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EvidenceEvidence-based guidelines Music therapy for CSHCN

Dr Suvarna Nalapat

A new project
No side effects Cost effective Result-oriented, client-oriented esultclient community oriented Basic scientific principles on which it work
& Practical methods for executing it

Integrated interdisciplinery
Naada, laya, yoga-Yoga terminology Naada, laya, yoga swara, sruthi, thaalam, raagam- Music swara, sruthi, thaalam, raagam-

terminology Saamkhya thridhosha-thriguna balancingthridhoshabalancingAyurveda Panchabhootha have three guna Balance organised ,integrated function of the panchendriya of senses and panchendriya of karmakarma-sensorimotor Indian Philosophy

Physics of sound and hearing Aakaasa


ATH absolute threshold of hearing in
decibel

SPL sound pressure level Together expressed dBSPL

8080-85 dBSPL above pollution level



90 heavy truck ,loud factory 1 m away 100 pneumatic hammer,inside disco 2 m 110 accelerated motor bike 5 m 120 jet engine 100m ,and a rock concert 130 pain threshold exceeded 130 jet engine 30 m 180 rocket engine 30 m

6060-80 range of instrumental music



80 7575-80 70 60 vacum cleaner,heavy traffic 1m very loud harsh angry voices heavy traffic 5 m office,busy restaurant ,instrumental music

Jaagrad waves beta. beta.

Vocal music alone 20-30 20


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

Jagrath waves . 35-40 intrauterine audiophonic state 35Familiar. Familiar. The maximum is 80 . Beyond that human brain do not tolerate.

8-13.9 Hz dhaarana alpha waves


0 the threshold with max hearing capacity .can
hear voices of silence 10 breathsounds alone at 3 m praanaayaama

Serotonin,norepinephrine increase
.parasympathetic stage 14-100 jaagrad sympathetic.beta waves 14-

Comparison
4-7.9 REM Theta Dhyaan.meditation.Integration Dhyaan.meditation.Integration of emotional change by imagination,dreams 0.10.1-3.9 samadhi rejuvenation Yoga, Yoga, EEG waves, Vocal/instrumental music for waves, music therapy purposes

Emotional content

Vaatsalya Maadhurya Bhakthi 3 private languages . Direct communication, communication, touch heart and soft feelings Each has voiceprint . Mathrubhaasha. Mathrubhaasha. Use of swara, vyanjana as soul and body (Uyir swara, (Uyir Mey in Tamil )

Chimp and human 99 % same gene


21 genes only in humans-for learning, talking humanslearning,
and singing

Through singing learn and talk To train this natural for all mothers, all mothers,
languages, languages, even birds, animals birds, Most natural Story of Bambaatha in South Africa

Human /mothers voice


Pitch, rhythm, tempo, length of swara, the stressed Pitch, swara,
vyanjana at the end of a word, cyclical repetitions, the word, repetitions, place of stops The rocking movements of mother Security Chanjaadunnni Thappo thappo Akkaam pukkaam Urumbe urumbe Asking ponnumon evideeeeee? Child communicates evideeeeee?

Musical language
Sruthi raise one octave , slowly , with stops, repeat the stops,
same in small words. Hide and seek , kaaa-kkka, pooo-chha etc kaaa-kkka, poooKaaakkkaii to make a crow fly with kaimudra eye contact with the object , identify the object Saa saa saa flat Saa nii N3 Saa paa saaa

Film songs/devotionals

Kizhakku kizhakoraanaa Thumbee thumbee vaa vaaa Kaakkakkum poochaakkm kalyaanam Panchathanthram kathayile Oonjaalaa oonjaalaa Ayigiri nandini Achutham kesavam Govinda raama raama Kannanaam unniye Ambadi thannilorunniyundangane Anjanasreedhara Adharam madhuram Neelakkarmukil varnananneram raadha ennoru

Musical drama plays


Common stories . Tell them, sing to them and them,
enact to them as action songs Improvise according to childs needs Not according to what we expect them to do Imitate the childs voice / manners of expression to make them understand Less of spoken instructions . More of sing, play sing, and natural undersatanding

First Guru, Amarakosa, healer Amarakosa, for a child



Amma 1st psychic experience in utero The first mahaamanthra her vaalsalyanaada Music therapy for children facilitates this natural healing creative therapy. Both for normal and CSHCN. The difference is only in time taken and more understanding needed from adults.

CSHCN general goals /specific objectives



Developing response Initiation of communication/verbal or nonverbal Turntaking,social skill Body awareness Physical rehabilitation Memory Depend on each individual child as a unique person. Chollum vannilla pallum vannilla nammude unnikannanu

Role of therapist
Care of individual child as a unique person Care of stress of family Development of systems of care at
community level CoCo-operative effort as a member of a team for common welfare of community

Guidelines
Plan, study, act. The small cycle of improvement Plan,
model. Longitudinal continuity of care . Follow up , long term relationship with therapist Orderly transfer of care from the therapist to assistants Family centered supporting the entire family and its stress

The broad plan


1st most basic. Diagnosis by a PCP. And get all details of child from basic. PCP.
doctor, doctor, teacher, parent Prepare how to work with a multidisciplinery team Verbal and written communication between team members and family. family. Keep a diary with the child . Every member of the team can assess the work and improvement of other team members Both pretest and posttest conditions are thus transparent Parents/teachers/therapists/PCP co-operation co-

From the pretest condition start planning


Group/individual/both Grouping children Infant/toddler, preschool, Infant/toddler,
school/adolescent Or on class basis Whichever is convenient

Each Group with parents/music therapists/teachers


1st 15 days with sruthipetty/thamburu /or keyboard
whichever available Mandram,madhyam.athitaaram Two different notes of recognisable difference Esp useful for children with no language/monosyllables See whether they are trying to make sounds.dont worry about the pitch .need not be perfect.but just making sounds would be a good begining

Turn taking
Some silent for 2-3 days, even weeks/months then start 2- days,
making sounds Hence 15 days minimum trial given Note down in diary each day/each time the child makes/try to make sounds/improvements Tolerance 30 mts . Max 45 mts initially. Later they initially. tolerate more At home in privacy they may try to vocalise . with selfconfidence start vocalising in group also. give time also. for that. that. do not rush the child.

Already singing vocalising children


Raaga with low frequency at random from a
music source with sruthipetty alone Film/light/action/classical . Reduce BGM sounds because it distract childs attention, and disturbs attention, his cognition. Value of play/musical drama . The triad of competence . communication, sensitivity and creativity needed in all areas of life.

Examples of role play/drama



Mother play Krishna play Doctor play Engine driver play Elephant play /animal /panchathanthra musical drama /panchathanthra By imitation, purposeful activities done imitation, Musical play session tolerate for 40-45 seconds . act with 40children, children, changing the roles, act with siblings, parents, roles, siblings, teachers as a playtime action not as a learning action. They should enjoy it . It should be flexible for individual child.

Neurophysiology of actionplay sradhaavaan labhathe gnaanam. gnaanam.


Acetylcholine increase when child plays. Concentration in the play facilitate free association
thinking Imagination-actingImagination-acting-music and the sharing of it with others.Social competence and co-operation coTurntaking when the children enact a role-they rolelisten,watch have eyecontact with other actors in the play (other children), imitate other children , imitate (other children), emotions. emotions. A balanced musical dialogue

Musical chairs
Keep a hat on head of 1st child or something in his hand
to pass on Sing two lines . All repeating /or teacher alone When last word said the child pass on hat to next childs head/hands Repeat Turntaking learnt. Assess which object each child loves learnt. best . What music is loved by each child in a natural way. way. (By observation .Not by questioning the child ) Informal way of finding out through play . Small group teaching/play /singing

Other research methods



Shadow a child whole day observing 10 mt videotape on each child Interviews with PCP,Speech therapists,parents and teachers of each child Homebased evaluations Questionnaire Pre and post test assessment of behavioural improvements behavioral psychologist Speech improvement speech therapists Day to day satisfactory improvement parents Analysis of entire data with music /type of method employed/raaga/swara by music employed/raaga/ therapist Comprehensive integrated analysis of all the data to arrive at a conclusion Communication of results by the final analyst to the group members and planning further action.

Different checklists

Ratings Statistics Value of EEG and Brain mapping fMRI Fear amygdala stimulation On volunteers/parents of children with autism Family and autistic children known to the researcher for long time the fear complex will be less.

Reasons
Toddler should be able to sleep in the scanner
for imaging to take place in sleep .sleepscan .sleepscan done on weeknights.It should be done between 2727-32 months age Repeated at 30-42 months age 30 Normal controls between 15-20 months and 15between 18-30 months 18-

fMRI
Has to hold controller and lie down quietly and
do play and watch overhead screen for 20-30 20mts Autism children have less activation of deeper part of brain responsible for execution function -attention, reasoning, problem solving. attention,

Empathy
They have psychic ability to sense
emotions . Are unable to understand thoughts of others Telepathy. Music is empathy . It touch the heart. Through empathy and not by analysis or logic they learn .

Yamuna vrindavana Thulsi Melakartha

Amygdala/social Amygdala/social score inverse Rt Infr F gyrus/s score direct same gyrus/s in control.

Communication interaction research in autism UK


CIRA UK (pronounce keera)

Echolalic child 6 yrs elementary repetitive song


RAS rhythmic auditory stimulus Do you eat an apple? Yes , yes, yes apple? Do you eat a pencil ?no, no, no ?no, Repetitive swara, pitch as saabdikabheshaja swara,
(sound as medicine).

Berard, Tomatis, Berard, Tomatis, Mozart effect ?


Berard approach 10-12 days . select high and low 10frequencies from a music . send via headphones. Modulated throughout the 10 hrs of training. safe,but training. expensive. Tomatis approach 6-12 months(Mozart) for right ear dominance. dominance. MOZART Effect Tomatis method did not help in developing language skills. Krishna-MeeraKrishna-Meera-MSS Effect Rama-TyagarajaRama-Tyagaraja-Jesudas Effect Suvarnas approach / Method Name tags ?.

Thank you .

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