There are approximately 700,000 people in the UK living with Autism Spectrum Disorder (ASD) (Autism.org.uk, 2017) and with that number constantly increasing, due to the population of the UK being on the rise, I decided to carry out my research in the area of therapies for Autism. Therapy for ASD provides a chance for a child with Autism to express emotions that they would be unable to express otherwise. This extra freedom that a child can be given could allow them to engage in more interactions with other children and in turn, improve their communication skills.
The National Health Service describes ASD as ‘the name for a range of similar conditions, including Asperger syndrome, that affect a person’s social interaction, communication, interests and behaviour.’ (NHS.uk, 2016). ASD is an umbrella term for a group of developmental disorders which all have similar characteristics. These characteristics have potential to be recognised and diagnosed within the first two years of a child’s life. (The National Institute of Mental Health, 2016) These include, but are not restricted to: behaviour, social interaction and communication.
· Intense interest in a limited number of interests or activities (Ambitious about Autism, 2017)
· Insistence on following specific routines (autismspectrum.org.au OR autism spectrum Australia, 2017).
· ‘Unusual sensory interests such as sniffing objects or staring intently at moving objects’ (autismspectrum.org.au OR autism spectrum Australia, 2017).
· Difficulties with interaction with others therefore affecting ability to make and sustain friendships (autismspectrum.org.au OR autism spectrum Australia, 2017).
· Difficulties with understanding and comprehending non-verbal communication (https://www.nidcd.nih.gov/health/autism-spectrum-disorder-communication-problems-children)
· Children with ASD commonly experience a delay in the development of their language
· Difficulties starting and holding conversations https://www.autismspectrum.org.au/learning-module/communication
· ‘Repetitive or rigid language’ (https://www.nidcd.nih.gov/health/autism-spectrum-disorder-communication-problems-children)
ASD is a lifelong developmental disorder (Autism.org.uk, 2017) and because of this, there may never be a ‘cure’. However, the lives of those living with ASD can be drastically improved by the use of different therapies to manage the disorder, such as Music Therapy.
The definition of Music Therapy, given by the British Association for Music Therapy, is as follows: ‘An established psychological clinical intervention, which is delivered by Health and Care Professions Council (HCPC) registered music therapists, to help people of all ages, whose lives have been affected by injury, illness or disability through supporting their psychological, emotional, cognitive, physical, communicative and social needs.’ (Bamt.org, 2017)
Music therapy has many clinical applications
Benefits of Music Therapy
Music therapy may not directly aid the child’s social development, however, general social interaction between the child and another human allow the child to build their knowledge of how relationships work and how they are formed. This could give the child the confidence boost they needed to communicate to other children and attempt to form a relationship. Music therapy may just be the gateway to involving a child in social interaction and the benefits of music therapy may not linked to the music itself, but the responses the therapist gives the child and the opportunity for the child to form a relationship with the therapist.
Managing ASD with Music Therapy is not widely known. Because of this, the case studies that have been carried out have been relatively small. This also means that the results from these studies cannot realistically represent the majority of the autistic community therefore in most of the conclusions of these studies, the author states that the results support the idea that a larger case study should be carried out on the subject. Unfortunately, to date, there has not been a large case study carried out on the subject of Music Therapy and ASD and so I will have to rely on the number of small case studies which assess the management of ASD with Music Therapy.
In almost all of the case studies, Music Therapy has proven to be superior to the control group involved, generally the control group will involve usual play conditions. The benefits from these studies include an increased level of concentration, imagination and communication. (Bamt.org, 2017)
In the first case study I will be referring to, there are many reported benefits of Music Therapy on children with ASD; these include an increased level of joy, initiation of engagement by the child and emotional synchronicity with the therapist and the child (Kim, Wigram and Gold, 2009). This study was carried out by Jinah Him, a music therapist that has worked in the UK since 1994 (http://www.tandfonline.com/doi/full/10.1080/08098131.2013.854269) , Tony Wigram, a Professor and Head of PhD Studies in the Institute for Music Therapy, Faculty of Humanities, Aalborg University, Denmark (http://www.tandfonline.com/doi/abs/10.1080/08098139909477950), and Christian Gold, Principal Researcher, Grieg Academy Music Therapy Research Centre, Bergen, Norway (http://folk.uib.no/cgo022/), in 2009 and highlights the various benefits regarding Music Therapy as a management for children with ASD. These are traits that children with ASD often find difficult to express due to the nature of the disorder. This case study shows that children with ASD have the opportunity to express these emotions that they would be unable to before with the help of Music Therapy.
This case study includes a subsection titled ‘inter-observer reliability’ in which the authors write about different measures taken to avoid bias and increase reliability. In this particular case study, ’30 percent of the total DVD recordings were randomly selected and rated using the intraclass correlation coefficient (ICC)’ (Kim, Wigram and Gold, 2009). The intraclass correlation coefficient, by definition, is ‘a measure of the reliability of measurements or ratings.’ (Schoonjans, 2017). The value of the ICC in this case study demonstrates a very high reliability as the value ranges from 0.86 to 0.98 except for two of the sections of the study, compliant response and no response. Despite this, the average value of the ICC for this case study still remains relatively high at 0.84 (2 d.p.). This figure shows that the reliability of the results from this case study is quite high. Because of this high value of the ICC, I can quite confidently conclude that this study was carried out in a professional manner and is of a high enough standard to include in my report. I strongly feel that this study gives a credible case that larger studies, in the area of Music Therapy and ASD, should be conducted.
Another benefit of Music Therapy for children with Autism is an increased attention span (Chris Blake, 2017). In his article regarding Music Therapy and Autism in children, Blake, ‘co-founder of RiChmusic and Specialist Music Teacher for people with severe learning difficulties (SLD)’ (Network Autism, 2016), states that he regularly received comments from the parents of children undergoing Music Therapy such as ‘my child never pays attention like that’ and ‘our children don’t sit that long’. These responses show a reaction that suggests Music Therapy was far superior to any management before, such as simple toy-play.
I emailed The British Association of Music Therapy and they forwarded my email to an expert, Ruth Wawszczyk. Ruth stated that the use of Music Therapy when working with children with ASD ‘allows for relationships to develop when interaction is normally exceedingly difficult’ Ruth continues and states that ‘This happens through small musical connections over a long period of time as the child gets to know and trust the Therapist in a safe space.’ (Ruth Wawszczyk, 2017).
This response from Ruth
This email gives further evidence that supports the use of Music Therapy as a management for children with ASD. It also shows that Music Therapy, in Ruth’s view, allows for relationships to be formed between the child and the therapist.
The ability to build relationships for those with ASD is normally a challenging task (Tammie Smith, 2012) and so if this difficult concept is met in Music Therapy sessions, and is successfully addressed, the child could start to trust and have confidence in the therapist which are extremely positive emotions to feel. This could encourage the child to embrace the Music Therapy and possibly even look forward to it. Even if the relationship formed between the therapist and the child is not directly due to the Music Therapy, positive interaction with other people could make it easier for the child to form stronger relationships with their peers or new relationships altogether.
In her second statement, Ruth raises an interesting point. She states that the child must come to ‘trust the Therapist in a safe space.’ This is one that has not appeared in any case studies I have evaluated and should be considered in future case studies. If the child does not trust the space they are in then they will most likely not feel comfortable in that environment, this may have an adverse effect on the results of the Music Therapy, therefore changing the findings of the study.
Issues regarding Music Therapy
Despite the evidence supporting the use of Music Therapy as a management for children with ASD, there are still some issues surrounding the use of this as a therapy for Autism.
I quoted an email earlier from Ruth Wawszczyk regarding the benefits of Music Therapy. Later in her email, Ruth talks about the issues surrounding the use of Music Therapy as a management for children with ASD. Ruth states that ‘Issues are usually linked with the high levels of anxiety that children with Autism experience, which in a lot of cases causes challenging behaviour varying from hitting/spitting to throwing instruments etc.’ (Ruth Wawszczyk, 2017).
Issues like these are expected when working with a disorder such as Autism. There are not many ways to combat these problems that are encountered because of the fact they are completely random, however, the reaction from the therapist must be professional and the appropriate response. If the therapist reacts in a way that the child does not like, it could be detrimental to their relationship. When children with ASD react this way, it is a very sensitive subject and should be treated with great care. If the therapist reacts in a way that provokes the child, this could pose a problem in the future when that child is attempting to form new relationships. The child could relate the previous negative experience with the current relationship and this could confuse them. However, all professional therapists are meticulously trained and are not likely to make this mistake.
Another problem that must be taken into account is accidentally ‘triggering negative emotional associations’ (Lillieth, 2012). This must be taken into consideration by all music therapists but especially those using Music Therapy with children with ASD. Lillieth talks about how in different situations, Music Therapy can actually have the adverse effect on the subject and mentions a previous situation in which such an event happened. In this anecdote, Lillieth mentions how a music therapist had sung a song to a subject and the woman become extremely upset. This happened because of her emotional attachment to that specific song. Fortunately, in this case, the music therapist was trained and responded with total decorum, however, the subject in this specific case was not a child with ASD. If this was the case, the outcome could have been very different.
If a negative emotional association is encountered by a child with ASD, caused by Music Therapy, depending on the severity of the attachment to the music, it could have a long-term effect on the child’s relationships and levels of trust. Trust is an emotion that some people with ASD may struggle to express in their day to day life and so an event like this could really affect the child’s relationships in a bad way. This could be prevented by the music therapist having meetings with the child’s parent/guardian prior to the first session to discuss any emotional triggers that have become evident before, or to talk about any types of music that the parent/guardian thinks will cause the child to become distressed.
Lillieth also talks about how music may not have a relaxing effect on a subject if the child does not like the style of music. This could cause the child to become agitated and feel uncomfortable. Once again, this could be discussed in meetings prior to sessions, however, if the parent/guardian was not aware that a style of music caused their child to become distressed then they would obviously not be able to warn the therapist.
Obviously, there are likely to be risks in every form of therapy for those with ASD or similar disorders and these cannot be completely avoided due to the unpredictability of the disorder, however, the risks can be reduced through lots of communication and feedback from both the therapist and the parent/guardian.
As I stated in my introduction, the results from Music Therapy and ASD case studies cannot be generalised. This is because the spectrum for Autism is so broad that not one therapy will have the same effect on a child with ASD on one side of the spectrum compared to a child with ASD on the other. However, in my evaluation, I will attempt to consider whether Music Therapy is an effective management for the majority of those with ASD.
First of all, there is no guarantee that Music Therapy as a management for children with ASD will work for every child with Autism. There is no possible way the effectiveness of Music Therapy can be measured on every single child with ASD and because ASD is a spectrum disorder, what works as a useful management for one child with ASD may not for another. From my research, I could not find a case study that focused on a specific degree of autism. I suggest that in the future, where possible, case studies measuring the effectiveness of Music Therapy for children with ASD should focus on one type of autism. I also think it would be incredibly beneficial to attempt to recruit more participants in each new case study. In most studies, the results of the case study can only prove that there needs to be further research into the area due to the small number of participants. A larger case study would require meticulous planning and would probably need to be on an international scale.
Increasing the size of the study would also increase the reliability. Only one of the case studies I found contained a section dedicated to inter-observer reliability. Because of this, I can’t easily compare the reliability of the studies. This poses a problem because a lot of the benefits of music therapy are shown through case studies and if I cannot be sure on the reliability of these case studies, I am unable to come to a reliable conclusion. In future case studies, I suggest that the case study should be filmed and sent to an expert in the subject of ASD for a second opinion. Their results should then be compared and if there is a significant difference between the two, the footage should then be evaluated further and discussed. Using an external assessor will help to reduce bias because the expert is not involved in the case study and so their opinion will not be swayed by an emotional attachment to the study.
An idea that occurred to me whilst writing my Extended Project was that the benefits that surround the use of Music Therapy could actually be caused by the therapy being something new and different for the child to enjoy. The child may be intrigued by the use of the music and so this will increase their involvement and increase their levels of interaction with the therapist. Increasing the child’s interaction with people is key to building social skills and tackling obstacles that children with ASD may struggle with such as holding conversation and maintaining concentration (Research Autism, 2016). If this can be achieved through the use of music therapy then this is definitely a positive outcome for all of those involved.
Another idea that occurred to me during the making of my Extended Project was because the measuring of interaction is qualitative; the level of interaction measured may be different for each individual assessor. This means that two assessors that observe the same tape may draw different conclusions and this will affect the final findings and conclusion. This makes it difficult to assess the reliability of the case study. I will take this into account in my conclusion
The fact the results from the case studies are not generalisable posed an issue to me because I am not aware of the severity of the autism of the children in the case study. This means that I cannot even evaluate the effectiveness of music as a therapy for children with a specific type of autism. This could be resolved in future case studies by trying to include children that have a have specific form of autism.
After assessing the benefits and issues surrounding music therapy and the factors that affect the accuracy of the case studies, I am unable to confidently state whether or not music therapy is an effective management for children with ASD.
This is because of several reasons. Firstly, the fact the results from the case studies are not generalisable posed an issue to me because I am not aware of the severity of the autism of the children in the case study. This means that I cannot say whether or not music therapy works as an effective management for children with ASD because these case studies may involve only children with only mild ASD or only children with severe ASD.
Another reason I cannot come to a definite conclusion is the fact that I am unsure on the reliability of most of the case studies. There will generally always be bias when an internal assessor is measuring the levels of certain emotions/levels of interaction and it is mostly down to personal interpretation when assessing these. Once again this affects the reliability of the case study, especially when it is internally assessed and by only one expert.
As I mentioned in my introduction, I was unable to assess the effectiveness of music therapy of children with ASD in either long or short term, however, I think this should be considered in future case studies. Generally, long-term treatments are favoured, however, music therapy as a short-term treatment could provide the child with the essential basic social skills in a short length of time which can then be used and practiced later on in that child’s life. By studying long and short-term effectiveness, experts would be able to assess the extent music therapy can be relied upon for management which could give a better insight into the complicated disorder.
Despite all this, there does seem to be potential for music therapy as a management for children with ASD. However, even with all these points taken into account in future studies, due to the nature of the disorder being incredibly complex, it is unlikely that a definite conclusion will be met.