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Music Therapy and Autism

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Ranking : Strong positive evidence

Type(s) : Standard

Introduction

Music therapy uses live music making and composition techniques to encourage children, adolescents and adults with autism spectrum disorders to engage in spontaneous and creative musical activities.

The therapist and client use a variety of percussion or tuned instruments, or voice, to develop shared and interactive musical activities.

The individual with autism does not need musical skills to benefit from music therapy but the music therapist does need a high level of musical and therapeutic skill.

Supporters of music therapy believe that it can be used to develop social engagement, joint attention, communication abilities, while also addressing emotional needs and quality of life.

Opinion

Based on the literature to date, music therapy has shown good effects in influencing joint attention, social interaction, verbal and gestural communication and behaviour.

It is a worthwhile intervention, particularly with very young children, and where language acquisition is either delayed or disordered to a severe degree.

Disclaimer

Please read our Disclaimer about this intervention.

Audience

The supporters of music therapy suggest that music therapy may be of use to anyone with autistic spectrum disorders, such as autism or Asperger syndrome.

It has also been used with clients with other forms of pervasive developmental disorder, moderate and severe learning disability, genetic and inborn metabolic disorders. In addition, it has been used with a wide range of other clients including people with mental health problems, dementia, physical and or neurological disabilities.

Applicable Age Ranges

All ages

Aims

According to the National Autistic Society

‘Music therapy aims to encourage increased self-awareness/self-other awareness, leading to more overt social interactions. The therapy stimulates and develops the communicative use of voice and pre-verbal dialogue with another, establishing meaning and relationship to underpin language development. The client may also benefit from increased tolerance of sound, tolerance of and capacity for two-way communication, the opportunity to exercise joint attention, and other emotional needs met in the therapeutic process.’ (National Autistic Society, 2005)

Claims

There have been a number of claims for the use of music therapy with individuals with autism. For example, Wigram, Gold and Oldfield have claimed the following benefits for music therapy.

In the area of Communication:

  • Activating inter-subjective behaviours
  • Spontaneous initiation of contact
  • Development of meaningful gestures and signs
  • Development of communicative vocalisation
  • Emergence of language in songs

In the area of Social development:

  • Motivated interaction
  • Shared and understood experiences
  • Relationship building skills
  • Tolerance of change
  • Entrained responses
  • Flexibility

In the area of Emotional needs:

  • Developed and Increased sense of self
  • Empathic synchronicity – shared emotions
  • Containment of emotional expression
  • Emergence of insight and self-esteem

In the area of Cognitive development:

  • Development of awareness, attention and concentration
  • Development of organisational skills
  • Development of memory

In General:

  • Tolerance of sounds ( increasingly identified as a problem of perception by Donna Williams, Temple Grandin)
  • Meaningful use of objects – coming from a background of stereotyped and unimaginative use of objects and part-objects
  • To divert away from habitual, stereotyped, ritualistic, perseverative or obsessive behaviours.

(Personal communication with Research Autism, July 2008., Wigram 2002)

Detail

Music therapy is usually part of a multi-disciplinary programme, offering an enriched learning environment for the development of communication and other aspects of a child’s personality.

‘As a general rule both client and therapist take an active part in the sessions by playing, singing and listening. The therapist does not teach the client to sing or play an instrument. Rather, clients are encouraged to use accessible percussion and ethnic instruments and their own voices to explore the world of sound and to create a musical language of their own. By responding musically, the therapist is able to support and encourage this process.

‘The music played covers a wide range of styles in order to complement the individual needs of each client. Much of the music is improvised, thus enhancing the individual nature of each relationship. Through whatever form the therapy takes, the therapist aims to facilitate positive changes in behaviour and emotional well-being. He or she also aims to help the client to develop an increased sense of self-awareness, and thereby to enhance his or her quality of life. The process may take place in individual or group music therapy sessions.’ (Association of Professional Music Therapists, date unknown.)

Time

The length of treatment varies from individual to individual because some children may improve much faster than others. Those with more serious or ongoing problems may take longer to help.

Music therapy sessions vary in length but usually last about 30 to 50 minutes. Sessions are held on a regular basis, often weekly. For children with autism more frequent, shorter sessions may be easier for the child to access. Sessions can be provided in individual or group settings.

Involvement

The time required will depend on the needs of the individual receiving the therapy and on how the therapist prefers to work.

Costs

In the UK, the costs of intervention within the National Health Service are calculated pro rata to the overall revenue cost of a qualified music therapist. The session costs will be calculated on current pay agreements on Bands 6-8 in the Agenda for Change bands.

Music Therapists employed within education services or social services will be governed by similar fixed salary scales for qualified staff. Equipment costs will vary, but include the need for piano, percussion, guitar and other musical equipment.

For music therapists working privately, the recommended rates from the Association of Professional Music Therapists are currently in the region of £35 ($70) per hour.

Credentials

In the UK the profession was recognised by the National Health Service as a Profession Allied to Medicine in 1982, and in 1999 music therapy became a State Registered profession, and was incorporated, together with Art and Drama therapy as an amendment to the 1960 legislation governing the Council for the Professions Supplementary to Medicine.

Currently music therapy is governed by the Allied Health Professions Council (AHPC) where music therapists working in the public sector are required to maintain registration.

In the United States, a music therapist is most commonly designated by MT-BC (Music Therapist, Board-Certified). In Canada, the designation is MTA (Music Therapist Accredited/Musicotherapie Accreditee).

Availability

Music therapy is established as a profession in over 50 countries and a World Music Therapy Federation has been formed to promote the understanding, use and development of music therapy for the international mental health community.

In the UK there are now more than 200 registered professional music therapists. Many are employed by the National Health Service, local education authorities and social services while others work freelance.

Music therapy departments are well-established within some Child Development Centres, and other primary and tertiary care provisions. In addition, some charitable organisations provide music therapy services.

Hazards

There are no known adverse effects.

Contraindications

There are no known contraindications for music therapy.

History

Music therapy as a formal discipline was developed in the USA in the mid 1940s, when Michigan State University and the University of Kansas began courses.

Music therapy was introduced to the UK in the 1950s and 60s by pioneer practitioners like Juliette Alvin, Paul Nordoff and Clive Robbins.

In the USA music therapy grew up initially as a palliative treatment for returning war veterans, and subsequently became more adapted as a behavioural intervention. In Europe, behavioural and developmental influences were present at the beginning, and music therapy had a remedial role in special education. However, music therapy in Europe, and particularly in the UK, has developed predominately as a psychotherapeutic intervention.

In all countries where music therapists are trained and qualified as clinical practitioners, music therapy is influenced by, and allied to music psychology, music in medicine, musicology, music science and technology, and some forms of sound therapy.

Accounts

There have been numerous personal accounts of the benefits of music therapy which have come from a variety of people in a wide range of countries. For example, according to Wigram T. (2002)

‘During the assessment session, Joel demonstrated many potential abilities and skills. He could share, take turns, initiate, use verbal language spontaneously, concentrate for relatively long periods – for example the first period of time he played on the piano lasted 13 minutes without stopping, and share emotions – emotional synchronicity. He could also follow musical cues, develop structure, go into imaginative play, and anticipate the way the therapist was thinking and reacting. Musically, he demonstrated his ability to follow musical ideas by matching tempo, dynamic and rhythmic patters, and could build music structure by creating his own short melody ideas (both on a piano and vocally) and establishing form in his music with complimentary phrases and patterns. The musicality of his response and initiations served to establish and build a communicative link to the therapist, to whom he gave consistent eye contact, humour and with whom he established a working relationship.

“The results from this assessment do not infer he did not meet criteria for ASD, but it demonstrated that in a developed music therapy interaction he could learn, develop, engage and demonstrate his potential. His awareness and communication were better than reported in other situations.”

Research

We have identified 16 scientific studies of music therapy published in peer-reviewed journals.

These studies included a total of 135 individuals aged from 3 months to adult.

  • 9 studies (Aldridge, Gustorff, and Neugebauer, 1995; , Buday, (1995; Edgerton, 1994;, 1999; Kim, Wigram, and Gold, 2008; Kostka ,1993; Miller and Toca, 1979; Oldifield and Adams, 1990; Oldfield, Bunce, and Adams, 2003; Pasiali, 2004; Saperston, 1973; Staum and Flowers, 1984; Stevens and Clark, 1969) reported significant improvements.
  • 3 studies (Brownell, 2002; Kern and Aldridge, 2006; ) reported limited or mixed results.
  • No studies reported negative results.

We have been unable to obtain sufficient information from the other 3 studies (Fuggle, Fixter and Brown, 1995; Mahlberg, 1973; Wimpory, Chadwick and Nash, 1995) to be able to grade them.

We have yet to evaluate the study by Lim (2010).

Status

There are three relevant systematic reviews of research studies (Whipple 2004; Ball 2004; and Gold, Wigram,and Elefant, 2006) that provide good evidence for the use of music therapy with individuals with autism but they also demonstrate some problems that need to be addressed.

The first two were conducted on a wide range of included studies, while the third, a Review for the Cochrane Library, applied more rigorous parameters. The first two reviews showed conflicting results. For example, there was little overlap between the reference lists of the two reviews, and only one study (Brownell, 2002) was included in both. The third study was conducted to overcome the shortcomings of these previous reviews.

Whipple 2004

The first review (Whipple, 2004) included experimental studies of any design which examined the effects of music (interventions ranged from music therapy to background music) versus no music on outcomes such as challenging behaviour and social interaction. Ten studies were included. Participants were individuals with autism ranging from 2.5 to 21 years. Sample sizes ranged from 1 to 20. Results showed a large, significant, and homogeneous overall effect size (d = 0.77), suggesting that conditions involving music were more effective than conditions without music. However, the interventions used in the included studies were so heterogeneous that it is difficult to draw specific conclusions on the effects of music therapy from this review. Furthermore, important design features of the primary studies used, such as randomisation and blinding, were not made transparent.

Ball 2004

The second systematic review (Ball, 2004) addressed the effects of music therapy versus no treatment on outcomes such as behaviour, communication, and social interaction in children with ASD. RCTs, controlled clinical trials (CCTs), and case series with at least 10 participants were included. Three studies were identified that met these criteria. Their results were summarised in a narrative way without meta-analytic pooling. Although all included studies had found significant effects, the authors concluded that the effects of music therapy were unclear.

Gold, C., Wigram, T., and Elefant, C. (2006).

The third, Cochrane review focused on RCTs and CCTs comparing music therapy (or music therapy added to standard care) compared to standard care, placebo or no treatment. Relevant studies were identified from the two previous reviews and through searching a number of relevant databases using a highly sensitive search strategy (full details in Gold & Wigram, 2003). In addition, relevant music therapy journals were searched by hand, and reference lists of identified studies were checked for any further studies. The identified studies were then inspected independently by both authors, and data on design type, population, music therapy, additional treatment, outcome assessment, and results were extracted.

From 311 identified records, 50 were identified as potentially relevant. Of these, three were excluded because they concerned other populations (related disorders or relatives of children with ASD). Six studies used other interventions than music therapy (background music, auditory integration training, or melodic intonation therapy). Thirteen further studies were excluded because they concerned an assessment rather than an intervention. Seven unpublished studies could not be obtained to date. Among the remaining studies which addressed music therapy as a treatment for children with ASD, there were eight case studies, eleven case series, and three RCTs with small sample size (Brownell, 2002; Buday, 1995; Farmer, 2003).

These RCTs used a dismantling approach to identify specific aspects of music as a medium for therapy. Such dismantling strategies usually require large samples, because both treatments contain active ingredients and therefore effect sizes are expected to be lower than when comparing an active treatment to no intervention or as an add-on to standard care. It is therefore quite impressive that some significant effects were found in these studies even with extremely small samples. The findings from these studies are important because they demonstrate the potential of the medium of music therapy for autistic children. However, the generalizability of these studies to clinical practice is limited. The treatment in all studies was highly structured and specifically targeted towards one behaviour, and only receptive music therapy techniques were used. The conclusion from this review was that music therapy may have positive effects on the communication behaviour of children with autism spectrum disorder.

Conclusion

Generally, the research that has been conducted on the effects of music therapy for ASD to date has largely the character of pilot studies. These studies have shown promising results and are a good starting point for more rigorous research. Larger RCTs examining interventions which are close to clinical practice are needed to confirm the positive results of the available pilot studies. Large RCTs are always expensive, and especially so when researching complex interventions for rare conditions. However, the results of previous research strongly suggest a need for such studies.

Trials

New or Additional Research

The National Institute for Health Research is currently calling for research proposals into ‘Music intervention for children and adolescents with autistic spectrum disorder’, as part of its Health Technology Research programme. More information

Future

The efficacy of music therapy as an intervention has had a limited number of small studies supporting it, together with an extensive literature reporting case examples, clinical reports, and theoretical foundations.

There is a need for outcome studies with larger samples evaluating the value of music therapy to influence some of the serious social, communicative and behavioural problems in ASD, as described above.

Summary

We have identified 16 scientific studies of music therapy published in peer-reviewed journals, nine of which reported positive effects.

There are a number of anecdotal reports from a variety of individuals from a variety of countries.

Reading

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Issues

Challenging and Disruptive Behaviour and AutismCommunication and AutismHearing and AutismJoint Attention and AutismPlay Abilities and AutismRestricted, Repetitive Behaviours and AutismSensory Sensitivity and Autism

Links

American Music Therapy AssociationAssociation of Professional Music TherapistsBritish Society for Music TherapyResearch AutismWorld Federation of Music Therapy, Incorporated

Keywords

Bang Bell Bells Blow Cymbal Cymbals Drum Drums Guitar Guitars Hit Hum Humming Improvise Improvisation Instrument Instruments Music Musical Percussion Percussive Piano Pianos Play Playing Rattle Rattles Shake Sing Singing Song Songs Strike Tambourine Therapy Therapies Treatment Triangle Tune Tunes Voice

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Comments

Research Autism project

Research Autism was successful in helping to obtain sponsorship for a two year project investigating music and autism.

For details of this study please see Music and Autism

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Last Updated : 04/08/2010   Back to Top

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