Kim, J., Wigram, T., & Gold, C. (2008). The effects of improvisational music therapy on joint attention behaviors in autistic children: A randomized controlled study. Journal of Autism and Developmental Disorders, 38(9), 1758-1766.
Reviewed by: Sunita Chhatwani, MSc, MEd and Karen Fried, PsyD, BCBA-D
Why research this topic?
“Joint attention” occurs when two people share a focus on an object or experience. Children with autism spectrum disorder (ASD) commonly have poor joint attention skills. They may not initiate joint attention (e.g., not shifting their gaze between an interesting toy and an adult; not showing anything to anyone) and/or may not respond to other people’s bids for joint attention (e.g., not looking where someone points). Joint attention skills lay the foundation for social communication and interaction. It is, therefore, critical to find effective strategies to improve joint attention.
This study investigated the effect of improvisational music therapy on joint attention in preschool children with ASD. In this approach, the music therapist uses improvised music to respond to the child’s musical and non-musical expressions. The musical interaction is intended to draw the child’s attention toward a shared (or ‘joint’) social experience, thereby encouraging the child to join in or even initiate new interactions.
What did the researchers do?
Participants were 10 boys with ASD, ages 3-5 years, whose diagnoses were confirmed by independent examination. Developmental assessment indicated that all had moderate to significant developmental delays. Participants were randomly divided into two groups. Group 1 began with improvisational music therapy (by a music therapist) for 12 weeks while Group 2 started play sessions with toys (by a play therapist) for 12 weeks. All sessions occurred once weekly for 30 minutes. Participants had no previous experiences in music therapy or play therapy. After 12 weeks, each group participated in the other intervention for another 12 weeks. A “semi-flexible treatment manual” was developed and used for both conditions. For each condition, a consistent, pre-selected set of materials was made available to participants. For each 30-minute session, in both conditions, the first 15 minutes were led by the child, and the second 15 minutes were directed by the therapist who introduced modeling and turn-taking activities.
All sessions were video recorded and analyzed for eye contact and turn-taking behavior, the dependent measures of joint attention in this study. The primary coder was the first author. The second coder was unaware of the order of conditions. In addition, two instruments were used as pre-, mid-, and post-treatment measures of joint attention behaviors. The first, the Social Approach subscale of the Pervasive Developmental Disorder Behavior Inventory (PDDBI), was completed by the mothers of participants and by professionals involved with each participant. The second, the abridged version of the Early Social Communication Scales (ESCS), was completed by independent evaluators unaware of the order of conditions.
What did the research find?
Session analysis showed that eye contact and turn-taking occurred for longer durations in the music therapy condition than in the play condition. On the PDDBI, agreement between the mothers and the professionals was low, and neither therapy (music or play) significantly changed participants’ social approach scores. On the ESCS, initiating and responding to joint attention improved in both groups, and the improvement appeared greater after music therapy than play therapy, no matter the order of conditions. Increases in joint attention involved “low level behavior” (i.e., making eye contact with the therapist and alternating eye contact between a toy and the therapist). For “high level behavior,” including pointing and showing, there were hardly any changes over time, or even a slight worsening.
What are the strengths and limitations of the study?
The strengths of this study included confirming the participants’ ASD diagnoses through independent examination and conducting a developmental assessment of each participant. Another strength was using several different outcome measures to judge effects of the interventions.
There were many limitations, however. Children with ASD, especially those with moderate to significant developmental delays, commonly have little or no interest in age-appropriate toys. Therefore, they may have preferred the musical instruments in music therapy over the toys in play therapy, and this difference might account for the larger gains in music therapy. It is a limitation that steps were not taken to select objects for both conditions that were equivalent in value to the subjects. This likely created a distortion in favor of the music therapy objects, creating the appearance of an effect.
A “semi-flexible treatment manual” was developed and used for both conditions. Future studies might take steps to better ensure the two treatment conditions are well defined, are truly different from each other and are carried out consistently and as intended. It might also be prudent to compare the music therapy intervention to an intervention that already has a strong evidence base for improving social communication and interaction in ASD. Finally, greater care might be taken to control for possible observer bias. In the current study, the first author was the primary coder and the study took place at the first author’s private practice music therapy clinic.
What do the results mean?
The results are inconclusive. Further research is needed to determine whether or not music therapy is effective as an intervention for children with ASD.
Citation for this article:
Chhatwani, S., & Fried, K. (2017). Research synopses: The effects of improvisational music therapy on joint attention behaviors in autistic children. Science in Autism Treatment, 14(2), 23-24.
