Francesca Crozier-Fitzgerald, MEd, CTVI, Perkins-Roman CVI Range Endorsee

with Marie Miller MT-BC, NMT & Andrea Coiro, Music Therapist

As we know, students with Cortical Visual Impairment (CVI) require modifications and adaptations to their learning materials and environments in ways that decrease complexity and increase access. As instructors, service providers, parents and therapists on the child’s team, we know that these adaptations can take many different forms. We may be modifying text (outlining parts of words or letters; increasing size and spacing between letters and words), providing stories and lessons on Google Slides, modifying graphics by highlighting and teaching the salient features of objects, or using mixed media instructional alternatives. That last category is where we’re exploring new avenues, getting creative, and adding the fun! One of these alternatives comes in the form of something we rely on in all stages of life—music.

Music Therapy in the NICU

As defined by the American Music Therapy Association, “Music Therapy is the clinical and evidence-based use of music interventions to accomplish individualized goals within a therapeutic relationship by a credentialed professional…to address physical, emotional, cognitive, and social needs of individuals.” Music therapy interventions are applied across the lifespan from birth until death and they are used to address a wide range of needs, otherwise left unmet. These needs may start as early as the first days of life after birth, especially for babies born prematurely, placed in the NICU.

Studies conducted on the importance that the maternal voice has for the baby show that sound stimulation is critical for the psychophysical development of the fetus. In fact, music therapists and medical teams within the NICU have utilized this research for these babies born prematurely—as are many infants diagnosed with CVI—by supplementing the intrauterine sound universe, as well as frequencies mimicking the maternal voice and heartbeat. Results show that premature babies exposed to these treatments demonstrate faster psychophysical development— decreased stress levels, stabilization of sleep and wakefulness, faster sucking rhythms, decreased hospital stay—than children who have not been treated at all.

Precisely, studies conducted on premature babies receiving these treatments between the thirty-first and the thirty-second week indicate exponential developmental progress, so much so that two weeks later, premature babies with typically developing visual systems have the same visual abilities as forty-week-old babies with typically developing visual systems (Manfredi & Imbasciati). From this, we might infer that adequate sensory stimulation in children with CVI living their first days in the NICU could benefit their development and encourage the development of the child's neighboring abilities. This same sensory stimulation and music based interventions after life in the NICU have proven beneficial, across all age groups, to address various needs.

Marie Miller, owner of Rhythm and Strings Music Therapy, is a Neurologic Music Therapist. She is trained in the the neuroscience of music perception, music production, and music cognition and uses standardized techniques to achieve non-musical goals such as speech, physical movement, cognition and other functional abilities. Before the recent pandemic, Marie served her students of all ages in a variety of environments—private one-on-one instruction, hospitals, school classroom group therapy sessions, and rehabilitation centers throughout New Hampshire and Southern Maine. Coming to this challenge with a strong background in neurological processes and behavior and a fascination for lifelong learning in her field, a therapist like this is a key addition to the team.

Since she started working with her first kiddo with CVI a few years ago, Marie has been diving head first into adapting her approach to be accessible for students with CVI. She has been absorbing all the ways that her traditional therapy delivery model could be modified to amplify its meaning for students with CVI. She has since taken on additional students with CVI and has been having a lot of fun adjusting, modifying, and learning new routes for accessing her students.

As she says, “Music-based intervention is effective in targeting students with a variety of developmental goals because it is such a global experience in the the brain. If any pathway in the typical network is down, music-based intervention promotes the creation of alternate pathways and alternate routes for processing…it activates the whole brain, which primes it for learning.”

A Natural Motivator

Research has shown, for centuries, that students enjoy pairing learning with music, for obvious reasons. Marie notes, “Music is such a natural motivator, so if you have a song that is really motivating and you’re working on a concept or doing something that is maybe not preferred, they’re going to be more motivated to participate.”

A parent, Caryn Lasante-Ford’s adds, “My daughter is highly motivated by music. When she is motivated, she uses her vision in a more functional way. We have seen her scan her visual area and hone in on an item, particularly if it plays music…Music has been the one constant in my daughter's life.” Lasante-Ford’s daughter has been diagnosed with CVI and is currently receiving 1:1 music based intervention at the Morrison Center in Maine.

And music therapy is far more than just playing soothing or engaging music—a common misconception—or leading a group to play music together for fun. As the American Music Therapy Association clarifies, “Through musical involvement in the therapeutic context, clients' abilities are strengthened and transferred to other areas of their lives.” The individualized therapy, just as individualized instruction should be, is geared to address the unique specific needs of each client, student, or patient.

Assessment Drives Individualized Instruction
Assessments conducted by music therapists in the early stages of service provision are critical, just as performing the CVI Range Assessment or an Orientation and Mobility Assessment would be for a child with CVI. The assessment gives the music therapist insight into the student’s strengths and needs, in order to determine the strategies and nature of the therapies and treatment.

As the American Music Therapy Association explains,“Music therapy also provides avenues for communication that can be helpful to those who find it difficult to express themselves in words. Research in music therapy supports its effectiveness in many areas such as overall physical rehabilitation and facilitating movement, increasing people's motivation to become engaged in their treatment, providing emotional support for clients and their families, and providing an outlet for expression of feelings.”

In learning the needs of her kiddos with CVI, Marie Miller found that working on communication and literacy skills would need to take a different form. Based on their Perkins-Roman CVI Range score and needs for modified complexity in the environment and learning materials, Marie pushed aside the traditional word cards (without favorable contrast) and 2D picture cards of various animals in the song. She began using 3D objects to introduce animals, word cards with bright yellow letters on a black background; she adjusted the song’s lyrics to describe the salient features of key objects, rather than just labels.

“Say we’re learning spoon, and uses of a spoon, and overall ‘spoonness.’ I’ll be playing a familiar, favorable tune, pausing to increase those opportunities for the student to fill in the empty space. In this time, I also encourage the student, in a quiet environment, to explore the object, explore it’s “spoon-ness” and hope that the music—which is a tune he loves—will be that little push into correctly labeling the object. So, we go back to the chorus:

‘All these things, they come together come together at the table
Here comes the…spoon!’ ”

And motivation through music works the other way, too. “I also see that their motivation to participate and do the hard work during our session is fueled by their desire to get away from the novel unfamiliar space. They’re so eager to get back to that fun, familiar chorus, that they’ll work harder to label —‘spoon’ and get back to the song.”

Trust in this routine and the vehicle—music—is really critical to the success of the music therapy. “The music itself creates so many opportunities to access and fire up the brain through alternative routes which, ultimately, set these kiddos up for success in learning.”

Novel and New in a Safe, Structured Space

“In a world where things are just hard to piece together, due to various impairments or developmental delays, music can be this really safe space, because its highly structured, predictable and repetitive.” She gives examples of how she may change a word, or add a new character/object to the song, introducing something new and novel that could be scary. “But, in the end, its okay and they’re willing to follow along because the kiddo also knows were going to get back to the chorus eventually, to our safe zone.”

Marie provides additional aids—visual “first-then schedules,” timers, strategic sensory breaks, brushing, movement breaks, various 3D manipulatives—where they are needed, to create the most accessible, structured learning space that our kiddos with CVI absolutely need.

“The brain loves predictable, predictable, predictable, oooh, slight change, predictable, predictable...we would get so tired of a song if it was always exactly the same, so we integrate improvisation to elicit attention, and then we’re back to the familiar. We’re constantly adapting and constantly adjusting.”

She also works on gradually reducing the aids, as they are no longer needed. Proof of progress came, recently, when one of her students with CVI, who had trouble maintaining focus and attention for their 10 minute intervals is now, with strategic visual breaks, attending for his full 45 minute session. This does not happen without a therapist that knows and understands the value in constantly evolving model and integrating the appropriate opportunities to recharge.

Salient Features in Song

Music and music therapy also lend themselves to become the package through which we can deliver salient feature instruction of common objects that our children with CVI encounter in their daily lives and experiences—the salient features we work so hard to teach, reinforce, and solidify for our children with CVI. 

“By nature, kids will learn to sing the words of a song before they fully solidify the concept of what they’re singing about,” says Marie. Which, in many ways, sounds like the “compensating” we witness in a lot of our students with CVI as they move throughout the school day in the school environment. They may not be able to parse through the complexity of a classroom, or interpret facial expressions of peers, so they avoid them; they find the familiar landmarks, and aim to get their bearings of a complex set-up; they latch on to the features they recognize like voices, long hair, familiar shoes. 

Marie gets to the root of that problem through music. Rather than allowing our kids to just “go with it,” music therapy can give our kids strategies to give meaning to each lyric, and each object we meet in our song. Instead of a lyric without meaning, it has three or four new meanings, per song. Ideally, this strategy can be applied throughout the day, to push our “master compensators” to take a closer look at the salient features of the object and use their vision to identify it. Rather than rushing past that novel blob in the middle of the room, let’s see: it has legs, a flat surface, books inside, it’s just a desk in a new spot.

“Using music to develop those connections between hearing the words of the features, feeling the features, hearing the tune, seeing the real 3D or 2D object, we’re building learning strategies to be applied in all parts of their world.”

One student, Griffen Waugh, who also happens to have CVI, has been receiving music therapy services since he was in the NICU and consistently for the last 6 years. He comments, “It’s made me have more of an interest in playing an instrument. It’s fun!” His mom, Alisha Waugh, PT/COMS and Perkins-Roman CVI Range Endorsee, mentions how emphasizing the salient features of music notation itself has benefitted Griffen’s journey in music literacy: “Music therapy has really helped Griffen learn to use his hands in coordination with his vision. He has learned to read music after being adapted with color, as well as extra spacing and enlargement. It has been a great addition to his educational program!”

Because of this global experience in the brain, Marie explains, you are more likely, better trained, to retain that information. “So if I have a kiddo, and Im teaching concepts and salient features of common objects, rather than just repeating the words of the salient features over and over, we put the features into a song and we make it catchy. The hope is that every time hes holding that fork at the table, hes feeling its long handle and seeing its pointy prongs, and he’s hearing our song list the salient features of the fork, solidifying the concept.

Building Literacy Skills

When serving her students with CVI, Marie Miller is also very deliberate in fostering the development of communication and useful literacy skills. Just like the components of a story taught in the classroom, the music and songs that she uses during therapy are designed to teach phonics, fluency, recall, and story elements such as characters, setting, and plot sequencing.

For her students with CVI, Marie presents these elements in various accessible ways, depending on their needs. She may be using 3D real objects, 2D realistic picture cards, black trays, backgrounds, and all the other various adaptations to create a non-complex learning environment. She has been having a lot of fun adapting Pete the Cat books by Eric Litwin and James Dean. Her kids have probably been introduced to Pete through the famous songs and stories in the classroom, but as the graphics are cartoon drawings, 2D non-realistic images and complex, these stories can be so much more easily accessed when they’re accompanied by 3D objects and salient feature lyrics to introduce concepts along with a tactile, fun, interactive musical experience. Currently, she has been adapting “Four Groovy Buttons” with a velcro strip, four large buttons, and interactive activities where the student is in charge of removing and placing the buttons in a receptacle with each new verse.

With evidence-based research supporting the value in sound stimulation in the NICU as well as the increased access it can provide school-aged students with CVI, music therapy provides us with yet another avenue to reach our children’s needs. It is clear that Marie Miller’s music therapy strategies, especially those addressing communication, social skills, literacy, self-advocacy and expression, are making an impact on the learning experience and lives of students with CVI.

Hopefully, as knowledge on these impacts spreads, music based interventions through music therapy will become more common, increasing access to learning. It can provide a more wholesome approach to daily living skills that is not only productive, its a lot of fun!

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1Roman-Lantzy, C. (2018) Cortical Visual Impairment: An Approach to Assessment and Intervention. 2nd ed., New York, NY: AFB Press
2Dutton, G  and Lueck, A (Ed.). (2015). Vision and The Brain. New York, NY: AFB Press. 
3Manfredi, P and Imbasciati, A. (2004) Il Feto ci ascolta...e impara. Rome, IT. Edizioni Borla.
4Roman-Lantzy, C. (2019). Cortical Visual Impairment: Advanced Principles. Louisville, KY: APH Press.

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