See discussions, stats, and author profiles for this publication at: https://www.researchgate.

net/publication/275144327

The Music Therapy Communication and Social Interaction Scale (MTCSI): Developing
a New Nordoff-Robbins Scale and Examining Interrater Reliability

Article  in  Music Therapy Perspectives · August 2014

DOI: 10.1093/mtp/miu002

CITATIONS READS

5 302

4 authors, including:

Adam Patrick Bell

The University of Calgary
11 PUBLICATIONS   12 CITATIONS   

SEE PROFILE

Some of the authors of this publication are also working on these related projects:

writing a book on music making and learning with DIY recording studios View project

All content following this page was uploaded by Adam Patrick Bell on 20 December 2015.

The user has requested enhancement of the downloaded file.

 The Music Therapy Communication and Social
Interaction Scale (MTCSI): Developing a New Nordoff-
Robbins Scale and Examining Interrater Reliability
ADAM PATRICK BELL
RICKY PERRY
MANDY PENG
ALEXANDRA J. MILLER
ABSTRACT:  Building on the Musical Communicativeness scale
(Nordoff & Robbins, 1977, 2007), the Music Therapy Communication
and Social Interaction scale (MTCSI; Guerrero et al., 2014), was devel-
oped to document and evaluate communicative and socially interac-
tive responses that are elicited during mu sic therapy sessions. Piloted
with 36 children ages 2–5 in a special education setting, this article
documents the development of the MTCSI and presents preliminary
interrater reliability data. Four raters from 4 different academic back-
grounds employed the MTCSI to code the music therapy sessions of 8
participants. With one exception, interrater reliability of the MTCSI was
consistently high. While the MTCSI demonstrates promise as a research
instrument for evaluating social interaction and communication, prag-
matic concerns raise questions regarding its utility as a clinical tool.
ASD and Nordoff-Robbins Music Therapy
Communication and social interaction competencies are
core deficits experienced by children with autism (Joseph &
Tager-Flusberg, 2009). Understanding the extent of these defi-
cits and how children respond to therapy is important not only
in demonstrating progress in a single session, but also in map-
ping the course of change over time. Further, as many chil-
dren with autism receive music therapy in groups, developing
a tool that can be used in a group setting may be advantageous
for therapists and researchers.
Nordoff-Robbins (NR) Music Therapists have worked with
children with autism for decades, developing and refining inter-
ventions to maximize each child’s social and communicative
skills, within the core framework of improvisational musical
experiences (Aldridge, Gustorff, & Neugebauer, 1995; Guerrero
& Turry, 2013). While indexing has been a core part of this pro-
cess, in which NR therapists review videos of each therapy ses-
sion (Nordoff & Robbins, 2007), Paul Nordoff and Clive Robbins
(1977), also developed evaluative scales to document music
therapy sessions quantitatively (Mahoney, 2010; Nordoff &
Robbins, 2007; Trevarthen, Aitken, Papoudi, & Robarts, 1998).
Adam Patrick Bell, PhD, is Assistant Professor of Music Technology and Music
Education at the John J.  Cali School of Music, Montclair State University. Ricky
Perry, MA, MT-BC, is a LCAT music therapist at Kings County Hospital Center in
Brooklyn, NY. Mandy Peng is a recent graduate of the New York University School
of Medicine, NY. Alexandra J. Miller is a Prevention Specialist at Concept Health
Systems, a substance abuse center in Miami, FL.
© the American Music Therapy Association 2014. All rights reserved.
For permissions, please e-mail: journals.permissions@oup.com
doi:10.1093/mtp/miu002
Advance Access publication June 18, 2014
Music Therapy Perspectives, 32(1), 2014, 61–70
61
John J. Cali School of Music, Montclair State University
& Nordoff-Robbins Center for Music Therapy, New York
University
Kings County Hospital Center
New York University School of Medicine
Department of Applied Psychology, New York University
Building upon this foundation, NR clinicians and research-
ers identified a need to develop a new scale with better-
defined constructs that expand upon the core concepts of the
Downloaded from http://mtp.oxfordjournals.org/ by guest on September 8, 2014
original scales. The Music Therapy Communication and Social
Interaction scale, abbreviated to the MTCSI (Guerrero et al.,
2014), was designed to provide a method of measuring behav-
iors perceived as either communicative or socially interactive
that are commonly elicited during a music therapy session. It
resembles most closely Scale II, Musical Communicativeness,
from the original scales. (see Appendix A: “MTCSI – Group”)
Developing the MTCSI
Creating the MTCSI occurred in multiple, sequential stages,
commencing with identifying behaviors associated with com-
munication and social interaction that could be observed
and evaluated using a video recording. Since its opening in
1990, therapists at the Nordoff-Robbins Center have amassed
a wealth of clinical experience interacting with young chil-
dren with ASD. This pooled resource was drawn upon to draft
the domains that constitute the MTCSI, namely the elemental
construct of engagement, which is defined by behaviors asso-
ciated with social interaction and communication.
Guerrero et al. (2014) theorized that in a controlled experi-
mental study, a music therapy intervention would demonstra-
bly improve the deficit behaviors associated with ASD, which
they identified principally as communication and social
interaction. According to Joseph and Tager-Flusberg (2009),
“Autism is diagnosed solely on the basis of behavioral impair-
ments and anomalies, specifically in the three core symptom
domains of reciprocal social interaction, communication, and
repetitive interests and activities” (p.  201). Further, Tsatsanis
(2005) likens the behavioral traits of autism with those of peo-
ple with prefrontal cortical damage: “These characteristics
include response preservation, disinhibition, narrow range of
interests, failure to plan, difficulty taking the perspective of
others, and lack of self-monitoring” (p. 372). Taken together,
the existing findings from ASD research inside and outside of
music therapy contexts provide firm foundational support for
the theoretical structure of the MTCSI, an elemental block of
establishing content validity.
The second step involved operationalizing the behav-
iors attributed to communication and social interaction and
the rating scale proposed to assess them. Table 1 details the
62
Table 1
Observable Behaviors of Engagement and Emotional Communication Measured by the MTCSI
Engagement
Engagement (Socially Interactive
Preengagement
Attention Vocalization Instrument Transitions Joining Turn
Use In Taking
Note. Transitions can be coded as Preengagement or Engagement. Emotional Communication is conceptualized as having two distinct compo-
nents, affective and physical responses.
organizational structure of the MTCSI. For a detailed descrip-
tion of each construct measured by the MTCSI, please refer to
Appendix A.
The first category is Engagement, or in its absence,
Preengagement. Engagement is exhibited by communica-
tion and/or social interaction with peers or the therapists. To
encourage communication and social interaction, the music
therapists scaffold “joining in” and “turn taking” activities
for the children, providing multiple avenues into music-
making through singing and playing instruments. The cat-
egories used to rate Engagement are Joining In, Turn Taking,
Reciprocal Musical Communication, and Reciprocal Verbal
Communication. These categories are rated on a three-point
scale where a rating of “3” is the highest and denotes sus-
tained engagement, intermittent engagement is scored a “2,”
and “1” is reserved for infrequent engagement.
If a child does not demonstrate behaviors associated with
Engagement, he or she is categorized as being in a state of
Preengagement, which is typified by a resistance to participate
in group activities. The categories used to rate Preengagement
are Attention, Vocalization, and Instrument Use. Similarly,
Preengagement is evaluated on a three-point scale, with these
actions receiving higher scores as they approach a state of
Engagement. The key distinction on the continuum between
Preengagement and Engagement is whether a participant’s
actions are socially interactive and/or communicative.
Preengagement and Engagement are evaluated during times
between activities, aptly labeled Transitions.
The remaining category, Emotional Communication is the
overarching term for the constructs of Affective Responses and
Physical Responses. These two constructs rely on the observable
physical actions of the children such as smiling at a peer or wav-
ing goodbye at the end of a session. Affective Responses are also
coded on a three-point scale: a rating of “3” is used to label affect
that is shared or reciprocal, a score of “2” signifies the affective
response is in context to the social situation, but not directed
towards peers or therapists, and a “1” designates demonstrations
of affect that have no apparent connection to the music therapy
context. Deviating from the three-point rating system that typifies
the MTCSI, the Physical Responses category utilizes a two-point
scale. Socially appropriate touching or acceptance of touch-
ing (e.g., holding hands) is designated a “1,” whereas a “2” is
reserved for communicative gestures such as hugging.
Lastly, rigorous refinement of the definitions and descrip-
tions of the instrument were necessary to optimize it for ease
of use. This has been accomplished through testing within the
Nordoff-Robbins Center and through a pilot study that will be
discussed in the following section. Using data from the same
Music Therapy Perspectives (2014), Vol. 32
Emotional
communication
Affective Physical
or Communicative) Responses Responses
Reciprocal Musical Reciprocal Verbal
Communication Communication
pilot study, Guerrero & Turry (2013) reported promising pre-
liminary findings of the correlations between the domains of
the newly created MTCSI and those of the well-established
Vineland-II, but no preliminary data on any form of reliability
was reported. The purpose of this paper is to detail the devel-
opment of the MTCSI and report the results of a recently com-
Downloaded from http://mtp.oxfordjournals.org/ by guest on September 8, 2014
pleted pilot study of its interrater reliability.
It should be noted that the MTSCI was crafted such that it
could complement the existing qualitative method of video-
based analysis in place at the Nordoff-Robbins Center (com-
monly referred to as “indexing”). The hallmark of the index-
ing procedure is the premium placed on the attention to the
minutia and subtleties of the interactions between the clients
and therapists. Dating back to the early work of Paul Nordoff
and Clive Robbins (e.g., Nordoff and Robbins, 1965; Nordoff
and Robbins, 1968), Nordoff-Robbins music therapy has a
rich history of employing a qualitative case study model that is
steeped in narrative and thick description. The qualitative case
study model remains a pillar in the foundation of the training
protocol at Nordoff-Robbins Centers, as evinced by the annual
advanced certification candidates’ case study presentations.
Method: Piloting the MTSCI at “TOTS”
Location and Participants
In the fall of 2008, a research team at the Nordoff-Robbins
Center for Music Therapy consisting of two therapists, two
researchers, and three research assistants commenced a pilot
study at These Our Treasures School (TOTS) in the southeast
Bronx, NY. TOTS is a not-for-profit special education school
that provides “home-based and center-based intervention ser-
vices for children with special needs (birth to age 5)” (TOTS,
n.d., p. 5). The pilot study was deemed mutually beneficial
for both parties as it provided the researchers with a conveni-
ent sample and provided music therapy services to the study’s
participants, 36 children aged 2 through 5 years, half of whom
were diagnosed with ASD.
Resembling what Aldridge, Gustorff, and Neugebauer
(1995), refer to as “waiting-list control” (p.  192), the TOTS
study utilized a lagged-cohort quasi-experimental design to
ensure all participants received therapy. Half of the children
received music therapy in the fall semester only (designated
as the experimental group), and the lagged control group con-
sisting of the remaining students commenced music therapy
sessions in the spring semester. The subgroupings within the
experimental and control groups were naturalistic, mirror-
ing the students’ class groups within the school. These sub-
groups ranged in size from three to eight students and were
Music Therapy Communication and Social Interaction Scale
accompanied by their regular teachers and teaching assistants.
Sessions were video-recorded from two different perspectives
in the room by the research assistants at the beginning, mid-
dle, and end of the 12-week-long therapy course.
Music therapy was provided in weekly 30-min group ses-
sions. A typical TOTS music therapy session commenced with a
hello song and concluded with a goodbye song. Kern, Wolery,
and Aldridge (2007) explain: “In music therapy, ‘hello’ and
‘good-bye’ songs are used frequently to establish predictable
routines and structure, provide undivided attention, and com-
municate a welcome” (p.  1265). These bookends are inter-
spersed with improvised “joining-in” and “turn-taking” activi-
ties. Kim, Wigram, and Gold (2009) posit: “Improvisational
music therapy is just such an individualized intervention that
facilitates moment-by-moment motivational and interpersonal
responses in children with autism” (p.  391). As a result, no
two music therapy sessions at TOTS featured the same con-
tent. While the overarching session structures were similar and
the durations were identical, each session was unique.
Procedure
The MTCSI was designed with the intent that nonmusic
therapists could understand and execute it with the goal that
its utility would extend into interdisciplinary collaborations
and studies. To test how the constructs defined in the MTCSI
are interpreted and scored by raters from different academic
fields, a preliminary examination of interrater reliability was
undertaken. In the interest of fostering an interdisciplinary
perspective on the constructs measured by the MTCSI, four
raters from four different academic backgrounds (music edu-
cation, music therapy, psychology, & medicine) participated
as coders. In total, 24 video-recorded music therapy sessions
were coded using the MTCSI and split evenly amongst two
teams of coders, Team A and Team B. Both coding teams were
assigned four different children and tasked with coding three
music therapy sessions per child. The eight TOTS students
assigned to the coding teams were selected randomly from
the original pool of 36 participants. Coders were trained by an
experienced tutor before commencing the interrater reliability
study. The prestudy tutoring phase consisted of 3 hr of training
in which the coder and tutor watched music therapy sessions
filmed at TOTS and discussed the constructs the MTCSI aims
to measure: Engagement (or in its absence, Preengagement),
Affective Responses, and Physical Responses.
Coding a 30-min TOTS music therapy session with the MTCSI
is a labor-intensive process that typically requires 1 to 2 hr to
complete. Sessions are microcoded, requiring the rater to assign
a score for each minute of activity. After watching each minute
of video, raters assign scores in the appropriate categories.
To assess interrater reliability, the rating teams watched the
video-recorded music therapy sessions together, but coded the
behaviors of the children independently. Raters were not per-
mitted to dialogue with each other while coding, other than to
request re-watching an interval or indicate that they were ready
to move on with the next interval. Each of the three categories
was analyzed in a two-phase process. In the first phase, cat-
egorical agreement was examined as either “agreement” or “no
agreement.” In this phase, the MTCSI was tested to see if two
independent raters using this instrument agree if the child under
63
observation exhibited the same quantity of Engagement behav-
iors, Affective Responses, and Physical Responses on a minute-
by-minute basis. In the second phase, the “agreement” intervals
from the first phase (categorical) were further analyzed, again
as either “agreement” or “no agreement” on the basis of level.
This phase tested whether or not raters agree on the degree of
Engagement, Affective Response, and Physical Response exhib-
ited by the child in the music therapy session. For both phases
of analysis, agreement was calculated and reported as a coef-
ficient, as were the means and standard deviations of each cate-
gory to examine the consistency of the raters. A caveat of utiliz-
ing a percentage-based assessment of interrater reliability is that
the scores are less robust than a kappa approach (Gwet, 2010),
which accounts for agreement that may occur due to chance.
However, being that this was a preliminary investigation of
interrater reliability with the aim of improving the functional-
ity of the MTCSI, the simpler statistical procedure was chosen.
Even with its inherent inflations, the data serves its purpose in
Downloaded from http://mtp.oxfordjournals.org/ by guest on September 8, 2014
guiding actions for revision and refinement.
Results
Tables 2 and 3 present the agreement coefficients and
accompanying means and standard deviations for Rater Team
A and Rater Team B respectively.
For both teams, it is evident that categorical agreement coeffi-
cients were very high. The mean categorical coefficient scores for
Team A were 0.93 (SD = 0.05) for Engagement, 0.88 (SD = 0.24)
for Affective Responses, and 0.91 (SD  =  0.08) for Physical
Responses. The mean categorical coefficient scores for Team
B were 0.99 (SD = 0.02) for Engagement, 0.94 (SD = 0.09) for
Affective Responses, and 0.97 (SD = 0.04) for Physical Responses.
Despite these high coefficients, it should be noted that the stand-
ard deviation for Team A’s Affective Responses agreement coef-
ficient was high, reflecting their inconsistent ratings for Session
2 of Child 4 (0.13). Both teams struggled to produce consistent
results for Engagement Level, with comparatively lower coeffi-
cients and higher standard deviations than the other constructs
assessed. The Engagement Level agreement coefficients for Child
2 were especially low (0.22, 0.38, & 0.29). In contrast, both rat-
ing teams produced high agreement coefficients for Affective
Responses Level and Physical Responses Level. With regard to
Affective Response Level, Team A’s agreement coefficient was
0.91 (SD = 0.08) and Team B’s agreement coefficient was 0.97
(SD = 0.04). With regard to Physical Response Level, Team A’s
agreement coefficient was 0.89 (SD = 0.10) and Team B’s agree-
ment coefficient was 0.99 (SD = 0.02).
Discussion
With the exception of Engagement Level, interrater reliabil-
ity of the MTCSI’s categories are consistently high. The large
standard deviations reported for subspecific scales are indica-
tive of the fact that the sample size is small and one outlying
result skews this statistic.
As a clinical tool, the MTCSI remains in a state of gestation in
which it requires further testing and refinement. Including the
findings of this report and the earlier cited report of Guerrero
and Turry (2013), the MTCSI has shown promise to be both a
reliable and valid measure of social interaction and communi-
cation. Despite the authors’ optimism, there are a number of
pragmatic concerns that make utilizing the MTCSI problematic.
64 Music Therapy Perspectives (2014), Vol. 32

Table 2 
Agreement Coefficients for Rater Team A

Agreement coefficient
Engagement Affective Physical
Child Session Categorical Level Categorical Level Categorical Level
1 1 0.93 0.36 0.93 0.93 0.82 0.82
2 0.92 0.67 0.92 0.92 0.92 0.92
3 0.95 0.55 0.95 0.95 0.82 0.82
2 1 0.91 0.22 0.96 0.87 1.00 1.00
2 1.00 0.38 0.93 0.93 0.93 0.93
3 0.90 0.29 1.00 0.95 0.95 0.95
3 1 0.96 0.86 1.00 1.00 0.86 0.86
2 1.00 0.84 1.00 1.00 1.00 1.00
3 0.96 0.88 1.00 1.00 1.00 1.00
4 1 0.96 0.61 0.93 0.93 0.89 0.89
2 0.86 0.45 0.13 0.90 0.97 0.69
3 0.82 0.55 0.77 0.77 0.77 0.77

Downloaded from http://mtp.oxfordjournals.org/ by guest on September 8, 2014

Mean 0.93 0.55 0.88 0.93 0.91 0.89
SD 0.05 0.23 0.24 0.06 0.08 0.10

Table 3 
Agreement Coefficients for Rater Team B

Agreement coefficient
Engagement Affective Physical
Child Session Categorical Level Categorical Level Categorical Level
5 1 1.00 0.93 1.00 1.00 1.00 1.00
2 1.00 0.97 1.00 1.00 1.00 1.00
3 0.95 0.90 0.95 1.00 1.00 1.00
6 1 1.00 0.89 0.93 1.00 0.93 1.00
2 0.96 0.71 0.96 0.96 0.96 1.00
3 1.00 0.92 0.96 0.96 0.96 1.00
7 1 1.00 0.67 1.00 0.92 1.00 1.00
2 1.00 0.66 0.92 1.00 1.00 1.00
3 0.96 0.58 0.96 1.00 0.92 1.00
8 1 1.00 0.73 1.00 1.00 1.00 1.00
2 1.00 0.71 0.69 0.83 1.00 0.92
3 1.00 0.48 0.95 1.00 0.91 1.00
Mean 0.99 0.76 0.94 0.97 0.97 0.99
SD 0.02 0.16 0.09 0.05 0.04 0.02

First, the training required to employ the MTCSI is very time-
intensive, typically requiring trainees to spend 3 hr with an
experienced coder to guide them through the process. Second,
once trained, the coding time required to completely analyze a
single session is approximately twice the real time of the video
excerpt. Experienced coders can complete a session in real
time plus one-third to one-half of the video excerpt’s duration.
For example, the coders involved in the interrater reliability
study typically completed a 20-min session in 30 min.
The microcoding process contributes a systematic dimen-
sion to the analysis of NR music therapy sessions, wherein each
single minute necessitates analysis—this is not the case with
the qualitative indexing method, where subjective decisions
determine which parts of a video excerpt should be analyzed
more closely. Marcus (personal communication, December
15, 2013) suggests that because indexing is intended to probe
for clinical implications, a client’s unresponsiveness to therapy
may result in a dearth in data generation from the indexing pro-
cess. As one trainee remarked, “the MTCSI forces you to recog-
nize that there is always something, even when it seems there is
nothing.” While not expected, the MTCSI has the added benefit
of challenging researchers and practitioners alike to consider
the seemingly diminutive events as well as the glaringly salient
events that occur within a music therapy session in order to
develop a comprehensive clinical picture of the client.
The “agreement” versus “no agreement” approach utilized
in this analysis is conservative, but eschews an analysis of rater
tendencies to be “hard” or “easy” coders. Therefore, an alter-
native statistical approach such as calculating Cohen’s kappa
could produce a more authoritative result for this preliminary
analysis of the interrater reliability of the MTCSI. Further, in
an effort to improve the interrater reliability of the construct
Engagement Level in the MTCSI, heeding the feedback of
the raters, the instructional materials will be further refined
Music Therapy Communication and Social Interaction Scale
to remove ambiguities and provide more specific examples
of what to observe in an activity to make the coding process
more concrete and less interpretive.
This quantitative approach to analysis is a double-edged
sword of sorts, as despite its aforementioned advantages, it
presents some philosophical problems for NRMT therapists.
For example, the construct under most scrutiny and criticism
amongst the MTCSI’s authors is emotional communication,
because it frames the acts of smiling or laughing as evidence of
“positive” affect. Clients of NRMT display a broad range of emo-
tions that could be perceived as “positive,” and are not limited
to smiles and laughs. The challenge for a non-NRMT-trained
coder is that these other displays of affect were often subtle and
required in-depth acquaintance with the client that only the
therapist possesses. The MTCSI was not designed to supplant
the indexing process, and should not be regarded as its quanti-
tative analog. Delimiting the affective behaviors accounted for
by the “MTCSI – Group” confines coders, which for the purpose
of establishing interrater reliability, is necessary as it reduces the
variability in interpreting responses to the therapy.
As the data analysis of the TOTS study enters its final stages,
the correlations of the Vineland-II and the MTCSI will be
examined for concurrent validity. The MTCSI was not intended
to be used as a clinical tool as it is likely too time consuming
for most clinical applications. However, clinicians wishing to
diversify their analytical methods may find the MTCSI to be
a welcome complementary tool that provides an additional
and alternative lens through which to examine data. For the
qualitatively-oriented researcher, the MTCSI provides a portal
to engaging in mixed methods research, generating quantita-
tive data to complement qualitative findings.
In its current state the MTCSI has been refined to the point
where it is ready to undergo comprehensive and rigorous reli-
ability and validity testing. Appropriately, it builds upon the
foundational theories of NRMT and extends them by incorpo-
rating findings from relevant and related research on children
with autism. Like the original Nordoff Robbins scales (2007),
the MTCSI provides a method of measuring communication
and social interaction observed during music therapy sessions.
Conflicts of interest: None declared.
References
Aldridge, D., Gustorff, D., & Neugebauer, L. (1995). A preliminary study of creative
music therapy in the treatment of children with developmental delay. The Arts
in Psychotherapy, 22(3), 189–205.
Guerrero, N. & Turry A. (2013). Nordoff-Robbins music therapy: An expressive and
dynamic approach for young children on the autism spectrum. In P. Kern & M.
Humpal (Eds.), Early childhood music therapy and autism spectrum disorders
(pp. 130–144). London: Jessica Kingsley Publishers.
Gwet, K. (2010). Handbook of interrater reliability (2nd ed.). Gaithersberg, MD:
Advanced Analytics.
Guerrero, N., Hummel-Rossi, B., Turry, A., Eisenberg, N., Selim, N., Birnbaum, J.,
Marcus, D., & Ritholz, M. (2014). Music Therapy Communication and Social
Interaction Scale – Group.
Joseph, R., & Tager-Flusberg, H. (2009). Face and gaze processing in autism. In T.
Striano & V. Reid (Eds.), Social cognition: Development, neuroscience, and
autism (pp. 201–215). West Sussex, UK: Wiley-Blackwell.
Kern, P., Wolery, M., & Aldridge, D. (2007). Use of songs to promote independence
in morning greeting routines for young children with autism. Journal of Autism
and Developmental Disorders, 37(7), 1264–1271.
65
Kim, J., Wigram, T., & Gold, C. (2009). Emotional, motivational and interpersonal
responsiveness of children with autism in improvisational music therapy.
Autism, 13(4), 389–409.
Mahoney, J. (2010). Interrater agreement on the Nordoff-Robbins Evaluation Scale
1: Client-therapist relationship in musical activity. Music and Medicine, 2(1),
23–38.
Nordoff, P., & Robbins, C. (1965). Improvised music for autistic children. Music
Journal, 23(8), 39 & 67.
Nordoff, P., & Robbins, C. (1968). Improvised music as therapy for autistic children.
In E. T. Gaston (Ed.), Music in therapy (pp. 191–193). New York: MacMillan.
Nordoff, P. & Robbins, C. (1977). Creative music therapy. New York: Harper & Row.
Nordoff, P., & Robbins, C. (2007). Creative music therapy: A guide to fostering clini-
cal musicianship (2nd ed.). Gilsum, NH: Barcelona.
TOTS (n.d.). Retrieved from: http://www.theseourtreasures.com/services.html
Trevarthen, C., Aitken, K., Papoudi, D., & Robarts, J. (1998). Children with autism:
Diagnosis and interventions to meet their needs (2nd ed.). London: Jessica
Kingsley Publishers.
Tsatsanis, K. (2005). Neuropsychological characteristics in autism and related condi-
tions. In F. Volkmar, R. Paul, A. Klin, & D. Cohen (Eds.), Handbook of autism and
pervasive developmental disorders: Vol. 1 (3rd ed., pp. 365–381). Hoboken,
NJ: Wiley.
Downloaded from http://mtp.oxfordjournals.org/ by guest on September 8, 2014
Wigram, T., Nygaard Pedersen, I., & Ole Bonde, L. (2002). A comprehensive guide to
music therapy: Theory, clinical practice, research, and training. London: Jessica
Kingsley Publishers.
Appendix 1
Music Therapy Communication and Social
Interaction Scale - Group
The Music Therapy Communication and Social Interaction
scale (MTCSI) (Guerrero et  al., 2014) is designed to assess
the communication and social interaction behaviors that a
child demonstrates during a music therapy session. The MTCSI
may be of particular value in tracking the behavioral changes
that occur over the course of music therapy with a child with
developmental delays or related difficulties. The instrument is
not intended to measure the child’s musical skills. There are
two forms of the MTCSI: the MTCSI – Group, presented here,
which is used for group music therapy sessions, and the MTCSI
– Individual, used for individual music therapy sessions, which
will be published at a later date.
The observer using this instrument must successfully com-
plete an authorized training program which includes dem-
onstrating high interrater agreement with a master observer.
A trained observer need not be a music therapist or a musi-
cian; however, he or she should have some training or experi-
ence in developmental psychology so as to be familiar with
the behavior of children. Experience with children with spe-
cial needs is desirable.
Use of the MTCSI requires that children be video-recorded
by a videographer trained in filming for the purpose of cod-
ing with this instrument. When more than one child is being
observed, recording by a second videographer will likely be
needed to adequately capture the children. Behaviors are
coded in one-minute intervals using the MTCSI – Group cod-
ing sheet, which is available upon training.
There are four sections of the MTCSI – Group. The first
section is Section A: Preengagement – Sound Making and
Attention. Categories in this section include:
1. Vocalization
2. Instrument Use
3. Attention
66
The behaviors coded in this section are typically seen early
in the course of music therapy. The coded behaviors reflect
that the child is not yet actively participating in the session or
is just beginning to participate in and attend to the session. At
times during the course of therapy, a child may revert to the
behaviors of this section.
The second section of the observation scale is Section B:
Engagement – Communication and Social Interaction with
Therapist or Peer(s). Categories in this section include:
1. Joining In an Activity with Therapist or Peer(s)
2. Turn Taking
3. Reciprocal Musical Communication with Therapist or
Peer(s)
4. Reciprocal Verbal Communication with Therapist or
Peer(s)
The behaviors coded in this section indicate that the child
is engaged in the session, although the level of engagement
may fluctuate. The codes reflect the nature and extent of the
child’s communication and interaction with the therapist and
peers. Often, the format of a session activity will determine the
appropriate coding category.
The third section of the scale is Section C: Transition, which
assesses the extent to which the child can sustain engage-
ment during periods of transition between structured activities
in a session, when behavioral expectations may be unclear.
2. Instrument Use
Given that transitions may be particularly challenging for chil-
dren with developmental disabilities, it may be valuable to
assess possible changes over time in a child’s ability to remain
engaged during transitions.
The fourth section of the scale is Section D: Emotional
Communication and Interaction with Therapist or Peer(s).
Categories in this section include:
1. Affective Response
2. Physical Response
The behaviors coded in this section reflect the child’s emo-
tional reactions to the therapy. Categories in this section can
be coded simultaneously with other categories when relevant.
Finally, note that throughout the scale, the coder is asked to
record certain behaviors as Sidebars. The Sidebars thus serve
to track unusual or idiosyncratic behaviors which are unre-
sponsive to the session context. In addition, Sidebars are used
to describe briefly the events being coded in each interval. For
example, if the child receives a code of 3 under C3: Affective
Response, the Sidebar may indicate that the child shared a
reciprocal smile with a peer.
An important rule to remember while coding is that if one is
undecided between two levels of a code, the lower code level
should be chosen. It is not unusual to encounter behaviors that
appear to border two code categories and, for the purposes of
consistent scoring and instrument construct validity, the more
conservative approach of choosing the lower code level is
adopted for this instrument.
A Definition of Terms is provided at the end of this manual
for clarification of technical terms used.
A. Preengagement – Sound Making and Attention
1. Vocalization
Music Therapy Perspectives (2014), Vol. 32
Vocalization codes begin with nonverbal sounds (e.g.,
grunts, shrieks, vowel or consonant sounds), speech-
related sounds (e.g., la la la), or words that are not in
response to or directed toward peer(s), therapist, or ther-
apy objects (Code 1). The sounds are not in reaction to the
content of the session. Codes 2 and 3 represent the emer-
gence of vocalizations that are in response to peer(s), ther-
apist, or music, but are not apparently communicative.
The behavior does not meet criteria for Joining In (Section
B1), although it may be a direct precursor to Joining In.
Code Vocalization as:
1 – Makes sound or verbalization with no relation to ses-
sion context.
2 – Makes or alters sound or verbalization partially or
intermittently in response to session context.
3 – Makes sound or verbalization in response to session
context, but with no direct communication or social
Downloaded from http://mtp.oxfordjournals.org/ by guest on September 8, 2014
interaction with peer(s) or therapist; that is, no Joining In
with peer(s) or therapist.
Sidebar – Note vocalizations that are repetitive, self-
stimulating, or self- soothing. Indicate any therapist
or peer prompting, as contrasted with independent
vocalization.
Code 1 under Instrument Use indicates the child’s manip-
ulation of an instrument in a nonmusical way that is not in
response to therapist, peer(s), or therapy context. In Code
2 the child begins to play an instrument, but with no rela-
tion to therapist or peer(s); for example, the child may
experiment with different ways of playing the instrument
in order to discover how the instrument works. Code 3
represents the emergence of instrumental play that is in
response to therapist, peer(s), or music, but is not appar-
ently communicative. The behavior does not meet criteria
for Joining In. The difference between Codes 2 and 3 is
that in Code 2 the child is involved in self-directed explo-
ration of the instrument, whereas in Code 3 the child’s
playing reflects some response to the session context.
Code Instrument Use as:
1 –Nonfunctional use of instrument, e.g., stacking horns,
spinning a cymbal. Exploration of physical characteris-
tics of the instrument.
2 –Begins to play instrument with no apparent relation to
session context. Exploratory playing of instrument, often
brief; not Joining In behavior.
3 –Plays instrument in response to session context, but
with no direct communication or social interaction with
therapist or peer(s); that is, no Joining In with therapist or
peer(s).
Sidebar – Note instrument use that is repetitive, self-
soothing, or self- stimulating, e.g., beating a cymbal in
a perseverative manner. Indicate any therapist or peer
assistance with play, as contrasted with independent
play.
Music Therapy Communication and Social Interaction Scale
3. Attention
The lowest level of Attention is inattention to the ses-
sion (Code 1). In Code 2 the child shows intermittent
attention to the session, and in Code 3 the child demon-
strates sustained attention. Attention to session would
not be coded simultaneously with another behavior
that includes attention to session, such as Joining In
an Activity. Attention is evidenced by such visible
behaviors as changes in body orientation; changes in
facial expression; eye contact with therapist or peer(s);
alerting to therapist’s or peer(s)’ communications; or
approaching therapist or peer(s). Note that the child’s
body may be oriented toward the therapist, peer(s),
or music source even while the child is not looking
directly at the therapist or peer(s). A child may move
back and forth between Attention and Engagement.
Code Attention as:
1 –Inattention to session, e.g., paces around, rocks back
and forth (not in relation to music); does not alter behav-
ior in response to music; does not look at therapist or
peer(s); plays with nonmusical object; does not relate
his/her activity to therapist, peer(s), or session context;
actively avoids therapy session. Self-soothing or self-
stimulating behavior.
2 –Intermittent attention to therapist, peer(s), or therapy
activities; attention alternating with inattention. Briefly
approaches therapist or peer(s) or orients body in
response to the session.
3 –Sustained attention to therapist, peer(s), and therapy
activities. Approaches or orients towards therapist or
peer(s), but with no direct communication or social
interaction.
Sidebar – Note persistent unresponsiveness of child.
Indicate any therapist or peer attempts to elicit response
from child.
B. Engagement – Communication and Social
Interaction with Therapist or Peer(s)
In Engagement, the child is interacting or communicating
with therapist or peer(s). The child may be interacting only
with peer(s), only with therapist, or with both peer(s) and ther-
apist. If the child disengages from the interaction, communi-
cation, or session activity, indicate inattention using Code 1
under Section A3: Attention. In children with developmental
disabilities, it may be common to alternate frequently between
participation and disengagement.
1. Joining In an Activity with Therapist or Peer(s)
Joining In an Activity with Therapist or Peer(s) is often
the first actual sign of communication and social inter-
action in a session, and is the usual entry point into
engagement behavior. Joining In codes begin with the
child’s simultaneous participation in an activity (musi-
cal, dramatic, or movement) with therapist or peer(s).
Such behavior is contrasted to performing an activity on
one’s own, which is a behavioral marker of Section A:
67
Preengagement – Sound Making and Attention. Whereas
Code 3 under Vocalization (Section A1) or Instrument
Use (Section A2) indicates musical activity with no
evident communication or social interaction, Code 1
under Joining In reflects some form of communication
or social interaction. The communication or social inter-
action may be evidenced by, for example, looking at
therapist or peer(s); smiling at therapist or peer(s); mov-
ing, singing, or playing along with therapist or peer(s);
touching therapist or peer(s); clapping with therapist or
peer(s); moving toward therapist or peer(s) to engage
with them; or cooperative playing on a single instru-
ment with therapist or peer(s). Some of these behaviors
can simultaneously be coded in Section D: Emotional
Communication and Interaction. Furthermore, if a child
initiates a verbalization beyond what is accounted for by
Joining In an Activity, that behavior may also be coded
under Section B4: Reciprocal Verbal Communication
Downloaded from http://mtp.oxfordjournals.org/ by guest on September 8, 2014
with Therapist or Peer(s).
Codes 2 and 3 of Joining In represent higher levels
or more frequent occurrences of communication and
social interaction. Communication and social inter-
action may be demonstrated by any of the examples
of behaviors listed above. Codes 2 and 3 are applied
depending on the context of the situation. If the child
has a brief moment of highly connected and commu-
nicative behavior within an interval but is otherwise
merely attentive to the situation, coding may be divided
between Code 3 of Joining In and Code 3 of Section
A3: Attention. However, if the child’s communication
or interaction is intermittent throughout the interval,
a code of 2 for Joining In can account fully for this
behavior, without any need to code under Section A3:
Attention.
Code Joining In an Activity as:
1 –Simultaneous participation in an activity (i.e., musi-
cal, dramatic, or movement) along with therapist or
peer(s), parallel play, with minimal communication
or social interaction. The child demonstrates minimal
affective response, physical response, or musical con-
nection (in dynamics, tempo, or melody) with therapist
or peer(s).
2 –Simultaneous participation in an activity (i.e., musical,
dramatic, or movement) along with therapist or peer(s)
with intermittent communication or interaction. Child
shows some affective response, physical response, joint
attention, or musical connection (in dynamics, tempo,
or melody) with therapist or peer(s).
3 –Simultaneous participation in an activity (i.e., musi-
cal, dramatic, or movement) along with therapist or
peer(s) with strong or sustained communication or
interaction. Child shows strong affective response,
physical response, joint attention, or musical connec-
tion (in dynamics, tempo, or melody) with therapist or
peer(s).
Sidebar – Note attempts to join in, even if unsuccessful.
Note therapist or peer assistance with play.
68
2. Turn Taking
Turn taking occurs when the therapist creates an
explicit, predictable format within a group activity in
which two or more children are each given opportuni-
ties to participate individually at a specified time, while
the other children are expected to wait their turns.
A child (or subgroup of children) is prompted or cued
by therapist or music to participate at a specified time.
Turn Taking requires each child to wait for his/her turn
and respond when appropriate. This is not an activity
in which only one child takes a turn. For greeting or
farewell songs with very brief individual turns, or for
instrumental improvisations with spontaneous turns,
code under Section B1: Joining In rather than under
Turn Taking.
Turn Taking differs from Reciprocal Musical
Communication because although the child gives musi-
cal responses, he/she does not seek to gain responses as
a consequence of his/her musical actions. Turn Taking
also differs from Joining In because Joining In involves
simultaneous activity with the therapist or peers while
Turn Taking involves sequential activity, although the
child may share a cue with a peer.
Code Turn Taking as follows:
1 –Child does not respond, responds infrequently, or
responds only upon explicit prompting when it is his/
her turn, OR does not wait for peer(s) to take a turn,
plays out of turn, and may be distracted or disruptive
(e.g., grabs instrument during peer[s]’ turn). The child
may appear to show attention to the group most of the
time, but does not actively participate.
2 –Child intermittently responds when it is his/her turn,
while at other times does not respond. Additionally, or
alternatively, the child may at times be distracted or dis-
ruptive. The child may appear to show attention to the
group most of the time and intermittently participate
actively.
3 –Child responds all the time or almost all the time
when it is his/her turn, AND waits for peer(s) to take
a turn, does not play out of turn, and is not disruptive.
The child shows attention to the group and actively
participates.
If there is a difference in the level of disruptiveness of
a child’s behavior depending on whether he is wait-
ing for his turn or taking his turn, code for the more
disruptive behaviors. For example, if the child takes
his turn at the proper times but is highly disruptive or
distracted between his turns, he would receive a code
of 1.
Sidebar – Note nature and degree of therapist assistance
or cueing (e.g., physical assistance—indicating it is the
child’s turn to play the drum by presenting the drum to
the child or tapping the drum; or verbal assistance—
“Leo, now it’s your turn!”). Indicate nature of any dis-
ruptive behavior.
Music Therapy Perspectives (2014), Vol. 32
3. Reciprocal Musical Communication with
Therapist or Peer(s)
Responding to musical statement – answering back
musically. Musical exchange that occurs between child
and therapist or between child and peer(s), with the
following element of “conversation”: a directed musi-
cal statement (melodic or rhythmic sound or series of
sounds, played or sung, with a clear beginning and
end) that is answered with another musical statement.
This may lead to a series of statements or to a sustained
musical exchange between child and therapist or
between child and peer(s). The child’s vocal response to
therapist’s or peer(s)’ musical statement may be sung or
spoken.
Code Reciprocal Musical Communication as follows:
1 –Answers a musical statement with another musical
Downloaded from http://mtp.oxfordjournals.org/ by guest on September 8, 2014
statement.
2 –Initiates a musical statement directed toward therapist
or peer(s) that implies a request for a response.
3 –Sustains musical conversation with at least two
exchanges with therapist or peer(s). The musical
modality can change; that is, the child can move from
one instrument to another or between instrument and
voice.
Sidebar – Note repetitious or habitual musical state-
ments that do not invite any particular response and
are inflexible, uncommunicative, and unchanging in
response to session context.
4. Reciprocal Verbal Communication with
Therapist or Peer(s)
Conversation that occurs within a therapy session.
Code 1 responses may include gesturing, and intelli-
gible or unintelligible words that are spoken or sung;
however, in Codes 2 and 3, comments or questions
(spoken or sung) must be intelligible. If spoken or sung
words are not intelligible to the coder, the child can-
not be coded 2 or 3.  Instead, the behavior should be
described in a Sidebar under this category, with a note
of whether the verbalization appears to be directed at
therapist or peer(s). Reciprocal Verbal Communication
is distinct from Vocalization (Section A1), which does
not involve direct communication or social interaction
with therapist or peer(s). Note: If the therapist is pro-
viding a musical framework for response and the child
responds verbally, code using B3: Reciprocal Musical
Communication.
Code Reciprocal Verbal Communication as follows:
1 –Responds to question or comment by therapist or
peer(s). Response may be through gestures (e.g., hand
wave or head nod), or intelligible or unintelligible spo-
ken or sung words.
2 –Initiates intelligible comment or question in spoken or
sung words directed toward therapist or peer(s). Usually
Music Therapy Communication and Social Interaction Scale
implies a request for a verbal, musical, or behavioral
response.
3 –Sustains conversation in spoken or sung words for at
least two intelligible exchanges.
Sidebar – Note any disruptive, impulsive, perseverative,
or tangential verbalizations.
C. Transition
A transition is the period after one music therapy activity has
ended and another has yet to begin. A transition is marked by
the clear stopping of one activity, followed by a period without
organized activity (the transition), and the starting of another
activity. During a transition there may be no explicit directions
to the children as to what they should do. The therapist might
be silent, express reactions to the previous activity, query
as to what the group would like to do next, sing about the
transition, or combine some of these behaviors. Code under
Transition only if the aforementioned criteria for Transition are
met; do not code under Transition when the therapist quickly
shifts from one activity to another. Only Section D: Emotional
Communication and Interaction with Therapist or Peer(s) may
be simultaneously coded with Transition.
Code the child’s behavior during a transition as follows:
1 –Child appears to “tune-out” or withdraw and does not
interact with peers or respond to therapist.
2 –Child is partially engaged in the transition and shows
some response to the situation, peers, or therapist.
3 –Child is fully engaged in the transition and communi-
cates or interacts with peers or therapist. Alternatively, if
the child does not communicate or interact with others,
his/her facial expression and body movements indicate
active attention to the transition and attentive waiting for
the next activity.
Sidebar – Note behavior during transition that suggests
lack of self-regulation, such as running around the
room.
D. Emotional Communication and Interaction
with Therapist or Peer(s)
The following categories may be coded simultaneously with
all preceding categories.
1. Affective Response
Visible or audible display of emotion in response to ses-
sion, therapist, or peer(s) – e.g., facial expressions indi-
cating joy, sadness, or anger; laughing, crying, or shout-
ing. Upon reviewing intervals of the session, the coder
should make a point of searching for affective responses,
as they may go unnoticed in the initial viewing of an
interval.
Code Affective Response as follows:
1 –Displays affect, but not in response to therapy session
and not directed at therapist or peer(s).
2 –Demonstrates affective response to therapy session, but
not directed at therapist or peer(s). Possibly accompanied
69
by body movement, e.g., jumping up and down or clap-
ping hands in apparent happiness or excitement.
3 –Shared or reciprocal display of affective response with
the therapist or peer(s). Possibly accompanied by body
movement such as clapping along with a peer’s music
making.
Sidebar – Describe nature and intensity of affective
response. Note a child’s absence of affective response,
or flat affect.
2. Physical Response to Therapist, Peer(s), or
Therapy Session
A socially appropriate or positive physical response to
therapy session, therapist, or peer(s). A  behavior may
start out as socially appropriate but may be sustained
in an inappropriate manner. In this case, the behavior
would be noted as a Sidebar.
Downloaded from http://mtp.oxfordjournals.org/ by guest on September 8, 2014
Code Physical Response as follows:
1 –Deliberately touches or accepts touch of therapist or
peer(s) in a socially appropriate manner. Moves closer
to therapist or peer(s) in a socially appropriate manner.
2 –In a socially appropriate manner initiates or accepts a
communicative gesture, such as waving hello or good-
bye, shaking hands, or blowing a kiss.
Sidebar – Note any inappropriate physical response,
such as hitting or other aggressive behavior, avoidant
behavior (e.g., running to door; lying on therapist’s lap
rather than participating in session activity), or inappro-
priate touching of therapist or peer(s).
Coding a session in one-minute intervals allows the
observer to estimate the portion of a session during which a
child is actively engaged in communication and social inter-
action – i.e., the number of intervals or amount of time coded
under Section B: Engagement, as compared with Section A:
Preengagement. The observer may calculate the child’s aver-
age level of engagement in a session within or across the dif-
ferent categories of engagement, or during moments of transi-
tion between activities.
In addition to one-minute interval coding, each session is
given overall ratings in three categories, as follows:
The child’s overall affect during the therapy session was
1. Distressed, fearful
2. Neutral, with little visible affect
3. Occasional moments of positive affect
4. Frequent moments of positive affect
5. Sustained positive affect
The child’s overall relationship with the therapist was
1. Detached, disengaged
2. Detached, with occasional engagement
3. Intermittently engaged
4. Frequently engaged, with occasional detached or dis-
tracted behavior
5. Consistently engaged
70
The child’s overall relationship with peer(s) was
1. Detached, disengaged
2. Detached, with occasional engagement
3. Intermittently engaged
4. Frequently engaged, with occasional detached or dis-
tracted behavior
5. Consistently engaged
Definition of Terms
Attention A  state of awareness in which the senses are
focused selectively on aspects of the environment and the
central nervous system is in a state of readiness to respond to
stimuli. (VandenBos, 2007, p. 82).
Communication  The transmission of information, which
may be by verbal (oral or written) or nonverbal means. Humans
communicate to relate and exchange ideas, knowledge, feel-
ings, and experiences, and for many other interpersonal and
social purposes. (VandenBos, 2007, p. 200).
Joining In  Participating in an activity with another person
or persons. In the course of this participation, an individual
demonstrates some form of communication and social inter-
action with the other person(s). This particular definition was
formulated for the MTCSI.
Joint Attention Attention focused by two or more peo-
ple on the same object, person, or action at the same time.
Joint attention is an important developmental tool. Infants of
around nine months can follow their parents’ gaze and begin
to imitate what their parents do. Thus, by focusing attention on
an object as well as on the adult’s reaction to it, children can
learn about the world. (VandenBos, 2007, p. 509). Joint atten-
tion may be a psychological process underlying Engagement,
particularly Joining In an Activity (Code B1).
Musical Statement  A melodic or rhythmic sound or series
of sounds, played or sung, with a clear beginning and end.
Used in Reciprocal Musical Conversation.
Nonverbal Communication The act of conveying infor-
mation without the use of words. Nonverbal communication
occurs through facial expressions, gestures, body language,
tone of voice, and other physical indications of mood, attitude,
approbation, and so forth, some of which may require knowl-
edge of the culture or subculture to understand. (VandenBos,
2007, p. 630–631).
Nonverbal Singing Tonal vocalizations without recogniz-
able words; may be vowel sounds, syllable strings (e.g., la la
View publication stats
Music Therapy Perspectives (2014), Vol. 32
la), jargon, or humming. (J. Birnbaum, personal communica-
tion, May, 2008).
Perseveration  1. In general, persistence in doing something
to an exceptional level or beyond an appropriate point. 2. In
neuropsychology, the inappropriate repetition of behavior
that is often associated with damage to the Frontal Lobe of
the brain. 3.  An inability to interrupt a task or to shift from
one strategy or procedure to another. (VandenBos, 2007,
p. 687–688).
Reciprocal Musical Conversation  A musical exchange that
occurs between a child and the therapist or between a child
and peer(s) with the following element of “conversation”: a
directed musical statement (melodic or rhythmic sound or
series of sounds, played or sung, with a clear beginning and
end) that is answered with another musical statement.
Social Interaction Any process that involves reciprocal
stimulation of response between two or more individuals….
Social interaction includes the development of cooperation
Downloaded from http://mtp.oxfordjournals.org/ by guest on September 8, 2014
and competition, the influence of status and social roles, and
the dynamics of group behavior, leadership, and conformity.
(VandenBos, 2007, p. 866).
Transition  The time period after one therapy activity has
ended and another has yet to begin. It is marked by the clear
stopping of one activity, followed by no organized activity (the
transition), and the starting of another activity. Transitions are
important in group therapy as they provide opportunities for the
child to self-regulate his/her behavior and to interact and com-
municate with peers. It is hoped that the previous musical activ-
ity or the anticipation of the next activity will sustain the child’s
attention and awareness of the environment and stimulate him/
her to interact with peers. (J. Birnbaum, D. Marcus, M. Ritholz,
& A. Turry, personal communication, September, 2008).
Tempo  Refers to the overall pace or speed of the music. It
is the rate in which one beats, claps, or moves to the music.
(Levitin, 2006).
Vocalization  In the broadest sense, any audible use of the
voice. Vocalizations in the form of speech are called verbali-
zations. (D. Marcus, personal communication, May, 2008).
References
Levitin, D. (2006). This is your brain on music. New York: Dutton.
VandenBos, G.  R.(Ed.). (2007). APA dictionary of psychology. Washington, DC:
American Psychological Association.