Using a Music Therapy Collaborative Consultative Approach - World ...

Institut für Musiktherapie, Lehrstuhl für Qualitative Forschung in der Medizin
Using a Music Therapy Collaborative Consultative
Approach for the Inclusion of Young Children with
Autism in a Childcare Program
vorgelegt von Petra Kern
aus Aalen
2004
Inaugural-Dissertation
zur
Erlangung des Grades eines Doktor rerum medicinalium
der
Universität Witten/Herdecke
im
Bereich der Medizin

“One sees clearly only with the heart.
Anything essential is invisible to the eyes.”
‘The little prince’
by
Antoine de Saint-Exupéry, 1943
Mentor: Prof. David Aldridge, Ph.D.
1. Gutachter: Prof. Dr. rer. medic. Lutz Neugebauer
2. Gutachter: Prof. Mark Wolery, Ph.D.
Akademiereferent: Prof. Dr. rer. medic. Lutz Neugebauer
Tag der Disputation: 19. April, 2004

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ABSTRACT
Using a Music Therapy Collaborative Consultative Approach for the Inclusion of
Young Children with Autism in a Childcare Program
BACKGROUND. Young children diagnosed with Autism Spectrum Disorder
(ASD) are increasingly being included in childcare programs and receiving their therapeutic
services in the context of ongoing class activities and routines. The rationale for this
approach is at least threefold: (a) to minimize stigma and isolation; (b) to capitalize on
children’s naturally occurring learning opportunities; and (c) to increase the number of
experiences that promote learning. Despite widespread studies of preschool inclusion, thus
far there exists no scholarly research specifically evaluating the effectiveness of music
therapy interventions – particularly the collaborative consultative model of service delivery –
for the inclusion of young children with autism in childcare programs.
PURPOSE. The purpose of this cumulative study is to examine the effects of
embedded music therapy interventions on the functioning of young children with autism
during challenging classroom routines within an inclusive childcare program. The key
research questions are: (1) Will individualized music therapy interventions increase target
children’s independent performance during specific routines; and (2) Can classroom teachers
implement interventions based on music therapy principles in ongoing classroom activities
and routines, when music therapy collaborative consultation is provided?
INTERVENTIONS. Each of three interventions addresses a key difficulty targeted
children face. These correspond to (a) the morning greeting routine (Experiment I); (b)
multiple-step tasks within classroom routines (Experiment II); and (c) peer interactions on
the childcare playground (Experiment III), respectively. To increase target children’s independent
performance, seven uniquely composed songs and two pre-composed songs are used
and an outdoor music center is added to the childcare playground. Children’s individual
educational goals, coupled with the strategies commonly used with children with autism, are
taken into consideration in the design of the intervention and song development.
Collaborative consultation, including staff development activities, are provided prior to and
during each intervention.
METHOD. The effects of the song interventions are evaluated by using single-case
experimental designs. These are cumulated as a “case study design.”
Experiment I: Participants in this study are two three-year old children, diagnosed
with ASD (n=2), who exhibit difficulties with the classroom’s morning greeting routine, and
their peers with and without special needs (n=13), classroom teachers (n=5), and the target
children’s respective caregivers (n=2). The aim of the intervention is to increase the
independent performance of target children during the morning greeting routine by way of
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unique greeting songs implemented by classroom teachers and the inclusion of peers and
caregivers. Using an A-B-A-B withdrawal design for subject 1, and a modified version of
this design (A-B-C-A-C withdrawal design) for subject 2, the effectiveness of the song
interventions is evaluated. Categories of behaviors are coded through direct observation
using an event recording system. The experimental design involves two conditions for
subject 1 (Baseline-Intervention) and three conditions (Baseline-Intervention-Modified
Intervention) for subject 2.
Results: Results of this study indicate that during baseline (Condition A) subject 1
has a low level of independent performance (M=33.3%). With the introduction of the song
intervention (Condition B), he steadily becomes more independent (M=54%). The
withdrawal of the song intervention immediately decreases his performance (M=46.7%),
while re-introducing the song increases his independence once again, this time on an even
higher level (M=77.8%). During baseline (Condition A), subject 2 also exhibits a low level
of independent performance (M=23.3%). The initial implementation of the song intervention
(Condition B) does not change his performance significantly (M=30%), while the modified
song intervention (Condition C) increases subject 2’s independent actions significantly and
immediately (M=60%). After withdrawing the song, subject 2’s independent behavior
decreases (M=40%), re-introducing the modified song intervention produces a high level of
independent performance (M=80%). As evaluated in subject 2, the song intervention
changes the classmates’ greeting behavior toward the target child and increases peer
interaction. As for the positive outcomes of the interventions, it can be concluded that
classroom teachers successfully implement interventions based on music therapy principles
into the ongoing classroom routine.
Experiment II: A three-year old boy, diagnosed with ASD (n=1), who has difficulties
managing the sequences required for the multiple-step tasks (i.e., hand-washing, toileting and
cleaning-up independently) is the subject of this study along with his classroom teacher
(n=1). The intentions of this investigation are to evaluate the effectiveness of songs
embedded by the classroom teacher as structural prompts in increasing the independent
performance for the target child during these classroom routines, and to evaluate whether the
musical presentation or the verbal presentation of the sequencing is more effective. Using an
alternating treatment design replicated across these three tasks, the effectiveness of the song
intervention (Condition A) versus lyric intervention (Condition B) is compared. Six
categories of behaviors for each multiple-step task are coded through direct observation using
event recording.
Results: Results of this study indicate that the implementation of either form of the
intervention (song intervention - lyric intervention) is successful in increasing the target
child’s independent performance for each multiple-step task. However, the song intervention
is more effective than the lyric intervention for the hand-washing (song intervention M=66%
versus lyric intervention M=57.1%) and cleaning-up procedures (song intervention M=66.6%
versus lyric intervention M=36.7%), whereas for toileting the lyric intervention (M=38.2%)
is slightly more effective than the song intervention (M=32%). As for the child’s positive
learning progress, it can be affirmed that the teacher embeds both forms of the presented
sequencing in the ongoing classroom routines effectively.

Experiment III: This investigation involves four boys, ages three to five, diagnosed
with ASD (n=4), who display a lack of peer interaction on the playground, typically
developing children as well as children with other disabilities (n=32), and their classroom
teachers (n=6). Two peers for each target child are trained as formal peer helpers. The goal
is to improve the target children’s interactions with peers and play and engagement on the
childcare playground. Using a multiple baseline design across four subjects, the effectiveness
of the intervention is evaluated. Categories of interaction behaviors are coded through direct
observation using a 15-second momentary time sampling recording procedure. Procedural
fidelity data on the teachers and peers task behaviors are recorded as well. Four sequential
conditions (Baseline [Condition A]; Adaptation of the playground [Condition B]; Teachermediated
intervention [Condition C]; Peer-mediated intervention [Condition D]) are
implemented for all subjects, except condition D, where only three subjects participated.
Results: Results of this study indicate that prior to the musical adaptation of the
playground, the targeted children have few positive peer interactions on the playground
(M=3.2%). The musical adaptation of the playground enhances positive peer interactions
slightly but not significantly (M=7.1%). The teacher-mediated intervention results in an
immediate and significant increase in positive peer interactions (M=66.2%). With only one
exception, a high level of the teacher’s ability to implement the intervention is observed
(M=84%). Peers participate and model the tasks on a high level (M=85.3%). Peer
interaction, meanwhile, decreases during the peer-mediated intervention (M=21.1%) but
significantly improves compared to both the playground adaptation and especially the
baseline. Play and engagement increase significantly for three subjects and remain the same
over conditions for one subject.
CONCLUSION. These studies demonstrate the potential benefits of a cumulative
case study design for music therapists working in early intervention. Single-case
experimental designs enable professionals to evaluate clinical practice and consultation with
other professionals and to ask important questions about the practices and principles of music
therapy in a quantitative and experimental way. The results of each study shed light upon the
broader project while the individual results can be cumulated in a singular discussion.
This cumulative case study supports the contemporary model of service delivery in
early intervention/early childhood special education, and shows that music therapy
interventions can be meaningfully embedded in ongoing classroom activities and routines.
The music therapy collaborative consultative approach was effective in enabling teachers to
implement the interventions successfully. Through individualized song interventions, target
children acquired new skills and/or improved in key deficit areas of autism, such as
transitioning, following multiple-step tasks, and social interactions with peers in the natural
environment.
Collaborative consultation, widely employed elsewhere in early intervention/early
childhood special education to promote program sustainability, is an appropriate and
effective way of providing music therapy treatment as well; indeed, it allows for the
expansion of music therapy services more broadly. Overall, music therapy enhances services
for young children with autism, and should be considered as a routine treatment option.
However, training for music therapists in collaborative consultative methods of service
delivery, along with continued research into the effects of embedded music therapy
interventions in inclusive childcare programs, continues to be warranted.
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ZUSAMMENFASSUNG
Anwendung eines musiktherapeutischen kollaborativen Beratungsansatzes zur
Integration von Kleinkindern mit Autismus in einer Kindertageseinrichtung
HINTERGRUND. Kleinkinder mit der Diagnose Autistisches Syndrom werden
zunehmend in Kindertageseinrichtungen integriert und erhalten ihre therapeutischen
Massnahmen im Kontext der alltäglichen Gruppenaktivitäten und routinemäßigen Tagesabläufe.
Dafür gibt es mindestens drei Gründe: (a) um Stigmatisierung und Isolation zu
minimieren, (b) um die im kindlichen Umfeld natürlich vorhandenen Lernmöglichkeiten zu
nutzen, und (c) um die Anzahl an lernfördernden Erfahrungen zu erhöhen. Trotz weitverbreiteter
Studien zur Kindergartenintegration hat sich noch keine Forschungsarbeit mit der
Wirkungsweise von musiktherapeutischen Interventionen auf die integrationsfördernde
Behandlung von Kleinkindern mit frühkindlichem Autismus in Kindertageseinrichtungen
unter Anwendung eines kollaborativen Beratungsmodells beschäftigt.
ZIELSETZUNG. Zielsetzung dieser kumulativen Studie ist, die Wirkung zu
überprüfen, die in das Alltagsleben eingebettete musiktherapeutische Interventionen auf die
Handlungsfähigkeit von Kleinkindern mit frühkindlichem Autismus während für sie
schwieriger Gruppen- und Tagesabläufe in einer integrativen Kindertageseinrichtung haben
können. Die zentralen Forschungsfragen sind: (1) Verbessern individualisierte musiktherapeutische
Interventionen das selbständige Handeln der Zielgruppe während spezifischer
Routinen?, und (2): Können Erzieherinnen Interventionen, die auf musiktherapeutischen
Grundprinzipien beruhen, innerhalb der normalen Gruppenaktivitäten und -abläufe ausführen,
sofern musiktherapeutische kollaborative Beratung angeboten wird?
INTERVENTIONEN. Die Interventionen fokussieren Schwierigkeiten, denen die
ausgewählten Kinder gegenüberstehen, und zwar (a) während der morgendlichen
Begrüßungsroutine (Experiment I), (b) bei Aufgaben innerhalb des üblichen Tagesablaufs,
die mehrere Schritte einer komplexen Handlung umfassen (Experiment II), und (c) bei der
Peerinteraktion auf dem Spielplatz der Kindertageseinrichtung (Experiment III). Um das
selbständige Handeln der ausgewählten Kinder zu verbessern, werden sieben Lieder
komponiert und zwei den Kindern bereits bekannte Lieder verwendet; darüber hinaus wird
der Kinderspielplatz um ein Musikpavillon ergänzt. Beim Design der Interventionen und der
Liedentwicklung, werden individuelle pädagogische Ziele der Kinder sowie Strategien, die
generell bei Kindern mit frühkindlichem Autismus angewendet werden berücksichtigt.
Kollaborative Beratung, einschließlich Mitarbeitertraining, werden vor und während jeder
Intervention gewährleistet.
METHODE. Die Wirkung der Liedinterventionen wird durch die Anwendung von
experimentellen Einzelfallstudiendesigns ausgewertet, die zu einem kumulativen Fallstudiendesign
zusammengefasst werden.
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Experiment I: Teilnehmer dieser Studie sind zwei 3-jährige Kinder mit der Diagnose
Autistisches Syndrom (n=2), die Schwierigkeiten bei der morgendlichen Begrüßungsroutine
zeigen, sowie ihre Peers mit und ohne Behinderungen (n=13), Erzieherinnen (n=5) und die
Fürsorgenden der ausgewählten Kinder (n=2). Ziel der Intervention ist, das selbständige
Handeln der Kinder während der morgendlichen Begrüßungsroutine zu verbessern, indem
speziell für diese Kinder komponierte Begrüßungslieder verwendet werden, die von den
Erzieherinnen implementiert werden und Peers sowie die Fürsorgenden einbezieht. Mit
einem „A-B-A-B-Withdrawal Design“ für Kind 1 und einer modifizierten Version dieses
Designs („A-B-C-A-C-Withdrawal Design“) für Kind 2 wird die Wirksamkeit der Liedinterventionen
evaluiert. Verhaltenskategorien werden durch unmittelbare Beobachtung mit
einem „event recording system“ codiert. Das experimentelle Design umfasst für Kind 1 zwei
Konditionen (Baseline; Intervention) und für Kind 2 drei Konditionen (Baseline;
Intervention; modifizierte Intervention).
Ergebnisse: Ergebnisse dieser Studie zeigen, dass während der Baseline (Kondition
A) Kind 1 ein niedriges Niveau des selbständigen Handelns (M=33.3%) hat. Mit der
Einführung der Liedintervention (Kondition B) wird es stetig selbständiger (M=54%). Die
Wegnahme der Liedintervention verringert sofort sein selbständiges Handeln (M=46.7%),
während die Wiedereinführung des Liedes seine Selbständigkeit noch einmal erhöht, dieses
mal sogar auf einem höheren Niveau (M=77.8%). Während der Baseline (Kondition A) hat
auch Kind 2 ein niedriges Niveau des selbständigen Handelns (M=23.3%). Die erstmalige
Einführung der Liedintervention (Kondition B) ändert sein selbständiges Handeln geringfügig
(M=30%), während die modifizierte Liedintervention (Kondition C) das selbständige
Handeln sofort erheblich erhöht (M=60%). Nachdem das Lied entzogen wird, verringerte
sich das selbständige Handeln des Kindes 2 (M=40%), die Wiedereinführung der
modifizierten Liedintervention führt zu einem hohen Niveau des selbständigen Handelns
(M=80%). Wie für Kind 2 ausgewertet wird, ändert die Liedintervention das Grußverhalten
der Peers in bezug auf das ausgewählte Kind und erhöht die Peerinteraktion. Aufgrund der
positiven Ergebnisse der Intervention kann gefolgert werden, dass die Erzieherinnen
Interventionen, die auf musiktherapeutischen Grundprinzipien basieren, in die normalen
Gruppenaktivitäten und routinemäßigen Tagesabläufe erfolgreich einführen.
Experiment II: Ein 3-jähriger Junge diagnostiziert mit Autistischem Syndrom (n=1),
der Schwierigkeiten hat, komplexe Handlungsabläufe, wie selbständiges Händewaschen,
Zur-Toilette-Gehen und Aufräumen, zu bewältigen, sowie seine Erzieherin (n=1) nehmen an
dieser Studie teil. Die Intention dieser Untersuchung ist auszuwerten, ob Lieder, die von der
Erzieherin als strukturierte Anleitung in den Handlungsablauf eingebettet werden, das
selbständige Handeln des ausgewählten Kindes während dieser routinemäßigen Gruppenaktiviäten
und -abläufe verbessern und ob die musikalische oder aber die verbale Darbietung
der Sequenz wirkungsvoller ist. Anhand eines über diese drei Handlungsabläufe replizierten
„alternating treatment design“ wird die Wirksamkeit der Liedintervention (Kondition A) mit
der verbalen Intervention (Kondition B) erforscht. Sechs Verhaltenskategorien werden für
jede komplexe Handlung durch direkte Beobachtung der Handlungsabläufe codiert.
Ergebnisse: Ergebnisse dieser Studie zeigen, dass die Implementierung beider
Interventionsformen (Liedintervention, verbale Intervention) erfolgreich ist, um das selbständige
Tun des Kindes innerhalb der jeweiligen komplexen Handlung zu verbessern. Die
Liedintervention ist jedoch wirkungsvoller als die verbale Intervention für das Hände-

waschen (Liedintervention M=66% gegenüber verbaler Intervention M=57.1%) und die
Aufräumaktionen (Liedintervention M=66.6% gegenüber verbaler Intervention M=36.7%),
während für den Toilettengang die verbale Intervention (M=38.2%) gerinfügig wirkungsvoller
als die Liedintervention (M=32%) ist. Aufgrund des positiven Lernfortschritts des
Kindes kann bestätigt werden, dass die Erzieherin beide Formen der dargestellten Sequenzen
erfolgreich in die fortwährenden Gruppenaktivitäten und -abläufe einbettet.
Experiment III: Dieses Experiment involviert vier Jungen mit der Diagnose
Autistisches Syndrom (n=4) im Alter von 3 bis 5 Jahren, die einen Mangel an Peerinteraktion
auf dem Spielplatz aufweisen, normal entwickelte Kinder sowie Kinder mit Behinderungen
(n=32) und ihre Erzieherinnen (n=6). Für jedes ausgewähltes Kind werden zwei formale
Peerhelfer ausgebildet. Ziel ist es Interaktionen mit anderen Kindern sowie das Spiel und die
Tätigkeit der ausgewählten Kinder auf dem Spielplatz der Kindertageseinrichtung zu
verbessern. Die Wirksamkeit der Intervention wird mit einem „Multiple Baseline Design“
ausgewertet, das über die vier Kinder repliziert wird. Interaktionskategorien werden durch
direkte Beobachtung mit einem „15-second momentary time sampling recording procedure“
kodiert. Verfahrensqualitätsdaten bezüglich des Erzieherinnen- und des Peerverhaltens
werden ebenfalls festgehalten. Vier aufeinanderfolgende Konditionen [Baseline (Kondition
A); Modifizierung des Spielplatzes (Kondition B); Erziehervermittelte Intervention
(Kondition C); Peervermittelte Intervention (Intervention D)], ausgenommen Kondition D,
bei der nur drei Kinder teilnehmen, werden für alle Kinder durchgeführt.
Ergebnisse: Ergebnisse dieser Studie zeigen, dass vor der musikalischen
Modifizierung des Spielplatzes die Zielgruppe wenig positive Interaktionen mit anderen
Kindern auf dem Spielplatz (M=3.2%) zutage treten. Die musikalische Modifizierung des
Spielplatzes erhöht die positiven Interaktionen mit anderen Kindern geringfügig, aber nicht
signifikant (M=7.1%). Die erziehervermittelte Intervention resultiert in eine sofortige und
signifikante Zunahme der positiven Peerinteraktionen (M=66.2%). Mit nur einer Ausnahme
wird bei den Erzieherinnen ein hohes Niveau der Fähigkeit die Intervention einzuführen
beobachtet (M=84%). Peers machen mit und bewältigten die Aufgabe auf einem hohen
Niveau (M=85.3%). Die Peerinteraktion nimmt während der peervermittelten Intervention
jedoch ab (M=21.1%), ist aber signifikant höher als vor und mit der Spielplatzmodifikation.
Das Spielen und die Tätigkeiten erhöhen sich signifikant für drei ausgewählten Kinder und
bleiben für ein ausgewählten Kinder über die Konditionen hinweg gleich.
SCHLUSSFOLGERUNG. Die Studien zeigen den potentiellen Vorteil eines
kumulativen Fallstudiendesigns für Musiktherapeuten, die in der Frühförderung tätig sind.
Experimentelle Einzelfallstudiendesigns ermöglichen Fachleuten, klinische Praxis und
Beratung mit anderen Berufsgruppen auszuwerten und wichtige Fragen über die Praxis und
Grundsätze der Musiktherapie in quantitativer und experimenteller Weise zu stellen. Die
Ergebnisse der Studien geben Einblick in das umfangreiche Projekt, während die einzelnen
Ergebnisse in einer Diskussion zusammengefasst werden können.
Diese kumulative Fallstudie unterstützt die derzeit aktuelle Behandlungspraxis in der
Frühförderung und in der Sonderpädagogik und zeigt, dass musiktherapeutische Interventionen
in normale Gruppenaktivitäten und Tagesabläufe eingebettet werden können. Der
musiktherapeutische kollaborative Beratungsansatz ermöglicht es Erzieherinnen, Inter-
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ventionen erfolgreich einzusetzen. Durch individualisierte Liedinterventionen erwerben die
ausgewählten Kinder neue Fähigkeiten und/oder verbessern zentrale Defizitbereiche des
Syndroms, wie Übergänge, Befolgung von Schritten einer komplexen Handlung oder soziale
Interaktionen mit Peers in ihrer gewohnten Umgebung.
Kollaborative Beratung, die vielfach in der Frühförderung und Sonderpädagogik
angewendet wird, um Nachhaltigkeit zu unterstützen, ist eine angemessene und
wirkungsvolle Art und Weise Behandlungen anzubieten und erweitert zudem das
musiktherapeutische Angebot. Insgesamt verbessert Musiktherapie die therapeutischen
Maßnahmen für Kleinkinder mit frühkindlichem Autismus und sollte routinemäßig als
Behandlungsoption betrachtet werden. Es ist jedoch notwendig, Musiktherapeuten in
kollaborativen Beratungsmethoden auszubilden und die Effekte von eingebetteten
musiktherapeutischen Interventionen in integrativen Kindertageseinrichtungen weiter zu
erforschen.

ACKNOWLEDGEMENTS
I would like to take this opportunity to thank those whose expertise and
companionship had a major impact on my academic and personal growth during the progress
toward my doctorate.
Very special thanks goes to my mentor, Prof. Dr. David Aldridge, for sharing his
immeasurable knowledge and wisdom, generosity and British humor, as well as for his gentle
pushes and challenges, open conversations and vision. Thank you for giving me space and
guidance for my academic and personal growth. Many thanks to Prof. Dr. Lutz Neugebauer
for being an inspiration, and for his open conversations, “Geselligkeit,” and profound ideas.
My deepest appreciation goes to Prof. Dr. Mark Wolery for introducing me to the world of
research. Thank you for your contributions, support, honesty, open heart and belief in me.
I would also like to thank the children and families, teachers and colleagues at the
Frank Porter Graham Childcare program at the University of North Carolina at Chapel Hill.
Without their dedication, collaboration and support, this dissertation would never have
happened. Many thanks to Dr. Debby Cryer, Dr. P. J. McWilliam, Dr. Ann Garfinkle, Mary
Jenne, Maggie Connolly, and Prof. Dr. Don Bailey at the FPG Child Development Institute
for making this research project and my stay in the U.S. possible. Thanks to Prof. Dr. Lee
Marcus and Prof. Dr. Gary Mesibov from Division TEACCH for inviting me to the students’
research meetings.
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Extraordinary thanks to Linn Wakeford, Maureen Furlong, and Rob McCouch for
patiently proof-reading this thesis, and for their encouragement and valuable feedback.
Thanks to Don Trull, Thomas Turanchik, Michael Schuschk and Rainer Dörrer for media and
technical support. Thank you to my colleagues at the University Witten-Herdecke, especially
Dr. Jörg Fachner, for their hospitality, open minds, incredible musicianship and many laughs.
Thanks to my American music therapy colleagues, particularly Laura DeLoye and Yasmine
White, for sharing their expertise, inspiring moments and friendly collaboration.
Thanks to Jon Metzger, my jazz teacher and friend, for keeping me swinging and
nurturing my spirit and soul through music. Deep gratitude goes to Kathleen Hannan, Darby
Ottom, Sonja Steward, and many others thanks for the endless pleasure of jamming and
musicking. Thanks to Friderike Gerling, Susanne Hitschold, Volker Gronwald, Christine
Arnsberger, Nives Ebert, and Tonia Morrison for their friendship, sharing of life experiences
and encouragement. Thanks to my godchildren, Tamara and Fiona, and to Amelie,
Constantin, and Leonie, Jana, Ronya, Anne and Elias, Niklas, Elea, Owen and Anna for
sharing their beautiful children’s spirit, curiosity, wisdom and music.
Thanks to my parents, Alois and Angela Kern, for being my roots and Swabian home,
as well as to Gertraud and Helmut Schmid for their belief in education and being my second
family. My sisters Christine and Sarah Kern, my thanks for sharing family stories,
adventures and love. Last but not least, thanks to Joachim Schmid for his unconditional love,
countless hours of talking and listening, his generosity and belief in me.

TABLE OF CONTENTS
Chapter Page
List of Tables ……………………………………………………………………………. xix
List of Figures .…………………………………………………………………………... xxi
List of Video Excerpts ………………………………….………………………...…… xxiv
List of Audio Excerpts ………………………………………………………………… xxvi
1. Introduction …………………………………………………………………………… 1
2. Literature Review …….……………………………………………………………….. 9
2.1 Early Intervention/Early Childhood Special Education ………………..…. 9
2.1.1 Definitions and Rationale ………………………………………….…... 9
2.1.2 Inclusion …………………………………………………….………… 10
2.1.2.1 Definitions, Philosophy and Rationale ...……………..…..….…… 10
2.1.2.2 Developmentally Appropriate Practice ……………………...…… 12
2.1.3 Early Intervention/Early Childhood Special Education Services …….. 13
2.1.3.1 Embedded Model of Service Delivery …………………………… 13
2.1.3.2 Interdisciplinary Team Approach and Individualized Family
xiv
Service Plan/Individualized Education Program …………………. 14
2.1.3.3 Integrated Therapy ……………………………………………….. 15
2.1.3.4 Integrated versus Segregated Model of Service Delivery …...…… 18
2.1.4 Music Therapy in Early Intervention/Early Childhood Special
Education ………………………………………………………...…… 19

xv
2.1.4.1 Music Therapy and Children with Special Needs ……………...… 19
2.1.4.2 Music Therapy in Inclusive Childcare Programs ……………….... 20
2.1.4.3 Models of Service Delivery in Music Therapy ……………...…… 25
2.1.4.4 Collaborative and Consultative Models of Service Delivery in
Music Therapy …………………………………………………… 26
2.2 Autism ……………………………………………………………………. 29
2.2.1 Definition, Prevalence, Causes and Diagnosis ……………………….. 29
2.2.2 Characteristics of Autism ……………………………………………... 31
2.2.2.1 Social Interaction and Relationships ……………………………... 32
2.2.2.2 Language and Communication Development ………………….… 33
2.2.2.3 Repetitive, Restricted and Stereotypic Behaviors ………………... 33
2.2.2.4 Other Characteristics ……………………………………………... 34
2.2.3 Contemporary Education and Treatments for Young Children with
Autism ……………………………………………………………….... 35
2.2.3.1 Medical Treatments ……………………………………………… 36
2.2.3.2 Educational and Behavioral Approaches and Programs …………. 37
2.2.3.3 Complementary Therapies ……………………………………….. 38
2.2.4 Including Children with Autism in Preschool Education Program ...… 39
2.2.4.1 Rationale for Inclusion ………………………………………….... 39
2.2.4.2 Theoretical Framework for Teaching Children with Autism ……. 40
2.2.4.3 Early Intervention Programs for Children with Autism …………. 43
2.2.4.4 Teaching Strategies ………………………………………………. 45
2.2.5 Music Therapy for Children with Autism …………………………..… 51

2.2.5.1 Benefits of Music Therapy for Children with Autism …………... 51
2.2.5.2 Music Therapy and Autism: Clinical Practice and Research ….… 52
2.2.5.3 Music Therapy in Inclusive Preschool Education Programs for
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Children with Autism …………………………………………..… 59
2.2.5.4 Inside-Out Reports Related to Music ………………………...…. 53
2.2.5.4.1 From Adults’ Perspectives ………………………………... 63
2.2.5.4.2 Interview with a Ten-Year-Old Jazz Pianist …………….... 65
3. Methods………………………………………………………………………………... 71
4. Experiment I: Increasing Independent Performance of Children with Autism
during the Morning Greeting Routine ……………………………………………... 77
4.1 Introduction ……………………………………………………………….… 77
4.2 Research Questions ……………………………………………………….… 79
4.3 Method …………………………………………………………………….… 80
4.3.1 Participants ………………………………………………………….… 80
4.3.2 Setting ………………………………………………………………… 86
4.3.3 Materials …………………………………………………………….... 87
4.3.4 Procedure …………………………………………………………...… 93
4.3.5 Experimental Design ………………………………………………….. 96
4.3.6 Measurements ……………………………………………………….... 98
4.3.7 Reliability ………………………………………………………….… 100
4.4 Results ……………………………………………………………………… 101
4.4.1 Interobserver Agreement …………………………………………….. 101
4.4.2 Outcome Data ……………………………………………………….. 102

xvii
4.5 Discussion ………………………………………………………………..…. 108
5. Experiment II: Increasing Independent Performance of a Child with Autism
during Multiple-Step Tasks ………………………………………………………... 121
5.1 Introduction ……………………………………………………………….. 121
5.2 Research Questions ……………………………………………………..…. 130
5.3 Method ……………………………………………………………………... 130
5.3.1 Participants …………………………………………………………... 130
5.3.2 Setting …………………………………………………………….…. 135
5.3.3 Materials …………………………………………………………….. 137
5.3.4 Procedure ……………………………………………………………. 141
5.3.5 Experimental Design ………………………………………………… 144
5.3.6 Measurements ……………………………………………………..… 145
5.3.7 Reliability ……………………………………………………………. 148
5.4 Results ……………………………………………………………………… 148
5.4.1 Interobserver Agreement ………………………………………….… 148
5.4.2 Outcome Data ……………………………………………………..… 149
5.5 Discussion ………………………………………………………………..… 153
6. Experiment III: Increasing Peer Interaction of Children with Autism on
Childcare Playground through Music ……………………………………………. 161
6.1 Introduction ………………………………………………………………... 161
6.2 Research Questions ……………………………………………………...… 165
6.3 Method ………………………………………………………………...…… 165
6.3.1 Participants …………………………………………………………... 165

xviii
6.3.2 Setting ……………………………………………………………..… 177
6.3.3 Materials …………………………………………………………..…. 180
6.3.4 Procedure ……………………………………………………………. 199
6.3.5 Experimental Design ………………………………………………… 204
6.3.6 Measurements …………………………………………………..…… 206
6.3.7 Reliability ………………………………………………………….… 210
6.4 Results ……………………………………………………………………… 211
6.4.1 Interobserver Agreement ……………………………………………. 211
6.4.2 Outcome Data ………………………………………………..……… 212
6.5 Discussion …………………………………………………………..……… 241
7. General Discussion……………………………………………………………...…… 263
8. Conclusions ……………………………………………………………………..…… 273
References……………………………………………………………………………...… 277
Appendices …………………………………………………………………………...…. 315
Appendix A: Data Sheet Experiment I ……………………………………… 315
Appendix B: Data Sheet Experiment II ……………………………………... 317
Appendix C: Data Sheets Experiment III …………………………………… 318

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LIST OF TABLES
Table 3.1 Participant composition of experimental groups ……………………… 74
Table 4.1 Overview of Phillip’s and Ben’s IEP goals incorporated in “Song
for Phillip” and “Song for Ben” ………………………………...….… 89
Table 4.2 Interobserver agreement in Conditions A, B, and C …………..…...…. 102
Table 5.1 Interobserver agreement over Task #1, #2, and #3 ………………..…. 149
Table 6.1 Summary of characteristics for each subject …………………..….…. 172
Table 6.2 Overview of Eric’s IEP goals incorporated in the song
“Hey You” …………………………………………………………..... 188
Table 6.3 Overview of Ben’s IEP goals incorporated in the song
“You and I”………………………………………………………….... 190
Table 6.4 Overview of Phillip’s IEP goals incorporated in the song “Phillip’s
Groove” ……………………………………………………………… 193
Table 6.5 Overview of Lucas’ IEP goals incorporated in the song “Lucas’
Dance” …………………………………………..…………………… 196
Table 6.6 Interobserver agreement for each target child in conditions
A, B, C, and D ……………………………………..………………… 212
Table 6.7 Range (Min% and Max%), Mean (M%), and Standard Deviation (SD) of
positive peer interaction for each target child, by each condition of
Experiment III …………………………………………………..…… 213
Table 6.8 Range (Min% and Max%), Mean (M), and Standard Deviation (SD)
of teacher task behavior for each target child in Condition C …….… 223
Table 6.9. Range (Min % and Max %), and Standard Deviation (SD) of peer

task behavior for each target child in Condition D …..……………… 228
Table 6.10 Range (Min% and Max%), Mean (M%), and Standard Deviation
(SD) of stays in the Music Hut for each target child, by Conditions
B, C, and D of Experiment III ...……………………………………… 232
Table 6.11 Range (Min% and Max%), Mean (M%), and Standard Deviation
(SD) of play and engagement for each target child, by each
condition of Experiment III ………………………………………… 237
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LIST OF FIGURES
Figure 4.1 “Hello” picture symbol employed to greet classroom teachers and
peers during the morning greeting routine ……..…………………… 87
Figure 4.2. Transcript of ”Song for Phillip,” written to address Phillip’s
demands of the morning greeting routine, social interaction and
specific IEP goals ……………………………………………….…….. 91
Figure 4.3 Transcript of ”Song for Ben,” written to address Ben’s demands of
the morning greeting routine, social interaction and specific IEP
goals …………………………………………………………………... 92
Figure 4.4 Number of independent responses performed by Phillip during the
morning greeting routine in baseline and intervention sessions …..… 104
Figure 4.5 Number of independent responses performed by Ben during the
morning greeting routine in baseline, intervention, and modified
intervention sessions ……………………………...……………….… 106
Figure 4.6 Number of peers greeting Ben during the morning greeting routine
in baseline, intervention, and modified intervention sessions …….… 107
Figure 4.7 Transcript of the song ”Wait,” written for Phillip addressing the
ability to wait ………………………………………………...……… 112
Figure 5.1 Transcript of the song ”Let’s go potty,” written for Andy,
Addressing the demands of his toileting routine while in the
classroom …………………………………………………….……… 140
Figure 5.2 Number of independent steps correctly performed by Andy for
hand-washing, toilet training, and cleaning-up …….………………… 151

Figure 6.1 Playground equipment, including the Sound Path on the FPG
xxii
childcare program’s playground ………………………………..…… 179
Figure 6.2 Panorama view of the outdoor music center (Music Hut), showing
the instruments and construction …….……………………………… 181
Figure 6.3 Transcript of the medley: “Everybody in the Music Hut,” written
for the Grand Opening of the Music Hut ……………………………. 187
Figure 6.4 Transcript of the song ”Hey You,” written for Ben addressing
social interaction and specific IEP goals …………………………..… 189
Figure 6.5 Transcript of the song ”You and I,” written for Ben addressing
social interaction and specific IEP goals ……………………………. 192
Figure 6.6 Transcript of the song ”Phillip’s Groove,” written for Phillip
addressing social interaction and specific IEP goals ……………...… 194
Figure 6.7 Transcript of the song ”Lucas’ Dance,” written for Lucas
addressing social interaction and specific IEP goals ...………………. 198
Figure 6.8 Percentage of positive peer interactions for each target child, by
each condition of Experiment III ……………………………….…… 214
Figure 6.9 Percentage of positive peer interactions for Eric during Conditions
A, B, and C ……………………………………………...…………… 216
Figure 6.10 Percentage of positive peer interactions for Ben during Conditions
A, B, C, and D …………. …………………………………………… 218
Figure 6.11 Percentage of positive peer interactions for Phillip during
Conditions A, B, C, and D …………………………………………… 220

xxiii
Figure 6.12 Percentage of positive peer interactions for Lucas during
Conditions A, B, C, and D …………………………………………… 222
Figure 6.13 Teacher’s Task behaviors and positive peer interactions in
Condition C for Eric (top panel), Ben (second panel), Phillip
(third panel), and Lucas (bottom panel) ……………………………… 224
Figure 6.14 Peer’s task behaviors and positive peer interactions in
Condition D for Ben (top panel), Phillip (middle panel), and Lucas
(bottom panel) ……………………………………………………….. 229
Figure 6.15 Percentage of positive peer interactions and stays in the Music Hut
for Eric (top panel), Ben (second panel), Phillip (third panel), and
Lucas (bottom panel), in all conditions ….….……………………….. 233
Figure 6.16 Percentage of play and engagement and stays in the Music Hut for
Eric (top panel), Ben (second panel), Phillip (third panel), and Lucas
(bottom panel), in all conditions …………………………………….. 238

LIST OF VIDEO EXCERPTS
Video Excerpt 4.1 Phillip’s morning greeting time behaviors during baseline
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condition ………………………………………………………… 83
Video Excerpt 4.2 Ben’s morning greeting time behaviors during baseline
condition ……………………………………………...………… 86
Video Excerpt 4.3 Phillip, his classroom peers, parents and teachers during a
song intervention session (Condition B) of the morning
greeting routine …………………………………………………. 111
Video Excerpt 4.4 Ben, his classroom peers, and teachers during a modified
intervention session (Condition C) of the morning greeting
routine …………………………….…………………………… 115
Video Excerpt 5.1 Andy performing the multiple steps included in cleaning-up
during lyric intervention and song intervention ………..……… 157
Video Excerpt 6.1 Video collage of Eric’s typical playground behaviors
during baseline condition ………….…………………………… 167
Video Excerpt 6.2 Video collage of Ben’s typical playground behaviors during
baseline condition ………….…………………………..……… 169
Video Excerpt 6.3 Video collage of Phillip’s typical playground behaviors during
baseline condition ………….………………………………..… 170
Video Excerpt 6.4 Video collage of Lucas’ typical playground behaviors during
baseline condition ………….………………………………..… 172
Video Excerpt 6.5 Eric’s performance during the teacher-mediated intervention
phase of the playground interaction study ……………..………. 245

xxv
Video Excerpt 6.6 Ben’s performance during the teacher and peer-mediated
intervention phase of the playground interaction study ……….. 248
Video Excerpt 6.7 Phillip’s performance during the teacher and peer-mediated
intervention phase of the playground interaction study …..…… 251
Video Excerpt 6.8 Lucas’ performance during the teacher and peer-mediated
intervention phase of the playground interaction study ……...… 254

LIST OF AUDIO EXCERPTS
Audio Excerpt 5.1 Recording of the first part of the hand-washing song, sung
xxvi
by Andy’s classroom teacher …….……………….………….… 138
Audio Excerpt 5.2 Recording of the song “Let’s go potty,” featuring the
classroom teacher on vocals …………….……………………… 139
Audio Excerpt 5.3 Recording of the first part of the cleaning-up song, sung by
the children of the FPG childcare program …………….…….… 141

xxvii

1. Introduction
“Children are the touchstone of a healthy and sustainable society. How a culture
treats its youngest members has a significant influence on how it will grow, prosper, and be
viewed by others.”
(Meisels & Shonkoff, 2000, p. 3)
Providing support and assistance to young children with special needs, and to their
families, is an important act for both the individual and the society. Early education and
treatment of children with special needs, including those with autism, significantly enhances
a child’s ability to participate meaningfully in family and community life, and to play a vital
role in society (Autism Society of America, 2003; TEACCH, 1999; Wolery et al., 2001).
Because the socio-cultural environment is an integral force in a child’s learning and
development (DEC, 2000; Vygotsky, 1978, Wolery & Wilbers, 1994), full inclusion of
children with special needs in their natural environments – such as early childhood programs
– has been supported on ethical, legal and educational grounds (Wilson, 2002; Wolery &
Wilbers, 1994). For young children with autism, whose social interactions and relationships,
language and communication, and behaviors are significantly affected, inclusion greatly
enhances the child’s development and quality of life in numerous ways (American
Psychiatric Association, 2000; Autism Society of America, 2003; National Research Council,
2001). Early experiments on inclusion give children with autism the opportunity to imitate
peer models, interact and communicate with competent partners, provide realistic learning
experiences in a natural environment, and foster friendships with typically developing peers.
Typically developing peers involved in such experiments, for their part, might likewise
1

2
improve their social skills and attitudes toward individuals with disabilities (Buysse, 1993;
Jellison, 1985; Peck, Odom, & Bricker, 1993; Wolery & Wilbers, 1994).
This knowledge has led to a trend toward more widespread inclusion of young
children with autism in community-based preschools or childcare programs (Dawson &
Osterling, 1997; Handleman & Harris, 2001; National Research Council, 2001). But to
ensure successful inclusion, and to meet individual learning and developmental needs, the
application of specific, individualized interventions and strategies is imperative (Sandall,
McLean, & Smith, 2000; Wolery & Wilbers, 1994). Several educational and therapeutic
interventions and strategies have been suggested for effectively including and educating
children with autism (Koegel & Koegel, 1995; National Research Council, 2001). Towards
this end, the Division of Early Childhood (DEC) (Sandall et al., 2000), as well as the
Committee on Educational Interventions for Children with Autism (National Research
Council, 2001), recommend that interventions be embedded in ongoing classroom routines.
The rationale for this procedure is at least threefold: (a) to minimize stigma and isolation; (b)
to capitalize on children’s naturally occurring learning opportunities; and (c) to increase the
number of experiences that promote learning (McWilliam, 1996; Wolery & Wilbers, 1994).
Contemporary service delivery, therefore, is based on an integrated therapy model – that is,
that specialized therapies are delivered in the context of the child’s naturally occurring
environments, routines and activities (McWilliam, 1996). To ensure normalization,
continuity, maintenance and generalization, therapists work with the individual child or a
group of children within the ongoing classroom routines, or as consultants to the classroom
staff and families to embed therapeutic goals (National Research Council, 2001; McWilliam,

1996). Occupational therapists (Dunn, 1996; Sandler, 1997), speech/language pathologists
(Wilcox & Shannon, 1996), physical therapists (Rainforth & Roberts, 1996; Sandler, 1997)
and special educators (Garfinkel & Schwartz, 2002; Venn et al., 1993; Wolery et al., 2002)
have evaluated and successfully applied this approach in inclusive childcare settings. But
this approach has not been widely applied, nor has it yet been evaluated by music therapists.
Music therapy has a long tradition of serving young children with special needs,
especially those with autism (Alvin & Warwick, 1991; Nordoff & Robbins, 1977). Studies
on interest in music and relative strength of musical abilities in children with autism
(Applebaum et al., 1979; Blackstock, 1978; Thaut, 1987, 1988) and anecdotal reports on the
quality of music as a means of nonverbal communication, social contact and self-expression
(Alvin & Warwick, 1991; Nelson, 1984; Nordoff & Robbins, 1968a; Schuhmacher, 1994),
suggests that music therapy is a suitable treatment option for individuals with autism. Music
therapy interventions address the challenges associated with autism in an intentional and
developmentally appropriate manner, and might be effective in facilitating development of
core skills and personal growth. Key strategies applied for educating children with autism –
such as individualization, structure and predictability, and emphasis on the child’s strengths
and individual needs – are incorporated in music therapy treatments or are part of the nature
of music itself (AMTA, 2003c). Music therapy also strongly supports and facilitates
inclusion of children with special needs in various educational settings (Wilson, 2002). That
said, the effectiveness of music therapy interventions for the inclusion and improvement of
core skills in young children with autism enrolled in inclusive preschool settings is
3

4
documented by few (Furman, 2001, 2002; Humpal & Wolf 2003; Snell, 2002); and
controlled studies of any kind are missing alltogether.
Although music therapy services can either be provided directly to clients or through
consultation with professionals and others directly involved with the client (AMTA 2003a),
only 13% of the music therapists in the U.S. provide consultative services (Smith &
Harrison, 1999). Some attention has been paid to embedded treatments and the collaborative
and consultative models of music therapy service delivery as effective strategies for
including students with special needs within public school settings (Furman, 2002; Humpal,
2002; Johnson, 2002; Snell, 2002). But the literature that has ensued – program descriptions,
guidelines, strategies, and benefits of this model of service delivery – is not the result of
formal scholarly research investigations, but rather of formative best practices research.
Additionally, no information is currently available to describe whether or not the integrated
models of service delivery, especially collaborative and consultative strategies, are common
clinical practice in music therapy for serving young children with special needs in inclusive
preschool settings.
The purpose of the following series of studies was to understand if individually
designed music therapy interventions will increase the performance of young children with
autism during challenging routines in an inclusive childcare program, and to learn if the
interventions can be embedded in the ongoing classroom routine by teachers. The
interventions addressed difficulties the targeted children faced during (a) the morning

greeting routine, (b) multiple-step tasks within classroom routines, and (c) peer interactions
on the childcare playground.
For many children – those with and without disabilities alike – one of the most crucial
transitions is that from home to preschool (Alger, 1984). Making transitions is particularly
difficult for children with autism. The preferences for sameness and sensitivity to changes,
as well as the lack of understanding of symbolic gestures (such as waving for greeting or
good-bye), are among the defining characteristics of autism (Dawson & Osterling, 1997;
Mesibov et al., 1997).
The childcare day is not only filled with transitions, but also with many routines, such
as hand-washing, toileting and cleaning-up, which are repeated on a daily time schedule.
These routines require children to follow a sequence of steps that typically cause significant
difficulty for children with autism (Boswell & Gray, 2003). In order to function
independently in daily life, children must learn to understand, remember and perform the
sequence of these tasks.
During the childcare day, children spend large blocks of time in outdoor play. The
large undefined space, unstructured playtime, and play styles on the playground is highly
challenging for children with autism as measured by the ability to engage in meaningful play
and interact with peers. The severe delay in understanding social relationships and
communication as a defining characteristic of autism often results in a lack of peer
interaction (Danko & Buysse, 2002; Quill, 2001). To ensure the time spent on childcare
5

6
playgrounds promotes the development of children with autism, predictable play routines and
different play activities that support these children’s interests and strengths need to be
identified and established.
Diverse cultures’ use of song to accompany daily life activities and to heal (Hart,
1990; Morgan, 1994; Silver, 2003); as well as the wide range of professionals using songs
with preschoolers to address academic, social, language and communication and motor skills
and to express emotions (Enoch, 2002; Furman, 2001; Humpal, 1998), led to the design of
song interventions. The playground used in this study has been modified by adding an
outdoor music center, so as to structure and create a musical environment that enhances the
social and play experiences of young children with autism, together with their peers, on the
playground.
The music therapy interventions were designed and implemented by using a
collaborative consultative model of service delivery. Staff development activities on the use
of music therapy techniques to implement the intervention were provided prior to the studies.
In addition to the teacher-mediated interventions, peer-mediated strategies were applied to
increase peer interactions on the childcare playground. Parents and caregivers were fully
included in the morning greeting routine intervention and supported through frequent
communication prior to, during and after the experiments.

The effects of the music therapy interventions were evaluated by using single-case
experimental designs (Aldridge, 1996; Kazdin, 1982; Tawney & Gast, 1984; Wolery, Bailey,
& Sugai, 1988).
The following chapters will provide a detailed review of related literature and a
separate description of each Experiment, including a specific Introduction, Method, Results
and Discussion followed by a General Discussion and Conclusions of this thesis.
7

2. Literature Review
2.1 Early Intervention/Early Childhood Special Education
2.1.1 Definitions and Rationale
Early Intervention/Early Childhood Special Education provides support to young
children with special needs, their families and community to promote the child’s
development and inclusion. Children with special needs are those who are gifted and
talented, as well as those who have disabilities or developmental delays or are at risk for
future morbidity (DEC, 1998). U.S. legislation distinguishes early childhood intervention
services (children from birth through age three) from early childhood special education
services (children ages three through eight) (DEC, 2000; IDEA, 1997; Mellard, 2000). Both
Early Intervention and Early Childhood Special Education services include therapy,
education, health and medical services, assisting technology support, transportation,
integration support in early childhood services, formal and informal family support, and the
provision of information and support for transition into school systems (IDEA, 1997;
Mellard, 2000). While these services are available for all children identified with special
needs, the remainder of this thesis will focus on services for children with disabilities and
developmental delays.
Recognizing and respecting the importance and influence of family in a child’s life,
Early Intervention / Early Childhood Special Education services are delivered by using a
family-centered approach. This means services are delivered within the context of the family
and as a response to the concerns and priorities established by the family (Bailey, 1994;
9

10
Dunst et al., 1996; McWilliam, Tocci, & Harbin, 1998). Services may be delivered in the
family’s home, in early childhood intervention centers, in preschools or daycare centers, or in
hospitals or community health centers. The reason for providing services as early as possible
are at least threefold: (1) to enhance the child’s development during her/his state of
maximum readiness for learning; (2) to support the family’s well-being which might be
affected by the child’s condition and affect the child’s development; and (3) to maximize
long-term social and economic benefits to society by decreasing dependency upon social
institutions and increasing the child’s independent performance in society (Wolery &
Wilbers, 1994). The positive consequences and lasting effects of early intervention are
evident in a number of research reports (e.g. Barnett, 1998; Caine & Caine, 1991; Casto &
Mastropieri, 1986; Jonsdottir, 2002; Stern, 1985; Lazar & Darlington, 1982; Schweinhart &
Weikart, 1996).
2.1.2. Inclusion
2.1.2.1 Definitions, Philosophy and Rationale
One aspect of Early Intervention / Early Childhood Special Education is the inclusion
of children with special needs in their natural environments. Natural environments are
generally thought of as those in which the child would typically spend time, regardless of any
special needs (DEC, 1998; McWilliam, 2000). Given the structure of U.S. society, many
families require out of home care for their young children so that local preschools or fullday
childcare programs are often a natural environment (Cryer, Hurwitz, & Wolery, 1999; Scar,
1998; Willer et al., 1991). Serving young children with special needs in community-based
childcare programs together with their typically developing peers, rather than in special

programs, is called inclusion (Buysse et al., 2000; DEC, 2000). Inclusion begins with the
underlying assumption that children with special needs have more in common with typically
developing children than what separates them by their disability; they can participate actively
in natural environments within their community; and the socio-cultural environment has a
positive influence on the child’s learning and development (DEC, 1998; Gold et al., 1999,
DEC, 2000, Salisbury, 1991; Wolery & Wilbers, 1994).
“Development appears to be a result of the ongoing interactions and transactions
between a biologically maturing organism with a specific genetic endowment and the social
and physical dimensions of the environment embedded within a complex ecological system”
(Wolery, 2000, p. 190). The influence and importance of the child’s experiences with the
social and physical environment on her/his learning and development is discussed in most
prominent theories of child development. Piaget (Piaget, 1951; in Berk, 1997) described four
aspects influencing the child’s cognitive development: (1) interaction with the social world;
(2) interaction with the physical world; (3) equilibration; and (4) biological maturation.
Vygotsky (1978; Berk & Winsler, 2002) recognized in his sociocultural theory that all higher
cognitive processes develop out of the child’s social interactions with members of her/his
society. He stresses the influence of joint activities with more mature members of the society
(adults and peers) on the child’s mastery of activities and thinking, in ways that have
meaning in her or his culture. And Stern (1985) maintained that the infant’s core self is in a
relationship with the core self of the caregiver and that of others of significance. This
relationship forms a crucial axis of development.
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12
The importance of the natural environment, alongside inclusion and free appropriate
public education, is also recognized and manifested in the U.S. legislation with the
Individuals with Disabilities Education Act (IDEA) of 1997. An extensive body of literature
finds that providing inclusive services for children with special needs has positive influences
and benefits for all children and their families, whether with or without special needs. For
example, children with special needs have peer models for learning and development,
competent partners with whom to interact and communicate, realistic learning experiences in
a natural environment, and opportunities of finding friends without disabilities. At the same
time, their typically developing peers may improve their social skills, learn altruistic actions,
and develop positive attitudes toward individuals with disabilities. The families of children
with disabilities might feel more integrated in the community and be spared negative effects
such as labeling or feeling different and not accepted (e.g. Bricker, 1978; Buysse, 1993;
Davis, 1990; Hundert et al., 1998; Humpal, 1991; Jellison, 1985; Peck, Carlson, &
Helmstetter, 1992; Peck, Odom, & Bricker, 1993; Odom & Diamond, 1998; Wolery &
Wilbers, 1994).
2.1.2.2 Developmentally Appropriate Practice
Contemporary models of inclusion in high-quality childcare programs are based on
the concept of developmentally appropriate practice (Bredekamp & Copple, 2002; Carta,
1994; DEC, 2000; Gold et al., 1999; NAEYC, 1996). Developmentally appropriate practice
is built on two dimensions: age-appropriateness and individual-appropriateness. Age-
appropriateness refers to relatively predictable age-related sequences of the physical,
emotional, social and cognitive development in young children. Individual-appropriateness

acknowledges that each child is unique in her/his development and allows practice to
accommodate individual differences in personality, learning styles, growth, strength,
interests, experiences, and family background. To be most beneficial to children’s
development, an appropriate learning environment is provided and appropriate experiences
are planned by the childcare program based on this knowledge in response to individual
needs, interest and abilities (Bredekamp, 1991). These guidelines, developed for general
early childhood education, can be the baseline for Early Intervention/Early Childhood
Special Education, but might need modifications and adaptations to ensure that the individual
needs of children with special needs are met (Carta, 1995; Sandall, McLean, & Smith, 2000;
Wolery, Strain, & Bailey, 1992; Wolery & Bredekamp, 1994). Substantial modifications and
adaptations for special early childhood education practice are set forth in several sources,
among them the Division of Early Childhood (DEC) and National Association for the
Educating Young Children (NAEYC) documents (Bredekamp & Copple, 2002; DEC, 1993;
Sandall, McLean, & Smith, 2000).
2.1.3 Early Intervention / Early Childhood Special Education Services
2.1.3.1 Embedded Model of Service Delivery
Many studies conducted in inclusive childcare programs indicated that, prior to the
application of specific interventions, children’s needs for learning and development were not
being met (Venn et al., 1993; 1997; Kaiser, Yoder, & Keetz, 1992). The inclusion of
children with special needs in community-based childcare programs is only sufficient and
successful if the children’s learning and developmental needs are also addressed. Therefore,
the application of specific individualized interventions might be required (Lamorey &
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14
Bricker, 1993; Wolery & Wilbers, 1994). It is recommended practice that young children
with special needs receive their special and related services embedded in ongoing classroom
routines and activities (Buysse & Bailey, 1993; Lamorey & Bricker, 1993; Sandall, McLean,
& Smith, 2000). Bricker, Pretti-Frontczak, and McComas (1998) define embedded as “a
procedure in which children are given opportunities to practice individual goals and
objectives that are included within an activity or even that expands, modifies or adapts the
activity/event while remaining meaningful and interesting to children” (p. 73). The
rationales for inclusive service delivery are manifold: (a) to minimize stigma and isolation,
by having the child remain in class with her/his peers; (b) to capitalize on the child’s
naturally occurring learning opportunities by providing support in context; (c) to increase the
number of experiences that promote learning, by addressing the problem whenever it occurs;
(d) to promote social competence by keeping the child involved in activities with classroom
peers; (e) to increase generalization by practicing the skills needed in the place they are
needed; and (f) to ensure consistency by having all the adults working with a child be aware
of why and how to provide intervention (McWilliam, 1996; Wolery & Wilbers, 1994).
2.1.3.2 Interdisciplinary Team Approach and Individualized Family Service
Plan/Individualized Education Program
In order to understand and address the complex needs of young children with
disabilities and their families, a team (including family members and members across
professional disciplines) is needed to ensure the availability of adequate support and services.
In Early Intervention/Early Childhood Special Education, it is recommended that
professionals work in interdisciplinary teams. Each specialist is responsible for his area of

expertise, but may work on the same goals as other team member, and receives support from
other team members in achieving the goal (transdisciplinary) (Johnson, 2002; Mackey, &
McQueen, 1998; McWilliam, 1996; Wolery, & Wilbers, 1994). The philosophical
foundation of service delivery is the collaboration of these individuals to ensure the child’s
learning and developmental needs are addressed. Both planning and implementing services
require a collaborative team process (Bruder, 1994, 1996; DEC, 1998, McWilliam, 1996;
Wolery & Wilbers, 1994); this process is documented in writing, establishing an
Individualized Family Service Plan (IFSP) for children under three years or an Individualized
Education Program (IEP), for children over three years of age. The IFSP includes the child’s
present level of development, family resources, priorities, and concerns, child and family
goals, procedure, intensity, location and duration of early intervention services, identification
of a service coordinator, and a transition plan to further services. The IEP identifies and
describes each child’s present individual performance, short-term and long-term goals for
service delivery, frequency, duration, and location of services, as well as strategies and
examples how to achieve those goals (Bailey, 1994; Mellard, 2000; Humpal, 2002).
2.1.3.3 Integrated Therapy
One innovative model of service delivery in high-quality center-based childcare
programs is integrated therapy. In an integrated therapy approach, therapists provide services
to a child with special needs within the context of the child’s natural environment, routines
and activities. Using the integrated therapy model in inclusive classrooms, therapists work
with the individual child or a group of children within the ongoing classroom routines or as a
consultant to the classroom teachers (Mackey & McQueen, 1997; McWilliam, 1996, 2000).
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The following continuum of six models of service delivery within a childcare setting, from
most segregated to the most integrated, was defined by McWilliam and colleagues
(McWilliam, 1995, 1996; Scott, McWilliam, & Mayhew, 1999):
• Individual pull-out. The focal child is removed from the classroom to a separate
location and the therapy focuses directly on the child’s functioning. Teachers provide
information before the session and receive information afterwards.
• Small-group pull-out. In addition to the focal child, one to six peers with and/or
without disabilities are taken out of the classroom for a group session. The therapy
focuses directly on the functioning of the focal child or children with special needs.
Teachers decide which peers will participate, and provide information before the
session and receive information afterwards.
• One-to-one in classroom. Therapy is provided to the focal child in the classroom, but
separated from her/his peers and ongoing classroom activities. The therapy focuses
directly on the child’s functioning. This approach is used primarily for assessment or
experimentation with new interventions or equipment, with the expectation that it
might later be incorporated into classroom routines and activities. It is distinct from
individual within routines, because the child is actively removed from ongoing
activities. Peers might be present, but not involved in, the therapy. The teachers
involve the other children and keep them from disrupting the therapy. Teachers
watch the therapy session, providing and receiving information after the session.
• Group Activity. The group therapy approach includes the focal child and peers with
and without disabilities within the classroom routine. The therapy focuses on social
skills of all children and emphasizes focal child’s needs. The teachers participate in

group activities and planning. Teachers’ role can be different (leading/assisting) or
the same (co-therapist/co-teaching), can switch back and forth during the activities, or
from day to day.
• Individual within routines. The therapist works with the child within the context of
ongoing classroom routines and activities. The focus of therapy is directly, but not
exclusively on the target child. If possible, the teacher is actively involved. If not,
therapist and teacher consult with each other during allocated therapy time.
• Consultation. The therapist works primarily with the teacher, rather than with the
child. The purpose is for the therapist and teachers to collaborate on the best
approach the teaching staff should use in order to meet the child’s identified goals.
Consultation can range from “expert consultation,” where the therapist provides
guidance, information, and training on the use of therapeutic techniques, to
“collaborative consultation,” where the therapist (consultant) and teacher engage
equally in defining the problem; identifying the goals of intervention; planning the
intervention; and engaging in follow-ups. The therapist provides training for teachers
on the use of therapeutic strategies and supports the teachers during implementation
(Achilles, Yates, & Freese, 1991; Buysse et al., 1994; Bruder, 1996).
When using the integrative model of service delivery, developmental and functional
goals (i.e. those that are useful for a child’s life circumstances) for the child’s IFSP/IEP
should be developed through routine-based assessment rather than domain-based assessment.
Routine-based assessment is the process of identifying skills a child needs to perform
successfully and independently in the place where she/he spends time. This is accomplished
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by family interviews and observation of the child in the context, where the problems arise.
Skills that are immediately useful for the child are identified, rather than applying a priori
developmental prerequisites or foundations for future needs. Routine-based assessment
considers the whole child and increases the chance that goals and strategies are relevant and
realistic (McWilliam, 1992, 1996; Wolery, 1996).
2.1.3.4. Integrated versus Segregated Model of Service Delivery
Research addressing the effectiveness of integrated services versus segregated
therapy shows that there is no evidence for the superiority of one model over the other.
Integrated therapy has similar effects as segregated therapy on the child’s acquisition,
generalization, and goal-related progress (Cole at al., 1989; Davies & Gavin, 1994; Hundert
et al., 1998; McWilliam & Bailey, 1994; Wilcox, Kouri, & Caswell, 1991). Additionally,
Cole, Harris, Eland, and Mills (1989) find that classroom staff prefers an integrated versus a
segregated model of therapy. Dunn (1990) reports that teachers contributed more to the
accomplishment of children’s IEP goals when engaging in collaborative consultation with
occupational therapists and had better comments on an attitude scale compared to teachers
whose children received segregated therapy. Palsha and Wesley (1998) provide evidence
that on-site consultation and collaboration in childcare programs improved the physical
environment, service delivery, and teachers’ comfort and satisfaction. In addition, a study by
Davies and Gavin (1994) indicates that the consultation method resulted in a significant
increase in fine and gross motor skills for preschool children with developmental delays.
Overall, the integrated therapy model of service delivery is more compatible with the current
philosophical trends in Early Intervention/Early Childhood Special Education. The

incorporated principles of normalization, inclusion, developmental appropriate practice,
individualization, and collaboration suggest that integrated services are more preferable to
segregated therapy for preschoolers with special needs and who are enrolled in inclusive
childcare programs (McWilliam, 1996). The most integrated model of service delivery,
collaboration in conjunction with consultation, is desirable because it might enhance services
for children with special needs and result in more comprehensive intervention and higher-
quality treatment. Together, collaboration and consultation provide continuity of service and
a more holistic intervention, because no aspect is completely isolated. Sharing of knowledge
among professionals might have benefits for those involved, particularly children and
families receiving services (Sandler, 1997).
The integrated therapy approach has been evaluated and successfully applied in
inclusive childcare settings by occupational therapists (Dunn, 1996; Sandler, 1997), speech-
and language pathologists (Wilcox & Shannon, 1996), physical therapists (Rainforth &
Roberts, 1996; Sandler, 1997), and special educators (Garfinkel & Schwartz, 2002; Wolery et
al., 2002), but is thus far not widely applied, not has it been evaluated by music therapists.
2.1.4 Music Therapy in Early Intervention / Early Childhood Special Education
2.1.4.1. Music Therapy and Children with Special Needs
Music therapy has a long tradition of providing services for young children with
special needs. A wealth of case studies concerning music therapy for the treatment of
children with special needs, including implications and applications (e.g., Gustorff, 1997;
Gustorff & Neugebauer, 1997; Schmid & Janssen, 2001; Brusica, 1996) as well as music
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therapy assessment tools (e.g., Brunk & Coleman, 2000; Wigram, 2002), can be found in the
music therapy literature. A large body of research supports the positive impact of music on
the child’s development and quality of life. Music therapy can significantly enhance the
exceptional child’ cognitive/academic development (Campbell, 2000; Standley & Hughes,
1997; Register, 2001, Colwell & Murrless, 2002; Wolfe & Horn, 1993), physical
development (Galloway & Bean, 1974; Neugebauer, 2001), communication and language
development (Harding & Ballard, 1982; Horn, 1988; Hoskins, 1988; Edgerton, 1994),
emotional development (Crocker, 1968; Giles, Cogan & Cox, 1991; Hillard, 2001), and/or
social development (Krout, 1986; Jellison, Brooks, & Huck, 1984; Brownell, 2002). It
should be noted that music therapy never addresses only one area of the child’s development.
Music therapy interventions are unique in reaching the whole child in a developmentally
appropriate and holistic manner (Aldridge, Gustorff, & Neugebauer, 1995). An overview of
research publications especially addressing newborns to age three (early intervention) and
toddlers to school entry (early childhood special education) in various settings can be found
in Humpal’s (2001) “Annotated bibliography of music therapy articles related to young
children: from music therapy journals (1990-2000).” The following literature review focuses
on music therapy programs and studies conducted in inclusive preschool settings.
2.1.4.2. Music Therapy in Inclusive Childcare Programs
For more than a decade, music therapists in the U.S. have recognized the potential for
professional involvement in early childhood programs. Music activities designed for specific
therapeutic interventions and guidelines for applying and implementing interventions have
been proposed. Inclusion has been facilitated by creating developmentally appropriate

curricula for young children with special needs, and for their typically developing peers.
Some attention has been given to evaluate the effectiveness of music therapy interventions in
Early Intervention / Early Childhood Special Education programs.
In a literature review related to early intervention and music therapy, Humpal (1990)
describes the appropriateness and implications for music therapy among young children with
disabilities, and suggests music therapy techniques to accomplish early intervention goals
within different domains. She also stresses that music therapy might be provided as a related
service to children with special needs and their families. In a more recent publication,
Warlick (2000), Director of the Office of Special Education and Rehabilitative Services in
the United States Department of Education, confirmed in a letter to Andrea H. Farbman
(Executive Director of the American Music Therapy Association, AMTA) the legal status of
music therapy under the U.S. legislation. This letter reflects that music therapy is recognized
as a related service under IDEA, but continues to be omitted from the written form of
legislation.
Davis first introduced a model for the integration of music therapy in daily classroom
routines for children with physical disabilities or language delays in an inclusive preschool
setting in 1990. As a contracting music therapist, her role involved consultation to teachers
regarding musical recourses and activities enhancing other therapist’s goals, and direct
services with individuals and small groups within and outside the classroom. In 2001, Davis
gave an extended description of the model design, incorporating a “hierarchical approach to
group music therapy intervention.” Based on child development theories and music therapy
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models, including hierarchies of skills (Briggs, 1991; Steele, 1985), Davis presented three
levels of functioning and related goals “through which children can learn, practice, and
expand their repertoire of skills” (p. 37). The described program incorporates many aspects
of McWilliam’s (1995) proposed model of integrated therapy, and emphasizes the
importance of interdisciplinary collaboration and the possibility of co-treatment with other
specialists. No research has been conducted to evaluate the effectiveness of this music
therapy model.
One intervention technique Davis applied to enhance social interaction within
classroom routines was first introduced and studied by Gunsberg in 1988 and 1991. He used
improvised music and lyrics to facilitate and maintain social play between children with
developmental delays and their typically developing peers age three to five during free time
play in a preschool program. By analyzing ten videotaped episodes, Gunsberg’s
investigation provided evidence that when using this technique (Improvised Music Play),
social play episodes lasted more than three times the duration of typical free-time play
episodes among children with developmental delays and their typically developing peers. In
William’s (1995) continuum of six models of service delivery, Gunsberg’s approach can be
seen as a group activity within classroom routines.
Another pilot program conducted by Hughes, Robbins, McKenzie, and Robb (1990)
provided structured music activities and unstructured social playtime activities for one
hundred pre-kindergarten children with special needs and typically developing children
coming from various schools. Although quantitative data were not reported due to

questionable reliability, the following beneficial outcomes of the structured music activities
were observed by live and videotaped observations and statement analysis of teachers and
paraprofessionals: growing willingness to interact with one another, increasing acceptance
and friendships among children with and without disabilities, and positive validation of the
music sessions by participating staff.
Because music might enhance social interactions among children with special needs
and their typically developing peers, Humpal (1991) designed a weekly integrated early
childhood music program to increase social interaction between preschool-aged children with
moderate level of mental retardation and preschoolers from a typical school. The model
included session plans and strategies, in-service training of staff, parent meetings, and a
“handicap awareness session” for the typically developing peers. Based on trend analysis
and a staff questionnaire, Humpal provided evidence that social acceptance and interaction
between preschool-aged children with disabilities and typically developing peers does not
automatically occur, but rather can be taught by structured music activities. This replicated
the results of an earlier study conducted by Jellison, Brooks, and Huck (1984) with school-
aged children. Humpal also reported that staff rated the integrated early childhood music
program as outstanding “in providing opportunities for following group directions, in
fostering positive self-concepts, in increasing acceptance of handicapped conditions, and
teaching social skills” (p. 173).
In another study addressing social interactions among other aspects, Kern and Wolery
(2001) found that a child with visual impairment engaged in more social interactions with his
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peers, both with and without special needs, as well as with adults, after adding musical
instruments to meaningful locations on an inclusive preschool playground and providing staff
development activities. Additional results, gained by using a within single-subject
experimental design, were increased engagement with materials, a significant decrease of
stereotypic behaviors, and more goal-directed movement within the playground environment.
With this study Kern and Wolery (2001) demonstrated that music therapy interventions can
be successfully applied in inclusive childcare settings by using a collaborative consultation
model of service delivery.
As evident in a study by Standley and Hughes (1997), music activities can also
enhance academic skills of preschoolers enrolled in inclusive early intervention programs.
By testing two groups of children with repeated measures and counterbalanced
treatment/control conditions, Standley and Hughes found that music can significantly
enhance their print concepts and prewriting skills. More specifically, “music can help
children practice language patterns, learn print and book conventions, develop
comprehension through song dramatization, and begin decoding written language” (p.85). In
2001, Register replicated this study with a larger sample size (n=50). Results reinforced the
previous outcomes and provided evidence that music therapy sessions specifically designed
to improve academic skills are more efficient for desirable outcomes than those designed for
multiple goals.
Further, Standley and Hughes (1996) demonstrated that music therapy activities can
be applied within the guidelines of developmentally appropriate practice (NAEYC, 1986).

Lesson plans addressing communication, academic, social, emotional and music skills
following the standards of the NAECY were designed and implemented in an inclusive pre-
kindergarten. Results of the study indicated that children’s level of response and on-task
behavior was extremely high and the therapists’ and teachers’ implementation of the lesson
plans followed the guidelines for developmentally appropriate instruction.
Attention to the importance of music for young children’s learning and development
has also come from the National Association for Music Education (MENC), the National
Association for the Education of Young Children (NAEYC) and the U.S. Department of
Education. A series of projects and events was conducted to help preschool children in the
U.S. grow through music (Humpal & Wolf, 2003; Neelly, Kenney, & Wolf, 2000; Boston,
2000). In addition, the American Association of Music Therapy (AMTA) joined “Support
Music,” the largest initiation dedicated to providing music as an integral part of education to
every child in the U.S. (AMTA, 2003a). Finally, the current action to add music therapy to
the list of related services under the reauthorization of the IDEA – known as 1401 (22) and
1432(4) (F) – might also have a huge impact for future music therapy service delivery for
children with special needs in early childhood intervention/special education settings
(Simpson, 2003).
2.1.4.3. Models of Service Delivery in Music Therapy
With the changing landscape of service delivery in Early Intervention / Early
Childhood Special Education, along with the growing awareness of the potential benefits of
music for children’s learning and development, music therapists need to adapt their practice
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to the needs of individuals and their families, the public resources, and trends in Early
Intervention / Early Childhood Special Education. More effective and contemporary models
of service delivery are sought (Chester at al., 1999; Register, 2002; Reuer, 1996). Reuer
(1996) says: “For music therapists who embrace change, unlimited opportunities exist to
actively participate in the redefinition of health care and the transformation of practice
settings” (p. 16). In her article she encouraged music therapists to explore new methods of
service delivery and introduced consultative strategies as a career option for music therapists.
The AMTA’s Standards of Clinical Practice (2003b) states that music therapy can be
provided both as a direct service to clients or consultative services “to other professionals in
music therapy and related disciplines and to others directly involved with the client” (p. 20).
Smith and Hairston (1999) cite outcomes of a national survey investigating the current
practice of music therapy in U.S. school settings showed that 62% of the study participants
engaged in the traditional direct-service delivery model each week, whereas only 13%
provided consultative services.
2.1.4.4. Collaborative and Consultative Models of Service Delivery in Music Therapy
Music therapists have given some attention to collaborative and consultative models
of service delivery as effective strategies for inclusion of students within public school
settings. A revised monograph by Wilson (2002) focuses on the most current information on
models of music therapy service delivery in school settings. In this publication, Coleman
(2002) gives specific information on direct and consultative models of service delivery for
children with severe disabilities. Snell (2002) discusses models for school-aged students
with ASD, Gladfelter (2002) for students with learning disabilities, Darrow and Grohe (2002)

for students with deaf/hard-hearing conditions, Hughes, Rice, DeBedout, and Hightower
(2002) for students in comprehensive schools settings, and Furman (2002) as well as Humpal
(2002) for children with special needs enrolled in community early education settings.
In addition to direct services in self-contained special education and inclusive school
settings, Johnson (2002) described four categories of consultative music therapy services.
According to Johnson, the role of a music therapy consultant is: (1) to facilitate inclusion by
designing and providing appropriate musical activities for students with special needs, and to
support regular classroom teachers and music teachers in implementing these activities, (2) to
facilitate music education by helping music educators understand handicapping conditions of
students, and supporting the teachers to meet all students’ needs and educational goals (3) to
facilitate musical performance by increasing the student’s musical abilities to contribute to
the performance, and (4) to consult with non-music education staff by designing appropriate
musical activities to meet the student’s IEP goals, to train staff to implement basic music
activities, to provide appropriate music resources, and to facilitate in-class demonstration of
appropriate music activities and expectations.
Chester, Holmberg, Lawrence, and Thurmond (1999) also introduce a description of a
“program-based consultative music therapy model” serving preschoolers with disabilities in
self-contained language-based programs among other public elementary school programs.
The following benefits of this model are described as follows: “more students receive
services, teachers use music therapist-generated strategies regularly, collaboration occurs
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across disciplines, and the music therapist’s time serving the classrooms is maximized” (p.
82).
Nevertheless, the description of these programs and service delivery models is not the
result of systematic, scholarly research investigation. Data to support the effectiveness of a
consultative model of music therapy service delivery have thus for eluded the field.
Register (2002) recently conducted a national survey investigating collaboration and
consultation practices of music therapists in the U.S. She reports that 87% of study
participants collaborate with team members or professionals regarding the treatments of their
clients whereas as only 44% music therapists provided consultative services. Consultation
was primarily delivered in educational settings (38.8%) by providing workshops/seminars/in-
services (72.6%) and one-to-one meetings (67.7%). The individuals with whom music
therapists mostly consult were educators (62.0%); and parents, caregiver, and other family
members (59.7%). Twenty-one-point-one percent of participants reported that they provided
consultative services on a weekly or monthly basis. Subject areas most cited for goals and
objectives of consultation were educational (84.0%). Register elucidated that “future
research should seek to define both collaboration and consultation and how each of these
techniques are acquired and implemented by music therapists” (p. 320). The survey did not
specify the educational settings where music therapists administered collaborative and
consultative services. At this point, no statement can be made as to whether or not
collaborative and consultative strategies are common practice for music therapists working in

inclusive preschool settings. A survey investigating collaborative and consultation practice
of music therapy in preschool settings is warranted.
Clearly, collaboration and consultation models of service delivery do play an
important role in the growth and understanding of music therapy as a profession (Register,
2002). Not only does it have potential for professional involvement; it also supports the
contemporary model of service delivery in Early Intervention/Early Childhood Special
Education. Only one study that provides data-based information of the effects of
collaborative and consultative models of music therapy service delivery in inclusive
preschool settings emerged. More research is necessary in order to clarify whether a music
therapy collaborative consultation model of music therapy service delivery is effective.
2.2. Autism
2.2.1 Definition, Prevalence, Causes and Diagnosis
Autism is a complex developmental disorder that significantly affects the individual’s
verbal and nonverbal communication and social interaction, and is associated with
engagement in restricted, repetitive and stereotypic patterns of behavior, usually evident
before age three (APA, 2000; ASA, 2003; WHO, 1993). Child psychiatrist Leo Kanner
originally described the essential features of autism, once considered a rare disorder, in 1943.
Today, it is estimated that autism occurs in as many as 1 to 6 per 1000 births, with an
increasing trend upward, and is four times more prevalent in boys than in girls (APA, 2000;
Gillberg & Wing, 1999; NICHCY, 2003; CDC, 2003; NINDS, 2003). This increasing
incidence is the subject of great controversy. Whether the numbers indicate an increased
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frequency of autism, or simply relate to changes in diagnostic criteria, earlier identification,
and an improved awareness of the condition, remains unclear at present (Dalldorf, 2002a;
Scott, Clark, & Brady, 2000). Although its causes are still unknown, autism is generally
accepted as a neurological disorder present at birth (APA, 2000). Autism is sometimes
observed in association with biological conditions such as Fragile X Syndrome, congenital
Rubella Syndrome, and Tuberous Scleroses (APA, 2000; Dalldorf, 2002a; Gillberg &
Coleman, 1996). Although a specific gene linked to autism has not yet been isolated,
genetics also seem to play a part in the disorder (Lauritsen & Ewald, 2001). Current research
investigates neurological damage and biochemical imbalances in the brain (Dalldorf, 2002a;
National Research Council, 2001; NICHCY, 2003). It is known that there is no racial,
ethnic, or social boundaries, and autism is not caused by parents’ lifestyles, educational level
or psychological factors in the child’s environment (Dalldorf, 2002a; NICHCY, 2003; ASA,
2003, TEACCH, 1999). A series of studies on attachment behaviors in autism refutes the
long-standing assumption that autism represents a failure of the attachment process between
child and caretaker (Capps et al., 1994; Rogers et al., 1993; Shapiro et al., 1987). However,
autism remains a heterogeneous, and indeed puzzling, disability. Currently, there are no
medical or genetic tests to identify autism. The most frequently clinical tool used to diagnose
autism is the Diagnostic and Statistical Manual of Mental Disorders (4 th ed.) Text Revision,
(DSM-IV-TR) (APA, 2000). Autism disorder is listed under the broader category of
Pervasive Developmental Disorders (PDD), which include Rett’s Disorder, Childhood
Disintegrative Disorder (CDD), Asperger’s Disorder, and PDD Not Otherwise Specified
(PDD-NOS). Differential diagnosis is based on observation of the child’s individual
developmental and functional level to determine if a specific number of characteristics within

the three key diagnostic areas (i.e., social interaction, communication, and behavior) listed in
the DSM-IV-TR are present. A number of screening tools (e.g., Checklist for Autism and
Toddlers (CHAT) (Baird et al., 2000), Autism Screening Questionnaire (Berument et al.,
1999), Screening Test for Autism in Two-Year Olds (STAT) (Stone et al., 2000) is available
to identify whether an individual is at risk of autism spectrum disorder or not. Various
standardized and documented diagnostic instruments, based on observation, parental
interviews and checklists, have emerged that identify the disorder and other associated
developmental delays (e.g. Psychoeducational Profile-Revised (PEP-R) (Schopler et al.,
1990), Autism Diagnostic Observation Schedule (ADOS) (Lord et al., 1999), Vineland
Adaptive Behavior Scales (Sparrow, Balla, & Cichetti, 1984), Childhood Autism Rating
Scale (CARS) (Schopler, Reichler, & Renner, 1988). Currently, children can be definitively
diagnosed as early as 18 months of age (Baird et al., 2000; Stone et al., 1999; Gillberg et al.,
1990; Wolery et al., 2001).
2.2.2 Characteristics of Autism
Autism is now understood as a spectrum of disorders, in which a combination of
some or all of the predetermined characteristics might be observed in varying degrees of
severity, ranging from difficulty with social interactions and relationships to language and
communication difficulties, repetitive, restricted and stereotypic behaviors, and other
characteristics. There is no typical single behavior of autism, even though there are unique
patterns and relative strengths (American Psychiatry Association, 2000; National Research
Council, 2001). The following description is based on the three diagnostic categories listed
in the DSM-IV-TR (APA, 2000), and other associated characteristics thoroughly described in
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the literature (e.g. Accardo, Magnusen, & Capute, 2000; ASA, 2003a; Doherty, McNally, &
Sherrard, 2000; Grandin, 2003; NICHCY, 2003; Society for the Autistically Handicapped
2003; TEACCH, 1999; Mesibov, Adams, Klinger, 1997; National Research Council, 2001;
Wolery et al., 2001).
2.2.2.1 Social Interactions and Relationships
The child with autism might have severe difficulty in relating to people. This
problem might be manifested in exhibiting difficulty with, or a lack of understanding of,
conventional nonverbal communication such as eye-gaze, facial expression, body postures,
and gestures necessary to facilitate social interaction. Temple Grandin (1999), diagnosed
with autism at an early age, describes this characteristic as following: “I didn’t know that eye
movements had meaning until I read Mind Blindness by Simon Baron-Cohen [(1995)]. I had
no idea that people communicated feelings with their eyes” (p. 1). Children with autism tend
to spend time alone and seem to “tune out” the outside world. They might have little interest
in peers and be passive in social situations both in initiating and responding. Often children
with autism fail to engage in symbolic and dramatic play or social imitation. Those who
interact socially might exhibit inappropriate, intrusive, or insensitive actions. Children with
autism most frequently don’t spontaneously seek to share enjoyment, interests and
achievements with others. Although they are capable of expressing emotions, a lack of social
and emotional reciprocity is often present. Consequently, many children with autism have
great difficulty developing social relations and friendships.

2.2.2.2 Language and Communication Development
The child with autism might have various difficulties regarding language and
communication, affecting both receptive language and expressive language. These problems
might be manifested in a delayed or total absence of language development. Many children
with autism do not use conventional body language in place of verbal skills. For example,
they often will not show, wave, point, or nod. Consequently, expressing needs and
understanding simple questions, verbal directions or understanding symbolic gestures might
be a challenging and frustrating experience for the child. When speech does develop, it often
includes repetition of words or phrases (echolalia). Children with more advanced language
skills tend to use a small range of topics or words without attachment to their usual meaning,
and they have great difficulty with abstract language. All these make initiating or sustaining
a conversation a major challenge. Those who are able to use language effectively often have
an abnormality in pitch, intonation, rate, rhythm or stress in their voice.
2.2.2.3 Repetitive, Restricted and Stereotypic Behaviors
The child with autism might exhibit restricted interests of abnormal intensity and
focus. These children might insist on specific routines and rituals (e.g. following the same
schedule each day), and can become very distressed when changes occur. People with
autism might perform stereotyped, repetitive motor movements, such as hand flapping, toe
walking, or whole body movements. Persistent preoccupations with parts of objects and
repetitive play skills (e.g., spinning object) are generally evident as well. Donna Williams
(1992), diagnosed with autism in early childhood, offers the following explanation for the
repetitive and restricted behavior patterns: “The constant change of most things never seemed
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to give me any chance to prepare myself for them. Because of this I found pleasure and
comfort in doing the same thing over and over again” (p. 44).
2.2.2.4 Other Characteristics
Children with autism also frequently display an inconsistent response to sensory
information during their toddler or preschool years (Ermer & Dunn, 1998). Often, a
hypersensitivity to sounds, lights, certain texture of fabrics, and taste and smell of food are
observed. At other times, the same individual might respond differently or have a lack of
responsiveness to the same stimuli (Dawson & Watling, 2000). Grandin (in Grandin &
Scariano, 1996) gives the following example of an inconsistent pattern of sensory response
for hearing: “Sometimes I heard and understood, and other times sounds or speech reached
my brain like the unbearable noise of an onrushing freight train” (p.145). Additional, in
infants with autism an insensitivity to pain is more commonly seen than in typical infants or
infants with other special needs (Hoshino et al., 1982).
Children with autism often have cognitive deficits. Their cognitive abilities can vary
widely and often they do have uneven patterns of intellectual functioning. For example,
some aspects of development (such as visual memory and visual-spatial organization) might
be close to normal, while others (such as problem-solving and abstract thinking) might be
seriously delayed. Other cognitive characteristics such as difficulty with attention,
information processing and social-cognition, including focusing on irrelevant details,
difficulty with perceiving or understanding thoughts, feelings, or intentions of others,
inability to generalize, and problems in sequencing and organization, have been described in

the literature (Baron-Cohen, 1995; Quill, 2000). Only a small percentage of individuals with
autism fall in the average or upper range of intelligence. Among them, a few do have “islets
of ability or intelligence,” such as unusual musical or artistic talents or extraordinary
calculation and memorization skills (Marohn, 2002; Mesibov & Shea, 2003). This
phenomenon is described in the literature as Savant-Syndrome (e.g., Dworschak, 2003;
Young & Nettelbeck, 1995). However, the majority of children with autism (about 70%)
have various degrees of mental retardation (National Research Council, 2001).
Professionals and parents of children with autism often report secondary effects, such
as problems with sleeping, eating, and toileting, extreme temper tantrums, aggressions,
impulsivity, obsessions, hyperactivity, and self-injury. Although not specific to the disorder
(or part of its defining diagnosis), these behaviors create major challenges in the daily life of
children with autism (National Research Council, 2001; Wolery et al., 2001).
2.2.3 Contemporary Education and Treatments for Young Children with Autism
While there is at present no cure for autism, research indicates that early diagnosis
followed by early education and treatment efforts can significantly enhance a child’s ability
to participate meaningfully in family and community life and play a vital part in society
(ASA, 2003; TEACCH, 1999; Wolery et al., 2001). A large body of literature and an
abundance of recent information on the Internet describe, evaluate and discuss contemporary
education and treatments for children with autism (e.g., ASA, 2003; Dalldorf, 2002b;
Dempsey & Foreman, 2001; Kraus, 2002; Marohn, 2002; McIntosh, 1999, NICHCY, 1998). 1
1 To be sure, use of the Internet as a source of information in scholarly inquiries – at least as a blanket
source of information – is not without controversy. There is no substitute for scientific, peer-reviewed
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Because each child has unique strengths and weaknesses, there is no one approach that is
suitable for all children. Educational and therapeutic interventions must be individualized to
the child’s individual needs and abilities (ASA, 2003; Kraus, 2002; National Research
Council, 2001; Schopler, 1997). A combination of individualized educational approaches
and treatments is often most beneficial for individuals diagnosed with autism, but should be
carefully selected (ASA, 2003). Based on the literature, treatment options for children with
autism can be placed into three general categories: medical treatments, educational and
behavioral approaches and programs, and complementary therapy. The following sections
review each of these treatments in turn.
2.2.3.1 Medical Treatments
According to recent research, no dietary or biomedical approaches can cure autism
(NINDS, 2003). However, some medical treatments have positive effects on some behaviors
associated with autism (ASA, 2003). Medical treatments for autism currently include (1)
medication; (2) nutrient therapy (vitamins and nutritional supplements such as vitamin B6, A,
C and magnesium zinc, folic acid); (3) hormone therapy (e.g., secretin, melatonin), (4)
Landau Kleffer Syndrome treatment; (5) heavy metal detoxification/chelation therapy (e.g.,
mercury or other substances in food, and other environmental sources); (6) dietary
interventions; (e.g., gluten, casein) to control food intolerances and allergies; (7) anti-yeast
therapy; and (8) immune system therapy (Dalldorf, 2002; Marohn, 2002; Society for the
journals as a source of evidence. That said, for the purposes of this inquiry the Internet serves a
valuable purpose for several reasons. First, it provides accessibility for individuals with ASD and their
families, as well as for professionals. Second, it is well suited to the particularly fast-changing nature
of ASD research. Third, and by extension, much of the scholarly work on ASD is in fact located on the
Internet. Finally, associations use Internet as a primary vehicle for the dissemination of information on
ASD and related disorders.

Autistically Handicapped, 2003b, Kraus, 2002). Some of these treatments have been tested
and proven effective, while others have not. Controversy remains over some outcomes and
methodology, and thus for no statistically significant improvements in the core symptoms
have been found (ASA, 2003; National Research Council, 2001).
2.2.3.2 Educational and Behavioral Approaches and Programs
As evident in the autism literature, educational and behavioral interventions are
currently the most effective and most commonly used approaches in the U.S. for treating
children with autism (Cambell et al., 1996; Dalldorf, 2002b; Green 1996). A variety of
intervention practice research (as reviewed in Wolery & Garfinkel, 2002) and the evaluation
of intervention programs (as reviewed in Dawson & Osterling, 1997; Handleman & Harris,
2001; National Research Council, 2001; Smith, 1999) can be found in the literature. A large
body of research has demonstrated significant improvement in the key areas, including social
skills (as reviewed in Hwang & Hughes, 2000; McConell, 2002; Pollard, 1998), language
and communication abilities (e.g., Buffington et al., 1998; Keen, Sigafoos, Woodyatt, 2001;
Koegel, O’Dell & Koegel, 1987) and behaviors (e.g., Koegel et al., 1992; Morrison &
Rosales-Ruiz, 1997) in relative short time periods when appropriate services, training and
information were provided. The committee on educational intervention for children with
autism (National Research Council, 2001) states: “Research is under way to predict
responders and non-responders to medication and to determine which child will benefit from
behavioral treatment alone and what combinations of medication and behavioral treatments
are most effective” (p. 130).
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2.2.3.3 Complementary Therapies
Other interventions might play an important role in improving social and
communication skills and in reducing inappropriate behaviors associated with autism as well.
These therapies might be provided in segregated therapy settings or integrated in educational
programs. When speech, language, and motor deficits hinder progress in school, IDEA
mandates that speech-language therapy, physical therapy, and occupational therapy be
provided (National Research Council, 2001). Although music therapy is not as well known
to the public as a related service under IDEA, its value is well established for the treatment of
individuals with autism (ASA, 2003; Dalldorf, 2002b, Grandin, 1988b; Kraus, 2002; The
National Autistic Society, 2002).
Many other innovative interventions such as Sensory Integration (Ayres & Tickle,
1980; Berger, 2002; Hutch-Rasmussen, 1995), The Squeezing Machine (Grandin, 1992),
Holding Therapy (Welch, 1988), Doman/Delacato Method (Delacato, 1974), Flexyx Therapy
(OchsLabs, 2002), Daily Life Therapy: Higashi (The National Autistic Society, 2001);
Cranosacral Therapy (Mehl-Madrona, 2003), Facilitated Communication (Calculator et al.,
1995; Shane, 1994), Animal-Assisted Therapy (Redefer & Goodman, 1989), the Son-Rise
program (Autism Treatment Center of America, 2003), Vision Therapy (Kaplan et al., 1998);
Auditory Integration Therapy (Berard, 1993), and Tomatis Therapy (The Tomatis Method,
2003) are available. Since there is not much scientific support of the effectiveness of these
widely publicized therapies, their application remains controversial. Turnbull, Wilcox and
Stowe (2002) report “(…) there is great emphasis in the [U.S.] law on using interventions
that are proven and that have some scientific evidence supporting their value” (p. 487).

Research including well-controlled studies demonstrates the effectiveness for these
interventions is strongly suggested (National Research Council, 2001).
2.2.4 Including Young Children with Autism in Preschool Education Programs
2.2.4.1 Rationale for Inclusion
Lovaas (1987) changed autism treatment dramatically by showing the benefits of
early intensive interventions in the form of behavior modification. Nearly half of the young
children with autism in his projects (47%) who underwent an intensive behavior modification
treatment eventually achieved normal intellectual and educational functioning in comparison
to the control group, where only a few children (3%) reached the same functioning level.
McGee, Paradis and Feldman (1993) find that simply close proximity to typically developing
peers in inclusive settings, children with autism significantly decreases levels of autistic
behaviors in contrast to self-contained settings or when they were alone. Strain, Odom and
their colleagues (1985; 1986) report that children with autism make social and educational
progress when exposed to typically developing peers in integrated preschools. Strain (1983)
also demonstrates that maintenance and generalization more likely occurs in integrated
preschool settings than in self-contained classes. Finally, Dawson and Osterling (1997)
report that in four out of six programs, approximately 50% of children receiving early
intervention services are in full inclusion classes later.
The data supporting early intervention and inclusion of children with autism, along
with the provision of special education and related services for children with autism in the
least restricted environment (NICHCY, 2003; Turnbull, Wilcox, & Stowe, 2002) specifically
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manifested under IDEA (U.S.C. 1401 [3] [A]) lead to an increasing trend toward including
children with autism in preschool education programs. The rationale for including children
with autism is similar to those generally described for other children with special needs.
Their severe difficulties with social interactions and relationships especially support
inclusion, which offers naturally occurring learning opportunities. The overall educational
goals for children with autism are the same as those for typically developing children:
“personal independence and social responsibility” (National Research Council, 2001, p. 216).
To assist a child accomplishing these goals, preschool education programs for young children
with autism not only emphasize the acquisition of academic skills; they also foster the
improvement of social, language and communication, and daily living skills and address
behavioral problems associated with autism (ASA, 2003; Dawson & Osterling, 1997; Koegel
& Koegel, 1995; National Research Council, 2001). According to the Committee of
Educational Interventions for Children with Autism (National Research Council, 2001), there
are two theoretical frameworks for teaching children with autism: developmental and
behavioral.
2.2.4.2 Theoretical Framework for Teaching Children with Autism
Whereas
The developmental approach is described by the National Research Council (2001) as
(…) a model of typical development to guide the educational process involving
assessment, goal setting, and teaching. It involves assessing each developmental
area — motor, cognition, communication, and social development, among others —
and using a child’s successes, emerging skills, and failures to determining a child’s
zone of proximal development (Vygosky, 2000). This zone indicates the set of skills
that a child appears to be ready to learn next, based on his or her assessed
performance. Those skills are the targeted for teaching (p. 72).

(…) in a behavioral approach child’s behavioral repertoire is evaluated according to
the presence of behavioral excesses — presence of abnormal behaviors or of an
abnormal frequency of certain behavior – and behavioral deficits – absence or low
frequency of typical skills (Lovaas, 1987). Behavioral strategies are then designed to
increase a child’s performance of deficit skills and decrease the behavioral excesses.
These strategies involve identifying the target of teaching, determining the
appropriate antecedent and consequence for the target behavior and assess students
progress (p. 72).
As described in section 2.1.2.2, contemporary models of inclusion are based on a
developmental approach (e.g., Bredekamp & Copple, 2002; NAEYC, 1996). Among the
many advantages of this approach are its typical application in early childhood education
settings, the described guidelines, familiar assessment tools, and availability of teaching
materials. Also, professionals involved in early education are usually trained in
developmental appropriate teaching practice. Some drawbacks of this approach are that
children with autism do not exhibit usual developmental patterns in domains such as
communication, language and social development in comparison to their typically
developing peers. Traditional developmental teaching strategies, such as verbal instruction,
imitation of teachers and peers, and independent learning, depend largely on a child’s
internal motivation to learn. Because of this, these strategies might not be effective tools for
teaching children with autism (National Research Council, 2001). The developmental
approach needs to be modified or combined with other teaching strategies to ensure that the
educational goals of children with autism are met (e.g., Sandall, McLean, & Smith, 2000;
Wolery & Bredekamp, 1994).
Some advantages of the behavioral approach are that there is some research-based
evidence of generalization and maintenance, that antecedents and consequences are
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incorporated, and systematic strategies are used to teach complex skills. Drawbacks of the
traditional behavioral approach are that the complex data system involved in this approach
might complicate the implementation in inclusive preschool settings, the use of “aversive”
techniques for behavior management is highly controversial, and staff members on early
childhood teams often do not receive enough training for proper implementation of this
approach in classroom routines (Dempsey & Foreman, 2001; National Research Council,
2001).
There are now more contemporary behavioral approaches, such as the natural
language paradigm (e.g., Koegel, O’Dell, & Koegel, 1987), incidental teaching (e.g. McGee
et al., 1999), time delay and milieu intervention (e.g., Halle, Marshall, & Spradlin, 1979),
pivotal response training (e.g., Koegel et al., 1999), and peer-mediated strategies (e.g.,
DiSalvo & Oswald, 2002; Goldstein et al., 1992; McGee et al., 1992) that emphasize
naturalistic delivery in group settings and are more compatible with inclusion. These
behavioral approaches are based on systematic teaching trials focusing on the child’s
initiation, the child’s interest, and natural reinforcers in the child’s environment. Although
not as well known to professionals and parents, these strategies have led to impressive
outcomes in numerous domains (Dempsey & Foreman, 2001; National Research Council,
2001; Schreibman, 2000). A detailed description of the continuum of behavioral approached
has been published in several summary documents (e.g., Anderson & Romanczyk, 1999,
Prizant & Wetherby, 1998, Schreibman, 2000).

To date, more empirical data are available to the behavioral approaches than to the
developmental approach. Because the developmental approach is commonly used in early
childhood education, it would be desirable to have more empirical validation supporting it.
2.2.4.3 Early Intervention Programs for Children with Autism
A number of university-based model programs empirically demonstrate effective
inclusion of young children with ASD. Intervention approaches and philosophical and
theoretical positions encompassed in these model programs vary greatly. These range from
the traditional discrete trial approaches (Lovaas, 1987) to more contemporary applied
behavior analysis programs (Harris et al., 1991; Fenske et al., 1985, McGee, 1999) to
developmentally oriented programs (e.g., Greenspan & Wieder, 1997; Prizant & Wetherby,
1998; Rogers & Lewis, 1989; Schopler et al., 1995). A detailed description of model
programs, including structure and context, diagnostic and assessment procedures, staffing
and administration, intervention components, integration aspects, family involvement,
outcome measures, and discussion on effects on children and families, can be found in
summary documents from Handleman and Harris (2001), Dawson and Osterling (1997), and
the National Research Council (2001). Well-established and reputable programs are the
University of California at Los Angeles (UCLA) Young Autism Project and Treatment and
Education of Autistic and Related Communication Handicapped Children (TEACCH) at the
University of North Carolina, School of Medicine at Chapel Hill.
The UCLA Young Autism Project. This model is based on early research by Ivar
Lovaas and colleagues, as well as subsequent investigations using applied behavior analysis
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(ABA). Application of the behavioral intervention curriculum for young children with
autism started in the seventies. The treatment usually lasts three years, is time-consuming
and involves an intensive training. In the first year, a trained therapist and parents primarily
use a one-to-one discrete trial format in the child’s home. In a discrete trail training, the
therapist-parent team breaks down the tasks into short simple pieces, or ‘trials.” The
appropriate response to cues is followed by consequences that are reinforcing for the
individual. The assumption is that behavior rewarded is more likely to be repeated than
behavior ignored. Intervention goals are responding to requests, imitating, playing with toys,
self-help skills and interaction with family members, followed during the second year by
teaching communicative language, abstract concepts, emotion discrimination, pre-academic
skills, and observational learning. Socialization and integration into school and other
community settings is the focus of the third year. A full-time aide who is familiar to the
child, assists her or him in generalizing previously mastered skills, following the classroom
routine and responding to classroom teacher and peers until the child functions independently
in the new environment (Smith et al., 2001).
Treatment and Education of Autistic and Related Communication Handicapped
Children (TEACCH). Founded in North Carolina in 1972, this program provides statewide,
comprehensive community-based services to people with ASD from preschool to adult life.
There are two preschool demonstration classrooms. In addition, educational services for
preschool children are provided within the child’s natural environment by assessment,
individual program planning, parent and teacher training, and consultation. Based on
research findings indicating that children with autism learn better in structured rather than in

unstructured learning situations (Schopler, Kinsbourne, & Reichler, 1971), a central aspect of
the TEACCH program is structured teaching, in which environments are modified with clear,
concrete, visual information. The physical structure of the environment includes specific
work areas for different activities designed to support children in accomplishing educational
goals. Daily schedules and clear visual cues are used to assist the child to learn directions
and understand the classroom routines. The TEACCH program is designed to address each
child’s individual needs and takes into consideration strengths, interests and learning styles.
Parental involvement is essential in the TEACCH program. Parents are seen as co-therapists,
and trained in individual strategies to work with their child. Support programs, such as a
mothers’ and a fathers’ group, a parent mentor program, a home teaching kit, a parent course
and workshops, are offered to the families (Marcus, Lord, & Schopler, 2001). TEACCH has
also developed a communication curriculum that uses a naturalistic behavioral approach,
along with alternative communication strategies for nonverbal children (Watson et al., 1988).
2.2.4.4 Teaching Strategies
Some preschool educational programs use unilateral approaches and strategies,
whereas others combine several strategies and treatment approaches for the inclusion and
education of young children with autism. A huge body of literature examines educational
practice for promoting social, language and communication development and addressing
problematic behaviors and other difficulties in young children with autism (e.g., Koegel &
Koegel, 1995; National Research Council, 2001; Wolery & Garfinkel, 2002). Both
practitioners and researchers have suggested teaching strategies for successful inclusion of
children with autism in preschool education settings.
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Social development. Interventions focusing on improving social skills, in children
with autism target both adults and peers. The variety of strategies used to improve social
skills in children with autism fall into three categories:
(1) adult-directed instruction of specific goals of social skills, such as joint attentions,
response by gaze, imitation, turn taking, and initiating social interactions;
(2) a child-centered approach, in which adults follow the child’s lead, encourage and sustain
interactions, scaffold to higher levels, and extend the duration of interaction; and
(3) peer strategies, in which typically developing peers prompt and maintain social
engagement (National Research Council, 2001).
According to McGee, Morrier and Daly (2001), true social inclusion only occurs by
teaching both children with autism and their typically developing peers how to interact with
one another. Peer-mediated strategies shown themselves to be the most powerful means of
improving social interactions of children with autism, and of generalizing and maintaining in
inclusive preschool settings (Strain et al., 1979; Goldstein et al., 1992; McGee et al., 1992).
When using peer-mediated strategies, teachers train typically developed peers how to interact
with their classmates with autism to model and role-playing. These strategies are then cued,
reinforced and systematically faded out by teachers (National Research Council, 2001).
Other strategies used to increase social interaction in children with autism are peer tutoring
through incidental teaching (McGee et al., 1992), adult instruction in social games (Goldstein
et al., 1988), script-fading procedures (Krantz & McClannahan, 1998), and social stories
(Gray & Garand, 1993). “(…) Peer-mediated approaches are complex to deliver, require
socially skilled typical peers, precise adult control in training peers, managing and fading

einforcement, and monitoring ongoing child interaction data” (National Research Council,
2001, p. 138). Interactions with peers are also important, providing as they do models of
appropriate language and communication, as well as behavioral skills.
Language and communication development. Strategies used to improve language and
communication in children with autism vary greatly along the continuum of behavioral to
developmental approaches. In general, it is recognized that the lack of motivation to use
language and communication in children with autism is an issue. Therefore, strategies to
increase language and communication in children with autism must encourage language and
communication by capitalizing on the child’s natural desires and preferences within her or
his environment. Often, environments are arranged to provide opportunities for
communication. The smallest attempt of the child to communicate is immediately rewarded,
imitated and expanded upon by adults (Dawson & Osterling, 1997).
If a child with autism demonstrates non-functional language, has limited verbal
communication skills or difficulty with language comprehension, augmentative and
alternative communication (AAC) is likely to be introduced. AAC strategies use assistive
devices, such as visual communication symbols (pictures, written words, objects), visual
schedules, displays on communication boards, voice output devices with digitized speech,
and sign language in place of or in combination with verbal language. The most widely
applied symbolic communication system is the Picture Exchange Communication System
(PECS) (Bondy & Frost, 1994), which capitalizes on the strong visual processing of many
children with autism. PECS is a systematic communication program designed to assist
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children with autism, regardless of their verbal and nonverbal skill to initiate communication
with others. Also based on a modified behavioral model, PECS teaches the child to approach
her or his communication partner by exchanging a picture symbol for the desired object or
activity. PECS is used within ongoing classroom routines and activities, and can function as
a bridge between learning to communicate and using independent speech.
Challenging behaviors. One of the most stressful issues faced by parents and
professionals in their efforts to include children with autism in preschool educational
programs are the exhibition of challenging behaviors such as “lack of compliance with or
disruption of classroom routines, tantrums, destruction of property, and aggression against
self or others” (National Research Council, p. 116). There is no single strategy that has
proved effective in reducing challenging behaviors in all children with autism. However,
there is a consensus that such problems should be addressed in the child’s early years, and
prevented before they occur, by strongly engaging the child in classroom activities (Darwson
& Osterling, 1997).
To reduce challenging behaviors, interventions vary from discrete trial, and
naturalistic behavior approaches such as pivotal response training and incidental teaching, to
developmental approaches, which recognize the needs of highly structured environments,
adult attention and consistency. Consequence-base approaches (with an applied behavioral
analysis theoretical framework) are the most empirically evaluated approaches, designed to
decrease or eliminate challenging behaviors (National Research Council, 2001). In pivotal
response training, children are given some control over their environments and are allowed

choices in certain areas, which might contribute to reducing challenging behaviors (Koegel et
al., 1992). Increasing the child’s interest and engagement by providing highly preferred play
materials or topic areas and choices regarding preferred activities is described as “Increase
fun decreases problem behaviors” by McGee and colleagues (2001, p. 176). Structured
teaching and highly structured environments also prevent problem behaviors, because
structure increases the child’s understanding of the classroom routines and activities (Marcus
et al., 2001). If the challenging behavior continues, a functional assessment of the behavior
is made and teaching alternative appropriate behaviors is provided. The functional behavior
assessment involves:
• keeping a detailed record of the behavior, including situations, time of the day, events
that proceed the behavior, and how others respond;
• developing hypotheses regarding the functioning of the behaviors; and
• changing the environment to support appropriate behaviors, teaching appropriate
behaviors, teaching to request help through words, objects, gestures or sign language
(Donnellan et al., 1984).
The wide range of learning styles and individual differences within children with
ASD requires that educational strategies and approaches be tailored to each child’s individual
strengths and needs. A combination of approaches is essential to successfully include
children with autism in preschool education programs. The approaches notwithstanding,
according to Dawson and Osterling (1997) effective early intervention models include the
following common features:
• specific curriculum content;
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• highly supportive teaching environment and generalization strategies;
• predictability and routine;
• use of functional approaches to problem behaviors;
• carefully planned transitions from preschool to school; and
• active family involvement.
Additionally, Anderson and Romanczyk, (1999) report that effective programs have
• Highly trained staff, specialized in autism
• Adequate resources
• Supervisory and review mechanisms
All programs emphasize the importance of starting interventions as early as possible, are
intensive in hours, and have a low staff-child ratio (i.e., 1:1 or 1:2) (National Research
Council, 2001).
Specialized therapies in these programs include speech language pathologists,
physical therapists, social workers, school psychologists, and occupational therapists. Only
one program (The Children’s Unit for Treatment and Evaluation, State University of New
York, SUNY) describes having art and music therapists on staff. Programs vary as to
whether specialized therapists are part of the regular staff. Research strongly suggests that
generalization is the most valuable effect of direct treatments for children with autism.
Therefore, most programs emphasize that the therapist’s role is one of consultant who assists
in embeding therapeutic goals in ongoing classroom routines. The Committee of Educational
Interventions for Children with Autism (National Research Council, 2001) states: “There is
little reason to believe that individual therapies carried out infrequently (e.g., once or twice a

week) have a long-term value for young children, unless the techniques are taught to and
used regularly by the child and the people whom they interact with in natural contexts”
(National Research Council, p. 139).
Grandin (in Grandin & Scariano, 1986) concludes: “ I have visited many autism
programs for young children. Effective programs often use many of the same procedures
even though the theoretical orientation is different. The most successful programs start
treatment by age three or four and provide contact with normal children. They are also very
intense. Passive approaches do not work. A good program should also have flexible
nonaversive behavior modification, sensory treatments, speech therapy, exercise, and music
therapy” (p. 179).
2.2.5 Music Therapy and Children with Autism
2.2.5.1 Benefits of Music Therapy for Children with Autism
The American Association of Music Therapy (AMTA) (2003c) states: “For
individuals with diagnoses on the autism spectrum, music therapy provides a unique variety
of music experiences in an intentional and developmentally appropriate manner to effect
changes in behavior and facilitate development of skills” (p.1).
Music therapy can be effective in addressing difficulties associated with autism, because
music might
• capture the child’s attention and cause positive response;
• encourage social interaction and build relationships in a non-threatening way;
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• facilitate verbal and nonverbal communication;
• reduce negative and/or self-stimulatory responses;
• provide multi-sensory stimulation and enhance perceptual and motor functioning;
and
• be a vehicle for identifying and expressing emotions.
In addition, musical elements and music therapy sessions provide structure and
predictability, thereby emphasizing the child’s strengths and individual needs. Music therapy
might also have positive impacts on a child’s family by improving the child’s skills, sharing
music-making among family members, and showing alternative ways to interact and
communicate with one another. Families might see their child in a “different light,” which
might give confidence in the child’s abilities and growth (AMTA, 2003).
2.2.5.2 Music Therapy and Autism: Clinical Practice and Research
Early pioneers in music therapy described the positive impact of music therapy on
children with autism in the seventies. Nordoff and Robbins (1977) illustrated the progress of
a five-and-a-half-year-old boy with autism who was also emotionally and behaviorally
disturbed. Musically matching and meeting the boy’s emotional intensity of screaming and
crying enhanced the child’s self-awareness, leading to “singing-crying response” that
demonstrated features of musical relatedness in pitch, in rhythm and in melody patterns.
With the assistance of improvised music, this boy was able to express enjoyment, engage in
nonverbal conversational exchanges, use words more appropriately, and was more
emotionally stable. Juliette Alvin (in Alvin & Warwick, 1991) described a case study with a

oy, diagnosed with autism, who was hyperactive and had uncontrolled strength, no speech,
and seemed fairly unaware of his environment. During a short moment of quietness, Alvin
struck a cymbal near to the boy’s face. Alvin describes his unexpected responds as follow:
“His expression of wonder when he heard the sound turned into a radiant smile and he looked
me in the eyes” (p. 4). In the following sessions the boy related to Alvin through the cymbal,
learned to play the cymbal and listen to the sound.
Meanwhile, the interest in and positive response to music, as well as improvements in
core difficulties of children with autism through music, is extensively described in numerous
case studies (e.g., Allgood, 2002; Alvin & Warwick, 1991; Brown, 1994; Clarkson, 1991;
Fisher, 1991; Gustdoff & Neugebauer, 1997; Hales et al. 2002; Howat, 1995; Lecourt, 1991;
Mahlberg, 1973; Nordoff-Robbins, 1968a, 1977, 1992; Schuhmacher, 1994; Warwick, 1995),
and by anecdotal evidence from parents (e.g., in Gustdoff & Neugebauer, 1997; Nordoff &
Robbins, 1992; Stevens & Clark, 1969; Saperston, 1973; Warwick, 1995). As documented
by these authors, children with autism frequently exhibit a relatively high interest in and
positive response to musical stimuli. Therefore, music has often been introduced to develop
curiosity and exploratory interests in children with autism, and as a motivator to participate
in activities aimed at achieving therapeutic goals (Nelson et al., 1984).
Interest in music, and the relative strength of musical abilities in children with autism,
is also supported by various research studies. Applebaum, Egel, Koegel and Imhoff (1979)
measure musical abilities of children with autism and find that these children imitated
individual tones and series of atonal tones including timbre as well as or better than typically
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developing children. In an experiment by Thaut (1987), children with autism and two control
groups (including a group of typically developing children) were given a choice between
auditory musical and visual stimuli. Results indicated that children with autism showed no
significant preference for the auditory musical stimulus, but engaged significantly longer in
the musical stimuli than their typically developing peers. In a later study Thaut (1988) finds
that children with autism score almost as well as typically developing children with respect to
the rhythm, restriction, complexity, rule adherence, originality of improvised tetrachordic
tone sequences on a xylophone, and scored significantly higher than children with mental
retardations. Several additional studies support the interest in music and musical abilities of
children with autism (e.g., Blackstock, 1978; Frith, 1972; Hairston, 1990; Sherwin, 1953).
The effectiveness of music therapy interventions in addressing the characteristics of
autism is documented by anecdotal reports, as well as numerous research accounts. One of
the earliest studies addressing social skills in five boys diagnosed with autism comes from
Stevens and Clarks (1969). By using a preexisting Autism Scale (Ruttenberg et al., 1966),
pre- and posttest data were gained on the subject’s functioning in the following categories:
nature and degree of relationship to adult, communication, and drive to mastery. During the
18 weeks of music therapy interventions, a variety of instruments and techniques such as
singing, improvising on the child’s responses and action songs were applied. Results
indicate that four of five subjects significantly improved their skills in all categories. Only
one subject made no significant gains. According to the authors, three of the children were
able to attend regular kindergarten and first grade class afterwards.

Wimpory, Chadwick and Nash (1995) explore the effects of synchronizing live piano
music to mother-child interactions (Musical Interaction Therapy, MIT) to foster the social
and symbolic development of a young child with autism. The mood, timing, and meaning of
the dyad’s activities were reflected musically on the piano to motivate the child to anticipate
her mother’s actions. The result of this single case study and a two-year follow-up indicate
an improvement in the child’s social acknowledgement, eye contact, and the child’s
initiations of interactions, which obtained over time.
In a case study by Brownell (2002), the effects of a musical presentation of a social
story on the social learning and behavioral appropriateness of four first- and second-grade
students were investigated. Social stories are individualized short stories sharing relevant
information surrounding a particular situation or event to assist the child to understand the
expected or appropriate response (Gray & Garand, 1993). Following three treatment
conditions (i.e., baseline, reading social story, singing social story), Brownell finds that both
reading and singing the social story to be significantly more effective in reducing target
behaviors than baseline condition. For one participant, the musical presentation of the social
story was more effective than the reading condition, whereas reading was slightly more
successful in changing the other participants target behavior.
Hollander and Juhrs (1974) introduced a boy named Bernie, diagnosed with autism
who was able to speak, but was not motivated to use language. However, he did respond to
chants and songs by dancing and moving to the rhythm. In a rondo form (as used in the Orff
Schulwerk method), Bernie used words to identify “body parts.” Hollander and Juhrs
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describe the further process as follows: “Then in an attempt to encourage Bernie to speak, all
rhythm and music was omitted and the ‘A’ part of the rondo was ‘mimed’ silently. He
immediately began pinching us [the authors] to attempt to make us sing the verse. When he
realized he could not force us to sing, he began singing the verse and we joined in with him.
Over a period of six months, his negativity towards verbal language has been greatly reduced
and he is using more appropriate speech spontaneously in Orff-Schulwerk as well as in the
ward family and on home visits” (p. 7).
Edgerton, (1994) provides evidence of the effectiveness of improvised music on the
communication behavior of eleven children with autism ranging in age from six to nine
years. During 10 weeks of individual sessions based on the Nordoff- Robbins’ (1977)
Creative Music Therapy approach, the experimenter created music (i.e., piano and singing) as
a means of contact, and enabled the children to respond and develop musical
communicativeness. A reversal design and a specifically designed checklist (Communicative
Response/Act Score Sheet, CRASS) that provided pre- and posttest data on the subject’s
musical and nonmusical communication was used. During the reversal session playing and
singing structured and pre-composed music versus improvised music were used. Analysis of
the pre and post data following the categories of the checklist revealed that improvisational
music therapy significantly and constantly increased the communication behaviors (musical
vocal behaviors and nonmusical speech production) of each child within the musical setting.
When reversal was applied, an abrupt decrease in data was noted in all subjects. Edgerton
suggested that children with autism can make gains in communication during low-structured
interventions. This notion contradicts the current literature suggesting structured approaches.

However, this statement does not find strong support in the application of the reversal design,
because experimental control was only established by way of one data point. To measure
consistency in response, it is essential that sufficient stability be exhibited (i.e., stable pattern,
constant trend) (Aldridge, 1996; Holcombe, Wolery & Gast, 1994; Kazdin, 1982; Tawney &
Gast, 1984). The resistance to change in individuals with autism was taken into account for
the first and last intervention phase, but not during the reversal phase. In addition, a
Behavior Change Survey was handed out to parents, teachers and speech therapists. Little or
no change in the child’s communication behavior outside the music sessions was reported.
A study by Bunday (1995) indicate that the use of manual signs in conjunction with
music and speech with children with autism is significantly more effective in achieving
accuracy of imitating signs and spoken words than the use of manual signs in conjunction
with rhythm and speech. These results have been obtained by testing 10 children in a public
school offering a special program for children with autism by using a within-subject design.
Koska’s (1993) research investigation has examined the arm flapping, body swaying,
and appropriate participation of a nine-year-old boy diagnosed with autism while attending
regular elementary music classes in comparison to his special education classes. Data was
collected by analyzing videotaped segments using time sampling techniques. The results
suggest that all three behaviors were less frequent during regular music classes. Detailed
analysis of the activities (i.e., singing, playing, moving, listening) revealed that the subject
was most attentive during listening. Koska concluded: “This data appears to indicate that, for
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this particular subject, being mainstreamed had a positive effect on his appropriate social
behaviors” (p.1).
Skille (1989) gave an overview of the effects and applications of VibroAcoustic
Therapy (VA). In VA, low-frequency sinus tones in combination with selected music are
transmitted as a vibration to the body. It is reported that after receiving VA, children with
autism subsequently allowed more body contact and stimulation by staff than in other
situations. However, no data are provided to support this observation.
Schuhmacher (1999) evaluated the effects of a long-term music therapy treatment of a
child with autism by using an analyzing system (Assessment of the Quality of the
Relationship, AQR), including seven modi of contact/relation developed by the authors. In a
detailed qualitative analysis of the children’s physical, vocal, and instrumental responses, the
ability of this child in expressing himself and building relationships through music is
demonstrated.
Additionally, the literature contains several reviews that outline music therapy
strategies and techniques accommodating the characteristics of autism (e.g., Thaut, 1984;
Nelson et al., 1984; Toigo, 1992). There is no standardized music therapy assessment for
children with autism, but Snell, (2002), Edgerton (1994), Nordoff & Robbins (1977), and
Wigram (1995, 2000, 2002) have developed descriptive “codings” of musical relationship,
communicativeness, behaviors, and adaptive skills.

Although methods and strategies used in educating and treating children with autism
have changed over the past thirty years, the clinical documentation and research-based
knowledge of the impact of music for children with autism continue to have value. Still,
more updated intervention research is warranted that incorporates contemporary strategies on
the effectiveness of music therapy interventions for children with autism.
2.2.5.3 Music Therapy in Inclusive Preschool Education Programs for Children with
Autism
It is currently unknown how many music therapists are providing services for
children with autism in inclusive preschool settings, nor what model of service delivery is
generally used. The music therapy literature contains only a few descriptions that outline
music therapy services explicitly for children with autism in school settings. The following
paragraphs describe three music therapy programs of key authors in this particular field.
Snell (2002) describes serving students with autism in the Monroe County
Intermediate School District, Michigan. Music therapy is included in the continuum of
programs and services for Monroe County and serves many other students with special
needs, including preschoolers with autism who are partly enrolled in inclusive settings. The
music therapy program uses both an Integrated Service Delivery Model and a Caseload
Service Delivery Model. That means music therapy services are provided as direct therapy
(small and large group therapy), consultation (parents, teachers, support personnel,
community), and workshops and presentations (parents, staff, community). The music
therapy program emphasizes the connection to the community and the support of the child’s
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individual growth toward independence. In several case studies, Snell describes the close
collaboration with teachers and the importance of incorporating the student’s curriculum
content in the music therapy intervention. According to Snell, it is imperative that music
therapists working in school settings be familiar with strategies used with a particular student
by other team members (e.g., behavioral approaches, communication systems, sensory
program) to facilitate the student’s development and generalization of skills in different
settings. She also notes that administrators, teachers and parents are often not aware of the
unique qualities of music therapy in assessing and serving children with autism. Therefore, it
is the music therapist’s role to educate and advocate making music therapy accessible for
children with autism within public schools.
Warwick (1995) reports on her work with school-aged children with autism, both in
special and mainstreamed settings, within the Oxfordshire Education Authority in Britain.
According to her, one of the major issues in providing music therapy services in educational
settings is the economic climate and the lack of knowledge about music therapy. She states:
“(…) music has seemed to become over-specialized. Rather than being central to our culture,
it is too often considered only for those who are talented” (p. 209). It is the music therapist’s
responsibility to share the value of music as a means of “(…) promoting the balance between
the emotional, physical, intellectual and social development of the individual” (p. 209). Like
Snell, Warwick also asserts that exchanging information on the child’s progress with
teachers, specialists and parents is a vital part of working in public school systems.
However, Warwick’s music therapy services are based on a psychotherapeutic approach and
seen as a (…) “space and time to explore who [students with autism] are and how they can

elate to an adult who is not a teacher or classroom assistant - someone outside the world of
school who can support and encourage a creative journey where music is the medium for
self-discovery” (Warwick in Hales et al., 2002, p. 1). Students are seen once a week, both
individually and in groups outside the classroom. Advisory services are provided to teachers
regarding specific problems related to the child’s pathology, and are aimed at developing a
suitable repertoire to be implemented by the teacher in the classroom.
Furman (2002) describes the music therapy program at the Longfellow Early
Education Center in Minneapolis, Minnesota. The center hosts two Early Childhood Special
Education-Autism Spectrum Disorder (ECSE-ASD) classes among other ECSE and regular
classes. Music therapy has been a part of the program since the seventies and plays a vital
role in serving children with autism among other children with special needs starting from
age two. Therapists practice inclusion by using reverse mainstreaming, mainstreaming, and
special grouping, depending on the child’s readiness for successful inclusion. The program
follows an integrated therapy approach (McWilliam, 1995). Music therapy sessions are
integrated in the child’s classroom routine, and incorporate or generalize current therapeutic
goals developed in collaboration with other team members for each child with autism.
“Developing and demonstrating activities that allow the student to participate at their
individual level and yet function as a part of the group is a key responsibility of the music
therapy position” (p. 382). In addition, Furman (2001) gives clinical examples of how to
combine music activities in accordance with the characteristics of autism and contemporary
strategies used with children with autism during music and movement time within the
classroom routine. For example, to provide successful experiences, she suggests
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accommodating the need for structure and predictable routines of children with autism by
starting classes at the same location, with a clearly identified place to sit, and the same
opening song each time. Additionally, placing the child with autism across from the leader
of the group and next to a good role model and friend might enhance the child’s
understanding of the activity and by extension, his or her participation. Furman emphasize
the need of visual cues (e.g., PECS) to indicate transitions and prevent problem behaviors.
As an example, she illustrates a visual lesson plan, pictures for song selection, and pictures
representing activities in action songs. To fully experience the music and movement
activities, some children with autism might need additional support from an adult.
According to Furman, children with autism experience social interactions, learn to imitate,
and might accept transitions when participating in music group activities. She also gives
examples of how skills learned during group activities can be generalized to free-play
situations. Like Snell and Warwick, Furman states that it is essential to communicate and
share information with teachers and incorporate strategies and goals used by the classroom
teachers in order to be most beneficial for the development and growth of the child with
autism.
In summary, all authors report the unique potential of music for accommodating
the needs of children with autism. As demonstrated in clinical documentations, music
therapy has given students with autism positive learning experiences and has supported
their personal growth. Each music therapy program has been recognized and valued by
administrators and parents as an integral part of the excellence in programming for
children with autism. However, the positive effects of the described music therapy

programs are not results of research investigations. More research is needed to
understand the effects of music therapy for children with autism within inclusive
preschool settings.
2.2.5.4. Inside-Out Reports Related to Music
2.2.5.4.1 From Adults’ Perspectives
Clinical documentations and research-based knowledge from various disciplines,
along with parental reports, have provided a better understanding of autism and of the
development of services for individuals with autism. Although there are unique
characteristics that identify individuals with autism, as well as educational/therapeutic
approaches that enhance the individual’s ability to participate meaningfully in their family
and community life, no one individual with autism exhibits the same behaviors or responses
in the same way. Professionals serving individuals with autism must realize that current
perceptions of children with autism are limited. Reports from individuals diagnosed with
autism who are articulate, and willing to share their experiences and perspectives, give
valuable insight and can be helpful to professionals to increase understanding and awareness
of the condition. Temple Grandin and Donna Williams, both diagnosed with autism in
childhood, reference in publications the following musical abilities and the impact of music
in their lives:
Grandin (2003) reports that throughout elementary school, she had difficulties with
speech, but ”singing however was easy” (p. 2). She also describes that melodies are the only
nonverbal information she can memorize without a visual image (Grandin & Scariano, 1996).
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She states: “I have perfect pitch and I can effortlessly hum back the tune of a song I have
heard only once or twice” (Grandin, 2003, p. 2). Rhythms such as synchronizing clapping at
a concert or following the rhythm of a conversation, however, seem difficult to her. Grandin
believes rhythmic activities with instruments for children with autism enhance their rhythm
skill she associates with having difficulties with speech (Grandin, 1988a). According to
Grandin, music might also have value for children with autism because of its pleasurable and
predictable component (Grandin, 1988b).
Donna Williams (1996) describes having “memory for long strings of patterns” such
as movement and sound patterns. When she was a child, words, pitch, movements and
sounds of TV advertisements, jingles and tunes triggered a “mental replay” of the music
accompanied with her fingers dancing to it in her. When she was a teenager, Williams had a
deep experience with playing a piano, which she described as follows: “I had sneaked peeks
at the piano and hit one note here and another note there. I was left in the room with it and I
played the range of its notes (…). A composition created itself in my head. My fingers
danced along the keys. The sound coming back was coherent and whole and beautiful” (p.
245). Later in her life, she played various music styles on the piano, which had an emotional
impact on her. “Some [music] created definite feelings of aloneness, some made me wild
and manic, some made me cheerful, some felt ‘beautiful’ ”(p. 245). She never shared her
music making with others, because she felt that what “came out” of her in music was too
intimate and was anxious not to expose it. Through the lyrics and music of tunes of others,
Williams experienced thoughts and feelings. She says: “The lyrics spoke my life and the
music spoke my emotions” (p. 246). Williams recommends the use of songs for memorizing

a sequence (e.g., teeth brushing) and the use of sounds and musical compositions to express
emotions. She adds: “To allow you to hear what the ‘autistic’ person has created can be an
indirect sharing of emotions and true self. In this way, a musical ‘dialogue’ can be
established back and forth in an equally indirect-confrontational way” (p. 298).
Toigo (1992) describes synthesized Temple Grandin’s insights with practice in music
therapy in accordance with the challenges and needs of individuals with autism. Another
literature review on the insights of adults diagnosed with autism combined with implications
and applications in music therapy practice, is found in Gottschewski (2001).
Both Grandin (1988a) and Williams (1996) recommend the nurturing of talents and
vocational skills of individuals with autism. For those who are musically gifted, a musical
career can provide a socially valued arena for the expression of competence and the
achievement of self-worth.
2.2.5.4.2 Interview with a Ten-Year-Old Jazz Pianist
The following chapter features an interview with a 10-year-old jazz-pianist diagnosed
with high functioning autism. The intention of the interview was to learn more about the
benefits and impact of music on individuals with autism from a child’s perspective.
Although the young musician and his mother gave permission to publish his musical
experiences and thoughts in this thesis, his name is omitted in order to respect his privacy
and that of his family. The young jazz-pianist’s extraordinary musicianship and original
compositions can be heard during live performances around the world and on several
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recordings. He has met and played for many famous jazz musicians, and is the only child
honored by a well-known piano company. In his music and recordings, his interplay with
other musicians, empathy, creativity, joy and great humor can be heard. The author is
grateful for his insights, his mother’s support and the opportunity to share his wisdom with
the professional community.
1. Does music get your attention when you are not playing an instrument yourself?
Oh yeah, in fact you'll probably pass by me playing an imaginary piano.
2. When do you like listening to music and when does music or sound bother you? Can you
give an example?
I like listening to music when I need some resting time and music or sound bothers me
when I'm doing something like schoolwork.
3. Why do you like jazz music most? Can you describe it in a picture or story? Playing jazz
music is like...
Because instead of being restricted to some melody or lyrics like some types of music you
are free to do whatever you want. It's simply the liberty of playing freely that is missing in
other types of music. Playing Jazz is like a world in which you can do anything you want,
simply, and I feel like I'm in a new world.
4. What is it in the music that fascinates you most? Is it the rhythm, melody, harmony, tempo
or something else? Why?

The answer? None of the above. In fact, as I already told you, it's the freeness in jazz...
and the solos are probably my favorite part.
5. Is the structure of jazz pieces helpful? Why yes or no?
Chords, yes. Melody, no. Well, the chords keep the piece from being free jazz. Without
the chords, jazz would simply be Cecil Taylor Jazz (Free Jazz). Melody is simply the
tune itself and the solos are pretty much what make it fun to listen to.
6. Why have you chosen to play the piano? Are there other instruments you like to play,
too?
Well the piano gives more notes (88 of them), while other instruments have only a few
octaves. I also like the sound of the piano. I like to play other instruments, but the piano
seems to go with me.
7. Is it more fun playing alone or with others?
A jazz ensemble is a few people communicating together. A single person is like
someone who is acting like everyone in the ensemble at once. The ensemble gets the real
or imaginary people better communicated, which means better music. So, that's why I
like the ensemble better.
8. When you play with your jazz trio, how do the other musicians fit into your music?
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The drum creates the rhythm, which holds the music together. The bass controls the
form, which makes the piece be a piece (as in question 5). They, as I told you, make very
good communication together.
9. How does it feel playing with them?
They are very good musicians, and they are good friends, and the combination of those
two good things means a well-connected trio.
10. How do you let each other know who is playing a solo or when to end the piece?
To show the end of a solo, you let the intensity of the music drop down until it becomes
almost nothing for a few measures, and then the people know it is time for a solo. You
can also give cues with your body or you can talk softly. To end a piece, you always
have an out chorus, and to show that the out chorus is coming up, the last soloist of the
piece communicates with his body, mouth, or music to tell that the piece is going to end.
This is the communication part of playing.
11. What comes to your mind, when you play for thousands of people?
Thousands of people simply means thousands of fans. I know that the thousands of
people weren't built to make me nervous, which is why I usually DON'T get nervous.
The thousands of people are just people who like my talent.
12. Why do you think that young children with autism like to sing and play instruments?
I think that when they get autism, they start getting the behavioral problems, and then

they start playing the instruments because they know it in their hearts that they can be
good musicians, they just don't know it with their brain.
13. What would you like to tell adults to think of or do when playing music with children?
You can be honest! Tell us...
Age is not a factor in talent. Babies are very good at some things and not at others.
Children can also be stars. Shirley Temple did. And when I get together with two adult
musicians, when the trio makes music, it doesn't sound like it is a kid playing. The adults
simply don't know that kids can be as good as adults, and I would like the adults to know
that.
14. Is there something else you would like to share?
Do you know about my new CD? It's called "(…)." It includes 10 songs, including four
"world premier" tunes. Seven of the ten songs were written by me. You can find out
more at my website.
Note from his mother: “My son read your questions one at a time, and answered them in his
own words. I transcribed exactly what he said. I found his insights to be amazing! I
thoroughly enjoyed learning more about my son.”
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3. Methods
Given the importance of early intervention and inclusion, and the increasing trend to
enroll young children with ASD in regular childcare programs, there is a need to demonstrate
innovative therapeutic techniques and interventions for successful inclusion. As mentioned
in section 2.2.4.3, quite a few university-based model programs empirically demonstrate the
effectiveness of individualized strategies for the inclusion of young children with ASD
(Dawson & Osterling, 1997; Handleman & Harris, 2001; National Research Council, 2001).
However, no model has yet demonstrated the effectiveness of music therapy interventions in
these settings. The purpose of this cumulative study was to understand whether individually
designed music therapy interventions will increase the performance of young children with
autism during challenging routines in an inclusive childcare program, and whether teacher
can embed these interventions in the ongoing classroom routine.
The following intervention studies were conducted within the context of the “Center-
Based Early Intervention Demonstration Project for Young Children with Autism” (Wolery
et al., 2001), which operated within the Family and Childcare program of the Frank Porter
Graham (FPG) Child Development Institute at the University of North Carolina, Chapel Hill
(FPG Child Development Institute, 2003a, 2003b). The Family and Childcare program
enrolled about 80 children from six weeks of age to five years old. Of the 30% of the
children with disabilities, 11 were diagnosed with ASD. The Autism Project’s goals were
threefold: to develop a model for serving children with autism in inclusive childcare classes;
to provide families individualized support and assistance; and to train others to use the
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model. The philosophy of the project was based on a synthesis of current practice and
research-based knowledge in early childhood education, early intervention for young
children with disabilities, and specific strategies developed for children with autism and their
families. The design of the Autism Project was a cooperative venture between the FPG Child
Development Institute and the Division TEACCH of the University of North Carolina at
Chapel Hill. The University’s Division of Speech-Hearing Sciences and Division of
Occupational Therapy provided additional support and consultation. Two components were
important to the project: (1) the classroom component: inclusion of two and three year old
children with autism, use of individualized and structured teaching, establishment of
predictable routines and schedules, the use of integrated therapy; and (2) the family support
component: regular communication and home visits, and adherence to family centered
practices. The Early Intervention Program of the State of North Carolina funded this project.
Because the children identified for this study participated in the Autism Project, the
music therapy interventions attempted to follow parts of the projects’ conceptual design. As
such, the interventions were undertaken in inclusive classrooms using the integrated therapy
approach. Specific goals, strategies and procedures were individualized for each target child,
and predictable routines, structured teaching, and visual cues were taken into consideration in
the interventions’ design. In addition, parents and caregivers were partly included in the
intervention and supported through frequent communication.
The target children were diagnosed with ASD by external agencies using the
Psychoeducational Profile-Revised (PEP-R), Autism Diagnostic Observation Schedule

(ADOS), Vineland Adaptive Behavior Scales, Childhood Autism Rating Scale (CARS),
clinical observation, and parent interviews. The Psychoeducational Profile-Revised (PEP-R)
assesses skills across a range of seven areas: Imitation, Perception, Fine Motor, Gross Motor,
Eye-Hand Integration, Cognitive Performance, and Cognitive Verbal Performance (Schopler
et al., 1990). The Autism Diagnostic Observation Schedule (ADOS) is a semi-structured
play-assessment, designed to elicit social, communication and behavior skills to aid in the
diagnosis of autism. This test was originally designed for research purposes, and is
recognized as an international instrument for the diagnosis of autism (Lord et al., 1999). The
Vineland Adaptive Behavior Scales (Sparrow et al., 1984) is a structured interview designed
to assess the child’s communication, social, and motor skills as they are used in daily life.
And finally, the Childhood Autism Rating Scale (CARS) is a 15-item behavior rating scale
used to identify children with autism, estimate severity of the condition (from mild to
moderate to severe), and differentiate autism from other disorders (Schopler, Reichler, &
Renner 1988).
Classroom peers directly participated in Experiment I and III, and caregivers in
Experiment I, whereas classroom teachers participated in all three experiments. Consent was
obtained from parents and teachers to share the results of these studies with the professional
community. In addition, parents and teachers gave permission to use photographs, audio and
video recordings of the study participants for publication, teaching, and professional
presentations. Classroom peers included both male and females from different ethnic groups
and were ages two to five. Children with and without disabilities attended the same
classroom, where the philosophy followed developmentally appropriate guidelines
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(Bredekamp & Copple, 1997). Individual Family Service Plan (IFSP) and Individual
Education Program (IEP) objectives were addressed within the context of regularly occurring
classroom activities and routines. Teachers were trained in using routine-based interventions
(McWilliam, 1996), and a combination of curricular modifications, embedded learning
opportunities, and specialized instruction to address individualized learning objectives
(Sandall & Schwartz, 2002). All teachers had prior experience and expertise with young
children with autism, and attended in-services on autism held by the investigator of the
“Center Based Early Intervention Demonstration Project for Young Children with Autism.”
None of them had used music therapy interventions prior to the study. The composition of
each of the three experimental groups is summarized in Table 3.1.
Table 3.1. Participant composition of experimental groups.
Participant type Experiment I
n
Target children
Peers with and without
disabilities
Teachers
Parent/Caregiver
2
13
5
2
Experiment II
n
1
--
1
Experiment III
n
As described in the literature, songs are used by a wide range of professions working
with preschoolers with and without disabilities to address academic, social, language and
communication skills, as well as motor skills, and to express emotions (e.g., Enoch, 2002;
Furman, 2001; Humpal, 1998). At the FPG childcare program, well-known children songs
--
4
32
6
--

were part of the curriculum and practiced during group activities. Therefore, using
individualized songs with young children with autism to increase their performance during
challenging classroom routines seemed to be a successful and manageable approach for
teachers to implement. In all experiments a unique song, matching the target child’s
temperament and demands of the identified difficulties, was written and implemented by the
classroom teachers after staff development activities were provided.
The interventions addressed the following challenging moments: the morning
greeting routine, multiple-step tasks within classroom routines, and peer interactions on the
playground. Additional IEP goals, identified by the childcare’s interdisciplinary team, were
included in the intervention’s design. Since the songs were the vehicles for accomplishing
these goals, the song’s content and musical manifestation, as well as the staff development
activities, played an important role in the study.
The effects of the music therapy interventions were evaluated using single-case
experimental designs (A-B-A-B withdrawal design, alternating treatment design, and
multiple baseline design). This research methodology provides professionals in early
intervention a controlled experimental approach to the investigation of a single child under
different circumstances, as well as the flexibility to adapt the intervention to the child’s needs
and the particular treatment approach. Experimental control is achieved within the child,
meaning that each child serves as his or her own control by comparing the child’s
performance across two or more conditions over time (Alberto & Troutman, 1995; Aldridge,
1996; Barlow & Hayes, 1984; Hanser, 1995; Holcombe, Wolery, & Gast, 1994; Kazdin,
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1982; Tawney & Gast, 1984; Wolery, Bailey, & Sugai, 1988). “Single-case designs
highlight individual change in daily clinical practice and allow the practitioner to relate those
changes to therapeutic interventions” (Aldridge, 1994, p. 335). Single-case experimental
designs are commonly used across different professions in early intervention, and are a
scientifically accepted and valid method (e.g., Stile, 1988). Such designs are not unknown to
music therapists, and are quite prevalent in the literature (e.g., Nicholas, & Boyle 1983;
Gregory, 2002). Surprisingly, only a few music therapists have done early intervention
research using single-case experimental designs (e.g., Harding & Ballard, 1982; Kern &
Wolery, 2001). However, as Aldridge (1998, p.335) has poignantly stated: “There are many
methods; finding the appropriate method to answer the question that we are asking is the
central issue.”
Experiment I, II and III, including the specific introduction, research questions,
method, results and discussion are described in greater detail in the three chapters that follow.

4. Experiment I: Increasing Independent Performance of Children with Autism
during the Morning Greeting Routine
4.1 Introduction
The childcare day is filled with daily transitions between activities and routines
within the classroom, as well as to and from the school setting. These transitions include
arrival at the childcare program, greeting of teachers and peers, cleaning up materials,
preparing for new activities, going from indoor to outdoor play, preparing for mealtimes, and
getting down and up from naptime (Alger, 1984; Baker, 1992). Observational studies of the
way young children spend time in center-based programs indicate that they spend substantial
portions of their days making these transitions (Carta, Greenwood, & Robinson, 1987). For
many children, whether with and without disabilities, one of the most crucial transitions is
that from home to school. Sometimes children cry or are unhappy when separated from their
parents or caregivers. Parents and caregivers might be stressed and unsure of how to cope
with the situation (Alger, 1984). The child’s behavior might trigger contagious reactions
from peers or peers may turn away from the crying child. (Osborn & Osborn, 1981).
Making transitions is particularly difficult for children with autism. In fact, the
preferences for sameness and sensitivity to changes are among the defining characteristics of
the condition (Dawson & Osterling, 1997; Mesibov et al., 1997; National Research Council,
2001). In addition, children with autism often lack understanding of symbolic gestures such
as waving for signing hello or good-bye. This can make the morning greeting routine a
challenging experience. A research study by Hobson and Lee (1998), conducted among
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young adults with mental retardation and those with autism, investigate the spontaneous and
prompted greeting and farewell behaviors toward an unfamiliar adult. Results of this
comparison study indicate that persons with autism are less likely to express spontaneous
verbal and nonverbal gestures of greeting and farewell, and are less likely to establish eye
contact, even when offered a greeting. Compared with the control group, fewer people with
autism smile or wave good-bye.
A number of strategies have arisen to support children with autism in making
successful transitions. These strategies include: (1) the use of structure and predictable
routines (Dawson & Osterling, 1997; Marcus et al., 2001; Trillingsgaard, 1999; Wakeford,
2002), (2) the use of visual cues (Bryan, & Gast, 2000; Dettmer et al., 2000; Quill, 2001;
Schmit et al., 2000), and (3) the use of songs (Baker, 1992; Cole, 1993; Furman, 2001;
Gottschewski, 2001; Williams, 1999). “Hello” and “good-bye” songs are often used in music
therapy to establish a predictable routine and to structure the session through a clear
beginning and end, to welcome and get in contact with the individual or group, to give the
individual undivided attention and respect, and to establish awareness of where persons are
and what comes next (Bailey, 1984; Hughes et al., 1990; Krout, 1987; Loewy, 1995;
Schmidt, 1984). Many hello and good-bye songs are published in the music therapy
literature (e.g., Hafner, 1998, 1999; Nordoff & Robbins, 1968b, 1995; Schnur-Ritholz &
Robbins, 1999). All of these were invariably developed through music improvisation with
clients, or uniquely composed for a particularly situation. While there is empirical support
for using songs for transitioning, no studies have evaluated the effectiveness of greeting and

good-bye songs with young children with autism specifically within the context of a
childcare program.
The purpose of this initial experiment was to evaluate the effectiveness of a music
therapy intervention designed to increase the independent performance of two young boys
with autism, during the morning greeting time. This transition was chosen because the target
children, who attended the FPG childcare program, were having difficulty entering the
classroom in the morning. The difficulty they exhibited during the greeting time transition
was characterized by problems separating from the caregiver; hitting, biting or screaming
upon entering the classroom; difficulty engaging with materials in the classroom; and
interacting with peers. The effect of these problems were that the target children’s caregivers
reported feeling “bad” about leaving the child while he was upset, the parents of other
children in the class reported that their children were “afraid of” the target child, and the
teachers “dreaded” the arrival of the child, saying things like “it’s fine once he’s here, but
just getting him here is hard.” It should be noted that the target children were having
difficulties with this transition in spite of the fact that a set routine had been in place for
several months.
4.2 Research Questions
The purpose of this study was to evaluate the effects of individually composed greeting
songs on the independent performance of two young children with autism during the morning
greeting routine, implemented by the classroom teachers. The evaluation was guided by
three overarching research questions:
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(1) Does the use of an individually composed song, sung by teachers, increase
appropriate independent performance during the morning arrival routine of young
children with autism?
(2) Can classroom teachers learn to use the principles important to music therapy in a
particular routine?
(3) Does the song increase interaction of peers with the target?
4.3 Method
4.3.1 Participants
The participants in this study were two young children with autism (n=2), typically
developing children and children with other special needs (n=13), classroom teachers (n=5),
and the target children’s respective caregivers (n=2).
Target Children. Two boys with ASD, both three years old, participated in this study.
Both children were diagnosed with ASD by external agencies, using the diagnostic tools
described in chapter 3. The children used the Picture Exchange Communication System
(PECS) (Bondy & Frost, 1994), as well as other visual cues and prompts to support their
communication. Subject 2 participated in the study five months after subject 1, at which time
a new school year had begun. Since most of the classes are structured newly each school
year, subject 2 was attending the same class as subject 1. The children were selected for
participation in this study on the recommendation of their classroom teachers,
parent/caregiver and therapists based on their diagnosis of ASD, their difficulty with the
morning greeting routine, and interest in and positive response to music.

Subject 1. Phillip was a 3-year, 5-month-old African-American,
enrolled in the childcare program for 10 months prior to this study.
Phillip was a lively and humorous child. However, he was functioning
on the Childhood Autism Rating Scale (CARS) in the mild to moderate
range on the autism spectrum. Phillip’s communication skills were very restricted, he
demonstrated a deficit in social interactions, and he had a limited interest in play.
Occasionally, Phillip had episodes of staring into space and engaging in stereotypic
behaviors such as spinning objects or flapping his arms. Phillip communicated by using the
Picture Exchange Communication System (PECS) (Bondy & Frost, 1994). He was able to
independently select a picture and give it to the appropriate communicative partner. He also
had started to use some verbal sounds and a few words related to repeated social play
routines, food, or songs. His interaction with toys was limited and consisted mostly of
moving the objects around for a short period of time. He began to expand his ability to
perform a play sequence (i.e., cutting out, drawing a picture, placing a sticker on a paper)
with teachers’ support. Phillip showed sudden changes in mood and feelings, and he was
easily frustrated and frequently protested vocally. He tended to withdraw himself from social
interactions, but had a positive relationship with his family and familiar adults. Social peer
interaction only occurred when supported by adults in structured play activities. Phillip was
a large boy and sometimes used aggression (e.g., pushing, hitting, screaming) to start
interactions with peers or was physically too rough. He also took away or destroyed
belongings of other children. Peers seemed to be afraid of him and denied playing or
exchanging toys with him. Phillip received speech/language and occupational therapy
services while in the classroom.
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Phillip tended to have difficulty with transitions and changes in routines. The
transition from his mother to the classroom teachers was troublesome for Phillip every
morning. The difficulty Phillip had during the morning transition was characterized by his
refusal to enter the classroom; and slamming the door, escaping, lying on the floor, hitting,
biting, or screaming upon entering the classroom.
Phillip was quite interested in, and responded well to, music. He preferred
noisemaker toys, and loved to listen to selected musical pieces. Rhythmically based music
made him move and dance.
Classroom Peers. In addition to the target child, six other children between two and
three years of age were enrolled in the classroom. Peers included both males and females
from different ethnic groups. Five of the children were typically developing and one of the
classroom peers had Down Syndrome. The classroom peers participated in the study
voluntarily. More specifically, children who came forward to greet the target child were
included in the morning greeting routine. Thus, the particular children who participated each
day varied, based on the children’s own actions and on class attendance.
Classroom Teachers. A classroom teacher and an assistant teacher participated in the
study. The classroom teacher had a bachelor’s degree and was certified in early childhood
education. She had taught young children for four years. The assistant teacher had a high
school diploma, was licensed to work with infants and toddlers, and was working toward her
associate’s degree in child development. She had been teaching for two and a half years.

Both teachers participated based on their schedule (i.e., teachers’ start times are staggered,
such that the entire childcare day has coverage). However, the lead teacher participated more
frequently than the teaching assistant. Neither teacher had had prior experience with music
therapy interventions.
Target Child’s Parent. The target child’s mother requested strategies to facilitate the
transition of her child from home to school. She participated in the study on a daily basis by
bringing her child to the classroom and by participating in the greeting time procedures.
From time to time, parents of peers participated by singing and greeting, when
arriving while the intervention was going on. As the childcare program was affiliated with
the university, students, observers and visitors were occasionally in the classroom or
observing behind the one-way mirror in addition to the children and childcare program staff.
Video Excerpt 4.1. Phillip’s morning greeting time behaviors during baseline
condition.
Subject 2. Ben was a 3-year, 2-month-old European-American,
enrolled in the childcare program for 10-month prior this study. Ben
was a beautiful and adorable boy. However, he was functioning on
the Childhood Autism Rating Scale (CARS) in the mild to moderate
range on the autism spectrum. Ben had severe delays in
communication, social interactions, and play, and engaged frequently in repetitive interests
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and behaviors such as spinning around. Ben used the Picture Exchange Communication
System (PECS) (Bondy & Frost, 1994), and was beginning to develop some functional
speech. He had difficulties settling into play activities. His play involved mostly exploring
and manipulating toys, and simple interactive games initiated by familiar adults. Ben was
able to express emotions and show affections. He indicated joy and happiness through
smiling, vocalization, jumping, or spinning around, discontent through crying, pushing an
item away, or turning away from a person. Ben had limited interest in peers and was more
social with familiar adults. Social peer interaction only occurred when supported by adults in
structured play activities. Peers seemed not to take notice of him. Ben received
speech/language and occupational therapy services while in the classroom, and engaged in a
designed home program.
Transitions and changes in routines were somewhat difficult for Ben. The transition
from his caretaker (most frequently his nanny) to the classroom teachers caused great
difficulties every morning. The difficulty Ben had during the morning greeting time
transition was characterized by holding on to his caretaker, whining to intensive crying or
screaming for a long period of time (between five and 25 minutes), ignoring the efforts of his
classroom teachers’ greeting and play offers, stiffening his body, pulling teacher’s hair, or
wetting his pants.
Ben was very interested in actions that accompany familiar songs. He preferred
listening to selected music (e.g., “Twinkle, Twinkle Little Star”), playing computer games, or

watching videos including music. Additionally he engaged in playing musical instruments,
and soft and mellow music seemed to comfort and calm him.
Classroom Peers. In addition to the target child, seven other children between three
and four years of age were enrolled in the classroom. Peers included both males and females
from different ethnic groups. Five of the children were typically developing, one of the
classroom peers had Down Syndrome, and Phillip had been diagnosed with ASD. As with
subject 1, classroom peers participated in the study voluntarily.
Classroom Teachers. Ben’s lead teacher, together with a female and male assistant
teacher, participated in this study. The lead teacher was the same teacher as for Phillip
(subject 1). Neither of the two assistant teachers had been previously involved in any study
based on music therapy. One assistant teacher had a high school diploma and had been
teaching at the childcare program for two years. The other teaching assistant had a
bachelor’s degree in a field unrelated to child development. It was his first year working
with preschool-aged children. All classroom teachers participated equally in the
intervention.
Target Child’s Caregiver. Ben’s nanny participated in the study on a daily basis.
She was responsible for transporting him to his classroom and picking him up after lunch.
While Ben was participating in classroom activities, she frequently waited for him in the
teachers’ lounge.
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4.3.2 Setting
Video Excerpt 4.2. Ben’s morning greeting time behaviors during baseline
condition.
All experimental sessions occurred in the classroom of the target child’s childcare
program where the philosophy followed the guidelines for Developmentally Appropriate
Practice (DAP) (Bredekamp & Copple, 2002). The classrooms were structured in clearly
defined play areas such as a Music/Movement area, an Art area, a Language area, a Dramatic
Play/Housekeeping area, a Manipulative area, a Block area, a Nature/Science area, and a
Sensory Table area. Additionally, Ben’s class had a Computer area. Each area contained
clearly labeled toys and materials corresponding to the given areas (Harms, Clifford, &
Cryer, 1998; Marcus et al., 2001). Daily classroom schedules, predicable routines, and clear
and concrete visual information were used to allow the children with autism to function most
independently during the childcare day (Marcus et al., 2001; Schopler, et al., 1971). Located
in the hallway outside the class was a cubby for each child where she or he placed her or his
personal items. A picture symbol used by the subjects for the morning greeting routine was
placed at the target children’s cubby.
In the mornings, children arrived individually over a one-and-a-half-hour time period.
Each child, and her or his parent, placed her/his personal items, in the child’s cubby, and
entered the classroom together. The child would be greeted by and greet, the teacher and
peers, then engage in play. The classroom curriculum allowed free play during the morning
arrival time. Children engaged in different play areas by themselves or with each other. The

parents signed the child in and had a brief conversation with the teacher before saying “good-
bye” to the child and leaving the classroom. Sometimes parents would stay for a short period
of time and play or read a book to their child and/or classmates.
4.3.3 Materials
The materials used for Experiment 1 were as follows: (1) a picture symbol, (2) a
unique song composed for each target child, and (3) a practice compact disc (CD)
accompanied by a song transcription. Each is described in turn below.
(1) Picture Symbol. Prior to the study, the teachers
had used a 10 x 10 cm square laminated picture
communication symbol (Mayer-Johnson, 1992)
showing a waving stick figure and the word “Hello”
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printed on the top using 18 pitch letters and the Arial
font. The symbol was used to assist the target
children to initiate greeting classroom teachers and
peers, regardless of their language and
communication skills.
Figure 4.1. “Hello” picture symbol employed to greet classroom teachers and peers during
the morning greeting routine.

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(2) Unique song composed for each target subject. The songs were individualized
and matched each subject’s temperament and the demands of the morning greeting routine
musically. The intention of both songs was to ease the transition from home to school, to
increase the target children’s independent performance during the morning greeting routine,
and to support their interaction with peers. The greeting routine, developed by an
interdisciplinary team (i.e., classroom teachers, a special educator, and a music therapist),
was similar to the greeting procedure used by the target children’s classmates. The form and
lyrics of the “Song for Phillip” and “Song for Ben” focused on each step of the routine and
were incorporated composed as follows:
1. The teacher/peers greet the target child.
2. The target child greets a person (teacher or peer) in the classroom.
3. The target child greets a second person (teacher or peer) in the classroom.
4. The target child says “good-bye” to the caregiver and the caregiver leaves the
classroom.
5. The target child engages with a toy or material found in the classroom.
The five described steps are presented in a musical AAABA form and the lyrics as
outlined in Figure 4.2 and 4.3. The A parts reflect steps 1., 2., 3., and 5 as the procedure
happening in the classroom. Part B reflects step 4., the “good-bye” part, where the melody
and mood of the song change in order to emphasis the detachment from the caregiver. Step 5
(the last verse) encourages the target children to engage and settle into a play activity. Social
interaction is supported by greeting at least two peers as the song proceeded, and by handing

over the picture symbol showing the stick figure waving “hello.” Additional Individual
Education Plan (IEP) goals, such as verbalization for Ben and choice making for both Ben
and Phillip were incorporated in both songs. Choice-making was included by choosing two
different peers to greet, a toy to play with, and a weather condition at certain points of the
songs. Verbalization was practiced by saying or singing “hello” to a person, naming the
greeted person or saying “bye-bye” to the caregiver. The parents and caregivers were
included in the songs by participating in singing, greeting peers and teachers, and waving
good-bye. Table 4.1 furnishes an overview of the IEP goals incorporated in “Song for
Phillip,” and “Song for Ben.”
Table 4.1. Overview of Phillip’s and Ben’s IEP goals incorporated in “Song for Phillip” and
“Song for Ben.”
Make choices
Increase verbal skills
Increase peer interaction
IEP Goals Song
Choose different peers, toys/materials to play
with, and a weather condition
Say or sing “hello,” “good-bye,” or name peers
Greeting a peer by handing over a picture
symbol, saying/singing her or his name
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Figure 4.2. Transcript of ”Song for Phillip,” written to address Phillip’s demands of the
morning greeting routine, social interaction and specific IEP goals.
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Figure 4.3. Transcript of ”Song for Ben,” written to address Ben’s demands of the morning
greeting routine, social interaction and specific IEP goals.

(2) Practice compact disc (CD) accompanied by a song transcription. Each unique
song was recorded on separate practice CD and given to the teachers and parent/caregiver.
To ensure accurate learning, each song on the practice CD was presented as follow: piano
accompaniment and vocals with lyrics, to give the whole impression of the song, melody
played by the piano, to learn the melody properly, sing along with piano accompaniment, to
practice singing the song, and melody sung with lyrics, to model how to sing during the
morning greeting routine. Additionally, each song was transcribed as music and lyrics,
including melody, chords, and lyrics and handed out to the teachers and parent/caregiver.
4.3.4 Procedure
Experimental sessions occurred Monday through Friday during the morning arrival
time. Phillip usually arrived between 8:00 and 9:00 am, and Ben between 8:30 and 9:30 am.
Observation was based on the subject’s presence and availability of the teachers.
Staff and Parent/Caregiver Development Activities. Initially, a verbal orientation to
the intervention procedure was discussed with the teachers and parents/caregiver, as was a
sense of how the intervention would fit into existing classroom routines. Training and
consultation occurred after the intervention goals and procedures were identified and after
songs were composed. The songs, and how to use the practice CD (as described in the
material section), were introduced to the teachers and parents/caregiver individually, and to
children during circle time prior to the intervention. Specific instructions were given to
teachers and caregivers regarding how to greet and assist the target children to greet and
interact with their peers. This included explaining and modeling:
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• how to be prepared for the target child, by meeting him at the entrance of the
classroom and be present;
• how to personally greet the target child, by making eye and/or body contact, and
going to the physical and emotional level of the child;
• how to help the target child to find somebody to greet by gathering peers around
him and prompt him to hand over the picture symbol or model to say “Hello”
verbally when necessary;
• how to wave or shout bye-bye as incorporated in the song and, for the caregiver,
how to leave the classroom and wait outside if questions arise or information
needs to be shared;
• how to engage the target child in play by having toys/materials of interest of him
available and within the teacher’s reach;
• how to guide the child to a play area by offering a toy/material with which to
play, if necessary;
• how to follow the target child’s pace and give enough time to respond to each
step, by pausing or slowing down in the music;
• how to motivate and prepare peers to participate in greeting by singing the
greeting song and modeling how to take the picture symbol, as well as giving
verbal praise as positive reinforcement; and
• how to communicate a positive attitude toward the target children by anticipating
the greeting routine with enthusiasm and emphasis the strength of the target
children.

The teachers were asked to include more than two peers in the greeting routine, if
more than peers two showed interest in participating in the morning greeting routine. Staff
training ended when the teachers and parents/caregiver signaled to be comfortable with the
song and the procedure. During the intervention, feedback and suggestions about the
implementation of the intervention were provided to the teachers and parent/caregivers.
Baseline Procedure. During baseline condition (Condition A), the session started as
soon as the target child and his parent/caregiver opened the classroom door. The child had
already put his personal belongings in his cubby outside the classroom and picked up the
picture symbol showing the stick figure waving ”hello.” First, teachers greeted the subject
(step 1). Second, the subject greeted a teacher or peer by handing over the picture symbol,
and/or saying the greeted person’s name (step 2). Third, the subject greeted a second teacher
or peer by handing over the picture symbol, and/or saying the greeted person’s name (step 3).
Fourth, the subject said or waved “good-bye” to the caregiver and the caregiver left the
classroom (step 4). Fifth, the subject was encouraged to find a toy or material with which to
play or engage (step 5). A system of least prompts (Doyle et al., 1990; Wolery, 1992) was
used to both give the subject time to respond independently to each step of the greeting
routine, but also to ensure that the subject completed each step of the greeting routine.
Intervention. In the intervention phase (Condition B), the conditions were similar to
the baseline conditions. The same five steps and the system of least prompts were used. The
only change between the baseline conditions and the intervention conditions was the
introduction of each subject’s unique song. The song, whose musical format and lyrics
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matched each of the five steps of the greeting routine, was sung during each step of the
routine. That is, for Step 1, the teacher sang the first verse of the song. Thus, as the routine
progressed, so too did the song in tandem.
Modified Intervention for Ben. Due to the fact that Ben’s (subject 2) number of
independent behaviors did not change significantly with the introduction of the song
(Condition B), an error analysis was conducted and a change in the intervention procedure
implemented. The change in this modified intervention (Condition C) consisted of omitting
the good-bye section (step 4) of the routine. This was done because Ben had ongoing
difficulties separating himself from his caregiver. As soon as Ben entered the classroom
independently, his caregiver left and was not visible for him during the entire time Ben spent
in his daycare program. Teachers immediately started to sing and engage him in greeting his
peers and finding a preferred toy/material with which to play. Toys/Materials of interest to
him (e.g., a drum) were moved to the activity tables close to the entrance of the classroom.
Notwithstanding all prompting procedures, remained the same.
4.3.5 Experimental Design
An A-B-A-B withdrawal design was used for Phillip (subject 1) to evaluate the
effects of the individually composed greeting song sung by the classroom teachers, the
caregivers and peers during the morning greeting routine. In an A-B-A-B withdrawal design,
experimental control is established by comparing baseline performance (Condition A) with
intervention performance (Condition B). If a difference in the data patterns exists each time
the conditions change, and if those differences are replicated across conditions, then

experimental control is achieved. Specifically, if there is a stable pattern of data in baseline,
followed by a change in the data pattern when intervention is introduced (that is, a change in
level, a sustained trend in one direction or the other, or both), a counter-therapeutic change
when the baseline condition is reintroduced, and finally another therapeutic change when the
intervention is reintroduced, then the investigator can conclude the changes are related to
intervention. This is considered to be a powerful demonstration of the effectiveness on an
intervention because it controls for threats to internal validity (Aldridge 1994; Aldridge,
1996; Hanser, 1995; Holcombe, Wolery & Gast, 1994; Kazdin, 1982; Tawney & Gast, 1984;
Wolery, Bailey, & Sugai, 1988).
The experimental design in Experiment I involved the following two conditions:
• The Baseline (Conditions A) followed the five steps of the morning greeting routine.
• The Intervention (Condition B) followed the five steps of the morning greeting
routine by using Phillip’s unique greeting song.
A variation of the same experimental design (A-B-C-A-C withdrawal design) was
used for Ben (subject 2). As mentioned earlier, the song intervention (Condition B) was
modified by eliminating the “good-bye” section (step 4) of the routine. Therefore the
Modified Intervention (Condition C), followed four steps (steps 1, 2, 3, and 5) of the morning
greeting routine using Ben’s unique greeting song. Data collection occurred over two month
for Phillip and over three month for Ben.
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4.3.6 Measurements
The following measurement procedure and responds definitions applied for Phillip
(subject 1): Seven categories of behaviors were measured through direct observation using
an event recording system. That is, data were collected as the target child and adult
performed each step of the greeting routine. Data were recorded during Conditions A and B
(baseline- intervention) when the subject and his caregiver arrived at school before the
transition to breakfast, when the teachers were present and available, and when classroom
peers were present. Data were collected by direct observation during the morning arrival
time. The observation time started as soon as the target child and his caregiver stepped over
the threshold of the doorway that leads from the classroom to the hallway. Data collection
time ended as soon as the target child picked up a toy/material in the classroom. Data
collection stopped even if the target child had not said “hello” or “good-bye.” Data
collection sessions lasted between two and ten minutes depending on the day. Some of the
sessions were videotaped with a Panasonic AG-195 Camcorder and analyzed immediately
afterwards. The event-recording system was employed as follows: (a) The observer made a
judgment about the target child’s and adult’s behaviors in each step of the morning greeting
routine; and (b) The observer recorded the results for each step on a specially designed data
sheet (see Appendix A).
The definitions of the categories were as follows:
(a) Adult behavior
• An Adult prompt was defined as a teacher or an adult other then the classroom teacher
(i.e., the subject’s mother, etc.) assisting the target child. This assistance was either

verbal (i.e., “Say, ‘Hello.’”) or physical (i.e., the classroom teacher or adult put her
hand on the subject in order to facilitate the exchange of the picture symbol).
• No adult prompt was recorded if the teacher or adult did not need to (or did not)
provide any support that helped the subject to perform the target behavior.
(b) Child behavior
• Independent response was defined as the target child performing the correct behavior,
without any adult support.
• Prompted response was defined as the target child performing the correct action, but
needing a verbal on physical prompt by an adult to do so.
• Error was defined as the target child either not following the sequence of the routine
or engaging in an appropriate behavior not prescribed by the routine.
• Inappropriate response was defined as the target child engaging in a behavior that
was inappropriate (i.e., hitting, screaming, biting, etc.).
• No response was defined as the target child not responding at all, even when
prompted.
These categories were coded for each of the five steps of the greeting routine.
The measures used for Ben (subject 2) were similar to those used for Phillip (subject
1). The only difference was that one additional measure was added to capture the number of
classroom peers with and without disabilities greeting Ben independently during the morning
greeting routine. The number of peers greeting independently was defined as peers receiving
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the “Hello” symbol from Ben without verbal or physical prompting from an adult. This
measure was added to answer research question 3: “Does the song increase interaction of
peers with the target child?”
Additionally, field notes were recorded for both subjects on the specially designed
data sheet provided in Appendix A.
4.3.7 Reliability
Interobserver agreement data were collected on the subjects, and adult’s behavior
during all conditions. A special educator and the investigator collected interobserver
agreement data for Phillip during baseline session (Condition A), and intervention session
(Condition B). Before the baseline was started the two observers coded the target child’s and
the adult’s performance during the greeting time by direct observation until they reached a
mean agreement level of greater than 80% for three consecutive sessions. A second observer
(a research assistant) was trained to collect interobserver reliability for Ben (subject 2) during
baseline sessions (Condition A), the intervention session (Condition B), and the modified
intervention session (Condition C). Agreement between the scores from the first and the
second reliability observer was calculated prior the start of the data collection phase, using
videotaped segments from previously evaluated sessions, to establish an acceptable level of
agreement of greater than 85%.
Reliability checks were carried out on an average of 22% of total observations within
each phase and for each child. Two coders coded the real-time performance or video taped

segments for each target behavior. Interobserver agreement levels for each code category
were calculated by summing the number of agreements (defined as the same coding interval)
and dividing the number by sum of agreements plus disagreements and multiplying by 100.
4.4 Results
4.4.1 Interobserver Agreement
Interobserver agreement data on the target children’s performance were collected in
21% of the baseline sessions (Condition A), 22.5% of the intervention sessions (Condition B)
for each child, and 22.2% of the modified intervention session (Condition C) for Ben.
During baseline condition (Condition A), reliability data illustrated observers agreed on the
participants’ performance in 97.7% (range: 90.9% - 100%) of the trials. The percentage of
agreement was 100% for Phillip, and 96.9% for Ben. During the intervention phase
(Condition B), reliability data demonstrated observers agreed on the participants’
performance in 90.7% (range: 75% - 100%) of the trials. More specifically, the percentage
of agreement on the participant’s responses was 92% for Phillip and 87.5% for Ben. During
the modified intervention phase (Condition C), reliability data showed that observers agreed
on Ben’s performance 100% of the time. The overall interobserver agreement was 94%
(range: 75% - 100%). Table 4.2 gives a summary of the interobserver agreement.
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Table 4.2. Interobserver agreement in Conditions A, B, and C.
Participants Condition A in % Condition B in % Condition C in %
Phillip 100 92 N/A
Ben 96.9 87.5 100
Overall 97.7 90.7 N/A
4.4.2 Outcome Data
The data associated with Experiment I present two outcomes: the number of
independent performance during the morning greeting routine for both Phillip and Ben, and
the number of peers greeting Ben during the morning greeting routine.
(1) Number of independent performance during the morning greeting routine
Both subjects with autism had a low level of independent performance (that is,
completing the correct steps of the five-step greeting routine without any adult support)
during baseline condition. With the introduction of the song intervention (Condition B), their
independent performance increased. This result was statistically significant for Phillip. After
the intervention was modified, Ben showed a significant increase in his independent
performance, too. After withdrawing the song intervention, both observers recorded a drop
in children’s independent performance. After re-introducing the intervention conversely,
Phillip’s and Ben’s independent performance was back to a very high level of independent
steps. Both children ended the intervention at the highest level. The number of peers
greeting Ben changed from no greeting during baseline condition to two peers greeting,
which was part of the original composition of the song.

Phillip. Phillip was observed for a total of 28 sessions. Figure 4.4 shows the number
of steps of the greeting routine that Phillip completed independently by each condition of the
study. In the first baseline condition, Phillip’s performance was steady. In all of the sessions
except session number four, Philip completed two steps of the five-step routine
independently. In session four, he did not do any of the routine independently. The steps
Phillip completed independently were entering the classroom and finding a toy with which to
play. With the introduction of the song intervention, Phillip’s performance initially dropped
to one step independently (entering the classroom), but after two days of song intervention,
Phillip’s performance was back at baseline level. By the forth day of intervention, Phillip’s
performance was better than at baseline level and by the sixth session, Phillip’s performance
was consistently higher than the baseline level. Throughout the intervention phase there was
a steadily acceleration, with a slope that indicates that Phillip’s performance steadily moved
toward independence. After ten sessions in intervention, Phillip’s performance appeared
consistent, as evidenced by three consecutive sessions with four independent steps at the
same level so that the intervention was withdrawn. Phillip’s performance immediately
decreased from intervention level. By the second day of withdrawal, Phillip’s performance
had returned to the level of his initial baseline performance with two independent steps
(again entering the classroom and finding a toy to play with). Once Phillip’s performance
was stable at baseline levels, the song intervention was again introduced. Immediately,
Phillip’s performance increased. After four sessions, Phillip’s performance was equal to his
performance at the end of the initial intervention phase. His performance remained steady at
this level until the ninth session of intervention where Phillip performed all of the steps of the
routine independently.
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Number of Independent Responses
5
4
3
2
1
0
Baseline Intervention Baseline Intervention
0 2 4 6 8 10 12 14 16 18 20 22 24 26
Sessions
Figure 4.4. Number of independent responses performed by Phillip during the morning
greeting routine in baseline and intervention sessions.
Ben. Ben was observed for a total of 31 sessions. Figure 4.5 shows the number of
steps of the greeting routine that Ben completed independently during each condition of the
study. In the initial baseline condition, Ben’s performance was steady. In the majority of the
sessions, Ben had one independent correct response. The step Ben completed was entering
the classroom independently. On session four of the first baseline condition, Ben had three
independent steps. With the introduction of the intervention, Ben’s performance was quite
variable. Ben responded in the majority of sessions with one independent response, which
was the same as during baseline conditions. In four out of 12 sessions, Ben completed more
of the greeting routine steps independently. Overall, the data did not indicate that the
implementation of the song significantly affected Ben’s greeting time behavior. After
conducting an error analysis, it was determined that the “good-bye” part of the routine was

difficult for Ben. Therefore the routine was changed, and the formal “good-bye” was
omitted. The modified song intervention (Condition C) resulted in an abrupt and sharp
increase in the level of data. Ben had consistently been performing three out of the four steps
of the routine independently. After five sessions of consistent performance, the intervention
was withdrawn. There was an immediate decrease in Ben’s independent behavior ending on
baseline level, which was evident in three out of the four withdrawal sessions. Only one
session during the withdrawal was at the level seen during the modified intervention
condition. Overall, there was a descending trend in this condition, and the behaviors were
lower then they were during the modified intervention condition. Immediately after the re-
introduction of the intervention, the data resulted in an abrupt and sharp increase. Ben was
completing four (out of four) steps of the greeting routine independently. This high level of
performance was consistently exhibited during the entire condition.
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\
Number of Independent Responses
5
4
3
2
1
Baseline Intervention Modified Baseline Modified
Intervention Intervention
0
0 2 4 6 8 10 12 14 16 18 20 22 24 26 28 30 32
Sessions
Figure 4.5. Number of independent responses performed by Ben during the morning
greeting routine in baseline, intervention, and modified intervention sessions.
(2) Number of peer greeting Ben during the morning greeting routine
Figure 4.6 shows the peers’ independent participation in the classroom greeting
routine. The data presented show both typically developing peers and peers with disabilities.
However, 94% of the peers who independently participated in the song intervention were
typically developing. During the six days of the initial baseline condition, no peers
participated in the greeting routine (Condition A). With the implementation of the song
intervention (Condition B), the greeting behavior of the peers changed. As soon as the song
intervention was introduced, at least two classroom peers participated in the intervention.
For the remainder of the study, in all but one of the experimental sessions, peer participation
was above baseline level. The majority of the sessions had two peers participating in the

greeting routine. On three occasions, more than two peers participated in the routine. This
was accomplished by the spontaneous decision of the teacher to repeat the greeting verse of
the song in order to accommodate all of the classmates who wanted to participate in the
greeting routine. Neither the modification of the intervention nor the withdrawal of the song
intervention returned the peers’ behavior to baseline conditions, with the exception of one
day. Nevertheless, it should be noted that in the withdrawal phase of the study the trend for
classmate participation decelerates.
Number of Peers Greeting Ben
5
4
3
2
1
0
Baseline Intervention Modified Baseline Modified
Intervention Intervention
0 2 4 6 8 10 12 14 16 18 20 22 24 26 28 30 32
Sessions
Figure 4.6. Number of peers greeting Ben during the morning greeting routine in baseline,
intervention, and modified intervention sessions.
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4.5 Discussion
The purpose of Experiment I was to investigate the effects of individualized greeting
songs on the independent performance of two young children with autism during the morning
arrival time at an inclusive childcare program. Additional purposes were to determine
whether teachers could implement the intervention in the ongoing classroom routine after
staff development activities were provided, and whether the intervention increases the peer
greeting behavior and positive interaction towards the target children.
From this study the following findings are apparent. Prior to the song interventions,
the data indicate that Phillip and Ben had great difficulties with the transition from home to
school and following the classroom’s morning greeting routine. Both individualized greeting
songs were effective at increasing the target children’s independent performance during the
morning greeting time, although the intervention for Ben needed some modification. The
interventions also had positive effects on peers’ greeting behavior toward the target children,
as both the informal observation for Phillip and the data based evaluation for Ben show. As
for the positive outcomes of the interventions, it can be concluded that classroom teachers
successfully implemented the interventions based on music therapy principles into the
ongoing classroom routine. The following field notes and reports by the target children’s
classroom teachers, caregivers, and parents of peers also indicate these positive changes.
Phillip. In the initial baseline phase, Phillip performed only two steps out of the
morning greeting routine and no peer greeting occurred. During the first two days of
intervention, his independent performance initially dropped to a lower level of data as in the

aseline phase. This observation is consistent with the defining characteristics of autism.
That is, children with autism might insist on specific routines and can become very
distressed, when change occurs (American Psychiatric Association, 2000; Dawson &
Osterling, 1997; National Research Council, 2001). Phillip’s familiar routine was changed
by having his teacher sing the greeting song to him and following the intervention procedure.
In addition, the novelty of the song, and the lack of experience with implementing
interventions based on music therapy, caused some excitement in the teacher’s behavior that
might have also transferred to Phillip and his peers. However, as the song intervention
continued, he made great progress in learning the steps and sequence of the routine, including
greeting peers and adults. Phillip was able to follow all steps out of the greeting routine
independently, except the “good-bye” part. It seemed to be difficult for him to understand
the symbolic gesture of waving good-bye. This finding is similar to that in earlier research
showing that individuals with autism are less likely to express spontaneous verbal or
nonverbal gesture of farewell (Hobson & Lee, 1998). Clinically, this step needed to be
practiced and given meaning for him. To understand and accomplish the farewell gestures,
his mother and teachers needed to set clear prompts and definitions of saying good-bye. The
withdrawal of the intervention resulted in an immediate decrease in his independent
performance. When the greeting song was re-introduced, his independent performance went
back to the prior intervention phase. On the last day of intervention, Phillip performed all
steps out of the morning greeting routine correctly and independently.
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A number of observations related to Phillip’s IEP goals are no less interesting than
the foregoing findings. Phillip finally verbalized “Ba” for good-bye or flapped his right hand
quickly next to his leg as a good-bye gesture. Most of the time this quick response was not in
the order of the set greeting routine and was therefore coded as an error. Phillip also
verbalized the greeting part by saying “Heho” for hello, and exchanged the picture symbol
first with an adult prompt, then independently. Most of the time Phillip independently chose
a toy or material with which to play. He preferred going to the art area to draw with crayons,
play with playdough, or cut out paper pieces and glue them on a paper. Phillip seemed to be
less frustrated when transitioning from home to school. Many times he smiled during the
morning greeting time and independently approached his peers for greeting. Although he
was still physically too rough at times, peers accepted him. The implementation of the
intervention changed the classmates’ behavior and interaction toward Phillip. Peers
volunteered in singing and greeting him, or participated by giving their input to the song
(e.g., statements about the weather condition) while engaging in other activities. Some peers
had stronger relationships with Phillip than others. One three-year-old African-American girl
was particularly interested in interacting with him through the greeting song and was able to
get his attention. Phillip often chose her to greet and gave her the picture symbol or said
“Heho” to her. On many days more than two peers asked for a turn to say “Hello” to Phillip.
It should also be noted that the many consumers of this study (the classroom teacher, the
target child’s parent, and the parents of the other children in the classroom) believed that the
intervention was clinically effective and valuable. One of Phillip’s peers’ mothers said that,
prior to the study, her child had been intimidated by Phillip’s inappropriate behavior at
greeting time. With the implementation of the song, her child would run to school hoping to

arrive before Phillip so that he could participate in Phillip’s greeting routine. Phillip’s
mother reported that she was very pleased by the success of the intervention and requested
further songs for other challenging situations.
A second individualized song to facilitate waiting was written for Phillip. A
transcription of the waiting song is shown in Figure 4.7. The goal of this song was to assist
Phillip learn the concept of waiting. The two measures of rests in measures six, seven, eight,
and nine are meant to encourage the child to wait for two periods of seven beats. The
waiting is rewarded by paying attention to the child in the last line of the song saying, “Now
it’s time for child’s name and me.” Counting more than seven beats can extend the waiting
time. The song was introduced and practiced during circle time in Phillip’s class by using
sign language for “wait,” and different instruments or body percussion to indicate the waiting
beats. A compact disc (CD) recording and transcription of the song was handed out to the
teachers and to Phillip’s mother. Phillip’s teachers and mother were encouraged to use the
waiting song during ongoing classroom routines and during waiting situations outside school
(e.g. while doing groceries). However, no data were collected on this song intervention.
Video Excerpt 4.3. Phillip, his classroom peers, parents and teachers during a song
intervention session (Condition B) of the morning greeting routine.
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Figure 4.7. Transcript of the song ”Wait,” written for Phillip addressing the ability to wait.

Ben. In the majority of the initial baseline and song intervention phases of the
morning greeting routine, Ben entered the classroom independently. Most of the sessions
were accompanied by crying or screaming, and by the behaviors described in chapter 4.3.1.
During the same baseline sessions, Ben only greeted one person with a teacher’s prompt,
while in the initial song intervention sessions, Ben responded to every single prompted
greeting and started to greet peers independently while crying. This performance, however,
was coded as either “prompted response” or “inappropriate response.” As with Phillip, the
farewell part of the song, combined with the unclear departure of the caregiver, was difficult
to understand and handle for Ben. It was not until the formal good-bye was omitted and the
modified song intervention was introduced to him that Ben stopped crying for most of the
sessions and followed three steps of the greeting routine without showing any inappropriate
behaviors. The withdrawal of the modified song intervention resulted in an immediate
decrease in his independent performance, ending at baseline level. When the greeting song
was re-introduced, Ben completed all steps of the modified morning greeting routine
independently and for four consecutive sessions. In addition, the data collected on Ben’s
classroom peers confirmed the informal observations made during the intervention with
Phillip. That is, the implementation of the song intervention changed classmates’ greeting
behavior toward Ben and increased peer interaction. In the initial baseline phase, no peer
greeting occurred. As soon as the song was introduced, Ben’s classroom peers showed an
interest in greeting and interacting with him. However, Ben’s difference in pace and
response, as well as his lack of conventional nonverbal communication (i.e., eye-gaze, facial
expression, and body posture), required some mediation by the children’s classroom teachers.
The peer greeting behavior never went back to the initial baseline level with the exception of
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the twentieth session, during which classroom peers were participating in a spontaneous
dance and movement activity and were not available for greeting. It is especially important
to note that this change was effective by the intervention alone and was not contingent on
Ben’s performance. That is, the greeting song motivated the peers to interact with Ben.
Ben’s performance did not change until the twelfth day of the intervention, yet the peers’
behavior changed on the first day of intervention. Further, during the withdrawal phase,
Ben’s independent behavior decreased whereas the peers’ behavior remained consistent.
Much like the case of Phillip, with Ben there are additional observations related to his
IEP goals that are noteworthy. Ben’s verbal skills increased through his verbalizing the
peer’s names during the morning greeting routine and singing parts of the song during the
intervention and throughout the day. The song intervention evoked a positive view and
piqued the interest of peers toward Ben, which was evident in peer comments and actions.
During the modified intervention phase, Ben’s peers noticed his change and made remarks
such as “He doesn’t cry anymore,” or “He did a great job.” Peer interaction frequently
continued when Ben played a floor drum or a hand drum that was offered to him as a toy to
play with for the last step of the routine. Ben started the day in the childcare program
without crying or screaming. On many days he entered the classroom with a smile on his
face, joyfully jumped up and down, and vocalized while looking for a peer to greet.
Furthermore, the stress level of teachers and parent/caregiver seemed to be reduced due to
the smooth transition of the target children during arrival time.

From the comments and reports by the teachers, parent and caregiver alike, the
intervention was determined a success as well. Ben’s caregiver, who was responsible for the
transition from home to school said: “I think this was perfect for Ben. He had a hard time
leaving me in the mornings, but with the help of the ‘Good Morning Song’ the transition
become much easier for Ben.” After evaluating the intervention and research procedures
with the lead teacher, she came to the following conclusion: “Transitions into the classroom
were stressful for the children, parents and teachers. The ‘Hello Songs’ allowed us to
implement a simple intervention each day. The songs are great and helped all of us
tremendously.”
Video Excerpt 4.4 Ben, his classroom peers, and teachers during a modified
intervention session (Condition C) of the morning greeting routine.
In conclusion, individualized greeting songs matching the subjects temperament and
the demands of the morning greeting routine are effective in facilitating the transition from
home to school, and in enhancing the morning greeting behavior of young children with
autism in ongoing classroom routines. These findings support the proposed strategy to use
songs for smooth transitioning for individuals with autism (Baker, 1992; Cole-Currens, 1993;
Furman, 2001; Gottschewski, 2001; Williams, 1999), and they provide evidence that greeting
songs can be effective in increasing the target children’s independent performance during the
morning greeting time.
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In addition, the greeting song interventions provided a valuable step toward inclusion
for the target children and their families. Teachers, classroom peers and parents of peers had
a more positive attitude toward the target children, as evidenced by their comments and
reports. This replicates the results of earlier findings in which music therapy interventions
increased the social acceptance and improved attitudes of school-aged and preschool children
toward their peers with disabilities in inclusive school settings (Jellison et al., 1984; Humpal,
1991).
The teachers successfully embedded the intervention in the ongoing classroom
routine, even though they did not previously know the greeting songs, nor did they have
formal musical training or experience with music therapy interventions. Additionally, they
had very short training time and ongoing classroom demands to manage. This replicates and
extends earlier studies showing that classroom teachers successfully implemented
interventions related to other disciplines in ongoing activities (Garfinkel & Schwartz, 2002;
Kaiser et al., 1993; Kemmis & Dunn, 1996; Sewell et al., 1998; Venn et al., 1993; Wilcox &
Shannon, 1996; Wolery et al., 2002). In previous studies, however, the interventions were
not based on music therapy principles and guidelines.
Despite their success, teachers were challenged with parts of the musical
characteristics of the songs. For example, in both cases the teachers did not implement the
change in music indicating the good-bye part of the songs (part B of the song). Interestingly,
and perhaps coincidentally, it was exactly this part, that distressed both target children. This
raises the question if the implementation of the change in music signaling the “good-bye”

part would have changed the target children’s performance during this step. No data are
available that suggest that the change in music would have resulted in a change of the target
children’s behavior, and other explanations for the children’s difficulty with this step (e.g.,
the lack of understanding of conventional gestures) might be more likely. Furthermore,
teachers did not explicitly perform musical elements such as expression or change in tempo
and dynamics. The songs were mostly sung in a linear voice with little punctuation. Elefant
(2001) describes musical elements such as tempo, vocal play (sound effects), inner tempo
(accelerando, riterdandos and fermatas), dynamics, rhythmical and melodic patterns and
upbeats as having influence on the song preference and response of girls with Rett
Syndrome. We do not know if these or other musical elements would have an influence on
the response of young children with autism, too. This study did not provide experimental
analysis of the specific mechanisms supporting the treatment effects; the procedure was
based on the assumption that the songs would improve the target children’s morning greeting
routine.
For future clinical applications, it might be more practical to use songs that require
fewer musical skills and/or provide more intensive staff training where specific musical
elements and techniques are mediated. At least for this study, assurance, motivation and
monitoring of the teachers’ implementation of the interventions were needed. Therefore,
prior to, during and after the intervention procedure, ongoing collaborative consultation was
provided. And yet, we do not know whether or not teachers’ implementation of the
intervention would continue or decline over time if they were not supported. Put simply,
there exists no counterfactual against which to compare this component with the intervention.
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This study admittedly has several limitations. For one, only a small number of
participants were involved. This limitation represents an unfortunate –albeit inevitable –
drawback of using the single-case experimental design. In order to understand the
generalizability of the intervention, replication with multiple participants is warranted. Still,
replication and generalization of these findings might be difficult, when the intervention is
only implemented if the skills are useful to the child in the instructional environment and the
vast difference between individuals with autism is taken in account. It cannot be assumed,
based on the results of this one experiment, that these results would be replicable with other
individuals, other settings, or both.
Further more, Ben’s data indicate that the use of the modified intervention
successfully increased his independent behavior during the greeting time routine. But due to
limitations of the experimental design, a strong statement cannot be made about the
effectiveness of the modified intervention alone. That is, because Ben had experience with
the first intervention before the modified intervention, it is not known whether the modified
intervention (without the exposure to the initial intervention) would have yielded a change, or
such an immediate change, in Ben’s level of independent performance. This limitation refers
to the threat to validity commonly known as learning effects.
Another limitation of this study is that we do not know if other songs or interventions
would have been equally or more effective. However, it is important to underscore that it
was neither the purpose of this study to examine the effects of different greeting songs, nor to
evaluate the superiority of greeting songs versus other strategies used for transitioning.

Rather, it was the intent to demonstrate the progress that might be accomplished by young
children with autism through the use of individualized song interventions more generally.
Further study should delve more deeply into specific intervention contours that result in
divergent outcome levels.
Several issues should be addressed in future studies. Future studies should also
investigate the effects of musical elements, such as expression or change in melody, tempo
and dynamics on the behavior of young children with autism. It would also be valuable to
investigate social acceptance of, and attitude changes toward, children with autism in
inclusive childcare programs resulting from music therapy interventions. In order to
understand the generalizability of the intervention, replication with multiple participants is
warranted. Further research is desirable that will provide evidence that music therapy
interventions can be implemented as embedded strategies in childcare settings.
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5. Experiment II: Increasing Independent Performance of a Child with Autism during
Multiple-Step Tasks
5.1 Introduction
The childcare day is not only filled with transitions, but also with many routines,
which are repeated on a daily time schedule. Some of these routines include everyday skills
such as hand-washing, toileting, and cleaning-up. These routines require children to follow a
sequence of steps. “A child with autism typically has significant difficulty organizing and
sequencing information and with attending to relevant information consistently” (Boswell &
Gray, 2003, p. 1). In order to function independently in daily life, children must learn to
understand, remember and perform the sequence of these tasks. Toward this end, strategies
similar to those for transitioning are used to support children with autism in managing
multiple-step tasks successfully. These strategies include: (1) the use of structure and
predictable routines (Bailey & Wolery, 1992; Boswell & Gray, 2003; Trillingsgaard, 1999),
(2) the use of visual cues (Boswell & Gray, 2003; Bryan & Gast, 2000; Fanjul & Ball, 1995;
Quill, 2000; Wheeler, 1998), and (3) songs (Gottscheweski, 2001; Williams, 1996).
Additional guidelines and methods, especially those used for toilet training, are described in
further detail below.
Research and clinical applications show that songs can transmit and be used to assist
children with memorization of a sequence of information (Aasgaard, 1999; Enoch, 2001;
Gervin, 1991; Gfeller, 1983; Jellison & Miller, 1982; McGuire, 2001; Wolfe & Horn, 1993),
and to teach them to manage self-help skills (Michel, 1976; Nordoff & Robbins, 1992).
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Therefore, using songs to cue or prompt a sequence might be a successful way for young
children with autism to accomplish everyday skills. Donna Williams, herself diagnosed as
having autism as a child, used songs to accomplish daily life tasks involving a sequence of
steps. She suggests to use music in the following way: “If someone listens, for example, to
the song Insy-Winsy-Spider, you can use this tune and write some of your words to the
chords of this song and sing simple lessons. The lessons can be anything you wanted to
teach from the different steps involved in going to the toilet to getting out a snack to eat or
having a bath. Things like washing hands, order of dressing, emotional expressions and how
they feel, whatever involves a simple lesson or sequence, can be put to music. Verses can be
added later as the songs are picked up and gradually lessons can be expanded upon”
(Williams, 1996, p. 298).
Hand-washing. Teaching proper hand-washing techniques is part of the National
Health Education Standards and therefore part of the preschool health and hygiene
curriculum (Fanjul & Ball, 1995; Joint Commission on Health Education Standards, 1995;
Squibb & Yardley, 1999). The rationales for hand-washing are to preserve the child’s
personal health, and to promote social acceptance and inclusion by encouraging good
hygiene. Within the daily classroom routine, hand-washing occurs at five key times: before
and after meals, after outdoor play, after sneezing or coughing, after playing with pets, and
after toileting (Education World, 2003; Geiger et al., 2000; Rumfelt-Wright, 2001). Children
with autism frequently have difficulty in managing the multiple steps involved in hand-
washing. The characteristics identifying children as having autism might interfere with the
hand-washing strategies used with typically developing children. Some of the issues

discussed in the toilet training literature for children with autism, but not yet discussed for
hand-washing, might also apply:
• Limited communication skills might interfere with understanding and associating
words, signs or pictures/symbols with the idea of hand-washing.
• Difficulty in organizing and sequencing information might interfere with the
navigation of multiple steps required in hand-washing.
• Sensitivity and unusual reactions to various sensory stimuli, such as smells, texture,
color, temperature or sound, might interfere with the hand-washing process (i.e., fear
of or over-interest in running water, a scented soap, water temperature, etc.).
These issues might contribute to feelings of frustration or anxiety, and be expressed in
inappropriate behavior (Boswell & Gray, 2003; Heffner, 2002; Siegel, 1998, Wheeler, 1998).
Some attention has been given to the steps involved in proper hand-washing
techniques for preschoolers (Rumfelt-Wright, 2001; Geiger et al., 2000; Fanjul & Ball,
1995). Guidelines have been proposed on learning strategies such as singing songs, playing
games, stories, and hands-on practice (Enoch, 2001; Geiger et al., 2000; Spear, 1998). Quite
a few commercial instructional products (videos, recorded music, and illustrated books) are
available on hand-washing (e.g., The American Red Cross, 1996; Ross, 2000; Soap and
Detergent Association, 1990). A large body of research focuses on infection control and
hand-washing habits (Education World, 2003). Few research studies investigated hand-
washing strategies for children with special needs (Quenville, 1980). A study by Kramer
(1978) investigated the effects of a unique song in maintaining hand-washing skills in
preschool children with and without special needs (learning disabilities, Down Syndrome,
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and cerebral palsy). After 10 training sessions in which the song was used, one group
continued to wash their hands without any instruction, the second with music only, the third
with verbal instruction, and the fourth listened to the entire song. Results indicate the entire
song and the verbal instruction proved to be equally effective in maintaining the hand-
washing procedure, whereas no instruction and music alone did not maintain the skills.
Kramer suggested that using songs for repeating daily routines might be more pleasant for
children and staff than giving verbal reminders. However, no studies are available that
compare the effectiveness of strategies used for learning a proper hand-washing procedure
with young children with autism within the context of an inclusive childcare program.
Toilet Training. Besides making the first step and speaking the first word,
independent toileting is a major developmental achievement. The rationales for being toilet
trained are at least three fold: (1) it allows the child more freedom and independence to fully
participate in community activities; (2) incontinence and poor toileting hygiene can
significantly interfere with social acceptance; and (3) it opens options for childcare, school
programs or future residential programs (Bailey & Wolery, 1992; Cicero & Pfadt, 2002;
Gallender, 1980; Heffner, 2002; Wheeler, 1998). Children with autism frequently have
difficulty in managing self-care in toileting and are often confused by the sequencing actions
involved (Dalrymple & Boarman, 1992; Wheeler, 1998). The characteristics identifying
children as having autism might interfere with toilet-training techniques practiced with
typically developing children or children with other disabilities.

• The social interaction deficits might interfere with closeness or imitation involved in
toilet training. Understanding and enjoying reciprocal social relationships and social
reinforcers (e.g., “big boy”) might mean very little or nothing to a child with autism.
• Limited communication skills might interfere with understanding and associating
words, signs or pictures/symbols with the idea of toileting. Children with autism also
might have difficulties expressing their urge or need to urinate or defecate.
• Difficulty in organizing and sequencing information might interfere with the
following of the multiple steps required in toileting.
• Preference for predictable routines and rituals, sameness and restricted interests might
interfere with establishing a new routine (toileting). Although, when toileting is part
of the routine, the insistence on routines might be beneficial for the process.
• Sensitivity and unusual reactions to various sensory stimuli such as smells, texture,
color, temperature or sound might interfere with the toileting process (i.e., fear of or
over-interest in, flushing the toilet is frequently observed in children with autism; a
fluffy rug, a cold tile, or colors in a bathroom might cause over-stimulation or fear).
• Medical conditions might interfere with toileting and need to be identified and ruled
out before toilet training.
General guidelines have been proposed for teaching toileting skills to children with
special needs. The first step in teaching toileting skills is to assess the child’s readiness,
defined as follows: Bladder control for a certain period of time, awareness of both the urge
and the need to urinate or defecate (i.e., desire to remove wet diaper) an ability to sit on the
toilet for approximately five minutes; an ability to imitate actions and follow simple
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directions, skills to communicate needs, basic dressing skills, and respond to positive
reinforcement; and the desire of parents to implement the toileting procedure (Baker &
Brightman, 1997; Bailey & Wolery, 1992; Gallender, 1980; Heffner, 2002; Siegel, 1998).
Furthermore, it is suggested to begin with daytime training rather than nighttime training,
bladder training before bowel training, initiate training in school and at home at the same
time, teach children to communicate their need to urinate/defecate, and teach each steps
involved in toilet training (Bailey & Wolery, 1992, Siegel, 1998).
toileting skills:
There are at least three established methods for teaching children with disabilities
(1) the Scheduled Method, meaning children are taken to the toilet at regular intervals or near
their natural elimination cycles (Bailey & Wolery, 1992; Siegel, 1998).
(2) the Distributed Practice/Improved Schedule Procedure, where baseline data on the
child’s elimination pattern is collected, analyzed and implemented at two identified times
using positive reinforcers. Over time, toileting times are expanded and the need to
urinate /defecate is communicated by the child (Fredericks et al., 1975 as cited in Bailey
& Wolery, 1992).
(3) the Massed Practice/Rapid Method, where self-initiated, independent toileting is
established within a short period of time by increasing the frequency of urinations
(through giving liquid), seating the child on the toilet for a period of time, positive
reinforcement immediately after urination and for staying dry when off the toilet, using
graduated guidance for prompting the child through the single steps of toileting, and
finally a self-initiated toileting by the child while decreasing prompts for the whole

procedure. For accidents, verbal reprimands, positive practice, opportunity to feel the
wet pants, and restitutional overcorrection are used. A urine alarm device is frequently
used with this method (Azrin & Foxx, 1971). Several authors have developed and
studied variations and adapted methods of the rapid method (e.g., Smith, 1979; Ando,
1977).
That said, teaching toilet training skills to children with autism might require different
strategies, considering their broader difficulties. Toilet training needs to be a unique
approach, integrating the individual’s differences. Because the toilet training is a complex
task for children with autism, the starting point might consist of establishing a routine,
including all steps involved in toileting, before expecting the child to use the toilet
independently. In this way, a bathroom routine will be in place when the child with autism is
ready for self-initiated toileting. Boswell & Gray (2003) suggest structured teaching
principles to toilet training children with autism. This technique includes: (a) assessment of
the child’s skills and readiness for scheduled training or for independent toileting; (b)
determining realistic, individual goals and a starting point; (c) task analysis and determining
each steps of the toilet routine; (d) establishing a positive and meaningful toileting routine
that incorporates setting up the physical environment (bathroom) and the communication to
the child (i.e., verbal and visual supported routines using transition objects and pictures for
each step of the routine), including where to go, what to do, and where to go afterwards; (e)
troubleshooting specific problems and making adjustments; and (f) a reward system for
successful accomplishment of tasks. Learning to manage the toileting skills independent
might require several months for children with autism.
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Quite a few commercial instructional products (i.e., video tapes, recorded music, and
illustrated books) are available on general toilet training (Cole & Miller, 1989; Frankel,
1999; Rogers & Judkins, 1997). A small number of research studies address issues related to
toilet training explicitly for children with autism. Two recent studies come from Bainbridge
and Myles (1999) and Cicero and Pfadt (2001). Bainbridge & Myles investigate the use of
priming (Video tape: “It’s potty time,” Howard, 1991), to introduce toilet training to children
with autism. The results indicate an increase in initiation of toileting use and a decrease in
wet diapers when priming was used. Cicero and Pfadt (2001) study the effectiveness of an
adapted version of the rapid method. Their procedure employs a combination of positive
reinforcement, graduated guidance, scheduled training and forward prompting, and
elimination of the restitutional overcorrection. Results indicate that this procedure is a rapid
method of toilet training with generalization to different environments. No study has yet
emerged that uses song as a strategy for following the multiple steps involved in toileting
with young children with autism.
Cleaning-up. Cleaning-up toys and materials is a task requested many times within
the childcare day: after free play periods (e.g., toys), after meals (e.g., plates and cups), after
circle time (i.e., clean up sitting carpets), and after other classroom activities. The rationale
for cleaning-up is at least fourfold: (1) to keep the classroom organized and functional; (2) to
signal the transition to the next activity; (3) to communicate concepts of personal
responsibility; and (4) to promote social skills such as helping skills. Especially for children
with autism, a clearly structured environment is necessary so that the child can function most
independently (Dawson & Osterling, 1997; Marcus et al., 2001; Schopler, et al., 1971).

Children with autism frequently have difficulty in understanding and managing the multiple
steps involved in cleaning-up. The inability to understand the demands of this classroom
routine might cause frustration and confusion, expressed in problem behaviors.
Alger (1984) proposed guidelines on how to signal and structure cleaning-up time,
and quite a few commercial products (recorded music and illustrated books) are available on
cleaning-up (e.g., Anderson, 2002; Bridwell, 1997; Wallance, 2001; Barney & Friends, 1992;
Preschool Education, 2003). Most of the clean-up songs currently employ the
“piggybacking” technique, meaning words are put to a familiar tune. A pre-composed song
frequently used and also suggested by Furman (2001) for cleaning-up with children with
autism is “Clean up!” by Barney & Friends (Barney’s Favorites Vol. 1, 1992). No study has
been found investigating cleaning-up strategies and behaviors of children with and without
disabilities in preschool settings. More specifically, no study has been conducted that
compares the effectiveness of strategies used for the cleaning-up task with young children
with autism in the context of an inclusive childcare program.
The purpose of this study was to evaluate the effectiveness of songs versus lyrics in
increasing the independent performance of a boy with autism, during hand-washing,
toileting, and cleaning-up. These multiple-step tasks were chosen because the target child
needed to expand his skills in these areas. Preliminary observation indicated that the target
child was very responsive to music. When sung to he transitioned and followed parts of
multiple-step tasks, whereas in the absence of the song, he demonstrated inappropriate
behaviors.
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5.2 Research Questions
One purpose of this study was to evaluate the effectiveness of songs as structural
prompts that increase independent performance for a young child with autism during
multiple-step tasks within classroom routines, and specifically, to evaluate whether the
musical presentation of the sequence is more effective than its verbal counterpart. Another
purpose was to determine whether the classroom teacher can learn basic principles of music
therapy and implement a song intervention. The specific research questions were as follows:
(1) Does the use of songs increase independent performance for a young child with
autism during multiple-step tasks?
(2) Is the use of songs more effective in improving skills to manage multiple-step
tasks than the verbal presentation of the sequence?
(3) Can a classroom teacher learn basic principles of music therapy, and as a result,
5.3 Method
implement song interventions in classroom routines?
5.3.1 Participants
The participant in this study was one young child with autism (n=1), and his
classroom teacher (n=1).
Target Child. Andy was a 3-year, 2-month-old European-
American, enrolled in the childcare program for eight months
prior this study. An external agency had diagnosed him with
ASD using the diagnostic tools describe in chapter 3. The child

was selected for participation in this study on the suggestion of his classroom teacher and
parents based on his diagnosis of ASD, tremendous interest in, and positive response to,
singing, and his difficulties with multiple-step tasks such as hand-washing, cleaning-up
and toileting. Andy was a lively and humorous child with strengths in early academic
concepts. However, he was functioning on the Childhood Autism Rating Scale (CARS)
in the mild to moderate range on the autism spectrum. Andy’s communication was
limited and he demonstrated a lack of interest in others. Sometimes he exhibited self-
stimulating behaviors such as hand flapping and he needed assistance with managing
several daily activities. Andy used the Picture Exchange Communication System (PECS)
(Bondy & Frost, 1994) to communicate during mealtimes, and simple objects were used
as visual cues (e.g., a bottle of soap to cue hand-washing) for transitions in the daily
classroom routines. Andy was able to say quite a few words to label objects when they
were in sight or in direct imitation of an adult. When he could not get his needs
expressed, he became frustrated easily and exhibited behaviors such as whining, fussing,
jumping up and down, or pulling on adults. Andy also had some difficulty attending to
language unless it involved a familiar song or physical routine. When enjoying a game or
activity, Andy accepted other children playing with him or nearby. He watched his peers
and sometimes imitated their play. Often, though he liked to play on his own with his
preferred toys (puzzle, magna doodle, books, shape sorters, peg boards).
Andy’s favorite things were to identify letters, numbers, shapes, and listen to music.
He knew the alphabet, was able to recognize all the uppercase letters, and he had already
identified numbers before age two years. Andy received speech/language and occupational
therapy services while in the classroom, and weekly external speech language services.
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Singing was employed by his teachers and therapists as a motivator to use words and
actions when he wanted to repeat an activity he enjoyed. For example, he had to say
“wheels” to ask for a repetition of the song ”The wheels on the bus go round and round”
(Traditional). To improve his language skills, songs like “Swing low, sweet chariot”
(American traditional) were used to work on sounds, imitation, and direct language
production during pauses in singing. Activity songs such as “Ring around the rosy”
(Traditional) and “Row, row, row your boat” (Traditional) were used to create opportunities
to interact with peers. Andy learned songs sung in school quickly, and repeated them at
home with gestures. He seemed to love to sing, listen and dance to music.
His classroom teacher described him in the following way: ”Andy really responds
well to music. He makes eye contact with me as soon as I start a melody. Singing songs
with him during major transitions in the classroom helps him to understand what to do next.”
She also noticed that Andy would stiffen his legs and body, flap his arms, whine, try to
escape and avoid transition if she just used words in the same situation. Andy’s mother
reported that the family uses music with Andy for nap and nighttime, for long trips in the car
and when he seems to be irritable. She observed that music calms him, and redirects him
from unwanted behavior.
Andy tended to have difficulties with transitioning and managing multiple-step tasks
during classroom routines. With music, Andy transitioned smoothly to the next activity, but
could not manage the required steps of routines such as hand-washing, toileting, and
cleaning-up independently. These three multiple-step tasks were chosen for an intervention,

ecause of the teacher’s and parent’s opinion and interest in improving the target child’s
hand-washing skills, his readiness to begin toilet training, and increasing his independent
performance during the classroom’s cleaning-up routine.
At the time of the study, washing hands throughout the day was an already familiar
routine for Andy. He transitioned to the sink easily when singing to him, but was not able to
follow the sequence of hand-washing independently. He was able to rub his hands under the
running water when prompted by his teacher. All other steps were performed by the teacher
or by using the hand-over-hand technique. The classroom teacher used the familiar song
“Row your boat” (American traditional) and changed the words to “Wash, wash, wash you
hands, gently in the sink, scrubbed them, scrubbed them, scrubbed them, scrubbed them, ‘til
they’re nice and clean” to motivate Andy to rub his hands under the running water.
Andy had started toilet training four weeks before the study. His teacher started to
prompt him to transition to the bathroom on a scheduled time. No task analysis of the steps
of toileting had been determined yet. For transitioning to the bathroom, the teacher
experimented with a familiar tune and added novel words saying, “Let’s go to the potty,” and
used a diaper as transition object. Andy wore diapers and had urination accidents on a daily
basis. He met some of the prerequisite skills for toilet training, including the ability to sit for
a few minutes, to imitate, and to follow simple directions. What is more, he responded
favorably to music. His dressing skills were very low. His mother was requesting a “potty
song,” to accomplish the new task. A toilet training video titled “It’s potty time” (Howard,
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1991) was given to her prior the study. No sophisticated song following the single steps of
toileting was found.
At the time of the study, cleaning-up at different times throughout the childcare day
was also a readily familiar routine for Andy. He started to clean up his toys / materials, when
the already familiar, pre-composed cleaning-up song was sung to him. If the teacher did not
sing, he did not engage in cleaning-up, or he demonstrated inappropriate behaviors when
assisted to complete the task.
Classroom Teacher. Andy’s lead teacher participated in this study. She had
bachelor’s degree, was certified in Early Childhood Education, and had taught young
children for 3 years. She had also participated in a continuity of care study for three years,
meaning all children, except Andy, had been in her classroom since infancy. The teacher had
no prior experience with music therapy interventions. She participated in the study based on
her schedule and classroom activities (i.e., teachers’ start times are staggered so that the
entire childcare day has coverage).
Classroom Peers. In addition to the target child, there were six other children who
were enrolled in the classroom. The classroom peers were between two and three years of
age. Peers included both males and females from different ethnic groups. Four of the
children were typically developing and one of the classroom peers had Pfeiffers Syndrome.
The classroom peers were not part of the study, but participated in the described multiple-
step tasks simultaneously as part of the classroom routine.

5.3.2 Setting
All experimental sessions took place in the target child’s classroom, where the
curriculum philosophy followed the same Developmentally Appropriate Practice (DAP)
(Bredekamp & Copple, 1997) as in Experiment I. Andy’s classroom was divided into in
different play areas and contained corresponding toys and materials (Harms, Clifford, & Cryer,
1998; Marcus et al., 2001) similar to Experiment I. There was a food counter including a sink
with a soap dispenser and a paper towel holder. A stepping stool was placed before the sink for
the children to reach the sink and tap. A huge garbage can was located next to the sink. A
bathroom designed for children was accessible from the classroom. It contained a small step
(made out of two duct-taped phone books) to reach the toilet sit more easily, a sink, a mirror, a
garbage can, and a chair for teachers.
Hand-washing occurred several times during the childcare day: before and after
meals, after messy activities (i.e., painting at the easel or outdoor play), after sneezing or
coughing, and after toileting. Before breakfast at 9:15 am, all children were prompted to
wash their hands. Each child went to the sink and waited for his or her turn to wash his or
her hands. The child climbed up the stepping stool, turned the water on by manipulating the
handle, got soap from the soap suspender, rubbed her/his hands against each other, rinsed the
soap off under the running water, and turned the water off, dried her/his hands by using a
paper towel, which was thrown in the garbage can afterwards. A sequence of pictures
showing the multiple steps of hand-washing was attached to the wall behind the water tap
and visible to all children. After finishing the hand-washing procedure the child climbed
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down the stepping stool, went to the breakfast table and sat down in her/his place, marked by
a picture of him or herself.
All of the children in Andy’s classroom went to toilet on scheduled times throughout
the day and whenever necessary. Every child went to the bathroom after breakfast.
Depending on the child’s self-care skills, support was offered by the teachers to successfully
manage the multiple-steps surrounding toileting. The procedure used for toilet training was
to undress, sit on the toilet, urinate, wipe, dress, flush, and wash hands. For children with
special needs part of the toilet training was to get used to the routine more generally and to
every single step involved in the task, even when a diaper was still needed throughout the
day.
The classroom curriculum allowed free play after breakfast and before circle time.
Children engaged in different play areas by themselves or with others. To cue the children to
finish their play activity and transition to circle time, a song for cleaning- up toys and
materials was used. Each child was expected to put the toys and material they used back in
the designated play area independently. The song was sung as long as it took to clean up.
The daily classroom schedule and predictable routines were set in place to allow the
target child to function more independently during classroom routines (Marcus et al., 2001;
Schopler et al., 1971). As in Experiment I, students, observers and visitors were occasionally
in the classroom or observing behind the one-way mirror.

5.3.3 Materials
Andy was assessed on his ability to accomplish the sequence of steps required for
each task. Each song used for each task was adapted to his skills, needs and learning goals.
The already pre-existing routines and songs used by the teachers within the classroom were
respected and integrated into the intervention. Therefore, a combination of transition and
multiple-step tasks, and familiar and novel songs were used.
The exact material used for this study was as follows: (1) three different transition
objects to initiate each multiple-step task; (2) a familiar, pre-composed song with
individualized lyrics for hand-washing; (3) an individually composed song for toilet training;
and (4) a familiar, pre-composed song for clean up. Each is described in greater detail
below.
(1) Transition objects. For hand-washing, a bottle of soap was used to cue Andy to
transition to the sink. Additionally, pictures showing seven steps of hand-washing, published
by the North Carolina Department of Human Resources, Division of Child Development
(Fanjul & Ball, 1995) were attached to the wall behind the sink. For toilet training, a diaper
was used to cue Andy to transition to go to the potty. For cleaning-up, the toy in use by
Andy functioned as a cue.
(2) Familiar, pre-composed song with individualized lyrics for hand-washing (Task
#1). The pre-composed song “Row your boat” (Traditional) was used for hand-washing,
because the duration of one verse matched the suggested time of 10 to 15 seconds necessary
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to kill germs. The classroom teacher applied this song for rubbing Andy’s hands by using
the “Piggybacking” technique; meaning words of a song are altered to contain the desired
information (Brownell, 2002). For the intervention, the following seven steps were described
within the lyrics of the song: (1) Turn the water on, (2) Wet your hands, (3) Get the soap, (4)
Wash your hands, (5) Rinse your hands, (6) Turn water off, and (7) Dry your hands. Audio
Excerpt 5.1 gives an example of the song and altered lyrics, sung by Andy’s lead teacher.
Audio Excerpt 5.1. Recording of the first part of the hand-washing song, sung by
Andy’s classroom teacher.
(3) Individually composed song for toilet training (Task #2). For toilet training, a
unique song was written, matching the target child’s temperament and conveying the demands of
the multiple steps for Andy’s toilet training. The intention of the song was to ease the transition
to the bathroom, and to increase independent performance during toileting. The toileting routine
was developed in collaboration with the classroom teacher, and reflected an adapted version of
the procedure used with the target child’s classmates. The lyrics of the song focused on each
step of the routine and were composed as follow:
1. Get up (get up from play; diaper uses as cue to transition to the bathroom)
2. Walk to the toilet
3. Climb (climb up a step to the toilet)
4. Pants down (lower the pants)
5. Sit down (sit down on toilet)
6. Pee (urinate)

7. Get up (get up)
8. T-Shirt up (participate in re-dressing, while teacher wipes him off and puts the
diaper on)
9. Pants up (re-dress)
10. Flush (flush the toilet)
The ten described steps were presented in the unique song “Let’s go potty,” as
outlined in Figure 5.1. The verses of the song reflect each single step of the routine in the
order of the toileting procedure. The refrain emphasized the major steps of toileting (go to
toilet, urinate and flush) and was repeated when more time was needed to accomplish the
step. Since music was one of Andy’s favorite things, the song itself functioned as a
motivator and a reinforcer. The musical style used for the refrain (swing) and the
accompanying activity (hand clapping) provoked positive effects on the target child’s
behavior in previous situations. The statement in the lyrics “Andy knows how,” reflects the
teacher’s belief in the child’s ability to accomplish the task. The Latin style used for the
verses stands in contrast to the refrain, and gives the piece a certain drive that reflects a
somewhat unusual way to sing about toilet procedures. The toilet training song “Let’s go
potty,” was recorded on a CD with the classroom teacher on vocals. Additionally, a song
transcription was handed out to both the teacher and to parents.
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Audio Excerpt 5.2. Recording of the song “Let’s go potty,” featuring the classroom
teacher on vocals.

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Figure 5.1. Transcript of the song ”Let’s go potty,” written for Andy, addressing the
demands of his toileting routine while in the classroom.

(3) Familiar, pre-composed song for clean up (Task #3). The pre-
composed song “Clean-up!” by Barney & Friends (Barney’s Favorites
Vol. 1, 1992) was used for cleaning-up toys and material after play
activities. Barney, the purple dinosaur in the picture is a children’s
character, broadcasted by U.S. public television. The “Clean up!”
song is compiled from the Barney & Friends series. This song was already an implemented
classroom routine for cleaning-up prior the study. The lyrics of the song read:
“Clean up, clean up! Everybody everywhere!
Clean up, clean up! Everybody do your share!”
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The lyrics of the song do not describe the steps of cleaning-up or define how many things
need to be put away. In the already established classroom routine, children were expected to
get up from play or an activity, pick up their toys or material, put them away and go where
directed by teachers.
5.3.4 Procedure
Audio Excerpt 5.3. Recording of the first part of the cleaning-up song, sung by the
children of the FPG childcare program.
Experimental sessions occurred Monday to Friday, one time daily for each multiple-
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at 9:30 am, and clean up before circle time at 9:55 am. As elsewhere in this inquiry, the
observation was based on the subject’s presence and the availability of the classroom teacher.
Staff Development Activities. The goals and procedures of the intervention were
identified and discussed with the classroom teacher. The unique song for toilet training was
developed and recorded in collaboration with the classroom teacher. The CD and transcribed
music was given to the teacher and parents. Specific instructions regarding how to involve
and prompt the child during the intervention was discussed with and demonstrated to the
teacher prior to the study. It involved the following topics:
• how to cue the child with different objects to transition to the multiple-step task
by walking toward the child approach his physical level and show him the object;
• how to sing the songs or speak the words during the multiple-step tasks by using
an engaging voice and facial expression, and looking at the child;
• how to prompt the target child, and how much support to give by singing or
saying each step, pointing to the next step, then using the hand-over-hand
technique; and
• how to follow the target child’s tempo and give him enough time to respond to
each step by pausing or slowing down in the music.
During the intervention, ongoing collaborative consultation was provided.
Song Procedure. In the song procedure (Condition A), each particular song for the
three selected multiple-step tasks was sung to the subject by the classroom teacher.

Task #1: Hand-washing. The already established and familiar routine for hand-
washing was kept and extended. As prior to the study, the subject was prompted with a
bottle of soap, accompanied by his teacher singing to him “ wash, wash, wash your hands,
wash your hands right now, lalala lalala lalala la, wash your hands right now,” as
demonstrated in Audio Excerpt 5.1. The subject transitioned to hand-washing by walking to
the sink. The experimental session started as soon as the subject climbed up the stepping
stool to reach the sink and was ready to manipulate the handle to turn the water on. The
teacher started to sing about the first step of the hand-washing procedure which was: “Turn,
turn, turn it on, turn the water on, lalala lalala lalala la, turn the water on.” As the song
proceeded, the teacher sang about the next steps of hand-washing, which was wet one’s
hands (step 2), get the soap (step 3), wash one’s hands (step 4), rinse the soap off (step 5),
turn the water off (step 6) and dry one’s hands (step7). For step 4, the words remained the
same as in the routine established prior to the study.
Task #2: Toilet training. The teachers and parents used the scheduled method and
structured teaching principles to toilet-train Andy. The song “Let’s go potty” was used as a
structural prompt to signal each step of the toileting routine. Since task #2 was a fairly new
to Andy, and since an established routine had been never introduced to him before, the
transition to the bathroom was included in the intervention. The experimental session started
as soon as the subject was prompted with a diaper accompanied by his teacher singing to him
“(Teacher’s name) brings the diaper, what does this mean …” as demonstrated in Audio
Excerpt 5.2. The subject got up (step 1) and transitioned to the bathroom (step 2). Thus, as
the song proceeded, so too did the further steps of the toileting routine. The next steps of
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toileting routine were climb up the step (step 3), un-dress (step 4), sit down on toilet (step 5),
urinate (step 6), get up from toilet bowl (step 7), assist teacher by holding shirt up while she
wipes him off and puts his diaper on (step 8), dress up (step 9), and flush toilet (step 10).
Task #3: Cleaning-up. The already-established and familiar routine for clean up was
kept. The subject was prompted with the toy or material in use for free play (e.g., bear cubs)
to start to clean up, accompanied by his teachers and class room peers singing the “Clean up”
song (Barney & Friends, 1992). The experimental session started as soon as the teachers
started the song. While singing the song, the subject was expected to manage the following
six steps: Get up and get ready to clean up (step 1), pick up toy/material (step 2), put it away
(step 3), pick up a toy/material (step 4), put it away (step 5), and go where directed by
teacher (step 6).
Lyric Procedure. In the lyric procedure (Condition B), the conditions were similar to
the baseline conditions. The same steps for each task were used. The only change between
the song procedure and the lyric procedure was the withdrawal of the music. Each single
step was verbally spoken twice for each step of the routines.
5.3.5 Experimental Design
An alternating treatment design (ATD), replicated across three tasks, was used to
evaluate the effectiveness of two different interventions (songs versus spoken word) in a
single subject. In an alternating treatment design, two or more interventions rapidly alternate
in a systematic order. The number of observation days for each intervention should occur

equally. The different effects of the interventions can be observed by comparing the
subject’s performance under each of the conditions. If a consistent difference in the trend
and/or level of data occurs, superiority of one treatment over another is demonstrated. The
advantage of this single-subject research design is the rapid comparison of the efficacy
between two interventions (Alberto & Troutman, 1995; Barlow & Hayes, 1979; Holcombe,
Wolery & Gast, 1994; Tawney & Gast, 1984 ). Because the child was leaving the childcare
program two months from the initiation of the study, this design allowed collecting data and
evaluating effects quickly.
In Experiment II, a Song intervention (Condition A) was compared to a Lyric
intervention (Condition B). The Conditions A (songs) and Condition B (lyrics) altered day
by day and were replicated over three tasks. The alternation of the treatment order replicated
across tasks was implemented to minimize any learning or order effects associated with
receiving the song intervention (Condition A) or lyric intervention (Condition B) first. The
treatment order for each task was as follow: Task #1 (hand-washing) A-B, Task #2 (toilet
training) B-A, and Task #3 (clean up) A-B. The Song Procedure (Conditions A), followed
the demands of the three selected multiple-step tasks by using songs. The Lyric Intervention
(Condition B), followed the demands of the three selected multiple-step tasks by using words
only. Data collection occurred over two months.
5.3.6 Measurements
In Experiment II, several measurement procedures and response definitions applied.
Essentially six categories of behaviors for each multiple step task were measured through
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direct observation using event recording. That is, data were collected as the target child
performed each step of each task (hand-washing, toilet training, cleaning-up). Data were
recorded during Condition A and B (song intervention, lyric intervention) when the subject
arrived to school before the transition to breakfast has started; and the classroom teacher was
available.
Data were collected by direct observation once a day on hand-washing before
breakfast, toilet training after breakfast, and clean up before the morning circle time. The
observation time started for Task #1 (hand-washing) as soon as the target child was ready to
manipulate the handle to turn the water on and his teacher started to sing or said “turn the
water on.” For Task #2 (toilet training) the observation time started as soon as the subject
was prompted with a diaper to transition to the bathroom and the teacher sang the song or
said ”Get up.” For Task #3 (cleaning-up) the observation time started as soon as the teacher
sang the clean up song or said “clean up.” Data collection ended as soon as the teacher went
through all the steps of each task. Some of the sessions were videotaped with a Panasonic
AG-195 Camcorder for reliability purposes, then analyzed afterwards. The event recording
was employed based on the observers judgment about the target child’s behaviors in each
step of each task, and on the results the observer recorded for each step and each task on a
specially designed data sheet.
The definition of the categories for each task were as follows:
• Did it was recorded when the subject performed the action by himself. His
teacher did not need to (or did not) provide any support that helped the subject to
perform the target behavior. It was an independent performance of the child.

Appendix B.
• Did not do it was recorded if the subject did not perform the correct step or
needed to be prompted more than once.
• Did it with a prompt was recorded if the subject responded correctly, but only
after receiving a physical prompt (i.e., the teacher put her hand on the subject’s
elbow in order to facilitate a step) to do so. Visual prompts (e.g., soap bottle,
diaper and toy/material) were not recorded as a prompt. After the first time
through the song, or after two times saying the step, a prompt could be made. If
the subject needed to be prompted more than one time, it was evaluated, as “Did
not do it.”
• Negative Verbalization
o Yes was recorded if the subject displayed any verbal behavior that was not
appropriate. This included screaming or whining.
o No was recorded, if the subject displayed appropriate verbal behavior.
• Escapes were recorded if the subject displayed any physical behavior that was not
acceptable. This included running away, flopping to the floor, or pulling away.
• The number of times he did any of the negative or positive verbalizations was
counted.
• Skipped the part was recorded, if the subject or his teacher skipped a step (e.g. the
subject was already “up” or “go where directed by teacher” was not requested).
These categories were coded for each of the steps of each multiple-step task.
Additionally, field notes were recorded on the bottom of the data sheet, as shown in
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5.3.7 Reliability
Interobserver agreement data were collected on the subject’s performance by an
educational specialist consultant, and by the investigator, for each multiple-step task and
during both conditions. Agreement between the scores from the two reliability observers was
calculated prior to the reliability data collection phase by using videotaped segments from
previously evaluated sessions.
Reliability checks were carried out on an average of 44.7% of total observations
within each phase and for each multiple step task. Two coders coded videotaped segments
for each target behavior. Interobserver agreement levels for each code category were
calculated by summing the number of agreements (defined as the same coding interval) and
dividing the number by sum of agreements plus disagreements and multiplying by 100.
5.4 Results
5.4.1 Interobserver Agreement
Interobserver agreement data on the subject’s performance were collected in 44.7%
for all multiple-step tasks. Reliability data showed that observers agreed on the participant’s
hand-washing performance in 98.5% (range: 92.8% - 100%) of the trials, on the toilet
training performance 93.8% (range: 85% - 100%) of the trials, and on the cleaning-up
performance 94.8% (range: 79.2% - 100%) of the trials. The overall interobserver agreement
was 96% (range: 79.2% - 100%) of the trials. Table 5.1 gives a summary of the interobserver
agreement.

Table 5.1. Interobserver agreement over Task #1, #2, and #3.
Multiple-step tasks InterobserverAgreement in %
Task #1 98.5
Task #2 93.8
Task #3 94.8
Overall 96
5.4.2 Outcome Data
Results of this study indicate that the target child’s number of independent steps
increased for each condition and for each multiple-step task. The positive effects of the
intervention were higher for hand-washing and clean up than for toileting. The use of
song was more effective in improving the target child’s skill for hand-washing and clean
up than for the toileting task. There was a significant difference between the song
intervention and the lyric intervention for Task #3 (clean up).
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Hand-washing. Andy’s hand-washing performance was observed a total of 17 days: nine
days for the song intervention and eight days for the lyric intervention alternating day by day.
The top panel of Figure 5.2 shows the number of independent steps of the hand-washing routine
completed correctly and independently by Andy in both conditions of the study. In the song
intervention condition, Andy’s performance was quite constant and on a high level. On the
majority of days, Andy completed five steps of the seven-step routine independently. Except on
day one and day eleven, he only performed three steps, and on day nine he performed six steps of
the routine. The steps Andy completed independently were not predictable (i.e., some days he

150
turned the water on, on others he completed other steps of the routine). In the lyric intervention
condition, Andy’s performance increased steadily but started on a lower level than the song
intervention condition. Initially, he completed two steps independently, but after ten days of
intervention, Andy’s performance was at the same level as the song intervention condition and
appeared consistent as evidenced by three consecutive sessions with five independent steps. On
the last day of the lyric intervention condition, his performance dropped to four independent
steps.

Number of Independent Steps
Alternating Treatments
7
6
5
4
3
2
1
0
Song Lyrics
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
Days
10
0
0 1 2 3 4 5 6 7 8 9 10 11
6
Days
Figure 5.2. Number of independent steps correctly performed by Andy for hand-washing, toilet
training, and cleaning-up.
9
8
7
6
5
4
3
2
1
5
4
3
2
1
0
0 1 2 3 4 5
Days
6 7 8 9 10
Hand-washing
Toilet Training
Cleaning-up
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Toilet Training. Andy’s independent toileting performance was observed a total of 11
days: six days for the lyric intervention and five days for the song intervention alternating day by
day. The middle panel of Figure 5.2 shows the number of independent steps of the toilet training
procedure that Andy completed correctly and independently in both conditions of the study. In
both conditions, little change was observed. Andy’s independent performance ranged from three
to five independent steps out of the 10-step routine. The steps Andy completed independently in
both conditions were mostly walking to the bathroom, sitting down, and getting up from the
toilet bowl. In the lyric intervention condition, Andy’s performance was slightly higher and
more stable than the song intervention condition. The song intervention condition was quite
variable and decreased over time.
Cleaning-up. The bottom panel of Figure 5.2 shows the number of independent steps
of the clean up routine that Andy completed correctly and independently in both conditions
of the study. Andy’s cleaning-up performance was observed a total of 10 days: five days for
the song intervention and five days for the lyric intervention alternating day by day. In the
song intervention condition, Andy’s performance was very consistently on a high level. In
all of the sessions Andy completed four steps out of the six-step routine independently. The
steps Andy completed independently were “pick up a toy/material” and “put it away,”
completing these two steps twice. In the lyric intervention condition, Andy initially had one
independent response, which was “put it away.” His independent performance was variable,
but increased to song level (four steps). However, immediately afterwards it dropped to two
independent steps, which were “pick up something” and “put it away.”

5.5 Discussion
The major purpose of the presented study was to evaluate the effectiveness of songs
as structural prompts to increase the independent performance for a young child with autism
during multiple-step tasks within classroom routines, and to evaluate whether the musical
presentation or the verbal presentation of the sequencing was more effective. Another
purpose was to determine whether or not the classroom teacher could learn basic principles
of music therapy and implement a song intervention.
From this study a series findings is warranted. Prior to the implementation of the
routines developed for the targeted multiple-step tasks, Andy had difficulties managing the
sequences required for hand-washing, toileting and cleaning-up independently. As
statistically claimed, the implementation of either form of the structured routines was
successful in increasing the target child’s independent performance. Nevertheless, the song
intervention was more effective than the lyric intervention for the hand-washing and
cleaning-up procedures, whereas for toileting the lyric intervention was slightly more
effective than the song intervention. As for the child’s positive learning progress, it can be
affirmed that the teacher effectively embedded both forms of the presented sequencing in the
ongoing classroom routines. Accordingly, it can be concluded that the teacher was able to
learn basic principles important to music therapy and successfully implement the song
interventions.
The results of the multiple-step task hand-washing show that Andy’s independent
performance increased during both conditions. Learning occurred as soon as either form of
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the routine was implemented. In the beginning, of the study Andy only accomplished one
step out of the routine independently (rubbing his hands). As the intervention progressed
Andy learned each step of the hand-washing routine, yet he did not practice them every day
or in a row. Overall Andy performed 62.2% of the hand-washing procedure. Particularly in
the beginning of the study the song intervention produced greater independent performance
(M= 66%) than the lyric intervention (M=57.1%). Over time, Andy became occupied by
playing with the running water, which distracted him from finishing the sequencing. In both
conditions the classroom teacher’s prompting was necessary to engage him in the next step of
the routine (turn water off). This observation is consistent with the reports from Boswell and
Gray (2003), which describe the excessive interest in running water during toilet flushing in
children with autism. For future clinical application, this step might need more attention and
support by teachers.
However, the results of this study confirm the effectiveness of one proposed learning
strategy which suggests singing songs for memorizing and structuring the hand-washing
routine as practiced in inclusive childcare settings (Enoch, 2001; Geiger et al., 2000; Spear,
1998; William, 1996). They also replicate earlier studies in which music was used to assist
individuals with memorization of sequences of information (Gfeller, 1983; Jellison & Miller,
1982; Wolfe & Horn, 1993) and extend previous studies showing that a pre-composed song
with individualized lyrics can be effectively used with children with autism to accomplish the
hand-washing task in ongoing classroom routines.

In spite of the short intervention phase (11 days), Andy made some progress in
learning parts of the toileting procedure as evidenced by the data. Andy learned and
performed all steps of the toileting routine, except step eight (assisting the teacher to re-dress
by holding his shirt up). During both conditions he performed a maximum of five steps of
the ten-step toileting routine at once. Overall, Andy learned 35.5% of the toileting
procedure. The lyric intervention produced a slightly greater independent performance
(M=38.2%) than the song intervention (M=32%). The complexity and novelty of both the
toileting procedure and the unique song might have been overwhelming for Andy. This
replicates earlier observations claiming that children with autism are often confused by the
sequencing actions involved in toileting (Dalrymple & Boarman, 1992; Wheeler, 1998), and
the novelty of songs (Brownell, 2002). The results of this study support the premise that
toilet training using the scheduled method and structured teaching approach might require
several months, particularly for children with autism (Boswell & Gray, 2003; Heffner, 2002;
Siegel, 1998, Wheeler, 1998).
In addition, the ATD used to evaluate whether the song intervention or lyric
intervention was more effective might have interfered with the child’s learning process. It
might have been confusing for Andy that the song was sung on one day and not on others.
Boswell and Gray (2003) strongly suggest using a predictable routine when toilet-training
children with autism. The predictable routine was only partly kept by following the same
sequence, but the presentation of the sequence (song-lyrics) alternated daily. An A-B-A-B
withdrawal design might have given clearer information on whether songs as a structural
prompt are more effective than the verbal presentation of this fairly novel routine and song.
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However, the ATD was used because it is an effective and rapid means of evaluating the
superiority of one treatment over another (Alberto & Troutman, 1995; Barlow & Hayes,
1979; Holcombe, Wolery & Gast, 1994; Tawney & Gast, 1984). This research design was
also chosen for the convenience of completing this project – that is, limited time available,
due to Andy’s impending transitioning to another school district.
As suggested in the literature (Bailey & Wolery, 1992; Boswell & Gray, 2003), this
intervention established an individualized toileting routine for Andy. It can be seen as a
starting point for his toilet training. This way, a bathroom routine will be in place when
Andy is ready for self-initiated toileting. For future implications it might be useful to
approximate more time, follow a steady routine, and to use a familiar song or practice the
unique song prior to the intervention with the target child to produce spontaneous and
frequent song recall.
Singing the cleaning-up song (Barney’s Favorites Vol. 1, 1992) clearly resulted in
higher independent performance (M=66.6%) than the verbal presentation of the sequencing
(M=36.7%). In all of the sessions, Andy completed four steps of the six-step routine
independently. Overall, Andy performed 51.7% of the clean up procedure. It should be
noticed that step 1 (“Get up!”) and 6 (“Get up and go to where the teacher wants him to go”)
almost never occurred. The reason for that was two fold: (1) most of the time Andy was next
to the area where his toys belonged and did not have to get up in order to clean them up, and
(2) his teacher never asked him to go anywhere after cleaning-up because the class was
waiting for the arrival of two other classmates before starting circle time activities.

Therefore, Andy accomplished all steps his teacher expected him to do for cleaning-up when
singing to him.
The results of this study confirm the effectiveness of the clinical use of songs for
cleaning-up (Alger, 1984; Furman, 2001). As the results of the first task, these findings are
similar to those in earlier research suggesting the use of songs for the memorization of
sequences of information (Gfeller, 1983; Jellison & Miller, 1982; Wolfe & Horn, 1993).
However, previous investigations have not examined the use of cleaning-up songs with
children with autism, nor were the studies embedded in an inclusive preschool program.
Video Excerpt 5.1. Andy performing the multiple steps included in cleaning-up
during lyric intervention and song intervention.
In summary, the multiple-step task cleaning-up, represented by a familiar pre-
composed song (Barney’s Favorites Vol. 1, 1992) and an already established routine was
most efficient in accomplishing the task. The multiple-step task hand-washing, which was
combined with a familiar, pre-composed song and individualized lyrics (“Row your boat”
with words altered to hand-washing), was more efficient than the verbal presentation of the
routine. The multiple step task toileting, which was combined with a novel song (“Let’s go
potty!” by author) and a novel routine was less efficient than the verbal presentation of the
routine. These findings are to some extent similar to those reported by Wolfe and Horn
(1993) who investigate the impact of combining spoken and sung stimulus input using
familiar and unfamiliar songs on typically developing preschool students. Results indicate
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that familiar and sung material promotes greater learning than unfamiliar songs or the spoken
word. Unlike Wolfe and Horn’s (1993) study and Experiment I, the unfamiliar song was less
efficient than the verbal presentation of the routine. However, it can be concluded that the
use of more familiar material promoted greater learning and overall the song interventions
were more effective in accomplishing the multiple-step tasks than the lyric interventions. For
future implications it might be more useful to select familiar songs and/or melodies, or
practice a new song prior to clinical application with the target child. In this way, the effects
of the novelty of a song can be eliminated and spontaneous and frequent recall in desired
situations can be given.
As in experiment I, here too there arose several salient findings above and beyond
those flowing from the main questions posed. During the intervention Andy started
unexpectedly speaking in two-word sentences. As a result, every so often he used the verbal
praise (e.g., “good job”) when accomplishing a multiple-step task. Andy repeatedly sang
parts of the song or clapped his hands. As reported by the classroom teacher prior to the
study, transitioning from one activity to an other went more smoothly, meaning Andy cried
less and transitioned better when sung to. Classroom peers often sang along with the songs
and participated in the routines as well. The participating classroom teacher summarized the
success of the intervention in the following way: “I have enjoyed doing this study, because it
has brought more structure to our routines. I believe it has made Andy understand what he is
doing at each step and what will come next. He loved to sing along, too.”

From this study, the following conclusions can be drawn: First, songs can be
effective for sequential learning for children with autism within inclusive classroom routines.
Secondly, as in Experiment I, the teacher successfully implemented the song intervention, in
spite of the short amount of training time, the novelty of implementing music therapy
interventions, and the demanding classroom setting. However, closer analysis indicates that,
in challenging moments (e.g., a large number of observers in the classroom), the teacher
would give prompts earlier than at other times. In any case, the teacher understood the
principles of music therapy and accurately implemented the procedures practiced during staff
development activities. Third, the song intervention was easily implemented by the teacher
within the daily classroom routine and was not more time-consuming than giving verbal
prompts. Fourth, as previously suggested by Kramer (1978) and Brownell (2002), using
songs for repeating classroom routines might be more pleasant and motivating for children
and staff than giving verbal reminders throughout the childcare day.
As with the previous study, this investigation has limitations. There are limitations
imposed by the experimental designs used. As mentioned earlier, the lack of consistency
within each condition when applying the ATD might have interfered with Andy’s leaning
progress. Additionally, the intervention has only been implemented for one participant,
because of Andy’s unique difficulties with the classroom routine. Generalization of these
findings to multiple participants, as well as other situations, is warranted. Moreover, as
elsewhere, it cannot be assumed from this study that other teachers are willing or able to
implement song interventions.
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From this study, a number of questions remain. For example, would an individually
composed song that matches the child’s personality and the demands of the task be more
effective than a familiar traditional song if practiced and well known to the target child prior
to the intervention? What influence do musical elements such as tempo, rhythm, or
dynamics have on sequential learning for children with autism? Does the vocal expression of
the songs have an influence on the child’s behavior? Would musical accompaniment
including harmonies be more motivating and structuring? Further research should
investigate the effects of those musical variables to better select melodies and improve
learning for children with autism. In addition, more research is warranted to provide
evidence that song interventions can be embedded by teachers in inclusive childcare
programs.

6. Experiment III: Increasing Peer Interaction of Children with Autism on a
Childcare Playground through Music
6.1. Introduction
One of the characteristics of children with autism is their severe delay in
understanding social relationships and communication, which often results in a lack of peer
interactions. Therefore, a major therapeutic objective is to increase the child’s interaction –
whether dichotomous or continuous, and whether quantitative or qualitative in nature – in the
context of their environment and among their peers (National Research Council, 2001). It is
recommended practice for preschool programs to give children a daily opportunity to spend
large blocks of time in outdoor play (Bredekamp & Copple, 2002). Playground time is
important for learning and social development for preschool children, and offers a variety of
play opportunities that distinguish it from indoor play (Cullen, 1993). There is a “free
choice” element to outdoor play that typically developing children generally perceive and
value. However, for children with special needs, especially those with ASD, huge and
unorganized spaces such as playgrounds are often not meaningful. Thus, predictable play
routines and therapeutic goals necessary to facilitate their participation in play and social
skill development are frequently missing. A reason for this might be the common belief that
playgrounds are a free play setting in which peer interactions occur naturally (Nabors et al.,
2001).
That this is not the case for children with special needs has been demonstrated in a
study by Nabors and Badawi (1997). A total of 45 typically developing children and 19
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children with special need ages three to five years from two childcare centers were observed
interacting on the playground. Using a scan-sampling method (“snap-shot” observation of a
child for 10 seconds at a time), the experimenter recorded three play types: playing alone,
playing with a teacher or playing cooperatively with peers. Results indicated that children
with special needs engaged less frequently in cooperative play and more often in playing
alone or with a teacher than their typically developing peers.
Fujiki, Brinton, Isaacson and Summer (2001) also provide evidence that elementary
students with language impairment spend significantly less time interacting with peers on
playgrounds than did their typically developing peers. They also demonstrate significantly
more withdrawn behaviors than their typical counterparts. No other notable differences in
other coded categories (adult interaction, aggression, victimization, and so forth) were
observed.
However, in a free play setting where no play routines are established, it is difficult, if
not outright impossible, for children with autism to join in the fast play pace and play styles
of their typically developing peers (Nabors et al., 2001). As a result, children with autism
often wander aimlessly around, or engage in stereotypic patterns such as spinning a leaf.
Clear structure of the physical environment, predictable play routines, and clear visual
information are among the educational/therapeutic strategies used for children with autism to
enable them to function independently in their classrooms (Marcus et al., 2001). But these
strategies have not yet been implemented on playgrounds. Playgrounds need to be viewed as
therapeutic settings as are classrooms (Nabors et al., 2001), especially in early childhood

programs using an integrated therapeutic approach. To utilize playground time to its fullest
potential in enhancing inclusion, predictable play routines and play activities supporting peer
interaction of children with autism need to be identified and established.
Specific individualized interventions incorporating the children’s strengths and
preferred activities need to be developed for both children with autism and their typically
developing peers. Peer-mediated strategies as described in chapter 2.2.4 have proved
successful in increasing peer interactions (Strain et al., 1979; Goldstein et al., 1992; McGee
et al., 1992). Teacher-mediated interventions, in which the typically developing children are
trained to engage a child with autism interpret their behavior and communication style, is a
first step toward more independent play among the children on playgrounds. Other supports,
such as prompts, cues, and reinforcement to interact successfully with one another, might be
necessary (Nabors et al., 2001). Typical peers who demonstrate high social skills and
interest in certain activities can be excellent role models and trainers for less skilled peers.
This procedure is referred to as Vygotsky’s “zone of proximal development,” meaning that
there is a range of tasks that a child cannot yet handle alone but accomplish with the help of
more skilled partners (Berk & Winsler, 2002).
Although many inclusive childcare programs enroll young children with autism
(Dawson & Osterling, 1997; Handleman & Harris, 2001; National Research Council, 2001),
no studies in the early intervention, special education or music therapy literature related to
promoting desirable outcomes in increasing positive peer interactions on inclusive childcare
playgrounds for preschoolers with autism are available. General guidelines have been
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proposed for constructing safe playgrounds (American Society for Testing and Material,
1993; Taylor & Morris, 1996; U.S. Consumer Product Safety Commission, 1997), for
playground activities (Henninger, 1994; Griffin & Rinn, 1998; Crosser, 1994), and for
promoting interaction and inclusion (Nabors & Badawi, 1997; Nabors et al., 2001; Stine,
1997; Wortham & Wortham, 1989). Additionally, attention has been given to constructing
playgrounds so they are accessible to young children with disabilities (Ministry of Education,
1990). Only a few studies have investigated the social behaviors of typically developed
children and children with special needs on playgrounds (Fujiki et al., 2001; Nabors &
Badawi, 1997 as described above), and some have examined play behavior and play styles on
playgrounds (Cullen, 1993; Ladd & Price, 1986). Only a small amount of research has
focused on promoting interactions between children with and without disabilities on
playgrounds (Hundert & Hopkins, 1992, Kern & Wolery, 2001).
The following study was undertaken for three reasons. First, the FPG childcare
schedule involves large blocks of time outdoors. Second, the playground is a huge space
with no predictable play routines. And third, the target children with autism had difficulty
engaging in meaningful play and interacting with their peers during outdoor play. An
important aspect of the physical outdoor environment is to provide play opportunities
accommodating different developmental levels, abilities and interests of children (Goldstein,
1991). To support social interaction on playgrounds, equipment and toys should encourage
cooperative play rather than solitary play (Martin et al., 1991). Preliminary observations of
the target children revealed an interest in the exciting musical equipment (The Sound Path)
on the FPG childcare playground (Kern & Wolery, 2001, 2002). Therefore, an outdoor

music center (Music Hut) was designed and built, incorporating elements grounded in the
relevant literature (e.g., Cuvo et al., 2001; Nabors et al., 2001; Thaut, 1984). Additionally,
an individualized music therapy intervention using the outdoor music center was designed
and implemented. This intervention was based on an integrated therapy model by the
classroom teachers and continued by the target children’s peers.
6.2 Research Questions
The purpose of this study was to evaluate the effects of a musical adaptation of a
childcare playground and an individually designed music therapy intervention, to increase
peer interaction of four young children with ASD on a playground, implemented by the
classroom teachers and subsequently by classroom peers. The specific research questions
asked in this experiment were as follows:
(1) Does the musical adaptation of a playground (Music Hut) increase peer interactions
among young children with autism on playgrounds?
(2) Does the use of an individually composed song, sung by the teachers and peers,
increase positive peer interaction on the playground for young children with autism?
(3) Can classroom teachers learn the principles important to music therapy to increase
peer interaction on the playground for young children with autism?
(4) Do peers participate and model targeted tasks?
6.3 Method
6.3.1 Participants
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The participants in this study consisted of young children with autism (n=4), typically

166
developing children and children with other special needs (n=32), and their teachers (n=6).
All attended the Frank Porter Graham inclusive childcare program.
Target Children. Four boys with ASD, ages 3 to 5 years old participated in this
study. All children were diagnosed with ASD by external agencies, using the in chapter 3
described diagnostic tools. The children used Picture Communication Symbols to a certain
extent as cues and visual prompts to support their communication. Two of the children
(subjects 2 and 3) had participated in Experiment I, while the other children had no prior
experience in music therapy-based interventions. Subject 2 and 3 attended the same
classroom. The children were identified for this study by suggestions of their classroom
teachers, parents and therapists based on (a) the diagnosis of ASD, (b) IEP goals, (c) absence
of specific peer-related interventions on the playground, and (d) interest in music. In order to
become more independent on the playground and in outdoor play, all children needed to
develop greater skills in interacting with peers, and be motivated to participate in ongoing
playground activities. A summary of demographic characteristics for each subject appears in
Table 6.1.
Subject 1. Eric was a 3-year, 4-month-old European-American boy,
enrolled in the childcare program for 12 months prior to this study. He
was a likeable, cheerful child and had a good temperament. However,
Eric was functioning on the Childhood Autism Rating Scale (CARS)
behavior rating scale in the mild to moderate range on the autism spectrum. He had
significant weaknesses in communication and social skills. Eric was communicating with

gestures and motor actions and used some non-speech sounds. He also used several words
and some approximations of two-word phrases such as “Hey you” and “All done.” Eric had
a strength in imitation, but had difficulties naming objects and vocalizing desires. He also
had a short attention span for play. Eric showed emotions of anger and frustration through
high-pitched vocalization. He received speech/language therapy and special education
services while in the classroom. Eric had positive social relationships with adults, but lacked
the skills to interact appropriately with peers.
Eric’s peer interaction on the playground was limited, although he approached his
peers frequently and seemed to be curious and interested in what they were doing. Most of
the peer interactions initiated by him were inappropriate (e.g., pushing peers, taking toys
away or screaming and crying when interacting). Peers rarely initiated playing with him. He
most often would ride a tricycle along the bicycle track, dig in the sandbox or manipulate a
bulldozer. He also spent time observing people and running around.
Eric vocalized to himself when doing activities and responded well to routines,
rhythm and music. Whenever music was involved in classroom activities (e.g., during circle
time), Eric was very attentive and motivated to participate. He had a good sense of rhythm
and loved to sing by vocalizing.
Video Excerpt 6.1. Video collage of Eric’s typical playground behaviors during
baseline condition.
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Subject 2. Ben was a 4- year old European-American boy, enrolled in
the childcare program for 25 months prior to this study. He participated
in Experiment I and therefore had prior experiences with music therapy
interventions. Ben came to the intervention with many strengths and
great potential for development. However, he was functioning on the
Childhood Autism Rating Scale (CARS) behavior rating scale in the mild to moderate range
on the autism spectrum. Ben had difficulty understanding language and communication and
with social interactions. He also had deficits in constructive/pretend play activities. He
engaged in repetitive patterns and behaviors (e.g., spinning around). In familiar routines,
Ben was able to make requests using three-word phrases with minimal prompts from adults,
and he understood the meaning of single words. However, he was not able to direct his
phrases towards others, and used gestures and motor actions for communication. Ben was
able to imitate words and sounds, some motor actions (e.g., clapping), and some actions
using objects (e.g., beating a drum), if these tasks were modeled and directly taught. He
received speech/language, occupational therapy and behavioral therapy while in the
classroom, as well as additional external speech/ language therapy services and a specially
designed home program. Ben indicated emotions through vocalizations and gestures that
reflected feelings of happiness or dislike. Ben had a limited awareness of and interest in
others. He interacted with familiar adults, when he wanted something or needed to be
comforted. An adult prompted nearly all of his interactions with peers.
Ben rarely interacted with peers on the playground. He most often would stroll and
run around aimlessly, unless an adult assisted him with meaningful play. Frequently he

turned around in a repetitive pattern while singing and signing familiar songs. Often he
kneeled in the sandbox or lay on a bench. Sometimes he went down a slide independently or
observed the bunny in a hutch.
In general, Ben preferred videos and computer games that included music. He
engaged well in musical activities (e.g., singing, dancing and drumming) during the daycare
routine. Soft and mellow music seemed to interest and calm him. He seemed to enjoy
accomplishing tasks and specific actions when accompanied by familiar songs.
Video Excerpt 6.2. Video collage of Ben’s typical playground behaviors during
baseline condition.
Subject 3. Phillip was a 4-year, 9-month-old African-American boy,
enrolled in the childcare program for 25 months prior to this study.
Phillip was a friendly child with a sense of humor and a good
169
temperament. However, he was functioning on the Childhood Autism
Rating Scale (CARS) behavior rating scale in the mild to moderate range on the autism
spectrum. Phillip had particular difficulty with communication strategies and social
interactions and deficits in his range of interests and play skills. Occasionally he engaged in
repetitive movements such as spinning objects. Phillip communicated with gestures and
motor actions. He also used some non-speech sounds, several words, and some
approximations of two-word phrases such as “I want.” Phillip was very attentive in
attempting to imitate sounds and cues, but he was not able to express comments, protests, or

170
information with functional language. Phillip showed anger and frustration by vocalizing
loudly, and happiness and joy by laughing, giggling and acting silly. He received
speech/language and occupational therapy as well as special education services while in the
classroom, and engaged in a specially designed home program. Phillip had a positive social
relationship with adults unless he was asked to do a non-preferred activity.
Phillip showed interest in his peers indoors as well as outdoors, but did not always
know how to approach them appropriately. At times he became physically rough with peers
as play progressed and peers assigned to give him a negative role or were afraid of him. He
most often engaged in behaviors such as wandering aimlessly, flapping his arms, spinning a
leaf or stick, sitting on a bench, or observing peers unless adults involved him in meaningful
activities (e.g., riding a tricycle).
Phillip responded well to singing, dancing and musical activities. His teachers used
drumming as a reward for completing difficult tasks during classroom routines.
Rhythmically based music seemed to capture his attention often.
Video Excerpt 6.3. Video collage of Phillip’s typical playground behaviors
during baseline condition.
Subject 4. Lucas was a 3-year, 9-month-old African-American
boy, enrolled in the childcare program for 25 months prior to this
study. Lucas was a happy and energetic child. However, he was

functioning on the Childhood Autism Rating Scale (CARS) behavior rating scale in the
moderate to severe range on the autism spectrum. Lucas had severe weaknesses in imitation,
social and communication skills. He engaged in play activities for four to five minutes time
with maximal adult support. Lucas also engaged frequently in repetitive behaviors such as
spinning toys or objects. His play activities were often accompanied by vocalization, and he
engaged most often in motor activities. Lucas communicated by using objects, an adult’s
hand and some non-speech sounds, but only for a limited number of purposes. Lucas
received speech/language and occupational therapy as well as special education services
while in the classroom. He appeared to be very interested in people and seemed to watch
their activities and behaviors, but did not initiate or interact in appropriate ways. His
interaction was usually limited to indicating his need for help.
During playground time, Lucas frequently twisted objects (e.g., ball, acorns, plastic
bottles, buckets) and followed moving objects (e.g., ball, tricycle) around the playground.
He sought motor activities such as running around and engaged in body rocking. His peer
interaction on the playground was minimal, often occurring only when he was interested in
an object used by peers. When frustrated or overwhelmed he responded with screaming or
scratching and biting others. He seemed to be scared of certain peers and some of his peers
seemed to be afraid of him and refused to play with him.
Lucas responded well to music combined with movement and fast changing
sequences. Long sounding instruments (e.g., gong and cymbal) and rhythm, as well as the
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imitation of his vocalization and repetitive movements, drew his attention. Dancing,
spinning around, tickling and squeezing him seemed to be pleasurable for him.
Video Excerpt 6.4. Video collage of Lucas’ typical playground behaviors
during baseline condition.
Table 6.1. Summary of characteristics for each subject.
Name Chronological
Age
Eric 3 years
4 months
Developmental
Information
Used objects and nonspeech
sounds to
communicate
Good imitation skills
Short attention span
for play
Minimal interaction with
peers
Ben 4 years Three-word phrases and
gesture, not directed to
others to communicate
Imitation of words,
sounds, and motor
actions, when directly
modeled
Deficits in constructive
and pretend play activities
Engagement in repetitive
patterns
Minimal interest in peers
Playground Behavior Musical Preferences
and Behaviors
Motor activities
such as riding a tricycle,
digging in the sand,
running around sought
Interested in peers’
activities, inappropriate
interaction with peers,
few initiations from peers
Strolled and ran
aimlessly around
Turned around in
repetitive patterns while
singing and signing
familiar songs
Kneeled in the sandbox,
or observed the bunny in
a hutch
Rare interaction with
peers, no initiations from
peers
Vocalization to songs
and own activities
Motivated engagement in
rhythm and music
activities
Preference for rhythmbased
music
Vocalization to songs
and own activity
Video and computer
games including music
Musical activities such as
singing, dancing,
drumming
Preference for soft and
mellow music
Accomplishment of tasks
when accompanied with
familiar songs

Table 6.1. Continued
Name Chronological
Age
Phillip 4 years
9 months
Lucas 3 years
9 months
Developmental
Information
Two-word phrases,
gesture, and non-speech
sounds to communicate
Imitation sounds and cues
Deficits in range of
interests and play skills
Engagement in repetitive
patterns
Interest in peers,
inappropriate interaction
with peers
Objects and gestures to
communicate
Short attention span
for play, only with
maximal adults help
Frequently engagement in
repetitive patterns
Interest in peers, minimal
or inappropriate
interaction with peers
Playground Behavior Musical Preferences
and Behaviors
Wandered aimlessly
around
Engaged in respective
patterns such as flapping
his arms, spinning a leaf
or stick
Sat absent on a bench
or rode tricycle, when
prompted by adults
Interested in peers,
inappropriate interaction,
peers give him negative
role or avoid him
Motor activities such
running around and
following moving objects
sought
Engaged in repetitive
patterns such as spinning
objects or body rocking
Minimal or negative peer
interaction, scared of
peers, negative role
among peers
Musical activities such as
singing and dancing
Playing the drum, which
functioned as motivator
and reward
Preference for rhythm
Play activities
accompanied by
vocalization
Music combined with
movement and fast
changing sequences
Responded well to long
sounding instruments,
rhythm and imitation of
his vocalization and
movements
Classroom Peers. In addition to the target children, 32 other children with and
without disabilities, ages two to five years old, participated in this study. Peers included both
males and females from different ethnic groups. The classroom peers participated in the
study voluntarily. More specifically, children who came forward to interact with the target
children were included in the intervention. Thus, two peers in each classroom were formally
selected to act as “peer buddies” for each target child, and were trained by the teachers to
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play with their classmate with autism on the playground. The “peer buddies” were identified
for this study by their classroom teachers and therapists based on their (a) interest in music
(b) social skills, (c) relationship to the child with autism, and (d) willingness to participate.
The particular children who participated each day varied based on the children’s own actions
and on class attendance.
In addition to Eric (subject 1), eleven other children were
enrolled in his class. The classroom peers were between
three and four years of age. Nine of the children were
typically developing, one of the classroom peers had
cerebral palsy, and another one had autism. His “peer buddies,” were Becky, a 4-year, 5-
month-old European-American girl, and Ron, a 4-year, 9-month-old African-American boy.
Ben and Phillip (Subject 2 and 3), attended the same
classroom. In addition to them, 10 other children were
enrolled in their class. The classroom peers were
between three and four years of age. Eight of the
children were typically developing, one of the classroom peers had Down Syndrome, and
another one was diagnosed with high functioning autism. Ben’s (subject 2) “peer buddies”
were Carmen, a 4-year, 5-month-old African-American girl, and Victor, a 4-year, 4-month-
old European-American boy.

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Phillip’s (subject 3) “peer buddy” Justin, was a 4- year, 10-
month-old European-American boy, diagnosed as high
functioning autism. One of Justin’s occupational therapy
goals was to increase independent play activities on the
playgrounds. Justin showed a great interest in music, which encouraged his therapists to use
the music equipment (The Sound Path) as a motivator to accomplish IEP goals, such as (a)
initiating play activities, (b) persisting in play for longer time, and (c) playing with peer. At
the time of the study, engaging with the instruments of the Sound Path on the playground
was already a familiar routine to him. When he heard about making music with friends on
the playground, he made a request to his teacher to be the “peer buddy” for Phillip. Justin
had good conversation and listening skills. With an adult’s present he was able to follow
directions for play activities and understood turn-taking. Phillip’s second “peer buddy”
originally was Jeremy, a 4-year, 2-month-old African-American boy. As the intervention
began, it became clear that Jeremy was unable to sustain interest in the intervention, and he
was therefore replaced by Jacky after the second session. Jacky was a 4-year, 1-month-old
African-American girl who joined the class just prior the study. She initiated being part of
the study by telling her the assistant teacher that she knew the song and could play with
Phillip in the Music Hut.
In addition to Lucas (subject 4), 13 other children
were enrolled in his class. The classroom peers
were between two and four years of age. Eleven of
the children were typically developing, one of the

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classroom peers had Down Syndrome and another had Pfeiffers Syndrome. Lucas’ (subject
2) “peer buddies, were Kayla, a 3-year, 4-month-old African-American girl, and Megan, a 2-
year, 10-month-old European-American girl. Two other “peer buddies” were involved prior
to Megan. However, they were replaced very early in the intervention because of frequent
absences.
Classroom Teachers. The teachers participating in the study were all FPG childcare
program staff. Three lead teachers and three assistant teachers, all female, implemented the
intervention. Teachers participated based on their interest in the study and schedule (i.e.,
teacher’s break times are staggered so that the entire childcare day has coverage). Thus the
lead teachers and one assistant teacher participated more of the time than did the other
teaching assistants.
Eric’s (subject 1) lead teacher had a master’s degree and was certified in Early
Childhood Education. She had taught young children for two years. The teaching assistant
had a high school diploma and had been teaching at the childcare program for two years.
Neither teacher had prior experience with music therapy interventions.
Ben’s and Phillip’s (subject 2 and 3) lead teacher had a bachelor’s degree and was
certified in Early Childhood Education. At the time of the study, she was taking classes
toward a master’s degree in Early Childhood Education. She had taught preschool children
at the childcare program for five years. In this study, she implemented the intervention for
Ben. The classroom’s teaching assistant implemented the intervention for Phillip. She had a

high school diploma and had been teaching at the childcare program for three years. Both
teachers participated in Experiment I and therefore had prior experiences with music therapy
interventions.
Lucas’ (subject 4) lead teacher, had a bachelor’s degree and was certified in Early
Childhood Education and had taught young children for three years. She participated in
Experiment II and therefore had prior, experience with music therapy interventions. The
teaching assistant had an associate’s degree in Early Childhood Education and had been
teaching at the childcare program for five years. She had no prior experience with music
therapy interventions.
6.3.2 Setting
All experimental sessions occurred on the playground of the target children’s
childcare program. The playground (35 m x 47 m) contained different areas of play such as
three sandboxes, a huge climbing and sliding structure, a wooden playhouse with a bunny in
a hutch next to it, a concrete track (41 m x 2 m with loops on each end) for riding tricycles,
two large and two small trees with wooden benches around it, and three raised flower and
garden beds. The building and a 2 m high chain-linked fence to bound the playground. One
corner of the playground was divided into a smaller playground by a 1m high chained-linked
fence to provide a separate area for toddlers and infants. The playground contained several
tricycles, wagons, large plastic building blocks, sand toys, balls, hoops, large toy trucks, and
other common playground toys. Other toys and materials occasionally used by the teachers
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and therapists on the playground included a parachute, tunnels, mats, or material for dramatic
play.
In addition, the physical outdoor space has been enhanced and structured for children
with special needs by adding a Sound Path, which presented six music stations at meaningful
locations on the playground (Kern & Wolery 2001, 2002). The stations were connected with
a “path” made of a 109 m drainage pipe looping the central portion of the playground. The
instruments were accessible to all children, each was easy to play, and each complied with
playground safety regulations (American Society for testing and Material, 1993; U.S.
Consumer Product Safety Commission, 1997). The stations were designed to be multi-
sensory by using different materials, shapes, colors and sounds. Some ideas proposed by
Snoezelen (Cuvo, Might & Post, 2001; Hulsegge & Verheul, 1998) for indoor multi-sensory
stimulation environments were included in the station designs. All musical instruments were
hand-made from donated scrap materials.
The first music station, Touch Board, was near to an entrance to the playground. It
consisted of a bamboo xylophone, jingle bells, and rainmaker attached in line to the chain-
link fence and post. A second set of jingle bells and bamboo xylophone was set up as a
mirror image of itself. The second music station was a hardwood xylophone about 1 m in
length with wooden mallets for playing it. It was located near the climbing and sliding
structure. The third station was a Taxi Stand. It had a yellow painted bench and trellis with a
bicycle bell and horn attached. This music station was located near the tricycle track. The
fourth music station, Sound Pipes, included seven copper pipes of different lengths attached

to a tree trunk with wooden mallets to activate the sound. This tree had a bench around it and
was a place where teachers and children often congregate to converse and interact. The fifth
station, Triangle Tree, consisted of two large triangles hung from the branches of a second
tree. The wind activated them, and a metal mallet was attached to the triangles so that they
could be rung. The sixth station, Bucket Drums, were three galvanized pails attached
between wooden posts in one of the sandboxes. The music stations were connected to one
another through the use of a 10 cm drainage pipe. The pipe had ridges on it (i.e., as a guiro)
producing sound when a stick was rubbed on it. The pipe stopped near each music station to
cue the location. Figure 6.1 depicts the playground equipment including the Sound Path.
Figure 6.1. Playground equipment, including the Sound Path on the FPG childcare
program’s playground.
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The daily preschool schedule included two blocks of outdoor play, adjusted to the
needs of the children. Experimental sessions occurred on the playground during the regular
morning playground time. In addition to the three classes participating in the study, two
other classes, enrolling seven children, each ages two years, were on the playground at
staggered but overlapping times. As a result, the number of children during morning outdoor
play varied, based on the classroom schedule, classroom activities, attendance and weather
condition. Because the childcare program was affiliated with the university, students,
observers and visitors were often on the playground in addition to the children and childcare
program staff.
6.3.3 Material
Five major components were important for this study: (1) the Music Hut, (2) songs
for the Music Hut, (3) a unique song composed for each target subject, (4) an individualized
book, and (5) a practice CD accompaniment by a song transcription. Each is described in
more detail below.
(1) The Music Hut. The Music Hut is an outdoor music center, purposefully designed
to expand musical opportunities and therapeutic playground activities of young children,
especially those with autism (Kern, Marlette, & Snyder, 2002). It was built in collaboration
with an architect and employees of the carpentry shop at the University of North Carolina at
Chapel Hill. Design and construction meet the guidelines of U.S. playground safety
regulations (American Society for Testing and Material, 1993; U.S. Consumer Product
Safety Commission, 1997). The Music Hut is connected with the Sound Path, and is

accessible by a wooden wheelchair ramp. It consists of a 3 m x 2.4 m long hardwood deck,
located in the center of the large sandbox on the playground, and is covered with a 6.1 m x
8.2 m green fabric canopy.
The following instruments are attached to wooden beams, steel arches and Plexiglas
walls: a 56 cm Chinese Lion Wind Gong, three Tubanos in different sizes (large, medium,
small), a Kid’s Floor Drum with a 20 cm x 25 cm Head, Kid’s Bongos with a 13 cm x 15 cm
Heads, a High Head, a Mini Cabasa, three Sound Tubes made out of PVC pipes of different
lengths, one 71 cm Marching Drum and an 53 cm Ocean Drum. Twenty-centimeter-long
wooden dowels, wrapped on one quarter of an end with compressed foam material were used
as a drumstick to activate the instruments. Using a spatula to hit the pipes on the top
activated the Sound Tubes. The drumsticks were stored in two wooden boxes, attached to a
wooden beam next to the PVC pipes and the drums. All instruments were donated from
West Music and local musicians or built by the investigator. A CD player stand, as well as a
step for the cymbal, was added during the intervention. For the purposes of the study, the
second musical station of the Sound Path, a xylophone, was moved to the Music Hut. Figure
6.2 shows a panorama view of the Music Hut.
Figure 6.2. Panorama view of the outdoor music center (Music Hut), showing the
instruments and construction.
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(2) Songs for the Music Hut. A booklet and CD with songs and activities for the
Music Hut was distributed to the participating teachers and childcare program’s therapists
prior to the intervention. The booklet included songs incorporating instruments in the Music
Hut and three instrumental pieces to promote therapeutic goals such as interaction, initiation,
cooperative play, self-expression and awareness, attention, and body control (Schnur Ritholz
& Robbins, 1999). Piano accompaniment and voice, as well as a sing- along of each piece,
were recorded on the CD. Theses materials were provided to encourage teachers to expand
their own repertoire of musical activities. The teachers were also encouraged to introduce
the music during circle time in the classroom to expand the children’s musical repertoire for
the Music Hut.
A medley entitled “Everybody in the Music Hut” with distinct contrasts of mood,
tempo and rhythm for each instrument was written for the Grand Opening of the outdoor
music center. A transcription of the medley is shown in Figure 6.3. All children and staff of
the childcare program were invited to participate in this event. A special introduction of the
instruments using a puppet, the medley and musical games was given.

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Figure 6.3. Transcript of the medley: “Everybody in the Music Hut,” written for the Grand
Opening of the Music Hut.
(3) A unique song composed for each target subject. The themes of each song
match the subjects, their needs and abilities, musically. The intention of each song is to
increase positive peer interaction and to engage in meaningful play during outdoor
activities. The content of each song focuses on these general goals. Additionally, IEP
goals, developed by the interdisciplinary team of the FPG childcare program, were
incorporated for each child individually.
Eric. “Hey you” is a song written for subject 1. A transcription of the song is shown in
Figure 6.4. The song builds on Eric’s available imitation and verbal skills, and mirrors his
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cheerful personality musically. The following IEP goals were also addressed by the song:
increase vocalization, use appropriate body contact, make choices, take turns, and name
peers. The theme of the song picks up Eric’s favorite approximations of the two-word phrase
“Hey you!” in an appropriate voice range. Tapping a partner’s shoulder on count two and
three in measure one and two supports appropriate body contact and gets the children’s
attention. To practice choice-making, the target child chooses one of the instruments in the
Music Hut and names or points it out it in count three of measure three. The lyrics signal
when the children are expected to play together or to take turns. Musical rests in measure 10,
12, 14, 16, 18, 20, 22 and 24 anticipate the expected beating pattern on the chosen
instrument. In measure, 18 and 22, peers model how to play, followed by imitation by the
target subject in measure 20 and 24. In measure 17, 19, 21, 23 the children name the person
who plays the next beats. Overall, the song displays opportunities for positive peer
interactions and purposeful outdoor play. Table 6.2 gives an overview of the IEP goals
incorporated in the song “Hey you.”
Table 6.2. Overview of Eric’s IEP goals incorporated in the song “Hey You.”
Increase vocalization
Use appropriate body contact
Make choices
Take turns
Name peers
IEP Goals Song
Singing along the melody of the song
Clapping on partner’s shoulder
Choose an instrument in the Music Hut
Child 1 plays two beats, child 2 plays two beats
Inclusion of peer’s name in the lyrics of the song

Figure 6.4. Transcript of the song ”Hey You,” written for Ben addressing social interaction
and specific IEP goals.
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Ben. “You and I” is a song written for subject 2. A transcription of the song is
shown in Figure 6.5. The song builds on Ben’s available communication skills, imitation
skills and musical preferences, and mirrors his mellow personality musically. The following
IEP goals, developed by the interdisciplinary team of the FPG Childcare program, are also
addressed in the song: improve communication and sign language, increase interest in and
awareness of others, increase imitation of peers, increase choice-making. The theme of the
song reflected the central therapeutic goal for Ben, which was to increase interest in
interacting with others. American Sign Language (Bornstein, Saulnier & Hamilton, 1992), as
practiced in Ben’s class, was applied for “You,” “I,” and “music.” Ben was also encouraged
to sing the lyrics of the song. In measures seven and eight, the children’s attention to get
ready to play is supported through the accelerando. Peers model how to play the instrument
in measure nine, immediately imitated by Ben in measure ten. This alternation is continued
throughout the song. The lyrics and music clearly cue the children how to proceed.
Choosing and naming instruments in the Music Hut increases choice making. Overall the
song provides opportunities for positive peer interactions and purposeful outdoor play. Table
6.3 gives an overview of the IEP goals incorporated in the song “You and I.”
Table 6.3. Overview of Ben’s IEP goals incorporated in the song “You and I.”
Improve communication and sign language
Increase interest in and awareness of others
Increase imitation of peers
Increase choice making
IEP Goals Song
Singing the lyrics of the song combined with
signing “You”, “I,” and “music”
Joint peer activity
Play what peers model
Choose an instrument in the Music Hut

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Figure 6.5. Transcript of the song ”You and I,” written for Ben addressing social interaction
and specific IEP goals.
Phillip. “Phillip’s Groove” is a song written for subject 3. A transcription of the
song is shown in Figure 6.6. The song builds on Phillip’s available imitation and verbal
skills, and musically mirrors his good temperament. The following IEP goals are also

addressed in the song: improvement of verbal skills and sign language, make choices, name
peers and self, wait for turns, use appropriate body contact. Phillip’s common
approximations of two-word phrases are included in the song. American Sign Language
(Bornstein, Saulnier, & Hamilton, 1992) as practiced in Phillip’s class was applied for “all
done,” “good-bye,” and “thank you.” For choice making, the children choose one of the
instruments in the Music Hut and name it in measure two, four, and six. The chosen
instrument is introduced on beat four in measures two, four and six. In measures nine and
13, the children name whose turn it is to play. The named child plays along the rhythm of
the melody. The use of appropriate body contact was practiced with Phillip by hugging a
peer buddy and a teacher’s improvised verse on dancing (added at the second day of
intervention). The last verse of the song encourages signing “All done,” “Good-bye” and
“Thank you.” Overall, the song provides opportunities for positive peer interaction and
purposeful outdoor play. Table 6.4 gives an overview of the IEP goals incorporated in the
song “Phillip’s Groove.”
Table 6.4. Overview of Phillip’s IEP goals incorporated in the song “Phillip’s Groove.”
IEP Goals Song
Improvement verbal skills and sign language
Make choices
Name peers and self
Wait for turns
Use appropriate body contact
Singing the lyrics of the song, signing
“All done!,” “Good-bye,” and “Thank you”
Choose an instrument in the Music Hut
Inclusion of peers and Phillip’s name in the lyrics
of the song
Peer plays 4 measures, Phillips plays four measures
afterwards or vice versa
Give hugs for “Good-bye”
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Figure 6.6. Transcript of the song ”Phillip’s Groove,” written for Phillip addressing social
interaction and specific IEP goals.

Lucas. “Lucas’ Dance” is a song written for subject 4. A transcription of the song is
shown in Figure 6.7. The song builds on Lucas’ strong motor skills and his preference for
high level of sensory input, and mirrors his happy and energetic personality. The following
IEP goals were also addressed in the song: share attention, look at people and objects, point
to things of interest, wait for turns, use appropriate body contact, and increase play and
duration of play. All verses of the song require shared attention, to look at peers and objects.
The lyrics in verse 1, measure one to eight might encourage Lucas to share his attention with
his peers, and the activity is based on his motor skills. In verse 2 he is asked to point to his
preferred instrument. Participating in turn taking is encouraged in verse 2 and 4, measure
nine to 20. In verse 2, child 1 is encouraged to play the chosen instrument and hand over the
drumstick to the partner for the repetition of this section. In verse 4, child 1 is encouraged to
tickle Lucas, and vice versa for the repetition. To learn about appropriate body contact,
dancing with each other in verse 1, giving hugs in verse 3, and tickling in verse 4 are
incorporated in the lyrics of the song. The song was intended to increase Lucas’ play activity
and his duration of play to 10 minutes. The song is flexible regarding the mood and
temperament of the target child. The verses can be adapted to the situation, e.g., when Lucas
is too excited, using verse 3 (hugs) might calm him down, or if he looses interest in an
activity, verse 1 (dancing) can be repeated. Overall, the song provides opportunities for
positive peer interaction and purposeful outdoor play. Table 6.5 gives an overview of the
IEP goals incorporated in the song “Lucas’ Dance.”
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Table 6.5. Overview of Lucas’ IEP goals incorporated in the song “Lucas’ Dance.”
IEP Goals Song
Share attention; look at people and objects
Point to things of interest
Wait for turns
Use appropriate body contact
Increase play and duration of play
All verses of the song require shared attention, to look at
peers and objects
Point to preferred instrument
Hand over the drum stick to partner
Dancing, receiving/giving hugs, and tickling
Maintain play activities up to 10 minutes at a time

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Figure 6.7. Transcript of the song ”Lucas’ Dance,” written for Lucas addressing social
interaction and specific IEP goals.
(4) Individualized Picture Book. To cue the transition from the classroom to the
playground visually, a 18 cm x 22 cm laminated picture book was made for each subject.
The book included a picture of the Music Hut on the left and a picture of each selected
peer buddy on the right. The words written on the front side of the book was the
subject’s name and “Playground Activity.” The words written above the Music Hut
picture were “Play in the Music Hut with your friend ...,” and each peer’s name under
his/her picture.

(5) Practice CD accompaniment by a song transcription. The unique song for
each subject was recorded on separate practice CD’s and given to the staff. To ensure
successful learning, each song on the practice CD was presented as follows: (a) piano
accompaniment, vocals with lyrics and percussion, to give the whole impression of the
song; (b) melody played by the piano, to learn the melody properly; (c) sing and play
along with piano accompaniment, to practice singing and playing the instruments; and (d)
melody sung with lyrics, to model how to sing on the playground. Additionally each
song was transcribed as music and lyrics, including melody, chords, lyrics and percussion
and lyrics only.
6.3.4 Procedures
Experimental sessions occurred Monday to Friday, one time daily for each subject
during morning outdoor play. The playground schedule of each class was staggered. Lucas’
classes’ morning playground time started at 10:15 a.m. to 11:00 a.m., followed by Ben’s and
Phillip’s class at 10:30 a.m. to 11:15 a.m., and Eric’s class at 11:00 a.m. to 11:45 a.m. The
order of observation was based on the participants’ presence or availability. In the case of
Ben and Phillip, who entered the playground together, Ben was observed before Phillip for
most sessions. Data collection, staff development activities and intervention procedures are
described below in the order in which they occurred chronologically.
Baseline Procedure. In the baseline condition (Condition A), a session started as
soon as the subjects entered the playground. No instruction was given to either peers or
subjects. Staff was asked not to interact with the subjects during the 10-minute period of
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data collection, unless it was necessary (e.g., when the subject needed help) or the subject
initiated the interaction. The purpose in this was to allow evaluating the natural, unstructured
and unsupported peer interactions of the subjects occurring on the playground. Playground
equipment and material as described in the setting of the study was available for all children.
Procedure after the Adaptations of the Playground. As noted, the playground was
adapted with the Music Hut (Condition B). As soon as entering the playground, staff walked
the subject over to the Music Hut, gave him a drumstick and asked him to play in the Music
Hut. The session started as soon as the subject entered the Music Hut. As in the baseline
condition, no instruction was given to either peers or subjects. Once again it was required
that staff not interact with the subjects during the 10 minutes of data collection unless
necessary (e.g., when the subject needed help) or the subject initiated the interaction, for the
purpose stated previously under “Baseline Procedure.”
Staff Development Activities. Training and collaborative consultation occurred after
all goals and procedures for the intervention were identified by the interdisciplinary team
(including the teachers), and after songs were composed for each child with autism. Initially
the purpose of the study, how the intervention would fit into existing classroom routines, and
how data would be collected during the embedded intervention, were discussed with the
teacher. All teachers were trained, in a one-to-one format, to use principles of music therapy
and materials individually designed for the target children. The unique song for each subject
was transcribed and recorded on separate practice CD’s and given to the staff along with a
written description of the study procedure. The songs and how to use the practice CD (as

described in the material section) was introduced to each teacher individually, and to the
whole class during circle time indoors shortly prior to the actual intervention in the Music
Hut. The teachers were also encouraged to practice the specific song with their class.
Additionally, a verbal orientation to the procedure in the Music Hut, including hands-on
experiences and opportunities to role-play, was presented to the teachers. Specific
instructions regarding how to engage and assist the subject and peers to interact with each
other in the Music Hut were given verbally and modeled included:
• how to use the picture book as a visual cue for the transition from the classroom to
the outdoor play, by showing and reading the book to both the child with autism and
his peer buddies shortly before going outside, assisting the target child to chose a
peer and asking him if her or he wants to play and sing in the Music Hut;
• how to take the subject and a chosen peer to the Music Hut, by holding hands and
preparing/motivating the children verbally for the musical activities that follow;
• how to initiate play and include children on their level, by using the ISO-Principle
(Benenzon, 1997), including children’s ideas and strengths in the procedure;
• how to involve the children in singing the song and playing the instruments by
inviting the children to sing along the particular intervention song while playing the
named instruments in the Music Hut, and giving verbal praise as reinforcer;
• how to model verbalization, body contact, cooperative play, turn taking, choosing
instruments
o by saying/singing the words clearly and pausing to give the target child time
to respond to the music, and repeat if necessary
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o by holding the target child’s hand when guiding him to a certain area or while
dancing, touching him gently to get his attention, hugging and tickling him
gently
o by inviting both or more children to participate in singing, playing and
movement, sharing material and giving each child space and attention for
his/her contribution
o by following the lyrics in turn taking and/or handing over a drum stick for
turns
o by identifying the instrument’s name and sound and giving the children free
or limited choice to pick one
• how guide to other activities in the Music Hut by announcing and modeling the
activity and inviting them to participate;
• how to continue to play in the Music Hut for 10 minutes at a time by engaging the
children and motivating them through the activity;
• how to assist peers in developing a play routine by identifying their preferences and
strengths and asking or suggesting how to play with the target child;
• how to train the peers to model the tasks, by modeling the tasks, developing and
practicing a play routine, clarifying questions and misinterpretations, mediate
challenging moment, giving verbal praise;
• how to gradually reduce the verbal and physical prompting during Condition D
(Peer-Mediated Intervention) by giving the lead to the peers, stepping out of the
Music Hut, and reducing verbal guidance as much as possible; and

• how to communicate a positive attitude toward the target child by anticipating the
intervention with enthusiasm and emphasis the strengths of the target child.
The teachers were asked to use the material flexibly and to improvise in order to meet
the needs of the children (e.g., to add lyrics to the song, extend musical improvisation on the
instruments, or include musical ideas from children). They were also encouraged to include
other peers on the playground, if they showed an interest in participating in the musical
activity. Collaborative consultation, including feedback and suggestions, was provided
during and following intervention sessions.
Teacher-Mediated Intervention Procedure. In this intervention phase (Condition C),
a predictable routine and structure was established for each subject. First, an individualized
picture book (as described in the material section) was shown to the subject prior the outdoor
play to ease the transition from indoor to outdoor play. As a part of the intervention, two
peers were formally selected for each subject as peer buddies and trained by their classroom
teacher during the intervention phase. At least one peer was chosen for each day, based on
which one the subject pointed out in the picture book and willingness of the peer to
participate. Secondly, the teacher walked the subject and at least one peer to the Music Hut
and verbally prepared them for the activity. Thirdly, as soon as they entered the Music Hut
the teacher started singing the specific song written for the subject, initiated playing the
instruments or dancing, and encouraged the children to participate in the activity and interact
with one another as described in Staff Development Activities.
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Peer-Mediated Intervention Procedure. The goal of the peer-mediated intervention
Phase (Condition D) was to have the peer-buddy and subject interact and play with each
other independently. The procedure was similar to that in the teacher-mediated intervention
phase (Condition C). The only change was that teachers withdrew their support gradually
after the peer buddies and subjects learned the song and play routine. First teachers reduced
the physical prompting by stepping out of the Music Hut and giving verbal prompts from
outside, and second by just giving prompts when necessary.
6.3.5 Experimental Design
A multiple baseline design replicated across four subjects was used to evaluate the
effects of adapting the playground (Condition B), the teacher-mediated intervention
(Condition C), and subsequently the peer-mediated intervention (Condition D). In a multiple
baseline design, the first step is to identify the target behavior, which is commonly shared by
all subjects. This target behavior becomes the baseline. Experimental control is established
by collecting baselines for each subject until a sufficient stability is exhibited (a stable pattern
or constant trend, and a minimum of three data points). Then the intervention is applied to
one subject while the baseline conditions are continued with the other individuals. If stability
is achieved during treatment for the first subject, the intervention is applied to the second
individual. This procedure is repeated on a staggered times for all remaining subjects and for
all conditions. The treatment effects can be seen clearly in comparison to baseline condition
and/or in contrast to other applied conditions. Because the intervention is replicated across
several subjects at staggered times, it is very unlikely that external factors cause the response
change. One advantages of this single-case experimental design is that replication and

experimental control can be achieved without withdrawal of treatment (Alberto & Troutman,
1995; Aldridge, 1994, 1996; Hanser, 1995; Holcombe, Wolery, & Gast, 1994; Kazdin, 1982;
Tawney & Gast, 1984).
conditions:
The experimental design in this study involved four sequentially implemented
• Baseline (Condition A)
The subjects' positive interactions with all peers on the playground prior to the
availability of the Music Hut.
• Adaptation of the Playground (Condition B)
The subjects' positive interactions with all peers on the playground when the Music
Hut was available.
• Teacher-Mediated Intervention (Condition C)
A unique song was composed for each subject. Teachers, at least one “peer-buddy,”
the subject and other voluntary peers sang the song in the Music Hut.
• Peer- Mediated Intervention (Condition D)
The same song was sung in the Music Hut by at least one “peer-buddy” and the
subject.
The first two conditions (baseline without Music Hut, and Music Hut) allowed for an
A-B (baseline-intervention) evaluation of the absence and presence of the Music Hut.
However, this portion of the design does not allow for functional relationships to be
established, as there are no replications (intersubject) of the effects due to the nature of the
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206
intervention (i.e., the addition of the Music Hut). However, starting with the third condition
(teacher-mediated intervention), a multiple baseline across subjects design was used. This
portion of the design allows for functional relationships to be evaluated, because of the
intersubject and replications. Data collection occurred over eight months.
6.3.6 Measurements
In Experiment III, the following three measurement procedures and responds
definitions applied:
(1) Categories of interaction behaviors.
Categories of interaction behaviors were coded through direct observation of a 10-minutes
videotaped segment using a 15-second momentary time sampling recording procedure. Data
was recorded during Condition A and B (baseline- adaptation of the playground) when the
subject and his peers were present on the playground. During Condition C and D (teacher-
mediated intervention-peer-mediated intervention) when the subject, his teacher, peers and at
least one of his “peer-buddies” were present on the playground. Each observation lasted 10-
minutes per day. In Condition A (baseline) the observation started as soon as the target child
and his peers entered the playground or after class activities on the playground, in Condition
B (adaptation of the playground) as soon as the subject entered the Music Hut or when he
was already in the Music Hut, and in Condition C and D (teacher-mediated intervention-peer-
mediated intervention) as soon as the subject and at least one peer-buddy entered the Music
Hut. All sessions were videotaped with a Sony Digital Video Camera Recorder DCR-
TRV17 and analyzed afterwards. The momentary time sampling system was employed as

follows: (a) The observer used a CD recording cuing her every 15 seconds to the time for
observation/recording; (b) At each 15-second point, the observer made a judgment about the
occurrence of behaviors in each category for both peers and subjects at that point in time; and
(c) The observer recorded the results for each category on a specially designed data sheet.
The following behaviors were coded for both (a) interaction of peer, and (b)
interaction of child with autism:
(a) Interaction of peer.
• Initiates Interaction was defined as a peer making the first step toward an interaction.
• Positive Interaction was defined as a peer initiating a positive interaction with the
subject or responding positively to the interaction initiated by the subject. If the
peer’s intention of interaction was positive, but received a negative response from the
subject, it was evaluated as a negative interaction and not recorded on the data sheet.
Negative interaction was defined as inappropriate behavior of peers and the subject
(e.g., pushing, taking something away, screaming, scratching) and was not coded.
• Stays in the Music Hut was defined as the chosen peer stayed in the Music Hut for the
period of data collection in Condition C and D.
(b) Interaction of child with autism
• Initiates Interaction was defined as the subject making the first step towards the
interaction.
• Positive Interaction was defined as the subject initiating a positive interaction with
peer or responding positively to the interaction initiated by peer. If the subject’s
intention of interaction was positive, but received a negative response from peers, it
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was evaluated as a negative interaction and not recorded on the data sheet. Negative
Interaction was defined as inappropriate behavior of peers and the subject (e.g.,
pushing, taking something away, screaming, scratching).
• Stays in the Music Hut was defined as the subject stayed in the Music Hut for the
period of data collection in Condition B, C and D (to determine weather the
interaction was tied to a musical activity).
• Play and Engagement with Material and Equipment was defined as actively
manipulating a material and using the equipment (e.g., digging in the sand box,
sliding, riding a tricycle, walking purposely to a location, activating the instruments
in the Music Hut or Sound Path).
• Interaction Supported by Adults was defined as the teachers prompting the subject
and his peers verbally/musically (e.g., “Gentle, stop scratching!” or “Play the drum”)
or physically (e.g., teacher puts her hand on either child in order to facilitate positive
interaction). For both subjects and peers, examples for positive interaction are as
follows:
o Singing/Playing together including vocalization and/or playing an instrument
or engaging in a musical or in Condition A in a non-musical game with peers
o Communicate with each other, meaning any positive verbalization or
vocalization was made toward each other
o Giving/taking/sharing objects in a positive way
o Reaching for or touching each other with the intent for positive physical
contact
o Watch each other’s activity or have eye contact

(2) Task behaviors of teacher and peers.
Additionally five steps of teacher’s task behaviors in Condition C, and peer’s task behaviors
in Condition D were recorded on a separate data sheet. A judgment was made, whether or
not the sequence of tasks were completed during the 10 minutes of data collection each day.
• Teacher’s task behaviors in Condition C was defined as follows: (1) entering the
Music Hut with the subject and at least one peer buddy; (2) initiating play, including
both children on their level; (3) singing the individually composed song and playing
the instruments in the Music Hut; (4) modeling the content of the song, e.g., choosing
an instrument, naming peers, waiting for turns, appropriate body contacts; and (5)
continuing to play in the Music Hut for 10 minutes at a time.
• Peer’s task behaviors in Condition D was defined as follows: (1) entering the Music
Hut with the subject, (2) initiating play, including the subject (3) singing the
individually composed song and playing the instruments in the Music Hut, (4)
modeling the content of the song, e.g. choosing an instrument, naming peers, waiting
209
for turns, appropriate body contact, and (5) continuing to play in the Music Hut for 10
minutes at a time.
(3) Field Notes
Field notes were recorded on the bottom of the task following data sheet as
outlined in Appendix C and in a separate logbook.

210
6.3.7. Reliability
Interobserver agreement data were collected on the subjects, peers and teachers
behavior. A music therapist and the investigator collected interobserver agreement
during baseline sessions (Condition A), adaptation of the playground (Condition B),
intervention session (Condition C), and peer-mediated intervention session (Condition
D). Before the baseline was started, the two observers coded the peer interaction on
playgrounds by using 10-minute videotaped recordings until they reached a mean
agreement level of greater than 85%. A second observer was trained due to the drop out
of the music therapist in the last phase of Condition C and D. Agreement between the
scores from the first and second reliability observer was calculated prior the start of the
data collection phase by using videotaped segments from previously evaluated sessions to
establish an acceptable level of agreement of greater than 85%. Reliability checks were
carried out on an average of 36.8% of total observations within each phase and for each
child. Two coders coded the videotaped segment for each target behavior. Interobserver
agreement levels for each code category were calculated by summing the number of
agreements (defined as the same coding interval) and dividing the number by sum of
agreements plus disagreements and multiplying by 100.

6.4 Results
6.4.1 Interobserver Agreement
211
Interobserver agreement data on subject, peer and teacher performance were collected
in 39.5% of the baseline session, in 38.5% of the adaptation of the playground (Condition B),
in 33.8% of the intervention session (Condition C), and in 35.7% of the peer-mediated
intervention session (Condition D) for each child. During baseline condition, reliability data
showed observers agreed on participants’ performance 99.5% of the trials (range: 99.3% to
99.8%). The percentage of agreement was 99.3% for Eric, 99.5% for Ben, 99.3% for Phillip,
and 99.8% for Lucas. During the adaptation of the playground phase (Condition B),
reliability data showed observers agreed on the participants’ performance 99.5% of the trials
(range: 99.4% to 99.6%). The percentage of agreement on participants’ responses was
99.6% for Eric, 99.4% for Ben, 99.5% for Phillip, and 99.5% for Lucas. During the teacher-
mediated intervention phase (Condition C), reliability data showed observers agreed on
participants’ performance in 97.4% of the trials (range: 96.6% to 98.3%). The percentage of
agreement on the participants’ responses was 98.3% for Eric, 98.0% for Ben, 96.6% for
Phillip, and 96.7% for Lucas. During the peer-mediated intervention phase (Condition D),
reliability data showed observers agreed on the participants’ performance 96.3% of the trials
(range: 93.8% to 98%). The percentage of agreement on the participants’ responses was
93.8% for Ben, 97.0% for Phillip, and 98.0% for Lucas. The overall interobserver agreement
was 98.2% (range 93.8% to 99.8%). Table 6.6 gives a summary of the interobserver
agreement in Experiment III.

212
Table 6.6. Interobserver agreement for each target child in conditions A, B, C, and D.
Participants Condition A, in % Condition B, in % Condition C, in % Condition D, in %
Eric 99.3 99.6 98.3 N/A
Ben 99.5 99.4 98 93.8
Phillip 99.3 99.5 96.6 97.0
Lucas 99.8 99.5 96.7 98.0
Overall 99.5 99.5 97.4 96.3
6.4.2 Outcome Data
The outcome data of Experiment III are presented in the following order:
(1) Positive Peer Interactions
(2) Teacher’s Task Behaviors and Positive Peer Interactions
(3) Peer’s Task Behaviors and Unsupported Positive Peer Interactions
(4) Positive Peer Interactions and Stays in the Music Hut
(5) Play and Engagement
(1) Positive Peer Interactions
All children with autism had few interactions with their peers during baseline
condition (M=3.2%). After the adaptations of the playground (Music Hut), peer interactions
increased slightly, but stayed at a very low level (M=7.1%). During the teacher-mediated
intervention phase (Condition C), meanwhile the peer interactions increased substantially for
all children. This change was abrupt and stayed high through out the entire condition
(M=66.2%). During the peer-mediated intervention (Condition D), the supported peer

interaction appeared slightly lower than in Condition C, but stayed at a very high level
(M=69.5%). The independent peer interaction was at a lower level as the supported peer
interaction, but was significantly higher than during baseline condition and the adaptation on
the playground phase (M=21.1%). One exception was Eric (subject 1). His teachers made a
commitment for a limited time to participate in the study, which did not allow enough time
for Eric to go into Condition D (peer-mediated intervention). Table 6.7 gives an overview of
the mean intervals and range of positive peer interaction for each target child by each
condition of the study. Figure 6.8 shows the percentage of positive peer interactions for each
target child by each condition of the study.
Table 6.7. Range (Min% and Max%), Mean (M%), and Standard Deviation (SD) of positive
peer interaction for each target child, by each condition of Experiment III.
Condition Min Max
Eric
M
SD
Min
Ben
Max
M
SD
Min Max
Phillip Lucas
M
SD
Min Max
A 0.0 17.5 5.9 6.0 0.0 12.5 1.4 3.8 0.0 15.0 4.1 6.8 0.0 5.0 1.5 1.6
B 2.5 40.0 16.7 14.1 0.0 12.5 2.7 3.7 0.0 32.5 6.3 8.4 0.0 10.0 2.5 2.8
C 32.5 67.5 48.8 12.1 52.5 92.5 77.5 10.8 32.5 95.0 77.4 14.5 27.5 80.0 61.0 14.4
D sup N/A N/A N/A N/A 42.5 80.0 66.9 9.3 60.0 92.5 70.3 10.6 62.5 80.0 71.6 6.5
D unsup N/A N/A N/A N/A 0 30 17.3 10.9 7.5 32.5 21.9 8.8 12.5 40 24.1 8.6
M
SD
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A B C D
100
80
Eric
60
40
20
0
5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85 90
100
80
Ben
60
40
20
0
5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85 90
100
80
% of Positive Peer Interactions
Phillip
60
40
20
0
5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85 90
100
80
Lucas
60
Unsupported
Interaction
Supported
Interaction
40
20
0
5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85 90
Figure 6.8. Percentage of positive peer interactions for each target child, by each condition of Experiment III.

Eric. Eric was observed a total of 30 sessions. Figure 6.9 shows the percentage of
Eric’s positive peer interactions by each condition of the study. In the baseline condition,
Eric’s positive peer interaction was quite low and variable. All data points were 18% or less,
with a range from 0% to 18%. In four sessions out of 11, no positive peer interaction was
observed. In the majority of observations the positive peer interaction was below 6%. The
adaptation of the playground (Music Hut) resulted in an increase of Eric’s positive peer
interactions, but the quality of these interactions was quite inconsistent from day to day,
ranging from 3.% to 40%. The teacher-mediated intervention (Condition C) resulted in an
abrupt and sharp increase in the level of data. The intervention increased significantly in
positive peer interaction, although it was variable across days. On all observations, Eric’s
percentage of positive peer interaction was greater than 33%, with a range from 33% to 68%.
For the last four observations, the positive peer interaction was stable in a range from 40% to
45%. On every day of observation, positive peer interaction was noted. The peer-mediated
intervention (Condition D) was not implemented due to teacher’s time commitment based on
classroom schedule issues.
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Figure 6.9. Percentage of positive peer interactions for Eric during Conditions A, B, and
C.
% of Positive Peer Interactions
100
95
90
85
80
75
70
65
60
55
50
45
40
35
30
25
20
15
10
5
0
A B C
0 5 10 15 20 25
Sessions
Unsupported Interaction
Supported Interaction
Ben. Ben was observed a total of 56 sessions. Figure 6.10 shows the percentage of
Ben’s positive peer interactions by each condition of the study. In the baseline condition,
Ben’s positive peer interaction was very low and fairly stable. All data points were 13% or
less, and ranged from a low of 0% to a high of 13%. Only in two out of 11 sessions, positive
peer interaction was observed. The adaptation of the playground (Music Hut) resulted in a
small increase in Ben’s positive peer interaction, whereupon the subsequent readings were
variable. All data points were still 13% or less with a range from 0% to 13%. In seven out
of 15 observations, positive peer interaction was observed. The teacher-mediated

intervention (Condition C) resulted in an abrupt and sharp increase in positive peer
interactions, although day-on-day changes fluctuated considerably. On all observations,
Ben’s percentage of positive peer interaction was greater than 53%, with a range from 53%
to 93%. The majority of observations were above 80%. On every day of observation
positive peer interaction was noted. On nine out of 18 observations, peer interaction was
greater than 80%. The peer-mediated intervention (Condition D) resulted in a small decrease
of supported positive peer interaction. The percentage of supported positive peer interaction
continued at a very high level, however, ranging from 43% to 80%. The majority of
observations were above 65%, except for one day of intervention, which resulted in 43%.
The peer-mediated intervention resulted in a greater percentage of unsupported positive peer
interaction, compared with Condition B, and was quite variable. All data points ranged from
0% to 30%. The majority of observations topped 20% and reverted back to 0% in only two
sessions.
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218
Figure 6.10. Percentage of positive peer interactions for Ben during Conditions A, B, C, and
D.
% of Positive Peer Interactions
100
95
90
85
80
75
70
65
60
55
50
45
40
35
30
25
20
15
10
5
0
A B C D
0 5 10 15 20 25 30 35 40 45 50 55
Sessions
Unsupported Interaction
Supported Interaction
Phillip. Phillip was observed for a total of 63 sessions. Figure 6.11 shows the
percentage of Phillip’s positive peer interactions by each condition of the study. In the
baseline condition, Phillip’s positive peer interaction was quite low. All data points were
15.0% or less, with a range from 0.0% to 15.0%. In five out of eight sessions, no positive
peer interaction was observed. The adaptation of the playground (Music Hut) resulted in a

small increase in Phillip’s positive peer interaction, and subsequent readings were quite
consistent. During the first 15 observations, peer interaction was below 7% with one
exception. In the second part (9 sessions), readings were variable and ranged from 0% to
23%. The teacher-mediated intervention (Condition C) resulted in an abrupt and sharp
increase in the level of data. The intervention increased significantly in positive peer
interaction although it was variable across days. On all observations, Phillip’s percentage of
positive peer interaction was upwards of 33%, with a range from 33% to 93%. The majority
of observations were above 64%, except the first day of intervention, which resulted in 33%.
On every day of observation positive peer interaction was noted. On nine out of 22
observations, the peer interaction was greater than 80%. The peer-mediated intervention
(Condition D) resulted in a small decrease of supported positive peer interaction during the
first four observations and consistent day-to-day for the second half. All data points were
above 60%, with a range from 60% to 93%. The peer-mediated intervention (Condition D)
resulted in an increased percentage of unsupported positive peer interaction compared with
Condition B and was quite variable. All data points were above 8%, with a range from 8% to
33%. The majority of observations were above 23%, but never approached baseline readings
of 0% positive peer interactions.
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220
% of Positive Peer Interactions
Figure 6.11. Percentage of positive peer interactions for Phillip during Conditions A, B, C,
and D.
100
95
90
85
80
75
70
65
60
55
50
45
40
35
30
25
20
15
10
5
0
A B C D
0 5 10 15 20 25 30 35 40 45 50 55 60
Sessions
Unsupported Interaction
Supported Interaction
Lucas. Lucas was observed a total of 71 sessions. Figure 6.12 shows the percentage
of Lucas’ positive peer interactions by each condition of the study. In the baseline condition,
Lucas’ positive peer interaction was very low – and stably so. All data points were 5% or
less, with a range from 0% to 5%. In six out of 13, sessions no positive peer interaction was
noted. The adaptation of the playground (Music Hut) resulted in a small increase of Lucas’

positive peer interaction and was quite consistent. All data points were 10% or less with a
range from 0% to 10%. In 13 out of 29, observations no positive peer interaction was
observed. The teacher-mediated intervention (Condition C) resulted in a sudden and acute
increase in the level of data. The intervention increased significantly in positive peer
interaction, though very variable across days. On all observations, Lucas’ percentage of
positive peer interaction was greater than 28%, with a range from 28% to 80%. The majority
of observations lay above 58%. Day on day, positive peer interaction was noted. In the peer-
mediated intervention (Condition D), no apparent change was observed on a consistent basis.
All data points were above 63%, with a range from 63% to 80%. The peer-mediated
intervention (Condition D) resulted in an increased percentage of unsupported positive peer
interaction compared with Condition B, but this change resulted in variable readings as well.
All data points were above 13% , with a range from 13% to 40%. The majority of
observations was above 20%, never deflated back to baseline levels of 0%.
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222
Figure 6.12. Percentage of positive peer interactions for Lucas during Conditions A, B, C,
and D.
% of Positive Peer Interactions
100
95
90
85
80
75
70
65
60
55
50
45
40
35
30
25
20
15
10
5
0
0 5 10 15 20 25 30 35 40 45 50 55 60 65 70
(2) Teachers’ Task Behaviors and Positive Peer Interactions
Procedural fidelity data were collected on teachers’ task behaviors during the teacher-
mediated intervention (Condition C) to answer the third research question: Can classroom
teachers learn the principles important to music therapy to increase peer interaction on the
playground for young children with autism?
A B C D
Sessions
Unsupported Interaction
Supported Interaction

All data of the target children’s teachers’ task behavior were consistently on a high level,
except for Eric’s teachers’ data, which dropped abruptly to a low level of data after the first
half of Condition C. Interestingly, the teachers’ task behavior correlated with the positive
peer interaction. That is, when the teacher’s task behavior was on a high level, the peer
interaction was also on a high level and vice versa. With only one exception, all teachers
implemented the intervention on a very high level.
Table 6.8. Range (Min% and Max%), Mean (M), and Standard Deviation (SD) of teacher
task behavior for each target child in Condition C.
Condition
Eric
Min Max
M
SD
Min
Ben
Max
M
SD
Min Max
Phillip Lucas
M
SD
Min Max
C 1 4 2.4 1.4 4 5 4.8 0.4 4 5 4.9 0.4 3 5 4.7 0.6
M
SD
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% of Positive Peer Interactions
100
80
60
40
20
0
0 1 2 3 4 5 6 7 8 9
Sessions
100
5
80
60
40
20
0
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
100
Sessions
5
80
60
40
20
0
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21
100
Sessions
5
80
60
40
20
0
0 1 2 3 4 5 6 7 8 9 1011121314151617181920
Sessions
Figure 6.13. Teacher’s task behaviors and positive peer interactions in Condition C for
Eric (top panel), Ben (second panel), Phillip (third panel), and Lucas (bottom panel).
4
3
2
1
0
4
3
2
1
0
4
3
2
1
0
5
4
3
2
1
0
Steps of Teachers‘ Tasks
Eric
Ben
Phillip
Lucas
Supported
Interactions
Teachers’ Task
Behaviors

Eric. The teachers’ task behavior was observed a total of 10 sessions. The top panel
of Figure 6.13 shows the number of steps Eric’s teachers completed correctly, as well as
Eric’s positive peer interaction during Condition C. Eric’s teachers’ task behavior was on a
high level and consistent for the first half of Condition C, then abruptly dropped to a low
level for the second half of Condition C. During the first five sessions, except session four,
Eric’s teachers completed four out of the five steps of the teacher-mediated intervention
procedure correctly (except continuing to play in the Music Hut for 10 minutes). During the
second half of the teacher-mediated intervention procedure, only one step was accomplished
(model tasks of song), with the exception of session eight (2 steps). In the beginning of
Condition C, Eric’s positive peer interaction increased. Data show a decrease in Eric’s
positive peer interaction as soon as the teacher’s task behavior dropped to a very low level.
Ben. The teacher’s task behavior was observed a total of 18 sessions. The second
panel of Figure 6.13 shows the number of steps Ben’s teacher completed correctly, as well as
Ben’s positive peer interaction during Condition C. The teachers’ task behavior was on the
highest level and very consistent. On all sessions his teacher performed all steps. Only in
three sessions during the second half of Condition C valid, Ben’s teacher complete four steps
of the teacher-mediated intervention procedure (except continuing to play in the Music Hut
for 10 minutes) correctly. Ben’s positive interaction was also at a very high level, but was
variable across days. The data indicate that the variability correlated with the teacher’s task
behavior, meaning that he had less positive peer interactions on the three sessions his teacher
accomplished only four steps out of the five steps procedure.
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226
Phillip. The teacher’s task behavior was observed a total of 22 sessions. The third
panel of Figure 6.13 shows the number of steps Phillip’s teacher completed correctly,
together with Phillip’s positive peer interaction during Condition C. The teachers’ task
behavior was on the highest level and very consistent. In 19 sessions his teacher performed
all five steps. In only three sessions did Phillip’s teacher complete “only” four steps of the
teacher-mediated intervention procedure correctly (except enter Music Hut with the dyad and
continuing to play in the Music Hut for 10 minutes). Not surprisingly, Phillip’s positive
interaction was also on a very high level, and variable across days. The data indicate that the
variability coincided closely with the teacher’s task behavior, meaning that he had less
positive peer interactions on the three sessions in which his teacher accomplished only four
steps out of the five-step procedure.
Lucas. The teachers’ task behavior was observed a total of 21 sessions. The bottom
panel of Figure 6.13 shows the number of steps Lucas’ teachers completed correctly, as well
as Lucas’ positive peer interaction during Condition C. The teachers’ task behavior was on
the highest level and very consistent. On 16 sessions, his teachers performed all steps. Only
in four sessions did Lucas’ teachers complete four steps (continuing to play in the Music Hut
for 10 minutes), and in one session only three steps, of the teacher-mediated intervention
procedure (except model tasks of song and continuing to play in the Music Hut for 10
minutes) correctly. On the majority of days, Lucas’ positive interaction was greater than
58% but was variable across days. The data indicate that the variability correlated with the
teacher’s task behavior, meaning that even small differences in the teachers’ task behavior

made a difference in Lucas’ positive peer interactions. This relationship is evident in the
data.
(3) Peers’ Task Behaviors and unsupported Positive Peer Interactions
Procedural fidelity data were collected on peer’s task behaviors during the peer-
mediated intervention (Condition D) to answer the third question: Do peers participate and
model targeted tasks?
The data related to peers’ task behavior show that all peers implemented parts of the
five steps of the peer-mediated intervention procedure correctly. The data of Phillip’s and
Lucas’ peer buddies was consistent and on a high level. The data of Ben’s peer buddies were
variable, however, ranging from two steps to five steps. No data were collected on Eric’s
peers’ task behavior, because Condition D was not implemented. As with teacher fidelity,
peers’ task behavior correlated with the positive peer interaction for Ben and Phillip. That is,
when peers’ task behavior was on a high level, the interaction among them was also on a
high level and vice versa. As addressed in the Discussion section 6.5, Lucas’ anomalous
reaction to the peer based intervention might be more readily understood as function of his
specific ASD symptomatology.
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228
Table 6.9. Range (Min % and Max %), and Standard Deviation (SD) of peer task behavior
for each target child in Condition D.
Condition Min Max
Eric
M
SD
Min
Ben
Max
M
SD
Min Max
Phillip Lucas
M
SD
Min Max
D N/A N/A N/A N/A 2 5 3.6 0.9 4 5 4.9 0.4 2 5 4.3 1
M
SD

% of Positive Peer Interactions
100
80
60
40
20
0
100
80
60
40
20
0
0 1 2 3 4 5 6 7 8 9 10 11
Sessions
5
0
0
0 1 2 3 4 5 6 7
Sessions
100
5
80
60
40
20
0
0
0 1 2 3 4 5 6 7
Sessions
Figure 6.14. Peer’s task behaviors and positive peer interactions in Condition D for Ben (top
panel), Phillip (middle panel), and Lucas (bottom panel).
5
4
3
2
1
4
3
2
1
4
3
2
1
Steps of Peers’ Tasks
Ben
Phillip
Lucas
Unsupported
Interactions
Peer Task
Behaviors
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230
Ben. The peers’ task behavior was observed for a total of 12 sessions. The top panel
of Figure 6.14 shows the number of steps Ben’s peer buddies completed correctly, as well as
Ben’s unsupported positive peer interaction during Condition D. His peers’ task behavior
was very variable and ranged from two steps to five steps. On two of the sessions Ben’s
peers completed five steps, and on one day only two steps (initiate to play and include child
with autism, sing the song with the child with autism) of the peer-mediated intervention
procedure correctly. Ben’s unsupported positive interaction was quite variable. All data
points ranged from 0% to 30%, with very low levels when peers’ task following dropped to
lower levels (session 2, 3 and 10).
Phillip. The peers’ task behavior was observed a total of eight sessions. The middle
panel of Figure 6.14 shows the number of steps Phillip’s peer buddies completed correctly as
well as Phillip’s unsupported positive peer interaction during Condition D. The peers’ task
behavior was on the highest level and very consistent. On seven sessions the peers
completed all steps. In only two sessions, Phillip’s peers completed four steps of the peer-
mediated intervention procedure correctly (except enter Music Hut together). Phillip’s
unsupported positive peer interaction was variable across days and ranged from 8% to 33%.
On six out of eight days, positive peer interaction was quite stable. On only two days did this
drop to 8%. And on one day of this, this drop-off coincided with a concomitant drop-off in
the number of peer steps completed (i.e., from five to four).
Lucas. Lucas’ peers’ task behavior was also observed in eight sessions. The bottom
panel of Figure 6.14 shows the number of steps Lucas’ peer buddies completed correctly, as

well as Lucas’ unsupported positive peer interaction during Condition D. The peers’ task
behavior was on quite a high level, that is, always four steps or higher. Except on the first
session, Lucas’ peers completed only two steps of the peer-mediated intervention procedure
(initiate to play and include child with autism, sing the song with the child with autism)
correctly. Lucas’ unsupported positive peer interactions were variable across days and
ranged from 13% to 40%. The data indicate no correlation between peers’ task behavior and
unsupported positive interactions.
(4) Positive Peer Interactions and Stays in the Music Hut
The correlation of positive peer interactions and staying in the Music Hut is presented
to answer the third research question. Does the musical adaptation of a playground (Music
Hut) increase the peer interaction of young children with autism on playgrounds, and
demonstrate if musical activity – this as opposed to more traditional activities on the
playground increased peer interaction for the target children. When in the Music Hut, the
children more likely engaged in musical activity such as playing the instruments, singing and
dancing than on other areas of the playground. With the original playground setting
(Condition A) the target children had few interactions with their peers. When the outdoor
music center was available (Condition B), the target children spend at least some time almost
every in the Music Hut. However, the data bear witness to only a small increase in positive
peer interactions over the previous condition, and then at a very low level. During the
teacher-mediated intervention phase (Condition C), the target children stayed significantly
more time in the Music Hut. In this scenario the peer interaction spiked to a high level and
stayed high through the entire condition for all children. During the peer-mediated
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intervention (Condition D), the target children continued to stay in the Music Hut. The
positive peer interaction appeared slightly lower than in Condition C, but remained a high
level nonetheless.
Table 6.10. Range (Min% and Max%), Mean (M%), and Standard Deviation (SD) of stays
in the Music Hut for each target child by Conditions B, C, and D of Experiment III.
Condition Min Max
Eric
M
SD
Min
Ben
Max
M
SD
Min Max
Phillip Lucas
M
SD
Min Max
B 2.5 90.0 28.1 34.5 0.0 50.0 15.7 12.8 2.5 62.5 16.9 15.7 2.5 80.0 23.0 20.7
C 27.5 77.5 52.3 18.8 85.0 100 98.1 4.0 70.0 100 96.1 7.9 50.0 100 90.8 15.9
D N/A N/A N/A N/A 65.0 100 92.3 10.7 95.0 100 97.8 2.1 82.5 100 92.8 5.4
M
SD

% of Positive Interactions and Stays in the Music Hut
100
80
60
40
20
0
100
80
60
40
20
0
80
60
40
20
0
A B C
0 5 10 15 20 25
A B C D
Sessions
0 5 10 15 20 25 30 35 40 45 50 55
Sessions
100
00 05 10 15 20 25 30 35 40 45 50 55 60
Sessions
100
80
60
40
20
0
0 5 10 15 20 25 30 35 40 45 50 55 60 65 70
Sessions
Figure 6.15. Percentage of positive peer interactions and stays in the Music Hut for Eric (top
panel), Ben (second panel), Phillip (third panel), and Lucas (bottom panel) in all conditions.
Eric
Ben
Phillip
Lucas
Positive
Interaction
In Music Hut
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Eric. The top panel of Figure 6.15 shows the percentage of Eric’s positive peer
interactions and staying in the Music Hut. Eric was observed a total of 30 sessions. In the
baseline condition, no Music Hut was available, and Eric’s positive peer interaction was
quite low and variable. When the Music Hut was opened (Condition B), Eric’s stay in the
Music Hut ranged from 2.5% to 90% of the daily observation time. Only on three sessions
he stayed more than 50%. The adaptation of the playground resulted in a small increase of
Eric’s positive peer interaction. With the teacher-mediated intervention (Condition C), Eric
stayed significantly longer in the Music Hut (range: 27.5% to 77.5%). The positive peer
interaction increased significantly after the intervention was introduced, although it was
variable across days. The peer-mediated intervention (Condition D) was not implemented.
Ben. The percentage of Ben’s positive peer interactions and stays in the Music Hut is
shown in the second panel of Figure 6.15, broken down by each condition of the study.
Altogether, Ben was observed for a total of 56 sessions. At baseline, no Music Hut was
available and Ben’s positive peer interaction was predictably quite low and very stable.
When the Music Hut was opened (Condition B), however, Ben’s stay in the Music Hut
ranged from 0% to 50% in the Music Hut. Only on three sessions he stayed more than
27.5%. The adaptation of the playground resulted in a small increase of Ben’s positive peer
interaction, and was quite consistent. With the teacher-mediated intervention (Condition C)
Ben stayed significantly longer in the Music Hut overall (range: 85% to 100%). The positive
peer interaction in the Music Hut increased significantly after the intervention was
introduced, even though it was variable across days. During the peer-mediated intervention
(Condition D) Ben’s stay in the Music Hut decreased a bit and was less stable (range: 65% to

100%). The peer-mediated intervention resulted in a small decrease in positive peer
interaction. Again, however, the percentage of positive peer interaction was still at a very
high level.
Phillip. The third panel of Figure 6.15 represents the percentage of Phillip’s positive
peer interactions and stays in the Music Hut in the four study conditions, with a total of 63
sessions altogether. In baseline measurements, no Music Hut was available, and Phillip’s
positive peer interactions were expectedly quite low. After the Music Hut was opened
(Condition B), Phillip’s stay in the Music Hut ranged from 2.5% to 62.5%. Only in six
sessions did he stay more than 30% of the allotted time. The adaptation of the playground
resulted in a small increase in Phillip’s positive peer interactions with quite consistent
readings to follow. With the teacher-mediated intervention (Condition C), Phillip’s stay in
the Music Hut ranged from 70% to 100%. It resulted in a sharp increase in the level of data,
although it was variable across days. During the peer-mediated intervention (Condition D)
Phillip continued to stay in the Music Hut for a sustained period (range: 95% to 100). The
peer-mediated intervention resulted in a small decrease of positive peer interaction, but the
percentage of positive peer interaction remained at a very high level.
Lucas. Lucas was observed a total of 71 sessions. The bottom panel of Figure 6.15
shows the percentage of Lucas’ positive peer interactions and stays in the Music Hut, broken
at by each condition of the study. In the baseline condition, no Music Hut was available,
and Lucas’ positive peer interaction was very low and stable. When the Music Hut opened
(Condition B), Lucas’ stay in the Music Hut ranged from 2.5% to 80%. In 15 sessions he
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stayed more than 20%. Adaptation of the playground, for its part, resulted in a small increase
of Lucas’ positive peer interaction and was quite consistent. With the intervention
(Condition C) Lucas stayed significantly longer in the Music Hut (range 50% to 100%). The
positive peer interaction in the Music Hut increased significantly after the intervention was
introduced although, it was very variable across days. During the peer-mediated intervention
(Condition D), Lucas’ stay in the Music Hut decreased a little and was less stable (range:
82.5% to 100%). In the peer-mediated intervention (Condition D), positive peer interaction
appeared to be similar to the previous condition. The percentage of positive peer interaction
was still at a very high level.
(5) Play and Engagement
Play and engagement with material and equipment was defined as actively
manipulating material and using the equipment in a meaningful way. In Condition A and B,
Ben’s, Phillip’s and Lucas’ percentage of play and engagement with material and equipment
was on a low level and variable across days. In Condition C and D, their play and
engagement abruptly increased to a very high level while variability continued to be hallmark
of postvention reading. Eric’s play and engagement was very variable across all Conditions,
and in Condition A on a higher level than the other children’s play and engagement.

Table 6.11. Range (Min% and Max%), Mean (M%), and Standard Deviation (SD) of play
and engagement for each target child, by each condition of Experiment III.
Condition Min Max
Eric
M
SD
Min
Ben
Max
M
SD
Min Max
Phillip Lucas
M
SD
Min Max
A 25.0 97.5 52.7 22.9 0.0 37.5 13.6 12.8 0.0 97.5 20.0 33.4 0.0 20.0 4.0 6.7
B 25.0 80.0 52.8 14.9 0.0 60.0 20.8 15.2 0.0 60.0 15.3 12.9 0.0 57.5 18.0 13.6
C 37.5 95.0 65.3 19.1 40.0 95.0 72.9 14.6 47.5 95.0 71.4 12.6 17.5 57.5 40.7 12.2
D N/A N/A N/A N/A 40.0 67.5 59.2 8.2 47.5 85.0 61.6 11.6 10.0 50.0 28.8 12.3
M
SD
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% of Play and Engagement and Stays in the Music Hut
100
80
60
40
20
0
0 5 10 15 20 25
A B
Sessions
C D
100
80
60
40
20
A B C
0
0 5 10 15 20 25 30 35 40 45 50 55
Sessions
100
80
60
40
20
0
00 05 10 15 20 25 30
Sessions
35 40 45 50 55 60
100
80
60
40
20
0
0 5 10 15 20 25 30 35 40 45 50 55 60 65 70
Sessions
Figure 6.16. Percentage of play and engagement and stays in the Music Hut for Eric (top
panel), Ben (second panel), Phillip (third panel), and Lucas (bottom panel), in all conditions.
Eric
Ben
Phillip
Play and
Lucas
Engagement
In Music Hut

Eric. Eric was observed a total of 30 sessions. The top panel of Figure 6.16 indicates
the percentage of Eric’s play and engagement by each condition of the study. In the baseline
condition, Eric’s play and engagement with material and equipment was very variable with a
low of 25% and a high of 97.5%. The level of data appeared similar across Conditions A and
B (baseline-adaptation of the playground). Eric’s play and engagement was still variable
across days, with a low of 25% to a high of 80%. The teacher-mediated intervention
(Condition C) resulted in an increase of Eric’s play and engagement and a decreasing trend
after the third session, ranging from a low of 37.5% to a high of 95%. The peer-mediated
intervention (Condition D) was not implemented.
Ben. The number of Ben’s observations spanned over 56 sessions. The second panel
of Figure 6.16 shows the percentage of Ben’s play and engagement with material and
equipment by each condition of the study. At baseline, Ben’s play and engagement was on a
low level and was variable from day to day, with a range of 0% to 37.5%. The level of data
was similar across Conditions A and B (adaptation of the playground). Ben’s play and
engagement was still variable across days, with a low of 0% to a high of 60%. The teacher-
mediated intervention (Condition C) effected an abrupt and large change in his play and
engagement, though with a low of 40% to a high of 95%, and still variable across days. The
peer-mediated intervention (Condition D) resulted in a lower level of data than the teacher-
mediated interventions, and ranged from a low of 40% to a high of 62.5%. Ben’s play and
engagement was still significantly higher than in Conditions A and B.
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Phillip. The third panel of Figure 6.16 corresponds to the percentage of Phillip’s play
and engagement with material and equipment, by each condition of the study. Phillip was
observed a total of 63 sessions. In the baseline condition, Phillip’s play and engagement was
at a low level (except in session five) and variable across days, however, with a low of 0% to
a high of 97.5%. The level of data appeared similar across Conditions A and B (baseline-
adaptation of the playground). Phillip’s play and engagement was still variable across days,
however, with a low of 0% to a high of 60%. The teacher-mediated intervention (Condition
C) resulted in a sudden, striking change in data readings on Phillip. His play and engagement
was on a much higher level, with a low of 47.5% and a high of 95%, while variability
continued across days. The peer-mediated intervention (Condition D) resulted in a lower
level of data than Condition C, ranging from a low of 47.5% to a high of 85%, but was still
significantly higher than Phillip’s play and engagement in Conditions A and B.
Lucas. Lucas was observed a total of 71 sessions, as represented in the bottom panel
of Figure 6.16. In the baseline condition, Lucas’ play and engagement was on a low level
and was variable across days, with a low of 0% to a high of 20%. The adaptation of the
playground (Music Hut) shows an increasing trend of Lucas’ play and engagement.
Variability continued, with a low of 0% to a high of 57.5%. The teacher-mediated
intervention (Condition C) resulted in an abrupt change in the level of data. Lucas’ play and
engagement was on a higher level, with a low of 17.5% to a high of 57.5%, variable across
days, and shows a decreasing trend toward the end of Condition C. The peer-mediated
intervention (Condition D) resulted in a lower level of data than Condition C. Lucas’ play

and engagement ranged from a low of 10% to a high of 50%, and produced similar play and
engagement levels as in Condition B.
6.5 Discussion
The major purpose of Experiment III was to evaluate the effects of the musical
adaptation of a childcare playground, more generally and more specifically, the effects of an
individually designed music therapy intervention, on on-playground peer interactions among
four young children diagnosed with ASD and their peers. An additional purpose was to
determine whether the classroom teachers could implement the intervention into ongoing
playground activities after staff development activities were provided, as well as whether the
child’s peers could be trained to continue with the intervention.
From this investigation an array of findings are worth noting. Prior to the musical
adaptation of the playground, the data indicate that the target children with autism had hardly
any positive peer interactions on the playground. The musical adaptation of the playground
enhanced the target children’s positive peer interactions slightly, but not significantly. Two
out of the four target children engaged in more meaningful play by using the musical
equipment available in the Music Hut. The implementation of the teacher-mediated song
intervention increased the children’s positive peer interactions immediately and significantly.
As evidenced by the procedure fidelity data, with only one exception the teachers’ accuracy
in implementing the intervention into the ongoing playground activities was very high.
Furthermore, a correlation between correct implementation and the target children’s skill
improvement was observed. Peers participated in the intervention and learned to facilitate
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the song and play activity, although a minimum of ongoing mediation and encouragement by
the children’s teachers was necessary. The peer-mediated intervention resulted in greater
positive peer interactions compared to baseline and the adaptation of the playground, but was
less effective than the teacher-mediated intervention, even though peers’ accuracy in
implementing the intervention was fairly high. Both the teacher-mediated and peer-mediated
song intervention enhanced the target children’s play and engagement on the playground.
However, for this study, ongoing music therapy collaborative consultation was necessary. In
addition to these overarching findings, a series of observations, no less important to the
effectiveness of this inquiry, were noteworthy. These findings are enumerated in the
following passages, broken down by child subject.
Eric. The results of the study indicate that Eric’s positive peer interactions on the
playground were modest (M=5.9%), whereas his play and engagement with toys and
materials was rather high (M=52.7%). With the adaptation of the playground, positive peer
interaction initially increased (M=16.7), while his play and engagement remained at the same
level as in the previous condition (M=52.8). In playground observations, novelty of the
Music Hut captured most children’s attention and motivated them to explore and play the
instruments. And because Eric was consistently curious and interested in his peers’
playground activities, he followed his classmates to the Music Hut where positive
interactions occurred while playing the instruments. When over time a smaller number of
children played in the Music Hut, Eric returned to his previously preferred solely playground
activities (e.g., riding a tricycle). The introduction of the song intervention by Eric’s
classroom teacher produced a significant increase in positive peer interactions (M=48.8%).

Due to the actions that are part of the song intervention, Eric’s play and engagement with the
material in the Music Hut increased slightly (M= 63.3%). Eric’s tendency to return to well-
known playground activities, this as soon as fewer children participated in singing and
playing in the Music Hut, led to some modifications to how the song was presented. It was
hypothesized that he would stay engaged in playing with peers longer if more children were
engaged and more structure and predictability were given. Accordingly, Eric’s teacher took
his entire class to the Music Hut, his unique song was sung with a 6.5 minute sing along
recording, and a predictable sequence of the instruments used for the progression of the song
was followed. However, Eric still needed to be redirected by his teacher to facilitate
interactions with peers. Additionally, after the third session of the teacher-mediated
intervention phase, Eric was sick for two consecutive weeks. When he returned to school, he
seemed to be weak and unstable, and had great difficulty following familiar classroom
routines. This absence resulted in a temporary decrease in his positive peer interactions,
which increased immediately in the next session. After the sixth session, Eric’s positive peer
interaction dropped to a lower level for all remaining intervention sessions. As already
mentioned, the peer-mediated intervention was not implemented due to the classroom
teacher’s time commitment prior to the study.
Eric’s formally selected “peer-buddies,” Becky and Ron, learned the song prior to the
intervention and were able to sing it independently. Both children were highly motivated to
engage in the song intervention and interact with Eric for a total of four to five minutes at a
time. Subsequently, they wanted to go about their play and interact with other friends on the
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playground, while Eric’s teacher encouraged other peers playing in the Music Hut to interact
with him.
Eric’s lead teacher finally implemented all sessions. As the procedural fidelity data
shows she performed the tasks mediated during the staff development activities on a
moderate level (M=48%). After the fifth session, her task behavior dropped to one step only
and stayed at a very low level for the entire intervention phase. It is very likely that it is for
this reason that Eric’s positive peer interactions decreased. Eric’s teacher expressed some
frustration with “peer buddies” leaving the Music Hut and with redirecting Eric to a
structured playground activity (versus a free choice of play). This teacher’s decrease in
accuracy in implementing the intervention might be owed to the challenge of keeping both
Eric and the other children engaged in the activity, and to her belief that playground time
should be a free-play setting in which peers have a free choice of play and peer interactions
occur naturally. That Eric’s peer interactions do not occur naturally has been demonstrated
by the baseline data. Clearly, teachers’ attitudes and beliefs have a major impact on
providing successful learning experiences for students with autism in inclusive settings. This
observation is consistent with previous studies, which evaluated the influence of teachers’
attitudes and beliefs on successful inclusion (e.g., Mulvihill, Shearer, & Van Horn, 2002;
Odom & Diamond, 1998), and is consistent with findings from previous studies providing
evidence that interventions are necessary to produce increases in social interaction in children
with autism (e.g., Myles et al., 1993).

What is more, Eric improved his vocalization by singing along parts of the song. He
imitated his peers in playing the instruments and took turns in playing. He frequently
expressed dislikes vocally when he wanted to go about his play, but he also expressed joy
and happiness. After the intervention, playing instruments while vocalizing parts of the song
(e.g., “Hey you!”) were some of his preferred playground activities.
Video Excerpt 6.5. Eric’s performance during the teacher-mediated intervention
phase of the playground interaction study.
Ben. During the baseline condition, the data indicate that Ben had almost no positive
peer interactions on the playground (M=1.4%), and he was modestly involved in meaningful
play with toys and playground materials (M= 13.6%). With the musical adaptation of the
playground, his play and engagement with toys and materials was slightly greater than in the
baseline condition, but his play activities changed (M=20.8%). Ben frequently played the
instruments in the Music Hut while vocalizing familiar songs. Every so often, positive peer
interaction occurred when peers joined in his play (e.g. manipulating the ocean drum),
resulting in a negligible increase in peer interactions (M=2.7%). The introduction of the song
intervention by Ben’s classroom teacher produced a tremendous and immediate increase in
positive peer interactions (M=77.5%). Owing to the design of the song intervention, his play
and engagement with materials in the Music Hut increased significantly (M= 95.0%). His
teacher performed the tasks, learned during the staff development activities, on a very high
level (M=96.0%), and was flexible in adjusting the intervention to the needs of the children.
After the sixth session of the teacher-mediated intervention phase, Ben, his family and his
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teachers faced some challenging moments. Ben was absent from school for four consecutive
weeks because of sickness, followed by a two-week winter break. Shortly afterwards, his
medication changed, and his secondary caregiver left. During this time, Ben had difficulty
following familiar classroom routines, and absenteeism and variations in his mood (e.g.,
being needy, cranky, whinny) were observed. During the Music Hut activity, his classroom
teacher needed to give physical and verbal prompts, as she had in the beginning of the
teacher-mediated intervention phase.
Ben’s formally selected “peer-buddies,” Carmen and Victor, learned the unique song
prior to the intervention, and were able to sing Ben’s song independently. Field notes point
out that during the teacher-mediated intervention, both children were very motivated in
participating in the song and play activity in the Music Hut, and expressed their joy in
singing and playing the instruments with one another. However, during the long period of
the teacher-mediated intervention (11 weeks), Ben’s “peer buddies” lost interest in this
admittedly repetitive intervention procedure. For the sake of variation, and to motivate them
to continue to participate to participate, the classroom teacher altered the presentation of the
song (e.g., Ben’s whole class played in the Music Hut, pretending to be a rock band
accompanying the song), and gave more verbal praise. The peer-mediated intervention
resulted in a slightly lower level of peer interaction than the previous condition (M=66.9%).
The unsupported peer-mediated intervention, in which no teacher’s support was given,
resulted in significantly fewer positive peer interactions, but was still above the baseline
condition and the adaptation of the playground condition (M=17.3%). As evidenced by the
procedural fidelity data, Carmen and Victor performed the tasks on a high level (M=72%).

Both children saw the song intervention as a joint mission to train Ben how to sign, sing and
play the song in the Music Hut. During the peer-mediated intervention, Carmen and Victor
came up with an effective self-motivator. They proposed to record the “Song for Ben,” and
to produce their own CD after practicing with Ben for many more days. However,
difficulties in reading Ben’s cues and with communication caused non-negligible frustration
among peers and required interpretation and mediation by their classroom teacher. For
example, Carmen and Victor made comments such as “He doesn’t want to play with me,”
when Ben did not immediately respond with the desired action at hand (e.g., taking a drum
stick), with eye contact or with verbal language. Over time, peers became more persistent in
interacting with Ben, but verification and reassurance from their teacher was still necessary.
Therefore, the teacher’s support was never fully withdrawn.
There was also a number of major improvements in Ben that are important to
highlight. During the teacher-mediated and peer-mediated intervention, Ben improved his
communication and imitation skills, his awareness and interest in peers, and his play
activities (including choice-making). Ben was able to stay and play in the Music Hut with
his peers for 10 minutes at a time. He sang the complete song verbally, and signed “You,”
“I,” and “Music.” Ben imitated his peers, and learned to pass a drumstick to his peers
whenever the song required it. No teacher’s prompt was necessary. He chose different
instruments independently, approached peers, and followed verbal prompts of his teachers
and peers. Ben also expressed joy and happiness by smiling and jumping up and down.
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To support and motivate Ben’s family during challenging periods, video excerpts of
Ben’s positive peer interaction at school were given to the family. Ben’s parents expressed
that they were delighted to see their son making progress and interacting with other children.
Ben’s parents shared the video recording with family members, Ben’s home program
therapists, and future kindergarten teachers. After evaluating the intervention with Ben’s
teacher, she came to the following conclusion:
The intervention was fun, easy and very effective. I was pleased, astonished and
touched by the clinical progress Ben made. The intervention was a good learning
process for myself. During the teacher-mediated intervention, I realized that I don’t
have to be in Ben’s face all the time and make him do things.
Video Excerpt 6.6. Ben’s performance during the teacher and peer-mediated
intervention phase of the playground interaction study.
Phillip. Positive peer interactions on the playground occurred very infrequently for
Phillip (M=4.1%), and his play and engagement with toys and materials was moderate (M=
20%). When the Music Hut was accessible, there were modest increases in positive peer
interactions, with increases becoming more marked toward the end of the phase (M=6.3%).
His play and engagement with toys and materials on the playground was on a slightly lower
level than baseline condition, but his playground activities changed (M=15.3%). Phillip
explored the instruments (e.g., feeling the vibration of the cymbal) and playfully chased his
peers. What was initially positive contact turned into negative peer interaction as play
continued. For example, peers were teasing him and Phillip started to show aggressive
behaviors toward them. Frequently, teachers needed to facilitate conflict resolution. This
behavior was not observed when he engaged in activities in the Music Hut. The introduction

of the song intervention by Phillip’s teacher produced a tremendous and immediate increase
in positive peer interactions (M=77.4%). Due to the actions incorporated in the song his play
and engagement also increased (M=71.4%). Phillip’s teacher performed the tasks on a very
high level (M=98.0%). She was very persistent in performing exactly the tasks mediated in
the staff development activities. From the seventh to the thirteenth session of the teacher-
mediated intervention phase, Phillip was absent for a short period of time. He showed
interest in the music by listening or playing the instruments, but did not respond to his
teacher or peers. Toward the end of the teacher-mediated intervention, his positive peer
interaction increased and the Music Hut routine became part of his playground activities.
Phillip’s formally selected “peer-buddy,” Justin, learned the song prior to the
intervention, and Jacky, who was new to the class, picked it up on the playground. Both
children were able to sing Phillip’s unique song independently. During the teacher-mediated
intervention, Justin was very motivated and persistent in participating in the intervention.
Jacky was interested in interacting with Phillip. However, over time, her motivation to
volunteer in the repetitive procedure decreased. Repetition was not an issue for Justin
(diagnosed with high functioning autism). In fact, when he was available, he requested to
sing and play with Phillip in the Music Hut. The peer-mediated intervention resulted in a
slightly lower level of positive peer interaction than the previous condition (M=70.3%). The
unsupported peer-mediated intervention, in which no teacher’s support was given, resulted in
significantly fewer positive peer interactions, but was still above the baseline condition and
the adaptation of the playground condition (M=21.9%). Phillip’s “peer buddies” performed
the tasks on a very high level (M=98%). Both children were very persistent in following the
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routine. Jacky was able to get Phillip’s attention easily. She was consistent, insistent, and
direct in her actions, but also in singing and playing the song. She was able to follow
Phillip’s lead or redirect him to the song activity, when he was distracted. Justin had the
same qualities, but was not flexible in following Phillip’s lead and got distracted when
Phillip did not follow the developed Music Hut routine. In these situations, Justin needed the
teacher’s guidance. Justin’s behavior is characteristic of the restricted and repetitive
behavior of autism (American Psychiatric Association, 2000; Dawson & Osterling, 1997;
National Research Council, 2001). As a result, the teacher never fully withdrew her support.
The following array of observations is also worth noting. Phillip frequently initiated
playing the instruments in the Music Hut. Phillip learned to observe, listen and imitate
playing the musical instruments. He also learned to wait for his turn to play. For example,
he often smiled happily and waited for Justin to hand him over the drumstick for his turn. In
addition, Phillip improved his language and communication skills. For example, sometimes
he initiated dancing by taking Justin’s hand or signing “dance.” Phillip also started to request
the song by singing the song’s opening line “I want.” When his teacher paused in singing, he
filled in longer phrases of the lyrics as well as names of peers or his name. Phillip used
appropriate body contact when tickling or hugging each other as a good-bye gesture. Phillip
also used sign language in combination with words for “All done!” “Good-bye!” and “Thank
you!” to end playing together in the Music Hut.
It should also be noted that other peers on the playground, particularly those with
special needs, came forward to participate in the teacher-mediated intervention, too. Phillip’s

teacher integrated them into the procedures and mediated peer interaction with Phillip.
Additionally, a younger child who was anxious, but interested in interacting with Phillip, was
observing him during the Music Hut activities. He overcame his fears and joined in dancing
and playing with Phillip and even hugged him. In general, Phillip seemed to have fewer
difficulties on the playground and frequently joined peer groups when playing in the Music
Hut. After the study, teachers reported that Justin and Phillip continued to sing and play
together in the Music Hut, but for a shorter period of time. However, these observations fall
outside the scope of this data collection period.
Phillip’s mother, who observed her son’s developmental progress during the
playground intervention on video recordings, evaluated the song intervention as a success.
She reported sharing the song with Phillip’s home program therapist, who used it as reward
when he accomplished tasks.
After the intervention with Phillip, his teacher made the following comment:
I have had a wonderful time working with Phillip in the Music Hut. This was a fun an
effective intervention. The best part for me was having Phillip look up at me with his
big brown eyes in wonder while I sang to him.
Video Excerpt 6.7. Phillip’s performance during the teacher and peer-mediated
intervention phase of the playground interaction study.
Lucas. Per the data presented here, Lucas had almost no positive peer interaction on
the playground (M=1.5%) at baseline, and his play and engagement with toys and materials
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was very low (M= 4.0). With the musical adaptation of the playground his play and
engagement was greater than in the baseline condition, and his activities changed (M=18%).
Lucas frequently ran in and out of the Music Hut, especially when peers produced sounds.
He also explored instruments (e.g., manipulated the ocean drum and cabasa, explored
vibration of the gong), or tapped a beat on one of the wooden beams of the Music Hut while
vocalizing loudly. Most of the positive peer interactions occurred accidentally while playing
in the Music Hut, which resulted in a very small increase in peer interaction (M=2.5%). The
introduction of the song intervention by Lucas’ classroom teachers produced a tremendous
and immediate increase in positive peer interactions, especially during the second half of the
teacher-mediated intervention (M=61%). Additionally, his play and engagement with
materials in the Music Hut rose significantly (M=40.7%). His teachers performed the tasks
on a very high level (M=94%). The lead teacher was creative and flexible in using the
provided materials and training. The assistant teacher for her part, was very consistent in
performing exactly the tasks mediated during staff development activities. In the beginning
of the intervention Lucas didn’t have a concept of the activities and procedure. But over
time, learning took place. During the second part of the teacher-mediated intervention phase,
Lucas participated in the activities without trying to escape from the activity.
Kayla and Megan, Lucas’ formally selected “peer buddies” learned the song prior to
the intervention and were able to sing it independently. On the second day of the teacher-
mediated intervention, Kayla played the gong very loudly and persistently. Lucas was most
likely over-stimulated and tried to escape. Escaping and over-stimulation were the major
challenges his teachers and peers had to face during the song intervention in the Music Hut.

Teachers and peers met him on his high energy level by using the following strategies
offering fast-changing sequences to keep him engaged, making fast and smooth transitions to
avoid waiting times, including his escapes in the intervention by adding a verse on running
after him and coming back to the Music Hut. Due to Kayla’s late arrival at school, her
participation was inconsistent. As the intervention progressed, other children besides Megan
– especially those with special needs – were interested and got involved in participating in
Lucas’ Music Hut activities. During the peer-mediated intervention, Megan and Lucas
usually continued singing and playing in the Music Hut. The positive peer interaction was on
a slightly higher level than the previous condition (M=71.6%). The unsupported peer-
mediated intervention, in which no teacher’s support was given, resulted in significantly
fewer positive peer interactions, but was still above the baseline condition and the adaptation
of the playground condition (M=24.1%). Lucas’ peers performed the tasks on a high level
(M=86%). However, difficulties in reading Lucas’ cues, coupled with his poor language
skills, required ongoing teacher support. Over time, peers became more persistent in
interacting with Lucas.
In terms of qualitative statements concerning these measures, the following major
improvements should be noted. Lucas was able to share his attention with peers, look at
peers, manipulate the instruments in a meaningful way, choose instruments to play with and
participate in turn-taking when assisted by teachers. Lucas seemed to enjoy movements and
accept body contact when interacting with peers. He reduced scratching and hitting
behaviors, and learned to hug and tickle peers. Often, he expressed pleasure and joy while
interacting by laughing, smiling and vocalizing. Lucas was able to stay and play in the
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Music Hut with his peers for 10 minutes at a time. A positive outcome of the intervention
study is also evident in the following lead teacher’s statement: “I love music therapy
research studies, because they are fun and make a lot of sense to me and the children.”
Video Excerpt 6.8. Lucas performance during the teacher and peer-mediated
intervention phase of the playground interaction study.
In summary, the design and musical adaptation of the playground had some
positive effects on the target children’s play behaviors on the playground. All of the
children were attracted by the sound produced by peers in the Music Hut and explored
the instruments for short periods of time. However, the musical equipment itself did not
produce the desired outcomes regarding the children’s social interactions with peers.
This observation is consistent with a previous study that evaluated the effects of adding
musical equipment to a childcare playground to increase the social interaction with peers
for a young child with visual impairment (Kern & Wolery, 2001, 2002), studies
investigating the efficacy of ecological variations for increasing social interaction of
young children with autism (as reviewed in McConnell, 2002), and is also described in
the literature related to playground activities for children with special needs (e.g., Nabors
et al., 2001). More specifically, adaptations to the environment, combined with
individualized interventions, are needed to achieve desired therapeutic goals.
Nevertheless, the attraction of the Music Hut, the proximity to peers, and the opportunity
to engage in joint musical activities (e.g., by sharing the materials) facilitated the
involvement and motivation of the children with autism to interact with peers on the

playground. This finding is consistent with other investigations describing that preschool
children with autism interact more with on another when doing activities they enjoy
(Koegel, Dyer, & Bell, 1987), and more social interaction might be attributed to structure
and access itself (DeKlyen & Odom, 1989). However, these findings expand upon
previous studies, showing that music therapy interventions can facilitate acquisition of
social skills in the context of the target children’s natural environment such as the
playground. Therefore playgrounds are important settings for music therapy
interventions.
Informal observation during this study showed that typically developing children and
children with special needs other than autism also benefited from the intervention. The
Music Hut provided opportunities to socialize, to develop sensory-motor and cognitive skills,
to engage in self-expression and communication skills, to create games and to benefit from
the enjoyment of music. In childcare programs using an integrated therapy approach, in
which therapists provide services to children with special needs within the context of the
child’s natural environment, as well as her or his routines and activities (Mackey &
McQueen, 1997; McWilliam, 1996, 2000), the playground should be seen as an
educational/therapeutic environment for promoting skills in each developmental domain.
The natural interest children have in music, the inherent opportunities in outdoor play, and
the engagement that comes from being creative, should be seen as a chance to enhance
learning and development for both children with and without special needs.
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The unique songs matching each target child’s personality and incorporating specific
therapeutic goals produced desirable outcomes. This finding is consistent with earlier studies
in which songs were used to assist individuals with autism to improve social skills (Stevens
& Clark, 1969; Brownell, 2002). It also supports the clinical application of songs for skill
development in early childhood intervention settings (e.g., Enoch, 2002; Furman, 2001;
Humpal, 1998). However, previous studies did not examine the use of unique songs to
increase positive peer interactions on inclusive childcare playgrounds for preschoolers with
autism, nor were song interventions embedded by teachers and peers in ongoing playground
activities. Contrary to Experiment I, the implementation of the song intervention increased
the target children’s positive peer interaction immediately. Importantly, the general reaction
of children with autism to be distressed when change occurs (American Psychiatric
Association, 2000; Dawson & Osterling, 1997; National Research Council, 2001) was not
observed.
Further, the songs also had social value and provided a step toward inclusion, both for
the target children and their families as well as for peers and their families. The songs were
sung with siblings and extended families and facilitated the sharing of the children’s social
experiences from school. These responses are consistent with reports made by other music
therapists regarding the meaning and power of unique songs in the client’s social
environment (e.g., Aasgaard, 1999; Ricciarelli, 2003). As Carmen and Victor suggested,
Ben’s and Phillip’s class recorded the songs “You and I” and “Phillip’s Groove.” After the
study, a CD with an individualized label was handed out to the class. Carmen’s parents
responded in an email with the following statement:

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We believe your work with the kids is a tremendous success. When Carmen first
notified us that she was going to record a CD, we said, "Carmen, what are you
talking about?” She responded, “We are going to record a CD with Petra.” You
should have seen the joy that was exuberating from her. After we heard the CD, we
thought “WOW, these kids did a great job,” and how wonderful it was that you and
the teachers explained to the kids what the instruments were and how to play them.
We were so in awe that we made copies of the CD and gave them to our parents and
close relatives. Everyone enjoyed them and said how great the CD was. Every now
and then, when I talk with my parents they recite some of the songs on the CD, ‘play
the cymbals, play the cymbals.’ We all just laugh and reflect on how well this song
was sung on the CD and how the kids seemed to enjoy it so much. I feel that the
songs and the instruments were more than just singing and playing but were also a
lesson on how to work together and how music is for everyone. We definitely
appreciate what it has done for Carmen. Thanks.
And, Justin’s mother responded in an Email with the following comment:
After receiving the CD, I slipped it into the CD player in the car on the way home
from school without telling Justin. When the music came on, he got very excited and
yelled, "Hey that's my class!" When the track of him singing "I want to play the drum
with you" came on, he yelled, "Hey that's me!" and "Hey, that's Petra!" He was
fascinated with hearing himself sing on the CD and asked me to play it about a
hundred times. It sparked great conversations about his experience in the Music Hut
and he taught me, my husband, and his little brother how to sing the song. I kept the
CD in the car and for the first few weeks, he asked to listen to it over and over again
on the way to and from school. Each time he heard "his song," his face would light
and he'd yell, "Hey that's me!” And "Hey that's Petra!" It became known in our house
as "Justin's song" and even his brother would request that I play "Justin's song,"
Having the CD was a great way for him to share his experience with us.
Teachers embedded the intervention successfully in the ongoing playground routine
as evidenced by the target children’s skill improvements. This finding is consistent with the
results of Experiment I and II, and expand upon earlier studies related to other disciplines
(Garfinkel & Schwartz, 2002; Kaiser et al., 1993; Kemmis & Dunn, 1996; Sewell et al.,
1998; Venn et al., 1993; Wolery et al., 2002) by showing that teachers can successfully
implement interventions based on music therapy principles and guidelines in ongoing
childcare routines when staff training and ongoing consultation is provided. As the

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procedural fidelity data show, with only one exception, the teachers’ accuracy in
implementing the intervention was very high. Clearly, the level of teacher fidelity to this
intervention is closely associated with its effect on positive interactions between children
with autism and their peers.
An important implication of this study is that high-quality staff training and ongoing
collaborative consultation by a certified music therapist is crucial for appropriate and
successful implementation of teacher-mediated interventions using music therapy principles.
In addition, teacher attitudes and beliefs do have a major impact on successfully embedding
interventions based on music therapy within childcare routines. There is a need for music
therapy-based in-services and staff training to ensure the sharing of professional knowledge,
beliefs and attitudes, as well as the teachers’ comfort level. This statement is also supported
in the music therapy literature (e.g., Chester et al, 1999; Furman, 2002; Snell, 2002;
Warwick, 1995). Overall, it can be concluded that the music therapy collaborative
consultative approach was effective in enabling teachers to implement the intervention
successfully in ongoing playground routines.
For clinical application, it is vital to establish a functional relationship between the
teachers and music therapist when using an integrated therapy approach. Both the teachers
and music therapist share equal responsibility in implementing the intervention successfully.
In consultative methods, it is the music therapist’s responsibility to provide and share
professional knowledge with the teachers to meet the needs of the child. To successfully
embed music therapy interventions in inclusive preschool settings, it is essential to respect

the teacher’s individual working style, be flexible and spontaneous both in scheduling and
implementing interventions to communicate clearly and frequently, and to provide
enthusiasm and motivation. It is also imperative to take the teachers’ fears and concerns
around singing and playing instruments seriously in order to let the music become a natural
activity within classroom routines.
The peer-mediated strategy was effective in increasing the target children’s social
interactions and meaningful play on the playground. The songs were easily learned by the
“peer buddies” and other classmates, and facilitated social involvement between the peers
and the children with autism. Peers’ accuracy in implementing the intervention was fairly
high. This finding is consistent with earlier research showing that peer-mediated strategies to
improve the social functioning of children with autism were effectively applied (DiSalvo &
Oswald, 2002; Goldstein et al., 1992; McGee et al., 1992; Strain et al., 1979). This study
expounds upon previous studies by showing that peer-mediated strategies can also be applied
on playgrounds and through joint musical activities. However, contrary to previous studies
including children with disabilities other than autism in natural environments other than
playgrounds (e.g., Odom et al., 1992), teachers’ support was never fully withdrawn in this
intervention. A minimum of ongoing mediation and encouragement was needed from
teachers. A major challenge of the participating peers was the interpretation of the
unconventional and unpredictable behaviors and communications styles, or the lack of
response of the children with autism. Another challenge was differences in pace and interest
of play on the playground. Overall, the freedom and variety of play opportunities inherent in
outdoor play, and the chance to engage in creative play activities with friends or siblings
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enrolled in other classrooms, makes the playground a more challenging environment to
implement structured peer-mediated activities. Consequently, strategies for how to engage
the child with autism in play, and how to interpret the behavior and different communication
styles in addition to positive reinforcement, need to be given by the teachers at all time.
These findings support the proposed clinical guidelines for encouraging peer interactions and
inclusion of children with special needs on playgrounds. More specifically, teacher-directed
activities are necessary to increase social experiences and involvement of children with
special needs on playgrounds (Nabors & Badawi, 1997; Nabors et al., 2001; Stine, 1997;
Wortham & Wortham, 1989), especially for children with limited language and
communication skills (Odom, 2002).
A potential implication of this study is that shorter periods of structured peer-
mediated activities (i.e., five minutes at a time) should be used on playgrounds.
Additionally, a greater variety of musical activities might motivate typically developing peers
to engage in peer-mediated strategies over a longer period of time. To maximize the positive
effects of peer-mediated strategies on playgrounds, a variety of peer-mediated strategies, and
a stronger managing and fading reinforcement systems should be applied.
This study has specific limitations. For example, only a small number of participants
were involved. In order to understand the generalization of the intervention, replication with
other young children with autism would be desirable. Further, for several reasons (e.g.,
inclement weather, children’s absence, field trips, winter break), the data were not collected
on a daily basis for each child. Thus, the study extended over several months because of the

above conditions and the nature of the experimental design. Another limitation, shared with
Experiments I, is that this experiment was not a comparison study. We do not know if other
interventions would have been equally effective, more effective, or less effective in
increasing the social interchanges among children with autism and their peers on
playgrounds. From this study it cannot be assumed that other teachers are willing or able to
implement interventions based on music therapy principles and guidelines. Nor do we know
if other “peer buddies” would have participated equally or more effectively in increasing the
target children’s positive interaction and play and engagement on the playground.
Several issues should be considered in future studies. For example, more research is
clearly warranted to provide further validity to musical adaptations of a childcare
playground. Research should investigate the use of an outdoor music center as a
motivational environment for learning and development for both children with and without
special needs. More intervention studies that apply music therapy on playgrounds to foster
social experiences and other therapeutic goals for children with special needs, especially
those with autism are needed.
To recapitulate, this study was not a comparison study. Therefore, it is not known if
more familiar songs (as the results of Experiment II suggest) or other interventions would
have been equally, more, or less effective. These considerations lie beyond the scope of this
inquiry, however, and more studies are needed that compare the effects of a variety of songs
and other interventions on social skill improvements of young children with autism on
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playgrounds. Studies are also needed to investigate which components of the music therapy
intervention result in the positive outcome.
Maintenance and generalization will be important features of future investigations.
From this study, we do not know whether or not peers maintain and generalize playing with
their classmates with autism. A major research question is how many trained peers are
necessary to sustain the intervention and which managing and fading reinforcement systems
works best on playgrounds. Future research should evaluate the effects of a variety of peer-
mediated strategies (e.g., DiSalvo & Oswald, 2002) on playgrounds, and examine the target
children’s skill generalization in different natural environments.
In the study at hand, continuing collaborative consultation was necessary. It is not
know, whether the teachers’ accurate implementation of the interventions will continue or if
it will decrease with lack of supervision. It is also unknown if implementation of the
intervention by a trained music therapist increase the participant’s acquisition of independent
functioning. More research illustrating the benefits of the collaborative consultative model
of service delivery in early intervention/early childhood special education is needed with
specific emphasis on music therapy.

7. General Discussion
This cumulative study endeavored to evaluate the effects of embedded music therapy
interventions using songs and a musical outdoor center on the functioning of young children
with autism during the morning greeting routine, specific multiple-step tasks and peer
interactions on the playground in an inclusive childcare program. It also examines whether
or not teachers can implement the interventions after staff development activities are
provided, and whether or not peer-mediated strategies to increase interactions on the
playground are effective.
All told, there are seven overarching findings that usher from this series of studies.
First, and foremost all children increase their independent performance within the childcare
routine. Through music, target children acquire new skills and/or improve in key deficit
areas of autism, such as transitioning, following multiple-step tasks, and social interactions
with peers. These findings are consistent with the reports from numerous anecdotal case
studies in music therapy, in which interventions were applied to improve core difficulties in
children with autism (Allgood, 2002; Alvin & Warwick, 1991; Clarkson, 1991; Gustdoff &
Neugebauer, 1997; Howat, 1995; Nordoff-Robbins, 1977; Schuhmacher, 1994; Snell, 2002).
Moreover, they replicate other studies showing that children with autism acquire social skills
when music therapy is provided in segregated settings by trained music therapists (Brownell,
2002; Edgerton, 1994; Schuhmacher, 1999; Stevens & Clark, 1969; Wimpory et al., 1995).
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The studies presented here expand upon previous studies by showing that acquisition
of social and adaptive skills occurs when the interventions are embedded in the context of the
target children’s natural environment. Music therapy interventions also facilitate a smooth
transition during the morning greeting routine and enable children with autism to follow
specific multiple-step tasks. Thus, as recommended by the Division of Early Childhood
(DEC) (Sandall et al., 2000) and by the Committee on Educational Interventions for Children
with Autism (National Research Council, 2001), embedding interventions in ongoing
classroom routines is supported. Further research should investigate whether or not music
therapy interventions embedded in inclusive preschool routines can be applied for
development of other skills and if they are helpful for children with special needs other than
autism.
A second major finding is that, in eight of nine cases, the songs produce desirable
outcomes. These findings are consistent with strategies that suggest the use of songs for
smooth transitioning with children with autism (Baker, 1992; Cole-Currens, 1993; Furman,
2001; Gottschewski, 2001; Williams, 1996) and provide evidence that greeting songs can be
effective during one of the most crucial childcare transitions, the morning arrival time. They
also replicate earlier studies in which music was used to assist individuals with memorization
of sequence of information (Gfeller, 1983; Jellison & Miller, 1982; Wolfe & Horn, 1993), as
well as to improve social skills (Stevens & Clark, 1969; Brownell, 2002). However, previous
studies had not examined the use of songs with children with autism for transitioning and
memorization of multiple-step tasks, nor were the studies embedded in an inclusive childcare
program. Yet once again, two of the three studies were not comparison studies, so. It is not

known if other songs or other interventions would have been equally effective or more so.
Only the multiple-step tasks study provided evidence that the songs were more effective than
the verbal presentation of sequencing, except for one task where the verbal presentation was
more (albeit not significantly) effective. More studies are needed that compare the effects of
a variety of songs and other interventions on the behavior of young children with autism.
A third finding centers on therapeutic effects that resulted from the design and
musical adaptation of the playground in Experiment III. Specifically, two out of the four
target children engaged in more meaningful play by using the musical instruments available
in the outdoor music center. However, no significant changes occurred in social interactions
with peers. Thus, at least for these participants, the combination of the musical playground
equipment and individualized interventions were needed to obtain the desired outcomes.
This was the same conclusion reached in another study of playground modifications (Kern &
Wolery, 2001, 2002) and is described in the literature (e.g. Nabors et al., 2001). That is,
adaptations to the environment and teacher-mediated interventions are often necessary to
achieve desired outcomes. However, the musical outdoor environment facilitated the
involvement and motivation of children with autism to interact with peers on the playground.
Informal observation during this study reveals that, on many occasions, other children with
special needs are attracted by the sounds of the instruments and become involved in musical
activities in the outdoor music center.
In general, the playground needs to be seen as an educational/therapeutic
environment. More studies that apply music therapy on playgrounds, both to children with
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and without disabilities, are needed. Further research should likewise investigate the use of
the outdoor music center as a motivation and natural learning environment for children with
special needs to accomplish IEP goals.
The fourth finding surrounds the collaborative consultative approach to music
therapy, and its effectiveness in enabling teachers to successfully implement the interventions
in ongoing childcare activities and routines. Teachers embed interventions successfully
during the morning greeting routine, specific multiple-step tasks, and on the playground, as
shown by the target children’s skill improvements. This replicates and extends earlier studies
showing that teachers can successfully implement interventions related to other disciplines in
ongoing activities successfully when staff training (e.g., literature, lectures, modeling, role-
playing, feedback) and monitoring is provided (Garfinkel & Schwartz, 2002; Kaiser et al.,
1993; Kemmis & Dunn, 1996; Sewell et al., 1998; Venn et al., 1993; Wolery et al., 2002). In
previous studies, however, interventions were not based on music therapy principles and
guidelines.
This series of studies adds to previous findings by showing that individualized
interventions based on music therapy principles can be incorporated by teachers in usual
classroom and playground routines, when staff development activities and ongoing
consultation is provided. With only one exception, the teachers’ accuracy in implementing
the intervention was very high, as evidenced by the procedural fidelity data in Experiment
III. Furthermore, there is a correlation between correct implementation and the target
children’s skill improvement. High quality staff development activities and ongoing

collaborative consultation are critical components for appropriate and successful
implementation of teacher-mediated interventions using music therapy principles. There is a
need for music therapy-based staff development activities to ensure both the teachers’
comfort level and the sharing of professional knowledge. There are several ways to provide
musical training to teachers as an intensive one-to-one training, as part of the classroom
curriculum including both children and teachers, as an in-service, or as a part of the
university early childhood intervention curriculum. Best practice depends on the time
available, on the childcare curriculum, and on classroom demands the teachers face.
For these studies, ongoing collaborative consultation was necessary. We do not know
whether or not the teachers’ accurate implementation of the interventions will continue or
decline over several months if they are not supervised. We also do not know if the
implementation of the intervention by a trained music therapist will result in equal, greater,
or less children’s acquisition of independent functioning. More research supporting the
efficacy of a music therapy collaborative consultative model of service delivery in early
intervention/early childhood special education is needed.
Toward this end, the fidelity ratings in this study introduce a preliminary measure of
how effective the collaborative consultation component can be in imparting intervention
partners with adequate tools for intervention sustainability. In this inquiry, only Experiment
III contained a systematic process for monitoring the degree of teachers’ and peers’
adherence to the intervention model; as a result, fidelity as a potential predictor/moderator of
intervention success could only be analyzed in this one experiment. (In Experiments I and II,
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adherence to the intervention model was far more categorical, laid out as it was in a series of
concrete, methodical steps from which little if any departure was possible.) At this early
stage of the literature, however, it is important to recognize the major finding that, in this one
experiment where fidelity was taken into account, fidelity indeed seemed to correlate
strongly with the level of children’s peer interactions. The implications of this finding for the
legitimacy of the field of music therapy cannot be underestimated.
Peer-mediated strategies, as used in Experiment III, are effective in increasing peer
interactions and meaningful play on the playground, and thus constitute a fifth key finding in
this inquiry. This finding is similar to that in earlier research, showing that peer-mediated
strategies are a powerful means of improving social interaction of children with autism and
their typically developing peers in the context of classroom activities (DiSalvo & Oswald,
2002; Goldstein et al., 1992; McGee et al., 1992; Strain et al., 1979). This study expands
upon previous studies by showing that peer-mediated strategies can also be applied on
playgrounds. Contrary to some previous studies including children with other disabilities
than autism (e.g., Odom et al., 1992), the teachers’ support was never fully withdrawn. A
minimum of ongoing mediation and encouragement from teachers was needed.
These findings support the proposed clinical guidelines for promoting peer interaction
and inclusion of children with special needs on playgrounds. That is, teacher-directed
activities are necessary to increase social experiences and involvement of children with
special needs on playgrounds (Nabors & Badawi, 1997; Nabors et al., 2001; Stine, 1997;
Wortham & Wortham, 1989). The “free choice” that is considered a natural part of outdoor

play, along with the variety of play opportunities compared to indoor play and the chance to
meet and play with friends or siblings enrolled in other classrooms, makes the playground a
more challenging environment to implement structured peer-mediated activities.
A potential implication of this study is that shorter periods of peer-mediated
interventions and stronger managing and fading reinforcement systems should be used to
maximize the positive effects. Experiment III is limited with regard to maintenance and
generalization. Although teachers reported some maintenance and generalization, no
measures have been applied. Based on this study it cannot be said, whether or not peers
maintain playing with the target children once the intervention is no longer in place. Future
research should evaluate maintenance and skill generalization, and examine the effects of a
variety of peer-mediated strategies with children with autism (e.g., DiSalvo & Oswald, 2002)
on playgrounds.
A sixth finding is that, the song interventions provided a valuable step towards
inclusion, for both the children and their families. Inclusion is facilitated on at least three
levels: (a) among classroom peers, (b) among parents of peers, and (c) among the
participating children’s extended families through sharing of the songs and social
experiences from school. The social value of the interventions and music itself is evident
through comments and reports made by the teachers, the target children’s parents, and the
parents of peers, and is consistent with reports made by other music therapists (e.g.,
Aasgaard, 1999; Ricciarelli, 2003). Additionally, the classroom peers changed their attitudes
toward the target children. This replicates the results of earlier studies with school-aged and
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preschool children, in which music was used for inclusion (Jellison et al., 1984; Humpal,
1991). However, this generalization is not based on systematically collected and analyzed
data. It would be valuable to investigate generalization and attitude changes caused by these
music therapy interventions.
Finally, this study demonstrates the potential benefits of a cumulative case study
design for music therapists working in early intervention. Single case designs enable us to
evaluate clinical practice and consultation with other professionals, and to ask important
questions about the practices and principles of music therapy in a quantitative and
experimental way. Although such designs are not unknown to music therapists – and in fact
are quite prevalent in the literature (Nicholas & Boyle 1983; Gregory, 2002) – only a few
music therapists have engaged in early intervention research using single-case experimental
designs (Harding & Ballard, 1982; Kern & Wolery, 2001). Different professions involved in
early intervention commonly use single-case experimental designs. They are a scientifically
accepted, valid research method (Stile, 1988) and might improve the credibility of music
therapy among other professions. However, a natural limitation of single-case experimental
designs is the small number of participants. In order to understand the generalizability of
interventions, replications with multiple participants is warranted. Nonetheless, ideally this
series of studies is a small contribution to establish music therapy as a widely recognized
related service in Early Intervention/Early Childhood Special Education.
To have greater involvement in early intervention/early childhood special education,
music therapists need to adapt their clinical practice to the needs of individuals and their

families, the public resources, and trends in Early Intervention/Early Childhood Special
Education. Music therapists must expand their role along the continuum of care, from direct
therapy (i.e., individual or group therapy sessions) only, to a combination of direct and
consultative therapy, to consultative therapy only as other therapeutic disciplines (e.g.,
speech-language therapy, occupational therapy, physical therapy) have done. Collaborative
consultation, the most integrated model of service delivery, is desirable because it results in a
more comprehensive and holistic intervention and allows for continuity of service, as no
aspect is completely isolated (Sandler, 1997). Collaborative consultation will enhance
services for children with autism and their families, and the early intervention/early
childhood special education discipline might be more willing to incorporate music therapy
into treatment options for children with special needs if such a model is used (Furman, 2002;
McWilliam, 1996; Sandler, 1997; Snell, 2002). For music therapists in training and practice
this means collaborative and consultative methods (e.g., Achilles, Yates, & Freese, 1991;
Buysse et al., 1994; Bruder, 1996) as well as excellent communication skills need to be
learned. Music therapists need to be prepared to collaborate with a wide range of disciplines,
respect individual working styles, and be flexible and spontaneous in designing, scheduling
and implementing interventions in collaboration with other professionals. Sensitivity and
empathy in training others, creativity in use of available resources (i.e., materials and
budgets, environments, knowledge and talents of colleagues), and the ability to motivate and
encourage teachers to use music as a natural tool within the childcare routines will be
essential. Continuously changing conditions of classroom demands and dynamics, the
constantly changing numbers of participating children and staff, and spontaneous interactions
with families, all require great flexibility and improvisation skills beyond the musical level.
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Integrated therapy has its limitations and is not the only way to provide services in
early intervention. However, it is an appropriate and effective way of providing treatment
and allows the extension of music therapy service. The use of a collaborative consultative
approach, in music therapy as elsewhere, and for the inclusion of young children with special
needs in preschool education programs, plays an important role in the growth, understanding
and ultimately the broader legitimacy of music therapy as a profession.

8. Conclusions
The conclusions of this study extent to teachers, parents, music therapists, other
service providers, and most importantly, young children with autism. Significant
implications of this cumulative study include the following:
• Individualized music therapy interventions are effective in increasing the
independent performance and broadening the social experiences of young
children with autism within an inclusive childcare program.
• Songs are powerful means of conveying therapeutic goals, and are relatively easy
to use within ongoing childcare activities and routines.
• Both the classroom and playground are natural environments where children’s
learning and development occurs. Therefore, these are appropriate contexts for
implementing music therapy interventions.
• A music therapy collaborative consultative approach is effective in producing
desired outcomes. Music therapists play a valuable role in consulting with, and
training, classroom teachers to embed music therapy-based interventions in
inclusive childcare settings. Although there are many ways of providing
therapeutic services in early intervention, the collaborative consultative approach
is desirable because it incorporates current trends and policy into early
intervention/early childhood special education. Moreover, it brings interventions
into closer proximity to children’s needs.
• Music therapists must evaluate current clinical practice in early intervention and
expand their role along the continuum of service delivery.
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274
• Music therapy training programs and continuing education courses need to
prepare students and professionals to completely fulfill contemporary models of
service delivery, so they may become efficacious members of on-site early
intervention teams.
• The application of single-case experimental designs can produce desirable
outcomes for clinical practice, and for consultation with other professions, with
the effect of enhancing future integrated services of children with autism in
inclusive childcare programs.
Music therapy interventions provide a valuable step toward inclusion, both for
children with autism and their families. Overall, music therapy enhances services for young
children with autism and should be considered as a routine treatment option. On the other
hand training for music therapists in collaborate consultative methods of service delivery, as
well as continued research on the effects of embedded music therapy interventions in
inclusive childcare programs, are needed.

“In the end, that is the real work of the explorer: to share all that you have learned, to make
it available to others, and to close the cycle that you started when you began the journey.”
by Robert Ballard
(as cited in Salz, 2000, p. 149)
It is hoped that this study demonstrates a practical way of how to better serve young children
with autism in community-based, inclusive childcare programs.
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276

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Appendix A: Data Sheet Experiment I.
Name: ___________________________
Date: ____________________________
Observer: _________________________
Condition: ________________________
Start Time: _______________________
Stop Time: _______________________
Total Time: _______________________
APPENDICES
Data Sheet
Step Adult Child
Behavior Behavior
1. Phillip enters the classroom + - I R NR E X
2. Phillip says “Hello” with symbol
(or word) to a teacher or peer
+ - I R NR E X
3. Phillip says “Hello” with symbol
(or word) to a teacher or peer
+ - I R NR E X
4. Phillip waves good bye to Mom + - I R NR E X
5. Phillip picks up a toy or material + - I R NR E X
+ = Prompt
- = No prompt
I = Independent Response
R = Prompted Response
NR = No response (to request, routine or prompt)
E = Error
X = Inappropriate response
FIELD NOTES:
315

316
Name: _________________________
Date: __________________________
Observer: _______________________
Condition: ______________________
Start Time: _____________________
Stop Time: _____________________
Total Time: _____________________
Data Sheet
Step Adult Child
Behavior Behavior
1. Ben enters the classroom + - I R NR E X
2. Ben says “Hello” with symbol
or word to a teacher or peer
+ - I R NR E X
3. Ben says “Hello” with symbol
or word to a teacher or peer
+ - I R NR E X
4. Ben waves or says good bye to Krista + - I R NR E X
5. Ben picks up a toy or material
Number of peers greeting Ben
+ - I R NR E X
+ = Prompt
- = No prompt
I = Independent Response
R = Prompted Response
NR = No response (to request, routine or prompt)
E = Error
X = Inappropriate response
FIELD NOTES:

Appendix B: Data Sheet Experiment II.
Name:
Date:
Observer:
Task #1: Hand washing
Condition:
STEPS
Turn on water
Wet hands
Get soap
Rub hands
Rinse soap
Turn water off
Dry hands
Did it Did not
do it
Task #2: Toilet Training
Condition:
STEPS
Get up
Walk to toilet
Climb step
Pants down
Sit down
Pee
Get up
T-shirt up
Pants up
Flush
Did it Did not
do it
Task #3: Clean up
Condition:
STEPS
Get up
Pick up s.th.
Put s.th. away
Pick up s.th.
Put s.th. away
Go where
directed by
teacher
Did it Did not
do it
FIELD NOTES:
Data Evaluation Sheet
Did it with Negative Verbalizations
prompts YES NO
Did it with Negative Verbalizations
prompts YES NO
Did it with Negative Verbalizations
prompts YES NO
Escapes Skipped
the part
Escapes Skipped
the part
Escapes Skipped
the part
317

318
Appendix C: Data Sheet Experiment III.
Date ______________ Children ________________ /_______________ Observer_________________ Condition_____________
Adults
Interaction of peer Interaction of child with autism Play and
Engagement
Interval
Interaction
Supported
by Adults
With Material
and
Equipment
Stays in the
MH
Positive
Interaction
Initiates
Interaction
Stays in the
MH
Positive
Interaction
Initiates
Interaction
1.1
1.2
1.3
1.4
2.1
2.2
2.3
2.4
3.1
3.2
3.3
3.4
4.1
4.2
4.3
4.4
5.1
5.2
5.3
5.4

319
Adults
Interaction of peer Interaction of child with autism Play and
Engagement
Interval
Interaction
Supported
by Adults
With Material
and
Equipment
Stays in the
MH
Positive
Interaction
Initiates
Interaction
Stays in the
MH
Positive
Interaction
Initiates
Interaction
Sub-Total #
6.1
6.2
6.3
6.4
7.1
7.2
7.3
7.4
8.1
8.2
8.3
8.4
9.1
9.2
9.3
9.4
10.1
10.2
10.3
10.4
Total #

320
Condition C: Teacher’s Tasks Following (Behaviors)
Tasks Yes
1. Enter Music Hut with the dyad
2. Initiate to play and include both children on the children’s level
3. Sing the song with the dyad
4. Model tasks of song: verbalization, body contact, play together, turn taking,
choose instrument, guide to other activities in the Music Hut
5. Continue to play in the Music Hut (total length of 10 minutes)
Total #
Condition D: Peer’s Task Following (Behaviors)
Tasks Yes
1. Enter the Music Hut together with the child with autism
2. Initiate to play and include child with autism
3. Sing the song with the child with autism
4. Model tasks of song: verbalization, body contact, play together, turn taking,
choose instrument, guide to other activities in the Music Hut
5. Continue to play in the Music Hut (total length of 10 minutes)
Total #
Field Notes:

LEBENSLAUF
________________________________________________________________
PETRA KERN GEBURTSDATUM 28.9.1968
STAATSANGEHÖRIGKEIT Deutsch
GEBURTSORT Aalen
SCHULBILDUNG
1975 - 1979 Grundschule, Aalen
1979 - 1985 Schubart-Gymnasium, Aalen
1985 - 1988 Haushalts- und Ernährungswissenschaftliches Gymnasium, Aalen
VORPRAKTIKUM
1988 - 1989 Siftung „Haus Lindenhof“, Schwäbisch-Gmünd, Einrichtung
für behinderte und alte Menschen
STUDIUM
1989 Studium der Medizin an der Eberhard-Karls-Universität Tübingen
1989 - 1994 Studiengang Sozialwesen, Schwerpunkt Musiktherapie an der Fachhochschule
Würzburg-Schweinfurt
1997 Musiktherapeutin BVM; Anerkennung durch den Berufsverband der
Musiktherapeutinnen und Musiktherapeuten in Deutschland e.V.
2001 Music Therapist, MT-BC; Anerkennung durch das American Certification
Board for Music Therapists, Inc., USA.
BERUFLICHER WERDEGANG
1994 - 1995 Musiktherapeutin im Kreis-Alten- und Pflegeheim, Würzburg
1995 Musiktherapeutin im Kuratorium „Wohnen im Alter“, Albstift Aalen
1996 - 1997 Musiktherapeutin in der Stiftung „Haus Lindenhof“, Schwäbisch-Gmünd
1996 - 1998 Musiktherapeutin an der Interdisziplinären Frühförderstelle,
Sozialpädagogisches Zentrum St. Canisius, Schwäbisch-Gmünd
Seit 1999 Research Scholar am Frank Porter Graham Child Development Institute,
University of North Carolina at Chapel Hill, USA
LEHR-UND FORTBILDUNGSTÄTIGKEITEN
1991 - 1992 Instrumentallehrerin für Klavier an der Musikschule Oberkochen
1996 - 1998 Kursleiterin des Familienbildungswerks, Aalen
1996 - 1999 Lehrbeauftragte an der Berufsfachschule für Altenpflege, DAG Aalen
1996 - 2000 Referentin bei der Fortbildungsdozentur Süd, Fortbildungsmaßnahmen für
Einrichtungen der Behindertenhilfe, Schwäbisch Hall
1996-2001 Lehrbeauftragte bei der Ganzheitlichen Bildung, Weiterbildungszweig
Altentherapeut/Altentherapeutin, Nürnberg
Seit 2001 Lehrbeauftragte bei Pluspunkt, Weiterbildung in der Altenpflege, Nürnberg