Music Therapy for People with Autism Spectrum Disorder
Abstract and Keywords
Music as a non-verbal form of communication and play addresses the core features of autism, such as social impairments, limited speech, stereotyped behaviors, sensory-perceptual impairments, and emotional dysregulation; thus music-based interventions are well established in therapy and education. Music therapy approaches are underpinned by behavioral, creative, sensory-perceptional, developmental, and educational theory and research. The effectiveness of music therapy in the treatment of children with autism spectrum disorder (ASD) is reflected by a huge number of studies and case reports; current empirical studies aim to support evidence-based practice. A treatment guide for improvisational music therapy provides unique interventions to foster social skills, emotionality, and flexibility; in developmental approaches, the formation of interpersonal relationships is key. Since ASD is a lifelong neurodevelopmental condition, music therapy is also appropriate in the treatment of adults with intellectual disability. Diagnostic approaches using musical-interactional settings to assess ASD symptomatology are promising, especially in non-speakers.
Music is one of those mood stabilizers, a grounding force that helps me to bring my mind back in to focus […]. It’s akin to being scattered from one end of the room to the other and the music brings all the pieces back into one cohesive unit. It allows me to focus and function. It is the background noise that provides rhythm and pace and gives my restless mind something to grab onto.
Autism and music are closely linked with each other, as the above words by an affected woman from an internet blog of people with Asperger’s syndrome suggest. Leo Kanner’s publication of a case series of three girls and eight boys was the first description of the contemporary autistic phenotype (Kanner 1943). In this report, Kanner repeatedly mentioned the musical abilities and interests of six of the children who were included. Since then, music therapy has developed in parallel with the research, diagnosis, and changing understanding of autism. Nowadays, music therapy is regarded as an option with high potential in the treatment of autism (Gold et al. 2006). Current research on music processing in autism provides models for understanding the role and function of music for people with autism, either in a therapeutic context or in everyday life for recreational and other purposes, such as learning a musical instrument, or enjoying concerts, and making music with others (Khetrapal 2009; Molnar-Szakacs and Heaton 2012; Srinivasan and Bhat 2013).
Autism spectrum disorder
Autism is a pervasive developmental disorder marked by qualitative impairments in social interaction and communication as well as restricted and repetitive patterns of behavior and (p. 187) interests with early onset (World Health Organization 2008). Autism Spectrum Disorder (ASD) is the umbrella term used in the current diagnostic manual DSM-5 (American Psychiatric Association 2013) to describe a continuum of neurodevelopmental conditions, including infantile autism, Asperger’s syndrome, and pervasive developmental disorders not otherwise specified (PDD-NOS). The concept behind this term is a dimensional view of a broader autistic phenotype, i.e. certain conditions belonging to the individual’s personality that have a strong impact on their behavior and social functioning along a continuum of varying severity across the lifespan (Howlin and Moss 2012).
People with ASD have communication deficits, such as responding inappropriately in conversations or misreading non-verbal interactions, or having difficulty building friendships appropriate to their age. Language development is delayed or abnormal, the language often seems strange and does not serve primarily for two-way communication, or speech is missing completely. In addition, people with ASD are overly dependent on routines, highly sensitive to changes in their environment, or intensely focused on inappropriate items.
In addition to social and behavioral features, affective deregulation and anxiety-like psychomotor tension are described in the ICD-10 diagnostic manual as other nonspecific problems. Motor clumsiness and coordination deficits belong to Gillbergs’ criteria for Asperger’s syndrome (Gillberg and Gillberg 1989) and are discussed as cardinal features of ASD over the entire spectrum as well (Fournier et al. 2010; Heasley 2012). Impairments in the emotional system are evident, as first described by Leo Kanner, who conceptualized autism as a lack of “affective contact” (Kanner 1943). Meanwhile, multiple studies have shown deficiencies in various aspects of emotional development, e.g. perception, recognition, understanding, expression, and regulation of emotions (Kasari et al. 2012). Specifically, perceptual difficulties in processing facial features (Hobson 1986), altered eye-gaze processing (Klin et al. 2002), impaired recognition of emotions (Bölte and Poustka 2003), and deficits in cognitive empathy (Dziobek and Köhne 2011) are described. However, emotional empathy is not limited, i.e. people with ASD respond by feeling pain when perceiving other’s distress (Fan et al. 2013). The conflict between heightened empathic arousal and a lack of social understanding may be revealed in the most frequent co-morbidities of depression and anxiety disorders in higher functioning individuals (Caamaño et al. 2013; Strang et al. 2012) and challenging behaviors, particular self-injury and affective deregulation, in individuals with ASD and intellectual disability (McTiernan et al. 2011; Rojahn et al. 2010). These often chronic conditions may lead to social isolation, frequent temper tantrums, and psychotropic long-term medication, as well as unemployment in higher functioning individuals, and require appropriate treatment and support. (p. 188)
ASD is a lifelong condition that is currently estimated to affect around 1:100 individuals (Centers for Disease Control and Prevention 2012). Thus, it is a major social and health concern within society (Ganz 2007). Males are affected at a higher frequency than females, with average estimates suggesting a 4:1 ratio for the spectrum as a whole (Fombonne 2009). ASD and intellectual disabilities (ID) are frequently co-occurring neurodevelopmental conditions with an increasing prevalence of ASD being linked to the increasing severity of ID (Charman et al. 2011). Within the ID group, every fourth person has an additional diagnosis of ASD (Bryson et al. 2008; Sappok et al. 2010). This underlines the special educational and treatment needs of this subgroup. (p. 189)
What causes ASD?
ASD can be caused by many different disorders or conditions. “Idiopathic” ASD is assumed to result from polygenetic alterations (Abrahams and Geschwind 2008), which, in turn, affect brain functions. On a neurobiological level, a hypothesis of aberrant network connectivity has increasingly been favored over one of focal brain dysfunction (Courchesne et al. 2011; Dziobek and Köhne 2011). According to this hypothesis, the brains of individuals with ASD are characterized by short-range over-connectivity and long-range under-connectivity, the latter being thought to be associated with the social-emotional and communication impairments of autism. Various further hypotheses aim to explain the neuropsychological deficits in ASD: Atypical Theory of Mind development (Baron-Cohen et al. 1985), which results in problems in attributing mental states to oneself and others and in understanding that others have beliefs, desires, and intentions that are different from one’s own; weak central coherence (Frith and Happé 1994), which describes the limited ability to understand the situational context or to “see the big picture” in favor of a detail-oriented perception; limited executive functions (Ozonoff and Pennington 1991), which relate to planning, goal-directed action, self-monitoring, attention, response inhibition, and coordination of complex cognition and motor control; reduced social drive (Kohls et al. 2012), with a preferred interest in the material world; and sensory perceptual issues (Ben-Sasson et al. 2009; Bogdashina 2003), such as reduced filter functions and cross-modality matching, synesthesia, and hyper- or hypo-sensitivity to certain stimuli. None of these theories explains all aspects of ASD, but they provide a basis for an understanding of the condition and thus for music therapy treatment concepts and interventions (Geretsegger 2005).
The diagnosis of ASD
Given the lack of defined biological markers specific for ASD, diagnosis is based on medical history and behavioral assessment. The diagnosis of ASD has evolved since Kanner’s first descriptions of the disorder. In the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association 2013) the triad of impairments (Wing 1981) in interaction, communication, and stereotyped behaviors is divided into two domains. The first encompasses deficits in social communication and interaction, such as a lack of social-emotional reciprocity, reduced sharing of interests and emotions, and difficulties with using or understanding non-verbal communicative behaviors, such as eye contact, pointing, or gesturing. The second domain consists of fixated interests and repetitive, stereotyped (p. 190) behaviors including repetitive speech abnormalities. This domain was extended from previous diagnostic criteria to include sensory aspects, such as hyper- or hypo-reactivity to certain stimuli or unusual interests in sensory aspects of the environment, for example, the smell or color of a musical instrument. The former domain of verbal communication merges with the DSM-5 ASD dyad, which includes non-verbal individuals on the lower functioning end of the spectrum.
In order to diagnose ASD, the person’s behaviors must have been present in childhood, even if the person is diagnosed later, for example, as a teenager or adult (American Psychiatric Association 2013). Early diagnosis is essential to make targeted early intervention possible to support speech and language development and to promote contact and relationship ability as well as to regulate emotional states as a basis for further psychosocial development. Later diagnosis in adulthood may explain psychosocial and biographical particularities and problems and can be a significant relief for the affected individual. In the treatment of co-morbid conditions, such as chronic depression or challenging behavior, it offers an explanatory model concerning the underlying disorder and serves to initiate appropriate treatment and support. A diagnostic standard exists in children and adolescents suspected of having ASD, including questionnaires, parental interview, and structured behavioral observation (Kim and Lord 2012). There is a lack of valid instruments to clarify suspected ASD in adults, particularly for non-verbal individuals (Matson and Shoemaker 2009; Sappok et al. 2014).
Living with ASD
The characteristics and symptoms of ASD influence the relationship to the self, to other people, and to objects, and thus the impact is experienced in all areas of life (Reddy et al. 2010; Schumacher and Calvet 2008a; Williams 2008). Wing introduced the idea of four prototypic social manifestations within ASD (Wing 1996). The aloof type of social manifestation means that the person shows almost complete indifference to other people and behaves as though other people did not exist; the passive and friendly type is indicated where the person will accept social approaches but does not initiate social interaction; the active but odd type describes a person who will initiate interactions with others but in an odd, repetitive, and often inappropriate way; and the stilted type refers to a person with ASD who is overly formal, trying hard to behave well and cope by sticking rigidly to the rules of social interaction. Wing suggested that these social manifestations are ways that people with ASD compensate for their deficits. Recognizing different compensation mechanisms and phenotypes in the context of ASD may be of importance for both diagnosis and therapy.
A diagnosis of ASD means that a person will have a specific cognitive and sensory perceptual style. This distinctive mode of being, feeling, thinking, and acting challenges normative assumptions about neuro-homogeneity. Apart from fundamental social restrictions, most of the functions and dysfunctions mentioned above have advantages and disadvantages. The ability to focus on details could be advantageous in some contexts, such as checking for errors in a data list, whereas problems in capturing the overall context in the field of central coherence could be challenging when trying to understand what is happening in a complex social situation, such as a competitive professional (p. 191) relationship. At the high functioning end of the spectrum, many affected people have problems with complex social demands, either in their families, at school, or at work, and may be preferred targets for bullying and mobbing (Zablotsky et al. 2014). At the other end of the spectrum, coping strategies to navigate through the social world are limited due to cognitive impairments. In particular, this group is dependent on stable environmental factors in order to lead a healthy and content life (Van Bourgondien et al. 2003). In the autobiographical literature of people on the autism spectrum, many authors describe the feeling of being cut off from the world or living on the wrong planet. As Temple Grandin stated: “I’m an anthropologist from Mars” (Cohen 2005). Could music bridge the distance between the planets?
Music and autism
Music is one area within which some individuals with ASD demonstrate exceptional skills. The jazz pianist and composer Matt Savage, for example, learned classical piano at the age of six and started his international career aged eight (Pine 2005). Brilliant technique, perfect pitch, and an excellent musical memory in terms of structured music are general characteristics of musical savants, i.e. people with exceptional musical talents in combination with sensory, cognitive, and/or neurodevelopmental impairments. In particular, perfect pitch, i.e. the ability to classify a note within a tonal system precisely without reference, has been extensively studied in connection with autism. Around five percent of individuals with ASD have this rare ability regardless of musical training, and in musicians with absolute pitch memory, autistic traits could be observed (Dohn et al. 2012). In addition, significantly improved intonation and melody memory was found in children with ASD compared to typically developed controls (Stanutz et al. 2012). This is in contrast to the usually impaired speech and language development among individuals with ASD. Reduced filter functions and a predominantly local, detail-focused cognitive processing style are assumed to explain this discrepancy in overlapping neural networks of music and speech processing (DePape et al. 2012). This connection, together with a preference for musical stimuli, has been used to develop promising music-based programs for targeted language training in children with ASD (Lim 2010; Wan et al. 2011). Furthermore, in a study of 199 children diagnosed with ASD, eighteen percent were shown to have hyperacousis, a type of hypersensitivity regarding certain acoustic stimuli (Rosenhall et al. 1999).
Limitations in detecting and sharing emotions and mental states are a central feature of ASD (Baron-Cohen 1995; Bons et al. 2013). In various studies on emotion recognition, individuals with ASD have been shown to be able to assign different emotional states in passages of music just as well as the control group without ASD (Heaton et al. 2008; Heaton et al. 1999; Quintin et al. 2011). However, in a more complex task, adolescents with ASD with average intelligence were not equally able to recognize the communication of emotion in music when the parameters of temporal and amplitude expressivity were altered in excerpts of Chopin’s Nocturnes (Bhatara et al. 2010). Regarding the potential improvement of emotion recognition among people with ASD, music may be a channel to communicate, experience, and differentiate emotions for this group.
(p. 192) Music therapy
History of music therapy as a treatment modality for people with ASD
The definition of music therapy as a treatment method and as a profession emerged alongside the first case reports concerning children with autism by Kanner and Asperger during the 1940s (Davis et al. 2008). In the following decades, many music therapists used adapted music education elements, such as singing, dancing, improvisation, and rhythm activities for the purpose of self-expression, recreation, and rehabilitation (Gilliland 1955; Scheerenberger 1953) and in order to integrate children with disabilities into groups with other children (Harbert 1955). During this early period, much of the literature emphasized autistic children’s unusual interest and outstanding abilities in music, such as the accurate reproduction of familiar pieces (Euper 1966; Sherwin 1953).
When Nordoff and Robbins published their book on Creative Music Therapy (1977), the improvisational music therapy approach in the treatment of developmentally disabled children gained a theoretical foundation. Their work pre-dated the DSM-III (American Psychiatric Association 1980), in which autism was first internationally classified as a distinct disorder, with six defined symptoms separated by schizophrenic type disorders, such as infantile autism. Thaut later presented a developmentally-based music therapy treatment model alongside diagnostic criteria and opened the window to future decades, which were characterized by evidence-based treatment and the question of efficacy (Thaut 1984). In her historical review of music therapy for people with ASD, Reschke-Hernández (2011) described the period from 1940–1989 as being characterized by trial and error, with innovative approaches but a lack of scientific research.
Together with the development of standards in autism diagnostics, the increase in discussions about autism in the media and among the general public, very active parent organizations of autistic children, and an autism community of highly functioning people, may have contributed to the considerable increase in the numbers of people being officially diagnosed with autism in recent years (King and Bearman 2009). Autism has changed from being a peripheral phenomenon to a social fact, with a huge variety of more or less relevant and effective methods of treatment. In music therapy, increasing numbers of empirical studies have focused on the measurable effects of clearly defined interventions. For instance, when analyzing effects on joint attention, Kim found significantly more and longer eye contact and turn-taking in the improvisational music therapy group compared to play therapy (Kim et al. 2008). As anecdotal reports outside her study design suggest, some non-verbal children developed initial language skills. In a meta-analysis of nine quantitative studies conducted with children and adolescents with ASD, Whipple found a significant average effect strength of d = 0.77 (Whipple 2004). She concluded that all musical intervention was effective, regardless of the purpose or the form of implementation. Another meta-analysis with more stringent inclusion criteria noted the short-term effects of music therapy on communication, but not on behavior problems (Gold et al. 2006). In a recent update of this, the Cochrane review provided evidence that music therapy may help children with ASD to improve their skills in primary outcome areas that constitute the core of the condition, including social interaction, (p. 193) verbal communication, initiating behavior, and social-emotional reciprocity. Furthermore, in secondary outcome areas, music therapy may contribute to increasing social adaptation skills in children with ASD and to promoting the quality of parent-child relationships (Geretsegger et al. 2014a). In a review of “novel and emerging treatments” in ASD, music therapy is the only psychosocial method among the most favorably assessed procedures in an evidence-based grading system (Rossignol 2009). Compared to an empirical standard, the conclusiveness is still limited due to small sample sizes, the methodological weakness of the underlying studies, and a lack of records regarding sustainability. However, much substantial work has been done and is currently being carried out to verify the evidence regarding the role music therapy might play in the treatment of ASD (Geretsegger et al. 2012). Together with a huge amount of case reports and research concerning music perception, the high potentials of music in the treatment and education of this group are underlined.
Music therapy potential and practice in the treatment of ASD
As indicated above, core features of ASD in the area of social interaction and communication; restricted behaviors; and sensory, motor, and emotional issues, can be matched to certain musical and perceptual qualities. Table 10.1 shows these correspondences in detail in order to highlight the potential of music for treating and educating individuals on the autistic spectrum.
Table 10.1 provides the potential to create multisystem interventions based on music in the treatment of the widespread symptomalogy of ASD with a focus on qualitative impairments in social interaction. Depending on the method, the framework, and individual indication, the ASD features mentioned in Table 10.1 can be seen as potential treatment goals. Outcomes supported by research in the treatment of ASD are increased socialization and attention, improved verbal and sensory-motor skills, decreased self-stimulation and agitation, as well as successful and safe self-expression (American Music Therapy Association 2010). Music-based therapies form about twelve percent of all autism interventions and 45 percent of alternate treatment strategies used within school settings (Hess et al. 2008; Simpson 2005). In the therapeutic context, the individual setting is preferred due to lower social demands and reduced stress in case of high irritability and sensory-perceptual sensitivity. In education, the group setting prevails; in this context, music and movement interventions are mostly components of superordinate, exercise-based concepts. In terms of method, active improvisational music therapy (IMT) dominates, which is based on active, spontaneous music-making, with the therapist generally following the client’s focus of attention, behaviors, and interests (Carpente 2011; Green et al. 2010; Kim et al. 2008, 2009; Schumacher 1999; Wigram 2002). This also includes receptive interventions, such as singing and improvising for the client or listening to recorded music. According to the upcoming IMT treatment guide for children with ASD (Geretsegger et al. 2014b), unique principles are as follows:
• facilitating musical and emotional attunement (by responding to and synchronization with musical, vocal and motor expression with holding, mirroring and matching technique). (p. 194)
Table 10.1 Potential of music in the treatment of individuals with ASD
1. Social interaction and communication
Joint attention deficits
• General musical interests in people with ASD
• Instrument and song/music as third object to relate to within an interaction
Limited socio-emotional reciprocity
• Intersubjective quality of playing or improvising together; musical dialogue
• Activation of multiple brain regions during music making and perception fostering long-range connectivity
Deficits in social cognition
• Potentially improved emotion recognition in music
Isolation, reduced social drive
• Undemanding relationship formation in music (e.g. playing for the client, no eye contact required)
Deficits in social awareness
• Joint singing, music making, and movement (e.g. hand clapping)
(Verbal) communication deficits
• Non-verbal interaction in music-making with shared neuronal networks of music and speech processing
• Audio-motor integration in singing
2. Stereotyped behaviors and imagination
Restricted and repetitive behaviors
• Structure and variability in musical form and development
Deficits in imagination and play
• Imagination in music perception (sounds, dynamics, mood, melody/songs)
• Creativity in musical improvisation
• Music as an age-independent form of play (→ adults)
Reduced exploratory behavior
• High inviting character and multisensory quality of musical instruments
Deficit in task planning and goal directed activity
• Song structure and content to organize/sequence activities
• Rhythmic impulses to initiate motor activity
3. Sensory and motor issues
Sensory issues, deficits in cross-modality matching
• Multisensory quality of instruments
• Multimodal perceptual experience during active music making (perception-action linkage)
• participation of the motor cortex in music processing
Motor clumsiness, coordination and motor sequencing/praxis problems
• Music and dance, whole body rhythmic actions (gross motor)
• Quality of movement when playing an instrument (fine motor)
4. Affect and emotion
• Tension in musical dynamics, dynamic attunement in joint play, possibility to control dynamics in play
• Psychomotoric action with sensory feedback in playing loud (e.g. beating a drum)
• Calming effect of music/sound on autonomic nervous system
Anxiety, need for sameness
• Repetitive structure of songs providing security
Disturbance of the sense of self
• Perception of a simple core self in musically coordinated atmosphere
• Experience of self-efficacy through auditory and sensory feedback
• Experience of “self with another” in playing together
(p. 195) • scaffolding interactions dynamically (by meeting the client’s initiatives/behaviors as communicatively intended and creating a musical form of recognizable patterns or motifs with rhythmic grounding, shaping, exaggerating, and frameworking technique).
• tapping into a shared history of (musical) interaction (by jointly creating musical/social patterns and routines but also creating moments where musical expectations are playfully violated with unexpected pauses and/or sudden dynamic variations, redirecting technique).
• facilitating enjoyment (by creating a pleasant and joyful atmosphere incorporating the client’s interests).
Basic principles that are essential in the treatment of ASD, but are not unique to music, are providing a secure environment, building and maintaining a positive therapeutic relationship, employing a non-directive approach, and setting treatment goals.
As social impairments are so prominent in ASD, in many music therapy approaches, relationship formation is both the basis and the content of therapeutic access. Issues such as high irritability with social demands, inappropriate proximity and distance, and functionalizing or ignoring others, are reflected in interactions in the therapeutic processes. In a relationship-based context, the music therapist offers unique opportunities for creating contact and progressively building trust and communication. This can start with playing live music, allowing the client to relate to the atmosphere in the room. The therapist can mirror the perceived emotional states and physical movements of the client, thus creating togetherness without introducing themselves as a person or requesting dialogue or imitation. In this case, music or song could be seen as an intermediary object that surrounds the client. An instrument as a third object played by both partners may facilitate the development of the relationship. The exchange of motifs and the development of a common musical form in free improvisation is a highly communicative process, requiring social skills and flexibility, and in many cases, is accompanied by shared joy in social reciprocity.
Music therapy approaches to assist people with ASD
Several music therapy approaches to working with people with ASD have been developed. Many of these draw on a theoretical foundation outside of music therapy, with corresponding assessments to allow therapy evaluation and structured intervention planning.
Alvin and Warwick 1992, pp. 30–31
Paul Nordoff and Clive Robbins pursued a child-centered improvisational approach in the development of their Creative Music Therapy (Nordoff and Robbins 1965). They used music to engage children with developmental disorders, including autism, in a musical experience. Juliette Alvin, pioneering music therapist and founder of the British Society of Music Therapy, has also pursued a child-directed approach based on sound, improvisation, and movement to recorded music in the treatment of autism. She considers establishing communication to be a primary treatment goal. The case described below demonstrates this approach using receptive techniques at the beginning of the music therapy process with an eight-year-old boy named Oliver, diagnosed as mute autistic and suffering from noise phobia. (p. 196)
Berger 2002, pp. 166–168
Dorita S. Berger has developed a method oriented to sensory perceptual features and brain and motor functions in individuals with pervasive developmental disorders, including autism (Berger 2002). The elements of music as well as the selection of instruments are interpreted in the sense of sensory adaptation. Her main treatment goals are rhythm internalization, adaptive responses to the environment, auditory integration and discrimination, sequencing, pacing of body movement and breath, creativity, self-initiative and task organization, behavioral redirection, speech and language, etc. These objectives demonstrate an approach that is less focused on the social behavior items that are formulated as diagnostic criteria and more on possible causes in terms of atypical brain functions. The following case study demonstrates music therapy based on sensory integration with a thirteen-year-old boy diagnosed with Asperger’s Syndrome, characterized as extremely verbal and well-developed for his age, and with an abundance of high energy:
Although autism is the main item covered by the term “pervasive developmental disorders” as defined in the DSM-IV (American Psychiatric Association 2000), developmental approaches in therapy are rare. During decades of work with autistic children, Schumacher and Calvet have created a music therapy approach based on recent findings of infant research (Schumacher 1999). The central element is the phenomenon of synchronization (Schumacher and Calvet 2008b), referring to the coordination of perception, motion, and emotion on the individual and interpersonal level. The Assessment of the Quality of Relationship (AQR, Schumacher and Calvet 2007) has been developed as a structuring aid for treatment planning and as an assessment tool for therapy evaluation. The scale is based on the self-development concepts of Daniel Stern (2000) and consists of eight graded modes that mainly relate to the pre-verbal development period. Three subscales assess the client’s instrumental, vocal, and physical-emotional behavior and expression while one scale assesses the therapist and his (p. 198) interventions. Matching with the client’s needs and socio-emotional capacities is seen as fundamental for a therapeutic relationship and for progress. Table 10.2 gives a condensed overview of the client-therapist matching within the particular AQR modes.
Table 10.2 Assessment of the Quality of Relationship (AQR): Developmental matching of client and therapist
Note: Adapted from “The AQR-Instrument: An observation instrument to assess the quality of a relationship”, by Schumacher and Calvet (2007).
To measure the client characteristics, the AQR provides three subscales relating to the instrumental quality (IQR), vocal pre-speech quality (VQR), and physical-emotional quality (PEQR) of the relationship. Items of each subscale have been strongly condensed to provide a concise overview.
Modus 1 to modus 4 provide unique musical interventions, like playing for the client in various ways without expectation of dialogue, that are integral to therapy for people with ASD mainly characterized by qualitative impairments of social interactive capacities and high irritability (Bergmann et al. 2011). The following example demonstrates this developmental approach to: first, support the client without intersubjective demands in musical exploration (AQR modus 3); second, achieve social referencing and affective attunement in joint play (AQR modus 4); and finally, achieve a perspective including (p. 199) turn taking and musical dialogue (AQR modus 5). It shows a 30-year-old woman with moderate ID, diagnosed with ASD, self-injurious behavior, and suspected traumatization during childhood:
In addition to approaches based on musical improvisation, there are also education-orientated song-based concepts. To allow children with ASD to manage daily transitions and routines successfully, songs could help by providing structure, predictability, and consistency. In combination with music and sound cues to convey a message or to sequence the steps of an activity, it is recommended this concept be implemented by parents and teachers by making up new lyrics to familiar tunes (Kern 2012). In an inclusive approach, the use of songs individually composed by a music therapist and sung by the teacher was able to help two young children with entering the classroom, greeting the teacher and/or peers, and engaging in play (Kern et al. 2007). A similar concept has been used in a community-based approach to support the outdoor play of young children with ASD (Kern and Aldridge 2006).
Several attempts are being made to add music therapy intervention to established child treatment programmes. Lim has incorporated music into the Applied Behavior Analysis Verbal Behavior (ABA VB), a widespread early-intervention training method (Barbera and Rasmussen 2007). Musical stimuli have been successfully used to enhance the functional verbal production in 22 children with ASD who were verbal or pre-verbal with immediate echolalia (Lim and Draper 2011). Social stories are a means of teaching social behavior in children with ASD and of strengthening the cognitive skills needed for social interaction. Brownell has combined this technique successfully with music by composing original songs for students of an elementary school using the text of the individual social story as lyrics (Brownell 2002). Similarly, music therapy has been used within the SCERTS model, i.e. a comprehensive curriculum designed to assess and identify treatment goals within a (p. 200) multidisciplinary team of clinicians and educators for children with ASD (Walworth et al. 2009). This can be seen as an interdisciplinary approach to integrate and evaluate music therapy within a context of multisystem interventions correlating to the multisystem nature of impairments in ASD (Srinivasan and Bhat 2013).
Alongside active or receptive music therapy methods based on musical improvisation, song, and movement, there are also medical approaches based on the functional use of music. Auditory Integration Therapy (AIT) typically involves twenty half-hour sessions over ten days listening to specially filtered and modulated music (Bérard 1993). This addresses sensory processing problems, such as hyperacousis. The emotional and intersubjective qualities of music are left out. Currently, there is no evidence that AIT or other sound therapies are effective as treatments for ASD (Sinha et al. 2011).
Considerations for the treatment setting
Individuals with ASD have a range of special needs regarding which the therapist must show sensitivity and respect. The therapist should understand the client’s need for sameness and particular sensory-perceptual characteristics, such as hypo- or hyper-reactivity to sensory input. Alvin recommended the use of a room specially designed for children with ASD, with suitable furniture and equipment. The room should allow freedom of movement and provide a sense of security (Alvin and Warwick 1992). To avoid panic, tantrums, and withdrawal, the arrangement and the order of the instruments should be kept the same from session to session, with an allowance to be made for small changes. This principle may also be taken into account when planning interventions, by working through a course of instruments in a structured way and providing certain qualities and opportunities with regard to contact and relationship formation, with a predictable beginning and end (Bergmann et al. 2009). On the one hand, sensory overstimulation should be avoided by ensuring good ventilation, warm room acoustics, and the possibility of regulating direct sunlight, while the room and the instruments should provide sufficient sensory stimulation to encourage curiosity and exploratory behavior. This may not only be the sound of an instrument, but also its color, form, smell, or surface texture, in order to appeal to a wide range of sensory modalities. Some additional features are proposed, such as an armchair as a safe place (Alvin and Warwick 1992), a hammock to stimulate proprioceptive perception (Schumacher and Calvet 2008b), and/or a drum table as a central structuring element (Bergmann et al. 2009).
Assessment tools and music therapy diagnostic instruments
Music therapy plays a relevant role in diagnostic and clinical assessment by providing a tool for evaluating strengths and weaknesses in many areas of development (Wigram and Gold 2006). Besides the AQR already described above, there are further approaches to assess the client’s musical behavior to facilitate therapy evaluation and intervention planning working in the field of ASD. Nordoff and Robbins designed two scales, the first to assess the child-therapist relationship in musical activity, the second to assess musical (p. 201) communicativeness (Nordoff and Robbins 1977). This assessment is widely used today in the context of the Nordoff-Robbins Creative Music Therapy approach (Nordoff and Robbins 1965) for the documentation, evaluation, and training of music therapists. Against the background of the Nordoff-Robbins approach, John A. Carpente developed the Individual Music-Centered Assessment Profile for Neurodevelopmental Disorders (IMCAP-ND; Carpente 2014). Within a musical-play and developmental and relationship-based framework, this assessment is a method for observing and rating musical emotional responses, cognition and perception, preferences, perceptual efficiency, and self-regulation. The IMCAP-ND is applicable to individuals at various developmental levels and chronological ages and serves to support the therapist in formulating clinical goals and strategies for working with the client.
Wigram has focused much of his work on the development of assessments in arts therapies (Wigram 1999a, 2000). In diagnosing autism in a music therapy setting, he selected the two subscales of autonomy and variability of Bruscia’s Improvisation Assessment Profiles (IAP) (Bruscia 1987). In reporting the case of a five-year-old boy, Wigram has demonstrated the qualities of the Harper House Music Therapy Assessment to study autistic core features for the purpose of differentiating between communicative disorders and ASD (Wigram 1999b). Oldfield has developed the Music Therapy Diagnostic Assessment (Oldfield 2006), modelled after the Autism Diagnostic Observation Schedule (Lord et al. 1989), an established play-based diagnostic instrument. Referring to borderline autistic children, Oldfield concludes that “the MTDA has given us useful information even with the most difficult group of children to diagnose […]” (Oldfield 2004). In the field of adults with intellectual disability with suspected ASD, Bergmann has developed the Musical Scale for Autism Diagnostics (Bergmann et al. 2012). Due to the lack of diagnostic instruments specifically designed for this group, he used the age-independent, non-verbal quality of musical play to assess adults with a low level of functioning in a structured diagnostic setting. The assessment was well accepted among 91 participants, and a preliminary study suggests positive records of its objectivity, reliability, and validity (Bergmann et al. 2015a; Bergmann et al. 2015b). Despite positive indications regarding the music therapy setting as an ideal framework for the identification of autistic symptomatology, work still needs to be done before these approaches can fulfil the criteria for test’s quality required to support clinicians and researchers in diagnosing ASD with valid tools based on musical interaction.
Conclusion and future directions
Most research concerning music and the brain has focused on special abilities, such as absolute pitch detection in individuals with ASD, thus underlining the link between ASD and music on a neurocognitive level. The field concerning emotionality, empathy, and affective regulation in connection with music reception and active music playing seems to be more relevant for the music therapy practice. Research on the efficacy of music therapy in the treatment of ASD is dominated by case reports and studies with small sample sizes. To provide evidence, more random controlled studies are needed, which should be possible as a result of the increasing “academization” of music therapy and the potential financial (p. 202) support of governmental and non-governmental organizations for ASD research projects. One promising example is the ongoing international multi-site TIME-A study (Geretsegger et al. 2012), which analyzes the effectiveness of improvisational music therapy for children with ASD. The aim is to overcome the methodological limitations of previous studies, e.g. by using a larger sample size and by examining the effects over longer periods of time. More activities of this kind could potentially emphasize and provide evidence for the appropriateness of music therapy for ASD and move it away from the orbit of complementary and alternative methods and in the direction of established procedures and best practice.
Music therapy approaches are well established in the treatment of ASD and have been developed against a behavioral, creative, sensory-perceptional, developmental, and educational background. Guidelines are needed in order to set standards in practice and research, as well as in the training of music therapists. Goals, settings, basic principles, and interventions should be further defined. Currently, a treatment guide for improvisational music therapy for children with ASD is being developed (Geretsegger et al. 2014).
Music therapy is used in the treatment of children with ASD, as reflected by the huge number of studies and case reports. Since ASD is a lifelong condition, and music is a highly interactive and age-independent medium, the possibilities of using musical interventions in the treatment of adults should also be considered (Boso et al. 2007). Music therapy has great potential, particularly for use with adults with cognitive impairments and limited language skills (Bergmann et al. 2011), and this should be further investigated.
Assessments in music therapy are needed as a basis for therapeutic practice. This concerns the treatment goals, intervention planning, therapy evaluation, and education of music therapists. In the field of therapy, the AQR (Schumacher and Calvet 2007) provides unique qualities through its developmental foundation correlating to ASD as a pervasive developmental disorder, while the IMCAP-ND (Carpente 2014) supports the formulation of clinical goals and strategies against a Nordoff and Robbins background. In the field of education, the SCERTS model makes it possible to assess music therapy within an interdisciplinary and multimodal approach (Walworth et al. 2009).
In diagnosing ASD, the music therapy setting is an appropriate framework for behavioral observation, since the multisystem and non-verbal character of music correlates with widespread autistic features. Various music-based assessments provide diagnostic hints, but until now, they have lacked a test-theoretical verification. A closer orientation to the criteria for test quality would be desirable in order to achieve valid results and to establish music-based diagnostic procedures in the clinical context.
The close connection between autism and music on many levels; the intertwined, parallel history of music therapy and autism; and the high potential of music-based interventions, as well as many open questions, suggest a common future.
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