Music therapy treatment for children with Autism Spectrum Disorder (ASD)

Published on July 6, 2018

There are so many different options these days specially designed to meet the unique needs of children that have learning difficulties due to their disabilities either physical condition, mental condition, or behaviour. All the various available centres are using different theories and remedies claiming to help children with different needs and disabilities, but what really works? The discussion in this paper is focusing on autistic children. Hence, I have chosen to discuss music therapy treatment for children with ASD. The discussions are also supported by some research reviews.

AUTISM AND AUTISM SPECTRUM DISORDER (ASD)
Autism and autism spectrum disorder (ASD) are both general terms for a group of complex disorders of brain development. These disorders are characterized, in varying degrees, by difficulties in social interaction, verbal and nonverbal communication and repetitive behaviours. According to the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) (APA, 2013), all autism disorders were merged into one umbrella diagnosis of ASD.


The word autism comes from the Greek word autos, which means self (Gillberg & Coleman, 2000). Autism is perceived as a developmental disability in which an individual lacks social responsiveness. According to Fidler (2009), there are three triads of impairments manifested in autistic disorder. Firstly, communication which refers to language impairment across all modes of communication such as speech, intonation, gesture, facial expression and another body language. Secondly, socialization which refers to difficulties with social relationships, poor social timing, lack of social empathy, rejection of normal body contact, inappropriate eye contact. Thirdly, imagination which refers to rigidity and inflexibility of thought processes, resistance to change, obsessional and ritualistic behaviour, lack of creative, imaginative play. These triads of impairments are sometimes accompanied by difficulties in physical coordination and unpredictable challenging behaviours. It is found that each autistic child has different and unique autistic spectrum disorder (ASD) (Quill, 1995).

As ASD is very different for each child. Two children with both the same diagnosis can act very differently from one another and have varying skills. What works for one child will probably not work for another (Smith, 2006). In DSM-5, people with ASD tend to have difficulties in communication such as delayed or absent speech or responding inappropriately in conversations; difficulties in reciprocal social interactions such as making eye contact or gesture or having difficulty building friendships appropriate to their age; and having restricted, stereotyped, and repetitive behaviors (APA, 2013). Besides, there are no facial characteristic or other physical features that can help to identify children with an autistic problem but ASD can be identified in infancy or early childhood around aged 3 to 4 years old or as early as 18 months old and last a lifetime. Autism now affects 1 in 68 children and 1 in 42 boys and the prevalence figures are growing (Facts about Autism, 2016). However, the cause of autism is not yet finalized (Friend & Bursuck, 2006). Autism may be linked to difficult births (Schendel, 2006).

WHAT IS MUSIC THERAPY?
Music plays an important part towards physical development in a variety of ways. It enhances body awareness, motor control, imitating movement, motivation to participate and duration of motor participation (Bibler & Sousa, 2006). According to the American Music Therapy Association (2009), music therapy is the systematic application of music directed by the music therapist in a therapeutic environment, to bring about desirable changes in behaviour. Baron-Cohen and Bolton (1993) had made an explicit report regarding music therapy and children with autism. Their study found that music therapy encourages communication and socialization, and also used to bring out the often normal or superior musical talents of children with autism. Trevarthen, Aitken, Papoudi, and Robarts (1999) also found that music therapy supported both communication and social skills in children with autism because it encouraged and accentuated body expression and gesture in interaction, increased empathy, cooperation and learning of children with autism. All kinds of music intervention, regardless of purpose or implementation methods have shown positive effects for autistic individuals (Whipple, 2004).


The National Autistic Society (2007) revealed that music therapy has become accepted as a valuable intervention for people with autism since it was introduced in England in the 1950s and 60s by practitioners. It is designed to impact the auditory, proprioceptive, and visual sensory systems and can also serve as a motivational tool (Brownell, 2002). Music therapists use functional behaviour assessment procedures to identify individual needs and preferences to develop interventions. For examples, using music as a calming medium; providing music as a reinforcer; and implementing music therapy to teach and encourage communication, behaviour, adaptive behaviour, and social skills (Brownell, 2002). Besides that, music therapy provides non-verbal communication in which sound changing is fun and playful. Therefore, it can serve as an emotional outlet for people who have difficulty in expressing themselves in words (Chiang & Zalizan, 2010).


The belief in the effectiveness of treatment with music therapy or the theory behind music therapy is based on the understanding that all people have an innate responsiveness to music (Smith & Patey, 2003). According to Alvin and Warwick (1991), the general principles of music therapy for children with autism were developing a trusting relationship, self-expression, and social interaction through free improvisational music therapy. They emphasized the qualities of musical sound, the therapeutically defined silence and space in which the autistic children may acquire new experiences. Many times, the therapists use their own voices, tuned instruments or even silent rest to respond creatively to the sounds produced by the client. The music therapist need not fall into conventional patterns or sequences or use words. They can respond only to cries, screams and body movement of the children that have rhythm and pitch and are susceptible to the organization in musical terms.


In the therapeutic context, the clients are not taught to play any musical instrument in a music therapy session. However, sometimes the clients may be taught to play some simple instruments and acquire musical skills in the therapy sessions (Chiang & Zalizan, 2010). Unlike the normal children in a regular music lesson, children with autism still demonstrate a need for structure and a systematic approach to promoting appropriate and meaningful interpersonal responses. Therefore, the primary goal of music therapy is initiating and sustaining joint attention for which improvisational music making provides a useful medium where the therapist would ‘meet the child’ in music (Alvin & Warwick, 1991).

REVIEW OF EXISTING RESEARCH 
The research study by Wigram and Gold (2006) has found that music is considered effective as a therapeutic medium because it contains many different levels of structure, yet provides the variability and flexibility needed to counteract more rigid characteristics of the pathology. The improvisational music therapy is typically a child-centred therapy, and for autistic children, their response to this approach emerges when they realized that the therapist’s music is reflecting on something to do with them. Music created spontaneously and creatively through structured and flexible improvisation attracts the attention and provokes engagement in children with ASD. It also promotes the development of reciprocal interactive communication and play (Wigram, 2002; Oldfield, 2001). Earlier research by Sigman (2001); and Shore (2002) had found that children with special needs such as autism show a high level of preference and respond well to music. There is also significant clinical documentation revealed that music therapy has been recommended as an effective treatment in facilitating communication because music is a medium that involves a complex range of expressive qualities, dynamic form, and dialogue, and offers some form of alternative communication to help achieve engagement, interaction, and relationship (Wigram, 2002).

On the other hand, music is the means of communication and developing relationships with some children (Stephen, 2002). His study revealed that music could help to organize verbal communication skills that already existed in the children which later enable them to perform nonverbal interaction such as imitative drumming, turn taking, write notes, and working on the recorder and piano (Stephen, 2002). Stephen’s study further emphasized that music can be the medium for enhancing verbal communication for some autistic children who were less severe. For example, use singing to facilitate communication is actually easier for these children to understand rather than speech. He also revealed that only sung communication could help the child to focus and to reduce self-stimulation activities. One child that has no functional communication was able to supply the missing words to songs he knew when the music teacher suddenly stops at points of maximal tension. Baron-Cohen and Bolton (1993), music therapy at the very least has a very calming effect on many children with autism. Another clinical documentation also showed that children with autism improved in social interaction through the use of either structured or more freely creative techniques through music therapy (Brownell, 2002). Music can be used as a motivator and alternative teaching method for selected skills that may be more difficult for the children to achieve by using typical non-music instructional approaches (Lee, 2006).

Gold, Voracek, and Wilgram (2004) reviewed in their first meta-analysis that music therapy generally has a medium to large effect on this broader population; however, only one of the included studies addressed ASD specifically. Systematic reviews by Whipple (2004) have found conditions involving music is more effective than conditions without music. A systematic review by Ball (2004) also addressed that there are effects of music therapy than no treatment on outcomes such as behaviour, communication and social interaction in children with ASD but the effects of music therapy were unclear. On the other hand, Whipple (2004) has done nine meta-analyses studies which compared music to non-music treatment for children and adolescents with autism concluded that all kinds of music intervention, regardless of implementation methods, treatment designs, and types of music used, are effective on autistic individuals. This means that all types of music treatments have a positive effect on autistic individuals.

In conclusion, all the existing research findings discussed here are important because they demonstrate the potential of the medium of music as a therapeutic intervention for autistic children. However, the generalizability of these studies to clinical practice is limited. Furthermore, the small sample size in music therapy had also made the research findings hard to be generalized. In Malaysia, there is a lack of attention given to group music intervention as therapy for autistic skills development. The music intervention profession is rare in Malaysia. Many of the people dealing with the autistic education focus on other interventions such as speech therapy, behavioural modification intervention, play therapy and medication therapy et cetera (Chiang & Zalizan, 2010). It is believed that the lack of venture into music therapy is due to low awareness of its importance and advantages. The existing studies have shown promising results and proved a good rationale for developing more rigorous research.

SUMMARY AND RECOMMENDATION
The discussion in this paper has highlighted some positive effects of music therapy to develop autistic children in their area of socialization, communication, and behaviour. Music therapy can be used by the therapist to enhanced development of helpful behaviours in all the three main skill categories, namely communication, social and motor skills. Below summarizes some of the benefits of using music therapy to teach children with ASD:
• Help to improve children with ASD in communication acquisition skills through verbal and nonverbal interaction.
• Increase language skills. For example, a pre-singing activity encouraged children to read the lyrics helped them to improve their reading skills too after music intervention.
• Increase socialization skills because music therapy increases child interactions with other individuals.
• Through music therapy, students learned to be disciplined. For example, they were taught to follow instructions like ‘stand up’ or ‘sit down’, and ‘taking a turn’.
• Increase sensory regulations.
• Help children to increase their attention span in learning and relieves anxiety.
• Increase independent leisure time activities through successful music experiences.
• Improve functioning motor skills that incorporate eye-hand coordination. For example, the children could imitate the teacher clapping in the greeting song; learn left and right and raised hands accordingly. Through this could improve intra-development of the self-initiation trait in the autistic children.
In summary, the benefits and the evidence from existing literature covering had supported the advancement of music therapy in helping children with autism spectrum to learning through a range of musical activities like singing, playing instruments, improvising which involved eye contact and taking turns. Therefore, besides other interventions music therapy treatment should also be integrated into the teaching approach for children with autism spectrum because it provides an opportunity for successful experiences in learning.

REFERENCES:
Alvin, J. & Warwick, A. (1991). Music therapy for the autistic child. Oxford: Oxford University Press.
American Psychology Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Washington, DC: American Psychiatric Association.
American Music Therapy Association. (2009). Quotes about music therapy. Retrieved July 5, 2016, from http://www.musictherapy.org/quotes.html
Ball, C. M. (2004). Music therapy for children with an autistic spectrum disorder. Bazian Ltd, London, UK. Retrieved July 15, 2016, from http://www.signpoststeer.org
Baron-Cohen, S. & Bolton, P. (1993). Autism: The facts. Oxford: Oxford University Press.
Bibler, V. & Sousa, C. (2006). How can music therapy benefits children with special needs? Retrieved July 18, 2016, from www.coastmusictherapy.com
Brownell, M. D. (2002). Musically adapted social stories to modify behaviours in students with autism: Four case studies. Journal of Music Therapy, 39, 117-144.
Chiang Ee Fong, & Zalizan Mohd Jelas (2010). Music education for children with autism in Malaysia. Procedia Social and Behavioral Sciences, 9, 70–75.
Facts about Autism. (2016). Retrieved July 18, 2016, from https://www.autismspeaks.org/ what-autism/facts-about-autism
Fidler, W. (2009). The Autistic Spectrum: Autism, Asperger Syndrome (AS) and Semantic Pragmatic Disorder (SPD) – a practical Montessori response. The National Autistic Society. Retrieved July 15, 2016, from http://www.na.org.uk/nas/jsp/polopolu.jsp? d= 3648a=8019
Friend, M. & Bursuck, W. C. (2006). Including students with special needs: A practical guide for classroom teachers. Boston: Pearson.
Gillberg, C. & Coleman, M. (2000). The biology of the autistic syndromes. London: Mac Keith Press.
Gold, C., Voracek, M. & Wigram, T. (2004). Effects of music therapy for children and adolescents with psychopathology: a meta-analysis. Journal of Child Psychology and Psychiatry and Allied Disciplines, 45, 1054–1063.
Lee, L. 2006. Music therapy enhances attention span and promotes language ability in young special needs children. Paper presented at the International Society for Music Education, K.L., Malaysia.
Oldfield, A. (2001). Music therapy with young children with autism and their parents: developing communications through playful musical interactions specific to each child. In D. Aldridge, G. Di Franco, E. Ruud, & T. Wigram (Eds.). Music Therapy in Europe (p. 47-62). Ismez, Rome, Italy.
Quill, K. A. (1995). Teaching children with autism: Strategies to enhance communication and socialization. London: Delmar Publishers.
Schendel, D. (2006). Autism may be linked to difficult birth-study. Retrieved July 20, 2016, from http://pediatric.healthcentersonline.com/newstories/autismmaybelinkeddifficultbirthstudy.cfm.
Shore, S. M. (2002). The language of music: Working with children on the autism spectrum. Journal of Education, 183(2), 97-109.
Sigman, M. (2001). Extraordinary talents of autistic minds. Science. 293 (5529), 435-436.
Smith, D. D. (2006). Introduction to special education: Teaching in an age of opportunity. (5th ed.). Boston: PEARSON
Smith, R. D. & Patey, H. M. (2003). Music therapy. London: Sage Publications Ltd.
Stephen, M. S. (2002). The language of music: Working with children on the autism spectrum. Journal of Education, 183(2), 97-109.
The National Autistic Society of United Kingdom Web page. (2007). Retrieved July 20, 2016, http://www.nas.org.uk
Trevarthen, C., Aitken, K., Papoudi, D. & Robarts, J. (1999). Children with autism (2nd. Ed.). London: Jessica Kingsley Publishers.
Whipple, J. (2004). Music in intervention for children and adolescents with autism: A meta-analysis. Journal of Music Therapy, 41, 90-106
Wigram, T. (2002). Indication in music therapy: Evidence from assessment that can identify the expectations of music therapy as a treatment for Autistic Spectrum Disorder (ASD); meeting the challenge of evidence-based practice. British Journal of Music Therapy, 16(1), 11-28.
Wingram, T., & Gold, C. (2006). Music therapy in the assessment and treatment of autistic spectrum disorder: Clinical application and research evidence. Child: Care, Health and Development, 32 (5), 535-542.


Category(s):Autism spectrum disorders

Written by:

Dr Alice Lee, PhD

Dr Alice Lee (PhD) a professionally trained counsellor and a Certified Anger Management Treatment Professional from International Association of Trauma Professionals (IATP), has many years of rich experience in the educational and counselling field. She had conducted various training workshops and talks related to anger management, stress management, personal development, parenting teens, time management, education, effective learning strategies, and premarital issues.

Recently, she moved to Singapore to start Life Station counselling services under Sing RJ Associates Pte Ltd. Life Station is a professional counselling services platform to provide individual and couple/group counselling, CBT interventions for anger management and social phobia. Life Station brings hope to individuals, couples and families who need help and emotional support. The understanding of You Are Not Alone, Genuineness, Openness, Sincerity, Empathy is the focus in all the sessions. Each counselling session is highly confidential. For more information, explore www.lee-alice.com.

Qualifications:
* PhD in Counselling
and Guidance - University of
Science Malaysia (USM)
* MEd in Counselling and
Guidance - University of Science
Malaysia (USM)
* Certified AMTP, IATP
* Certified Practitioner, CAPT Skills
* Dip Ed (Special Needs)

Other Credentials:
* CE for CBT, Beck Institute for
Cognitive Behaviour Therapy
(CBT), IAHB
* Accredited Level Two CBT for
Anger and Irritability, APT, UK

Memberships
* Penang Association and
Counselling Psychology (PACP)
* Association of Psychological and
Educational Counsellors of Asia-
Pacific (APECA)
* Penang Centre of Creative Art
Therapy (CCAT)
* The Association for
Psychological Therapies (APT).

Dr Alice Lee, PhD belongs to Sing RJ Associates Pte. Ltd. - Life Station in Singapore

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