Interaction Themes in Music Therapy: Definition and Delimitation

Music therapy for autistic people

BACKGROUND

Social interaction and social communication are among the central areas of difficulty for autistic people. Music therapy uses music experiences and the relationships that develop through them to enable communication and expression, thus attempting to address some of the core problems of autistic people. Music therapy has been applied in autism since the early 1950s, but its availability to autistic individuals varies across countries and settings. The application of music therapy requires specialised academic and clinical training which enables therapists to tailor the intervention to the specific needs of the individual. The present version of this review on music therapy for autistic people is an update of the previous Cochrane review update published in 2014 (following the original Cochrane review published in 2006).

OBJECTIVES

To review the effects of music therapy, or music therapy added to standard care, for autistic people.

SEARCH METHODS

In  August 2021, we searched  CENTRAL, MEDLINE, Embase, eleven other databases and two trials registers. We also ran citation searches, checked reference lists, and contacted study authors to identify additional studies.

SELECTION CRITERIA

All randomised controlled trials (RCTs), quasi-randomised trials and controlled clinical trials comparing music therapy (or music therapy alongside standard care) to 'placebo' therapy, no treatment, or standard care for people with a diagnosis of autism spectrum disorder were considered for inclusion.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methodological procedures. Four authors independently selected studies and extracted data from all included studies. We synthesised the results of included studies in meta-analyses. Four authors independently assessed risk of bias (RoB) of each included study using the original RoB tool as well as the certainty of evidence using GRADE.   MAIN RESULTS: We included 16 new studies in this update which brought the total number of included studies to 26 (1165 participants). These studies examined the short- and medium-term effect of music therapy (intervention duration: three days to eight months) for autistic people in individual or group settings. More than half of the studies were conducted in North America or Asia. Twenty-one studies included children aged from two to 12 years. Five studies included children and adolescents, and/or young adults. Severity levels, language skills, and cognition were widely variable across studies. Measured immediately post-intervention, music therapy compared with 'placebo' therapy or standard care was more likely to positively effect global improvement (risk ratio (RR) 1.22, 95% confidence interval (CI) 1.06 to 1.40; 8 studies, 583 participants; moderate-certainty evidence; number needed to treat for an additional beneficial outcome (NNTB) = 11 for low-risk population, 95% CI 6 to 39; NNTB = 6 for high-risk population, 95% CI 3 to 21) and to slightly increase quality of life (SMD 0.28, 95% CI 0.06 to 0.49; 3 RCTs, 340 participants; moderate-certainty evidence, small to medium effect size). In addition, music therapy probably results in a large reduction in total autism symptom severity (SMD -0.83, 95% CI -1.41 to -0.24; 9 studies, 575 participants; moderate-certainty evidence). No clear evidence of a difference between music therapy and comparison groups at immediately post-intervention was found for social interaction (SMD 0.26, 95% CI -0.05 to 0.57, 12 studies, 603 participants; low-certainty evidence); non-verbal communication (SMD 0.26, 95% CI -0.03 to 0.55; 7 RCTs, 192 participants; low-certainty evidence); and verbal communication (SMD 0.30, 95% CI -0.18 to 0.78; 8 studies, 276 participants; very low-certainty evidence). Two studies investigated adverse events with one (36 participants) reporting no adverse events; the other study found no differences between music therapy and standard care immediately post-intervention (RR 1.52, 95% CI 0.39 to 5.94; 1 study, 290 participants; moderate-certainty evidence).  AUTHORS' CONCLUSIONS: The findings of this updated review provide evidence that music therapy is probably associated with an increased chance of global improvement for autistic people, likely helps them to improve total autism severity and quality of life, and probably does not increase adverse events immediately after the intervention. The certainty of the evidence was rated as 'moderate' for these four outcomes, meaning that we are moderately confident in the effect estimate. No clear evidence of a difference was found for social interaction, non-verbal communication, and verbal communication measured immediately post-intervention. For these outcomes, the certainty of the evidence was rated as 'low' or 'very low', meaning that the true effect may be substantially different from these results. Compared with earlier versions of this review, the new studies included in this update helped to increase the certainty and applicability of this review's findings through larger sample sizes, extended age groups, longer periods of intervention and inclusion of follow-up assessments, and by predominantly using validated scales measuring generalised behaviour (i.e. behaviour outside of the therapy context). This new evidence is important for autistic individuals and their families as well as for policymakers, service providers and clinicians, to help in decisions around the types and amount of intervention that should be provided and in the planning of resources. The applicability of the findings is still limited to the age groups included in the studies, and no direct conclusions can be drawn about music therapy in autistic individuals above the young adult age. More research using rigorous designs, relevant outcome measures, and longer-term follow-up periods is needed to corroborate these findings and to examine whether the effects of music therapy are enduring.

Musical interaction with children and young people with severe or profound intellectual and multiple disabilities: a scoping review

This scoping review addresses peer-reviewed research on musical interaction with children and young people with severe/profound intellectual and multiple disabilities (S/PIMD). Twenty-five articles published between the years 2000 and 2020 met the inclusion criteria. A narrative synthesis was used to summarise and evaluate different features, including participant characteristics, study design and methods, type of musical interaction, the abilities and behaviours in focus, reported benefits, promising components of musical interaction, and quality appraisal of the studies. The results revealed a variation in participant characteristics and study designs, where small-sample descriptive case studies were most common. In terms of the type of musical interaction, active music therapy was the most commonly used approach, followed by technology-mediated and multisensory musical activities. In terms of abilities and behaviours, a large majority of the studies focused on social interaction and communication, followed by engagement, attention and affect. Six categories were identified as promising components of musical interaction: the responsivity of the interaction partner, singing songs, structure and predictability in the activities, long-term interventions, technology-mediated and multisensory musical activities, and a therapeutic alliance between interaction partners. Based on this review, we discuss future research and practical implications for musical interaction and music therapy for children and young people with S/PIMD.

Umberto Eco’s notions of the ‘open work’ and the ‘field of possibilities’: New perspectives on music therapy and co-creation?

Umberto Eco’s ideas and philosophy have proven to be a profound inspiration to the research team dedicated to the recently completed qualitative interdisciplinary research project ‘RHYME: rhythm & rhyme; co-creation through tangible interaction’, in which both of the present authors participated. The idea of RHYME is that ordinary objects in the home environment – a pillow, carpet or toy, for example – if they should become both musical and interactive, might afford meaningful, joyful and even health-promoting moments of co-creation in the everyday lives of families with a child with disabilities. This article develops the central RHYME notion of co-creation further by introducing it to music therapy. From our experiences with interactive and musical media from RHYME, and inspired by Eco and his notions of ‘open works’ and ‘fields of possibilities’, we have developed an understanding of music therapy as a configuration of possible events or interactive structural forces. Music, then, becomes one of many possible media in music therapy. Through a reflective synthesis which also includes the discussion of empirical RHYME data, we will address the following research question: Can Eco’s notions contribute something new to our understanding of co-creation in music therapy, and, if so, what and how?

Music therapy microanalysis of parent-infant interaction in a three-month-old infant later diagnosed with autism

<b>Background</b><br /> Infant research literature has described for a long time the main aspects of parentese (motherese and fatherese) referring to musicality and specifically to musical language. It is believed that there is a deep analogy between the vital affects experienced by the child during interaction with the parent and the type of parentese that is a direct representation of them. Disruption of parentese has been described in early autism. The aim of this paper was to achieve a better understanding of this disruptive process.<br /> <br /> <b>Participants and procedure</b><br /> Sequences of parent-infant interaction extracted from one home movie of a child later diagnosed with autism were analyzed in a micro-musical way in order to create a musical score that allows the description of parent-infant interaction in a new way (considering form, pulse, rhythm, melody, timbre and silence).<br /> <br /> <b>Results</b><br /> Musical microanalysis is able to highlight features not brought out by other kinds of analysis. The first fragment is dominated by the anxiety of the mother, who attempts to stimulate the unresponsive infant. In the second fragment there is a change in musicality parallel to changes in the relationship: the mother participates in and coordinates the infant’s experience through rhythm, prosody and musical dynamics. This change persists in the third fragment.<br /> <br /> <b>Conclusions</b><br /> Musical transcription of parent-infant interactions has allowed us to highlight changes occurring in a short time during early interactions and to get a closer view of the disruptive process created by autism. This kind of research represents a potential shift in autism research, by focusing on dynamic parent-infant interactions instead of single behaviors of the child or of the parent. The usefulness of Stern’s concept of intersubjective communion is discussed.

Turn-Taking in Music Therapy with Children with Communication Disorders

In a well-functioning dialogue, the nonverbal and often implicit visual and auditory cues ensure good continuation without interruptions or overlapping speak. In mutual interplay, both partners participate in turn-organisation, and therefore an analysis of cues indicating turn-taking and turn-yielding can provide information about the participants' social skills, whether or not the dialogue is verbal.

This article presents relevant concepts from conversation analysis literature in order to analyse music therapy interplay aimed at promoting preverbal and social skills. As the character of the turn-organisation is dependent on the developmental age of the participants, the described cues are compared to research in early mother–child interplay, as well as studies of turn-organisation in dialogues with disabled children.

The theoretical part of the article is illustrated by a turn-analysis of case material from music therapy with a 2½-year-old boy with communication disorders. The analysis was a part of the author's doctoral research and focuses on the boy's participation in turn-organisation as well as the therapist's use of turn-yielding and turn-overlapping.

The article concludes with a discussion of the applied theoretical concepts in relation to music therapy practice. It will be suggested that the turn-yielding cues can be compared to response-evoking techniques, while the management of simultaneousness (overlaps) naturally is very different in verbal than in musical dialogues.

Music therapy for people with autism spectrum disorder

BACKGROUND

The central impairments of people with autism spectrum disorder (ASD) affect social interaction and communication. Music therapy uses musical experiences and the relationships that develop through them to enable communication and expression, thus attempting to address some of the core problems of people with ASD. The present version of this review on music therapy for ASD is an update of the original Cochrane review published in 2006.

OBJECTIVES

To assess the effects of music therapy for individuals with ASD.

SEARCH METHODS

We searched the following databases in July 2013: CENTRAL, Ovid MEDLINE, EMBASE, LILACS, PsycINFO, CINAHL, ERIC, ASSIA, Sociological Abstracts, and Dissertation Abstracts International. We also checked the reference lists of relevant studies and contacted investigators in person.

SELECTION CRITERIA

All randomised controlled trials (RCTs) or controlled clinical trials comparing music therapy or music therapy added to standard care to 'placebo' therapy, no treatment, or standard care for individuals with ASD were considered for inclusion.

DATA COLLECTION AND ANALYSIS

Two authors independently selected studies, assessed risk of bias, and extracted data from all included studies. We calculated the pooled standardised mean difference (SMD) and corresponding 95% confidence interval (CI) for continuous outcomes to allow the combination data from different scales and to facilitate the interpretation of effect sizes. Heterogeneity was assessed using the I² statistic. In cases of statistical heterogeneity within outcome subgroups, we examined clients' age, intensity of therapy (number and frequency of therapy sessions), and treatment approach as possible sources of heterogeneity.

MAIN RESULTS

We included 10 studies (165 participants) that examined the short- and medium-term effect of music therapy interventions (one week to seven months) for children with ASD. Music was superior to 'placebo' therapy or standard care with respect to the primary outcomes social interaction within the therapy context (SMD 1.06, 95% CI 0.02 to 2.10, 1 RCT, n = 10); generalised social interaction outside of the therapy context (SMD 0.71, 95% CI 0.18 to 1.25, 3 RCTs, n = 57, moderate quality evidence), non-verbal communicative skills within the therapy context (SMD 0.57, 95% CI 0.29 to 0.85, 3 RCTs, n = 30), verbal communicative skills (SMD 0.33, 95% CI 0.16 to 0.49, 6 RCTs, n = 139), initiating behaviour (SMD 0.73, 95% CI 0.36 to 1.11, 3 RCTs, n = 22, moderate quality evidence), and social-emotional reciprocity (SMD 2.28, 95% CI 0.73 to 3.83, 1 RCT, n = 10, low quality evidence). There was no statistically significant difference in non-verbal communicative skills outside of the therapy context (SMD 0.48, 95% CI -0.02 to 0.98, 3 RCTs, n = 57, low quality evidence). Music therapy was also superior to 'placebo' therapy or standard care in secondary outcome areas, including social adaptation (SMD 0.41, 95% CI 0.21 to 0.60, 4 RCTs, n = 26), joy (SMD 0.96, 95% CI 0.04 to 1.88, 1 RCT, n = 10), and quality of parent-child relationships (SMD 0.82, 95% CI 0.13 to 1.52, 2 RCTs, n = 33, moderate quality evidence). None of the included studies reported any adverse effects. The small sample sizes of the studies limit the methodological strength of these findings.

AUTHORS' CONCLUSIONS

The findings of this updated review provide 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, verbal communication, initiating behaviour, and social-emotional reciprocity. Music therapy may also help to enhance non-verbal communication skills within the therapy context. 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. In contrast to the studies included in an earlier version of this review published in 2006, the new studies included in this update enhanced the applicability of findings to clinical practice. More research using larger samples and generalised outcome measures is needed to corroborate these findings and to examine whether the effects of music therapy are enduring. When applying the results of this review to practice, it is important to note that the application of music therapy requires specialised academic and clinical training.

How musical engagement promotes well-being in education contexts: the case of a young man with profound and multiple disabilities

Students with profound intellectual disabilities disorders (IDDs) have the right to participate in educational opportunities that recognize their unique resources and needs, as do all children. Because of their specific communication challenges, positive relationships with attentive communication partners are critical for success. In fact, the power of positive relationships in schools is recognized to be connected to student well-being more broadly. This article examines the case of one young man with profound IDD and his relationship with his music therapist using a duo-ethnographic informed paradigmatic case study. Video analysis based on multi-voice perspectives is used to generate hermeneutic phenomenological findings to closely examine the relationship between a young man with profound IDD and a music therapist. The voices of four allied health researchers were also gathered to inform the authors' construction of an informed commentary on the phenomenon. The results suggest that the essence lay in a combination of attentive, responsive and creative being with the other person over time. Four principles of musical engagement were identified in the video footage as critical to the meaningful relationships through music: the music therapist listens; the music therapist takes responsibility for structure; spontaneous initiation is sought from the young person; and the relationship is built over time. These concepts are contextualized within a discussion of student well-being that is underpinned by positive relationships and leads to students achieving their full potential within diverse school contexts.

Randomised controlled trial of improvisational music therapy's effectiveness for children with autism spectrum disorders (TIME-A): study protocol

Background

Previous research has suggested that music therapy may facilitate skills in areas typically affected by autism spectrum disorders such as social interaction and communication. However, generalisability of previous findings has been restricted, as studies were limited in either methodological accuracy or the clinical relevance of their approach. The aim of this study is to determine effects of improvisational music therapy on social communication skills of children with autism spectrum disorders. An additional aim of the study is to examine if variation in dose of treatment (i.e., number of music therapy sessions per week) affects outcome of therapy, and to determine cost-effectiveness.

Methods/Design

Children aged between 4;0 and 6;11 years who are diagnosed with autism spectrum disorder will be randomly assigned to one of three conditions. Parents of all participants will receive three sessions of parent counselling (at 0, 2, and 5 months). In addition, children randomised to the two intervention groups will be offered individual, improvisational music therapy over a period of five months, either one session (low-intensity) or three sessions (high-intensity) per week. Generalised effects of music therapy will be measured using standardised scales completed by blinded assessors (Autism Diagnostic Observation Schedule, ADOS) and parents (Social Responsiveness Scale, SRS) before and 2, 5, and 12 months after randomisation. Cost effectiveness will be calculated as man years. A group sequential design with first interim look at N = 235 will ensure both power and efficiency.

Discussion

Responding to the need for more rigorously designed trials examining the effectiveness of music therapy in autism spectrum disorders, this pragmatic trial sets out to generate findings that will be well generalisable to clinical practice. Addressing the issue of dose variation, this study's results will also provide information on the relevance of session frequency for therapy outcome.

Trial Registration

Current Controlled Trials ISRCTN78923965.

Predictors of change in music therapy with children and adolescents: the role of therapeutic techniques

Music therapy has been shown to be efficacious in experimental studies. However, there is little empirical research knowledge about what elements of music therapy influence its effectiveness in clinical practice. Children and adolescents with psychopathology (N=75) were assessed before and after participating in individual music therapy with 1 out of 15 music therapists in the Vienna region. Relationships between outcomes (as evaluated by parents) and therapy contents (as reported by therapists) were examined using general linear modelling. Results indicated that clients' symptoms and burdens on their social environment showed greater improvement when music therapy was limited to discipline-specific music therapy techniques and did not include other media such as play therapy elements. The findings indicate the importance of being aware of a therapy method's specific strengths and limitations. More research on the indicated specific ingredients of music therapy intervention is needed.