Abstract

This meta-analysis of 12 dependent variables from 9 quantitative studies comparing music to no-music conditions during treatment of children and adolescents with autism resulted in an overall effect size of d=.77 and a mean weighted correlation of r=.36 (p=.00). Since the confidence interval did not include 0, results were considered to be significant. All effects were in a positive direction, indicating benefits of the use of music in intervention. The homogeneity Q value was not significant (p=.83); therefore, results of included studies are considered to be homogeneous and explained by the overall effect size. The significant effect size combined with the homogeneity of the studies, leads to the conclusion that all music intervention, regardless of purpose or implementation, has been effective for children and adolescents with autism. Included studies are described in terms of type of dependent variables measured; theoretical approach; number of subjects in treatment sessions; participation in and use, selection, and presentation of music; researcher discipline; published or unpublished source; and subject age. Clinical implications as well as recommendations for future research are discussed.

Music in Intervention for Children and Adolescents with Autism:
A Meta-Analysis

According to the National Center on Birth Defects and Developmental Disabilities of the Centers for Disease Control (n.d.), the incidence of Autism Spectrum Disorders (ASDs) in the United States is not known. It is clear, however, that the rate of diagnosis of children has increased in recent years to the point that more than 15,000 3- through 5-year-old children and 78,000 6- through 21-year-old students received federally funded services during the 2000-2001 school year based on a diagnosis of autism. This does not include students with ASDs classified by a different category or receiving regular classroom, private school, or home school education.

The use of music in assessment of musical and nonmusical skills has provided insight into individual functioning of children and adolescents with ASDs. Based on a qualitative analysis conducted by Whipple (2003) of 11 American assessment studies, information obtained about musical abilities and preferences as well as other auditory discrimination skills and responses support the use of music in treatment with this population. In addition, 29 American studies involving music in treatment were identified, all demonstrating treatment benefits (Whipple, 2003). Still, additional analysis may be beneficial in more fully determining the efficacy of music in the treatment of this population.

Meta-analysis is a set of statistical procedures in which quantitative research data is compiled, allowing for greater confidence in conclusions about the efficacy of treatment and making large bodies of literature more manageable for readers (Johnson, 1989). In the field of music therapy, meta-analysis originated with examination of music in medical and dental treatment (Standley, 1986), with multiple updates warranted (Standley, 1992, 1996, 2000) due to the increasing literature base. In addition, music therapy meta-analyses have been conducted regarding treatment of dementia (Koger, Chapin, & Brotons, 1999) and premature infant (Standley, 2002), pediatric (Standley & Whipple, 2003), and psychiatric populations (Silverman, 2002).

In an endeavor to further examine benefits of music in intervention, the present meta-analysis will contrast the effects of music and no-music conditions on treatment of children and adolescents with autism.

Study Inclusion

Criteria for inclusion in this meta-analysis were studies

1) using group or individual subject experimental treatment designs;
2) with design, procedures, and results allowing replicated data analysis.
3) with subjects who were children or adolescents diagnosed with autism, eliminating studies incorporating diverse special education populations regardless of inclusion of students with ASDs;
4) utilizing music as a separate, independent variable contrasted with a no music control condition;
5) with quantitative results reported with sufficient information to extract an effect size; and
6) in the form of refereed papers and publications (i.e., theses, dissertations, journal articles, and poster session presentations) published or presented in the United States.

Based on accepted meta-analysis process (Johnson, 1989), an exhaustive literature search was conducted to find all studies meeting the defined criteria. Next, characteristics and qualities of the collected studies were identified, described, and coded. Finally, each study/s results were statistically analyzed and converted to computed effect sizes using meta-analysis software (Johnson, 1989).

The identification of applicable literature included searches of the Journal of Music Therapy (1964-present), Music Therapy Perspectives (1982-1984, 1986-present), Music Therapy (1981-1996), and ProQuest, the University of Michigan's on-line database of dissertations and theses, (1950-present), using music and autism or autistic as keywords. Full papers from all relevant American Music Therapy Association (AMTA) research poster session presentations from 2002 only were obtained from AMTA. Papers from previous years were unavailable. Reference lists of all collected published and unpublished papers were searched, as were the music therapy focus issue of Early Childhood Connections (Humpal, 2001) and an analysis of music research with disabled children and youth from 1975 to 1999 (Jellison, 2000).

Of the 29 treatment studies located, 10 studies met criteria for inclusion in the meta-analysis. An additional study met the criteria (Wylie, 1996), but was eliminated prior to data analysis as it was the only study involving children with the ASD of Rett's Disorder, rather than strictly children with autism. Consequently, the resulting meta-analysis focused exclusively on treatment for individuals with autism, not ASDs. The studies meeting criteria are marked with an asterisk in the reference section and are described in Table 1 in terms of type of dependent variables measured; theoretical approach; number of subjects in treatment sessions; participation in and use, selection, and presentation of music; researcher discipline; published or unpublished source; and subject age. Gender is not listed since all studies had all or mostly male subjects. This is to be expected since the rate of autism is four to five times higher in males than females (APA, 2000). Of the included studies, the earliest was published in 1976 and 50% were conducted by music therapists. Regarding type of dependent variables measured, social behaviors were considered to include those such as self-stimulation and attention to task.

Communication variables included incidences of vocalization, speech, sign, and eye contact. The category of cognitive skill included academic tasks, vocabulary acquisition, and following directions for motor tasks. Included studies are summarized below.

•In the category of social behaviors, Brownell (2002) and Pasiali (2002) explored the use of social stories set to music to reduce challenging behaviors. Clauss (1994) examined the effect of background instrumental music on the self-stimulatory behaviors of adolescents when engaged in a computer task. Wood (1991) measured the frequency of out-of-seat behaviors during mealtime of children exposed to background instrumental music.
• In the communication category, Watson (1979) explored the use of a token economy system in which tokens received for spontaneous speech were exchanged for participation in a music therapy session. Three studies measured overall communicative acts of children: Wood (1991), when exposed to background instrumental music during mealtime; O'Loughlin (2000), when exposed to language-based songs; and Wimpory, Chadwick, and Nash (1995), when provided with several music therapy sessions incorporating games, movement, singing, and musical accompaniment of activities.
• In the category of cognitive skills, Carroll (1983) examined the effect *of sung versus spoken instruction on the ability of children to follow instructions to complete a gross motor task. Similarly, Laird (1997) assessed the effect of sung versus spoken instructions on direction following and accuracy of geometric shape identification by children and adolescents. Clauss (1994) measured the response accuracy of adolescents in completing a computer task when exposed to background instrumental music. In the only included study utilizing a standardized assessment, Litchman (1976) used the Peabody Picture Vocabulary Test to measure the vocabulary acquisition of children and adolescents in background music and no-music conditions. O'Loughlin (2000) measured the ability of children to accurately look at and point to stimuli when provided with language-based songs, promoting picture identification and direction following.

Eighteen additional articles involving music in the treatment of children and adolescents with autism were evaluated and determined not to meet study inclusion criteria based on the following factors:

1) studies with insufficient data points for analysis (Bruscia, 1982; Goldstein, 1964; Griggs-Drane & Wheeler, 1997; Hadsell & Coleman, 1988; Mahlberg, 1973; Miller & Toca, 1979; O?Connell, 1974; Saperston, 1973; Staum & Flowers,1984);
2) studies without a no-music control condition (Buday,1995; Edgerton, 1993, 1994; Gore, 2002; Stevens & Clark, 1969);
3) studies in which the music condition could not be separated from another intervention (Chilcote-Doner, 1982; Hairston, 1990; O?Dell, 1998);
4) a study in which the music and no-music condition data could not be separated (Rao, 2001);
5) a study in which music intervention was a constant factor, with different non-music reinforcement interventions (Schmidt, Franklin, & Edwards, 1976).

In some cases, studies could have been eliminated for more than one factor,though only the primary factor is cited. One study (Chilcote-Doner, 1982) eliminated for inability to separate music from other variables, also could have been eliminated since a recorded drumbeat was the only form of auditory stimulation included in the study. For this meta-analysis, the incorporation of both pitch and rhythm were required in order for the auditory stimulation to be considered music. In another study (Buday, 1995), eliminated for lack of a clear control condition, used vocabulary signed and spoken in the rhythm of children?s songs, eliminating only the melodic element, for the non-music condition. Consequently, this operational definition of music may be important in future analyses.

Finally, five articles describing treatment techniques for children and adolescents with ASDs were not included in this analysis as they did not include quantitative data (Furman, 2001; Hollander & Juhrs, 1974; Nelson, Anderson, & Gonzales, 1984; Thaut, 1980, 1984; Toigo, 1982).

When selecting variables for analysis, the following hierarchy was employed:

• the single variable with quantitative data was recorded;
• if more than one variable was available, the primary variable based on the title of the study or otherwise identified focus of intervention was selected;
• if several variables met that criterion and all were of the same type of data (e.g., frequency of behavioral observations) and in the same category of variable measured (i.e., social behavior, communication, or cognitive skill), the data were combined into one variable;
• when it was not possible to select one variable or combine multiple variables into one measure, the two most important variables based on the already identified focus of the study were selected, with a limit of two variables set for each study to avoid disproportional weighting of studies.

This process resulted in selection of 13 variables from 10 studies. When multiple baseline conditions were reported and conditions in addition to the extractable music conditions were included in the original study, data from the baseline condition immediately prior to the music condition, rather than a mean of the baseline conditions, was used for this meta-analysis in order to avoid pollution from the other non-music condition. Variables were converted to an estimated effect size, Cohen's d, using meta-analytic statistical software (Johnson, 1989).

Listed in Table 2 are the sample size, 95% confidence interval, and Pearson r and Cohen's d statistics with their probability for each selected study variable. Effect sizes ranged from .09 to 3.36 with an overall effect size of d=.83 and a mean weighted correlation of r=.38 (p=.00). Since the confidence interval did not include 0, results were considered to be significant. All effects were in a positive direction, indicating benefits of the use of music in intervention with this population. In addition, the homogeneity Q value was not significant (p=.39), allowing results of studies to be considered consistent and explained by the overall effect size.

However, the largest outlier was Wimpory, et al. (1995), with an effect size (d=3.36) almost two standard deviations larger than the next highest effect size for Litchman (1976) (d=1.71). Since Wimpory, et al. (1995) was the only study included with a sample size of one and was the largest outlier, it was marked for exclusion from data analysis.

Data reanalysis without Wimpory, et al. (1995) resulted in an overall effect size of d=.77 and a mean weighted correlation of r=.36 (p=.00). Since the confidence interval did not include 0, results were considered to be significant. Again, all effects were in a positive direction, ranging from d=.09 to d=1.71, indicating benefits of the use of music in intervention with this population. The new homogeneity Q value was even less significant (p=.83); therefore, results of included studies are considered to be homogeneous and explained by the overall effect size.

Meta-analysis of research regarding children and adolescents with autism reveals that all use of music in treatment with this population has a relatively high effect. Benefits are not differentiated based on treatment design, age of subjects, music used, source of research, treatment methodology, or profession of the music provider.

Prizant, Wetherby, and Rydell (2000) described three theoretical approaches to intervention with clients with ASDs: discrete trial-traditional behavioral (DT-TB), developmental social-pragmatic (DSP), and contemporary applied behavioral analysis (CABA). The first, DT-TB was most prominent in the 1960s and 1970s. Intervention did not occur in natural environments based on the theory that clients with autism were unable to learn in a natural context due to their learning deficits and the limited quantity of trials and reinforcement available within daily routines. Emphasis was on teaching speech communication and motor behaviors related to activities of daily living. All elements were taught through repetitive trials massed in sets of approximately 100, though current practice supports sets of approximately 10 trials per session. An individual trial included presentation of the stimulus by the therapist or teacher; client response; consequence of verbal or primary reinforcement (e.g., food) or of verbal or physical punishment followed by physical prompting of the correct response; and a pause before beginning the next trial with presentation of the next stimulus. Over time, the use of physical punishment was largely eliminated from research and clinical practice. Research and clinical applications of DT-TB techniques were first to indicate the ability of individuals with autism to learn communication and appropriate social skills, but often behaviors did not generalize to other environments and were incompatible with spontaneous and initiated communication (Prizant, et al., 2000).

The DSP model is at the other end of the theoretical approach continuum. This model developed in the late 1970s and 1980s and focused on intervention within the context of daily routines and events. Avoiding exclusive prompting and shaping of responses, teachers, therapists, and family members were to respond to the child's communicative attempts within the context of social interaction. The DSP approach emphasizes creation of motivating contexts, routines, and activities; following the child's lead; analyzing children's unconventional and early communicative behaviors for meaning; assisting emotional regulation and expression; establishing individual goals based on current communicative abilities and learning strengths; and focusing on meaningful language and functional communication instead of building larger repertoires of speech and language lacking context and comprehension (Prizant, et al., 2000).

In between the DT-TB and DSP approaches is CABA, which began in the 1990s and incorporates the behavioral concepts of reinforcement for appropriate responses, yet structures intervention for generalization of skills. In contrast to a DT-TB approach, CABA allows either client-led or combined therapist- and client-led interactions to encourage communication initiation, emphasizes activities preferred or selected by the child, and relies on natural and minimally structured interactions. Like DSP, the aim of CABA intervention is to facilitate spontaneous communication and social interaction across settings and situations. Still, definite differences are apparent between CABA and DSP methods. The CABA approach focuses less consistently than DSP on the typical language development sequence, focuses more on measurement of behavioral responses than holistic successful participation, looks at isolated behaviors more frequently than targeting multiple goals within one experience, and places less emphasis on development of relationships and social and emotional expression (Prizant, et al., 2000).

In analysis of music intervention with this population based on theoretical approach, Whipple (2003) found that the preponderance of studies most closely fit the DSP approach, though most studies contained elements of more than one theoretical approach. Still, studies were determined to be from one approach based on a preponderance of the above defined characteristics within each individual study. Greatest emphasis was placed on the context in which treatment occurred, functionality of goals, and evidence of generalization. Based on categorization determined in Whipple (2003), studies included in this meta-analysis were spread among the three approaches, with four DT-TB, four CABA, and four DSP. Based on the non-significant homogeneity Q value, results of this meta-analysis showed no difference in treatment effect, whether theoretical approach was DT-TB, CABA, or DSP. This is of importance since current national research trends support DSP research focused on functional and spontaneous communication, socialization, play skills, generalization and maintenance, natural contexts, positive approaches to address problem behaviors, and functional academic skills (National Research Council, 2001; Prizant, et al., 2000). The most obvious need revealed by the meta-analysis process is for studies with quantitative data and non-confounding research designs, as evidenced by the reduction from 29 identified treatment studies to only 9 meeting criteria for this meta-analysis. Of those eliminated, nine were on the basis of insufficient data points for analysis. The elimination of others without no-contact control or exclusive music conditions was necessary for the purpose of this meta-analysis, but may not necessarily represent a gap in the research base in the same way as do those without adequate quantitative data.

Additionally, studies with larger sample sizes are needed. Several of the studies excluded on the basis of insufficient data were case studies. Others included were in the form of case studies but with data presented in such a way that they could be considered as a group of subjects with a common measured variable (Brownell, 2002; Pasiali, 2002). The largest samples were found in Litchman (1976) with a between groups design of 10 subjects per group, totaling 20 subjects, and Laird (1997) with a within subjects design of 13 subjects, each serving as their own control. The total sample size for the meta-analysis was 76 from the 9 studies included, resulting in a mean sample per study of 8.44. When calculated for the 12 study variables included, the sample size rises to 96, but the mean sample decreases to 8.00 per study variable. This is an extremely small sample size in quantitative research.

Many studies also appear to be in the form of post hoc analysis of clinical work. This limits the inclusion of these studies in meta-analysis, as they may have insufficient or no pre-treatment baseline data. Also, music treatment data may not be able to be extracted from other intervention variables. In addition, while not necessarily precluding their inclusion in meta-analysis, these studies often have small sample sizes and present difficulty in selecting primary variables to analyze due to global assessment approaches.

The body of literature regarding music in intervention with children and adolescents with autism reports the following benefits:

• increased appropriate social behaviors and decreased inappropriate, stereotypical, and self-stimulatory behaviors;
• increased attention to task;
• increased vocalizations, verbalizations, gestures, and vocabulary comprehension;
• increased echolalia, moving toward increased communication, and decreased echolalic percentage of total utterances;
• increased communicative acts and engagement with others;
• enhanced body awareness and coordination;
• improved self-care skills and symbolic play;
• anxiety reduction.

However, since the meta-analytic process required that many studies be excluded, only music uses found in Table 1 were supported in the current study. Additionally, treatment and program descriptions without quantitative data advocate the use of Orff-Schulwerk techniques (Hollander & Juhrs, 1974) in addressing a multitude of non-musical therapeutic goals. Also suggested without data support is learning to sing or play an instrument to provide long-term benefits for quality of life, self-esteem, and social acceptance (Nelson, et al., 1984; Toigo, 1992). Several suggestions regarding the use of music in teaching academic material have also been made, often based on music therapy treatment and research with broad special education populations, but need further clarification of the efficacy of specific techniques for this unique population (Furman, 2001; Thaut, 1980, 1984; Toigo, 1992; Nelson, et al., 1984).

The National Research Council (NRC) (2001) has stressed the need for integration of the diverse bodies of literature related to ASDs, encompassing differences based on experimental design, including single-subject and group experimental, as well as differences based on focus, to include neurological, behavioral, and developmental aspects. Only two of the 9 studies included in final analysis, and three of the 10 originally analyzed studies, were from published sources. Based on the NRC recommendations and to allow for better access to information, the greatest need at this point in time appears to be for more published studies regarding the use of music in intervention with this population.

Most important for music therapists is to be cognizant that all music intervention has been effective for children and adolescents with autism. Music appears to be so powerful a tool with this population that regardless of its purpose or how it is used for a particular client, it achieves positive effects. However, music therapists have not differentiated their professional role with this population. The goal of future research, while addressing the sample size and design clarity deficits already described, should be to assess the efficacy of specific applications of music in the treatment of children and adolescents with autism.

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Published on: 2004-10-03 (2336 reads)