark, shining, and so on. Furthermore, the visual features of music
appear in the topological relations that sounds remind us of. For
instance, music can be compared to or described as continuous or bro-
ken lines, or it can inspire a sense of closure or opening, and so on.
Finally, music takes shape in visuospatial isodynamic (it suggests upward
or downward jumps, approaching or departing trajectories, etc.).
The verbal register is involved at a primary level through the usage of
onomatopoeic symbols (e.g., musical sounds can be used to imitate natu-
ral or artificial sounds) and at a more sophisticated level through the use
of prosodic intonations, that can be achieved by using accelerations and
decelerations, variations of rhythm and intensity, or by changing the over-
all “tone”—solemn, whining, peremptory, friendly, etc.—with which the
musical discourse is pronounced. These strategies allow building a discursive
structure, better-organized thanks to the distribution of parts, entrances and
relative turns, repartition of topics introduced in the discourse, and so on.
What relationship exists between the different registers? The registers
are interdependent and synchronized. They are activated by the same
musical stimulus and mirror the same characteristics of this stimulus,
even if with a different emphasis. For example, an aspect of the piece will
be better reflected or expressed by the motor register, another within
the verbal one. Using different words, we can say that what is processed
within a given register is correlated to and presents some analogies to
what happens in another register.
Let us use a concrete example to describe this isomorphism among
different registers. If we imagine a path covered with gravel, we can
easily see how some stones will protrude more than others and some
depressions will form as well. Let us imagine pressing a piece of card-
board into the ground. Some features of the path—its protrusions and
depressions, etc.—will be found on the piece of cardboard. For instance,

where on the ground there was a sharp stone, on the card there will
be a narrow and high protuberance. In some way, the characteristics of
the ground have been “re-transcribed” in the shape the card has taken.
There are some correspondences between the two surfaces, even if each
one is “made” of different things (in this example, stones for the above
and cellulose mixture for the latter). If we now imagine pouring some
colored paint on the modeled card after it has been pressed into the
ground, we can see how the paint will run down along the protrusions of
the card and thicken in its depressions, coloring protrusions, and hollows
with different intensity. If we flatten the card now, we can still detect the
original roughness of the ground that has been impressed on it regard-
ing protrusions and hollows, because the different intensity of the paint
has “transcribed” the three-dimensional undulations of the paper. With
a different medium (the paint pigment) the characteristics of the ground
have been maintained since we can still find the same set of relationships
made of hollows and protrusions that are on the ground. We have three
different levels and three different materials—stones, paper, and colored
pigment. Although different, each of them represents the same system
of relations, since the same “print” has been impressed by these differ-
ent materials. A “transcription” is, therefore, a projection, on a certain
mental register, of characteristics emphasized in a different register. The
“transcriptions”, i.e., the correspondences that are formed among the
different registers (motor, iconic, and verbal), contribute to transform-
ing the mental processing of music into a consistent complex of acts that
generates an overall strong impression.
The ability to grasp the correspondences among different registers
appears quite early. According to Stern (2000), infants show an ability to
connect the perceptual information from various senses (sight, hearing,
touch). For example, infants capture the relation between the rhythm of
a repeated noise and a similar touch-based rhythm (for example a caress)
and they associate these rhythms with the on-off switching of a light
occurring at the same pace. At 3 weeks after birth infants grasp the rela-
tionship between a time matching hearing and visual patterns. When the
mother tries to calm her baby by singing or pronouncing some words
with rhythmical and prosodic inflections, and she accompanies her voice
with a synchronized movement of her hands caressing the child’s body,
the baby perceives the correspondence between the two experiences
(auditory and tactile).
Musical cognition is a multimodal form of knowledge that, through

the simultaneous activation of different registers, produces a global expe-
rience. We will now focus on each one of these registers and on how that
can potentially enhance rehabilitation.
The Motor Register
On a first level of the motor register, we find how music triggers neu-
rovegetative reactions and affects individuals’ biological rhythms. Within
a general tendency to synchronize the internal bio-physiological oscilla-
tions with the external rhythms that are heard, we can notice that the
musical rhythm induces variations in the cardiovascular and respiratory
rates that, in turn, affect other physiological changes. It has been con-
firmed that lullabies decrease the heartbeat and the respiratory rate by
synchronizing them with music (Scherer & Zentner, 2001). It is not
only rhythm that has these effects: The emotional quality of music also
changes the cardiorespiratory rate (Sloboda & Juslin, 2001).
On a different level of the motor register, it is proven that people per-
ceive the expressive tension-release dynamisms in music (Gabrielsson &
Lindström, 2001). When subjects were asked to press on a device chang-
ing the intensity of the pressure on the basis of the tension perceived
in the musical piece they were listening to, the researchers noticed that
moments of tension and relaxation alternated. Furthermore, a high ten-
sion was recognized in correspondence with sections of fortissimo, when
the melody was ascending, the density of notes increased, places of disso-
nance occurred, rhythmical and harmonic complexity was high, musical
segments were repeated, as well as during the pauses and in the parts
where some musical ideas were developed.
Similar responses can be found at the level of muscular reactions
linked to facial expressions. Usually, people respond with sublimi-
nal changes in their facial expression while they are listening to music
(Molnar-Szakcs & Overy, 2006; Sloboda & Juslin, 2001). These
responses tend to be specifically related to the type of music (Scherer &
Zentner, 2001): Music with negative emotional meaning tends to pro-
duce a greater corrugating muscular activity, whereas music with posi-
tive emotional meaning induces zygomatic activity. These associations
between music and motor responses appear early: 3–4-year-olds know
how to match musical pieces and facial expressions congruently with the
emotional character of the music (Sloboda & Juslin, 2001).
On a more sophisticated level, it has been shown that music gener-

ates in the listeners motor responses that allow them to mirror the ges-
tures performed by the interpreter (Leman, 2008). These findings are
supported by experiments showing that people can associate to music
the corresponding gestures and actions. For instance, only by watching
the videotape of a musical performance without any soundtrack, people
can successfully guess the artistic intentionality of the piece (Davidson,
1993, 1995). This skill can also be noticed when observing people mak-
ing sound-producing gestures in the air without playing any particular
instrument (Godøy, Haga, & Jensenius, 2006). Similar findings were
reported when considering ballet performances: Hearing only the music
or seeing only the body movements produced similar judgments about
the beginnings and the ends of the internal sections of the performance,
as well as about the tension and the emotions conveyed by the stimuli
(Krumhansl & Schenck, 1997). The visual experience of a musical per-
formance provides listeners not only with information about the context
where it takes place and the alleged personal features of the musician but
also with a variety of cues which can emphasize the expressive intention
of the executor (Antonietti, Cocomazzi, & Iannello, 2009; Thompson &
Russo, 2004). The gestures of the performer help de-codify also some
structural aspects of music. In an experiment (Thompson, Graham, &
Russo, 2005) a singer was videotaped while performing music intervals
varying in range. Subsequently, two samples were presented with only
the soundtrack or only the soundless filmed sequence. In both condi-
tions, the judges adequately identified the range of the different inter-
vals. In the visual video cues, such as the facial expression and gestures
of the singer, were enough to assess the extent of the performed melodic
interval.
Many attempts have been made to enhance (Colombo et al., 2013;
Gaggioli, Morganti, & Antonietti, 2010) and rehabilitate (Di Nuzzo
et al., 2015; Trobia et al., 2009; Trobia, Gaggioli, & Antonietti, 2011)
motor functions through music. Nowadays technology enables us to
expand the natural link between music and movement or to recover it
where physical disabilities have impaired it. For example, Tam and col-
leagues (2007) devised a computer system, called Movement-To-
Music, which allows children with impaired movements to play and
create music, resulting in broader horizons and increased quality of
life. Patients with spinal chord injuries were trained to create and play
music using an electronic music program: This tool led them to exercise
upper limbs which were connected to a synthesizer through a computer.

Other similar devices are Soundbeam and Wave Rider (Paul & Ramsey,
2000). In all situations when music contributes to restoring motor func-
tions (Thaut, 1988), music can be conceived as an anticipatory and con-
tinuous temporal template that facilitates the execution of the movement
that has to be rehabilitated thanks to auditory-motor synchronization.
The Iconic Register

On a first level of the iconic register, visual representations triggered by
music are perceived as scattered chromatic sensations. Through synaes-
thetic mechanisms, sounds elicit experiences afferent to non-acoustic
sensory modes (Bragança, Marques Fonseca, & Caramelli, 2015).
On a different level, music can elicit visual images that convey topo-
logical relations. First of all, it is clear that the flow of musical notes is
inscribed in a sound environment with basic spatial coordinate vecto-
rially oriented from left to right. The Spatial-Musical Association of
Response Codes (SMARC) effect (Lidji, Kolinsky, Lochy, & Morais,
2007; Rusconi, Kwan, Giordano, Umiltà, & Butterworth, 2005) can be
used as evidence for it. The SMARC effect is a form of stimulus-response
compatibility effect. The subject is asked to face a screen where some
stimuli appear; They can appear unpredictably either on the left or the
right sides of the screen. The task is to push a button as soon as one per-
ceives the appearance of the stimulus. If the position of the stimulus and
the button to be pushed are compatible (e.g., the stimulus appears on the
left side of the screen, and the button is at the left side of the subjects,
so that they use their left hand to push it), the response is quicker than
it would be in a situation of incompatibility (the stimulus appears on the
left, and the button for the answer is on the right). If the stimuli are musi-
cal notes and individuals are asked to determine whether, compared to a
standard note, the next stimulus is higher or lower, the SMARC effect
occurs. If the button corresponding to the answer “lower” is on the left
and the button corresponding to the answer “higher” is on the right, the
response is quicker as compared to the condition where the buttons are
switched. This happens because in the first condition there is compati-
bility between the stimulus characteristic (pitch) and the position of the
button. The musical notes are therefore mentally represented in a space
vectorially oriented from left to right so that low pitches tend to be psy-
chologically “located” on the left and high pitches on the right.
The iconic power of music is perceived very early. According to Spelke

(1976, 1979), 3 and 4-month-olds are capable of detecting when audi-
tory rhythm and visual rhythm are coordinated and when they are unco-
ordinated. In a series of experiments, infants were shown a visual scene
where a puppet representing an animal was making jumps. A sound was
produced either when the jumping puppet was landing or a little later.
Children preferred to watch the visual scene where jumps and sounds
were coordinated rather than the uncoordinated scene (their preference
was assessed according to the frequency and duration of visual fixations).
Other studies showed that 6–8-month-olds could understand numeri-
cal correspondences between sounds and images. For example, given a
choice to look at a scene where two objects were presented or a scene
with three objects, if the infants heard two sounds, they rather watched
the two-object scene, while they turned their gaze to the three-ob-
ject scene if there were three sounds. The skills highlighted by Wagner
and colleagues (1981) in 6–14-month-olds are even more surprising.
Children seem to be able to associate characteristics of sounds (such as
pitch) and characteristics of sound sequences (ascending or descending
sequences, sequences of continuous or intermittent sounds) with simi-
lar characteristics of lines. Children prefer to watch a low line, a small
circle, and a dark circle in concomitance with low pitch and a high
line, a big circle, and a clear circle in correspondence with a high pitch.
Moreover, they prefer to turn their attention to an ascending arrow if
they are listening to an ascending melodic line and a descending arrow if
the melody is descending, or to a continuous line if the sound sequence
is continuous and to a broken line if the sound sequence is intermittent.
Older children—as documented by Walker (1987)—know how to
make even more complex associations, such as matching weak and
strong, low and high, long and short notes with, respectively, long and
short lines, light and dark lines, low and high lines, empty and full sym-
bols. Fairly early on children understand that specific characteristics of
sound stimuli can be represented graphically with a variety of devices
(Bamberger, 1991).
To summarize, it seems that the figural aspects of musical language
can be assigned a role not only in these “peripheral” moments—
respectively “incoming” (perceptual organization) and “outgoing”
(emotional response)—of the process of listening, but also in the “cen-
tral” moment of the listening experience, when the formation of mean-
ing of the musical piece happens.
The visual resonances and spatial analogies activated by music are

often used in rehabilitative interventions to induce patients into a state
that favors the recovery of their cognitive and emotional resources. To this
end, a method called Guided Imagery and Music (GIM) has been devised.
It intentionally elicits visual imagery in the patient’s mind starting from
music-based stimuli. In addiction, Music-Assisted Relaxation and Imagery,
a variant of GIM, has been proven to be more effective in rehabilitation
than traditional music therapy (Mandel, Hanser, Secic, & Davis, 2007).
The Verbal Register

A first level where correspondences between music and verbal language
can be detected is the structural-syntactic level, where discrete elements
(notes in the former, words in the latter) are organized into a sequence
by respecting some formal rules. It is not surprising, then, that aphasic
people with difficulty in understanding the syntactic aspects of language
also show difficulty in perceiving syntactical aspects of music related to
harmonic relations (Molnar-Szakcs & Overy, 2006).
On a different level, the verbal dimension of music appears to be
related to how speech is organized. According to Schaffer (1992), music
can convey a narrative. The structure of a musical piece describes an
implicit event. The way the piece is performed gives shape to this event,
enriching it with emotional connotations. The gestures of musical expres-
siveness would then correspond with the emotional gestures of the
implicit main character of the story who participates in or witnesses that
event. In other words, the interpretation made by the performer has the
function of helping define the character of the protagonist in the narrative
script, which is implicitly embedded in the musical structure. The musi-
cal elements define the implicit event, i.e., the structure that has a deci-
sive and primary role in determining the range of gestures suitable for
that musical piece. The performer, like a storyteller, has to be loyal to the
structure of the story and, at the same time, has the freedom to modulate
the emotions of the characters. In other words, the performer has the task
to create the character to add profound meaning to the literal surface of
the musical piece. Schaffer argued that the details of musical expression are
more fully understood if regarded as corresponding to the gestures of an
implicit main character. Following this line of reasoning, Sloboda (1985)
pointed out that people recognize better a melody if, as they are listening
to it, they label it with particular titles that hint at its dramatization. This
is a potential way of using music that Noy (1993) designated as “narrative

path,” which leads the listener to identify with the experience of the com-
poser, feeling their emotions as if reliving their own narrative.
However, these ideas have to do with either the execution (the musi-
cian concretely renders the narrative dimension) or the reception (it is
the listener who projects a narrative plot into music). Following Shaffer’s
suggestions, how can we identify the narrativity in the structure of music
itself? Like in a story, the plot unfolds through premises, the creation of
preconditions, anticipations, escalation, dramatic turn of events, sudden
resolutions, and so on, and the unfolding of the musical discourse pro-
duces similar variations of the arousal levels. The emotional “path” of
music would be parallel to that of a story that could overlap it.
Music and verbal language share some prosodic inflections. It seems
that our nervous system has developed specialized structures and pro-
cesses to deal with the prosodic aspects of language (Peretz, 2001). The
superiority of the right ear (and consequently the left hemisphere) for
processing the content of words and the superiority of the left ear (and
therefore the right hemisphere) for the perception of the emotional
tone of voice has been demonstrated. Hence, brain damages compro-
mise selectively the identification of emotional connotations of the voice
as well as the grasping of prosodic variations in exclamations, questions,
and assertive sentences.
It is not a coincidence that children prefer songs addressed to them rather
than songs addressed to adults. Children know how to seize the prosodic
inflections of the former and perceive them as adapted to interact with
them. It is a fact that in all cultures children are the receivers of songs
addressed to them by the adults and that in many cultures these songs
are specific for children. Experiments conducted by Trehub and Trainor
(1998) showed that, when adults sing for a child, they make higher and
slower sounds, in a more loving tone, introducing longer pauses between
phrases as compared to when they sing for other listeners. Furthermore,
adults seem to use two specific singing styles with children: a lullaby-like
mode when they want to quieten and let the child fall asleep and a playful
mode aiming to activate the children and draw their attention on exciting
aspects of the environment.
The continuum existing between the spoken and singing languages
explains the prosodic correspondence between texts and sounds in vocal
music. However, it is less straightforward to explain the prosodic aspects
of instrumental music. Such aspects are grounded on the fact that com-
mon traits of music and the human expression of emotions can be found
in the characteristics of the voice. A voice expressing sadness and music

conveying sadness share some features, such as low pitch, a small range
of pitch variations, low intensity, trailing sound flow, slowness, pauses, a
progressively flat trend of the pitch and the rhythm, etc. The instrumen-
tal music tries to mirror these features through nonvocal sounds.
The analogies between prosody of verbal language and prosody
of music account for the use of singing in rehabilitating the fluency of
spoken language. For example, music is beneficial in the treatment of
acquired dysarthria following traumatic brain injury or strokes. The intel-
ligibility and the naturalness of speech of dysarthric patients improved
as a consequence of a set of sessions where they performed, besides res-
piratory motor exercises, rhythmic and melodic articulary tasks based on
intonation and singing (Tamplin, 2008). Singing is an effective way to
rehabilitate aphasia too. It has been proven that patients suffering from
severe forms of non-flowing aphasia benefit from the Melodic Intonation
Therapy, a rehabilitation technique based on the imitation of singing
(Molnar-Szakcs & Overy, 2006). Musical techniques can also be applied
to improve the vocal quality, the coordination, rhythm, and timing of
speech and pragmatic use of language in children with acquired brain
lesions (Kennelly, Hamilton, & Cross, 2001).
Also, dyslexic people can be trained through music. Besson and col-
leagues (2007) found that musical activities were successful in improving
pitch processing in speech, an ability that is fundamental in second lan-
guage learning and that is impaired in dyslexic children, hence suggest
ing that music can be employed as remediation in dyslexia to improve
people’s impaired reading skills. This is in agreement with the obser-
vation according to which dyslexic children show some difficulty
in the timing in music and, if they attend music classes, they improve
their reading skills (Molnar-Szakcs & Overy, 2006). Furthermore, spe-
cific rehabilitation programs based on the rhythm of reading have been
proved to be beneficial to these patients (Bonacina, Cancer, Lanzi,
Lorusso, & Antonietti, 2015; Cancer & Antonietti, 2017; Cancer,
Bonacina, Lorusso, Lanzi, & Antonietti, 2016).
Concluding Remarks
As we have been discussing in this chapter, if music can trigger representa-
tions and processes in different mental registers (motor, iconic, and ver-
bal)—given that sounds carry affordances, forces, vectors which drive
specific actions, images, and ways of speaking and that what occurs in the
various registers is reciprocally synchronized—both the power of music as

a spontaneous elicitor of emotions (Allevi, Colombo, & Antonietti, 2011)
and as a natural tool of communication (Antonietti & Colombo, 2014)
and the deliberate use of music for rehabilitative purposes are justified.
Music is intrinsically motor, iconic, and verbal, since gestures, images,
and words are not external elements to it. Motor, visuospatial, and verbal
elements are already present in the innermost nature of music. The reg-
isters that music activates (movements, figures, words) are not “added”
to music from the outside. They are deeply embedded in music. It is
because of this very embedding that we can argue that music can act
with a vicarious function within the rehabilitation context.
When the processes of motor planning are impaired, music can pro-
vide the sequential and rhythmical patterns required to perform actions
that need to be learned, and this is possible because these patterns are
embedded in the music itself. When mnestic processes fail in recalling the
past, music helps the memory emerge because it suggests colors, shapes,
spatial movements that can be found in visual scenes. If the organization
of verbal language is impaired, music can assist it, because it contains
discursive patterns. In other words, music, thanks to its multimodal
nature, offers “scaffolding” on which one can learn to perform move-
ments, carry out cognitive operations, or articulate verbal expressions
that need to be rehabilitated.
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CHAPTER 2
Enhancing Self-Regulatory Skills in ADHD

Through Music
Abstract  Music can play a role in the treatment of children and teens

with ADHD since it provides patients a self-regulatory system, which
enables them to manage the internal time according to variations in the
external time and to synchronize behavior with external stimuli. Thanks
to these mechanisms the individuals get control over their impulsive
tendencies and can plan their behavior according to the goals they set.
This chapter presents a review of the relevant literature about the effects
of musical interventions in ADHD. Some studies aimed at improving
self-control in people with ADHD employing music intervention pro-
grams (consisting of either individual or small-group sessions), as well as
some activities included in such programs, are also described.
Keywords  ADHD · Music · Music therapy · Self-regulation

Impulse control
Defining ADHD
Children with Attention Deficit-Hyperactivity Disorder (ADHD) tend
to have average or higher than average IQ, yet they cannot focus their
attention, are often restless, work in a disorganized and disordered man-
ner, and have considerable difficulties in tasks that require a high and
constant level of concentration. At times they are very present, while
at other times it seems that their mind is elsewhere and that they do

https://doi.org/10.1007/978-3-319-97151-3_2
not listen to or have not heard what has just been said to them. They
disperse, handle carelessly, or damage materials they are managing or
using. They frequently switch from one activity to another without fin-
ishing any of them. They are easily distracted by irrelevant stimuli. To
be more specific, they perceive the stimuli as an “assault” and frequently
interrupt the tasks they are carrying out to pay attention to unimpor-
tant noises or to events that are usually ignored by others. Children
with ADHD also show behaviors that do not have any specific aim (e.g.,
they might clap their fingers rhythmically, continuously change position
on the chair, open and close a zipper or a lid several times). They tend
to be always on the move. Sometimes they can appear clumsy in their
movements, hitting things or even falling to the ground. They nerv-
ously play with objects, tap with hands, and shake their hands and feet
too much. They often get up from the table during meals, while watch-
ing television, while they are doing their homework. They constantly talk
and make noise even when they are involved in calming or relaxing activ-
ities. They cannot wait for gratifications when they did something right,
and for this reason they immediately demand what they had been prom-
ised. They also prefer to have a little gratification immediately rather than
to commit time and effort to receive a bigger prize later.
The current classification of ADHD deficits includes three subtypes:
• the type with predominant inattention: ADHD-I. This subtype

describes a child who shows symptoms of inattention and only a few
symptoms of hyperactivity-impulsivity, which have persisted for at
least 6 months.
• the type with predominant hyperactivity-impulsivity: ADHD-H.
This subtype describes individuals presenting symptoms of hyperac-
tivity-impulsivity and few symptoms of inattention persisting for at
least 6 months.
• combined type: ADHD-C. This subtype can be used if children
present both symptoms of inattention of hyperactivity-impulsivity
for at least 6 months.
These different subtypes show different patterns of cognitive and behav-

ioral deficits. In particular, Stanford and Hynd (1994) found that the
type with prevalent inattention is more withdrawn socially, more iso-
lated, and children who have this subtype are generally described more
2 ENHANCING SELF-REGULATORY SKILLS IN ADHD THROUGH MUSIC 21
as “daydreamer”, shy, and less active (slow movements and low energy).
On the other hand, children with predominant hyperactivity act before
thinking, they often switch activities, have difficulty waiting for their
turn and shout in class. The observations of Stanford and Hynd (1994)
are consistent with other studies that have highlighted the presence of
greater “internalized symptoms” (shyness, cognitive difficulties), prob-
lems of academic learning, and deficit in the elaboration of informa-
tion in subjects with ADHD-I. In contrast, in children with ADHD-H
and ADHD-C, there is a higher frequency of “externalized symptoms”
(excessive movement, aggression) and adaptation problems.
The disorder is much more common in males than in females and
the male–female ratio varies from 4:1 to 9:1 depending on the condi-
tions (i.e., general population or hospitalized subjects). Hyperactivity is
the dimension that most distinguishes the two genders. It is more pres-
ent among males and the greater visibility of hyperactive behavior consti-
tutes a factor that can explain, in part, the highest incidence of ADHD
among males. In females, the attentional deficit could be underesti-
mated, as it is masked by the absence of hyperactivity (Epstein, Shaywitz,
Shaywitz, & Woolston, 1991).
Douglas (1983) addressed ADHD by emphasizing above all the cog-
nitive and motivational components and identifying four components in
the cognitive functioning of children with ADHD:
• the marked tendency to seek immediate gratification and

stimulation;
• a reduced attentional effort and commitment in complex tasks;
• difficulty in inhibiting impulsive responses;
• difficulty in modulating the level of excitation.
These components, together with secondary deficits, cause the feeling

of failure, which, on a circular basis, reinforce the behaviors of inatten-
tion and impulsivity typical of this disorder. This creates a vicious circle
that progressively increases the symptoms of ADHD which, in turn, will
increase the chances of encountering failure, and so on.
It is believed that ADHD originates from a self-regulation deficit,
namely a general difficulty in the modulation of behavior that includes
attentive, motivational, problem-solving aspects. The deficit also involves
limited interest in maintained attention, lack of ability to realistically
assess the solvability of a task, difficulty in committing to invest time and

effort; problems in the ability to self-reinforce oneself to maintain the
commitment and the right level of emotionality.
Children with ADHD cannot use thinking processes to monitor
the strategies used to analyze the demands of a task and to control the
choice of an appropriate procedure and its application. This situation is
mainly due to the lack of internal dialogue.
Another model that takes into account experimental data concerning
the functioning of the central nervous system is proposed by Stanford
and Hynd (1994). These authors found that the level of activation of the
central nervous system is significantly lower in subjects with ADHD than
in healthy subjects. This hypoactivation would manifest itself through
low energy and slow movements. This explains why children with
ADHD continuously search for stimulation, a behavior that turns into
motor hyperactivity.
Sechi, Corcelli, and Vasquez (1998), to explain some components
of attention deficit, referred to executive functions (EFs) (Pennington
& Ozonoff, 1996). EFs are defined as varied tasks that share the need
to use specific strategies to achieve the goal. For example, the inhibition or
delay of an answer, the strategic plans of action sequences to achieve a
purpose, and the mental representations of the tasks. The primary cogni-
tive element that unites these functions is the selection of specific actions
adapted to the context and the consequent inhibition of competitive and
less appropriate responses.
The domain of EFs overlaps with other concepts such as attention,
working memory, and problem solving. Several studies have identified
the headquarters of EFs in the frontal areas of the brain. Shallice (1998)
discovered that injuries in these areas generate difficulty in carrying out
actions with a clear purpose, which require a subject to choose among
several competitive responses. The weakening of these functions would
hence be linked to the inhibitory processes. The individual understands
the task but does not complete it, since two problems occur: persevera-
tion and distractibility. The first refers to the activation of schemas that
are unlikely to be replaced, regardless of their effectiveness. The second is
the tendency to be sidetracked by irrelevant stimuli of the environment.
The hypothesis that a dysfunction of the frontal areas causes ADHD
also seems to be confirmed by studies on patients with lesions in these
areas that often show hyperactivity, distractibility, and impulsivity (Levin,
Eisenberg, & Benton, 1991).
In conclusion, the three primary symptoms of ADHD (distractibil-

ity, impulsivity, hyperactivity) would seem to derive from a deficit of the
inhibitory control, considered an EF linked to the frontal areas. Shallice
and colleagues (2002) have applied some tests assessing EFs to healthy
subjects and individuals with ADHD. These authors identified three
domains within the ADHD symptomatology that are connected to three
specific areas of the brain. The authors located a center of inattention
oriented in the posterior parietal lobe, a center of alert inattention in the
right dorsolateral prefrontal cortex, a center of impulsivity-hyperactivity
in the anterior cingulate. ADHD would derive from an inadequate func-
tioning of the center of “alert inattention” or the failure of the high-
level effort system. ADHD can hence be seen as the result of the loss of
two systems: the right frontal vigilance system evolving into the monitor-
ing center and the top of the high-level effort system.
Focusing on the neurological basis of ADHD, Barkley (1997a,
1997b) believes that three brain areas are involved in ADHD dysfunc-
tions: the prefrontal cortex, a part of the cerebellum, and at least two
basal ganglia. In confirmation of his hypothesis, it has been shown that
the right prefrontal cortex, two basal ganglia, the caudate nucleus, and
the cerebellar vermis are significantly less developed in children with
ADHD. All of these areas are those most involved in the processes of
regulation of attention. It seems, in fact, that the right prefrontal cortex
is involved in behavioral programming, distraction resistance, self-aware-
ness, and time processing.
The caudate nucleus has the task of inhibiting the automatic responses
to allow a more accurate decision and coordination of the various
impulses deriving from the cortex. The cerebellar vermis is linked to
motivation. However, the inadequate functioning of working memory
(ability to hold information about a task while it is being carried out,
even if it is no longer in the presence of it) reduces the sense of time,
while enhancing the inability to keep events in mind, to perform retro-
spective evaluations, and to forecast. The internalization of the self-di-
rected speech (together with the self-instructions that the subject silently
gives) occurs late in subjects with ADHD causing deficiencies in self-reg-
ulated behaviors and reconstruction.
Self-regulation of mood, motivation, and attention makes it possi-
ble to achieve goals by modifying and delaying immediate reactions.
When this system does not work correctly, individuals will exhibit their
emotions without any censoring and reduce their ability to control

motivation and impulses.
Reconstruction can be defined as the ability to break down behaviors
into their components, to replace and recombine them to make them
more functional to achieve the goal. When this function is not ade-
quate, individuals are not able to analyze behaviors to process new ones.
Besides, they will have many difficulties in solving problems because they
lack flexibility and planning.
According to an alternative perspective (Fabio, 2001), higher arousal
originates in the organism a very low reception threshold, so that even
a mild or neutral stimulus tends to be perceived as significant. The per-
ception of a child with these levels of activation is that of a constant
“assault” of stimuli. This burst of stimuli increases the state of tension (it
is a process similar to stress in adults). To discharge this tension, children
produce behaviors of self-stimulation of both thought and movement.
Self-stimulation of thought produces a continuous attention shift, that
explains why children with ADHD continually change the focus of their
thought. Motor self-stimulation refers to the fact that these children
produce unplanned exploration behaviors, as well as micromovement
of the hands and the tongue. Self-stimulation lowers the state of inter-
nal tension and can generate a self-gratification circle that maintains the
symptom. Therefore children with hyperactivated arousal can alternate
moments of clarity (ability to receive stimuli) to other moments when
they are unable to process stimuli (in the presence of self-stimulation).
Hypoactivated arousal produces a low level of activation that gener-
ates a very high reception threshold in the organism so that even strong
and significant stimuli are perceived as neutral and therefore do not enter
the information processing system. In both cases the effect is the same,
i.e., the child may be more predisposed to attention deficit.
Recently, it has also been recognized that ADHD is a complex and
heterogeneous disorder that involves several brain networks regulating
cognitive, motivational, and emotional activity. Functional magnetic res-
onance imaging (fMRI) applied to ADHD children during wakeful rest
led researchers to identify atypical patterns of brain activity when no
specific task is being undertaken (Castellanos et al., 2008). The focus of
fMRI studies was a vast area of the brain that includes different regions
functionally connected: posterior cingulate cortex, precuneus, medial
prefrontal cortex, and inferior parietal lobes (Castellanos et al., 2008).
All these regions constitute the so-called default mode network (DMN).
DMN is a neural substrate that is involved in introspective cognitive pro-
cesses such as meditation (Hasenkamp, Wilson-Mendenhall, Duncan, &
Barsalou, 2012) and self-related thoughts in the present and the future
(Buckner & Carroll, 2007). In children with ADHD, there is a dysfunc-
tion of the activity of DMN during rest situation, that may disrupt pro-
cesses of prospection and undermine effective decision making. On the
other side, a lower activation of DMN activity is necessary for goal-ori-
ented tasks, in order to shift effectively from resting to working brain
states. It was found that an excessive DMN activity in individuals who
were working on processing tasks during fMRI studies is associated with
low performance (Sonuga-Barke & Castellanos, 2006). Studies in chil-
dren with ADHD showed that they fail in suppressing the DMN activ-
ity during cognitive tasks (Fassbender et al., 2009). This may explain the
patterns of ADHD-related periodic attentional lapses and intra-individ-
ual reaction time variability. Furthermore, studies on spontaneous very
low-frequency oscillations (VLFO) showed that these are attenuated
when individuals are working on attention challenging tasks or waiting
for rewards (Hsu, Benikos, & Sonuga-Barke, 2015). Individuals with
ADHD display excessive VLFO when engaged in attention tasks. They
also have difficulty in waiting for rewards.
Researchers underlined the motivational aspect linked with ADHD
and described this deficit as depending on hypersensitivity to reward-re-
lated delay (Sagvolden, Johansen, Aase, & Russell, 2005). In this case,
ADHD is assumed to be characterized by an abnormal sensitivity to rein-
forcement, including reward, punishment, and response cost. Because of
that, children with ADHD are described as “delay averse” rather than
“impulsive”.
A reconciliation of the two previous accounts, according to which
ADHD develops across two separate pathways, has been proposed. The
first pathway, the cognitive one, includes executive deficits such as work-
ing memory and inhibition. The motivational path is linked to delay sen-
sitivity and aversion (i.e., the tendency to choose a smaller immediate
reward rather than wait for a more substantial delayed reward) (Sjowall,
Roth, Lindqvist, & Thorell, 2013).
As we discussed above, many previous studies in the field of ADHD
focused on EFs. They approached EFs as either a unitary construct or
conversely as a set of separate and specific abilities (Miyake & Friedman,
2012). The first of these approaches over-assimilate different tasks into a
single construct, for example deriving assumptions on EF starting from

single tasks, which differ from study to study. The second approach, on
the other hand, over-splits, treating a long list of tasks—such as decision
making, planning, and verbal fluency tasks—as if they were assessing
separate abilities rather than a standard set of component processes that
support completion of the more complex tasks.
Rather than showing only “unity” or “diversity”, the best current evi-
dence indicates that individual differences in EF show both unity and
diversity.
Following this line of reasoning, a unity/diversity model has been pro-
posed, that focuses on three aspects of EFs: updating working memory,
shifting, inhibition, as well as an ordinary EF ability which spans these
components. This position is consistent with the view that the ability to
be captured by common EFs—actively maintaining task goal and goal-re-
lated information and using this piece of information to effectively bias
lower-level processing—is the critical requirement of response inhibition.
Secondly, common EFs and shifting specific components sometimes show
opposed patterns of correlations with other measures, consistently with
the hypothesized trade-offs between stability (normal EF) and flexibility
(shifting-specific) suggested in the literature (Goschke, 2000).
Music Interventions Addressed to ADHD

The treatment of the main symptoms of ADHD through music is still
not widespread and only a few studies explored the effectiveness of
music-based methods on this disorder (Moore, 2009). Back in the
Seventies, Wilson (1976) used rock music in association with the time-
out technique as a negative reinforcement to effectively reduce inad-
equate or destructive behaviors. A few years later, the intervention
conducted by Cripe (1986) can be considered as the first attempt to sys-
tematically evaluate the effectiveness of music as a therapy for ADHD.
Cripe argued that music therapy could be a possible alternative to tradi-
tional treatment approaches, mainly because of its “non-invasive” nature,
compared, for example, to pharmacological therapies. The underlying
assumptions of his study were as follows:
1. The intense and repetitive rhythm of rock music stimulates brain

activity of ADHD children, to the point that it can be considered
comparable to that of typically developing children.
2. The very pronounced rhythmic beats of rock music prevail over the
distracting elements present in the environment and trigger ade-
quate orientation responses in children with ADHD. As we have
discussed above, these children have high levels of distractibility
and a limited attention span. Music with a very marked rhythm
could reduce the distractibility from the environment, allowing the
child to pay attention to a single stimulus for a longer time.
3. Rock music, with its repetitive rhythm, tends to produce a reduc-
tion in muscular and skeletal tension that results in less motor
activity: Children with this disorder, in fact, show a greater mus-
cular tension. Music manages to reduce this type of tension. As a
result of this decrease, involuntary and not finalized motor activity
can also be reduced.
Cripe started from the hypothesis that when rock music, with an intense
rhythm, is introduced as an environmental stimulus, children with
ADHD experience a reduction in the level of activity and an increase in
attention span. The study was conducted on 8 male children between
the ages of 6 and 8 who were asked to listen, using headphones, to
some pieces of instrumental rock music. In the meantime, two observers
recorded the activities carried out by children using an observation grid.
It turned out that rock music had a statistically significant effect on the
level of activity. In fact, during the non-musical parts, higher levels of
activity were detected.
Morton and colleagues (1990) showed that music improves dichotic
listening and, consequently, can improve short-term memory while
reducing distractibility at the same time. Later Pratt and colleagues
(1995) found that background music can reduce hyperactivity and other
unwanted behaviors.
Montello and Coons (1996) investigated the effects of active music
interventions compared to passive ones and found that subjects with
serious attention problems benefit more from passive listening interven-
tions since they do not require the internal structuring that is involved in
active ones.
The use of music was also considered to support learning processes
since learning disabilities are often comorbid with ADHD. Jackson
(2003) carried out a study on the use of music therapy as a treatment
for ADHD with the following goals: to ascertain which music-therapy
techniques are most effective with children affected by ADHD; to check
how much music therapy can be effective for the treatment of this disor-
der; to evaluate the role that music-therapy interventions play in relation
to other forms of therapy. The study was conducted by administering a
questionnaire to 268 professional music therapists, who were first asked
to identify the methods they used to treat children with a diagnosis of
ADHD. Music and movement were the most used techniques with
these cases, followed by instrumental improvisation, by playing one or
more musical instruments, and by group singing. Each of these methods
requires motor involvement and, except for group singing, often acti-
vates the movements of both the right and the left sides of the body.
The methods used less frequently were relaxation through music, vocal
improvisation, the Orff method, body percussion, and vocal instructions.
The choice of a specific method depended on the age of the child and
the type of setting. Moreover, several specific characteristics of the music
played an important role in affecting the results of the ADHD-focused
intervention. These include the ability of music to guide structured
movement and its impact on the activation of both cerebral hemispheres
(Morton et al., 1990), the ability to increase mnemonic functions, and
the ability to improve learning (Jackson, 2003), the power of some
sounds or tones to influence brainwave production (Plude, 1995).
Secondly, music therapists had to indicate which types of objectives
they intended to achieve through music therapy when working with sub-
jects with ADHD. It turned out that the most common objectives were
mostly behavioral, followed by psycho-social and cognitive ones. Some
professionals replied that they intended to achieve two or more types of
goals with their treatment. In fact, regardless of the method used, music
is simultaneously experimented at multiple levels.
According to Jackson, the fact that cognitive objectives are less fre-
quently pursued than behavioral and psycho-social goals merits reflec-
tion. The author interprets this finding suggesting that behavioral and
psycho-social improvements are easier to record and demonstrate in an
“objective and measurable” way compared to cognitive ones; Moreover,
most music therapists do not have a thorough preparation on neuro-bio-
logical functioning.
Finally, therapists were asked to express a preference by choos-
ing between group and individual therapies. Most music therapists
responded that they used both modalities, whereas some favored group
therapies and a small part led only to individual therapies. Subsequently,
the participants involved in this study had to report their perception of
the effectiveness of music therapy for children with ADHD. In general,

they indicated that this type of therapy was effective.
Several studies have shown the effectiveness of some music-based
activities in improving self-regulation ability in children with ADHD.
For example, participation in music groups, composed primarily of
peers, requires considerable attention and self-control and there is gen-
eral agreement that the rhythmic tasks result in an improvement in inter-
nal organization and impulse control. The rhythm can also be used to
increase body awareness and motor coordination (Moore & Mathenius,
1987). Rickson (2006), however, argued that participation in
music groups can further hyper-activate children with ADHD. This
result is consistent with the more significant positive response of indi-
viduals with this disorder to structured programs with a high level of
predictability. As a result, music-therapy interventions should use highly
structured rhythm activities to be performed in individual settings or
very small groups.
Rickson (2006) examined 13 male adolescents (aged 11–16 years)
with ADHD to compare the impact of direct and improvisational
music-therapy approaches on the level of motor impulsivity. To measure
impulsivity, the ability of the boys to maintain a rhythmic beat synchro-
nized with an external stimulus was evaluated. The “directive” session
involved the subjects in a hierarchy of activities with the rhythm (from
the simplest to the most complex) using percussion instruments, char-
acterized by a strong structuring and repetitiveness, which culminated
in the execution of a simple rhythmic composition. Each session ended
with a farewell song. The members of the group received direct verbal
instructions and advice and feedback following their mistakes and were
frequently reinforced for the correct answers or improvements.
In the “improvisation” session, through the process of “making
music” and the promotion of social skills, the patients had the oppor-
tunity to increase confidence, self-esteem, self-awareness, and sen-
sitivity towards the needs of others. Following a greeting song, the
boys were asked to choose a style (Country, Rap, Blues, Rock, Jazz), a
mood (happiness, sadness, boredom, excitement, anger, tranquility), or
a theme (the train, the forest, the beach, the car race, the school) for
group improvisation. Each participant was also asked to choose a per-
cussion instrument that in his opinion could express the chosen style/
mood/theme. Each session ended with a farewell song. The role of the
music therapist was to support and test the subjects musically, so verbal
stimuli were reduced to a minimum, and the approach was non-directive.
Furthermore, for each session, the music therapists observed the fol-
lowing behaviors: restlessness and agitation, moving through the room,
touching the equipment inappropriately, “firing” the answers before the
questions were asked, not listening to others, inability to use the instru-
ments quietly or to wait for their turn.
This study showed that the directive approach is slightly more effec-
tive, compared to the one based on improvisation, in reducing restless
and impulsive behaviors. Yet, both methods improved the ability to
listen to others and to participate in group work.
Borghesi et al. (1995) designed a music-therapy treatment for a
7-year-old boy who had been introduced to him as intelligent, with lim-
ited attention and restless behavior. The intervention consisted of 20 ses-
sions of music therapy, twice a week, during which the therapist aimed at
influencing the behavioral restlessness.
First, an accurate anamnestic interview was carried out through sep-
arate meetings with teachers, parents, and the physician. Afterward,
the child’s observations were made within the therapeutic setting. The
observations highlighted that the patient did not seem to possess spa-
tial limits, seemed not to have a correct perception of the elements in
space, and he believed that the only possible way to express dissent and
frustration was through an increase in motor activity. Problems in the
perception of time also emerged: The child used very approximate and
sometimes inadequate words to provide temporal indications. Moreover,
two types of motor behaviors have been detected: the first hyperkinetic,
chaotic, communicationally dysfunctional; the second relaxed, commu-
nicative, with an overall reduction in motor skills.
The music-therapy intervention was conducted according to a psy-
chotherapeutic model, based on the creation and maintenance of a stable
and meaningful relationship between the therapist and the patient. The
therapist assumed the function of promoting the organization and con-
tainment of spontaneous expressive behaviors of the child.
The setting and the sound-music mediators, on the other hand, have
been the modifiable elements of this relationship.
Borghesi also created two types of delimitation:
1. “definition of the setting”: progressive delimitation of space and

time;
2. “delimitation of the sound field”, through:

• the disincentive of “rough” methods of sound production: When
the child used intense methods of approach to the instruments,
the therapist refrained from continuing the sound dialogue;
• the progressive elimination from the setting of the instruments
that the child used forcefully and in a preferential way (“timbric
delimitation”);
• the decrease in the density of notes produced.
At the beginning of the meetings, it was difficult to get the child into
a “listening mood”: He was irritated by this type of request; He did not
even tolerate the therapist mirroring his musical productions. He only
agreed to be left free to move around the room and “to have the atten-
tion, the listening, the musical responses of the therapist, who had to be
absolutely in line with his expectations”.
This approach was modified during the meetings and it was noted
that sometimes the child’s sound production was a response to that of
the therapist; This dynamic, therefore, involved listening, accepting com-
munication rules and sharing a code.
The musical and bodily gratification and the satisfaction of the
need of containment carried out through the exposure to soft sounds
and hugs led to the discovery of relaxed motor behaviors, character-
ized by a low level of activity but at the same time a high degree of
communicativeness.
The child, during the course of the therapy, began to “re-learn his
motor skills” and every activity seemed, according to Borghesi, aimed at
the evaluation of his body dimensions and the results of his actions.
Starting from the twelfth meeting, some activities were introduced
that aimed at increasing the child’s skills in measuring time; For example,
the child was asked to count aloud the number of his hits on percussion
instruments and then to compare that number with the time elapsed or
the missing time.
During the meetings the child began to measure the limits by himself,
evaluating the reaction of others to his infractions; Borghesi interprets
this behavior as a way to discover the existence and function of limits.
The expression of feelings took on a more communicative and less
destructive connotation as the patient was more relaxed from a behav-
ioral point of view. This expression has been made symbolic and met-
aphorical by the therapist through the use of musical instruments; For

example, the child was asked to “dramatize on the drums the beatings
received, those given and those he would have liked to give”.
During treatment, a relaxed functioning modality in the child was
highlighted and promoted, characterized by:
• low sensory levels, in concomitance of which the transition to men-

tal processing of stimulations became possible;
• a decrease in motor activity and better coordination in the transi-
tion to a relaxed mode;
• object relationship characterized by a depressive, reflective structure
and by readiness to listen, with recognition of the other as a distinct
entity.
The intervention approach presented by Borghesi is undoubtedly excit-

ing and offers some guidelines from which to take inspiration to design
a music-therapy treatment with children affected by ADHD. The idea
of structuring and progressive de-structuring the spatial and tempo-
ral setting is compatible with the characteristics of the subjects with this
disorder. In the first place, Borghesi provided the child with a strongly
structured and predictable setting, so that his need for containment from
the outside was satisfied by using a regulation that he was not able to
give himself from inside; Subsequently, through the process of de-struc-
turing, the external containment gradually faded in, bringing out the
child’s self-control capabilities. This allowed him to experiment his limits
and to promote his flexibility and adaptability concerning changes and
contingencies.
The primary objective is that these skills acquired in the therapeutic
setting can be transferred and expressed outside the therapeutic settings
(e.g., at home and school).
It is important to highlight that the author has taken into consider-
ation the definition of “hyperkinetic conduct syndrome” present in the
ICD-10 and which has concentrated above all on impulsive and restless
behaviors compared to the inattentive ones, despite the child having dif-
ficulties in this area. It is also true that the problems of weak attention,
probably, have been addressed indirectly. In fact, self-control, especially
in the first moments in which it is experienced, implies a subject’s delib-
erate effort and the activation of the attention and concentration skills
both on himself and on the environmental and relational context in
which he is inserted. Moreover, the very fact of interacting with the ther-
apist and carrying out specific activities following specific prescriptions
implies good attention. From these considerations, we can understand
how the problems of inattention and those related to hyperactivity are
not entirely split and therefore should be treated simultaneously.
Music and ADHD: Possible Relationships

As we have seen in Chapter 1, music is a powerful tool that allows
achieving multiple therapeutic goals. Moreover, it is very flexible and can
undergo structural modifications (e.g., increase or decrease of the repro-
duction speed, change of the tonality, increase or decrease of the vol-
ume) according to the aims to be reached.
Firstly, like any other type of therapy that aims to affect psychological
dimensions, music-therapy sessions offer a privileged setting where
patients can establish a meaningful relationship with the therapist, where
they feel recognized, reflected, and accepted as they are. This happens
because the therapist does not assume an attitude of prejudice and judg-
ment towards the patient. On the contrary, the starting point is specif-
ically determined by accepting the individual characteristics of a client,
even the dysfunctional and pathological ones. Changes are then gradually
introduced in those areas that are problematic; Within this process, the
music therapist stands as a “model” for the full and free opening of the
patient or the introduction of alternative modes of self-expression.
Children with ADHD certainly have to satisfy their relational needs
because, from this point of view, they are mostly frustrated by peers and
adults because of their “disturbing” and inadequate behavior. As a result,
within the music-therapy setting, they will be able to experiment work-
ing within a “confirmatory” relationship, where the therapist will use
their problems as a resource to get to know them better and to promote
greater awareness of dysfunctional behaviors in them. For example, the
music therapist could imitate the child’s agitation/hyperactivity level by
playing it with an instrument.
Regarding the hyperactivity and hyper-motility of these subjects, the
sound-music mediators could be used with two different objectives.
A first type of purpose may be to reduce the level of hyperactivity, i.e.,
the child may be involved in some psycho-physical relaxation activities,
with the help of relaxing melodies, both active (the subject must per-
form movements following the slow rhythm of the music) and passive
(the subject will remain relaxed, firm, with eyes closed and will only
listen to music and be calmed by it). The music therapist can, in turn,
take an active or passive attitude; In the first case, he will facilitate relax-
ation by suggesting to the person the movements he has to make or
images of relaxing landscapes/situations, while in the second case they
will limit their intervention to the initial instructions. Clearly, children
will initially have difficulty relaxing and will probably prefer active relaxa-
tion that involves a certain degree of motor activity. Gradually, then, they
will learn to alleviate the states of tension and will succeed in sustaining a
passive relaxation.
The second type of purpose may be to discharge excess energies. In
this case, it will be possible to propose to the subjects to move follow-
ing a rather fast pace of music or to play percussion instruments using
as much energy as they can. A limitation of this strategy, however, is the
unpredictability of the outcome. In fact, if on the one hand, it could
exhaust excess energies so that the child returns for a specified period to
a “normal” level of arousal, on the other hand, it could have an opposite
effect and therefore increase hyper-activation, as claimed by Rickson
(2006). In fact, it should not be forgotten that these children are
attracted to all high-impact stimuli able to increase arousal.
The tendency to impulsiveness, on the other hand, can be addressed
through activities that will try to increase, for example, the ability to
respect one’s turn. The therapist may ask the child to play on a drum a
rhythmic sequence, but only after a signal (e.g., only after the facilitator
clapped his hands); A variant of this activity consists in asking the child to
count aloud up to three before reproducing the rhythmic sequence. This
can count as training for self-education; First, the guide will be entirely
external, then the child will self-regulate his impulsivity by counting
aloud until this behavioral guide will be internalized.
Finally, the treatment of attention problems is transversal to that of
all other problems. In fact, on a relational level, being careful means
being able to listen to the other and to nurture interest in the commu-
nication, both verbal and non-verbal; Moreover, it means modulating
one’s conduct and self-expression based on the progress of the relational
process. As for hyperactivity-impulsivity, attention allows the child to
be “sensitive” to contextual variables to control their behavior accord-
ingly; A good attention span is indeed functional for a critical self-regula-
tion ability.
The activities proposed so far are all good options for the promotion
of self-regulation competence. Besides, a music therapist could propose to
the child, for example, activities that involve the identification of a sound
source or the reproduction of a simple sequence of sounds. To increase the
attention span, it is essential to be able to use temporal variables flexibly:
At the beginning, the children will be involved in short-term tasks compat-
ible with their sustained attention capacity and, little by little, the therapist
will increase the time from devoting to the execution of these activities.
In general, to get the collaboration, it is essential that intrinsic
motivation is promoted. These children need to be continually involved
in exciting and highly stimulating activities, being motivated to partic-
ipate to eventually achieve gratification. It should be remembered that
they are sensation-seekers and that it is critical for them to receive appre-
ciation for what they do, given that their “disruptive” behavior attracts
more negative and positive judgments and therefore they live constant
frustration. As a result, it will be appropriate to provide positive feedback
for every minimum progress they make.
A Single-Case Study Intervention

Based on previous research, a music-based intervention project was
developed for a child with ADHD (Zugno, 2010b; see also, for another
single-case study, Zugno, 2010a). The patient, Simon, is a 7-year-old
child. While he was attending preschool, the mother and the teachers
observed that Simon seemed to reach the main developmental stages later
compared to other children. In particular, he presented difficulties at the
motor level and in the acquisition of language. After several years of psy-
chomotor therapy improvements have occurred. The mother reported
that around the age of 14 months the child began to perform “strange
and repetitive” movements that left the people who cared for him per-
plexed. A series of neuropsychiatric investigations showed a slight cogni-
tive delay. Because he also had learning difficulties, he was followed by
a special-ed teacher while attending kindergarten. When he started pri-
mary school learning difficulties were confirmed. Moreover, the child
began to show behavioral problems: He used to beat his classmates, was
agitated, and could not sit still. He was diagnosed with ADHD and it
was recommended that a special-ed teacher supported the child. Besides,
he was sent to a center for cognitive training and in the meantime
psychomotor sessions continued.
Structure of the Intervention

The child took part in 18 sessions, which were weekly and lasted about half
an hour each. The meetings were characterized by a strong spatial and tem-
poral structure, which had the function of organization and containment
of spontaneous expressive behaviors of the patient. This strategy is consist-
ent with the hyperactive child’s way of being, which needs predictable and
constant situations over time because he does not tolerate changes well. It
is crucial, therefore, to provide within the setting a coherent and organized
set-up that the child could not otherwise find autonomously and which he
strongly needs to feel content and to learn to contain himself. The hope is
that the structuring that is offered from the outside is then assimilated.
The temporal structuring has been obtained both through a strict
respect of the start and end times of the meetings and through the
organization of all the sessions in three moments: (a) beginning: wel-
coming the child and relaxing; (b) performance: involvement of the child
in the planned activities; and (c) conclusion: relaxation and farewell.
Thanks to this structure, the child got the idea that there is a time for
everything and that not all moments are adequate to do what you want.
In fact, people with ADHD, taking up the interpretation of this disor-
der as a “pathology of synchronization between internal time and exter-
nal time”, have difficulty adapting their behavior based on external time
(contextual, environmental, social), and for this reason they tend to fol-
low the rhythms of their own time. Increasing awareness of the existence
of an external time means re-educating or re-enabling the child to syn-
chronize with others and with the environment.
The spatial structuring, on the other hand, has been obtained by keep-
ing the setting and the arrangement of the objects unchanged; Afterwards,
the therapist tried to deconstruct the space by introducing elements of
change (e.g., by modifying the arrangement of some objects in the room)
or novelties (e.g., by providing the child with new musical instruments).
At first, therefore, the poor tolerance towards changes that is typical of
people with ADHD was respected, while later the therapist tried to pro-
mote and increase the flexibility of the child and his ability to adapt.
Aims of the Intervention

The general purpose of the intervention was the facilitation of the recov-
ery of some cognitive-behavioral skills through both listening to music
and related activities and through music production.
More precisely, the child’s ability to autonomously manage and reg-

ulate the different dimensions connected to the body such as behavior,
actions, gestures, movement in space, and contact with objects has been
promoted. Secondly, the child has been helped to regain ownership of
his body and to become more attentive and sensitive to the signals that
the body sends and that precede the occurrence of certain states: For
example, perceive the state of agitation that may precede the putting in
the act of some hyperactive or impulsive behavior.
Finally, activities have been proposed aimed at involving the child
gradually in slower and more relaxed rhythms than the fast and frenetic
ones he frequently experiences.
Starting from the hypothesis that in people with ADHD there may
be a dysregulation between the trend of their internal timer and that
of the external/environmental time, in the sense that the internal timer of
those subjects would have a faster pace than that of healthy people (Rubia
et al., 2003; Smith et al., 2002). A re-synchronization between the
child’s internal time and the external time has been promoted. In the
first place, the therapist tried to make the child acquire the awareness
of his impulsiveness and then to provide him with strategies to man-
age it. In fact, most individuals with ADHD are not able to under-
stand that the impulsive behaviors are inadequate because for them it
is normal to behave in this way. The same explanation can be given for
hyperkinesis/hyperactivity.
It is crucial, therefore, to make the child understand that these
behaviors are dystonic with the expectations and rhythms of the exter-
nal environment and that before taking specific actions or behaviors it is
necessary to stop and reflect not only on how to articulate an action for
reach a particular goal but also on the consequences that these behaviors
can have both on itself and on others.
Finally, the therapist tried to teach the child to respect the shifts both
during the communication processes and during the activities. The pres-
ence of a single person beside him has undoubtedly constituted a facili-
tating condition to achieve this goal since the child had to consider and
respect a single interlocutor. The ability to respect the shifts again implies
the ability to exert control over impulsivity, to delay one’s response, wait-
ing for the right moment to express it and to synchronize with the inter-
locutor at the temporal level.
Activities Included in the Intervention

Particular attention has been given to proposing activities appropriate
to the child’s skills and preceded by clear, short, and straightforward
instructions. Relaxation, music production, and music reproduction
activities have been presented. The pieces used for relaxation remained
unchanged for the duration of the treatment so that this activity also
contributed to providing structure and predictability to the sessions.
Initial and final relaxation took place in the same way and the child could
choose to passively or actively participate. Also, the brightness of the
room was adjusted by lowering the lights a little. The therapist’s inter-
vention was as discreet as possible and only consisted of giving sugges-
tions to the child about the best way to relax.
In addition to relaxation, the following activities have been proposed.
The rhythms of the body. With this activity, the therapist tried to
make the child understand that different types of rhythms characterize
our body and that can be considered in all respects a “sound object”. He
tried, therefore, to focus the child on the heartbeat, breathing, speech,
and walking. In turn, the rhythms of the body were mirrored by playing
a percussion instrument.
The mirror. Sequential movements have been proposed (e.g., clap-
ping twice, then tapping the right foot once and then tapping the hands
twice) that the child should repeat afterward in the right sequence and
the right number. It started with simple sequences to gradually get to
more complex sequences.
The enchanted forest. The therapist told the story of a child who,
during a school trip in the woods, got lost. He could only find the way
back if he passed some tests that consisted in reproducing some rhythmic
structures with a tambourine or rattles.
The magic bag. A small sack was prepared to contain little cards that
suggested the child different ways of pronouncing his name (e.g., very
slow, very fast, loud, in a low voice, angry, happy). In turn, the therapist
and the child extracted a card from the bag and pronounced their names
following the card’s indication.
The carnival of animals. The child was asked to listen to the differ-
ent songs from Saint Saens’s “The Carnival of the Animals”; For each of
them, he had to say which animal came to his mind and which aspects of
music suggested to him to pick that specific animal. He was also asked
to imitate the movements and behaviors typical of the animal he had

thought.
Where does the sound come from? Several pieces of the metallophone
have been arranged in a large circle; The child was invited to sit with his
eyes closed in the center of the circle. The therapist started by placing
only two pieces and then gradually increasing the number to increase the
level of difficulty. He played the different pieces of the metallophone cre-
ating different music sequences and the child, after hearing them, had to
open his eyes, get up, and go to play it the same way.
Assessment of the Intervention

A pre- and post-intervention evaluation was conducted through a series
of tests aimed at investigating the following areas: attention, rhythm, and
synchronization. Therefore, both the cognitive and the motor-related
aspects were taken into consideration.
To assess attention skills the Deux Barrage test was employed. The
task presents stimulus-target symbols (squares with adjacent segments
coming out of them or one of the vertices or one of the sides) within
a broad set of stimuli-fillers or distractors (squares with different ori-
entations of the adjacent segments). It is a test of visual search that
involves selective attention. Every 4 minutes the point where the child
had arrived was marked in the matrix (in this way five-time intervals were
obtained: T1-T2-T3-T4-T5). The scoring of the test was carried out by
calculating the following indices:
1. The Incorrectness Index, determined by computing the ratio

between the total coding errors (Omissions + Commissions) and
the total number of signs examined;
2. The Speed Index expresses the speed in ticking the signs, or the
number of signs discriminated in one minute. It was assessed by
computing the ratio between the total number of signs examined
and the total duration of the test.
The Stamback test, consisting of three parts:
1. Spontaneous time: The researcher places a pencil in front of the

child and asks him to beat it on the table in the way he prefers,
but always with the same rhythm. After 5–6 shots, the researcher
starts the stopwatch, counts 21 shots, then stops the stopwatch

and scores the time the child has used to beat them. Also, he notes
any accelerations, delays, irregularities.
2. Reproduction of rhythmic structures: The researcher puts a screen
between himself and the child so that the latter does not see the
hand with which he will beat the shots. The child is told to listen
as well as he beats and then to beat exactly as the researcher did.
If the child is wrong, the researcher makes a note and repeats the
exercise.
3. Understanding the symbolism of rhythmic structures and their
reproduction: The researcher shows the child the sequences of
symbols of the different rhythmic structures and asks him how he
thinks they should be beaten.
Outcomes of the Intervention

In the Deux Barrage Test, there was a decrease in the number of stimuli
analyzed. A decrease, comparing the pre- and post-tests, was found in the
number of omissions and commissions. The Incorrectness Index was equal
to 6% in the pre-test, in which there was a slight progressive decrease
in the inaccuracies from T1 to T4 that could reflect gradual learning. In
T5, on the other hand, researchers reported an increase in the percent-
age of inaccuracy, probably due to a lowering of attention for tiredness.
During the post-test, there was a decrease in this index, which was equal
to 1%.
A decrease was also observed in the Speed Index. In fact, while in the
pre-test phase this index was equal to 24.15, in the post-test it was
equal to 20. In conclusion, slight improvements were noted in the sus-
tained and selective attention span.
In the Spontaneous Rhythm test, differences in the frequency
of behaviors between the two tests emerged. In both, the child
performed more movements of the lower limbs, followed by behaviors
aimed at synchronizing with the music and by the better interaction with
the therapist. Furthermore, he identified the same number of rhythmic
variations (14 out of 20) even if, during the post-test, the synchronous
movements were increased and asynchronous ones decreased accord-
ingly. There has therefore been an improvement in the ability to listen
and attend to the musical stimulus, accompanied by a higher sensitivity
in the perception of rhythmic variations.
Concerning the Reproduction test of rhythmic structures, during the

pre-test the child did not make many mistakes. Specifically, Simon pro-
duced more beats (one or two) than those provided by the structure,
but at the same time he respected the combination of groups of beats
and breaks between one group and another. During the post-test, on the
other hand, fewer mistakes were made; In fact, only one rhythmic struc-
ture was completely wrong. The result of the post-test, therefore, shows
improvements.
Final Comments
The evaluation and identification of improvements in self-control and
attentional behaviors were more straightforward than the ability to syn-
chronize internal and external time. The hypothesis according to which
some symptoms such as impulsivity and hyperactivity may be the expres-
sion of EFs in charge of the sense of timing has only recently entered the
literature.
Thanks to the activities built ad hoc for the intervention described
above, it was possible to focus on some specific deficits. The use of
sound-music mediators has allowed promoting the ability to listen to
two sources of communication: the therapist and the musical stimulus.
In fact, to perform the activities correctly, the child had to pay selective
attention to these sources. In the beginning, considering the deficit in
his attentional skill, Simon showed difficulties because he could selec-
tively focus only on one of the two sources. Thanks to the continuous
exercise and learning of some strategies, however, the child has started to
use his attentive resources more functionally. These improvements were
also made evident by the comparison between the results of the pre-test
and the post-test.
During the intervention, it was also possible to observe a posi-
tive evolution concerning self-control and impulsivity. The music
itself includes and subtends precise rhythms and times. The work on
respecting these rhythms allowed the therapist to promote the abil-
ity to inhibit and procrastinate the response at the right time. There
are endogenous rhythms “created by consciousness” and exogenous
rhythms belonging to the external context; During the intervention,
the therapist manipulated exogenous rhythms to regulate endogenous
ones.
If the hypothesis that the environmental rhythms can exert an influ-

ence on the subjective ones is valid, then one could also suppose that
the incompetence in the deferral of the behavioral output has its origins
in the first years of life, that is when, through educational practices, the
child is led to follow the environmental rhythms rather than the subjec-
tive ones. In other words, concerning children with ADHD, dysfunc-
tional regulation between subjective time and objective time may have
occurred early in life.
A Group Intervention for ADHD Children Based

on Music
The primary objective of this intervention (Bertoni et al., 2014) con-

cerned the improvement of compromised cognitive and behavioral skills
in children with ADHD.
The general objectives were:
1. To promote the development of skills that are lacking in patients

with ADHD. More specific objectives were: increasing the ability
to regulate attention, concentration, and listening and improving
the ability to respect rules and instructions.
2. To promote the ability to self-control psychomotor behaviors. This
goal is articulated in specific objectives, including improving aware-
ness of one’s body, enhancing the sense of control of one’s motor
activity, regulating the movements of one’s body in a controlled
manner, refining the rhythmic function of one’s body.
3. To promote synchronization between internal and external time.
This is linked to other objectives such as increasing awareness of
one’s impulsiveness, acquiring the ability to regulate the tendency
to perform impulsive actions, learning to modulate the strength of
movements, learning to respect the shifts.
4. To promote the improvement of introspection. This is linked to
the following specific objectives: to promote self-reflection, to
increase awareness of one’s feelings and emotions, to increase the
ability to recognize emotions, to increase the ability to manage
emotions, and to improve the ability to associate emotions with
the sensations experienced.
5. To increase the level of self-esteem. To this end it is necessary to
increase the awareness of being able to achieve goals, to increase
the sense of self-efficacy, to favor a positive self-image, to increase

the feeling of satisfaction towards oneself, to diminish the sense of
learned impotence, to increase resilience.
Activities Included in the Intervention

The intervention comprised a total of 10 meetings on a bi-weekly basis
(for five continuous weeks). The second and the ninth meetings of the
program were devoted respectively to the initial and final phases of the
treatment, while in the six central meetings the actual music interven-
tion took place. Each meeting was characterized by a core theme, in
particular: rhythmic training, inhibition and self-regulation, attention,
self-efficacy, tuning with the other and managing emotions. The chil-
dren were randomly assigned to one of two small intervention groups.
Each session was conducted maintaining a high level of structuring and
predictability. The meetings took place in a protected, large, and bright
space, where attempts were made to limit the presence of distracting
stimuli.
As for the individual meetings (each lasting about one hour), they
always respected a standard structure for the activities:
• moment of welcoming (about 10 minutes);

• active relaxation (about 5 minutes);
• first activity (from 10 to 15 minutes);
• second activity (from 10 to 15 minutes);
• reading a story (about 5 minutes);
• passive relaxation (about 5 minutes).
At the beginning of the session, the children sitting in a circle together

with the therapists were prompted to share with the group an experience
lived during the week, with the aim of fostering a welcoming atmosphere
and mutual exchange.
Relaxation was proposed at the beginning and at the end of each
meeting with the aim of reducing the level of psychophysiological acti-
vation and the state of tension of children. Some authors argue that
relaxation activates the child’s resources, promoting activities related
to physical functions, but also supporting communication (Caffo &
Camerini, 1991). For these reasons relaxation is believed to be particu-
larly useful when it is proposed before a rehabilitative or therapeutic
activity to facilitate its startup, or in parallel with the treatment. In par-

ticular, the “active” relaxation technique used for this program was
linked to imagery (body scan), while the passive one exploited the char-
acteristics of audio tracks selected ad hoc.
Concerning the rehabilitation activities proposed, these have been
developed by a group of psychologists who are ADHD experts. The
activities have been conceived by re-elaborating classical techniques of
music-therapy treatment and cognitive-behavioral techniques involving
musical stimulation and manipulation of musical instruments.
Assessment of the Intervention

As stated above, the intervention comprised a total of 10 meetings on a
bi-weekly basis (for five continuous weeks). A sample of 6 children with
ADHD aged between 8 and 12 took part in the intervention.
The first and last meeting was dedicated to the cognitive and behav-
ioral evaluation of each child. During these meetings, researchers used
assessment tools aimed at assessing attention, evaluation scales for
ADHD, tools for the assessment of musical discrimination, and tools for
assessing rhythmic ability.
In particular, the tools were applied with the aim of investigating the
following areas:
• sustained attention and selective attention;

• hyperactivity;
• self-esteem;
• life quality;
• capacity for musical discrimination;
• rhythmic ability.
The following is a list of the tools used for the assessment:
• Ranette test, taken from the Italian Battery for ADHD, evaluating
selective attention, maintained one, and motor inhibition.
• TAU (Hearing Supported Attention Test), taken from the Italian
Battery for ADHD;
• SDAG questionnaire, an evaluation scale for ADHD which
aims to investigate the two areas most affected (inattention and
hyperactivity/impulsivity).
• Two questionnaires were also devised to investigate self-esteem and

quality of life of children with ADHD. They were administered to
both parents and children.
• Seashore test, which provides a series of tests aimed at measur-
ing musical attitudes; The ability to discriminate height, intensity,
rhythm, duration, timbre is evaluated. For this research, in par-
ticular, three parameters were investigated: melody, volume, and
intensity.
• Three Stamback rhythm tests: The ability to reproduce rhythmic
structures is investigated.
• Behavioral observation grid: Explicitly built to record the behavior
of inattention, hyperactivity, and impulsivity at every meeting and
every activity.
Outcomes of the Intervention

Comparing the results obtained during the initial evaluation phase (pre-
test) with those obtained from the final evaluation phase (post-test) it
can be said that the two groups have responded positively to the pro-
posed musical intervention. The abilities related to ADHD were par-
tially improved as a result of the intervention, in particular, selective
and sustained attention, rhythmic abilities, and the level of hyperactiv-
ity, while the constructs of self-esteem and quality of life did not change
significantly.
The results show that the two groups benefited from the intervention
and the intervention has strengthened some of the skills compromised
in ADHD, in particular, selective and sustained attention and control of
hyperactivity. The objectives of improving attention span, psychomotor
self-control, and synchronization between external time and internal time
were also met. The objectives related to introspective skills and increased
self-esteem were only partially achieved. The short duration of the inter-
vention is one of the factors that determined the weaker effects in the
areas as mentioned earlier (self-esteem, introspective abilities, quality of
life), which generally require longer times for changes to take place.
Concluding Remarks
ADHD is a widespread disorder that affects children and adoles-
cents; Therefore, the need arises to look for alternative therapeu-
tic approaches to traditional pharmacological therapy. On the one
hand, psychopharmacological treatment can be considered as the least

expensive route both in terms of costs and commitment, as it allows
immediate positive results to be achieved; On the other hand, research
has shown that the duration of these results is short-term and that the
symptoms tend to re-emerge as soon as the drug is stopped.
The real challenge, therefore, is not the suppression of symptoms, but
to find strategies to make these children acquire a level of awareness with
respect to their dystonic behaviors, to reduce them within the limits of the
possibility of that particular individual, to bring out the alternative resources
that are undoubtedly present in each individual and to help the person to
live with their symptoms and to develop a reasonable level of adaptation.
Music interventions can help achieving these goals since activi-
ties based on sounds and rhythms foster basic mental processes which
are impaired in ADHD, so leading children to master them in order to
self-regulate their behavior efficiently.
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CHAPTER 3
Enhancing Social Skills in Autism Through

Music
Abstract  Music treatments addressed to individuals with autism are

usually aimed at enhancing social skills. To do so, musical activities are
paired with a series of underlying competencies to be acquired. This
chapter focuses on some of these basic competencies, such as the detec-
tion of the congruence between the emotional valence of music and the
mood states it elicits, the identification of the relationships between the
sounds (hearing) and the motor acts (vision) which produced them,
the ability to mirror the partner’s mental state through the production
of musical acts. Experimental findings supporting the notion that these
basic competencies can be acquired or refined by people with autism,
as well as the outcomes of music treatments focused on those skills, are
reported and discussed in the chapter.
Keywords  Autism · Music therapy · Social skills · Emotions

Assessment · Intervention
Defining Autism
Autism Spectrum Disorder (ASD) is a pervasive disorder whose causes
have not been understood fully. Many studies will suggest that it is
probably due to genetic inheritance (Faras, Ateeqi, & Tidmarsh, 2010).
People with ASD have communication challenges and typically struggle
with deficits in social-emotional reciprocity, lack of understanding and

https://doi.org/10.1007/978-3-319-97151-3_3
expressing nonverbal and verbal communication, and show difficulties

in developing and/or maintaining and understanding personal relation-
ships. Another challenge that is often faced with ASD is behavioral. This
disorder includes repetitive motor movements, use of objects, or speech,
insistence on inflexibility or sameness, adherence to routine, ritual pat-
terns of verbal or nonverbal behaviors, and fixated interests that are
abnormal in intensity or focus (American Psychiatric Association, 2013).
As human beings, we require the abilities of empathy and emotional
recognition in our daily life to maintain relations with others around us.
ASD is a condition in which social-communication, confined obsessions,
and the ability to understand emotions of others are deficient. Empathy
enables people to understand emotions of others surrounding them and
to share their feelings. We come to articulate these feelings in joint effort
through emotion recognition—which is essentially the process where
humans identify other human beings’ emotions through facial, verbal,
and bodily expressions (Sucksmith, Allison, Baron-Cohen, Chakrabarti,
& Hoekstra, 2013). Unfortunately, children who suffer from ASD com-
monly have these impaired abilities to match empathy and emotional rec-
ognition (Stephenson, Quintin, & South, 2015).
Empathy has become one of the greatest hallmark traits of those
with ASD. However, research has gone into whether or not people
who have ASD can truly empathize with others. Empathy towards
others requires the ability to resonate with others’ feelings while
maintaining a healthy understanding of one’s own and to identify
what others are thinking without resonating with that state of being.
Essentially to understand the facial expression, body language, and
vocal tone is the key to empathy (Jones, Happé, Gilbert, Burnett, &
Viding, 2010). Processing emotional recognition difficulties within
ASD stems from attentional and perceptual activity. In other words,
those with ASD analyze face differently, resulting in lower atten-
tion to expression (Dawson et al., 2004; Klin et al., 2002). Studies
have shown that this may be due to surrounding information that is
received by the eyes (Baron-Cohen et al., 1995). The struggle for
people with ASD is to understand what people think.
A typical developing individual learns how to appropriately express
words and body language through empathy. For example, if a child sees
a person get injured they may run up to that person and kiss the area
that was hurt because that is what they were taught to be an appro-
priate response to someone else’s pain. However, people with ASD,
3 ENHANCING SOCIAL SKILLS IN AUTISM THROUGH MUSIC 53
because of their lack of recognizing body language, fail to express empa-

thy for that individual. This is a result of the precise skills that are com-
promised by the disorder (Montgomery et al., 2016). Society is prompted
to scrutinize and validate each other’s emotions through emotion
recognition.
Fortunately, there are many forms of therapy that can assist in the
enhancement of the quality of life in individuals with ASD. According
to the American Music Therapy Association (2012), one form of therapy
that has proven to adjust bodily regulation, create personal connections,
relaxation, personal expression and pursue long-term goals is music
therapy. As trained professionals, music therapists are capable of produc-
ing significant interventions for their clients with ASD.
The diverse applications of music therapy have proven to assist
children with ASD to excel in their interpersonal and social lives.
In order to adequately serve such a purpose, it is important to under-
stand how patients’ emotion recognition and empathy operate within
an emotional and cognitive standpoint. Once a relationship is imple-
mented between the music therapist and the client, they can begin to
work on music making of rhythmic notes, pitch, temporal beats, and so
on, that will enable a better dynamic between them. With this relation-
ship in place and the musical engagement, the individual on the ASD can
begin working on self-expression, social interaction, and interpersonal
emotions.
The Benefits of Using Music with Autism

Some of the characteristics of music appear to promote or trigger specific
positive responses in individuals on the ASD, both from a cognitive and
an emotional stance. From a cognitive standpoint, the fact that individu-
als with ASD are so focused on the details allows them to develop a bet-
ter “relative pitch”, that is, the ability to identify a musical note within
a melody by comparing it to a reference note and being aware of the
interval between them. This allows them to recognize and categorize
musical excerpts more easily (Baron-Cohen, 2002; Mottron, Dawson, &
Soulières, 2009). Yet they do not show any difficulty, when compared
to neurotypical individuals, in the global elaboration of music (Heaton,
2005; Heaton, Pring, & Hermelin, 2001) and that supports the fact
that using music-therapy inspired approaches can be very effective when
working with patients with ASD.
From an emotional standpoint, music appears to benefit individu-

als with ASD from several points of view. Examining the neurophys-
iological effects caused by listening to music, studies have reported
increased relaxation, mainly considering muscle tension (Skille &
Wigram, 2013). In children who have impaired basic communica-
tion skills because of ASD, music can be a catalyst for mutual inter-
action and mitigate the lack of flexible behaviors and social patterns.
This form of active music advocates and motivates the individuals
with ASD and draws shared engagement and attention (De Marchi,
Benatti, Traficante, & Antonietti, 2009; Wigram & Gold, 2006). As
these social and behavioral patterns begin to diminish, music can also
improve the functions of the autonomic nervous system (Hirstein,
Iversen, & Ramachandran, 2001; Lundqvist, Andersson, & Viding,
2009) and reduce anxiety (Wigram & Gold, 2006) and stereotyped
behaviors (Rapp, 2007) as well.
In addition, music can be effectively used by individuals with ASD as a
self-regulation strategy, as can be derived from the internally focused lan-
guage that they use when describing the effects of music on their mood,
a type of language that is not used by neurotypical individuals (Allen,
Hill, & Heaton, 2009). This is linked to an overall better processing of
main emotions (Heaton, Allen, Williams, Cummins, & Happé, 2008;
Heaton, Hermelin, & Pring, 1999).
There are many forms of music therapy that are widely used, but
one in particular—improvisational music therapy—has become a rapidly
growing intervention treatment for children with ASD. Improvisational
music therapy is an effective treatment intervention that focuses on the
spontaneous communication, expressions of self, and how to engage in
social constructs. As other therapeutic interventions using music as
a backdrop to engage a client, in improvisational music therapy the
therapist and client use interactive live music within the session to meet
therapeutic needs (Gold et al., 2006; Trevarthen, 2001). Studies sup-
ported the importance of the emotional role that interpersonal relation-
ships play in children with ASD. It has been proven that improvisational
therapy helps shape interpersonal relationships, goal incentives, emo-
tional engagement, and responsiveness in children with ASD (Wigram &
Gold, 2006).
Which specific aspects of music seem to promote these positive
effects? First of all people on ASD seem to appreciate the physical aspects
of sounds as well as their resonance, elements that help them focusing
their attention. The fact that music shares many similarities with ver-
bal language and can be used to create a well-structured (and, hence,
reassuring) symbolic system that can, if needed, overcome the semantic
aspects of communication that could be problematic for individuals on
the ASD. The similarities between music and language also include the
similarities between the elements of musicality embedded in every lan-
guage, which characterize language as a multimodal experience (Besson
& Schön, 2001; Jackendoff, 2009).
In a study conducted by Kim, Wigram, and Gold (2009) the music
therapist identified elements in the child’s musical and non-musical
behavior and provided the child with empathic, supportive musical struc-
ture in an attempt to engage the child. The elements identified included
rhythmic patterns, dynamics of expression, pitch range, temporal beat,
and melodic contour. The supportive musical structure, also known as
musical attunement, used by the therapist included vocal and instrumen-
tal exchange, eye contact, movement and gestures, and facial expressions.
This study also indicated a significant difference in the effects of improvi-
sational music therapy and toy play sessions. This was especially evident
regarding social-motivational aspects. Improvisational music therapy
elicited joy and emotional synchronicity more frequently and for longer
durations than the toy play sessions did.
Because of the elements mentioned above, music can trigger the acti-
vation of the mirror system while playing or listening to music (Lahav,
Saltzman, & Schlaug, 2007). Moreover, the activation of the mir-
ror system can be enhanced with music practice (Bangert et al., 2006).
Another element that can explain the multiple benefits of using music-
based intervention when working with individuals with ASD is rhythm.
Internal rhythm is fundamental to promote baby’s development and
healthy interaction since the first days of life (Malloch & Trevarthen,
2009). Moreover, rhythm helps organizing life and work activities. Since
this kind of organization helps these individuals deal with anxiety, pro-
viding addition rhythm-based support can be seen as another effective
use of music.
Several studies have shown that people with ASD have a preference
for auditory stimuli in the formation of music over other sources of
stimuli. It was also found that people with ASD engage with music as
a stimulus for longer periods of time in comparison to other children
without ASD. In regard to responsiveness to music improvisations, it was
found that children with ASD had no significant difference in rhythm,
restriction, or originality compared to their same-aged peers without

ASD. This indicated that the music responsiveness was intact within the
ASD group (Simpson & Keen, 2011). In a study conducted by Molnar-
Szakacs and Heaton (2012), children responded to sounds and were
coded for vocalization, orientation-coordination, anticipation-increased
focus, and positive affect. They found that children with ASD were more
responsive to all stimuli compared with the neurotypical children. It was
argued that this is an indicator of sensory or attention difficulties. It was
also found that the children with ASD presented a significant increase in
response to music compared to speech or environmental noise. This was
suggestive of music eliciting special attention in children with ASD.
Examples of Assessment Techniques and Training

Programs
In the previous paragraph, we examined the strong links between dif-
ferent music elements and the autistic mind and we discussed different
possible music-therapy inspired approaches that rely on these links to
promote emotional and cognitive well-being in an individual with ASD.
Music-therapy interventions, as we have just seen, use the “musical lan-
guage” as a privileged communication channel to trigger a multimodal
connection among movement, emotions, and cognition. Effectiveness
of the music-therapy intervention described above supports the benefits
of this approach. Yet, to be able to better design targeted interventions
it is important for professionals to be able to assess individuals’ ability
to understand and appreciate a congruent connection between music
and gestures (a fundamental prerequisite for the work on the activation
of the mirror system and the connection between music and language/
expression).
Having good assessment strategies that can be used to evaluate this
competency in a population with ASD can help specifically to evaluate
individuals who are considering a music-therapy inspired intervention in
order:
1. To know how music can facilitate global perception against the
tendency of individuals on the ASD to focus mainly or exclusively
on the details;
2. To explore the relationship between individuals’ motivation and

interest in musical language and music specific intermodal motor
components. To be more specific, to assess the specific role of
speed, intensity, and rhythm (the three main dynamic components
that are the foundation of the link between music and movement)
to promote a multimodal perception of gestures and movement
and their synchronicity;
3. To collect enough reliable information to assess if there is evidence
to support the possibility from people with ASD of using the rec-
ognition of synchronicity between gestures and music to promote
an emotional synchronization within a therapeutic setting;
4. To identify which out of the aforementioned communication dimen-
sions (intensity, speed, and rhythm) would be the most relevant to
target in order to promote the most effective therapeutic session
when working with high functioning individuals on the ASD.
To reach these goals, Dirito and Stevens (2010) developed four specific
assessment tasks, which they tested on a sample of 103 participants, both
children and adults. Half of the sample consisted of individuals with ASD
and the other half was a control group of neurotypical individuals.
Information derived from this set of tasks can help in identifying spe-
cific preferences of individuals with ASD, considering their different level
of functioning, and this specific information can be used to plan more
effective music-therapy interventions.
Perception and Discrimination of Musical Rhythm, Intensity,

and Speed
The first assessment task aims at assessing the perception of the three
main structural variables of music language (rhythm, intensity, and
speed). This task allows therapists to specifically assess if individuals are
or are not able to detect congruence and incongruence in music ele-
ments produced by two different players hitting drums at the same time.
Individuals are shown a video of a musical dialogue presenting the two
players beating the drums, where Player B would respond to Player A
by imitating what Player A has just played. Respondents are then asked
to assess how adequate Player’s B imitation was, with reference to inten-
sity, speed, and rhythm. Research evidence (e.g. Accordino, Comer,
& Heller, 2007) shows that rhythm is the most significant interactive
element within a music-therapy section with individuals with ASD when

it comes to build a music dialogue that fosters a feeling of a safe sense of
“be together”.
Perception of Synchronization Between Sounds and Gestures in Music-

Based Communication
The main aim of this second assessment task is to test if individuals with
ASD can recognize synchronization between gestures and sounds dur-
ing a music-based communication. In order to be able to focus mainly
to this specific skill, the emotional and expressive components of music
communication have been reduced as much as possible. As is the case
of the task described in the previous paragraph, each video clip is quite
short (37 seconds each) to allow testers examining immediate percep-
tion. We know from the literature (Schutz & Lipscomb, 2007) that
neurotypical individuals tend to be more influenced by visual than by
auditory perception. For this reason, they should perceived a musical
gesture as synchronized with music even when it is not, because they
perceive gesture and music as a whole.
Preferences for Different Aspects of Emotional Music Stimuli

This task is divided into two subtests: “Pingu at the disco” and “The
Ballerina”.
“Pingu at the disco” is based on a video clip (1 minute and 37 sec-
onds length) derived from the popular Cartoon Pingu, which appears to
be a favorite of children with ASD. The target video clip shows Pingu
and his friends dancing to a very upbeat music. Music and dance music
are well synchronized. Emotions are expressed by using nonverbal ele-
ments linked to movements and gesture. In the second version of the
video clip, the same visual elements are presented, but the soundtrack
is replaced by classical music piece (a waltz by Strauss) that conveys the
same emotion but with a more moderate rhythm. Moreover, in this sec-
ond version, the music is not synchronized with the characters’ move-
ments. This task is similar to the first one but in this case the emotional
and semantic aspects of the music-based communication are not present.
Comparing these two video clips is interesting for a few reasons. First
of all because the cartoon Pingu, having animals as main characters, does
not involve human body. This allows testers to focus exclusively onto the
congruence between gesture and music, without the possible interfer-

ence of other variables, like the different levels of activation of the mirror
system. Because of the preference of high functional subjects with ASD
for nonhuman stimuli like objects, cartoons, and animals, this cartoon
appears to be adequate to be used with this specific population. As men-
tioned above, individuals with ASD tend to like this cartoon and this
increases their attention to any stimulus related to it.
The second subtest (the Ballerina task) is structured the same way as
the previous one, but a human element is added. Hence, this can be con-
sidered a higher-level task to assess similar skills in high function individ-
uals with ASD. It can be matched to the previous task to assess the effect
of processing human elements (in this case a ballerina) when evaluating
musical stimuli and the congruency between gesture and music. This task
also controls for music preference because, in this case, a classical music
piece is the one that is perfectly synchronized with the ballerina move-
ments, while the more modern upbeat music is not synchronized (the
opposite was true for the Pingu task).
An interesting characteristic of these tasks is linked to the fact that
these videos are longer than the ones used for the previous tasks so to
allow testers to better analyze individuals’ perception on a longer time
span.
These two subtests, taken together or separately, specifically allow
to explore the preference of individuals with ASD for video clips with
upbeat music, detection of congruence between music and images, and
level of appreciation for this coherence. Again the preference for a global
elaboration or for processing single details can help to plan more effec-
tive music-therapy interventions.
Perception of Synchronization of Different Musical Elements

in Music-Based Communication
This task aims at assessing how well individuals with ASD process three
different aspects of the music communication: speed, intensity, and
rhythm.
The video clips used for this assessment show a musician playing a
djembè and participants are asked to assess if the musicians’ movements
were synchronized with the music. Using a percussion instrument, like
the djembe, allows to control for the influence of pitch that could affect
responses.
To be more specific, this task allows to assess the role of each of the
three aforementioned elements, as well as to highlight any preference for
one of them. It allows to assess if high functioning individuals with ASD
tend to consider, at least to some extent, all these elements when evaluat-
ing the congruence of a musical communication or focus only on one or
two of them.
Individuals are asked to rate the congruency between music and
movements of 12 videos. Each video lasts 30 seconds. Six videos are syn-
chronized while the other 6 are not. The videos are matched either for
speed (low and high), intensity (low and high), and rhythm (simple and
complicated) and could be either matched or not matched with the con-
gruent soundtrack. The videos show only the instruments and the hands
of the player in order to exclude the possible interference by emotional
expressions derived by the presence of a human face.
Results from the Assessment and Ideas for the Intervention

The tasks described in the previous paragraphs have been tested (Dirito
& Stevens, 2010) on a sample of 103 individuals, half with ASD and half
neurotypical. Data confirmed the validity of the assessment tasks in high-
lighting differences between individuals with ASD and neurotypical ones.
Interesting differences that can be used to effectively plan music-therapy
based interventions emerged.
High-functioning individuals with ASD perform better than neu-
rotypical individuals of the same age group in recognizing when music
and gestures are not synchronous, being less affected by the illusion of
a global coherence between music and gesture. The same is true when
congruence between intensity of gesture and intensity of music is lack-
ing: Individuals with ASD point out discrepancy between low-intensity
movements and high-intensity music more often. Individuals with ASD
tend to prefer upbeat music, making them overlook incongruences more
when upbeat music is played.
Individuals who are in the middle of the spectrum tend to prefer
upbeat music, while this is not true for high functioning individuals with
ASD. High functioning individuals tend to prefer intense upbeat music,
regardless of the possible coherence between music and the commu-
nication behind it, thus showing more difficulties in recognizing and
responding to rhythm.
How can we read these data and how can this information help
planning more effective music-based interventions? The fact that indi-
viduals with ASD perform better in recognition tasks can be explained
by their preference for an elaboration focused on details and not on the
global stimulus. As reported in the literature, both children and young
adults with ASD are better than neurotypical individuals in isolating sin-
gle elements in music and body-based communication (Baron-Cohen,
2002; Bishop, 2008; Spencer et al., 2000). To be more specific, the
responses to the assessment tasks described above confirmed results
derived from similar samples regarding lower susceptibility to visual
illusions (Happè, 1995; Ropar & Mitchell, 1999, 2001), higher
discrimination ability when evaluating highly confounding visual and
auditory patterns (Plaisted, O’Riordan, & Baron-Cohen, 1998), high
ability in globally processing music stimuli (Heaton, 2003; Mottron,
Peretz, & Menard, 2000), even if the perception of coherence within
gestures used as communication tools can be lacking in high function-
ing individuals with ASD (Bertone, Mottron, Jelenic, & Faubert, 2003;
Milne et al., 2002; Spencer et al., 2000).
Individuals who are in the middle of the spectrum do not need or
look for upbeat music. This happens because of the problems they have
in regulating emotions. In this case, an intense, upbeat music does not
coach them to better regulate emotions, but would only increase their
anxiety. This would also be increased by their high sensitivity to per-
ceptual stimuli. For these individuals music-based interventions should
start with more relaxing, low-intensity music, that would guide them
toward a better emotional regulation. The intervention could introduce
progressively more intense or upbeat music. The same principle should
guide the choices of gestures or tunes to accompany music: The therapist
should avoid anything that is too intense in order not to over-stimulate
the patient and trigger an even lower level of self-regulation. Following
this line of reasoning, an intervention should be planned so that patients
start by learning to cope with emotions elicited by low intensity relaxing
music, by the way of using soothing properties of music to enhance this
effect. This kind of music will also promote a better and more coher-
ent perceptual organization, which will eventually lead to the possibility
of using more upbeat music and work on the higher level of emotion
regulation.
When working with high functioning individuals with ASD, their
difficulties in recognizing and processing rhythm might be the first
ones to be addressed. Starting by utilizing music that presents a clear,

simple, and repetitive pattern could be useful. Good examples are lull-
abies or metal music, which are both favorite of individuals with ASD.
The ideal starting point for each patient could be easily assessed by using
tasks similar to the ones described above. Progressively, the complexity
of the rhythm could be increased and variations could be introduced.
An improvisational music therapy could be the most effective, given
the way it is structured, to help manage social, communication-based
interactions.
Imitation Interventions Based on Technological Devices
Imitation and Autism
As seen in the previous paragraphs and as it is discussed in the literature
(Williams, Whiten, & Singh, 2004), imitation difficulties are common
in children with ASD. The capability of imitating others is thought to
be critical for the development of social skills and language (Rizzolatti
& Arbib, 1998, 1999; Tettamanti et al., 2005; Tomasello, Savage-
Rumbaugh, & Kruger, 1993), which, as we have seen, are impaired in
ASD.
Specific interventions aimed at addressing these issues have been
designed. Relying on what we have been discussing earlier in the chap-
ter, it will be evident that these interventions can be beneficial, especially
if they are music-based, because they address a primary symptom of the
disorder and, at the same time, they indirectly positively affect social
skills (Rogers, Hepburn, Stackhouse, & Wehner, 2003; Small, Buccino,
& Solodkin, 2012) through the possible activation of the mirror system
(Iacoboni et al., 1999). Mirror neurons are activated when imitation is
involved (Fadiga, Fogassi, Pavesi, & Rizzolatti, 1995; Grèzes, Armony,
Rowe, & Passingham, 2003; Iacoboni et al., 2001; Mashal, Solodkin,
Dick, Chen, & Small, 2012) and, since they allow individuals to assim-
ilate other people’s actions into their own motor schemas (Iacoboni
et al., 2001; Oberman et al., 2005), they are hypothesised to represent
one of the bases of an effective communication (Iacoboni et al., 2001;
Rizzolatti & Arbib, 1999). A large body of evidence confirmed dysfunc-
tions in the mirror function in patients with ASD (Hadjikhani, Joseph,
Snyder, & Tager-Flusberg, 2007; Martineau, Andersson, Barthélémy,
Cottier, & Destrieux, 2010; Oberman, Ramachandran, & Pineda,

2008). They correlate with the severity of the symptoms (Dapretto et al.,
2006) and have been related to social and imitation deficits in these
patients (Iacoboni, 2009; Kolb & Gibb, 2011).
Building interventions to address these issues are justified by the
fact that experience can lead existing neurons to change their synap-
tic connectivity (Kolb & Gibb, 2011). Hence, the functioning of the
mirror network might be improved by activities based on the imita-
tion. Imitation, in fact, can be seen as the mirror exercise by definition
and—by eliciting the visual, auditory, and proprioceptive canals together
(Iacoboni et al., 1999)—may maximize the activation of the mirror
neuron network. Imitation indeed can assume several shapes: oral-facial
imitation, actions (with or without objects), and gestures (symbolic or
meaningless). The question of whether such abilities are moderately
separated and unrelated or, rather, depend on a unitary general imi-
tation ability is still controversial. However, meaningless gestures are
particularly difficult to be trained in imitation, in particular with chil-
dren with ASD, given their difficulties in sustained social attention.
These gestures produce neither physical effects that may act as feed-
back for imitation, nor semantic effects that may help to sustain atten-
tion. For this reason, when designing a music-based intervention, it is
worth reminding that is the imitation of meaningless body gestures that
seems universally impaired in children with autism. On the other hand,
the imitation of meaningful gestures is impaired only in low functioning
autism (Vanvuchelen, Roeyers, & De Weerdt, 2007). This suggests that
different forms of imitation (e.g., object, gesture, vocal) may represent
independent dimensions as there is evidence that children with ASD only
generalise within the imitation category they have been trained to (Stone,
Ousley, & Littleford, 1997), although Rogers and colleagues (2003)
and Ingersoll, Meyer, Bonter, and Jelinek (2012) reported correlations
between different imitative behaviors (even if meaningless gestures were
not considered or largely underrepresented in these studies). A spe-
cific imitation intervention for autism has been developed by Ingersoll
and her colleagues (Ingersoll, 2010, 2012; Ingersoll & Gergans, 2007;
Ingersoll & Lalonde, 2010; Ingersoll, Lewis, & Kroman 2007; Ingersoll
& Schreibman, 2006), based on the object-related actions and mean-
ingful gestures, which appeared to be effective in increasing the qual-
ity of both spontaneous and elicited imitation. However, children with
ASD may be facilitated by adding meaning to the gestures (in con-

trast with normally developing children: Rogers, Bennetto, McEvoy, &
Pennington, 1996). On the other hand, children with ASD show unusual
difficulties in imitating meaningless body gestures (DeMyer et al., 1972;
Stone et al., 1997; Vanvuchelen, Roeyers, & De Weerdt, 2007).
If the assumption of independent imitation dimensions is true, only
an intervention grounded on the imitation of meaningless body gestures
may address the core difficulty of patients with ASD (Wild, Poliakoff,
Jerrison, & Gowen, 2010). However, achieving this goal is extremely
problematic for children with ASD, given the paucity of social interaction
and their reduced sustained attention. Imitating meaningless movements
has no effects on the physical world and the lack of such feedback makes
this kind of imitation particularly demanding. In addition, the lack of
relation with a semantic/social meaning of the action prevents to sustain
attention during training. Technological devices allowing individuals to
receive feedbacks to their meaningless actions might enable trainers to
overcome such limits.
The Soundbeam Intervention Project

Forti and colleagues (2012) designed a music-based intervention for
children with ASD, the Soundbeam Imitation Intervention (SII). In SII
imitation is trained for meaningless gestures by coupling movements
with sounds through Soundbeam5® ultrasound-to-midi converter.
When two Soundbeam5®s are used in a child-model imitation setting
and generated sounds are sequenced in a melody, they represent direct
feedback for the accuracy of imitation and engage children’s attention.
SII is designed as an individual intensive intervention in a progression
of imitation exercises: synchronous/one arm imitation, synchronous/
two arms imitation, and delayed imitation. Exercises are based on the
repeated movements-melodies associations of increasing difficulty.
The sequencing of sounds enables the actor to generate melodies and
it has been documented that music represents an attractive and moti-
vating stimulus for children with ASD (Molnar-Szakacs & Heaton,
2012; Reschke-Hernández, 2011). Thus, musical feedback can make
an intervention grounded on the imitation of meaningless body ges-
tures possible for these patients. The intervention is designed as 12
individual SII sessions of 30 minutes each, run biweekly over a 6 weeks
period.
Assessment
To check for actual efficacy of the program, imitation and social atten-
tion assessment took place one week before and one week after comple-
tion of the SII programme. Both motor imitation and social attention
were assessed in a synchronous video-modeling task, similar to the ones
described in the previous paragraph. In this specific assessment task,
participants were required to play a drum copying a model shown on
a video. They sat on a child sit in front of a bongo drum. Behind the
drum, the video was played on a 15″ laptop PC placed on a height-ad-
justable desk. The video started with an initial “beep” to grab partici-
pants’ attention. For the first 10 seconds, they were asked to watch
the video, where the model was shown while playing the same kind of
drum, two strokes with the left hand and one stroke with the right hand,
at a slow rhythm. After the second “beep,” participants were asked to
copy the model on their drum while keep watching the video where
the model was still hitting the drum. They were encouraged to carry on
playing for 60 seconds.
Through motion capture, motor imitation was precisely measured
regarding accuracy. Sustained social attention was measured through the
analysis of video recordings: The amount of time during which partici-
pants were looking at the video returned an indicator of sustained social
attention.
Intervention
SII is designed as training for synchronous imitation of up and down
arm movements of a model standing in front of the child. Soundbeam5®
(Soundbeam project, UK), shaped like a red plastic microphone, allows
returning a sound each time one’s hand is moved in front of the sen-
sor. The sequence of generated sounds can be preprogrammed. Thus,
repeated movements make it possible to play a predefined melody.
Two Soundbeam5®s were used in SII: one for the participant and
one for the trainer. Although they were programmed on the same mel-
ody, different tunes were used to make it possible to identify the sound
generated by one’s movement.
SII sessions were designed as a series of steps whose progression is
individualized and regulated by the acquisition of competencies meas-
ured as two consecutive trials on the same exercise with no mistake. In
the first two exercises, participants are asked to play the melody with
Soundbeam5® by moving hands together with the trainer (synchronous
imitation): Exercise 1 concerns the right arm; Exercise 2 concerns both

arms, although they are moved one at a time in a randomized order.
The trainer regulates the movement-melody rhythm on the basis of the
child’s promptness to imitate. If one movement is not copied, the trainer
sings to grab the child’s attention and solicits the movement. In Exercise
3, participants are asked to play the melody alone, immediately after the
demonstration by the trainer (delayed imitation) using their dominant
hand.
Once the three exercises are learned for a melody, they are repeated
with a more difficult melody. Difficulty is manipulated both regarding
familiarity and regarding rhythm complexity. The progression of mel-
odies is as follows: (i) familiar children song/rhythmically easy: “Frère
Jacques”; (ii) familiar children song/rhythmically difficult: “Happy
birthday”; (iii) unfamiliar rhythm/rhythmically easy: “We will rock
you” chorus by The Queen; (iv) unfamiliar melody/rhythmically
difficult (purposely composed).
Outcomes
The study designed by Forti and colleagues to test their intervention
involved 14 children with ASD and lasted 6 weeks. The effectiveness of
the intervention has been evaluated for imitation accuracy and sustained
attention, both assessed at a video-modeling task. In that procedure,
participants were required to imitate a model shown at a video while
playing the drum. After SII, imitation increased considerably. Social
attention was measured as the time interval children attended the video.
After SII intervention, attention improved from 68 to 97% of total time.
Older children made a quicker progression in SII exercises and partici-
pants with higher IQ were somewhat facilitated. A positive relationship
between developmental skills and growth during treatment has been pre-
viously suggested (e.g., Kraemer & Kupfer, 2006; Sallows & Graupner,
2005). Despite such relationship, in this study gains in imitation and
attention skills were similar for all children. For this reason, SII might
represent a valid intervention for children with autism between 5-and
9-years-old. Also, SII might be a potentially viable intervention for chil-
dren with ASD with severe intellectual disability and indeed one of the
few for nonverbal patients.
SII is not only focused on the meaningless gestures, but also on
simultaneous, rather than delayed, imitation. Thus, SII might address a
specific timing and coordination deficit of children with ASD, evident
both in imitation settings (Trevarthen & Daniel, 2005) and in other

areas, such as gait (Nobile et al., 2011).
As Small and colleagues (2012) suggested, the selection of appro-
priate therapy for autism should ultimately depend on knowledge of
the underlying biology. The approach described above is based on the
hypothesis that mirror-neurons deficit may represent the cause for the
incomplete development of social functioning in children with ASD and
that a systematic activation of such system through the simultaneous
observation-execution of meaningless body gestures may affect func-
tional changes of mirror-related functions. According to Rizzolatti and
collaborators (Rizzolatti & Arbib, 1998, 1999; Tettamanti et al., 2005),
movements represent the basis for interindividual communication and the
development of speech. In fact, neural interactions between movement
and language have been discovered (Rizzolatti & Arbib, 1999; Tettamanti
et al., 2005), there is high comorbidity for movement and language defi-
cits (Kimura & Archibald, 1974; Nobile et al., 2011; Rizzolatti & Arbib,
1999), and imitation abilities of patients with ASD are strictly related to
language skills (Arbib, 2008).
Concluding Remarks
In this chapter, we introduced and explained the benefits of using a
music-therapy-based approach to help individuals with ASD and pre-
sented different ways of assessing individuals’ responses to the different
components of music, as well as a possible way of planning and imple-
menting a music-based intervention that could benefit patients on the
spectrum.
Research data have been discussed to highlight the relevance of
using music therapy with patients with ASD, as well as the need to create a
music-therapy program that can meet the individual characteristics of each
patient on the spectrum. Depending on where on the spectrum a patient
is, they will not only have a different therapeutic need but will also
respond differently to a different type of music.
If used correctly, music proves to be extremely beneficial in sup-
porting patients on ASD in interactive in a more effective way with
their surroundings, by way of improving emotion regulation and enhanc-
ing the quality of social interaction by promoting a better understand-
ing of rhythm in conversation and triggering the activation of the mirror
system.
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CHAPTER 4
Stimulating Motor Coordination in Rett

Syndrome Through Music
Abstract  In the case of Rett syndrome, among the variety of possible

goals that can be reached thanks to music-based interventions (associated
to the different pathological manifestations of the syndrome), motor
coordination has been chosen as one of the critical deficits characterizing
the disorder. Literature supporting the benefits of musical activities when
working with Rett syndrome patients are summarized and reasons high-
lighting why music might be particularly effective in this fields are dis-
cussed. An intensive training program implemented with a girl affected
by Rett syndrome is described in detail and some activities carried out
during the intervention are also exemplified.
Keywords  Rett syndrome · Music therapy · Intervention

Motor skills
Defining Rett Syndrome

Rett Syndrome (RTT) is a rare neurodevelopmental disorder that affects
one in 10,000–15,000 girls and it is due to a mutation in a MECP2 gene
(Elefant & Lotan, 2011; Fabio et al., 2014). This syndrome causes an
increasing loss of intellectual and cognitive abilities, as well as motor
and communication skills. Girls with RTT develop normally for the first
6 months of their life when the regression starts. The most pronounced

https://doi.org/10.1007/978-3-319-97151-3_4
changes generally occur at 12–18 months of age, suddenly or over a

period of weeks or months.
Eventually RTT will cause symptoms that include, but are not limited
to: slowed growth of brain and, later on, of other parts of the body; loss
of movement and coordination, which usually starts with reduced hand
control; loss of communication abilities, that include not only speak-
ing but also the ability to make eye contact and communicate in other
ways; abnormal hand movements that include repetitive and purposeless
movements like hand clapping, tapping, or rubbing; breathing problems
during waking hours, like hyperventilation or breath-holding; emotion
regulation problems that leads to agitation and irritability; cognitive dis-
abilities; seizures; scoliosis; irregular heartbeat, which is a life threating
problems for individuals affected by RTT.
The regression follows four defined stages: early onset, rapid destruc-
tion, plateau, and late motor deterioration. Stage I (early onset) gener-
ally starts between 6 and 18 months and its duration varies between a
few months and one year. Babies start to lose interest in their surround-
ings and avoid eye contact, they might also show some delays in motor
developments milestones, like sitting or crawling. When the babies are
between 1 and 4 years of age, they go through Stage II (rapid destruc-
tion): They more or less gradually loose ability that they have previously
acquired. During this stage, other common symptoms of RTT, like
slowed head growth, abnormal hand movements, hyperventilation, loss
of emotion regulation and social interaction, and problems with motor
coordination. The Stage III (plateau) can begin anytime between age 2
and 10 and usually lasts for several years. Children can experience some
improvements during this phase. These improvements can be related to
emotion regulation, communication, and hand use. Motor coordination
tends not to improve. Some children start experiencing seizures during
Stage III. Stage IV (late motor deterioration) happens after the age of
10 and lasts up to decades. It brings reduced mobility, associated with
muscle weakness and scoliosis. Other symptoms are usually stable and
seizures occur less often.
People affected by RTT tend to have a strong desire for human
contact and interaction, but they are unable to express themselves in a
conventional way. For some people it is hard to interpret nonverbal mes-
sages that are communicated from people with RTT. Generally, patients
express pleasure and displeasure through facial expressions and body
4 STIMULATING MOTOR COORDINATION IN RETT SYNDROME … 77
language. Their physical activity appears to be exclusively focused on

hands, engaged in either simple or complicated stereotypical movements
that basically last all day (Elefant & Lotan, 2004).
Music Therapy and Rett Syndrome

Different therapeutic approaches are used to help patients deal with
RTT, the most common being pharmacotherapy, physiotherapy, hydro-
therapy, horse therapy, occupational therapy. Music therapy is also used
with positive results.
Interestingly enough, it was Rett himself—who first described the
syndrome—to recommend music as an helpful approach to support girls
with RTT (Rett, 1982). Music appears to be beneficial because it pro-
motes the patients’ desire to interact and to communicate with their
surroundings as well as in developing their cognitive, affective, senso-
ry-motor, and physical abilities (Elefant, 2002, 2005, 2009; Hill, 1997;
Merker, Bergström-Isacsson, & Engerström, 2001).
Music and Rett Syndrome

The first question that should be addressed is if girls with RTT do like
music. To achieve this goal, Merker and colleagues (2001) distributed
questionnaires to parents of girls with RTT that contained questions
regarding music and the patients’ responses to it. Results indicated that
music is a significant aspect of the patients’ everyday life experience. This
affirmation was supported not only by the 90% of the parents’ positive
responses to the first question (that asks if their daughter is interested
in music), but also by the specificity and richness of the answers relative
to music preferences. Data from Merker and colleagues’ study also high-
lighted that all of the girls were exposed to music many hours a week.
They tend to have a preference for children’s songs and this preference
remains constant in adult life.
Considering all the characteristics of music that can promote emo-
tional regulation, increase cognitive abilities, and strengthen coordina-
tion, the fact that music is such an important part of the RTT girls’ life
supports the inclusion of music when planning interventions that aim to
enrich the quality of their lives.
Music Therapy to Promote Emotion Regulation

and Emotional Communication
Girls with RTT experience problems when trying to express and com-
municate their emotions and feelings. As we have seen, RTT causes the
loss of communication abilities that affect not only language but also
other form of communication. For this reason patients can use loud
sounds or screaming to express both happiness or pain or can easily bar-
rier themselves behind a blank expression to communicate discomfort
(Bergström-Isacsson, Lagerkvist, Holck, & Gold, 2012). Music can be
used in a therapeutic setting to reflect and support these expressions.
This music-based mirroring helps creating a safe and enabling environ-
ment, helping to broaden and to increase the girls’ communication. The
same concept is also supported by Wigram (2007), who reported that
all the RTT patients he examined responded positively to music therapy.
Music-based interventions were particularly helpful in improving atten-
tion and general motivation, fine motor skills, nonverbal interaction
and communication skills, as well as emotional expression and relaxa-
tion. According to Wigram (2007), people with RTT are often unhappy,
frustrated, anxious, and hypertensive. Making music and the ability to
vocalize and create simple sounds with the instruments allow patients
to express their emotions and improving their overall mood at the same
time.
Musical interactions can also be read the other way. The therapist can
use them to become more familiar with the way each child expresses her
feelings. In turn, this might foster the creation of a closer and hence more
therapeutically effective interaction (Elefant & Lotan, 2004). (Elefant &
Lotan, 2004) believes that music can certainly trigger emotions, but it
is necessary to have someone who recognizes those feelings and is able
to contain the emotions provoked by music, for it to make sense. It is
therefore essential to have a significant and structured interaction as
foundation. Following this line of thought, Garred (2001) claimed that
reciprocity is one of the more important variables of music therapy: A
one-way mechanical relationship between the music and patient would
most likely have no effect; On the other hand, when the therapist, the
patient, and music are mutually interconnected in a dynamic relationship
the intervention can be effective.
Wigram, Cass, Riley, Wisbeach, and Weekes (1994), while work-
ing at the Harper House Children’s Service of Hertfordshire, practiced
improvisation music therapy combined with vibroacustic therapy.

Vibroacustic therapy, or VAT, is a form of sound therapy that uses sound
to produce vibrations that are applied directly to the body. Wigram used
a combination of these two approaches to promote relaxation, reduce
hyperventilation, decrease the stereotypy, increase awareness, atten-
tion, and concentration, develop voluntary movements. As an example,
the therapist discussed a case study (Claire). During the initial sessions
the girl would sit on the physiotherapist’s lap while the music therapist
played the piano in front of her. Slowly she started putting her hands
on the instrument and began playing with her right hand. Whenever the
rhythm became faster and stimulating, Claire started playing. During
this part of the intervention the girl never twisted her fingers. The next
instrument was the drum. Initially played by the therapist, who, in the
meantime, tried to keep Claire’s hand on it. He hit the drum with an
open palm and sometimes he lifted the patient’s hands to help her play.
This procedure helped focusing Claire’s attention. After a while she
started playing the instrument with both hands, while at the beginning
of the intervention she would only use her left hand. Finally the therapist
encouraged the girl to hold the drumstick with her right hand. She took
the stick and twice she hit the drum. The third time she took the stick
and she held it for several seconds. During this intervention she didn’t
show any stereotype. Wigram concluded that music therapy was clearly
a very positive experience for this patient. Claire was able to express her
emotions and she did it through the sounds and the music she created.
Music-Therapy Interventions to Improve Communication

and Social Relationships
Based on results from case studies similar to the one presented above,
Wigram (2007) sustained that music can act as a language and the devel-
opment of vocalization and a wider range of expression skills through
sounds are more important for a child who has limited possibilities of
communication, as it is the case for patients with RTT.
Several other case studies reported in literature support the efficacy
of different types of music therapy to improve communication skills in
girls with RTT. For example, Wigram (1991) discussed the case of an
11-year-old girl, Helen, who attended music-therapy sessions over a
period of 22 months. The therapist started with a structured, direc-
tive approach and progressed with the intervention until he guided
the patient to interact within a more unstructured session based on

free interaction. The initial assessment showed that the girl’s principal
areas of difficulty were in the constructive use of the hands, attention,
and communication abilities. It was also clear that she liked music, but
she could not create it or even understand what she could do with the
instruments. After the first assessment, Helen started a 2-phase therapy
period. The first phase consisted of 25 weekly sessions of 45 minutes.
Each session comprised the same activities, which were always per-
formed in the same sequence. Progress was slow at the beginning. Each
time the therapist handed something to Helen, she just let it slip on the
floor. After 4 weeks, she started interacting with some of the percussion
instruments. During this period important milestones were achieved:
She learned to hold the instruments and the sticks and she became more
focused. Although she still exhibited stereotyped movements during the
sessions, there were longer intervals during which she used her hands
voluntarily with purpose. She even started to use her right hand, to the
point that her mother reported the generalization of this ability at home.
Toward the end of this phase she began to acquire the ability to express
herself through music. She was able to communicate her mood and
her emotions both by producing sounds and by coherently using body
language.
Similar results are reported by Hill (1997), when discussing Lisa’s
case, a 12-year-old girl with RTT. Hill and Lisa met for 12 times, in
weekly half-hour sessions. One of the goals was to improve vocalization.
Lisa was very responsive to the voice and tone changes, but could not
use them to communicate. The therapist realized that by using Lisa’s
name as part of vocalization exercises, producing different variations with
tones and sounds, triggered stronger and more dynamic vocal responses
from the patient. More important, this kind of interaction allowed Lisa
to produce meaningful vocalizations, so that she began to be able to
express her needs to others.
Sometimes music appears not only to foster communication per se,
but also to promote understanding of what a meaningful communica-
tion is. This, in turn, helps promoting a better emotion regulation within
meaningful social interaction.
A good example is reported by Garred (2001), when describing the
case of Anne, a 14-year-old girl with RTT. The purpose of the interven-
tion was to try engaging the patient in significant activities. She was very
introvert and presented incessant stereotypy. During their first session
together, when the therapist gently took a hand, “preventing” her from
rubbing it continuously against the other, Anne did not protest but the
other hand continued to make automatic movements. Following up
on this, the therapist held a tambourine next to her moving hand and
when she accidentally touched it she was positively surprised and con-
tinued doing so. Garred, following an improvisational music-therapy
approach, began intoning a song that adapted to the same rhythm she
was making hitting the instrument. Session after session, Anne became
more involved and started to recognize the song and the actions of the
therapist. Even though at first the beats she was giving the tambourine
were automatic, over time she started to follow the rhythm of the song.
The patient seemed to be having fun and she seemed to understand
this uncommon conversation. The author suggested that what really
appeared to elicit Anne’s amusement and awareness of the meaning of
the shared activity was her realization that each action she performed
had an effect on the other person. The communicative exchange took
place through music and the specific qualities of the “medium” favored
it. Without it, Garred claimed, he would not have been able to reach
Anne and it is really because of music that has been able to establish a
contact with the therapist. This patient could not use verbal language.
Therefore it was important for her to express herself by doing some-
thing meaningful so that it was recognized by the other for what it
really was.
The Use of Music to Promote Motor Skills

As we have seen so far, music promotes many positive outcomes, which
affect different aspects of life of RTT patients. We have seen that in many
cases, even if the main focus of the intervention is on some other symp-
tom (like, e.g., emotion regulation and expression or communication),
the tactile and auditory stimulations provided by musical instruments
appear to be beneficial in motivating the patients and engaging their
hands in meaningful activities. Following this line of reasoning, the pur-
pose of Wylie’s (1996) study was to investigate the use of various rhythm
instruments and noninstrumental objects accompanied by songs to
allow two girls affected by RTT to touch, grasp, and restrain in a coor-
dinated and voluntary way. The research aimed at assessing possible dif-
ferences between a pre-test and a post-test evaluation in the number of
times the patients hit or touched the musical instruments or the objects
following vocal suggestion. They also measured the number of seconds

the girls restrained or put their hands on the percussion instruments that
were available during the sessions. Each child was observed individually
once a week for 30 minutes during their music-therapy sessions. The
therapist sang simple children’s melodies to accompany their use of the
instruments. With each song, the child was encouraged to briefly touch
an instrument, then to touch it for the entire duration of the song, and
then grab, restrain, or actually play an instrument. There was an increase
from the pre-test to the post-test of the number of times when both girls
played or touched percussion instruments following verbal encourage-
ment. They also spent significantly more time holding the instrument or
just restraining their hands on them. These results highlight that music
therapy can encourage a more functional use of the hands in girls with
RTT. These results are consistent with those documented in other stud-
ies that have used music therapy to improve the use of hands in girls with
RTT (Hadsell & Coleman, 1988; Wigram, 1991).
More recently, Yashuara and Sugiyama (2001) used an active music
therapy in individual sessions with RTT patients to evaluate, in particular,
the effects of music in increasing functional use of hands and commu-
nication skills as well as mental and physical development. Each session,
on a weekly basis, lasted 30 minutes. The girls were initially evaluated
based on their ability to: listen, play musical instruments, sing, perform
fine motor tasks, use language, and demonstrate an appropriate rela-
tional behavior. Regarding the use of hands, they were evaluated based
on the duration and frequency with which they held the sticks and
also the number of times the girls would grab them. After a few ses-
sions, the patients began to indicate their favorite instrument by point-
ing with their hand. They were able to choose between 2 instruments
being shown to them and they attempted playing the piano, taking turns
with the therapist. After some more sessions, they started making sounds
that meant “yes.” At the end of the intervention, they were able to hold
sticks in their hands for a long interval of time, with a good hand–eye
coordination, to recognize short melodies and they demonstrated a sig-
nificant cognitive improvement. The therapists reported that the activity
that picked their interest the most was allowing them to freely play the
instruments by themselves, and that led to an improved and more func-
tional use of their hands. Improvement in language comprehension had
also been observed.
The Effects of Music Therapy in Rett Syndrome

From what we have been discussing in this chapter, it looks like music
therapy plays more than a simple motivation role when used with girls
with RTT. It is evident that it can improve the relationship between
the therapist and the patient. Both can communicate through a speech
that is more attainable to these children, because it is not based on
words. Moreover, these kinds of interventions appear the affect the
patients’ overall development. After a period of music therapy, chil-
dren’s self-esteem is improved, as well as physical abilities, and there is a
decrease in stereotypes and they are able to use their body and voice to
produce musical sounds.
If it is clear that musical therapy can develop communicative, motor,
cognitive, and affective skills, it is also important to stress that the most
important aspects in music therapy is the construction of a musical rela-
tionship with the patients and, through it, find a way to match and share
their needs. These results have been achieved thanks to repetitive and
structured activities that give the girls the opportunity, space, and time
to express themselves and interact. To support this idea, we can notice
that what all the interventions presented above have in common is
building a relationship, so to give the patients a sense of security and
acceptance and to validate every gesture/action that they bring to
the sessions. Music therapy can certainly help girls with RTT to have a
more fulfilling emotional and interactive life and this, for them, is of
fundamental importance.
An Intervention to Promote Motor Coordination

in Rett Syndrome
As we have seen above, one of the main characteristics of RTT is

the severe expressive and receptive communication impairment.
Consequently, the ability to communicate has continuously been seen
as a priority in the primary educational interventions with this popula-
tion (Sigafoos & Woodyatt, 1996). The first studies focused mainly on
the improvement and development of speech. Later, however, there
has been an emphasis on enhancing multiple processes of communica-
tion (Stasolla et al., 2014; Wandin, Lindberg, & Sonnander, 2015).
Following this perspective, Sigafoos and colleagues (2000) suggested to
look for and try to promote the Potential Communicative Acts in chil-
dren with communication impairments. Potential Communicative Acts
are defined as idiosyncratic and informal behaviors of communication. As
detailed above, music therapy is effective in promoting this kind of non-
conventional communication, on top of being a substantial motivating
factor. When RTT patients find themselves in an exciting, safe, and moti-
vating context, such as music therapy, they become active, engaged, and
more willing to learn.
Starting from these assumptions, Cardani and colleagues (2009)
designed a music-therapy intervention that was tested working with
Stella, a 20-year-old girl with RTT. The main objective was to analyze
her expressive and communicative skills during the sessions, hypothesiz-
ing that music could act as a medium between her and the surrounding
environment and that this could, in turn, trigger her desire to express
herself and eventually improve her expressive abilities. A second goal of
the intervention was to analyze her specific stereotyped behaviors and
promote a more functional use of the hands thanks to instruments and
mallets that could be grasped or restrained, thus improving her ability to
use pressure, which has been severely compromised since she was 2.
Patient’s Assessment
From the first assessment it clearly emerged that the most evident clinical
aspects of Stella were: the inability to use verbal and nonverbal language,
stereotypy (hand twisting and finger rubbing), bringing her hands in her
mouth, inability to use pressure, cognitive and relational difficulties, ina-
bility to feed, dress, and wash herself, incapability to communicate any
kind of need and to choose or express preferences.
Stella was able to walk and sit upright without support (while she
needed help in going up and down the stairs). She did not have any
respiratory crisis or hyperventilation, no records of epileptic attacks
for 3 years, no severe scoliosis problems, and no signs of any form of
self-harm.
She tended to express strong vitality and energy, especially while play-
ing with her toys and listening to music. She was a happy child, with
deep, expressive eyes, whose attention was captured mostly by people’s
face and eyes. She was reported to be friendly to everyone, even with
strangers, and she continuously needed physical contact.
Structuring of the Intervention

The intervention took place over a 6 months period, with weekly 2-hour
sessions. During the sessions the patient would first have snacks and play
with her favorite games. After that, she would engage in music-based
activities, usually for a period of 40–50 minutes. The music-therapy ses-
sions were divided into two phases:
• Receptive Phase: took the first 20–30 minutes, when the therapist

and Stella would listen to recorded music. This phase was further
divided into:
– Passive Listening: the therapist and the patient would listen to
Stella’s favorite and non-favorite songs;
– Active Listening: they listened to the same songs a second time,
but this time the therapist would mimic the songs and sing along
with them.
• Interactive Phase: this part consisted of music improvisation using
different rhythmic and percussion instruments. The therapist
would work to include Stella more and more into active co-playing
progressively.
The first phase had the main goal of analyzing Stella’s expressive capability
while listening songs that she liked (favorite) and the ones that she did
not like (non-favorite), comparing at the same times responses during
active and passive listening. The idea was that Stella would have been
able to communicate—using gestures, facial expressions, and stereotypy
behaviors—her like or dislike for a song, thus expressing a preference.
Having two listening phases (active, with no interaction, vs. passive,
where singing along and mimicking were added) helped the therapist to
better understand Stella’s responses to music with and without human
interaction.
The second phase (interactive phase) had the primary aim of pro-
moting a more functional use of the hands. Stella could not grab any-
thing since she was 2 years old. The hypothesis behind this specific part
of the intervention was that, by using music and interaction with musi-
cal instruments, she would be motivated to grab, manipulate, and play
them, starting to improve both gross and fine motor skills.
Each session was video-recorded after obtaining the consent by Stella’s
parents. At the end of each session the therapist wrote a short report
focused on the events of the music-therapy session and how Stella was
feeling and behaving.
Receptive Phase
The first 20 minutes of the music-therapy session were devoted to music
listening. The therapist had compiled a playlist with approximately 20
songs. Half of these songs were picked from Stella’s favorites (mostly
cartoons songs or songs for children), whereas the other half were songs
that she had never heard before, randomly chosen from an Italian music
book for children (Ciurleo, 2005). In each session the therapist would
listen with Stella to 4 different songs, always pairing a favorite one with
a non-favorite one, to be able to analyze differences in her reactions and
to investigate her potential to communicate her preferences or emotions.
To assess Stella’s reaction to different kind of songs (favorite vs.
non-favorite) during different ways of listening to them (interactive vs.
noninteractive), recordings and note from two sessions that happened at
the beginning of the intervention and of two from two sessions that hap-
pened toward the end of the intervention have been analyzed.
Stella’s reactions to her favorite songs were similar both during inter-
active and noninteractive listening, even some differences emerged.
During passive listening of her favorite songs, Stella smiled and produced
minor vocalizations and a few stereotypy behaviors. She tried to reach
out for eye contact (but soon she moved her gaze toward the stereo),
looking for physical contact by leaning against the therapist through
the duration of the song. No loud vocalizations, proto-words, or body
movements appeared during passive listening.
While actively listening to her favorite songs, Stella smiled continously
(smiles were broader in this case) and from time to time she laughed.
Stereotyped behaviors were continuous: She would rub her fingers
and gently tap on the part of one hand with the other hand. Her facial
expression was focused, and yet happy. She looked constantly at the ther-
apist and rarely to the stereo. Physical contact was also constant. There
were more vocalizations but no proto-words.
Reactions when listening to non-favorite songs are interesting as well.
During passive listening body movements, as throwing herself back on
the couch or letting her arms fall heavily next to her body, occurred,
whereas they were absent during the listening to the favorite songs. As
a consequence, there were not any stereotypes, because her hands were
separate almost all the time and, when they were joined together, they
would remain still. Stella would not smile or laugh all the time. There
was no attempt to make eye contact. Her expression was bored, at the
moment even annoyed, and the few vocalizations she produced were
weak moans. The physical contact was less constant as well: She tended
to lie down, as if trying to go to sleep, instead of that against the thera-
pist. No proto-words or loud vocalizations were recorded.
During the active listening of non-favorite songs, Stella produced few,
rare, and weak smiles. Her hands remained or next to her body, sepa-
rated, or joint together. She would rub her fingers from time to time.
The eye contact was almost absent: She looked at the therapist because
her attention was captured by the mimic gestures, but she diverted her
gaze quickly. She sat close to the therapist during all song, but some-
times she distanced herself. No vocalizations or proto-words were
recorded.
According to Elefant & Lotan (2004), girls with RTT do not smile
or assume an annoyed expression when they are experiencing something
they do not like. These expressions are usually matched with the other
coping mechanisms that these patients use to avoid unpleasant situations,
like avoiding eye contact and not producing any vocalization. Results
reported by Cardani and colleagues (2009) are coherent with Elefant’s
remarks, showing that Stella would smile only while listening to music
she liked and frowned and avoided eye contact while listening to unfa-
miliar music.
Both Sigafoos and colleagues and Elefant & Lotan (2004) reported
that girls with RTT look for eye contact and manifest stereotyped behav-
iors only when a music-therapy session includes music and the therapist
is active. Again, results reported by Cardani and colleagues (2009) con-
firm these data, since stereotyped behaviors were recorded mainly during
active listening and only when Stella was listening to her favorite songs.
This is interesting mainly because several researchers suggest that hand
stereotypy movements can be read as Potential Communicative Acts used
by girls with RTT (Hunter, 1999; Lindberg, 1991), mirroring their feel-
ings. So we can read Stella’s motor activation as her way of communicat-
ing her excitement in response to a pleasant situation. Following this line
of reasoning, Kerr (1992) suggested that there could be a link between
the stereotypy behaviors and the cerebral activity of girls with RTT and
that these movements could be an auto-stimulation used to expresses
they excitement. Even if they are considered pathological behaviors—and
to some extent they prevent to use the hands in more functional ways,
interfere with other movements, and might cause tissue injuries—there
still is not a consent about possible methodologies to containing these
stereotypy movements, and if these strategies could actually be useful
(Fabio, Giannatiempo, Antonietti, & Budden, 2009). Girls with RTT do
not have many other ways to express their emotions: Preventing them
from moving their hands would mean depriving them of one of most
powerful methods of communication they can use to interact with the
external environment.
Stella appeared to be able to use other strategies, like body move-
ments, eye contact, and physical contact, to communicate her prefer-
ences. She would also vocalize more while listening to her favorite songs.
Her communication strategies were apparent, with her being able to
show a clear preference or to protest against something she did not like.
In conclusion, analyzing this first part of the training, we can con-
clude that Stella was able to communicate emotions, feelings, and level
of excitement through unconventional communicative acts, as eye and
physical contact, facial expressions, stereotypies, vocalizations, smiles,
and body movements. These Potential Communicative Acts are coherent
and adequate to the external situation that triggers them, demonstrating
that the patient could discriminate different contexts and behave accord-
ingly, showing her preference for a situation over another one.
Interactive Phase
During the interactive phase, Stella and the therapist would improvise
together using percussion instruments (e.g., marimbas, drums, bongos,
rattles, etc.). This second part of the music-therapy session would usu-
ally last between 15 and 20 minutes. The primary aim of this part of the
intervention was to improve Stella’s way of using her hands, by way of
the coproduction of music as a way of foster better use of her hands by
learning how to grab and manipulate different objects.
Stella appeared to favor the marimba and the bongos above the other
available instruments. The therapist focused her analysis on Stella’s inter-
action with these two instruments, by counting the number of grabs and
their duration, as well as the number of hits over the bongos, during
seven sessions over the overall 6-month intervention.
Concerning Stella’s interaction with the marimba specifically, the ther-
apist analyzed the number of times the patients grabbed the mallets and
the total time Stella has been holding them during the sessions. Both
indexes increased significantly when comparing the beginning to the end
of the intervention. This mirrors her improvement in overall fine motor
abilities. Over the 6-month time, she learned to grab the mallets and
hold them with ease for several seconds without dropping them.
From a more qualitative standpoint, Cardani and colleagues (2009)
reported that the marimba was Stella’s most favorite instrument. She
started laughing and producing vocalizations as soon as she saw it.
She also moved immediately closer to the instruments and started play-
ing it. At the beginning of the intervention, when she was not able
to grab and hold the mallets, she still attempted to play the instru-
ment just using her hands. Then she transitioned into trying to use the
therapist’s arms to have her play the marimba and produce the well-de-
fined notes she could not produce just using her hands. These interac-
tions with the marimba made Stella extremely happy: She vocalized a
lot and even used several proto-words (which never emerged, as noted
above, during the receptive phase). This emotionally positive interaction
led Stella to be more self-confident while interacting with the marimba,
so that she started to try taking the mallets from the therapist’s hand and
imitate her way of holding them. During the final meetings Stella was
able to effectively hold the mallets and use them to play the marimba.
This is a significant result because RTT leads the girls to be unable to
grab and hold an object after they are 2 years old: This was the first time
Stella was able to perform this action in years.
Stella was also very interested in the bongos, mainly because it was
effortless for her to play them, just by hitting them with her open hands.
The therapist analyzed Stella’s interaction with the bongos over six dif-
ferent music-therapy sessions overall 6 months of the intervention.
Stella’s interaction did not change drastically per se: The number of hits
remained almost constant since the second meeting when she under-
stood how easy it was to play them. This is not surprising, given the fact
that RTT does not affect gross-motor abilities, such as those required to
play the bongos. These data confirmed that Stella had good gross-mo-
tor abilities, good eye-hand coordination, and a good understanding of
the cause-effect relationship: She was able to understand from the very
beginning that she needed a specific amount of strength to obtain the
desired sound.
An impressive result that emerged from the analysis of the video
recording is that Stella slowly started to use the right hand too when
playing the bongo. This is remarkable given the fact that Stella has not
been using the right hand at all during the first sessions.
The interactive phase showed that the intervention was successful not
only at a motor level but also in motivating Stella in wanting to learn
new skills (like playing the marimba). Cardani and colleagues (2009)
suggested that this can be read as an improvement at the cognitive level
too: Stella improved her observation skills and her ability to mime the
therapist’s movements, by reproducing the position of her hands while
holding and using the mallets. The same could be said about her intro-
ducing the use of her right hand while playing the bongos, possibly in
response to the fact that the therapist has been continuously playing that
instrument using both hands. To be able to achieve these goals Stella
needed to be able to carefully observe the therapist’s movements, rec-
ognize the patterns of actions, and memorize them and repeat them in a
finalized and appropriate way.
Final Comments
The intervention designed and applied by Cardani and colleagues (2009)
allowed deriving some relevant information that could be effectively used
when planning music-based interventions targeting girls with RTT.
First of all, vocalization appears to be remarkably different when using
active or passive music-therapy approach. Active music therapy seems
to trigger more continuous and intense vocalizations, which were often
associated with smiles and laughers. When playing her favorite instru-
ments, Stella also produced some proto-words, which were absent in the
receptive, passive phase. What caused this difference is most likely the fact
that during the active parts of the sessions Stella had more space, time,
and freedom to express herself. This allowed the girl to interact more
directly with the therapist, using the instrument to promote a more com-
plex form of emotional communication than during the receptive phase.
The interactive intervention promoted what Garred (2001) defined as
a triangular relationship among Stella, the therapist, and the music, which
is supposed to be the ground of a successful music-based intervention.
Music constitutes a positive experience for almost all patients with RTT,
but the structured interaction with a trained therapist is the critical factor
that can promote social interaction, emotion regulation, and motivation
and eventually lead to the cognitive, emotional, and motor improvements
described above.
It is also important to report that what Stella learned during the

music-therapy intervention was then transferred to her everyday life. A
few weeks after the conclusion of the music-therapy intervention, Stella’s
mother reported that the girl has begun to use both hands in a way that
she never did before: She was able to grab different objects and bring
them to another place in the house.
Concluding Remarks
The current way of considering RTT leads researchers and practitioners
to believe that some improvements can be induced in the behavioral rep-
ertoire of girls affected by this syndrome (Fabio, Antonietti, Marchetti,
& Castelli, 2009). The several studies and interventions reported and
discussed in this chapter showed that music therapy can be used as a
practical approach when working with patients with RTT. Music-based
interventions appear to be effective in promoting communication, foster-
ing emotion regulation, and even recovering some of the motor abilities
lost due to the progression of the syndrome. Grabbing is a good exam-
ple, giving the fact that this skill is fundamental for the patients’ auton-
omy and for their self-esteem and self-efficacy.
Music can also lead to better communication between patient and
their therapist or caregivers, allowing them to identify the emotional
reactions and the different behaviors that can be identified as patients’
attempts to communicate.
Music therapy can hence be considered a base for the development
and growth of the patients with RTT and it is crucial that the future
researchers explore and continue to investigate the potentiality that
music can have on these patients and, vice versa, the signs of progress
that these patients can reach thanks and through music.
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Conclusions
Abstract  Some general remarks about why music can be employed in

rehabilitation interventions, which can be valid for all the neurodevelop-
mental disorders considered in the book, are reported. Future directions
of research are outlined. Practical suggestions for parents and rehabilita-
tors, as well as music teachers, are also discussed.
Keywords  Music · Music therapy · Rehabilitation
This book presented a picture of studies, theories, and techniques sup-

porting the notion that music can be used to improve different skills that
are affected by neurodevelopmental disorders. The book, after present-
ing a general overview about why and how music can be used within
therapeutic settings, focused on specific interventions for ADHD, ASD,
and Rett Syndrome.
The book tried to guide readers to understand the empirical bases that
stand behind some music-based intervention, while describing examples
of interventions and their expected results.
Given how widespread ADHD is among children and teenagers, and
how invasive pharmacological interventions might be, finding alterna-
tive approaches that could help children and teenagers to deal with their
symptoms even when they are off their medication is relevant and timely.
© The Editor(s) (if applicable) and The Author(s), 95

under exclusive license to Springer International Publishing AG,
part of Springer Nature 2018
https://doi.org/10.1007/978-3-319-97151-3
96 Conclusions
From what we discussed in Chapter 2, music seems to be a good can-

didate to address this need. Music can be used to address symptoms at
many different levels. To be more precise, from what we discussed in
the chapter, music can help at an emotional, behavioral, and cognitive
level. At an emotional level, music can be used as a basis to build a safe
space where the patient can experiment confirmatory relationship, which
will support any other growth process they might go trough during
music-therapy sessions. At a behavioral level, music can help to promote
relaxation and foster more awareness about what can cause hyperactivity
and suggest spontaneous strategies that could be subsequently sponta-
neously used by children outside the therapeutic sessions. The rhythm
components of music can also be used effectively to enhance children’s
control and manage more effectively their impulsiveness, by the way of
learning how to respect turns and listen to others, while being aware of
different context-related variables. This promotes better overall cogni-
tive performance even in structured learning tasks. Working with ADHD
patients, music will not aim at suppressing the symptoms: It will fos-
ter a deeper awareness regarding the patients’ specific behaviors, and
this awareness will be functionally used by the therapist to reduce the
symptoms always respecting the individual possibilities of each person.
Using the same approach, music will also trigger compensatory resources
that each child can use to improve the quality of interaction with their
environment.
A similar approach, using music to work both an emotional and a cog-
nitive level, can be applied when working with individuals with ASD.
Music can be employed to assess individuals’ responses to different cog-
nitive and emotional stimuli, as well as a base for interventions that could
specifically benefit patients on the spectrum.
The research data discussed in Chapter 3 stressed the relevance of
using music therapy with patients with ASD, as well as the need to cre-
ate music-therapy programs that can meet the individual needs of each
patient on the spectrum. Depending on where on the spectrum patients
are, they will not only have a different therapeutic need but will also
respond differently to a different type of music.
If approached correctly, music proves to be extremely beneficial in
supporting patients on the spectrum in interacting in a more effective
way with their surroundings, by way of improving emotion regulation
and enhancing the quality of social interaction and by promoting a better
understanding of rhythm in conversation and triggering the activation of
the mirror system.
Conclusions 97
The several studies and interventions reported and discussed in

Chapter 4 showed that music therapy can also be used as a practical
approach when approaching patients with Rett Syndrome (RTT). As
it was the case for the other neurodevelopmental disorders discussed
above, music-based interventions addressed to RTT patients appear to
be effective in promoting communication, fostering emotion regulation,
and even recovering some of the motor abilities lost due to the progres-
sion of the syndrome. Grabbing is a good example, giving the fact that
this skill is fundamental for the patients’ autonomy, as well as for their
self-esteem and self-efficacy. Music can also lead to better communica-
tion between patient and their therapist or caregivers, allowing them to
recognize the emotional reactions and the different behaviors that can be
identified as patients’ attempts to communicate. Music therapy can hence
be considered a base for the development and growth of the patients
with RTT and it is crucial that the future researchers explore and con-
tinue to investigate the potentiality that music can have on these patients
and, vice versa, the signs of progress that these patients can reach thanks
and through music.
What can we derive from the role that music can play in helping and
supporting patients with different neurodegenerative disorders? Music
appears to promote benefits at emotional, behavioural, and cognitive lev-
els. This happens because sounds can be used to trigger the activation of
different mental registers: motor, iconic, and verbal. These registers are
naturally synchronized and foster emotions understanding and regulation
while promoting better communication. Motor, visuospatial, and verbal
elements are already part of the very nature of music, and hence deeply
embedded in any form of music communication.
As an example, music can provide support to foster a better motor
planning, thanks to the motor register associated with rhythm elements
embedded in any music-based communication. Rhythm can also pro-
mote a better emotion regulation, because of the intrinsic organization
of emotional elements that are associated with its nature. The visual
register can enhance mnestic processes, thanks to the visual images and
synesthetic elements that music spontaneously elicits. The discursive pat-
terns that are the base of each music sentence can finally support lan-
guage organization, reading and, to some extent, language production.
In conclusion, this book guided the reader to the discovery of how
music, thanks to its multimodal nature, offers “scaffolding” to fos-
ter learning of movements, carry out cognitive operations, or articulate
98 Conclusions
verbal expressions that need to be rehabilitated, as well as supporting

emotion understanding and control. What also emerged from the analy-
sis and discussion of the studies described in the book is that music alone
will not produce the desired effect: It is critical that its use or produc-
tion is associated with well-designed assessment aimed at evaluating the
individual needs of each patient. Moreover, building a safe and interac-
tive relationship between the therapist and the patient is also a crucial
element that can predict the success of any music-based intervention.

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Music Interventions

ISBN 978-3-319-97150-6 ISBN 978-3-319-97151-3 (eBook)

Library of Congress Control Number: 2018949614

Cover illustration: © Melisa Hasan

particular psychophysical conditions, experiencing pleasure) or collective

interventions, and the results obtained. Beside providing examples

The second chapter is focused on Attention Deficit-Hyperactivity

proposed so to allow readers to link the outcomes of research to what

Milan, Italy Alessandro Antonietti

1 The Reasons Supporting the Use of Music

2 Enhancing Self-Regulatory Skills in ADHD Through

Assessment of the Intervention 44

3 Enhancing Social Skills in Autism Through Music 51

4 Stimulating Motor Coordination in Rett Syndrome

The Reasons Supporting the Use of Music

Keywords Music · Rehabilitation · Music therapy · Neurogenerative

The variety of music-based methods commonly employed for therapeu-

© The Author(s) 2018 1

to something that is peculiar to music. Hence, it is crucial to compre-

Three Mental Registers

about music in spatial terms. In an experiment, Halpern (mentioned in

Relationships Within and Between Registers

depressions, etc.—will be found on the piece of cardboard. For instance,

Musical cognition is a multimodal form of knowledge that, through

On a more sophisticated level, it has been shown that music gener-

upper limbs which were connected to a synthesizer through a computer.

The Iconic Register

The iconic power of music is perceived very early. According to Spelke

The visual resonances and spatial analogies activated by music are

The Verbal Register

is a potential way of using music that Noy (1993) designated as “narrative

in the characteristics of the voice. A voice expressing sadness and music

various registers is reciprocally synchronized—both the power of music as

Enhancing Self-Regulatory Skills in ADHD

Abstract Music can play a role in the treatment of children and teens

Keywords ADHD · Music · Music therapy · Self-regulation

© The Author(s) 2018 19

• the type with predominant inattention: ADHD-I. This subtype

These different subtypes show different patterns of cognitive and behav-

• the marked tendency to seek immediate gratification and

These components, together with secondary deficits, cause the feeling

assess the solvability of a task, difficulty in committing to invest time and

In conclusion, the three primary symptoms of ADHD (distractibil-

emotions without any censoring and reduce their ability to control

single construct, for example deriving assumptions on EF starting from

Music Interventions Addressed to ADHD

1. The intense and repetitive rhythm of rock music stimulates brain

the effectiveness of music therapy for children with ADHD. In general,

1. “definition of the setting”: progressive delimitation of space and

2. “delimitation of the sound field”, through:

aphorical by the therapist through the use of musical instruments; For

• low sensory levels, in concomitance of which the transition to men-

The intervention approach presented by Borghesi is undoubtedly excit-

Music and ADHD: Possible Relationships

A Single-Case Study Intervention

Structure of the Intervention

Aims of the Intervention

More precisely, the child’s ability to autonomously manage and reg-

Activities Included in the Intervention

to imitate the movements and behaviors typical of the animal he had

Assessment of the Intervention

1. The Incorrectness Index, determined by computing the ratio

The Stamback test, consisting of three parts:

The Reasons Supporting the Use of Music

Keywords  Music · Rehabilitation · Music therapy · Neurogenerative

Relationships Within and Between Registers

Enhancing Self-Regulatory Skills in ADHD

Abstract  Music can play a role in the treatment of children and teens

Keywords  ADHD · Music · Music therapy · Self-regulation

Music Interventions Addressed to ADHD

1. The intense and repetitive rhythm of rock music stimulates brain

1. “definition of the setting”: progressive delimitation of space and

2. “delimitation of the sound field”, through:

Music and ADHD: Possible Relationships

Structure of the Intervention

Aims of the Intervention

Activities Included in the Intervention

Assessment of the Intervention

1. The Incorrectness Index, determined by computing the ratio

1. Spontaneous time: The researcher places a pencil in front of the

Outcomes of the Intervention

A Group Intervention for ADHD Children Based

The primary objective of this intervention (Bertoni et al., 2014) con-

1. To promote the development of skills that are lacking in patients

Activities Included in the Intervention

• moment of welcoming (about 10 minutes);

Assessment of the Intervention

Outcomes of the Intervention

Enhancing Social Skills in Autism Through

Abstract  Music treatments addressed to individuals with autism are

Keywords  Autism · Music therapy · Social skills · Emotions

The Benefits of Using Music with Autism

Examples of Assessment Techniques and Training

2. To explore the relationship between individuals’ motivation and

Perception and Discrimination of Musical Rhythm, Intensity,

Perception of Synchronization Between Sounds and Gestures in Music-

Preferences for Different Aspects of Emotional Music Stimuli

Perception of Synchronization of Different Musical Elements

Results from the Assessment and Ideas for the Intervention

Imitation Interventions Based on Technological Devices

Stimulating Motor Coordination in Rett

Abstract  In the case of Rett syndrome, among the variety of possible

Keywords  Rett syndrome · Music therapy · Intervention

changes generally occur at 12–18 months of age, suddenly or over a

Music Therapy and Rett Syndrome

Music and Rett Syndrome

Music Therapy to Promote Emotion Regulation

Music-Therapy Interventions to Improve Communication

The Use of Music to Promote Motor Skills

The Effects of Music Therapy in Rett Syndrome

An Intervention to Promote Motor Coordination

Structuring of the Intervention

• Receptive Phase: took the first 20–30 minutes, when the therapist