By Sarah Murrin, MusicWorx Intern

Throughout internship, I’ve had the amazing opportunity to work alongside my incredible supervisor, Maureen “Mo” Dinsmore, in individual and group music therapy sessions with children, teens, and adults with developmental and intellectual disabilities. Mo is a Neurologic Music Therapist who has completed two of the four levels of the DIR®/Floortime™ certification. From opportunities in observation, co-facilitation, and supervision assignments and discussions, I have been discovering and gaining skills from work in DIR®/Floortime™ that the world needs to know about!

The DIR®/Floortime™ model is so enthralling to me that I decided to extend my original two-month placement with Mo to a full time placement throughout internship. Eventually, I even decided to use my case study project researching the impact of the DIR®/Floortime™ approach on the role of relationships in music therapy with individuals living with neurodevelopmental disabilities. You could say I’m hooked on everything this revolutionary intervention has to offer.

On March 29, 2019, I took the opportunity to share my case study with music therapy students, interns, and professionals at the research poster session during the Western Region American Music Therapy Association (WRAMTA) regional conference in Portland, OR. The feedback I received was extremely empowering. Basically, more people need to know about the DIR®/Floortime™ approach.

WHAT IS DIR®/Floortime™?

The DIR®/Floortime™ Model is an evidence-based approach to empowering human development through respectful, engaging, and meaningful play (Carpente, 2012). Designed by Dr. Stanley Greenspan specifically for individuals with emotional and developmental challenges, the fundamentals of this intervention provide direction and structure in client-therapist interactions (Greenspan & Wieder, 2005). Greenspan is a child psychiatrist dedicated to maximizing child development, which looks like getting down on the floor both to meet them where they’re at physically and developmentally. The DIR®/Floortime™ Model (Developmental, Individual difference, Relationship-based) refers to the act of parents, caregivers, and therapists alike getting down on the floor to play with the child (Carpente, 2016).

The DIR®/Floortime™ Model is composed of 5 pillars total (Greenspan, 2004):

DIR®:

1. Incorporate the unique developmental process for each child
2. Embrace the child’s individual differences
3. Use the relationship as the primary vehicle for helping the child move toward higher levels of development

Floortime™

1. Follow the child’s lead
2. Challenge the child to master new milestones

In combination, the DIR®/Floortime™ Model is a desirable approach for children, adolescents, and adults with neurodevelopmental disabilities because it allows parents and professionals to pull the child into a shared world with kindness, courtesy, and motivation while helping them reach their full potential in social and emotional development (Liao et al., 2014). It is easiest to understand these concepts by watching examples, like the video below.

WHAT DOES IT LOOK LIKE?

This client is invited into the intern’s world through engaging play with the boomwhackers. Once he’s engaged and sharing attention, we begin addressing music therapy goals.

LESSONS LEARNED FROM MY CASE STUDY

Through this research, I came to many personal and professional realizations. Here are the ones that I want you to consider:

• The DIR®/Floortime™ methods of measuring client progress were the container for my intense period of growth as a clinician
• The role of relationships in music therapy is a dense affair that encapsulates many rich, meaningful, and impactful layers
• The client’s progress is mostly dependent on the therapist’s interpersonal and clinical skills
• Structured self-reflective work can propel students, interns, and professionals into a new level of clinical practice

CASE STUDY OVERVIEW

BACKGROUND

The topic of relationships in music therapy and neurodevelopmental disabilities has been evolving in qualitative and quantitative research, and yet the topic is relatively new in music therapy research.

OBJECTIVE

The purpose of my phenomenological study was to explore the role that relationships play in music therapy with a young person living with a neurodevelopmental disability. The study explored the following research questions:

1. What is the importance of addressing relationships in music therapy?
2. How does the DIR®/Floortime™ approach support relationships in music therapy?
3. How does the self-awareness of the clinician support relationships in music therapy?

METHOD

A thirteen year-old male with Down Syndrome participated in ten weekly forty-five minute individual music therapy sessions over the course of eleven weeks. Sessions were supervised by a board-certified neurologic music therapist, who has completed two of the four levels of the DIR®/Floortime™ certification. Informed consent was obtained from the client’s parents to videotape each session and present the study findings.

MEASURE … (this is the best part!)

Functional Emotional Assessment Scale (FEAS)

The Functional Emotional Assessment Scale (FEAS) is a play-based assessment instrument designed for observation, assessment, and measurement of a child’s social functioning. Developed by Greenspan, DeGangi, & Wielder (2001), this tool can measure the client’s progress in social communication. The FEAS scoring system takes into consideration the level of support needed (full support = 0, some support = 1 point, little support = 2 points, and no support = 3 points) within each of Greenspan’s six functional developmental levels (Carpente, 2016):

1. Self-regulation and shared attention
2. Relating and engagement
3. Two-way, purposeful interactions and communication
4. Joint attention: Chains of back-and-forth emotional signaling and shared problem-solving
5. Representational capacities (create ideas, use words or phrases meaningfully, engage in pretend play, and think symbolically)
6. Logical thinking: Building bridges between ideas

Higher scores within each of the sections indicates a greater level of social functioning (Greenspan, DeGangi, & Wieder, 2001).  

Circles of Communication

Dr. Greenspan refers to emotional exchanges between children and their primary caregivers as ‘circles of communication’ (Brown, 2018). Circles of communication involve opening a circle, sending a communication and inviting a response, and closing a circle, receiving that communication and responding with verbal, gestural, or other non-verbal communication (Brown, 2018). In this study, circles of communication were measured to encourage MTI self-reflection and to increase continuous flows of communication between the MTI and client. The MTI followed this five-step procedure following each music therapy session:

1. Determine and record the duration of each music experience (ie. hello song, bilateral drumming, etc.)
2. Review the video for each music experience and categorize methods used by the client to close circles of communication (ie. verbally responding, making eye contact, etc.)
3. Review the video for each music experience for a third time and record the amount of instances the client closed a circle of communication within each of the determined categories (ie. verbally responded (17), made eye contact (4), etc.)
4. Review the video for each music experience for a fourth time and record the amount of instances the client closed a circle of communication within each of the determined categories to confirm an exact quantity
5. Bring any discrepancies in data points from steps four and five, if any, to the supervisor’s attention and operationally define a closed circle of communication for each music experience

Music Therapy Anxiety Scale

The ‘Music Therapy Services Medical Setting Anxiety Scale’ was used to code qualitative data concerning the MTI’s self-awareness (MusicWorx, Inc., 2012). The eleven-point scale ranges from ‘very calm’ to ‘very anxious’. Following each session, the MTI recorded brief statements of personal reflection on their intrapersonal experiences during the session. Upon completion of the treatment process, each statement was coded and ranked within the 11-point anxiety scale.

RESULTS

These graphs illustrate:

• General positive trend in client development
  • FEAS scores nearly doubled by the end of trea™ent
  • Closed circles of communication more than doubled by the end of treatment
• General negative trend in MTI anxiety level, which reached a score of 0 by the end of treatment

CONCLUSION

• The results uphold the perception that the role of relationships in music therapy is a dense affair that encapsulates many rich, meaningful, and impactful layers.
• The results suggest that there is a direct relationship between the MTI’s level of anxiety, the client’s developmental progress, and the relationship between the MTI and client.
• The MTI’s intrapersonal experience has prominent influence on the client’s music therapy treatment.

FUTURE DIRECTIONS

• Future studies could investigate the dynamics of each layer to the intramusical experience.
• Continued focus on structured self-reflection during the music therapy internship will illuminate areas for growth and development for music therapy students, interns, and professionals alike.

WHAT NOW?

Now that you have some sense of what DIR®/Floortime™ is, I encourage you to seek more information on all that this multifaceted approach has to offer! MusicWorx is fully embracing this intervention and, as you can see, interns are fully benefiting too! Visit http://www.icdl.com/home for more information on the DIR®/Floortime™ model or contact Mo to learn more about setting up DIR®/Floortime™ music therapy services for your loved one.

SOURCES

Brown, D. (2018, July 2). Circles of Communication in Floortime. Retrieved from  http://affectautism.com/2018/07/02/circles-of-communication/

Carpente, J. A. (2012). DIR®/Floortime™ Model: Introduction and considerations for improvisational music therapy. In P. Kern & M. Humpal (Eds.), Early childhood music therapy and autism spectrum disorders: Developing potential in young children and their families (pp. 145-161). Philadelphia, PA: Jessica Kingsley Publishers.

Carpente, J. A. (2016). Investigating the effectiveness of a developmental, individual difference, relationship-based (DIR) improvisational music therapy program on social communication for children with autism spectrum disorder. Music Therapy Perspectives, 35(2), 160–174. Retrieved from: https://doi.org/10.1093/mtp/miw013

Greenspan, S. I., DeGangi, G. A., & Wieder, S. (2001). The functional emotional assessment scale (FEAS) for infancy and early childhood: Clinical and research applications. Bethesda, MD: Interdisciplinary Council on Developmental and Learning Disorders.

Greenspan, S. I. (2004). Web-Based Radio Show. Floortime TM: What it Really Is and What it Isn’t. Retrieved from: https://tinyurl.com/yy3hafel

Greenspan, S. I., & Wieder, S. (2005). Can children with autism master the core deficits and become empathetic, creative and reflective? A ten to fifteen year follow-up of a subgroup of children with autism spectrum disorders (ASD) who received a comprehensive  developmental, individual-difference, relationship-based (DIR) approach. The Journal of Developmental and Learning Disorders, 9, 39-61.

Liao, S. T., Hwang, Y. S., Chen, Y. J., Lee, P., Chen, S. J., & Lin, L. Y. (2014). Home-based DIR/Floortime™ intervention program for preschool children with autism spectrum disorders: Preliminary findings. Physical & Occupational Therapy in Pediatrics, 34(4), 356-367.