School of Occupational Therapy

Touro University Nevada

OCCT 643 Systematic Reviews in Occupational Therapy

CRITICALLY APPRAISED TOPIC (CAT)
Focused Question:
Does music therapy intervention help improve socialization and communication skills in
children with autism spectrum disorders?
Prepared By:
Kelsey Puliafico & Jennifer Unck
Date Review Completed:
October 8th, 2015
Clinical Scenario:
Autism spectrum disorders (ASD) comprise a range of developmental disabilities. According to
the Centers for Disease Control and Prevention, approximately 1 in 68 children in the United
States are affected by ASD (Center for Disease Control and Prevention [CDC], 2012).
Individuals diagnosed with ASD have significant limitations in communication and social
interaction skills (Autism Society, n.d.). Symptoms of ASD usually appear during early
development and may include reluctance to make eye contact with others, inability to express
needs or wants, difficulty recognizing social cues, and displaying repetitive behaviors (Autism
Speaks, 2015). Due to these limitations, individuals diagnosed with ASD have difficulty with
occupational performance in a variety of areas. A few of these occupations include play,
education, and social participation (American Occupational Therapy Association [AOTA],
2014).
In the Occupational Therapy Practice Framework (OTPF), some social interaction skills that are
required for participation in those various occupations are listed under the area of performance
skills. A few of the social interactions skills that are impacted in individuals with ASD include
speech production, regulation of behaviors, emotional expression, and timely responses to social
cues (AOTA, 2014). Play is one of the main occupations of young children. Interacting with
others during play requires some level of joint attention and social interaction. Joint attention
requires sharing attention with another person while engaging in an experience (Kalas, 2012).

Trouble with joint attention is a commonly seen deficit in the early stages of ASD. Because
children with ASD are unable to respond to or initiate joint attention this is seen as one of the
most significant deficits to social interaction (Kalas, 2012). For example, children with ASD may
not initiate conversation or engage in play with peers at school which limits their social
interaction.
Communication difficulties affect a significant number of children with ASD. More specifically,
30-50% of children with ASD never gain useful speech (Pickett et al. 2009). Limited speech
affects a childs ability to effectively communicate their thoughts, feelings and needs to others.
Because children with ASD have these difficulties with communication more interventions need
to be developed to focus on communication and language skills (Lim, 2010).
Research supports a variety of interventions to help improve socialization and communication
skills in children with ASD. Music therapy is one area of research that has been considered and
has provided some effective results. Children with ASD usually need structured guidance for
appropriate interaction (Trevarthen, C., Aitkin, K., Papoudi, D., & Robarts, J., 1996). The
various structures in music, such as rhythms, patterns, and tempo, act as a good medium for
teaching children with ASD about these appropriate skills (Wigram & Gold, 2006). However,
study limitations warrant further research to validate the use of music therapy for ASD.
Summary of Key Findings:
Summary of Levels I, II and III:

Parent perception of childs social interaction skills was positive following music
intervention (LaGasse, 2014, Level I; Thompson, McFerran & Gold, 2013, Level
I)

Research showed improvements in social engagement, social behaviors and

emotional understanding after music therapy in children with ASD (LaGasse,
2014, Level I; Thompson, McFerran & Gold, 2013, Level I; Kim, Wigram &
Gold, 2008, Level II; Katagiri, 2009, Level III)

Individuals with Autism show affinity for music tasks due to increased activation
in specific brain areas related to music (Lim, 2010, Level I; Sandiford, Mainess
& Daher, 2012, Level I)

Music therapy may be an effective tool for speech production and verbalization
in children with ASD ((Lim, 2010, Level I; Sandiford, Mainess & Daher, 2012,

Level I; Lim & Draper, 2011, Level III)

Music therapy helped increase joint attention skills in children with ASD
(LaGasse, 2014, Level I; Kim, Wigram & Gold, 2008, Level II)

All Level I, II and III studies support further research to increase efficacy for
music therapy intervention in children with ASD (Thompson, McFerran & Gold,
2013, Level I; Sandiford, Mainess & Daher, 2012, Level I; LaGasse, 2014, Level
I; Lim, 2010, Level I; Gattino, dos Santon Riesgo, Longo, Leite, & Faccini,
2011, Level I; Kim, Wigram & Gold, 2008, Level II; Katagiri, 2009, Level III;
Lim & Draper, 2011, Level III)

Summary of Level IV and V:

More research with larger sample size and inclusion of control group is needed
to support the use of music intervention in children with ASD (Kalas, 2012,
Level IV; Kim, Wigram & Gold, 2009, Level IV)

Simple music is more effective on joint attention for lower functioning ASD and
complex music is more effective on joint attention for higher functioning (Kalas,
2012, Level IV)

Music therapy is effective in directing and obtaining attention of children with

ASD needed for interpersonal responsiveness (Kalas, 2012, Level IV; Kim,
Wigram & Gold, 2009, Level IV)

Improvisational music therapy promotes positive emotional expression in

children with ASD (Kim, Wigram & Gold, 2009, Level IV)

No Level V studies were appraised

Contributions of Qualitative Studies:

No qualitative studies were appraised
Bottom Line for Occupational Therapy Practice:

Clinical and community-based practice of OT:

The research supports the use of music interventions to improve communication and
socialization skills in children with ASD in a variety of settings (i.e. home health, school-based,
outpatient clinics, and community settings). Throughout all of the research studies conducted
music interventions proved to be a motivating factor to promote socialization and
communication skills. Client and family-centered music therapy interventions had positive
effects on overall outcomes. Although the research supports the use of music interventions, these
strategies should be implemented in collaboration with other interventions due to not enough
statistical significance to support music therapy interventions on their own.
Program development:
The variety of music based interventions utilized in the research could be used as a guide for new
program development. Incorporating child-led interactions within intervention sessions proved to
be an effective strategy for promoting improvements in socialization and communication skills
(Kim. Wigram & Gold, 2009). This premise should be considered when developing a new
program so that children are able to feel more engaged. Therapist should take into consideration
the level of stimulation that is most effective for the clients functional level when developing
programs (Kalas, 2012).
Societal Needs:
Due to stigma and stereotypes associated with ASD, these individuals need to develop effective
communication and socialization skills to interact appropriately in society and advocate for
themselves. Without the ability to effectively communicate, children with ASD will have
difficulty conveying their thoughts, feelings and needs. The increasing prevalence of ASD
diagnosis supports the development of pertinent interventions to meet the needs of individuals
with ASD. Based on the research, music therapy interventions could be a viable option.
Healthcare delivery and policy:
Based on the research, music therapy interventions should be utilized in conjunction with other
interventions due to the specificity of certain targeted deficits in communication and
socialization. The majority of studies reviewed had small sample sizes and therefore results were
not generalizable. Because of this, more research should be conducted in the area of music
interventions for communication and socialization prior to writing strict protocols for its use.
Education and training of OT students:
Discussion of benefits of music therapy intervention for children with ASD should be introduced
in entry-level occupational therapy (OT) curriculum, however, an entire course on the subject is
not necessary. Training could be provided on the various types of music therapy intervention that
are available. Overall, more research should be done to determine the effectiveness of music
therapy for children with ASD to make it a more substantial topic of interest in the field of OT.

Refinement, revision, and advancement of factual knowledge or theory:

This research supports music therapy intervention for positive outcomes in children with ASD. It
was found that music was a motivating factor for children with ASD and had positive effects on
parent-child relationships (Thompson, McFerran, & Gold, 2013). One study found the need for
various levels of stimulation (ex. simple vs. complex music) in intervention based on the
functional level of the child with ASD (Kalas, 2012). Various research studies support the theory
that music interventions are effective at fostering communication and socialization skills in
children with ASD such as joint attention, speech production and emotional understanding
(Thompson, McFerran & Gold, 2013; Sandiford, Mainess & Daher, 2012; LaGasse, 2014; Lim,
2010; Gattino, dos Santon Riesgo, Longo, Leite, & Faccini, 2011; Kim, Wigram & Gold, 2008;
Katagiri, 2009; Lim & Draper, 2011; Kalas, 2012; Kim, Wigram & Gold, 2009)

Review Process:

PICO question was developed based on a topic from AOTAs Research Opportunities
Tables- Participation in Performing Arts Programs to Reduce Emotional Problems

Initial PICO question Do children with emotional problems who engage in performing
arts have a reduction in symptoms associated with those emotional problems?

Initial PICO question was too broad for research capacity so it was narrowed down to
Does music therapy intervention help improve socialization and communication skills in
children with autism spectrum disorders?

PICO question was approved by the course instructor

A comprehensive literature review of the topic was performed using key terms

Inclusion/exclusion criteria were established

Articles obtained through the literature review were further examined to determine if they
met inclusion/exclusion criteria

10 articles met inclusion/exclusion criteria

Methodological quality of each article was assessed using the McMaster University
Critical Review Forms - Quantitative Studies

Work was peer reviewed

Reviewed articles were analyzed in an evidence table

The evidence table was reviewed by the course instructor

Further summarized in critically appraised topic (CAT)

Procedures for the Selection and appraisal of articles:

Inclusion Criteria:

Articles written in English

Articles published between 2005-2015

Participants age 0-21 years

Diagnosis of ASD

Interventions with music therapy

Intervention outcomes of socialization and communication skills

Peer reviewed journals

Exclusion Criteria:

Articles in language other than English

Articles published before 2005

Diagnosis other than ASD

Interventions not utilizing music therapy

Interventions with outcomes that do not include communication and socialization skills

Systematic Reviews

Search Strategies:
Categories
Patient/Client Population
Intervention
Outcomes

Key Search Terms

Children with autism, autism, ASD, autism spectrum disorders
Music therapy, music, music intervention, occupational therapy
Social skills, communication, communication skills, socialization,
socialization skills, social interaction, interaction, verbal skills

Databases and Sites Searched

CINAHL, Proquest Health & Medical Complete, Google, Google Scholar, hand-searching

Quality Control/Peer Review Process:

Focus question reviewed and approved by course instructor

Comprehensive literature search including databases and hand-search were completed

All appraised articles were peer reviewed and discussed for feedback

Critical reviews and evidence tables were reviewed and approved by course instructor

Results of Search:
Summary of Study Designs of Articles Selected for Appraisal:
Level of
Evidence
I
II
III

Study Design/Methodology of Selected Articles

Systematic reviews, meta-analysis, randomized
controlled trials
Two groups, nonrandomized studies (e.g., cohort,
case-control)
One group, nonrandomized (e.g., before and after,

Number of Articles
Selected
5
1
2

pretest, and posttest)

IV
Descriptive studies that include analysis of outcomes
(single subject design, case series)
V
Case reports and expert opinion, which include
narrative literature reviews and consensus statements
Other
Qualitative Studies
TOTAL:
Limitations of the Studies Appraised:

2
0
0
10

Levels I, II, and III

Level I:
Small sample size (Thompson, McFerran, & Gold, 2013; Sandiford, Mainess, &
Daher, 2012; LaGasse, 2014; Gattino, do Santos Riesgo, Longo, Leite, &
Faccini, 2011)

Use of parent report assessments, Parents non blinded may cause bias, Use of
one therapist limits generalizability of findings (Thompson, McFerran, & Gold,
2013)

Lack of follow-up (Sandiford, Mainess, & Daher, 2012)

Inconsistency among parent report, Objective measures to gauge progress,

Ranges in functional and behavioral levels between participants, Low power for
statistical analysis (LaGasse, 2014)

Duration of the training videos, Validity of the VPES (Lim, 2010)

Short duration of intervention, Need more accurate tools for outcome assessment
(Gattino, do Santos Riesgo, Longo, Leite, & Faccini, 2011)

Level II:
Small sample size; results could not be generalized to other populations (Kim,
Wigram, & Gold, 2008)
Level III:
Small sample size (Katagiri, 2009; Lim, & Draper, 2011)

No control group or randomization of participants (Katagiri, 2009; Lim, &

Draper, 2011).

No specific or valid outcome measures, Diverse ages and verbal abilities, Time
frame for the treatment was too short, No assessment data revealing if they were

able to transfer skills into social interaction in real life (Katagiri, 2009)

Division of the training conditions by the target words rather than by participant
groups, Different formats used for pre and post-tests, It was assumed that there
would be no carryover or period effects between each condition (Lim, & Draper,
2011)

Levels IV and V
Level IV:
Small sample size (Kalas, 2012; Kim, Wigram, & Gold, 2009)
No pre or posttests (Kalas, 2012; Kim, Wigram, & Gold, 2009)
No control group or randomization of participants (Kalas, 2012; Kim, Wigram,
& Gold, 2009)
No formal outcome measure (Kalas, 2012).
High number of dropouts (Kim, Wigram, & Gold, 2009)
No Level V studies appraised
Articles Selected for Appraisal:
Gattino, G. S., dos Santon Riesgo, R., Longo, D., Leite, J. C., & Faccini, L. S. (2011). Effects of
relational music therapy on communication of children with autism: A randomized
controlled study. Nordic Journal of Music Therapy, 20(2), 142-154.
doi:10.1080/08098131.2011.566933
Kalas, A. (2012). Joint attention responses of children with autism spectrum disorder to simple
versus complex music. Journal of Music Therapy, 49 (4), 430-452.doi:
10.1093/jmt/49.4.430
Katagiri, J. (2009). The effect of background music and song texts on the emotional
understanding of children with autism. Journal of Music Therapy, 46 (1), 15-31.
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, 1758-1766. doi: 10.1007/s10803-008-0566-6
Kim, J., Wigram, T., & Gold, C. (2009). Emotional, motivational and interpersonal
responsiveness of children with autism in improvisational music therapy. Music Therapy
and Autism, 13(4). 389-409. doi:10.1177/1362361309105660
LaGasse, A. B. (2014). Effects of a music therapy group intervention on enhancing social skills
in children with autism. Journal of Music Therapy, 51 (3), 250-275. doi:
10.1093/jmt/thu012
Lim, H. A. (2010). Effect of "developmental speech and language training through music" on
speech production in children with autism spectrum disorders. Journal of Music Therapy,
47(1), 2-26.
Lim, H. A., & Draper, E. (2011) The effects of music therapy incorporated with applied behavior
analysis verbal behavior approach for children with autism spectrum disorders. Journal of
Music Therapy, 48(4). 532-550.
Sandiford, G. A., Mainess, K. J., & Daher N. S. (2012). A pilot study on the efficacy of melodic
based communication therapy for eliciting speech in nonverbal children with autism.
Journal of Autism and Developmental Disorders, 43, 1298-1307. doi 10.007/s10803-0121672-z
Thompson, G. A., McFerran, K. S., & Gold, C. (2013). Family-centered music therapy to
promote social engagement in young children with severe autism spectrum disorder: a
randomized controlled study. Child: care, health and development, 40(6), 840-852. doi:
10.1111/cch.12121
Other References:

American Occupational Therapy Association. (2014). Occupational therapy practice framework:

Domain and process, (3rd ed). American Journal of Occupational Therapy, 68 (Suppl.1),
S1S48. http://dx.doi.org/10.5014/ajot.2014.682006
Autism Society (n.d). About autism. Retrieved from http://www.autism-society.org/what-is/
Autism Speaks (2015). DSM-5 Diagnostic Criteria. Retrieved from
https://www.autismspeaks.org/what-autism/diagnosis/dsm-5-diagnostic-criteria
Centers for Disease Control and Prevention (2015). Autism Spectrum Disorder (ASD). Retrieved
from http://www.cdc.gov/ncbddd/autism/data.html
Pickett, E., Pullara, O., OGrady, J., Gordon, B. (2009). Speech acquisition in older nonverbal
individuals with autism: A review of features, methods, and prognosis. Cognitive and
Behavioral Neurology, 22(1), 1-22.
Trevanthen, C., Aitkin, K., Papoudi, D., & Robarts, J., (eds) (1996) Children with Autism:
Diagnosis and Intervention to Meet Their Needs. Jessica Kingsley Publishers, London,
UK.
Wigram, T., & Gold, C. (2006) Music therapy in the assessment and treatment of autistic
spectrum disorder: Clinical application and research evidence. Children: Care, Health
and Development, 32(5), 535-542. doi: 10.1111/j.1365-2214.2006.00615.x