The 5 Levels of Contact

My work with children and adults with severe mental and physical handicaps is influenced by the American psychologist John McGee and his philosophy, Gentle Teaching: A good relationship is the prerequisite of development. Each individual must feel safe and loved to be able to let go of anxiety and protective strategies. When we meet a person with enthusiasm and confirmation and when we show our concern about who he is and what he does, then both of us will start to change and our relationship grow in the sense that we can do more things together.

Af Anne Steen Moller

As music therapists we have a unique accession to working with people who are very fragile. Music reaches out and embraces us. The essence of music is humanity and this is why music therapists are able to establish a contact with all kinds of people. We can meet people where they are and share with them experiences of being part of a social exchange. – That is how I see my work with multiply handicapped people.

Many of the children and adults I have worked with have a developmental age between 0 – 2 years.  The theory of 5 Levels of Contact is derived from 25 years of practice within this field, it deals with the early developmental stages. The theory can be used in assessing communicative resources and when advising parents and caregivers on their interaction with a child.

Level of Contact 1 is not equivalent to a stage in the development of a healthy baby. Levels 2, 3 and 4 are stages that we see in the normal development within the first year – still a normally developed baby will integrate impressions and develop much more advanced skills. Level 5 describes interactions in the improvised music. (Approx. from 3½- 4 years.)

Development can take place both at each level, - “proportion” - and from one level to the other, - “progression”-. In the following I refer to the child as being a boy.

Level of Contact 1: “I ( the therapist) feel  a contact between us now and then”.

The child is born with vast mental and physical disabilities. It is difficult to establish a contact, the child does not respond clearly to sounds, movements and cuddling. The connection between us is very frail and my observations subjective:  ”I sense a contact between us “ .

At level 1 I focus on what I see as a universal quality of music: The force of music to create attention to something outside of our selves. Music is a means of recognition of the outside world and supports the experience of separation between the child and the surroundings.

The role of music is here primarily an attempt to create a safe environment and to communicate myself to the child.

Reactions may be seen in a change of the breathing which I believe is an expression of sensation in the child. Other sporadic reactions may occur such as movements, vocal sounds and mimic changes.

It is my experience that very few babies are born with so extensive mental handicaps as here described. Most of the children I have worked with at this level slowly developed an outward going awareness and significant reactions as described in the next level of contact.

In general it is important to acknowledge the value of each moment. Longterm perspectives  of development are not relevant and takes the focus away from the intensity that is needed in the work with these children.

Level of Contact 2: “I see and hear the contact.” ( Age: 0 to 5-6 months.)

In the normal development there are clear patterns of reaction to the musical approach almost from just after birth. The reactions become more and more significant and characterize each individual: Vocalisations, movements, turning the head towards the sound, mimic expressions, smiles, laughter and sometimes crying. The children often respond in the breaks of the music which for that reason consists of short musical sequences. I imitate or match the expressions of the child and then wait for him to perceive, adapt and respond to the stimulation. The different expressions of the child are not yet conscious communication but an emotional response to the sensory impressions of music. This gradually leads to recognition of the outside world.

 Another universal quality of music is indeed the development of self-awareness. Around 3 months after birth the child is experimenting with making sounds with the fingers such as scratching on the sheet etc. Later he begins to reach out and make sounds on other things and instruments. In producing sounds the child experiences “to make something happen” which is part of the development of self-awareness. From 5-6 months the child is aware that his sounds attract the attention of other persons.

At this level my underlying aim can be expressed in a “play-rule”:

“I will sing/play when you make a movement” – (or look at me, vocalize etc.) This is not yet a conscious act of the child. I ascribe an intention to the child in order to direct our interactions towards the next developmental stage.  (Level of Contact 3.)

There are 3 ways that the child responds to music at this level:

1. Sound-reacting behavior. (As described above.) 2. Sound-seeking behavior: The child turns his head/body in the direction of the sound.  (Most of the children that I have worked with at this level were not capable of using their sight.) 3. Sound-creating behavior. (Making sounds on instruments etc. and vocalizing.)

The role of music is to make the child aware of his/her own expressions. I use the music as an approach to create the beginnings of communicative interplay.

Vibrations are an important part of the music. Many children respond positively to the sensation of a kalimba, drum, tonebar etc. placed on the chest.

Development can be seen in 1) faster reactions and shorter pauses. 2) More significant reactions. 3) Recognition of the place, the sounds, the instruments, the voice of the therapist. This indicates a growing awareness and an ability to form experiences.

Level of Contact 3: “You (the child) control the contact.” (From 6-7 months to 9-10 months.)

The child is now conscious about being able to call the attention of others. He uses vocal sounds or banging, clapping etc. and sometimes an intense look.

The actions of the child are getting more intentional, often they have a social purpose. Our interaction is based on the initiatives of the child. The music is a response to and a confirmation of the child´s expressions: When he moves, plays on an instrument, looks at me, etc. then I start to play or vocalize. Sometimes it is most adequate to play/sing simultaneously with the child. Other times it works better to respond subsequently. (This may seem to be a dialogue but it is not. The focus of the child´s attention is on me and on evoking my reaction. He does not yet recognize the fundamental structure of communication:  The turntaking.)

The playrule is seen from the child´s perspective: “When I make my sound/movement then the therapist starts to play.”

I pick up the tempo of beats, vocal sounds and other expressions of the child and as a start I shape it musically so that my responses are fairly predictable and recognizable. Later I may try out other ways of responding – for instance move away and come back to the child or dance to his playing. The purpose is to increase the child´s awareness of communicating and to motivate him to initiate our interaction.

The role of the music is mainly reactions to the child´s active participation.

Development at this level can be seen in the child´s increasing activity in our interaction. The way of playing the different instruments becomes more relevant, new patterns of movement are incorporated. – The quality and the length of time in the participation are still important issues in the perspective of development.

Level of Contact 4: “Our contact takes the form of dialogue.” ( From around 10 months.)

The child is conscious of our interaction: We take turns at producing sound and listening. He is developing joint attention and is able to focus on both of us and on the instrument. Our interaction takes the form of a dialogue. The basic rule of communication is gradually conceived by the child: The turn-taking.

There is mutuality in the playrule: “We take turns at producing sound and listening.”

Sometimes there may not be a balance in our exchange. The child has not yet fully understood the idea of turn-taking. A small drum that I pass back and forth between us is a very useful way to create an equilibrium in our interaction.

The aim is to create exchanges in the music where the child experiences that his mode of expression becomes the starting point of our dialogue. Children with a very limited vocabulary can unfold their communicative skills in the music. It is often surprising in the music therapy to see that the principle of turn-taking is fully established even though they have had very little opportunities to practice it. I believe that for some children music is the only possibility they have for experiencing themselves in a communicative and ongoing exchange with others.

The role of music is a reciprocal communication. With instruments like a drum the fundamental form of communication “materializes” , since the form can be perceived both visually, in the movements and the sound.

At level 4 the music basically has 3 forms:

1. As a dialogue.

2. As games of imitation. ( Imitations of different ways of playing and of small rhythmical patterns. – In most cases the child imitates me. The opposite demands a higher level of development.)

3. As musical interaction where the child is capable of playing the basic beat of a melody, around 3½ years. (Levin´s and Nordoff/Robbins´ Playsongs are excellent to use with for instance children in the autistic spectrum. )

Some children master all 3 forms, others can only take part in one of them. Development shows in the awareness of the dialogue –expectation of taking turn and signals of giving turn. Also the interaction can be extended from taking part on a shared drum for instance, to each of us playing an individual instrument with a larger distance between us. Dynamics is another field that some children begin to explore.

Level of Contact 5: “We communicate in the improvised music”. ( From around 3½ - 4 years)

The child interacts with other people. Often there is the beginnings of verbal communication although the attention span may be short. In the music the child is often more focused and displays communicative resources that is not otherwise expressed. There is an ongoing exchange and a reciprocal influence on the musical interaction. Music provides a non-confronting space for the child to experience independency and autonomy. In the musical interaction he may further develop communicative skills such as sensitivity, flexibility, creativity, listening and responding to what you hear etc. The improvised music blurs the aspects of timing and rules that is predominant in verbal communication. Thus music is free from demands and expectations that these children are very sensitive to. It is my impression that music represents a safe world with logical and meaningful structures that resonate with their perception of life and confirms their relationship with another human being.

References:

Daniel Stern (1985) The Interpersonal World of the Infant. Basic Books, Inc.

Colwyn Trevarthen,  Aitken … (1996) Children with Autism. Jessica Kingsley Publishers.

Tony Wigram & Jos De Backer (1999) Clinical Applications of Music Therapy in Developmental Disability, Paediatrics and Neurology. Jessica Kingsley Publishers.

Karin Schumacher and Claudine Calvet-Kruppa. The AQR – an Analysis System to Evaluate the Quality og Relationship during Music Therapy. Nordic Journal of Music Therapy 1999 8(2)

Even Ruud (1990) Musikk som Kommunikasjon og Samhandling. Solum Forlag, Norway.

John McGee, Maurits Eijgendaal, Anne Eijgendaal (2007) Gentling My Way Into Lonely Spaces. Publisher: Soelund, Skanderborg, Denmark.

Gail M. Levin, Herbert D. Levin, Nancy D. Safer.  Learning through Music. Teaching Resources Corporation.

Paul Nordoff, Clive Robbins. Childrens Playsongs.