Music Therapy as a Treatment Modality for Individuals with Autism

written by Jennifer Salah, University of Florida

As holistic practices continue to influence Western medicine, clinicians often utilize integrated treatment plans incorporating physical, mental, social, emotional, spiritual, and environmental factors to predict positive health outcomes. As such, new forms of clinical treatment have evolved (Stuckley & Nobel, 2010), including art therapy.

Art therapy employs creative engagement through visual arts, music, dance, and expressive writing to improve health and wellness. Empirical evidence suggests art therapy can enhance moods and emotions, as well as psychological and physiological states. Music therapy, a quickly growing sector of art therapy, continues to gain credence as an effective treatment for various diseases and disorders (Stuckley & Nobel, 2010).

Though music therapy as a credible clinical modality remains a somewhat novel practice, music's role in medicine dates to ancient times. Early healing ceremonies commonly featured musical incantations to exorcise physical and mental infirmities. By the late 1800s, physicians began to note music's effect on physiological function including heart rate, pulse, and blood pressure, and psychiatric hospitals gradually implemented primitive forms of music therapy (Halpern, 2010).

Music therapy as a profession evolved following World War I and II, when veteran hospitals invited musicians into soldier wards (American Music Therapy Association [AMTA], 1999). Physically and emotionally wounded soldiers showed significant responses to the presence of music in the hospitals (AMTA, 1999), leading to decreased recovery time (Halpern, 2010). Additionally, physicians noted the usefulness of instrument play as occupational therapy for increasing strength, joint motility, and coordination, as well as respiratory therapy for the lungs and larynx through singing and blowing (Halpern, 2010).

Though music therapy remained highly experimental and amateur in practice, hospitals continued to request musicians postwar. As the need for standardized curriculum and credentialing systems became apparent, music therapy evolved into a respected, professional competency (AMTA ,1999).

Music therapy currently involves the use of clinical, evidence-based musical interventions to achieve specified health outcomes within a trusted relationship between a therapist and an individual or group receiving the intervention. With potential for use in various settings, music therapy implementations aim to promote wellness, manage stress, alleviate pain, express feelings, enhance memory, improve communication, and promote physical rehabilitation (AMTA, 1999).

For instance, music therapy can foster memory recall in patients with Alzheimer's disease; enhance gait, balance, and range of motion in patients with Parkinson's; improve gross and fine motor functioning and coordination for those with traumatic injuries; relive pain and ease anxiety for sufferers of acute and chronic pain; and combat nonfluent aphasia in stroke victims (Institute for Music and Neurological Function, 2009).

In addition, clinicians now support the use of music therapy in treating a wide range of developmental disabilities, especially among children, adolescents and young adults, and this practice continues to gain merit through evidence-based practice (Pellitteri, 2000). Most notably, individuals with autism spectrum disorder (ASD) demonstrate significant gains when participating in music therapy interventions (Wigram & Gold, 2006).

Individuals with autism present with social challenges, communication problems, language delays, and unusual behaviors and interests. Children with autism often resist group activity, avoid eye contact, do not show interest in or interact well with others, experience difficulty showing or talking about their feelings, misunderstand gestures, body language, and tone of voice, participate in repetitive behaviors or schedules, and are easily frustrated (Centers for Disease Control and Prevention [CDC], 2010).

The expressive nature of music therapy may help those with autism communicate thoughts and feelings they may find difficult to convey otherwise. Additionally, many forms of music therapy foster relationship building and communication skills between the child and the therapist, and possibly with other children (Wigram & Gold, 2006).

In a study by Boso, Emanuele, Minazzi, Abbamonte, and Politi, young adults with severe autism participated in weekly interactive music therapy sessions for a year (2007). Each group session, lasting approximately 60 minutes, employed drumming, piano playing, and singing with an ultimate goal of encouraging social engagement, decreasing behavioral problems, and fostering creative music ability.

Researchers collected data at baseline, halfway through the program (at 26 weeks), and upon completion of the program. They utilized both the Clinical Global Impressions (CGI) scale, which assesses overall severity of a psychiatric ailment initially and overall improvement over time, and the Brief Psychiatric Rating Scale (BPRS), which assesses severity of specific psychiatric symptoms including psychomotor agitation, aberrant behavior, and lack of interaction with peers or therapists.

In addition to clinical parameters, researchers also assessed acquisition of musical skill through a questionnaire containing fivepoint Likert scales regarding the absence or presence of six skills: singing a short melody, singing a long melody, playing the C scale on the keyboard, music absorption, rhythmic reproduction, and execution of rhythmic patterns (Boso, et. al., 2007).

At the end of the 52-week period, improvements manifested in all three data areas; statistically significant improvements, however, only manifested within the first half of the program (week one to week 26) for all three data sets. Data concerning the execution of complex rhythmic patterns was the only exception, with no gains observed from baseline to the end of week 26, but vast improvements from week 26 to completion of the program. BPRS analyses showed significant positive gains in specific symptoms of autism, and CGI analysis indicated "much improvement" or "minimal improvement" in the vast majority of cases. Analyses of musical ability showed similar gains, with all skills improving over time (Boso, et. al., 2007).

These results support the use of music therapy, as data showed improvements in a number of specific symptoms associated with autism within the BPRS scale and overall within the CGI scale, likely due to the interactive, expressive environment music therapy provides. Additionally, observed increases in musical ability may have been a contributing factor to measured clinical improvements.

Though this study recognizes the potential benefits of music therapy, the small sample size (n=8) constitutes a major limitation and allows for possible type II error. Furthermore, the lack of a control group offers no means of comparison, making the study largely ungeneralizable (Boso, et. al., 2007). The study does, however, present significant results, and experimental research on a larger scale remains necessary to corroborate these findings for future use.

In another study, Kern, Wolery, and Aldridge implemented an individualized music therapy-based intervention to encourage the smooth transition of two young boys into their separate classrooms (Kern, et. al., 2007). As children with autism tend to resist change, the initial transition from home to school each morning often proves difficult. Behaviors such as crying, clinging to the caregiver, and avoidance of classmates and class activities commonly manifest during this time. Additionally, children with autism tend to lack understanding and mastery of common gestures, such as waving hello and goodbye, initially separating from the caregiver, and have much difficulty transitioning into the classroom (Kern, Wolery, and Aldrige, 2007).

Both boys, previously diagnosed with mild to moderate autism through DSM-IV criteria, presented with limited speech, poor peer interaction, participation only with adult support, and manifestation of typical autistic behaviors. The boys attended an inclusive school, enrolling both children of typical development and those with disabilities. Both boys experienced difficulty during the daily morning transition routine, exhibiting behaviors such as refusal to enter the classroom, crying, screaming, laying on the floor, clinging to caregivers, and ignoring teachers' welcomes (Kern, et. al., 2007).

To reduce these behaviors, Kern, et. al. applied established educational methods for children with autism, including elements of individualization, structure and predictability, attention to strengths/personal needs, and visual cues, and added traditional music therapy strategies. Music therapists developed an individualized song for each boy based on his personality.

The song, to be played and sung by his teacher upon arrival, encouraged the student to work through the five essential steps of the morning transition process: entering the classroom independently, greeting a teacher or peer verbally or through gesture, greeting another teacher or peer verbally or through gesture, saying or waving goodbye to the caregiver (who exits the classroom at this step), and engaging in appropriate classroom play. Through the use of this music therapy intervention, researchers aimed to ease transition from home to school, increase independent performance of the steps, and support social interaction (Kern, et. al., 2007).

Implementation of the song followed a repetitive withdrawal design, in which the intervention was absent for a period at baseline, implemented for a period, removed, and finally reinstituted. At the end of the study, the number of independent steps completed successfully by each of the boys increased dramatically (Kern, et. al., 2007).

In the first stage of data collection, the initial baseline condition, both boys generally completed two or fewer steps independently, one of which was entering the classroom. After the first implementation of the intervention, boy A's progress declined on the first two days, but then rose steadily over the next several sessions until he consistently completed four of the five independent responses on consecutive days. With intervention removal, his progress declined over three days to baseline levels, but upon reinstitution of the song his progress reached previous levels after only one day, and he eventually successfully completed all steps independently (Kern, et. al., 2007).

Boy B progressed differently. He showed variable performance during the initial intervention period, completing between one and three responses successfully each day with no true pattern. His progress seemed thwarted by difficulties during the "good-bye" step. In response, researchers eliminated this step, having the caregiver exit as he entered the classroom, and leaving only four daily steps to complete for the remainder of the study. When this modified intervention was reintroduced, boy B immediately exhibited the ability to complete three individual responses consistently over four days. Upon intervention removal, his performance gradually fell to baseline levels. With the final reintroduction of the song, he consistently executed all four steps successfully each day for the reminder of the study (Kern, et. al., 2007).

Though sample size proves a major limitation (n=2), the study presents promising findings. The success of the program supports music therapy for children with autism in the classroom, especially during transitional periods. Additionally, though both boys learned to greet others independently over the course of the study, boy A experienced a dramatic increase in the number of students who approached him to say hello during the intervention periods, which was an unexpected outcome (Kem, et. al., 2007). This not only shows that the program fosters social engagement for children with autism, but that it may encourage reciprocal social interaction. Interest from other students may further encourage inclusive group play and increased participation.

Finally, the study notes the possible benefits of a program tailored to a specific child based on his or her interests and needs. Though program success cannot be linked to the implementation without the use of a comparison group, the positive affect of an individualized program cannot be discounted. Given that the implementation was teacher-administered, potential for error and bias exist. Though teachers were adequately trained, researchers report some problems with program fidelity, specifically in regard to protocol during the "good-bye" step of the song. Whether or not that affected observed results remains unknown (Kem, et. al., 2007). At the very least, this study provides support for music therapy in inclusive classrooms and illustrates the need for further controlled studies.

In a final study by Kim, Wigram, and Gold, researchers attempted to improve changes in joint attention behaviors among pre-school children with autism using improvisational music therapy (2008). Children with autism possess poorly developed joint attention skills, which typically begin developing during infancy. These skills influence communication, social interaction, and language, and thus, children with autism tend to perform poorly in these areas. Improvisational music therapy may foster development of joint attentions skills by providing a structured environment for children to express themselves and their emotions creatively (Kim, Wigram, and Gold, 2008).

In this study, ten pre-school children with documented autism participated in 12 weekly thirty-minute improvisational music therapy sessions. Researchers compared data from these sessions with a control condition of 12 weekly, thirty-minute play sessions with toys. All ten children participated in both interventions each day, with half receiving music therapy before playtime and the other half receiving play time prior to music therapy sessions. The first 15 minutes of each music therapy session were child-led, or undirected, while the latter 15 minutes were therapist-led, or directed (Kim, et. al., 2008).

Researchers collected data at pretest, midway through the treatment, and post-treatment using two validated scales. The Pervasive Developmental Disorder Behavior Inventory-C (PPDBI), an instrument specifically developed for use among those with autism, measures intervention responsiveness.

Both researchers and mothers of the participants completed this scale while observing the sessions live on a television screen. Researchers also utilized the Early Social Communication Scale (ESCS), an established scale that assesses structured toy play to measure nonverbal communication skills. Though generally used among typically developing infants, this study applied the ESCS to measure the same parameters in pre-school children with autism. Finally, researchers videotaped both music and play treatment sessions, and analyzed short segments from selected sessions for changes in joint behaviors (Kim, et. al., 2008).

Differences in interpretation of observed sessions between researchers and mothers resulted in low levels of inter-rater agreement on the PDDBI. Data from researchers indicated benefits of music therapy over playtime, while data from mothers showed marginal benefits or no additional benefits over playtime. Reasons for this disparity remain unknown, but may be due to mothers' scores reflecting their expectations of the child, their understanding of their child's condition and functional abilities, or possibly their lack of understanding in these two areas.

Despite this disparity, data from the PDDBI scale supports use of music therapy (Kim, et. al., 2008). The ESCS and session analyses established good inter-observer reliability. In the ESCS analysis, joint attention behaviors improved in both music therapy and playgroups over time, but gains demonstrated due to music therapy were significantly higher than gains from the playgroups.

These findings align with researcher findings from the PDDBI scale, indicating researcher data from the PDDBI scale may have been more objective than the mothers' data, and thus, may hold more merit (Kim, et. al., 2008). Also notable, other parameters on the ESCS measuring joint behaviors, such as eye contact and alternating eye contact between a person and an object, indicated that the majority of participants improved joint visual attention skills markedly during and following music therapy only. Session analysis corroborated these findings. ESCS analysis and session analysis findings also demonstrated that music therapy sessions effectively improved social interaction between student and therapist (Kim, et. al., 2008).

As with the previous studies, major limitations exist. Once again, small sample size (n=10) limits generalizability. Additionally, all students participated in both the intervention session and the control session, which may have affected results, especially with back-to-back execution of sessions. The lack of inter-rater reliability also poses a problem (Kim, et. al., 2008). Subsequent studies could avoid this by using either an homogeneous rater pool (i.e. only researchers or only mothers) or by implementing a training session concerning how to objectively rate the child prior to the sessions.

The study provides additional evidence in support of music therapy, but additional trials are necessary to confirm the clinical merits of music therapy for those with autism. A subsequent study could evaluate the added benefits of improvisational music therapy over non-improvisational musical interventions to assess the individual merits of different forms of music therapy.

Music therapy as a treatment tool continues to gain support for clinical practice. With its multidimensional functions, music therapy can potentially treat various disorders and diseases (Pellitteri, 2000). People with developmental disorders, especially autism spectrum disorders, may greatly benefit from music therapy, in addition to providing music therapists an underserved population in need of intervention.

While studies of music therapy as a treatment modality for autism imply promising outcomes, available literature is lacking. Specifically, the need for larger, randomized samples is apparent, as most studies currently utilize convenience samples containing few participants. In addition, the need for studies following a true experimental design with appropriate control groups persists.

With successful completion of larger, scientifically sound studies, generalizations to outside autism treatment programs will follow. Though the most effective and generalizable protocol for delivery remains unknown, music therapy potentially provides cost-effective and readily adaptable supplemental interventions for various educational settings and treatment programs.

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Biography: Jennifer Salah, MS, CHES received a Master degree in Health Education and Behavior from the University of Florida in 2010, specializing in social marketing and health promotion. She spent two years working as a communications coordinator for the Northeast Florida Healthy Start Coalition, a maternal and child health organization in Jacksonville, FL. In addition, Jennifer was the project coordinator for the March of Dimes' statewide consumer education and awareness initiative to reduce elective deliveries prior to 39 weeks of pregnancy in Florida. She currently serves as Account Executive of Southeast Recruitment and Community Development for Be The Match, operated by the National Marrow Donor Program.

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