Music therapy and PMLD

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Through a description of her work, Madeline Aslan gives valuable insights into the wide ranging benefits of music therapy for children and young people with PMLD.

Many children with profound and multiple learning difficulties (PMLD) present with significant communication difficulties which can make it hard for them to express their emotions and to have them acknowledged. However, children with PMLD can often develop a social connection through improvised music making. Music therapy can be used to create meaningful connections with those who are often isolated and frustrated, and non- verbal musical exchanges between client and therapist can aid the development of communication, which can ultimately lead to improved wellbeing outside of the music therapy room.

William*, aged 5, was referred to Coram for music therapy by educational staff to support him with socialisation and communication. He has a complex medical history and often showed challenging behaviour at school and at home, frequently becoming frustrated and hitting people. William has disordered development, delayed gross and fine motor skills and has spent much of his short life in and out of hospital.

William’s teachers were keen for him to have an outlet to be creative and develop ways of regulating his emotions. Throughout our sessions, William was supported by a teaching assistant (TA) who informed me that William has little or no ability to communicate independently.

In his first music therapy session, William was initially tentative, he looked around the room actively avoiding eye contact with me. He carefully stepped over all the instruments that were laid out for him and because of his physical challenges, this took effort and consideration. After a few minutes in the room together I began to play the piano and sing a calm ‘hello song’. When William heard me sing his name he immediately looked at me and grinned. I realised very early on in our work together that he had a good sense of humour, and this became a big part of our relationship.

Creating music.

It was important to think about appropriate instruments before we started our sessions due to William’s challenges with fine motor skills. I chose various handheld percussion which he could easily hold but that would also make a lot of sound with little movement needed. I also placed the keyboard low to the ground within his reach. Although I knew I would need to support William with some of the instruments, it was necessary for him to have a reasonable level of autonomy in our sessions.

In this first session, I picked up on William’s early anxiety and was aware that he had not accessed these instruments before, so I sat down on the floor and began to show him the different sounds they could make – this caught his attention. Supported by his TA, William boldly took the instrument from my hands whilst shaking his head and smiling. We spent the rest of the session trying every instrument together and putting them all back in the box one by one. This was William’s idea.

As the sessions progressed, William confidently chose the instruments he wanted to play and learned very quickly that if he made a sound I would respond on the piano or guitar. We did a lot of musical turn taking and had long musical exchanges. When William didn’t want to play he communicated through shaking his head or by pushing instruments away. William would often sit on his chair and avoid looking at me and was able to communicate what he needed in that moment without using words. Sometimes I would just be with William, but other times I could see he was trying extremely hard not to laugh and was desperately avoiding eye contact, so I decided to play along and started responding to his body movements musically. William found this incredibly funny and would laugh and move his arms and legs or shake his head, just so I would play something on the piano in response. He would ask to be helped up by pointing and was supported by his TA to do magical dances across the room. William would suddenly stop and look at me with control, put his finger to his lips and say ‘shhh’, so I was quiet. Other times William would gently rock back and forth on his chair and watch me, so I played the piano to match him and we would fall into a steady pulse. I followed William’s lead.

This type of musical mirroring may seem somewhat intrusive, however with a child with PMLD it can often provide a rich, shared experience. Matching their movements with sound can support them to feel more grounded and aware of their body. William controlled his body in a very deliberate way. He was aware of cause and effect and really knew what he was doing.

Music therapy sessions have traditional therapeutic boundaries of time and space. I always use ‘hello’ and ‘goodbye’ songs and at times during the improvised music I may begin to sing other familiar songs which can be predictable and calming.

Children with PMLD have little or no opportunity for independence, therefore effectively communicating the capacity of the client, as seen in a music therapy session, with other adults is vital. Whether it be through video or having parents/carers in the sessions supporting the child.

I requested the same TA to support William every week as it was important for me to also develop a good relationship with her. Initially, William’s TA would actively tell him to play when he was communicating that he didn’t want to, or she would grab his hand and do it for him. I explained to her the importance of giving him space to be heard and that I felt he had capacity for more independence. She stepped back slightly and began to watch William in a different way. After a few sessions she began to join in and started communicating with him similarly to how I was. She would frequently comment that he was more focused than ever, and they had some really beautiful and communicative exchanges. Through weeks of explaining my process to her, I felt confident that the TA could support William in this way outside of the music therapy room. He knew that she had heard him too.

In my sessions with William, I learnt about his strengths, not his deficits. I was told he could not communicate effectively but I gave him space to be heard and responded to his music making. I noticed that he instantly developed interests in new sounds and became motivated to engage with me. William was playful and funny and extremely communicative. I only noticed William becoming frustrated when he was visibly unable to communicate his needs with me, but with space and time and the predictable structure of our sessions, William felt reassured and we developed a trusting therapeutic relationship.

Music has a beautiful and distinctive nature when working with children who have PMLD. It is extraordinary to observe how music-making can support those who are isolated in their environments. William was disengaged from people around him but through our shared music we developed a greater understanding of each other. The music therapist can go beyond any communication barriers and reflect back, or match, the smallest of communications presented by a client. This therapeutic relationship can offer a child with PMLD an experience of being acknowledged and heard, and a deeply meaningful connection can be formed on an entirely non-verbal level.

*Names have been changed.

Madeline Aslan
Author: Madeline Aslan

Madeline Aslan
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Madeline Aslan is a music therapist in Coram’s Creative Therapies team. Coram provides specialist educational provisions in both art and music therapy, working with children and young people with severe learning disabilities (SLD), social and emotional mental health issues (SEMH), as well as PMLD. Contact creativetherapyadmin@coram.org.uk for further information.

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