Effects of relational music therapy on communication of children with autism: a randomized controlled study

Using music to assist language learning in autistic children with minimal verbal language: The MAP feasibility RCT

LAY ABSTRACT

Research has shown that autistic individuals often have unusually good musical skills and that combining words and music helps autistic individuals to focus on spoken words. This study tests the idea that music will help with early language learning of preschool autistic children. The results show that when caregivers sing words to autistic children, the children pay more attention to the caregiver than when the words are spoken and that they learn word combinations more easily.

A systematic review of evidence-based interventions for child and adolescent mental health problems in low- and middle-income countries

BACKGROUND

Treatments for mental health problems in childhood and adolescence have advanced in the last 15 years. Despite advances in research, most of the evidence on effective interventions comes from high-income countries, while evidence is scarce in low- and middle-income countries (LMICs), where 90% of world's children and adolescents live. The aim of this review was to identify evidence-based interventions tested in LMICs to treat or prevent child and adolescent mental health problems.

METHODS

We conducted a systematic review of seven major electronic databases, from January 2007 to July 2019. We included randomised or non-randomised clinical trials that evaluated interventions for children or adolescents aged 6 to 18 years living in LMICs and who had, or were at risk of developing, one or more mental health problems. Results were grouped according to the studied conditions. Due to the heterogeneity of conditions, interventions and outcomes, we performed a narrative synthesis. The review was registered at PROSPERO under the number CRD42019129376.

FINDINGS

Of 127,466 references found through our search strategy, 107 studies were included in narrative synthesis after the eligibility verification processes. Nineteen different conditions and nine types of interventions were addressed by studies included in the review. Over 1/3 of studied interventions were superior to comparators, with psychoeducation and psychotherapy having the highest proportion of positive results. One-third of studies were classified as presenting low risk of bias.

INTERPRETATION

This review shows that different interventions have been effective in LMICs and have the potential to close the mental health care gap among children and adolescents in low-resource settings.

Art Interventions for Children With Autism Spectrum Disorder: A Scoping Review

IMPORTANCE

Autism spectrum disorder (ASD) is a neurological condition characterized by impairments in social interaction, communication, and behavior. Occupational therapy practitioners use creative arts interventions for children with ASD, but relevant evidence for these interventions is lacking.

OBJECTIVE

To provide occupational therapists evidence of the benefit of creative arts interventions for children with ASD by evaluating treatment efficacy and connecting the evidence with the Occupational Therapy Practice Framework: Domain and Process (4th ed.; OTPF-4).

DATA SOURCES

We searched peer-reviewed articles in six databases: CINAHL, Cochrane, PubMed, Ovid, PsycInfo, and Scopus. Eighteen articles published between 2000 and 2020 met Level 1b or 2b evidence criteria and were retrieved for full review; 15 were included in this scoping review.

STUDY SELECTION AND DATA COLLECTION

We used Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to extract data. Inclusion criteria were as follows: (1) Level 1b or 2b study; (2) quantitative data; (3) published in English; (4) population of children (ages <18 yr); (5) primary diagnosis of ASD; and (6) creative arts intervention in the forms of drawing, painting, or coloring; music; or theater.

FINDINGS

Creative arts interventions benefited children with ASD in two OTPF-4 areas (process and social interaction) pertaining to the Performance Skills domain and one OTPF-4 area (body functions) pertaining to the Client Factors domain. We found similar effects for group and individual intervention sessions, and significant improvements required multiple sessions.

CONCLUSIONS AND RELEVANCE

Our findings provide evidence for the efficacy of creative arts interventions to enhance occupation-based outcomes for children with ASD. What This Article Adds: Our findings support occupational therapy practitioners' use of creative arts interventions to improve OTPF-4-based client factors and process and social interaction skills for children with ASD.

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.

A Systematic Review of Scientific Studies on the Effects of Music in People with or at Risk for Autism Spectrum Disorder

The prevalence of autism spectrum disorders (ASD) is globally increasing, and the current available interventions show variable success. Thus, there is a growing interest in additional interventions such as music therapy (MT). Therefore, we aimed to provide a comprehensive and systematic review of music and people with, or at risk of, ASD. We used the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines and used PubMed, PsycINFO, and Web of Science as databases, with “music”, “music therapy”, “autism spectrum disorder”, and “ASD” as search terms. Among the identified and screened articles, 81 out of 621 qualified as scientific studies involving a total of 43,353 participants. These studies investigated the peculiarities of music perception in people with ASD, as well as the effects of music and MT in this patient group. Most of the music-based interventions were beneficial in improving social, emotional, and behavioural problems. However, the availability of studies utilizing a rigorous randomized controlled trial (RCT) design was scarce. Most of the studies had a small sample size, and the applied therapeutic and scientific research methods were heterogeneous.

Effectiveness of music therapy in children with autism spectrum disorder: A systematic review and meta-analysis

OBJECTIVES

This study was to investigated the efficacy of music therapy (MT) in children with autism spectrum disorder (ASD) via a meta-analysis that comprehensively evaluated data from all eligible research in this field.

DESIGN

Systematic review and meta-analysis.

SETTING

A systematic search of the PubMed, Embase, and Cochrane Library databases from inception to October 2021 to identify studies that administered MT to children with ASD.

RESULTS

Eight randomized controlled trials (RCTs) including 608 participants met the inclusion criteria. The meta-analysis showed that MT was associated with a significant increase in social reactions among children with ASD (standardized mean difference (SMD) = 0.24, 95% confidence interval (CI) [0.03, 0.46], I ² = 0%, P = 0.03). However, MT did not elicit a significant increase in symptom severity (SMD = 0.17, 95% CI [-0.04,0.38], I ² = 0%,P = 0.12), social adaptive behavior (SMD = 0.02, 95% CI [-0.44,0.48], I ² = 0%,P = 0.93) or speech (SMD = 0.04, 95% CI [-0.39, 0.47], I ² = 0%, P = 0.86) in children with ASD.

CONCLUSION

MT can improve social skills in children with ASD; however, there does not seem to be a consensus on the persistence of its effects. These findings can inform clinical practice. Promoting the use of MT in children with ASD and improving its symptoms are the ultimate goals.

Music therapy and Sanfilippo syndrome: an analysis of psychological and physiological variables of three case studies

Introduction

Mucopolysaccharidosis type III (MPS III) or Sanfilippo syndrome is a neurodegenerative disease caused by the accumulation of mucopolysaccharides in the body. As the symptoms are wide ranging, it is a challenge to provide a diagnosis and psychological treatment for affected children.

Method

The main objective of this study was to describe a form of music therapy treatment applied to three children diagnosed with MPS III. The psychological variables were evaluated by an ad hoc observation recording template, and the physiological variables were measured with a digital meter before and after each session. The perception of the parents was also considered through a semi-structured interview.

Results

An improvement in the psychological variables was shown in all cases. Changes in the physiological variables were also noted, although they varied according to each child. The parents report some benefit of music therapy and they share difficulty in assessing the extent of benefits of the music therapy.

Discussion

Findings indicate that music therapy can be a useful form of treatment with multiple benefits for children with conditions such as MPS III or similar conditions. However, further research is needed in this area and in the development of specific ways of evaluating music therapy.

Effects of Creative Movement Therapies on Social Communication, Behavioral-Affective, Sensorimotor, Cognitive, and Functional Participation Skills of Individuals With Autism Spectrum Disorder: A Systematic Review

Autism Spectrum Disorder (ASD) is a neurodevelopmental disorder affecting multiple developmental domains including social communication, behavioral-affective, sensorimotor, and cognitive systems. There is growing evidence for the use of holistic, whole-body, Creative Movement Therapies (CMT) such as music, dance, yoga, theater, and martial arts in addressing the multisystem impairments in ASD. We conducted a comprehensive quantitative and qualitative review of the evidence to date on the effects of CMT on multiple systems in individuals with ASD. The strongest evidence, both in terms of quantity and quality, exists for music and martial arts-based interventions followed by yoga and theater, with very limited research on dance-based approaches. Our review of 72 studies (N = 1,939 participants) across participants with ASD ranging from 3 to 65 years of age suggests that at present there is consistent evidence from high quality studies for small-to-large sized improvements in social communication skills following music and martial arts therapies and medium-to-large improvements in motor and cognitive skills following yoga and martial arts training, with insufficient evidence to date for gains in affective, sensory, and functional participation domains following CMT. Although promising, our review serves as a call for more rigorous high-quality research to assess the multisystem effects of CMT in ASD. Based on the existing literature, we discuss implications of our findings for autism researchers and also provide evidence-based guidelines for clinicians to incorporate CMT approaches in their plan of care for individuals with ASD.

Social Skills Instruments for Children with Autism Spectrum Disorder: A Critical Interpretive Synthesis

Identifying and critically analyzing the most frequently used social skills psychometric instruments (SSPI) for children with autism spectrum disorder (ASD) can inform future music therapy research and clinical practice. Therefore, the initial purpose of this critical interpretive synthesis was to identify the SSPI most frequently used as dependent measures in the Journal of Autism and Developmental Disorders (JADD) for children with ASD from 2012 to 2018. Results indicated that the Social Responsiveness Scale (n = 35), Autism Diagnostic Observation Schedule (n = 19), and Vineland Adaptive Behavior Scales (n = 15) were the most frequently used instruments. Congruent with critical interpretive synthesis methodology, we then identified the psychometric properties and advantages and disadvantages of the 9 most commonly used instruments. To compare these results with the existing music therapy literature, we also identified nonmusical SSPI used as dependent measures in music therapy research for children with ASD in studies published between 2012 and 2018. In comparing the data sets, music therapy researchers used 5 of the 9 SSPI we identified from our JADD review. Understanding frequently used SSPI has applications for consultation and communication with other professionals as well as how future music therapy research is conducted. Implications for clinical practice, limitations of the study, and suggestions for future research are provided.

Music Therapy for Children With Autistic Spectrum Disorder and/or Other Neurodevelopmental Disorders: A Systematic Review

Background: Several studies have reported contradictory results regarding the benefits of music interventions in children and adolescents with neurodevelopmental disorders (NDDs), including autism spectrum disorder (ASD). Methods: We performed a systematic review according to the PRISMA guidelines. We searched the Cochrane, PubMed and Medline databases from January 1970 to September 2020 to review all empirical findings, except case reports, measuring the effect of music therapy on youths with ASD, intellectual disability (ID), communication disorder (CD), developmental coordination disorder (DCD), specific learning disorder, and attention/deficit hyperactivity disorder (ADHD). Results: Thirty-nine studies (N = 1,774 participants) were included in this review (ASD: n = 22; ID: n = 7; CD and dyslexia: n = 5; DCD: n = 0; ADHD: n = 5 studies). Two main music therapies were used: educational music therapy and improvisational music therapy. A positive effect of educational music therapy on patients with ASD was reported in most controlled studies (6/7), particularly in terms of speech production. A positive effect of improvisational music therapy was reported in most controlled studies (6/8), particularly in terms of social functioning. The subgroup of patients with both ASD and ID had a higher response rate. Data are lacking for children with other NDDs, although preliminary evidence appears encouraging for educational music therapy in children with dyslexia. Discussion: Improvisational music therapy in children with NDDs appears relevant for individuals with both ASD and ID. More research should be encouraged to explore whether oral and written language skills may improve after educational music therapy, as preliminary data are encouraging.

A randomized controlled trial of 25 sessions comparing music therapy and music listening for children with autism spectrum disorder

BACKGROUND

Music therapy is based on the use of musical elements by a trained and qualified therapist. Clinical researches have suggested that children with Autism Spectrum Disorders (ASD) may benefit from MT. In this regard, this study examines if MT is more effective than simply listening to music for children with ASD.

METHOD

A 8-month RCT has been carried out comparing music therapy (MT) to music listening (ML) for children with ASD aged from 4 to 7 years old. Thirty-seven participants were randomly assigned to one of the two groups (MT vs. ML). The outcome measures were the Clinical Global Impression (CGI), the Childhood Autism Rating Scale (CARS) and the Aberrant Behavior Checklist (ABC) in each condition (MT and ML).

RESULTS

CGI scores decreased more for participants in the MT than in the ML condition. This clinical improvement was associated with an improvement of autistic symptoms on lethargy and stereotypy ABC subscales.

CONCLUSION

Our findings suggest that music therapy is more efficient than music listening for children with ASD. The present study thus supports the consideration of MT as a rightful add-on to ASD healthcare programs.

The role of technology-mediated music-making in enhancing engagement and social communication in children with autism and intellectual disabilities

Very little research has explored the impact of interventions combining music and technology on children with a dual diagnosis of autism and intellectual disabilities (ID) incorporating the active involvement of school staff. Video recordings and group interviews were used to collect data in this study. Video recordings of five children with autism and ID were conducted as they engaged with a technology-mediated music-making intervention over a period of 5 weeks. Additionally, five group interviews with classroom staff were carried out. This study is the first to explore the impact of a technology-mediated music-making intervention on the engagement levels and social communication skills of children with autism and ID at school. Some positive outcomes, especially regarding social communication skills, are reported, which are of significant value to educational researchers and school staff.

Music-Evoked Reward and Emotion: Relative Strengths and Response to Intervention of People With ASD

This review presents research findings showing that music is a unique domain to assess perception, reward, emotion, and associated physiological reactions and neural circuitry of people with autism spectrum disorder (ASD). There is growing evidence, reported in several studies in this review article, indicating that music is a relative strength of people with ASD including musical pitch perception, musical memory, and identification of music-evoked emotions. Listening to music activates neural circuits of reward and emotion response, which are described. Research presented shows adults with ASD also activate these systems when listening to music, although there may be developmental differences in the physiological and neural response to music in childhood and adolescence alongside typical behavioral response. Nonetheless, studies reviewed lend support to the use of music therapy and education for people with ASD, specifically to improve social skills and communication. Neural correlates of response to music therapy and education are also discussed. Taken together, findings reviewed provide evidence for music as a strength-based approach for ASD to assess reward and emotion response and as a powerful tool for intervention.

Revista Digital Internacional de Psicología y Ciencia Social | Volumen 5 | Número 1 | Enero-Junio 2019 | Los campos transdisciplinares de la psicología

Hablar de psicología y ciencia social es hablar de un amplio campo de aplicaciones de técnicasy conocimientos, así como el uso de distintas habilidades y recursos con un objetivo en común: ampliar el campo de conocimiento de los individuos y de la sociedad.Si bien se ha discutido mucho acerca de los términos que se refieren a este tipo de trabajo, para lograr este objetivo hoy existen varias disciplinas que se encargande investigar diversas problemáticas y temas de interés; sin embargo, aunque cada una de esas profesiones tiene sus principios para hacerlo, éstas pueden trabajar en conjunto con un interés en común; esta investigación es lo que conocemos como investigación transdisciplinaria, y no es sólo la investigación que se efectúa en conjunto respecto a una problemática en común.Este trabajo conjunto responde a las demandas que se presentan en la sociedad actual en que vivimos, donde se ha visto que en los últimos años se han reunido profesionales para investigar problemáticas desde distintos puntos de vista y que en algún punto ha surgido la necesidad de complementarse entre sí. Dicho trabajo corresponde también a la apertura que se ha tenido de otras profesiones de requerir ese trabajo con otros profesionales para explicar algunas problemáticas y que no sólo terminará enriqueciendo en conocimiento e investigaciones, sino en una experiencia profesional importante basada en comunicación, responsabilidades y ética.

Efecto de musicoterapia sobre la inteligencia y la interacción social en mujeres privadas de libertad con trastornos psiquiátricos

Existe poca evidencia científica de musicoterapia en población privada de su libertad; incluso no hay datos de alguna intervención en mujeres privadas de su libertad con trastornos psiquiátricos. El objetivo del presente estudio es analizar el efecto de la musicoterapia en el factor general de inteligencia y en la interacción social en mujeres sentenciadas con trastornos psiquiátricos. Se evaluó el factor general de inteligencia de 13 participantes antes y después de una intervención de musicoterapia. Se analizó la frecuencia de conductas prosociales y agresivas emitidas durante la intervención (34 sesiones). Se encontró que las participantes tuvieron una mejoría en el factor general de inteligencia antes ( = 18.15, D.E. = 12.09) y después ( = 21.15, D.E. = 12.43) de la intervención, pero los resultados no fueron estadísticamente significativas de acuerdo con la prueba t para muestras relacionadas (p = 0.167). Asimismo hubo un aumento en la frecuencia de conductas prosociales y un aumento en la frecuencia de conductas prosociales y una disminución de conductas agresivas durante las sesiones. En suma, la evidencia no es contundente en la mejora del factor general de inteligencia, pero facilita la interacción social al aumentar conductas prosociales y disminuir las agresivas. Se discuten las implicaciones del estudio para futuras investigaciones.

Long-term benefit of Microbiota Transfer Therapy on autism symptoms and gut microbiota

Many studies have reported abnormal gut microbiota in individuals with Autism Spectrum Disorders (ASD), suggesting a link between gut microbiome and autism-like behaviors. Modifying the gut microbiome is a potential route to improve gastrointestinal (GI) and behavioral symptoms in children with ASD, and fecal microbiota transplant could transform the dysbiotic gut microbiome toward a healthy one by delivering a large number of commensal microbes from a healthy donor. We previously performed an open-label trial of Microbiota Transfer Therapy (MTT) that combined antibiotics, a bowel cleanse, a stomach-acid suppressant, and fecal microbiota transplant, and observed significant improvements in GI symptoms, autism-related symptoms, and gut microbiota. Here, we report on a follow-up with the same 18 participants two years after treatment was completed. Notably, most improvements in GI symptoms were maintained, and autism-related symptoms improved even more after the end of treatment. Important changes in gut microbiota at the end of treatment remained at follow-up, including significant increases in bacterial diversity and relative abundances of Bifidobacteria and Prevotella. Our observations demonstrate the long-term safety and efficacy of MTT as a potential therapy to treat children with ASD who have GI problems, and warrant a double-blind, placebo-controlled trial in the future.

Systematic review and guide to management of core and psychiatric symptoms in youth with autism

OBJECTIVE

Evidence-based guidance of clinical decision-making for the management of Autism Spectrum Disorder (ASD) is lacking, particularly for co-occurring psychiatric symptoms. This review evaluates treatment evidence for six common symptom targets in children/adolescents with ASD and provides a resource to facilitate application of the evidence to clinical practice.

METHOD

A systematic search identified randomized controlled trials (RCTs) and high-quality systematic reviews published between 2007 and 2016, focused on: social interaction/communication impairment, stereotypic/repetitive behaviours, irritability/agitation, attention-deficit/hyperactivity disorder symptoms, mood or anxiety symptoms, and sleep difficulties. We then completed qualitative evaluation of high-quality systematic reviews/meta-analyses and quantitative evaluation of recently published RCTs not covered by prior comprehensive systematic reviews.

RESULTS

Recently published RCTs focused on social interaction and communication impairment (trials = 32) using psychosocial interventions. Interventions for irritability/agitation (trials = 16) were mainly pharmacological. Few RCTs focused on other symptom targets (trials = 2-5/target). Integration of these results with our qualitative review indicated that few established treatment modalities exist, and available evidence is limited by small studies with high risk of bias.

CONCLUSION

Given the current evidence-base, treatment targets must be clearly defined, and a systematic approach to intervention trials in children/adolescents with ASD must be undertaken with careful consideration of the limitations of safety/efficacy data.

International multicentre randomised controlled trial of improvisational music therapy for children with autism spectrum disorder: TIME-A study

BACKGROUND

Preliminary studies have indicated that music therapy may benefit children with autism spectrum disorders (ASD).

OBJECTIVES

To examine the effects of improvisational music therapy (IMT) on social affect and responsiveness of children with ASD.

DESIGN

International, multicentre, three-arm, single-masked randomised controlled trial, including a National Institute for Health Research (NIHR)-funded centre that recruited in London and the east of England. Randomisation was via a remote service using permuted blocks, stratified by study site.

SETTING

Schools and private, voluntary and state-funded health-care services.

PARTICIPANTS

Children aged between 4 and 7 years with a confirmed diagnosis of ASD and a parent or guardian who provided written informed consent. We excluded children with serious sensory disorder and those who had received music therapy within the past 12 months.

INTERVENTIONS

All parents and children received enhanced standard care (ESC), which involved three 60-minute sessions of advice and support in addition to treatment as usual. In addition, they were randomised to either one (low-frequency) or three (high-frequency) sessions of IMT per week, or to ESC alone, over 5 months in a ratio of 1 : 1 : 2.

MAIN OUTCOME MEASURES

The primary outcome was measured using the social affect score derived from the Autism Diagnostic Observation Schedule (ADOS) at 5 months: higher scores indicated greater impairment. Secondary outcomes included social affect at 12 months and parent-rated social responsiveness at 5 and 12 months (higher scores indicated greater impairment).

RESULTS

A total of 364 participants were randomised between 2011 and 2015. A total of 182 children were allocated to IMT (90 to high-frequency sessions and 92 to low-frequency sessions), and 182 were allocated to ESC alone. A total of 314 (86.3%) of the total sample were followed up at 5 months [165 (90.7%) in the intervention group and 149 (81.9%) in the control group]. Among those randomised to IMT, 171 (94.0%) received it. From baseline to 5 months, mean scores of ADOS social affect decreased from 14.1 to 13.3 in music therapy and from 13.5 to 12.4 in standard care [mean difference: music therapy vs. standard care = 0.06, 95% confidence interval (CI) -0.70 to 0.81], with no significant difference in improvement. There were also no differences in the parent-rated social responsiveness score, which decreased from 96.0 to 89.2 in the music therapy group and from 96.1 to 93.3 in the standard care group over this period (mean difference: music therapy vs. standard care = -3.32, 95% CI -7.56 to 0.91). There were seven admissions to hospital that were unrelated to the study interventions in the two IMT arms compared with 10 unrelated admissions in the ESC group.

CONCLUSIONS

Adding IMT to the treatment received by children with ASD did not improve social affect or parent-assessed social responsiveness.

FUTURE WORK

Other methods for delivering music-focused interventions for children with ASD should be explored.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN78923965.

FUNDING

This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 21, No. 59. See the NIHR Journals Library website for further project information.

Interventions Targeting Sensory Challenges in Autism Spectrum Disorder: A Systematic Review

CONTEXT

Sensory challenges are common among children with autism spectrum disorder (ASD).

OBJECTIVE

To evaluate the effectiveness and safety of interventions targeting sensory challenges in ASD.

DATA SOURCES

Databases, including Medline and PsycINFO.

STUDY SELECTION

Two investigators independently screened studies against predetermined criteria.

DATA EXTRACTION

One investigator extracted data with review by a second. Investigators independently assessed risk of bias and strength of evidence (SOE), or confidence in the estimate of effects.

RESULTS

Twenty-four studies, including 20 randomized controlled trials (RCTs), were included. Only 3 studies had low risk of bias. Populations, interventions, and outcomes varied. Limited, short-term studies reported potential positive effects of several approaches in discrete skill domains. Specifically, sensory integration-based approaches improved sensory and motor skills-related measures (low SOE). Environmental enrichment improved nonverbal cognitive skills (low SOE). Studies of auditory integration-based approaches did not improve language (low SOE). Massage improved symptom severity and sensory challenges in studies with likely overlapping participants (low SOE). Music therapy studies evaluated different protocols and outcomes, precluding synthesis (insufficient SOE). Some positive effects were reported for other approaches, but findings were inconsistent (insufficient SOE).

LIMITATIONS

Studies were small and short-term, and few fully categorized populations.

CONCLUSIONS

Some interventions may yield modest short-term (<6 months) improvements in sensory- and ASD symptom severity-related outcomes; the evidence base is small, and the durability of the effects is unclear. Although some therapies may hold promise, substantial needs exist for continuing improvements in methodologic rigor.

A systematic review of pragmatic language interventions for children with autism spectrum disorder

There is a need for evidence based interventions for children with autism spectrum disorder (ASD) to limit the life-long, psychosocial impact of pragmatic language impairments. This systematic review identified 22 studies reporting on 20 pragmatic language interventions for children with ASD aged 0-18 years. The characteristics of each study, components of the interventions, and the methodological quality of each study were reviewed. Meta-analysis was conducted to assess the effectiveness of 15 interventions. Results revealed some promising approaches, indicating that active inclusion of the child and parent in the intervention was a significant mediator of intervention effect. Participant age, therapy setting or modality were not significant mediators between the interventions and measures of pragmatic language. The long-term effects of these interventions and the generalisation of learning to new contexts is largely unknown. Implications for clinical practice and directions for future research are discussed.

The effects of embodied rhythm and robotic interventions on the spontaneous and responsive verbal communication skills of children with Autism Spectrum Disorder (ASD): A further outcome of a pilot randomized controlled trial

The current manuscript is the second in a mini-series of manuscripts reporting the effects of alternative, movement-based, rhythm and robotic interventions on the social communication skills of 36 school-age children with ASD. This pilot randomized controlled trial compared the effects of 8-weeks of rhythm and robotic interventions to those of a standard-of-care, comparison intervention. The first manuscript reported intervention effects on the spontaneous and responsive social attention skills of children. In this manuscript, we report intervention effects on the spontaneous and responsive verbal communication skills of children. Communication skills were assessed within a standardized test of responsive communication during the pretest and posttest as well as using training-specific measures of social verbalization during early, mid, and late training sessions. The rhythm and comparison groups improved on the standardized test in the posttest compared to the pretest. The rhythm and robot groups increased levels of social verbalization across training sessions. Movement-based and stationary contexts afforded different types and amounts of communication in children with ASD. Overall, movement-based interventions are a promising tool to enhance verbal and non-verbal communication skills in children with ASD.

Complementary and Alternative Therapies for Autism Spectrum Disorder

Background. Complementary and alternative medicine (CAM) represents a popular therapeutic option for patients with autism spectrum disorder (ASD). Unfortunately, there is a paucity of data regarding the efficacy of CAM in ASD. The aim of the present systematic review is to investigate trials of CAM in ASD. Material and Methods. We searched the following databases: MEDLINE, EMBASE, Cochrane Database of Systematic Reviews, CINAHL, Psychology and Behavioral Sciences Collection, Agricola, and Food Science Source. Results. Our literature search identified 2687 clinical publications. After the title/abstract screening, 139 publications were obtained for detailed evaluation. After detailed evaluation 67 studies were included, from hand search of references we retrieved 13 additional studies for a total of 80. Conclusion. There is no conclusive evidence supporting the efficacy of CAM therapies in ASD. Promising results are reported for music therapy, sensory integration therapy, acupuncture, and massage.

Music therapy for prisoners: pilot randomised controlled trial and implications for evaluating psychosocial interventions

Mental health problems are common among prison inmates. Music therapy has been shown to reduce mental health problems. It may also be beneficial in the rehabilitation of prisoners, but rigorous outcome research is lacking. We compared group music therapy with standard care for prisoners in a pilot randomised controlled trial that started with the establishment of music therapy services in a prison near Bergen in 2008. In all, 113 prisoners agreed to participate. Anxiety (STAI-State [State-Trait Anxiety Inventory], STAI-Trait), depression (HADS-D [Hospital Anxiety and Depression Scale]), and social relationships (Quality of Life Enjoyment and Satisfaction Questionnaire [Q-LES-Q]) were assessed at baseline; every 2 weeks in the experimental group; after 1, 3, and 6 months in the control group; and at release. No restrictions were placed on the frequency, duration, or contents of music therapy. Duration of stay in the institution was short (62% stayed less than 1 month). Only a minority reached clinical cutoffs for anxiety and depression at baseline. Between-group analyses of effects were not possible. Music therapy was well accepted and attractive among the prisoners. Post hoc analysis of within-group changes suggested a reduction of state anxiety after 2 weeks of music therapy (d = 0.33, p = .025). Short sentences and low baseline levels of psychological disturbance impeded the examination of effects in this study. Recommendations for planning future studies are given, concerning the careful choice of participants, interventions and settings, comparison condition and design aspects, choice of outcomes, and integration of research approaches. Thus, the present study has important implications for future studies evaluating interventions for improving prisoners' mental health.

TRIAL REGISTRATION

ISRCTN22518605.

Family-centred music therapy to promote social engagement in young children with severe autism spectrum disorder: a randomized controlled study

BACKGROUND

Limited capacity for social engagement is a core feature of autism spectrum disorder (ASD), often evident early in the child's development. While these skills are difficult to train, there is some evidence that active involvement in music-making provides unique opportunities for social interaction between participants. Family-centred music therapy (FCMT) endeavours to support social engagement between child and parent within active music-making, yet the extent of benefits provided is unknown.

AIM

This study investigated the impacts of FCMT on social engagement abilities.

METHODS

Twenty-three children (36-60 months) with severe ASD received either 16 weeks of FCMT in addition to their early intervention programmes (n = 12), or their early intervention programme only (n = 11). Change in social engagement was measured with standardized parent-report assessments, parent interviews and clinician observation.

RESULTS

Intention-to-treat analysis for the Vineland Social Emotional Early Childhood Scale indicated a significant effect in favour of FCMT. Thematic qualitative analysis of the parent interviews showed that the parent-child relationship grew stronger.

CONCLUSION

FCMT improves social interactions in the home and community and the parent-child relationship, but not language skills or general social responsiveness. This study provides preliminary support for the use of FCMT to promote social engagement in children with severe ASD.

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.

Interventions based on the Theory of Mind cognitive model for autism spectrum disorder (ASD)

BACKGROUND

The 'Theory of Mind' (ToM) model suggests that people with autism spectrum disorder (ASD) have a profound difficulty understanding the minds of other people - their emotions, feelings, beliefs, and thoughts. As an explanation for some of the characteristic social and communication behaviours of people with ASD, this model has had a significant influence on research and practice. It implies that successful interventions to teach ToM could, in turn, have far-reaching effects on behaviours and outcome.

OBJECTIVES

To review the efficacy of interventions based on the ToM model for individuals with ASD.

SEARCH METHODS

In August 2013 we searched CENTRAL, Ovid MEDLINE, Embase, CINAHL, PsycINFO, ERIC, Social Services Abstracts, AutismData, and two trials registers. We also searched the reference lists of relevant papers, contacted authors who work in this field, and handsearched a number of journals.

SELECTION CRITERIA

Review studies were selected on the basis that they reported on an applicable intervention (linked to ToM in one of four clearly-defined ways), presented new randomised controlled trial data, and participants had a confirmed diagnosis of an autism spectrum disorder. Studies were selected by two review authors independently and a third author arbitrated when necessary.

DATA COLLECTION AND ANALYSIS

Risk of bias was evaluated and data were extracted by two review authors independently; a third author arbitrated when necessary. Most studies were not eligible for meta-analysis, the principal reason being mis-matching methodologies and outcome measures. Three small meta-analyses were carried out.

MAIN RESULTS

Twenty-two randomised trials were included in the review (N = 695). Studies were highly variable in their country of origin, sample size, participant age, intervention delivery type, and outcome measures. Risk of bias was variable across categories. There were very few studies for which there was adequate blinding of participants and personnel, and some were also judged at high risk of bias in blinding of outcome assessors. There was also evidence of some bias in sequence generation and allocation concealment. Not all studies reported data that fell within the pre-defined primary outcome categories for the review, instead many studies reported measures which were intervention-specific (e.g. emotion recognition). The wide range of measures used within each outcome category and the mixed results from these measures introduced further complexity when interpreting results.Studies were grouped into four main categories according to intervention target/primary outcome measure. These were: emotion recognition studies, joint attention and social communication studies, imitation studies, and studies teaching ToM itself. Within the first two of these categories, a sub-set of studies were deemed suitable for meta-analysis for a limited number of key outcomes.There was very low quality evidence of a positive effect on measures of communication based on individual results from three studies. There was low quality evidence from 11 studies reporting mixed results of interventions on measures of social interaction, very low quality evidence from four studies reporting mixed results on measures of general communication, and very low quality evidence from four studies reporting mixed results on measures of ToM ability.  The meta-analysis results we were able to generate showed that interventions targeting emotion recognition across age groups and working with people within the average range of intellectual ability had a positive effect on the target skill, measured by a test using photographs of faces (mean increase of 0.75 points, 95% confidence interval (CI) 0.22 to 1.29 points, Z = 2.75, P < 0.006, four studies, N = 105). Therapist-led joint attention interventions can promote production of more joint attention behaviours within adult-child interaction (mean increase of 0.55 points, 95% CI 0.11 to 0.99 points, Z = 2.45, P value = 0.01, two studies, N = 88). Further analysis undermines this conclusion somewhat by demonstrating that there was no clear evidence that intervention can have an effect on joint attention initiations as measured using a standardised assessment tool (mean increase of 0.23 points, 95% CI -0.48 to 0.94 points, Z = 0.63, P value = 0.53, three studies, N = 92). No adverse effects were apparent.

AUTHORS' CONCLUSIONS

While there is some evidence that ToM, or a precursor skill, can be taught to people with ASD, there is little evidence of maintenance of that skill, generalisation to other settings, or developmental effects on related skills. Furthermore, inconsistency in findings and measurement means that evidence has been graded of 'very low' or 'low' quality and we cannot be confident that suggestions of positive effects will be sustained as high-quality evidence accumulates. Further longitudinal designs and larger samples are needed to help elucidate both the efficacy of ToM-linked interventions and the explanatory value of the ToM model itself. It is possible that the continuing refinement of the ToM model will lead to better interventions which have a greater impact on development than those investigated to date.

Individual music therapy for mental health care clients with low therapy motivation: multicentre randomised controlled trial

BACKGROUND

Music therapy (MT) has been shown to be efficacious for mental health care clients with various disorders such as schizophrenia, depression and substance abuse. Referral to MT in clinical practice is often based on other factors than diagnosis. We aimed to examine the effectiveness of resource-oriented MT for mental health care clients with low motivation for other therapies.

METHOD

This was a pragmatic parallel trial. In specialised centres in Norway, Austria and Australia, 144 adults with non-organic mental disorders and low therapy motivation were randomised to 3 months of biweekly individual, resource-oriented MT plus treatment as usual (TAU) or TAU alone. TAU was typically intensive (71% were inpatients) and included the best combination of therapies available for each participant, excluding MT. Blinded assessments of the Scale for the Assessment of Negative Symptoms (SANS) and 15 secondary outcomes were collected before randomisation and after 1, 3 and 9 months. Changes were analysed on an intention-to-treat basis using generalised estimating equations in longitudinal linear models, controlling for diagnosis, site and time point.

RESULTS

MT was superior to TAU for total negative symptoms (SANS, d = 0.54, p < 0.001) as well as functioning, clinical global impressions, social avoidance through music, and vitality (all p < 0.01).

CONCLUSION

Individual MT as conducted in routine practice is an effective addition to usual care for mental health care clients with low motivation.

Validity and reliability of electroencephalographic frontal alpha asymmetry and frontal midline theta as biomarkers for depression

Electroencephalographic (EEG) frontal alpha asymmetry (FAA) and frontal midline (FM) theta have been suggested as biomarkers for depression and anxiety, but have mostly been assessed in small and non-clinical studies. In a clinical sample of 79 adults with depression (ICD-10: F32), resting EEG and scales of depression (MADRS) and anxiety (HADS-A) were measured at intake and after 3 months. FAA and FM theta values were referenced to a normative population database. Internal consistency, test-retest reliability, and correlations with psychiatric tests were examined. Reliability was sufficient. However, FAA and FM theta values were close to the general population, and correlations with psychiatric tests were mostly small and non-significant, with the exception of FAA on F7-F8 z-scores and HADS-A. We conclude that the validity of FAA and FM theta and therefore their potential as biomarkers for depression and anxiety remain unclear.

Shifting effects in randomised controlled trials of complex interventions: a new kind of performance bias?

OBJECTIVE

Randomised controlled trials (RCTs) aim to provide unbiased estimates of treatment effects. However, the process of implementing trial procedures may have an impact on the performance of complex interventions that rely strongly on the intuition and confidence of therapists. We aimed to examine whether shifting effects over the recruitment period can be observed that might indicate such impact.

METHOD

Three RCTs investigating music therapy vs. standard care were included. The intervention was performed by experienced therapists and based on established methods. We examined outcomes of participants graphically, analysed cumulative effects and tested for differences between first vs. later participants. We tested for potential confounding population shifts through multiple regression models.

RESULTS

Cumulative differences suggested trends over the recruitment period. Effect sizes tended to be less favourable among the first participants than later participants. In one study, effects even changed direction. Age, gender and baseline severity did not account for these shifting effects.

CONCLUSION

Some trials of complex interventions have shifting effects over the recruitment period that cannot be explained by therapist experience or shifting demographics. Replication and further research should aim to find out which interventions and trial designs are most vulnerable to this new kind of performance bias.

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.