When reflecting on the past and future of music therapy for persons with ASD, Oldfield (2016) stated that this is probably ‘one of the clinical areas that has received the most attention in the music therapy literature’ (p. 96). In the first decades of music therapy literature, anecdotal reports, case studies and detailed descriptions of applied methods prevailed. The wealth of case studies of music therapy with individuals with ASD has been assembled in the book Case examples of music therapy for autism and Rett syndrome (Bruscia, 2011). Over the last two decades, research studies have increasingly investigated the effects of this treatment on developmental and behavioural outcomes in children with ASD more systematically. Indeed, by now, so many research projects in this area have been conducted that several literature reviews (Accordino, Comer, & Heller, 2007; Simpson & Keen, 2011), systematic reviews (Whipple, 2004, 2012), and Cochrane reviews (Gold, Wigram, & Elefant, 2006; Geretsegger, Elefant, Mössler, & Gold, 2014) have analysed and summarised the findings and the current state of research. Even outside the discipline, scientists and clinicians have recognised the number of high-quality studies in music therapy with individuals with ASD: A systematic review of novel and emerging treatments for ASD concluded that music therapy is one of the few promising interventions which received the highest grade of recommendation (Rossignol, 2009). Similarly, an overview of Cochrane reviews identified music therapy as a promising treatment option for children with ASD (Wheeler et al., 2008).
Two narrative reviews of the literature on music interventions for children with ASD are available (Accordino et al., 2007; Simpson & Keen, 2011). Accordino and colleagues (2007) identified 20 music therapy and auditory-integration training studies conducted between 1973 and 2000. The reviewers observed that case study designs accounted for most of the published studies. As a result, useful information regarding music therapy techniques, methods and approaches could be gathered, providing, however, only limited empirical
studies without experimental controls from their review. They identified 20 studies, published between 1993 and 2010, which mainly used composed songs and music improvisation as intervention techniques. The reviewers concluded that preliminary evidence supports the beneficial effect of music interventions on social, communicative and behavioural skills of young children with ASD.
Whipple (2004) provided the first systematic review on music interventions for young people with ASD. Nine quantitative studies with a total of 76 subjects were included in the meta- analysis. The effects of music and no-music treatment conditions on communication, social behaviour, and cognitive skills were compared. Results suggested that all music interventions, regardless of participants’ ages, investigated outcome, and treatment implementation, are effective for this client group. However, the findings have to be interpreted with caution as the author did not limit the review to music therapy research studies but also included intervention studies that used any (not necessarily therapeutic) application of music implemented by professionals not trained as music therapists. This was different in a later systematic review by the same author (Whipple, 2012), which focused specifically on music therapy for children with ASD aged five years or younger. The meta- analysis included eight quantitative studies (Finnigan & Starr, 2010; Kern & Aldridge, 2006; Kern, Wakeford, & Aldridge, 2007; Kern, Wolery, & Aldridge, 2007; Kim et al., 2008; Lim, 2010; Lim & Draper, 2011; Wimpory, Chadwick, & Nash, 1995) with a total of 91 participants and concluded that ‘music therapy may be considered an extremely effective treatment for young children with ASD for developing communication, interpersonal, personal responsibility, and play skills’ (Whipple, 2012, p. 72). As three out of eight studies in the review had a sample of only one individual, and as the review excluded studies that reported qualitative results or effects on caregivers of children with ASD, findings do not necessarily represent current clinical practice of music therapy for this client group.
The first Cochrane review on music therapy for people with ASD was published by Gold and colleagues in 2006. Due to the selection criteria, only three studies with a total of 24 participants could be included. Furthermore, these studies were only ‘of limited applicability to clinical practice’ (Gold et al., 2006, p. 1). Nevertheless, the results indicated that music therapy has a positive short-term effect on verbal and gestural communicative skills of children with ASD. The updated version of this Cochrane review (Geretsegger et al., 2014), which is also the most recent systematic review of music therapy treatment for individuals with ASD, added seven newer studies to the meta-analysis, so that 165 participants from ten studies (Arezina, 2011; Brownell, 2002; Buday, 1995; Farmer, 2003; Gattino, Riesgo, Longo, Leite, & Faccini, 2011; Kim et al., 2008; Lim, 2010; Lim & Draper, 2011; Thomas & Hunter, 2003; Thompson, 2012) were included. However, the authors noted that the sample size was still relatively small, compromising the methodological strength (Geretsegger et al., 2014). The studies included were RCTs or controlled clinical trials investigating short-
and medium-term effects of music therapy compared to ‘placebo’ therapy, no treatment, or standard care. Meta-analyses found significant improvements in the treatment group in social interaction, communicative skills, initiating behaviour, and social-emotional reciprocity. In addition, music therapy was superior to standard care in promoting social- adaptation skills and the quality of parent-child relationships. The authors highlighted that findings are promising but that more research with larger sample sizes and parallel designs, relevant and standardised outcome measures, as well as long-term or follow-up assessments is needed to strengthen the evidence. Furthermore, they recommended that future studies should be explicit about the type of applied music therapy, and that future trials should be pragmatic. A pragmatic study is ‘reflecting usual conditions’ (Thorpe et al., 2009, p. 466) and thus investigating the effectiveness of the treatment as opposed to the efficacy of the treatment which is assessed under experimental conditions (Geretsegger et al., 2014).
All these recommendations have been implemented by the international music therapy research study TIME-A, which has motivated this doctoral project. As outlined in the study protocol (Geretsegger, Holck, & Gold, 2012), TIME-A aimed to determine whether music therapy improves the social communicative skills of young children with ASD. Having enrolled 364 children in nine countries (Australia, Austria, Brazil, Israel, Italy, Korea, Norway, UK, USA), this single study included more participants than all the studies in the most recent systematic review combined, which makes it also ‘the largest randomised controlled trial on non-pharmacological therapy for autism so far’ (Uni Research, 2016). The large sample size allowed for a parallel rather than a cross-over design. Children had a diagnosis of ASD and were aged four to seven at the time of enrolment. After baseline assessments, children were randomly assigned to the low-intensity music therapy condition, the high-intensity music therapy condition, or the enhanced standard care condition. The allocation ratio was 1:1:2, resulting in half of the children receiving music therapy. The type of music therapy was clearly specified as improvisational music therapy and described in the detailed treatment guidelines (Geretsegger et al., 2015). As the primary outcome, symptom severity was measured with the Autism Diagnostic Observation Schedule (ADOS) social affect domain subscale pre- and post-intervention. The ADOS, which is mainly used for diagnostic purposes, was administered by blinded assessors. In addition, parents were asked to complete the Social Responsiveness Scale (SRS). Data from the standardised scales were collected at baseline (0 months), mid-intervention (2 months), post-intervention (5 months), and follow-up (12 months). Both the duration and frequency of treatment as well as the applied music therapy approach ensured that the trial was pragmatic, i.e. close to the standard clinical practice in most participating countries. The results were published in a high-impact journal (Bieleninik, Geretsegger et al., 2017) and received attention from music therapists as well as related research disciplines, the media and general public (Gold,
2017). Regarding the primary outcome, no significant difference in improvement could be found between the music therapy group and the enhanced standard care group. Furthermore, of the 20 exploratory secondary outcomes measured, only three (social motivation and autistic mannerism subscales of the SRS) showed a significant group difference. The study authors concluded that ‘these findings do not support the use of improvisational music therapy for symptom reduction in children with autism spectrum disorder’ (Bieleninik, Geretsegger et al., 2017, p. 534).
Not surprisingly, the results and this statement caused great concern for many music therapists as well as affected families who have benefited from and advocated music therapy. It was feared by some that instead of having a promoting effect, the study might have a detrimental effect on the reputation of music therapy as an intervention for children with ASD (Gold, 2017). As a response, the principal investigator (Gold, 2017), involved clinicians and researchers (Oldfield, Blauth, Finnemann, & Casey, 2019), as well as external music therapists (Bergmann, 2018; Turry, 2018) commented on the study results, highlighted the strengths and limitations of the trial, and reminded readers of positive quantitative and qualitative results that were not presented in the original report. For example, it was noted that the intervention protocol did not say anything about the quality and appropriateness of the musical material used, and that thus the quality of the therapy implementation might have been very diverse across the different sites, leading to inconsistent results (Bergmann, 2018; Oldfield et al., 2019; Turry, 2018). A critique voiced in all these responses to the trial was the choice of the ADOS as the primary outcome measure. As a diagnostic tool, it was not designed to measure small changes and effectiveness of treatment. This has also been acknowledged by the TIME-A study team (Bieleninik, Posserud et al., 2017; Gold, 2017). Maybe the most important comment on the study results relates to the choice of symptom-severity reduction as the primary outcome. Partly due to the increasing number of individuals with ASD who engage in the research discussion, it is now highly controversial whether symptom reduction can be considered an appropriate treatment aim (Silberman, 2015). Rather, ‘functional gains and quality of life’ (Turry, 2018), the opinion of and impact on parents (Blauth, 2017; Oldfield, 2006), and the resilience of children with ASD (Brooks & Goldstein, 2012; Szatmari, 2018) may be more relevant outcomes.
Nevertheless, this international RCT has clearly advanced music therapy research, built a strong basis on which to explore further, encouraged fruitful discussions about best clinical practice and research methods, as well as allowed for several related projects to emerge. For example, a TIME-A spin-off study (Mössler et al., 2017) analysed session videos of 48 children enrolled in TIME-A to determine whether changes in social skills, as measured by ADOS and SRS, were predicted by the quality of the therapeutic relationship, as rated by
the Assessment of the Quality of Relationship (AQR). Linear mixed-effect models confirmed that there were significant interaction effects between the therapeutic relationship and the development of social, communication and language skills.
Other recent music therapy research studies investigated interdisciplinary or family-centred approaches to assess their effect on outcomes relevant for affected children, their families, and the professionals working with them. A mixed methods study with high clinical relevance and applicability has been carried out by Tomlinson (2016). She investigated whether the effect of music therapy sessions on the development of verbal skills in young children in a special-needs school could be enhanced by additional music sessions conducted by teaching assistants. Results suggested that the collaborative approach of music therapists and teaching assistants was effective and a promising procedure for helping children reach their best potential.
Several recent studies put an emphasis on parents’ perception of music therapy with autistic children (e.g. Gottfried, 2017; Kaenampornpan, 2015; Schwartzberg & Silverman, 2017; Thompson, 2017; Thompson et al., 2013). Gottfried (2017) developed a music-oriented parent counselling model for parents of children with ASD. Participating parents reported feeling less stressed and more competent. A qualitative study by Kaenampornpan (2015) explored parents’ experiences in music therapy sessions with their children with special needs. Improved social and communication skills of the children, positive experiences for the families, and enhanced interaction patterns of the parents with their children could be observed. Schwartzberg and Silverman (2017) analysed semi-structured interviews with parents and discovered recurrent themes, such as ‘the collaborative approach benefits all aspects of treatment and promotes rapport and alliance’, and ‘parents independently implement techniques used in music therapy in other settings’. Thompson et al. (2013) concluded that family-centred music therapy strengthens the parent-child relationship. Parents perceived an improvement in the quality of their child’s social interactions as well as in their own abilities to relate positively to the child. In a four-year follow-up qualitative study, Thompson (2017) investigated whether positive effects sustained. Mothers reported that, because of the family-centred music therapy sessions, they felt more confident and competent, observed improved child social communication and wellbeing, and cherished the music-elicited mutual enjoyment. These results indicate that family-centred music therapy might improve social relationships in the family as well as the quality of life of the child with ASD and other family members.
Another exciting project on the long-term effects of music therapy with children with ASD and their families was carried out by Amelia Oldfield and resulted in the production of a documentary film (Thompson & Thompson, 2017). The film combines excerpts of music therapy sessions in 2001 and 2002 with excerpts of interviews with the same families 15
years later. The film was directed by Maxim Thompson who himself received music therapy 23 years earlier when he was three years old and had a diagnosis of ASD. The parents interviewed in the film reflected on the experience of participating in music therapy sessions with their child and were all very positive about it. This unusual format captures the emotional responses of families which gives the viewer an insight into the immense impact of music therapy on children with ASD and their parents.