Music therapy for adolescents with psychiatric disorders: An overview

BACKGROUND

Although it is true that adolescence is a stage of evolutionary development in which there are innumerable windows of opportunity, it is also the peak age at which some psychiatric disorders may appear. On the other hand, music is an auditory stimulus that interests and motivates youngsters, as it is used for identity, social connection, and emotional regulation.

METHODS

We conducted a strategic search by consulting scientific databases. The following search terms were employed: Music Therapy AND Psychology AND Psychiatry AND Adolescents. The following international electronic databases were searched: Medline, Ovid, and Cochrane Library.

RESULTS

A total of 142 sources were identified from which 9 papers on music therapy published exclusively in scientific journals specialized in psychology or child psychiatry were selected. The total number of participants was 651. The studies reported that music therapy interventions have the potential to improve self-esteem, social engagement, decrease social isolation, and depressive and anxiety symptoms in psychiatric adolescents (both in inpatient and outpatient settings).

CONCLUSION

Given the heterogeneity and methodological quality of the few studies included, it is complex to extrapolate and generalize results. More quality research is needed to expand music therapy interventions on youth mental health.

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.

‘Autism is a way of being’: An ‘insider perspective’ on neurodiversity, music therapy and social justice

Neurodiversity (the idea that autism is a natural part of human diversity) is a concept that is only just beginning to be explored in music therapy research. The idea of neurodiversity can be viewed as an important part of the emerging discourse around diversity and social justice in British music therapy, with a potentially radical influence on both music therapy practice and the way in which autistic clients and colleagues are viewed. This article, written from the ‘insider perspective’ of an autistic Music Therapist, explores the origins of the concept of neurodiversity, the emerging strand of music therapy research concerning neurodiversity, the re-framing of autistic characteristics such as stimming within the concept of autistic culture, and the potential influence on music therapy practice and discourse of a wider paradigm shift towards the neurodiversity paradigm. These topics are considered within a social justice context, situating autistic / neurodivergent people as a minoritized identity within society and examining the potential influence of power dynamics, unconscious bias and privilege within the therapeutic relationship. The characteristics of a neurodiversity-affirmative style of music therapy are considered, and a need is identified for more music therapy research in order to elucidate this way of working.

Communication of emotion via drumming: dual-brain imaging with functional near-infrared spectroscopy

Nonverbal communication of emotion is essential to human interaction and relevant to many clinical applications, yet it is an understudied topic in social neuroscience. Drumming is an ancient nonverbal communication modality for expression of emotion that has not been previously investigated in this context. We investigate the neural response to live, natural communication of emotion via drumming using a novel dual-brain neuroimaging paradigm. Hemodynamic signals were acquired using whole-head functional near-infrared spectroscopy (fNIRS). Dyads of 36 subjects participated in two conditions, drumming and talking, alternating between 'sending' (drumming or talking to partner) and 'receiving' (listening to partner) in response to emotionally salient images from the International Affective Picture System. Increased frequency and amplitude of drum strikes was behaviorally correlated with higher arousal and lower valence measures and neurally correlated with temporoparietal junction (TPJ) activation in the listener. Contrast comparisons of drumming greater than talking also revealed neural activity in right TPJ. Together, findings suggest that emotional content communicated by drumming engages right TPJ mechanisms in an emotionally and behaviorally sensitive fashion. Drumming may provide novel, effective clinical approaches for treating social-emotional psychopathology.

Acute Effects of Music Therapy in Subjects With Psychosis During Inpatient Treatment

OBJECTIVE

Previous studies have proposed music therapy (MT) as a useful rehabilitation approach for patients with psychosis, but few studies have focused on acute settings. The aim of the study was to evaluate the effects of a structured MT program on clinical and social functioning indices of patients with psychosis while hospitalized in an emergency psychiatric ward.

METHOD

The intervention followed a modified approach to Benenzon's MT model and was delivered biweekly to 61 patients with psychosis consecutively admitted to our ward. Before and after the MT program, all subjects were administered the Brief Psychiatric Rating Scale (BPRS) for assessment of general psychopathology, the Hospital Anxiety and Depression Scale (HADS) for affective symptomatology, the Clinical Global Impression (CGI) scale for severity of symptoms, and the Global Assessment of Functioning (GAF) scale for psychosocial functioning.

RESULTS

A repeated-measures analysis of variance revealed that patients who underwent the MT intervention had a statistically significant reduction of BPRS and CGI scores, compared to the control group; furthermore, the BPRS anxiety/depression factor and the HADS scores for affective symptomatology significantly decreased after the observation period compared to controls.

CONCLUSION

Our results are in line with previous studies showing favorable effects of MT in patients with psychosis, in particular on affective symptomatology, but extend this observation to an emergency setting with short periods of hospital stay.

KAMUTHE video microanalysis system for use in Brazil: translation, cross-cultural adaptation and evidence of validity and reliability

<b>Background</b><br /> KAMUTHE is a video microanalysis system which observes preverbal communication within the music therapy setting. This system is indicated for children with autism spectrum disorder (ASD) or multiple disabilities. The purpose of this study was to translate, adapt to Brazilian Portuguese language and analyze some psychometric properties (reliability and validity evidence) of KAMUTHE administration in Brazil for individuals with ASD.<br /> <br /> <b>Participants and procedure</b><br /> Translation, back translation, analysis by judges, and pilot application were performed to obtain evidence of content and face validity. The second part of this study was to administer KAMUTHE in 39 consecutive children with ASD. An individual session of improvisational music therapy was applied to assess the different behaviors included in KAMUTHE. The intra-rater reliability, concurrent validity and convergent validity were analyzed.<br /> <br /> <b>Results</b><br /> Translation and cross-cultural adaptation were followed and some cultural adaptations were needed. Inter-rater reliability was very good (ICCs 0.95-0.99) for the three child’s behaviors analyzed. Criteria validity with a moderate negative association was found (r = –.38, p = .017) comparing the behavior “Gazes at therapist” and the level of ASD along with the Childhood Autism Rating Scale (CARS). Convergent validity was established between the behavior “Gazes at therapist” and the two nonlinguistic communication scales (social interaction and interests) of the Children’s Communication Checklist (CCC) with a moderate correlation (r = –.43, p = .005).<br /> <br /> <b>Conclusions</b><br /> The administration of the KAMUTHE video microanalysis system showed positive results in children with ASD. Further studies are needed to improve the reliability and validity of the instrument in Brazil.

Evidence and Effectiveness in Music Therapy

Adopting a knowledge-based controversy perspective, this article considers critically the ‘fit’ or appropriateness of the so-called ‘gold standard’ of assessment – the Randomised Controlled Trial. It sets the growing dominance of this method within music therapy in the contexts of medical work and the changing social relations of medical expertise, the importance of local practice in music therapy (and healthcare more widely), and the politics of representation as they apply to medical modes of accounting and measurement. I then consider what is overlooked when experimental models are used as the prime mode of perceiving the music therapeutic process and suggest that they may not provide a good or appropriate way of observing, accounting for and assessing music therapy. I suggest that they are not amenable to the observation and documentation of temporal and local craft practices and that these practices provide the active ingredients of music therapy's effectiveness. I conclude that music therapy is poised to highlight the radical performative and social features of health status and that these features have far-reaching implications for our concepts of illness and the aetiology of illness and, most importantly, for the ways in which we conceptualise and implement therapeutic procedures of all kinds.

Music Therapy for Autistic Children and Their Families: A Creative Spectrum

A review of the literature shows that little has been published about music therapy for parents and children together, and Oldfield's recent article (Oldfield et al. 2003) describes this work as ‘fairly uncommon’.

This paper uses three clinical examples to illustrate a range of approaches to working with children with autism and their parents: a group for children with autism and their parents in a mainstream primary school, short-term work with a 4-year-old autistic girl and her mother, and work with a mother and her two young sons, one of whom has Asperger's Syndrome. Music therapy can help children with autism to communicate and interact and can build their self-confidence. It can also play an important role for parents of children with autism, who may be under great stress, by fostering relationships, developing positive interactions and helping them to feel contained and supported.

The effects of embodied rhythm and robotic interventions on the spontaneous and responsive social attention patterns of children with Autism Spectrum Disorder (ASD): A pilot randomized controlled trial

We compared the effects of 8-weeks of rhythm and robotic interventions with those of a comparison, standard-of-care intervention, on the spontaneous and responsive social attention patterns of school-age children with Autism Spectrum Disorder. Attention patterns were examined within a standardized pretest/posttest measure of joint attention (JA) and a training-specific social attention measure during early, mid, and late training sessions. The rhythm and comparison groups demonstrated improvements in JA. Social attention was greater in the rhythm followed by the robot and lastly the comparison group. The robot and comparison groups spent maximum time fixating on the robot and objects, respectively. Across sessions, the robot group decreased attention to the robot and increased attention to elsewhere. Overall, rhythmic movement contexts afford sustained social monitoring in children with autism.

‘The whole is greater’. Developing music therapy services in the National Health Service: A case study revisited

This article describes contemporary music therapy practice within Chelsea and Westminster Hospital National Health Service Foundation Trust in London. The authors revisit an earlier article about the service (‘The whole is greater than the sum of its parts: experiences of co-working as Music Therapists’, Fearn and O’Connor), which described an evolving approach of two Music Therapists based at one Child Development Service, part of Chelsea and Westminster Hospital in London. On this foundation, a team of 10 part-time Music Therapists has developed, working across three London boroughs and a number of multidisciplinary teams. This article will look at how the music therapy practice has developed in this setting over the past decade, in order to provide a practical and theoretical perspective for Music Therapists within multidisciplinary settings. Influences that have shaped the service and the wider music therapy profession will be explored, such as an increased emphasis on a goal-centred, multidisciplinary team approach, the changing needs and volume of the children presenting to the service and the consequent development of the music therapy team.

Auditory-motor mapping training as an intervention to facilitate speech output in non-verbal children with autism: a proof of concept study

Although up to 25% of children with autism are non-verbal, there are very few interventions that can reliably produce significant improvements in speech output. Recently, a novel intervention called Auditory-Motor Mapping Training (AMMT) has been developed, which aims to promote speech production directly by training the association between sounds and articulatory actions using intonation and bimanual motor activities. AMMT capitalizes on the inherent musical strengths of children with autism, and offers activities that they intrinsically enjoy. It also engages and potentially stimulates a network of brain regions that may be dysfunctional in autism. Here, we report an initial efficacy study to provide 'proof of concept' for AMMT. Six non-verbal children with autism participated. Prior to treatment, the children had no intelligible words. They each received 40 individual sessions of AMMT 5 times per week, over an 8-week period. Probe assessments were conducted periodically during baseline, therapy, and follow-up sessions. After therapy, all children showed significant improvements in their ability to articulate words and phrases, with generalization to items that were not practiced during therapy sessions. Because these children had no or minimal vocal output prior to treatment, the acquisition of speech sounds and word approximations through AMMT represents a critical step in expressive language development in children with autism.

A Dialogue with Prof. Tony Wigram

This article reviews the career and publications of Prof. Tony Wigram. This enables the reader to follow the changing face of British music therapy during the period from its origins to the present day. Through tracking the career of a prominent and internationally renowned UK therapist, it is possible to illustrate the ways in which music therapy has developed since the early days of working towards a professional profile, through the growth of the profile of the profession in a variety of ways, including the long period of work towards national registration. There is consideration of the changes in the topics and nature of publications and research, undertaken in response to the changing environments in which therapist work.

It is anticipated that current practising music therapists will find this review of interest in a number of ways: as a historic record of the growth of the profession seen through the eyes of an active teacher, author and researcher; a resource of great current and future value in terms of the ideas and publications presented across the spread of the UK profession; a springboard from which to view the future.

From music making to speaking: engaging the mirror neuron system in autism

Individuals with autism show impairments in emotional tuning, social interactions and communication. These are functions that have been attributed to the putative human mirror neuron system (MNS), which contains neurons that respond to the actions of self and others. It has been proposed that a dysfunction of that system underlies some of the characteristics of autism. Here, we review behavioral and imaging studies that implicate the MNS (or a brain network with similar functions) in sensory-motor integration and speech representation, and review data supporting the hypothesis that MNS activity could be abnormal in autism. In addition, we propose that an intervention designed to engage brain regions that overlap with the MNS may have significant clinical potential. We argue that this engagement could be achieved through forms of music making. Music making with others (e.g., playing instruments or singing) is a multi-modal activity that has been shown to engage brain regions that largely overlap with the human MNS. Furthermore, many children with autism thoroughly enjoy participating in musical activities. Such activities may enhance their ability to focus and interact with others, thereby fostering the development of communication and social skills. Thus, interventions incorporating methods of music making may offer a promising approach for facilitating expressive language in otherwise nonverbal children with autism.

Quietening the Voices

The article presents a case study of individual music therapy with an elderly Iraqi refugee in a day hospital for the elderly mentally ill. It highlights themes that arise from working with a traumatised client of a different culture and different generation, and the range of ways in which music was used. It draws on psychological theories to shed light on the developing relationship between therapist and client.

Emotional, motivational and interpersonal responsiveness of children with autism in improvisational music therapy

Through behavioural analysis, this study investigated the social-motivational aspects of musical interaction between the child and the therapist in improvisational music therapy by measuring emotional, motivational and interpersonal responsiveness in children with autism during joint engagement episodes. The randomized controlled study (n = 10) employed a single subject comparison design in two different conditions, improvisational music therapy and toy play sessions, and DVD analysis of sessions. Improvisational music therapy produced markedly more and longer events of 'joy', 'emotional synchronicity' and 'initiation of engagement' behaviours in the children than toy play sessions. In response to the therapist's interpersonal demands, 'compliant (positive) responses' were observed more in music therapy than in toy play sessions, and 'no responses' were twice as frequent in toy play sessions as in music therapy. The results of this exploratory study found significant evidence supporting the value of music therapy in promoting social, emotional and motivational development in children with autism.

Music therapy in the assessment and treatment of autistic spectrum disorder: clinical application and research evidence

BACKGROUND

Children and adolescents with autistic spectrum disorder (ASD) presenting with significant limitations in conventional forms of verbal and non-verbal communication are found to respond positively to music therapy intervention involving both active, improvizational methods and receptive music therapy approaches. Improvizational musical activity with therapeutic objectives and outcomes has been found to facilitate motivation, communication skills and social interaction, as well as sustaining and developing attention. The structure and predictability found in music assist in reciprocal interaction, from which tolerance, flexibility and social engagement to build relationships emerge, relying on a systematic approach to promote appropriate and meaningful interpersonal responses.

RESULTS

Published reports of the value and effectiveness of music therapy as an intervention for children with ASD range from controlled studies to clinical case reports. Further documentation has emphasized the role music therapy plays in diagnostic and clinical assessment. Music therapy assessment can identify limitations and weaknesses in children, as well as strengths and potentials. Research evidence from a systematic review found two randomized controlled trials that examined short-term effects of structured music therapy intervention. Significant effects were found in these studies even with extremely small samples, and the findings are important because they demonstrate the potential of the medium of music for autistic children. Case series studies were identified that examined the effects of improvizational music therapy where communicative behaviour, language development, emotional responsiveness, attention span and behavioural control improved over the course of an intervention of improvizational music therapy.