Benefits of Interactive Music Therapy on Children with Autism

Autism spectrum disorder (ASD) is a neurodevelopmental disorder with a wide range of severity, encompassing mild to severe levels of social, communicative, cognitive, and behavioral functioning. This social functioning disorder affects every 1 in 68 children born in the U.S., with prevalence rates doubling since 2000. ASD is associated with left hemisphere responsibilities, such as decreased joint attention, inability to comprehend social cues, insufficient linguistic knowledge, and a difficulty forming meaningful relationships. Children with ASD are faced with many problems, including a lack of friends, limited social activities, and are often excluded from mainstream school. Unfortunately, they are also frequently kept from valuable social, educational, and leisurely life experiences; from not being able to pick out their own clothes, to learning how to drive or becoming independent, the daily struggles of autism hinder them from living “normal” lives. In the most severe cases, some will commit crimes during adolescence due to their frustration and inability to control their aggression or understand other's perspectives.

The symptoms of autism impact not only familial relationships, but a family’s financial stability as well. Parents of autistic children often feel isolated, depressed, and emotionally and physically exhausted from the strenuous care involved in caring for and supporting their children. In a study of 196,159 households conducted by Saunders et. al. (2015), 52% of caregivers and parents of autistic children reported having financial difficulty, with many having to leave work to care for their children. However, these problems can be alleviated by providing an effective and appropriate therapy regimen that will not only help autistic children live more “normal” lives, but allow them to better integrate as active members of society, benefiting themselves and those who care around them.

Traditional social skill and communication therapies such as Pivotal Response Treatment (PRT) and Applied Behavioral Analysis (ABA) have helped many families and children diagnosed with ASD. However, they are concealing the benefits of using a more creative and flexible form of therapy more often: music therapy. Where speech therapies such as ABA and PRT are more structured and focused around specific objectives, music offers a means of self-expression, communication and interaction that can be more easily assimilated by children with autism. From previous studies, it is clear that music therapy provides an additional aspect to just the traditional patient-therapist treatment. Specifically, Wigram (2006), a professor of Music therapy in Aalong University, states that “music therapy has been recommended as an effective treatment in facilitating communication, as music is a medium that involves a complex range of expressive qualities, dynamic form and dialogue, and offers a means by which some form of alternative communication can be established to help achieve engagement, interaction and successful relationships” (p. 535).

Harrill and Jones (2009) describe music in therapy as therapy that “creates an activity setting that is far different from either traditional psychotherapy or naturalistic play settings” because vocalization, an especially encouraged portion of therapy, is a “crucial developmental prerequisite to satisfying social interaction” (p. 200). In addition, when compared to the structured “play” routine of the traditional therapies, “improvisational musical interaction can foster flexibility and creativity in a structured framework for those children who cannot readily adjust themselves to the unpredictability of daily life” (Kim, J. Wigram, T., & Gold, C.; 2008). Therefore, improvised music in relation to the child’s musical and non-musical expression is an ideal way to work through issues of self-stimulation, rigidity, and control. The therapist may also adjust the theoretical approach depending on the client’s needs. Hooper, J., Wigram, T., Carson, D., & Lindsay, B. (2011) explain that a practitioner can use “musical experiences to develop a relationship that promotes health by resolving an individual’s physical, emotional and psychological difficulties” or can promote “health by providing music as a stimulus to reduce or eliminate inappropriate behaviors that tend to be considered an ‘unhealthy’” (p. 23).

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More importantly, interactive and improvisational music therapy can circumvent monotonous and inefficient practices in learning social communication and behavioral skills that traditional therapies such as ABA and PRT often use. Unlike the creative format of music therapy, speech and occupational therapies rely on structured therapy sessions to achieve specific goals, obstructing the child’s naturally artistic thinking. So, can interactive music therapy really be an effective tool to overcome developmental obstacles in children with ASD? An increase in education and use of interactive music therapy can revolutionize current therapy protocol and allow for more efficient improvements in emotional expression, social responsiveness, and behavioral aspects that affect over 1% of the entire world population.

One example of music therapy, Melodic Based Communication Therapy (MBCT), is a treatment that utilizes a standard melody for each target word and the musical strengths of a child with severe autism (10 words or less) in order to increase verbal output. Standardization of the melody is made possible with a pre-recorded melody, which varies significantly from the other melodies. For example, for the word “apple,” the therapist will show a picture of an apple, while a melodic recording of the word “apple” will repeat 10 times, so the child is led to clap along while saying or singing the words. Sandiford, Mainess, and Daher (2013) describe their findings in a 5-week MBCT study of 12 children between 5 and 7 years old with, “While both therapies were found to be effective at the completion of the study, results suggest a possible faster rate of improvement for the MBCT group as well as greater overall gains in verbal attempts and imitative attempts” (p. 1303). Because the aim of the study was to compare the efficacy of MBCT and traditional therapy in eliciting speech in nonverbal children with severe autism, the increased success rate further supports the positive effects of music-based interventions.

In addition, the faster rate of improvement, greater number of verbal attempts, as well as the significant improvement in number of words said in the home environment might have been contributed to an increased motivation of the child to complete the task when melody and rhythm were implemented. So, if individuals with autism demonstrate strengths in tasks associated with the right cerebral hemisphere, such as creativity and imagination, then it may be expected that individuals with autism might show an affinity for tasks relating to music and rhythm. Sandiford, Mainess, and Daher continue to explain that, “research indicates an increase in fibers in the corpus callosum in those exposed to music, potentially allowing for better transfer of information,” (p. 1304) thus explaining how the corpus callosum, an area of impairment in children with autism, can be greatly helped with MBCT. This example utilizes scientific and behavioral analysis of 12 autistic children to show the many potential uses of music therapy. The anatomical aspect of evaluating the effect of music therapy bolsters the argument that music therapy is an effective way to help children appropriately communicate and better assimilate into society.

Another example, Orff-Schulwerk music therapy (Orff therapy), is a treatment that is based on imitation, exploration, improvisation, and composition. Compared to MBCT’s focus on outward communication, Orff therapy helps develop understanding of oneself to achieve a personal and interpersonal identity by practicing creativity and spontaneity in expressive environments. In a clinical setting, a trained music therapist can play or sing a song for the child, then hand the instrument over to allow the child to participate while the therapist repeats the song to reinforce the child’s “answer.” By interacting in this way, it is possible for the therapist to provide the child with a means of music and play in interaction. Specifically, Nabiollah et. al. (2015) describe their study of 27 mild-moderate autistic children who participated in Orff-Schulwerk music therapy sessions twice a week: “Musical activities were conducted based on the Orff-Schulwerk method with the help of two musical therapists in components of music hearing, singing songs, and clapping” (p. 43).

Because communication in Orff therapy groups is in the form of songs and chants, this method puts emphasis on the rhythm of speech and body movement, allowing the Orff–Schulwerk method to be considered nonverbal. Therefore, it can also be explained that since the Orff method puts emphasis on nonverbal elements of music, it has been able to improve poor nonverbal behaviors of children with autism and lead to enhancement of their social skills. For severely autistic children with significant impairments in their basic innate skills in communication, musical outlets provide a context and instrument for reciprocal interaction and development that considerably enhances the lack of sharing and turn-taking in traditional play therapies.

Nabiollah et. al. (2015) conclude that from their results, music is predictable, flexible and success-oriented; these characteristics bring a sense of security, encouraging the individual to take risks and be more spontaneous in their interactions with others. In the real world environment, these children will be better equipped to connect to others on a more substantial level, helping them form meaningful relationships. Overall, Orff music therapy is another underutilized form of therapy that can significantly help an autistic child’s social and behavioral skills.

Voices Together Music Therapy is an additional example of the effectiveness of music therapy. Voices Together therapy utilizes an engaging music-based therapy with evidence-based educational and specialized therapeutic techniques, such as “talking songs” to increase communication, social, and emotional learning. Technique strategies and songs are interactive by design and inherently have a high expectation of a reciprocal response by establishing a pattern for each song. For example, Mendelson et. al. (2016) published a 15 week study of 37 elementary school aged children with mild autism who participated in Voices Together and sang “The ‘Hello’ song, which acts as an introduction and requires the participants to greet each other and say their name as part of the song; the ‘Feelings’ song, which requires participants to respond to the group by describing how they are feeling that day; and the ‘Topic’ song, which requires the participants to respond by bringing up a topic of interest” (p. 3).

These songs use specific strategies to evoke social responses from all the children and are designed to improve social and communication skills by encouraging them to create unique responses within a familiar format. This pattern of brainstorming, listening, and responding all greatly contribute to the long-term success in terms of creativity of responses and level of communication. The teachers reported social improvement at three time points, to increase accuracy of the degree of development in all participating children. Behavioral observation outcomes were also measured at two time points to analyze the progress of the effects of the Voices Together program on real world communication, vocal assertion and engagement, and behavioral transformations. The results from this preliminary investigation in a classroom setting indicate that there was an increase in level of communicative response from all 37 participants. Mendelson et. al. predict that from the advances of the preliminary group, “longer duration of exposure to Voices Together may promote a greater degree of improvement” (p. 6) and that the use of interactive music in a classroom setting can be used as a basis for further research into the efficacy of music therapy. So, with the use of “talking songs,” Voices Together Music Therapy allows children with developmental disabilities a chance to practice and improve communication skills in an environment directly applicable to real world experiences.

Although it is clear that music therapy is exceedingly valuable to an autistic child’s early age development, many autistic children still do not receive music therapy treatment, often due to accessibility and financial reasons. As an autistic child enters school age curriculum, an individualized education plan (IEP) is written to ensure the child receives appropriate services while in school. An IEP is a legal document created by parents and an IEP committee of therapists and school administrators that explicitly describes the child’s needs, the services the school will provide, and how progress will be measured.

This process is extremely cumbersome, as only after an IEP meeting is held, an evaluation is requested, an evaluation is conducted, and an IEP meeting is held to discuss results, is the autistic child approved for therapy. Unlike occupational, speech, or other more “convenient” traditional therapies, music therapy is considered a “related service,” which is a list of services biasedly deemed unnecessary by the school IEP committee (Altom 2016). So, when school districts interpret a related service list as exhaustive, many services cannot, and will not be legally provided. In many cases, interactive music therapy is kept off this list due to financial and accessibility reasons. School administrators, often illegally, predetermine that they do not offer the service, because if the IEP team concludes the child requires the service, then it must be provided (Altom 2016).

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For example, if a school district is held responsible for providing music therapy to autistic children, but no local board-certified music therapist is available, then the district will have to pay for the relocation and salary of the music therapist, often an avoidable expenditure. Due to these many reasons, some school districts do not provide the financially inopportune music therapy service. If a child will greatly benefit from the advantages of music therapy, it is unjust to refuse an essential service.

The lack in music therapy education also reduces the use of music therapy. Not only are there only 12 certified music therapy programs in the US compared to the over 250 speech therapy certified programs, but there are only 5,000 board-certified music therapists compared to the over 300,000 speech and occupational therapists. Consequently, in a poll of 28,000 parents through the Autism Speaks organization, less than 1% of parents reported having used music therapy as a treatment for their child’s autism. Additionally, the Heartbeat Music Therapy program in Austin, Texas claims that music therapy cost will be similar to occupational therapy, physical therapy, or speech therapy sessions.

For example, if a family is looking for a music therapist that is trained in psychological or counseling techniques, the cost of music therapy may be similar to what other psychological services are offering. If the music therapist is not accepting private insurance payments, then the cost of music therapy will probably be lower than occupational therapy, physical therapy, or speech therapy sessions (Lindstrom 2012). It is this discrepancy between the availability and financial convenience of music therapy and the accessibility of settling for the more traditional speech or occupational therapies that is plaguing the autism therapy community.

Although there is much evidence that improvisational music therapy can be effective in short and long-term social, behavioral, and communicative aspects, many skeptics believe that there is still a paucity of current research and data regarding both the benefits and consequences of improvisational music therapy. Some scholars find studies that are afflicted with problems such as an insufficient sample size, poor study design, or poor description of therapy techniques resulting in unempirical generalizations and an inability to reproduce the therapy in a clinical setting. For example, Sandiford et al. (2013) referred to a case study where a 3-year-old nonverbal male with autism was introduced to melodic intonation therapy. He suggests that, “Despite the success of this case study, the use of a single subject cannot be generalized to the greater population, nor can it be determined without the use of a control group whether the adapted melodic intonation therapy in and of itself resulted in the increase in language...” (p. 2).

However, it is important to notice the complexity and intricacies that are inherent in the developing music therapy field. There will be inherent inconsistencies in study design due to the nature of the patient’s learning style; it is the advantage of personalization that will be most effective to patients with autism because the variability in music treatments can be specifically designed to fit the needs and wants of each patient. In addition, some music therapists, such as Aigen (2015), criticize the philosophical bases of the conventional view of music therapy to support the notion that alternative views are possible. Aigen questions that if music therapy is considered a healthcare profession, then why is the curriculum predominantly music? Here, Aigen does not consider the scope of the music therapy practice and education. With a proper musical background, therapists are more suited to utilize different harmonic, rhythmic, and intonational tools to provide medically based treatments that other therapists are not trained to use.

In another example, Aigen argues that if music, in the context of music therapy, is treated as a medical intervention, then why do many healthcare professionals believe that music is too idiosyncratic to be analogous to a medical intervention? Aigen again fails to notice that the predominance of the music therapy theory has been created from ideas originating in a variety of external disciplines, such as neurological science and psychoanalysis. It is the combination of empirical-based data from music-based interventions that allow music therapy to be useful to a wide range of autistic children.

Since its beginning in the 1940s, the profession of music therapy has developed significantly with the creation of national standards, evidence-based practice models, and an increase in the clientele served. An understanding of autism has also increased, which includes more succinct diagnoses, national awareness, and research on effective treatments. Currently, music therapy is emerging as a valid treatment option for children with autism through the use of therapies such as MBCT, Orff-Schulwerk, and Voices Together.

Although there is still more research to be done, many studies demonstrate how effective and motivating music can be to help children function across many domains. As more quantitative research is conducted in the field of music therapy for children with autism, this therapy may soon be recognized as an established treatment rather than an emerging one. The modern world has progressed towards interdisciplinarity in many realms of society, which can be directly applied to services such as music therapy. Therefore, it is imperative to further investigate this as a non traditional outlet for autism treatment, and not allow it to be overlooked as it has been in the past.

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References

Aigen, K. “A Critique of Evidence-Based Practice in Music Therapy.” Music Therapy Perspectives (2015). doi: 10.1093/mtp/miv013

Altom, M. "Can Music Therapy Be a Part of a Child’s IEP?" Music Therapy Kids. N.p., 23 Mar. 2015. Web. 4 June 2017.

Ghasemtabar, S. N., Hosseini, M., Fayyaz, I., Arab, S., Naghashian, H., & Poudineh, Z. (2015). Music therapy: An effective approach in improving social skills of children with autism. Advanced Biomedical Research, 4, 157. http://doi.org/10.4103/2277-9175.161584

Harroll, T. and Jones, P. (2009). The Use of Creative Therapies with Autism Spectrum Disorders. Springfield, Illinois: Charles C Thomas Publishers.

Hooper, J., Wigram, T., Carson, D., & Lindsay, B. (2011). The practical implication of comparing how adults with and without intellectual disability respond to music. British Journal Of Learning Disabilities, 39(1), 22-28. doi:10.1111/j.1468-3156.2010.00611.x

Kim, J., Wigram, T., & Gold, C. (2008). The Effects of Improvisational Music Therapy on Joint Attention Behaviors in Autistic Children: A Randomized Controlled Study. Journal Of Autism & Developmental Disorders, 38(9), 1758-1766. doi:10.1007/s10803-008-0566-6.

Lindstrom, J. “Cost of Music Therapy” Heartbeat Music Therapy. N.p., 30 June. 2009. Web. 4 June 2017.

Mendelson, J., White, Y., Hans, L., Adebari, R., Schmid, L., Riggsbee, J., & ... Dawson, G. (2016). A Preliminary Investigation of a Specialized Music Therapy Model for Children with Disabilities Delivered in a Classroom Setting. Autism Research & Treatment, 1-8. doi:10.1155/2016/1284790.

Sandiford, G., Mainess, K., & Daher, N. (2013). A Pilot Study on the Efficacy of Melodic Based Communication Therapy for Eliciting Speech in Nonverbal Children with Autism. Journal Of Autism & Developmental Disorders, 43(6), 1298-1307. doi:10.1007/s10803-012-1672-z.

Saunders, B. S., Tilford, J. M., Fussell, J. J., Schulz, E. G., Casey, P. H., & Kuo, D. Z. (2015). Financial and Employment Impact of Intellectual Disability on Families of Children With Autism. Families, Systems & Health: The Journal Of Collaborative Family Healthcare, 33(1), 36-45. doi:10.1037/fsh0000102

Wigram, T., & Gold, C. (2006). Music therapy in the assessment and treatment of autistic spectrum disorder: clinical application and research evidence. Child: Care, Health & Development, 32(5), 535-542. doi:10.1111/j.1365-2214.2006.00615.x