The effectiveness of music therapy in improving behavioral symptoms among children with autism spectrum disorders: a systematic review and meta-analysis

Objectives

This comprehensive review and meta-analysis aimed to thoroughly identify the effectiveness of music therapy (MT) in improving behavioral symptoms in children with autism spectrum disorders (ASD) by analyzing the data from all relevant randomized controlled trials (RCTs) related to this field.

Methods

From inception until September 18, 2024, PubMed, Web of Science, the Cochrane Library, SinoMed, and Embase were searched. Two reviewers extracted the data separately, and any controversies between the authors' assessments were resolved by conversation or speaking with another author. The behavioral symptoms scale score before and after the intervention was taken from the included trials and used to reflect the therapeutic effect of music therapy in children with autism.

Results

2607 records across all retrieved databases were discovered, thirteen of which were included in a meta-analysis with 1160 participants. According to the meta-analysis, children with autism showed a substantial improvement in their behavior symptoms when receiving music treatment (standardized mean difference [SMD] = -0.66, 95% confidence interval [CI]: -0.93 to -0.39, p < 0.001). With I 2 = 78% and P < 0.001, we did discover a medium level of heterogeneity among the included studies.

Conclusions

MT has a positive impact on improving behavioral symptoms in children with autism. However, given the significant heterogeneity and limitations in this study, RCTs with rigorous methodological quality are still required to confirm the curative benefits of MT in autistic children precisely.

Systematic review registration

https://www.crd.york.ac.uk/PROSPERO/, identifier CRD42024597939.

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.

Study protocol of a randomized control trial on the effectiveness of improvisational music therapy for autistic children

BACKGROUND

Music therapy is the clinical use of musical interventions to improve mental and physical health across multiple domains, including social communication. Autistic children, who have difficulties in social communication and often increased anxiety, tend to show a strong preference for music, because it can be structured and systematic, and therefore more predictable than social interaction. This makes music therapy a promising medium for therapeutic support and intervention. Previous clinical trials of music therapy compared to traditional therapy for autistic children have shown encouraging but nevertheless mixed results.

KEY AIMS

The primary aim is to conduct a randomised controlled trial (RCT) of improvisational music therapy for autistic children and test its effectiveness in at improving social communication and wellbeing, and to reduce anxiety.

RESEARCH PLAN

The RCT will be conducted with 200 autistic children in the UK aged 7 to 11 years old. Participants will be randomly assigned to either improvisational music therapy or support as usual. The trial will be an assessor-blind, pragmatic two-arm cluster RCT comparing the impact of 12-weeks of improvisational music therapy in addition to support as usual, vs. support as usual for autistic children.

METHODS

Researchers who are blind to which arm the children are in will conduct assessments and obtain data via caregiver reports. The primary outcome will be the absolute change in the total score of the Brief Observation of Social Communication Change (BOSCC) assessed at baseline, T1 (13 weeks) and T2 (39 weeks) follow-ups. The BOSCC consists of specific items that were developed to identify changes in social-communication behaviours. Secondary outcome measures include: (1) Parent reported anxiety scale for youth with ASD (Note that we do not use the term 'ASD' or Autism Spectrum Disorder, because many autistic people feel it is stigmatising. Instead, we use the term 'autism') (PRAS-ASD) (2) Young Child Outcome Rating Scale, for wellbeing (YCORS), (3) Strengths and Difficulties Questionnaire (SDQ); and (4) Vineland Adaptive Behaviour Scale (VABS). (5) The Children's Communication Checklist-2 (CCC-2) will be completed to evaluate pragmatic speech with fluent speakers only; (6) The Music Engagement Scale (MES); and (7) Assessment of the Quality of Relationship (AQR) will be used to evaluate the child-therapist relationships using video-analysis of music therapy sessions. Additional data will be collected by administering the Wechsler Abbreviated Scale of Intelligence (WASI-II), Music at Home Questionnaire (M@H), and children's versions of the Empathy Quotient (EQ) and Systemizing Quotient (SQ). Audio and video data from the therapy sessions will be collected and analysed (using both human and computer-based feature-coding, e.g., machine learning and AI-driven methods) to identify how music and non-musical interactions foster change throughout the therapy.

DISCUSSION

This study aims to observe if the interactions, engagement, and therapeutic modalities fostered during music therapy sessions can translate to non-musical contexts and improve autistic children's social communication skills, identifying possible mediating factors contributing to the effectiveness of music therapy, potentially informing policy making and governance.

TRIAL REGISTRATION

This randomised control trial is registered with the NIH U.S. National Library of Medicine:  https://clinicaltrials.gov/search?term=NCT06016621 , clinicalTrials.gov Identifier: NCT0601662, Registration Date 19th August 2023.

A handbook for Rhythmic Relating in autism: supporting social timing in play, learning and therapy

We present a handbook for Rhythmic Relating, an approach developed to support play, learning and therapy with young autistic children, unconventional communicators, and autistic people who have additional learning needs. Rhythmic Relating is based on the Movement Sensing perspective, a growing body of research that recognizes that autistic social difficulties stem from more basic sensory and motor differences. These sensorimotor differences directly affect embodied experience and social timing in communication. The Rhythmic Relating approach acknowledges that autistic/non-autistic interactive mismatch goes both ways and offers bidirectional support for social timing and expressive action in play. This handbook is presented in an accessible fashion, allowing the reader to develop at their own pace through three skill-levels and encouraging time out to practice. We begin with the basics of building rapport (seeing, copying, and celebrating interactional behaviors), introduce the basic foundations of sensory stability, and then move on to developing reciprocal play (using mirroring, matching, looping, and "Yes…and" techniques), and further to understanding sensory impetus (using sensory contours, accents and flows) and its potential in support of social timing. Rhythmic Relating is offered in support of each practitioner's creative practice and personal sense of fun and humor in play. The model is offered as a foundation for interaction and learning, as a base practice in schools, for Occupational Therapists, Speech Therapists and Physiotherapists, and can also provide a basis for tailoring creative arts therapies when working with autistic clients.

Treatment fidelity in a pragmatic clinical trial of music therapy for premature infants and their parents: the LongSTEP study

BACKGROUND

Treatment fidelity (TF) refers to methodological strategies used to monitor and enhance the reliability and validity of interventions. We evaluated TF in a pragmatic RCT of music therapy (MT) for premature infants and their parents.

METHODS

Two hundred thirteen families from seven neonatal intensive care units (NICUs) were randomized to receive standard care, or standard care plus MT during hospitalization, and/or during a 6-month period post-discharge. Eleven music therapists delivered the intervention. Audio and video recordings from sessions representing approximately 10% of each therapists' participants were evaluated by two external raters and the corresponding therapist using TF questionnaires designed for the study (treatment delivery (TD)). Parents evaluated their experience with MT at the 6-month assessment with a corresponding questionnaire (treatment receipt (TR)). All items as well as composite scores (mean scores across items) were Likert scales from 0 (completely disagree) to 6 (completely agree). A threshold for satisfactory TF scores (≥4) was used in the additional analysis of dichotomized items.

RESULTS

Internal consistency evaluated with Cronbach's alpha was good for all TF questionnaires (α ≥ 0.70), except the external rater NICU questionnaire where it was slightly lower (α 0.66). Interrater reliability measured by intraclass correlation coefficient (ICC) was moderate (NICU 0.43 (CI 0.27, 0.58), post-discharge 0.57 (CI 0.39, 0.73)). Gwet's AC for the dichotomized items varied between 0.32 (CI 0.10, 0.54) and 0.72 (CI 0.55, 0.89). Seventy-two NICU and 40 follow-up sessions with 39 participants were evaluated. Therapists' mean (SD) TD composite score was 4.88 (0.92) in the NICU phase and 4.95 (1.05) in the post-discharge phase. TR was evaluated by 138 parents. The mean (SD) score across intervention conditions was 5.66 (0.50).

CONCLUSIONS

TF questionnaires developed to assess MT in neonatal care showed good internal consistency and moderate interrater reliability. TF scores indicated that therapists across countries successfully implemented MT in accordance with the protocol. The high treatment receipt scores indicate that parents received the intervention as intended. Future research in this area should aim to improve the interrater reliability of TF measures by additional training of raters and improved operational definitions of items.

TRIAL REGISTRATION

Longitudinal Study of music Therapy's Effectiveness for Premature infants and their caregivers - "LongSTEP".

CLINICALTRIALS

gov Identifier: NCT03564184. Registered on June 20, 2018.

Music, families and interaction (MUFASA): a protocol article for an RCT study

Background

General mental health and interpersonal skills of families are crucial to children's development and future. Research suggests a link between participation in music activities and individuals' own sense of mental health, as well as an effect in objective measures of health such as quality of life, social skills, and rehabilitation of various kinds. However, in Denmark there are not many services for families with school-aged children (7–12 years) that focus on prevention and strengthening family interaction hereby minimising the risk of children not thriving and developing optimally in terms of social and emotional skills and competences. The purpose of this study is to investigate the effect of shared music activities on family interaction, parental stress, and child well-being.

Methods

The study is a controlled effect study where 40 family dyads from Aalborg and Aarhus are randomized into 4 different groups including music therapy activities, community music, family concerts and a control group. Measurements of family interaction (Assessment of Parent Child Interaction, APCI) and mental health (Parental Stress Scale, PSS, and the Strengths and Difficulties Questionnaire, SDQ) will be made at baseline/pre intervention, at post intervention and a follow-up measurement 12 month after baseline (month 1, 3 and 12) 3 times in total. Furthermore, data about the family dyad’s regular participation in music events as part of every-day life at the same measure points (month 1, 3 and 12). Since this is a planned prospective study, results are not yet available, but clinical experience from a feasibility study in 2021 were promising and expected challenges and changes are discussed in the article.

Discussion

Findings of this study will be relevant for all fields where music is applied for families, such as education, mental health, social work and for basic research on the study of music and interaction. Music used as a resource for families is crucial in understanding how different modalities can influence the family interaction including emotional communication and attachment.

Trial registration: ISRCTN, ISRCTN17290015, Registered 03 March 2022, https://www.isrctn.com/ISRCTN17290015

Date and protocol version

July 2022, version 1. Protocol is planned to be updated after finalized recruitment during second data collection point and again after the third and last data collection point (see Additional file 1: SPIRIT Checklist).

Rhythmic Relating: Bidirectional Support for Social Timing in Autism Therapies

We propose Rhythmic Relating for autism: a system of supports for friends, therapists, parents, and educators; a system which aims to augment bidirectional communication and complement existing therapeutic approaches. We begin by summarizing the developmental significance of social timing and the social-motor-synchrony challenges observed in early autism. Meta-analyses conclude the early primacy of such challenges, yet cite the lack of focused therapies. We identify core relational parameters in support of social-motor-synchrony and systematize these using the communicative musicality constructs: pulse; quality; and narrative. Rhythmic Relating aims to augment the clarity, contiguity, and pulse-beat of spontaneous behavior by recruiting rhythmic supports (cues, accents, turbulence) and relatable vitality; facilitating the predictive flow and just-ahead-in-time planning needed for good-enough social timing. From here, we describe possibilities for playful therapeutic interaction, small-step co-regulation, and layered sensorimotor integration. Lastly, we include several clinical case examples demonstrating the use of Rhythmic Relating within four different therapeutic approaches (Dance Movement Therapy, Improvisational Music Therapy, Play Therapy, and Musical Interaction Therapy). These clinical case examples are introduced here and several more are included in the Supplementary Material (Examples of Rhythmic Relating in Practice). A suite of pilot intervention studies is proposed to assess the efficacy of combining Rhythmic Relating with different therapeutic approaches in playful work with individuals with autism. Further experimental hypotheses are outlined, designed to clarify the significance of certain key features of the Rhythmic Relating approach.

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.

The State of Music Therapy Studies in the Past 20 Years: A Bibliometric Analysis

Purpose: Music therapy is increasingly being used to address physical, emotional, cognitive, and social needs of individuals. However, publications on the global trends of music therapy using bibliometric analysis are rare. The study aimed to use the CiteSpace software to provide global scientific research about music therapy from 2000 to 2019.

Methods: Publications between 2000 and 2019 related to music therapy were searched from the Web of Science (WoS) database. The CiteSpace V software was used to perform co-citation analysis about authors, and visualize the collaborations between countries or regions into a network map. Linear regression was applied to analyze the overall publication trend.

Results: In this study, a total of 1,004 studies met the inclusion criteria. These works were written by 2,531 authors from 1,219 institutions. The results revealed that music therapy publications had significant growth over time because the linear regression results revealed that the percentages had a notable increase from 2000 to 2019 (t = 14.621, P < 0.001). The United States had the largest number of published studies (362 publications), along with the following outputs: citations on WoS (5,752), citations per study (15.89), and a high H-index value (37). The three keywords “efficacy,” “health,” and “older adults,” emphasized the research trends in terms of the strongest citation bursts.

Conclusions: The overall trend in music therapy is positive. The findings provide useful information for music therapy researchers to identify new directions related to collaborators, popular issues, and research frontiers. The development prospects of music therapy could be expected, and future scholars could pay attention to the clinical significance of music therapy to improve the quality of life of people.

Joint engagement and movement: Active ingredients of a music-based intervention with school-age children with autism

BACKGROUND

The effectiveness of music-based interventions (MI) in autism has been attested for decades. Yet, there has been little empirical investigation of the active ingredients, or processes involved in music-based interventions that differentiate them from other approaches.

OBJECTIVES

Here, we examined whether two processes, joint engagement and movement, which have previously been studied in isolation, contribute as important active ingredients for the efficacy of music-based interventions.

METHODS

In two separate analyses, we investigated whether (1) joint engagement with the therapist, measured using a coding scheme verified for reliability, and (2) movement elicited by music-making, measured using a computer-vision technique for quantifying motion, may drive the benefits previously observed in response to MI (but not a controlled non-MI) in children with autism.

RESULTS

Compared to a non-music control intervention, children and the therapist in MI spent more time in triadic engagement (between child, therapist, and activity) and produced greater movement, with amplitude of motion closely linked to the type of musical instrument.

CONCLUSIONS

Taken together, these findings provide initial evidence of the active ingredients of music-based interventions in autism.

Attunement in Music Therapy for Young Children with Autism: Revisiting Qualities of Relationship as Mechanisms of Change

This study examined whether musical and emotional attunement predicts changes in improvisational music therapy with children with autism (4–7 years, N = 101, majority: no/limited speech, low IQ), assessed over 12 months. Attunement, as observed from session videos, and changes in generalized social skills, judged by blinded assessors and parents, were evaluated using standardized tools (Assessment of the Quality of Relationship, Improvisational Music Therapy Principles, ADOS, SRS). In contrast to the smaller pilot, we did not find significant effects between attunement and changes in outcomes, only tendencies in the same direction are observed. Findings suggest that symptom severity is associated with the therapist’s ability to attune to the child. They further raise questions concerning outcome selection and user involvement.

Music Therapists' Perceptions of the Therapeutic Potentials Using Music When Working With Verbal Children on the Autism Spectrum: A Qualitative Analysis

While there are numerous descriptions of the use of music and its therapeutic potential by music therapists working with nonverbal children on the autism spectrum, only limited literature focuses on exploring how music therapists use music and perceive its therapeutic potential when working with children on the spectrum who have verbal skills. This qualitative study aimed to explore music therapists' descriptions of the use of music and its therapeutic potential in their work with children on the autism spectrum who have verbal skills. Semi-structured interviews were conducted with six qualified music therapists from Israel and then analyzed according to the principles of interpretative phenomenological analysis (IPA). Three main themes were identified: (a) musical infrastructure, which describes how the music therapists facilitated musical experiences to support the children's ability to regulate their arousal, attention and emotions; (b) the meeting point between musical and verbal playfulness, which reflects the music therapists' beliefs about how musical experiences add vitality and support the development of both verbal and nonverbal imaginative play; and (c) musical responses, which describes the different ways music therapists use their voice and songs to interact musically with verbal children. The experiences described by the participants emphasize the importance of the therapist musically attuning to the child's emotional, physiological, creative, and playful qualities, even when the child has verbal skills. These musical interactions help to create a shared experience between the child and therapist that are perceived to help the child's different forms of regulation, continuity, and vitality within the play.

Evaluation of a Music Therapy Social Skills Development Program for Youth with Limited Resources

Background

Children living in low-resource communities are at risk for poorer socio-emotional development and academic performance. Emerging evidence supports use of group music therapy experiences to support social development through community afterschool programming.

Objective

To examine the potential benefit of a music therapy social skills development program to improve social skills and academic performance of school-aged children with limited resources in an afterschool program.

Method

We used a single-group pre/post-test design, and recruited 20 students (11 females, 9 males), ages 5 to 11 years, from an afterschool program. The music therapy social skills program consisted of eight 50-minute sessions, and we measured social competence and antisocial behavior using the Home & Community Social Behavioral Scale (HCSBS; Merrell & Caldarella, 2008), and social skills, problem behaviors, and academic competence using the Social Skills Improvement System (SSIS; Gresham & Elliot, 2008a, 2008b).

Results

Only students who attended a minimum of six sessions (N = 14) were included in data analysis. Results showed no significant change in individual HBSC subscale scores; however, the total number of low-performance/high-risk skills significantly decreased. SSIS teacher results indicated significant improvement in communication, significant decrease of hyperactivity, autistic behavioral tendencies and overall problem behaviors, and marginal decreases in internalization. Parent ratings mirrored, in part, those of the teacher.

Conclusions

Results indicated that music therapy has the potential of being an effective intervention for promoting social competence of school-aged children with limited resources, particularly in the areas of communication and low-performance/high-risk behaviors. Teaching skills through song lyrics and improvisation emerged as salient interventions.

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.

The case for treatment fidelity in active music interventions: why and how

As the volume of studies testing the benefits of active music-making interventions increases exponentially, it is important to document what exactly is happening during music treatment sessions in order to provide evidence for the mechanisms through which music training affects other domains. Thus, to complement systematic and rigorous attention to outcomes of the treatment, we outline four vital components of treatment fidelity and discuss their implementation in nonmusic- and music-based interventions. We then describe the design of Music Impacting Language Expertise (MILEStone), a new intervention that aims to improve grammar skills in children with specific language impairment by increasing sensitivity to rhythmic structure, which may enhance general temporal processing and sensitivity to syntactic structure. We describe the approach to addressing treatment fidelity in MILEStone adapted from intervention research from other fields, including a behavioral coding system to track instructional episodes and child participation, a treatment manual, activity checklists, provider training and monitoring, a home practice log, and teacher ratings of participant engagement. This approach takes an important first step in modeling a formalized procedure for assessing treatment fidelity in active music-making intervention research, as a means of increasing methodological rigor in support of evidence-based practice in clinical and educational settings.

Effects of Improvisational Music Therapy vs Enhanced Standard Care on Symptom Severity Among Children With Autism Spectrum Disorder: The TIME-A Randomized Clinical Trial

IMPORTANCE

Music therapy may facilitate skills in areas affected by autism spectrum disorder (ASD), such as social interaction and communication.

OBJECTIVE

To evaluate effects of improvisational music therapy on generalized social communication skills of children with ASD.

DESIGN, SETTING, AND PARTICIPANTS

Assessor-blinded, randomized clinical trial, conducted in 9 countries and enrolling children aged 4 to 7 years with ASD. Children were recruited from November 2011 to November 2015, with follow-up between January 2012 and November 2016.

INTERVENTIONS

Enhanced standard care (n = 182) vs enhanced standard care plus improvisational music therapy (n = 182), allocated in a 1:1 ratio. Enhanced standard care consisted of usual care as locally available plus parent counseling to discuss parents' concerns and provide information about ASD. In improvisational music therapy, trained music therapists sang or played music with each child, attuned and adapted to the child's focus of attention, to help children develop affect sharing and joint attention.

MAIN OUTCOMES AND MEASURES

The primary outcome was symptom severity over 5 months, based on the Autism Diagnostic Observation Schedule (ADOS), social affect domain (range, 0-27; higher scores indicate greater severity; minimal clinically important difference, 1). Prespecified secondary outcomes included parent-rated social responsiveness. All outcomes were also assessed at 2 and 12 months.

RESULTS

Among 364 participants randomized (mean age, 5.4 years; 83% boys), 314 (86%) completed the primary end point and 290 (80%) completed the last end point. Over 5 months, participants assigned to music therapy received a median of 19 music therapy, 3 parent counseling, and 36 other therapy sessions, compared with 3 parent counseling and 45 other therapy sessions for those assigned to enhanced standard care. From baseline to 5 months, mean ADOS social affect scores estimated by linear mixed-effects models decreased from 14.08 to 13.23 in the music therapy group and from 13.49 to 12.58 in the standard care group (mean difference, 0.06 [95% CI, -0.70 to 0.81]; P = .88), with no significant difference in improvement. Of 20 exploratory secondary outcomes, 17 showed no significant difference.

CONCLUSIONS AND RELEVANCE

Among children with autism spectrum disorder, improvisational music therapy, compared with enhanced standard care, resulted in no significant difference in symptom severity based on the ADOS social affect domain over 5 months. These findings do not support the use of improvisational music therapy for symptom reduction in children with autism spectrum disorder.

TRIAL REGISTRATION

isrctn.org Identifier: ISRCTN78923965.

Core Themes in Music Therapy Clinical Improvisation: An Arts-Informed Qualitative Research Synthesis

Background

Although clinical improvisation continues to be an important focus of music therapy research and practice, less attention has been given to integrating qualitative research in this area. As a result, this knowledge base tends to be contained within specific areas of practice rather than integrated across practices and approaches.

Objective

This qualitative research synthesis profiles, integrates, and re-presents qualitative research focused on the ways music therapists and clients engage in, and make meaning from, clinical improvisation. Further, as a conduit for broadening dialogues, opening up this landscape fully, and sharing our response to the analysis and interpretation process, we present an arts-informed re-presentation of this synthesis.

Methods

Following an eight-step methodological sequence, 13 qualitative studies were synthesized. This included reciprocal and refutational processes associated with synthesizing the primary studies, and additional steps associated with an arts-informed representation.

Findings

Three themes, professional artistry, performing self, and meaning-making, are presented. Each theme is explored and exemplified through the selected articles, and discussed within a larger theoretical framework. An artistic re-presentation of the data is also presented.

Conclusions

Music therapists use complex frameworks through which to engage clients in, and make meaning from, improvisational experiences. Artistic representation of the findings offers an added dimension to the synthesis process, challenging our understanding of representation, and thereby advancing synthesis methodology.

Peri-radiographic guidelines for children with autism spectrum disorder: a nationwide survey in Sweden

OBJECTIVE

This study aimed to investigate the prevalence of guidelines and routines used nationwide when children with autism spectrum disorder (ASD) are taken care of and examined in a radiology department during a peri-radiographic process.

METHOD

A nationwide survey was compiled and distributed to 94 radiology departments throughout Sweden, i.e. those performing more than 100 000 radiographic examinations annually. The survey was designed as a web questionnaire with seven questions on possible guidelines and/or routines for the departments when preparing and taking care of children with ASD in conjunction with a radiographic procedure. The data were scrutinized, using descriptive statistics.

RESULTS

In total, 86 radiology departments responded to the survey (response rate 92%). Of those departments, 40 did not examine children with ASD. None of the departments included in the study had existing guidelines underpinning the routines when preparing and performing radiographic examinations for children diagnosed with ASD. A few departments (n = 8) would set aside more time for the procedure if it were known in advance that the child to be examined had been diagnosed with ASD. Also, some departments (n = 7) had radiographers who were more experienced in the care of children who would be appointed to perform examinations for children with ASD.

CONCLUSION

It is suggested that guidelines should be developed in order to increase interaction in a supportive way and decrease anxiety during the peri-radiographic process with children with ASD.

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.

The role, function and identity of music therapists in the 21st century, including new research and thinking from a UK perspective

This article examines the identity of music therapy and music therapists, focussing upon the United Kingdom as a case study, but also considering international trends. Milestones in the history of music therapy in postwar United Kingdom and professional development in the 21st century are discussed, drawing upon research and clinical practice. Research outcomes across different specialities indicate that music therapy should be widely available to many populations, such as for people with dementia, autism, stroke and mental health problems and so on. These advancements mean that music therapists need to be clear about their role and identity in both doing the work and communicating about it. The article celebrates advances in research, thinking and provision and emphasis collaboration across multidisciplinary groups through an overview of different identities.