The Arts in Psychotherapy 35 (2008) 107–116

A music therapy clinical case study of a girl with childhood

apraxia of speech: Finding Lily’s voice
Beth Beathard, BM, MT-BC, Robert E. Krout, EdD, RMTh, MT-BC ∗
Music Therapy Program, Southern Methodist University, Dallas, TX, United States

Abstract
This clinical case study describes a 3-year-old girl diagnosed with childhood apraxia of speech and her progress in weekly music
therapy. The child was seen for a total of 24 sessions over a period of 9 months. The music therapy treatment involved a mixture
of behavioral, improvisational, and creative approaches in what has been termed a data-based music therapy approach. A variety
of musical interventions, visual, and interactive aids were used, as well as an engaging, playful dialogue between child and the
clinician. The child’s communicative methods at the beginning of her treatment process were almost exclusively non-verbal. By the
final session, she was pronouncing a number of syllables, combination sounds, and words. The treatment program is described as
it unfolded in three phases, and significant events from each individual session are described in detail.
© 2008 Elsevier Inc. All rights reserved.

Keywords: Childhood apraxia of speech; Music therapy

Apraxia, or absence of speech, has been defined as the inability to articulate sounds necessary for successful speech
or language production (ASHA, 2007; Cohen, 1992; Cohen & Masse, 1993; King, 2007; Velleman, 2002). Production
of speech depends on the precise motor coordination of the structures of the respiratory system, larynx, pharynx, and oral
cavity (Cohen & Ford, 1995; Coulson, 2004; Darley, Aronson, & Brown, 1975; Strand, 2001; Strode & Chamberlain,
2006; Van Riper & Emerick, 1984). Poor function and/or coordination of these oral neuromuscular movements may
result in multiple and inconsistent articulation errors (Cohen, 1994). Children with apraxia of speech have difficulty
in planning and producing the specific and coordinated movements of the lips, tongue, jaw, and palate necessary for
speech (ASHA, 2007). Impaired speech prosody has also been described as an identified feature of childhood apraxia of
speech (Peter & Stoel-Gammon, 2005). Childhood apraxia of speech (CAS) is sometimes termed verbal apraxia, verbal
dyspraxia, or developmental apraxia of speech (CASANA, 2007). The term CAS is used in this paper for consistency.
CAS is thought to be present from birth, although testing and an accurate diagnosis may not be able to be made
by the speech language pathologist until age 2 (CASANA, 2007). It is thought to be different from what is termed a
developmental delay of speech. Children with apraxia of speech often evidence a wide gap between their receptive
language abilities, which may be developing normally, and their verbal expressive abilities (CASANA, 2007). While
some authors believe that CAS is a disorder related to overall language development, others have suggested that it may
be a neurological disorder affecting the brain’s ability to send the necessary signals for the child to move the muscles
required for speech (NIDCD, 2007).

∗ Corresponding author at: Division of Music, Meadows School of the Arts, Southern Methodist University, P.O. Box 750356, Dallas, TX

75275-0356, United States. Tel.: +1 214 768 3175; fax: +1 214 768 4669.
E-mail address: rkrout@smu.edu (R.E. Krout).

0197-4556/$ – see front matter © 2008 Elsevier Inc. All rights reserved.
doi:10.1016/j.aip.2008.01.004
108 B. Beathard, R.E. Krout / The Arts in Psychotherapy 35 (2008) 107–116

As the child grows and matures, CAS usually results in reduced verbal expression and poor acquisition of expressive
language skills. Social interactions between the child with apraxia and other children may also be adversely affected
due to these poor speech and language skills (Cassidy, 1992). The first 3 years of life, when the brain is developing
and maturing, is the most intensive period of speech and language development (Coulson, 2004). As such, children
with expressive verbal disorders such as apraxia of speech frequently undergo various speech therapy interventions to
address the inconsistencies of the oral musculatory structures. As Strand (2001) states, “Sounds usually targeted for
speech therapy are those that are earlier-developing or the easiest to elicit and then progress to later developing sounds”
(p. 300).
The acquisition of language and/or speech for a child with apraxia of speech may require extensive instruction,
practice, repetition, and time. Music interventions can be developed to target and develop specific speech sounds,
complementing the work of the speech language therapist. Children with apraxia of speech who lack the motivation to
participate in conventional speech therapy drills and exercises may enjoy, and thus be motivated by, music interventions
(Adamek & Darrow, 2005; Braithwaite & Sigafoos, 1998; Kennelly, Hamilton, & Cross, 2001; Knoll, 1998; Nelson,
Anderson, & Gonzales, 1984; Thaut, 1984). For instance, singing may provide an alternative and pleasurable avenue
for communication while simultaneously addressing speech therapy goals (Cohen, 1994; Keith & Aronson, 1975;
Thaut, 1984).
There have been relatively few research studies or case reports in the literature that specifically describe the use of
music or music therapy with children diagnosed with apraxia of speech. Rosenbeck, Hansen, Baughman, and Lemme
(1974) described the use of music in a case study of a 9-year-old girl with CAS. At the end of 22 sessions, the child’s
speech was observed to be more intelligible than before beginning music therapy treatment. In a study by Gillis (1980),
instructed singing was used to help remediate the apraxia of speech in two young children. Significant improvements
in the children’s spontaneous speech were observed. In a study by Krauss and Galloway (1982), two young boys
with CAS and developmental language delays received 2 months of speech language therapy followed by the same
treatment with the addition melodic intonation therapy (MIT) as a warm-up. The authors reported significant gains
in the boys’ phrase length, noun retrieval, and verbal imitation tasks. Wheeler (1999) conducted a qualitative study
in which she examined her experiences of pleasure in working with children with severe and multiple disabilities.
Included in the study were two girls with CAS, aged 7 and 12 years. The author reported that speech gains were made
by the children. These included producing vowel and consonant combinations and words during drumming and other
instrument playing interventions.
The following clinical case study describes music therapy work over a period of 9 months with a child who will
be called Lily, a 3-year-old girl diagnosed with CAS. It should be noted that this was not an example of case study
research, as the essential aspects of a defined research method, various forms of data collection and analysis, and data
analyses that are checked by peers or members were not included (Smeijsters & Aasgaard, 2005). Rather, this was a
descriptive clinical case study, a detailed report following the progression of an individual client through a number of
sessions and phases of music therapy treatment as they developed based on the emerging needs of the client (Bruscia,
1991; Hanser, 1999).
The following background information was obtained from Lily’s parents as part of the referral and intake procedures.

Lily-background information

Born December 3, 2002, Lily was a healthy baby weighing 3.63 kg. Lily did not babble or coo as an infant, and
was a relatively quiet baby overall. Early developmental milestones were initially within normal limits. However, her
parents began to notice problems in the areas of gross motor movement and speech. She rolled over at 6 months, sat
up at 11 months, and finally walked independently at the age of 2 years. A diagnosis of hypotonia was given by her
developmental pediatrician for the apparent gross motor difficulties. Lily did not attempt the vocalization of any sounds,
with the exception of a period of time where she squealed and screamed. When questioned, both her physician and
developmental pediatrician stated that Lily’s language and communication abilities might be simply delayed. Desperate
to provide her with a method of communication, Lily’s parents taught her American Sign Language (ASL).
Hearing tests and an MRI were both within normal limits, and she seemed to process cognitive information appro-
priately. By the age of 20 months, Lily had demonstrated (by signing) that she knew all her colors, shapes, and the
numbers 1–10. She communicated (also by signing) that she knew at least half of the capital letters and appeared to
understand the concepts of counting, sorting, and comparing (e.g. same or different, bigger or smaller). Sensory issues,
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especially with regard to food, were also noted by her parents. For example, Lily refused to eat specific foods such as
mashed potatoes or oatmeal because of the texture.
Lily began receiving therapy at about 18 months through an Early Childhood Intervention Program that included
occupational, speech, and play therapy. She also had private sessions for speech and physical therapy. Lily’s mother
stated that she loved speech therapy and looked forward to her sessions. According to her mother, Lily learned how to
vocalize five phonemes including /bah/, /da/, /uh/, /oh/, and /puh/, but no words. She also commented that Lily seemed
to learn and remember sign language and music (especially specific tunes she loved) at a fast rate. She quickly learned
her favorite songs in sign language and was consistently happy when she listened to music.
According to her mother, Lily loved music and signing her favorite songs, which included Jesus Loves the Little Chil-
dren of the World, Itsy Bitsy Spider, If You’re Happy and You Know It, Barney and the Wiggles, She’ll be Coming Round
the Mountain, and The Wheels on the Bus. She could also recognize certain songs related to TV shows and come run-
ning into the living room when she heard the opening song. These shows were Law and Order and The Simpsons. When
the mother would play Baby Einstein videos, Lily would stand in front of the TV and appear completely mesmerized.
Lily was reported by her parents to be very social and affectionate around familiar people. When her cousin of the
same age would come to visit, Lily would usually scream in excitement. Her mother said that the difference between
the two children when they played together was very apparent to her. Both parents began to wonder if Lily suffered
from verbal apraxia and/or autism. After seeing a local television report on music therapy and autism featuring the
authors’ university music therapy clinic, the parents decided to see if music therapy might help their daughter, and
contacted the university. Following an initial telephone inquiry, Lily was scheduled for music therapy. A total of 24
30-min sessions were held over a period of 9 months. Informed consent and permission for treatment were obtained
from Lily’s parents, including permission to conduct the case study and submit the findings for publication. Guidelines
of the university institutional review board were also followed.

Treatment approach

The treatment approach used with Lily followed that used at the authors’ university, and has been described as
a data-based model for clinical music therapy (Hanser, 1999). In this model, 10 progressive stages or phases of
therapy include referral to music therapy, a first session for building rapport, assessment, determining goals, objectives
and target behaviors, observation, selection of music therapy strategies, designing the music therapy treatment plan,
implementation, evaluation, and termination (Hanser, 1999, p. 29). This model allows for the music therapy treatment
process to unfold in an organic manner, meeting the changing and evolving needs of the child based on their observed
progress. Within this model, various treatment approaches, methods, and techniques may by implemented as they best
suit the learning style of the child (Hanser, 1999).

Roles of the authors

At the time of this case study, the first author was completing her American Music Therapy Association university-
affiliated music therapy internship under the supervision of the second author. The first author served as and is referred
to in this article as the clinician, and provided all direct music therapy. She met weekly with the second author for
session planning, session review, and supervision. The second author observed sessions on a regular basis. Both authors
were involved in writing up the description of the case study.

Sessions 1–3: Developing rapport and the music therapy assessment

The assessment process took place over the course of three sessions scheduled approximately 1 week apart at the
university music therapy clinic (hereafter termed “Clinic”). The Clinic treatment room measures 18 ft. × 12 ft., with
two walls comprised of floor to ceiling shelves holding various instruments and resources. Curtains along the fronts
of the shelves can be closed to reduce visual stimulation. An upright piano stands adjacent to the shelves on one side
of the room. On another wall there is a large dry erase board, and on the fourth a large one-way mirror connecting
to the observation room. Video and audio junction boxes sit below the mirror. Each session was video recorded from
the observation room, which provided the added benefit of being able to study the tapes after each session. Separate
permission to videotape the sessions was obtained from Lily’s parents.
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Assessment sessions were designed to gather information on the following skill areas of concern to Lily’s parents: (1)
non-verbal and verbal communication; (2) socialization; (3) cognitive; (4) emotional; (5) motor skills and movement;
(5) sensory; (6) perception and spatial relations; and (7) responses to music.
The initial assessment session took place with both parents present in the Clinic. Lily was hesitant to enter the Clinic
at first, but eventually entered the room after the clinician began playing various instruments to get her attention. Lily
appeared to be non-verbal, but she did use a few signs (ASL) and made an /uh/ sound when she wanted something from
her mother. She appeared to have auditory sensory sensitivity and disliked the loud cabasa instrument, covering her
ears with her hands. Lily seemed to enjoy the music and instruments (in particular the piano), and began to slowly warm
to the clinician’s attempts to engage her. She was very active and in constant motion the entire session. The parents
were a good resource, especially when the clinician did not understand what she was signing. They also provided a
comfort zone for Lily since this was her first session. The clinician did talk with the parents about them transitioning
to the Clinic observation room so that she could begin to establish a therapeutic relationship with their daughter.
During the second session, Lily’s parents watched this session from the observation room. When Lily arrived for
her second session, the clinician took her into the observation room and showed her the window where she could view
the Clinic where she would be working. After the clinician explained to her where her parents would be sitting, Lily
headed down the short hallway into the Clinic without hesitation. She was excited and ready for her second music
therapy session. Lily was happy throughout the second session, and both eye contact and interaction appeared increased
over the first session. Lily vocalized the letter /b/ several times during the session and appeared cognitively aware of
the relationship of the letter /b/ to instruments that started with a /b/ (e.g. bongo drum, bell). She continued to use sign
language, especially in reference to colors. Lily seemed to show a preference for the piano and guitar.
During the third and final assessment session, Lily again appeared to enjoy the music and improvisation on the
piano over other instruments. She enjoyed playing the Q-chord, an electronic instrument similar to an autoharp. The
authors also began to notice a pattern of Lily making non-descriptive vocalization sounds when she wanted to play
an instrument. Lily demonstrated cognitive understanding of a few consonant sounds by vocalizing of these when
prompted in order to play the instrument.

Assessment summary

The assessment sessions provided a wealth of information about Lily’s current status in many important areas. Her
communication method at the point of assessment was mostly non-verbal and included a prolific awareness of ASL
sign language (75 signs as reported by her mother). Lily displayed a high energy level and a very short attention span.
She would often jump up from a sitting position on the floor after only a few words of the Hello Song. Lily had been
described as being socially and emotionally behind peers of her own age, perhaps because of her lack of speech. She
was hesitant about interacting with the clinician initially, but quickly decided that music (and perhaps the clinician)
was quite fun. There also appeared to be a delay in response to directives at times. However, the mother reported later
that Lily would usually go home and try whatever she did in music therapy.
The assessment of motor skills and movement revealed a deficiency in gross motor movements such as sitting upright
on the piano bench unaided. Lily had only been walking for a few months, so her balance and gait were unsteady. She
was able to clap her hands, raise her arms above her head, and turn around in response to song directives. Sensory
impairment was observed in her dislike for certain instruments (such as the cabasa) and her timid approach to touching
or pressing the piano keys and Q-chord. She later expressed displeasure at having anything on her fingers or hands
(especially paste).
In summary, the music therapy assessment resulted in the following initial observations of Lily: (1) she appeared to
be completely non-verbal except for a few /uh/ sounds when she wanted something, (2) she displayed the use of sign
language and other hand gestures, (3) she appeared to love music, and (4) she displayed a very short attention span.
Lily’s apparent love of music and strong desire to play an instrument (as demonstrated by vocalizing the beginning
instrument sound) was a great beginning to her therapy process.

Goals

Goals were established by both authors based on background information from Lily’s parents and observations from
the assessment sessions. The first general goal for Lily was increased speech recognition and generation. Both parents
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voiced a desire for their daughter to speak, while at the same time realizing that might not happen. The mother was
already working on the /m/ sound (for Mommy) and the /f/ sound (for the first letter of their last name). Both parents
would sing various songs at home with Lily, trying to emphasize these sounds. The mother stated that Lily would often
comprehend what they were saying and not react or respond right away. For example, sometimes at night when her
mother was rocking her to sleep, Lily would vocalize or try to repeat what she had learned that day. According to the
mother, it was almost as if she was mulling it over in her mind before she tried it out. Cognitively, the mother believed
that Lily was aware of what was happening around her. For example, a song about family members who had been on
a recent trip with Lily and her parents was composed and sung by the mother. After her mother finished singing the
song, Lily independently signed the name of another family member that her mom had not mentioned in the song.
The second general goal for Lily was improved social integration and communication skills. According to her
mother, Lily had no contact at all with other children except for 1 h of church Sunday school a week and occasional
visits from her cousin. Lily, an only child, was around her parents the majority of the time, so she had not learned
how to interact appropriately with peers her own age. Goals and objectives were designed and recorded on the Clinic
assessment form.

Session planning

Signs with large capital letters labeling the instruments were created and either affixed to the Clinic instruments
themselves or on the shelf holding the respective instruments. The shelves were rearranged so that a wide variety of
pre-selected instruments with their corresponding labels sat on the lower shelves. The intent in making the signs was
to provide visual cues while prompting Lily to sound out the initial instrument letter sound. Initial thoughts in session
planning also considered the use of augmentative and alternative communication (AAC) aids, such as picture exchange
communication (PEC) symbols and a communication board to use when Lily wanted an instrument.
According to Davis and Velleman (2000), increasing vocalizations of any kind (such as animal noises, vehicle
sounds, verbal routines with songs, etc.) may be a good place to start in developing verbal communication skills with
very young children. Hammer (2003) states that creative engaging play presents opportunities for repetitive sequences.
One of the most important aspects of session planning for Lily involved the use of toys, books, and other props that
elicited a sense of play while targeting vocalization of sounds. Music therapy sessions were organized around a core
framework for each week, beginning and ending with Lily’s unique Hello and Goodbye Song. At least one new song
and corresponding interactive visual aid was introduced each week and added to Lily’s book of songs (hereafter termed
as “Lily’s book”). The sessions included an eclectic mixture of behavioral, improvisational and creative approaches,
again within the data-based approach outlined by Hanser (1999).

Treatment process

Phase 1: Explorations—Sessions 4–7

The fourth session was designed to be one of spontaneity, exploration, and discovery on the part of Lily. Besides the
basic session format of the Hello and Goodbye Song, Lily had the freedom to independently explore her new musical
environment. She was very active during the entire session and displayed a short attention span. She did express
a particular interest in the large “gathering drum” by actively interacting with it and the clinician. Initial behavior
modification techniques which provided a reward of playing a desired instrument proved to be beneficial in stimulating
speech sounds. As Lily literally jumped from one instrument to the next, the clinician would prompt her to vocalize
the beginning consonant of the instrument. By the end of the session, Lily was independently vocalizing the consonant
/bah/ and /puh/ in order to play the instruments that began with that sound. Upon conclusion of the session, the mother
stated that Lily had just received a diagnosis of developmental apraxia of speech by the speech language pathologist.
In the fifth session, Lily again responded very positively to the instrument visual name cues, attempting to verbalize
the beginning letter sounds. The interactive therapeutic relationship between the clinician and Lily was also continuing
to develop. Lily seemed to enjoy playing the piano with the clinician, especially when smiles, giggles, and playfulness
were a part of the interaction. Short 1-note patterns on the piano provided a beginning communicative dialogue. Lily
began to grasp the concept of taking turns with instruments, handing the mallet or instrument to the clinician to play.
Lily also displayed increased attentiveness and adherence to behavior requests made by the clinician during this session.
112 B. Beathard, R.E. Krout / The Arts in Psychotherapy 35 (2008) 107–116

The highlight of the sixth session was the playful interactive relationship that was developing between Lily and the
clinician. As Lily began to explore the Q-chord, she discovered the demo switch that immediately played the Beatles
song Michelle. She seemed to take great pleasure in pushing this button, especially when the clinician playfully laughed
and pretended that she did not want to hear the song. Increased socialization skills were observed, as were increased
use of independent turn-taking. Lily again demonstrated attentiveness to behavior requests by the clinician.
During the seventh session, Lily began to show signs of disinterest in some of the activities she had previously
enjoyed. For example, she demonstrated less vocalization of consonants when asking to play an instrument. She also
began putting the mallets and guitar pick inside her mouth and simply looked at the clinician as if to challenge her. When
the clinician responded with a positive behavior request, Lily firmly resisted. She did express her usual excitement
over the singing of the Hello Song by smiling and giggling during the song.

Phase 2: Introducing visual and interactive aids—Sessions 8–14

As Lily progressed positively in her socialization, behavioral, and vocalization skills, it became apparent to the
authors that additional resources might be helpful in designing interventions and experiences that would stimulate Lily.
One resource was the use of Sound Box Songs (Musselwhite, 1995), which targeted specific sounds using familiar
tunes, and the Easy Does It for Apraxia-Preschool Series (Strode & Chamberlain, 1993).
The eighth session marked the beginning of what was to become a turning point for Lily. As the clinician researched
and planned for more interactive interventions (including toys, visual aids, and even blowing bubbles), Lily began to
demonstrate an increase in vocalization, attentiveness, and communication skills. She enjoyed communicating with
the clinician during the piano intervention, and demonstrated an increase in independent turn-taking skills. Lily also
began to imitate the specific word syllables of the goodbye song in this session through lip movements.
In the ninth session, Lily began to demonstrate an interest in drawing on the dry erase board. Beginning with the
initial assessment session, the clinician had written “Welcome Lily” in large letters. Below the writing, a large smiling
face and several music notes were also drawn with colored markers. At the beginning of this session, Lily attempted
to draw on the face on the board by taking the markers and trying to indicate what she wanted with hand motions and
sign language. This drawing intervention was to become a regular and an important part of subsequent sessions. Lily
demonstrated an increase in attentiveness, socialization skills, interaction with the clinician, independent turn-taking
skills, and time and attentiveness to new instruments. She continued to display a preference for the piano and seemed to
take great delight in the playful imitative dialogue that took place with the clinician. Lily displayed an ability to make
independent choices by pointing to the chosen song in her book that she wanted the clinician to do next in the session.
The highlight of the 10th session involved the smiling face on the dry erase board. Lily, with one verbal prompt,
vocalized the syllables /duh/ for draw, /muh/ for markers, and /bah/ for blue marker. Lily then handed the marker to the
clinician indicating what she wanted the clinician to draw. Lily pointed to her own mouth indicating that she wanted
the clinician to draw a mouth on the face. At the same precise moment both Lily and the clinician vocalized very loudly
the syllable /ah/. Lily burst into laughter and excitedly placed the marker in the clinician’s hand.
Lily also demonstrated improvement in communication skills during the Hello Song by imitating syllables with her
mouth and lips. Cognitive awareness of the visual PEC symbols was not demonstrated, as Lily did not respond to the
clinician’s directives for choosing an instrument. She did however continue to grasp the concept of vocalization of the
first letter of instrument names in order to receive the instrument. Lily continued to display increased socialization skills
in independent turn-taking, handing the instruments and markers to the music therapist to indicate her turn. During
Old MacDonald, Lily demonstrated increased communication and socialization skills by the imitation of the syllables
/e/, /i/ and /o/ using her mouth and lips. She was actively engaged with the clinician during this song with sustained
eye contact and playful closeness to the clinician.
During the 11th session, Lily demonstrated increased communication and socialization skills with the PEC symbols,
placing her choice of instrument via PEC symbol on the Velcro board. Further improvement in communication was
demonstrated by independently vocalizing a syllable twice during the session when she wanted to play an instrument.
In planning for this session, the clinician had continued to add new interactive songs and visual aids to Lily’s book.
Of particular interest to Lily this particular session was the Whose Name is This? song intervention that musically
prompted Lily to vocalize the letters of her name. Lily again expressed interest in drawing on the dry erase board.
Lily continued to demonstrate an increase in attention span and attentiveness during the 12th session, mouthing the
words of the Hello Song. An introduction of several brightly colored balloons to the session precipitated playfulness
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and enjoyment by Lily. Lily was distracted, however, by the balloons for the remainder of the session. In preparation
for future sessions, the clinician realized that the inclusion of the balloons would need to occur at the end of the session
as a reward to prevent further distraction. Lily again demonstrated marked interest and attention to the face-drawing
on the dry erase board and a new interest in the association of words with the parts of the face.
During the 13th session, Lily again demonstrated an increased attention span to the Hello Song, mouthing of the
words, especially /hello/. The clinician found that brief pauses or prompts in the music were helpful in motivating
Lily to respond with mouthing or vocalizing a sound. Lily demonstrated increased interaction with the clinician during
the Whose Name is This? intervention and placed all the letters of her name correctly on the appropriate page of her
book. Lily also vocalized the letter /e/ when appropriate (with minimal prompts). Plans for subsequent sessions by
the clinician would include using more words in print to visually cue Lily’s vocalization of the beginning sounds.
Additionally, because of Lily’s apparent affinity to the Hello Song and her increased association of words to various
objects, the clinician made a conscious decision to change the “Welcome Lily” to “Hello Lily” on the dry erase board.
From this point forward, the dry erase board would reflect this change.
For the 14th and final session of the Fall Term, the addition of a child-size table and chairs in the Clinic proved
to be beneficial for Lily to increase sitting time, attentiveness, and interaction with the clinician. Lily again demon-
strated increased communication and interaction with the clinician during the Whose Name is This? by independent
vocalizations and attentiveness. During the Old MacDonald intervention, Lily demonstrated enjoyment, increased
communication, and interaction with vocalizations, attentiveness, following directions of the clinician, smiles, and
laughter. Brief pauses in the music along with hand motions used during the speech therapy session observation for
vowels were helpful in motivating Lily to respond with mouthing or vocalizing a sound.
There would now be a break in Lily’s treatment as the fall term concluded. Spring term sessions were tentatively
scheduled to begin in late January after the university winter break. A mid-term assessment of Lily’s progress was
written and shared with her parents.

Phase 3: Verbalization and drawing—Sessions 15–21

The 15th session was held after a break of 8 weeks over the winter holidays. The authors were very interested
in observing how Lily would respond after such a long absence, especially regarding the interactive relationship and
vocalization skills. Lily was very happy to see the clinician and greeted her with smiles and excited hand gestures
motioning the clinician towards the Clinic. During this session, Lily seemed to enjoy the interventions that included
visual aids. Lily displayed appropriate, on-task behavior during the Name Song, placing the letters on the page after
sounding out the letter. Words corresponding to the parts of the face were written on the dry erase board by the clinician.
Lily’s verbal ability had increased dramatically since the previous session and she vocalized and verbalized several
words and sounds such as /e/, /i/, /e/, /i/, /o/ (Old MacDonald), /Mama/, /Dada/, /more/ and /bah/.
Lily displayed increased on-task behavior throughout the 16th session, and her overall cognition and vocalization
of letter sounds, words, and syllables had increased over previous sessions. She displayed increased cognitive accuracy
when asked a question, verbal responses during appropriate times in songs, and independent vocalization of the word
/more/ when she wanted more music. Lily enjoyed the introduction of several new farm animals to her favorite Old
MacDonald song intervention.
Lily arrived for the 17th session in a quiet, sleepy state, yawning and showing apparent disinterest in her usual
favorite activities. The clinician happened to choose this session to introduce a new Hello Song containing more words.
Lily immediately demonstrated complete disinterest and confusion over this new song with puzzled facial expression
and decreased interaction. In addition, Lily (not yet potty-trained) was evidently experiencing a bowel movement
during the session. In retrospect, the clinician realizes she should have allowed the mother to change her daughter’s
diaper despite the disruption of the session.
During the 18th session, Lily displayed renewed interest in the old Hello Song. She also demonstrated an increase in
vocalization of letters, sound combinations, and parts of words, including her dog’s name, Button. Lily also displayed
enjoyment of the Letter Tree Song intervention, as well as an increase in vocalization attempts. During the piano
intervention, Lily displayed an interest in pairing letters with the names of notes.
The highlight of the 19th session occurred during the flash card intervention. As the clinician showed Lily the
card depicting a piano, Lily immediately pointed to the piano in the Clinic and walked over and began to play on
the keyboard. The clinician continued the piano intervention by directing Lily to pair verbal and written letters with
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the actual notes on the piano. Lily also seemed to enjoy the Letter tree, Name, and Button Song interventions, and
demonstrated an increase in vocalization of letters, sound combinations, and parts of words during this session. Spring
term goals and objectives for Lily were written.
The 20th session was very productive for Lily. She displayed increased verbal and vocalization ability during the
Button Song, independently vocalizing the letters /buh/ and /oh/ of the word /Button/. She also appeared to enjoy the new
Ants Go Marching board book/song intervention. Lily particularly liked counting every ant on every page while vocaliz-
ing the word for the number. In future sessions the clinician planned to add the numbers with the corresponding word to
each page to further stimulate interaction on the part of Lily. Lily also continued to enjoy the flash card intervention, and
the authors planned to add the actual words for the pictures on the flash cards in order to enhance the learning process.
Lily also displayed an increased interest in the piano, using hand signals while playing for the words /loud/ and
/soft/. The clinician encouraged Lily to sound out the words for what she wanted. Her parents later reported that they
were also working on these particular words at home. Lily also used sign language and gestures to indicate music
when she saw printed music during the session. Plans by the authors for future sessions were to incorporate the word
music into Lily’s vocalization and/or music interventions. Upon leaving this session, Lily displayed an increase in
vocalization skills, independently vocalizing the words /Mama/, /Dada/, /more/, /e/, /i/, /e/, /i/, /o/, /Oh/ (for No!) and a
babbling/singing type of vocalization that parents reported was a new self-vocalization skill that was not taught to Lily.
The 21st session occurred approximately 1 month after the previous session due to unavoidable conflicts on the part
of the clinician. The authors again wondered how Lily might respond after experiencing another break in her weekly
sessions. However, Lily appeared excited and happy upon seeing the clinician again, running to the Clinic to play the
instruments for her mom. Lily further demonstrated enjoyment of being in the Clinic and participating with a consistent
increase in her level of excitement, happiness, high energy, and decreased time spent on any one task. During the Old
MacDonald intervention, Lily demonstrated frustration and possible boredom of this particular song, independently
vocalizing /e/, /i/, /e/, /i/, /o/ in a frustrated, emphatic manner. During several instrument interventions, including the
guitar for the Goodbye Song, Lily independently vocalized the phrase /baby do it/ while pushing the clinician’s hand
away. Lily wanted to play the instrument by herself. She also enjoyed the bubbles intervention, and attempted to say
the syllable /puh/ to “pop” the bubbles.

Phase 4: Music therapy termination—Sessions 22–24

Music therapy sessions in the Clinic would be ending in 4 weeks, as the spring term was nearing completion. The
authors realized that the music therapy termination process would be very important for Lily as the relationship between
the clinician and Lily was very strong. Plans were made to begin the termination process at the next session.
Because the 22nd session occurred right before Easter, the clinician introduced a new Easter Song and accompanying
interactive aids. Lily demonstrated excitement and enjoyment of the intervention, with increased participation, energy
level, smiles, laughter, and excited flapping of hands. During both the Name and Button Songs, she successfully
vocalized letter combination sounds and identified the appropriate letters in response to the clinician’s song directives.
Lily further demonstrated preference for visual and interactive aids. During the drawing intervention, Lily demonstrated
cognitive understanding of letters, drawing the letter /b/ on the board while vocalizing the syllable /bah/.
Lily again demonstrated an increase in cognitive and vocalization ability throughout the 23rd session. During the
Bubbles song intervention, Lily displayed an increase in self-control and following directions. The actual bubble activity
(blowing and popping bubbles) was used as a reward after singing the new song and vocalizing with the clinician.
During the 24th and final session, Lily demonstrated independence by her refusal to follow the clinician’s directions.
At one point during the session, Lily began running over to the light switch, turning it on and off. She also displayed
inappropriate use of the instruments as evidenced by throwing them on the floor. At the close of the session, the mother
indicated that similar behavior problems were present in their home. Lily did seem to enjoy the bubble activity as
demonstrated by her interaction, attentiveness, and smiles.

Summary of treatment and Lily’s progress

In summary, Lily’s music therapy treatment progress appeared to be the result of a combination of evolving treatment
approaches, musical interventions, visual and interactive aids, and an engaging playful dialogue between Lily and the
clinician. Lily’s communicative methods at the beginning of her treatment process were almost exclusively non-verbal.
 B. Beathard, R.E. Krout / The Arts in Psychotherapy 35 (2008) 107–116 115

By the final session, Lily was vocalizing the syllables /bah/, /duh/, /fuh/, /guh/, /huh/, /muh/, /oh/, /puh/, /que/, /tuh/ and
the combination sounds /ba/, /da/, /ma/, /la/ and /on/. Her growing verbal vocabulary now contained the words /oh/,
/no/, /more/, /mama/, /dada/, and /baby do it/.
An increase in vocalization skills and cognitive recognition of the individual letters of her name was also observed
by the authors. Lily could independently vocalize each letter of her name while placing the corresponding Velcro letter
in the correct sequence. By the end of her treatment period, Lily could vocalize the syllables of her dog’s name when
verbally prompted by the clinician.
Cognitive recognition of the parts of a face was demonstrated during the drawing intervention on the dry erase
board and by independent vocalization of the beginning sounds of words such as /mouth/, /eyes/, /ears/, /nose/, and
/face/ while drawing the corresponding parts of a face. During one particular session at the end of her treatment, Lily
independently drew the letter /b/ on the board while vocalizing the letter.
Lily also demonstrated a sense of humor and playfulness throughout the course of her music therapy treatment. She
also enjoyed blowing bubbles in the direction of the clinician for fun. Her animated facial expressions, smiles, and
giggles indicated obvious pleasure and enjoyment in the music therapy sessions.

Summary of significant music interventions

• Hello Song—recognition/vocalization of her name and vocalization of the beginning sound /huh/ of the word /hello/.
• Old McDonald Had a Farm (with farm animals)—vocalization of beginning sound of animals at appropriate times
in song. Learned to independently vocalize /e/, /i/, /e/, /i/, /o/.
• Name Song—recognition/vocalization of name (letters and syllables).
• Button Song—recognition/vocalization of dog’s name (letters and syllables).
• Pop Goes the Bubble—blowing bubbles while vocalizing /puh/.
• The Letter Song—recognition/vocalization of letters using flash cards.
• Wheels on the Bus—vocalization attempts at sounds within the song accompanying this colorful, interactive book.

Discussion and conclusion

Lily’s parents were delighted with the progress their daughter made over the course of treatment and offered the
following unsolicited written statement:
Lily has made significant progress as a result of therapy, but will require many years of intensive speech therapy
to treat her verbal apraxia. Although her sensory issues and physical limitations are less severe than her speech
delays, she will probably require occupational therapy and physical therapy for the foreseeable future. Lily has
benefited from music therapy also, both for its individual merit and for the reinforcement of speech therapy goals.
In conclusion, music therapy treatment appeared to be very beneficial for Lily in the following goal areas: (1) verbal
communication, (2) socialization, (3) cognitive/emotional, and (4) motor skills/movement. The data-based treatment
approach outlined by Hanser (1999) allowed for changes in treatment techniques based on Lily’s progress. The creative
use of music therapy combined with visual and interactive aids in the sessions proved to be motivating and beneficial
for this child as demonstrated by her overall responses and progress over the course of the study. While this was a
single clinical case study and lacked controls for comparison between treatment and non-treatment conditions, music
therapy did appear to make a meaningful difference in the life of this young child.

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