Music engages people. Autism advocates have recognized for years that engaging in music making can bring positive benefits to children with autism. The established profession of music therapy, which began in 1950 and currently has over 6,500 board certified music therapists throughout the United States has provided evidence-based treatment for a myriad of people including children on the spectrum. Here at the Nordoff-Robbins Center for Music Therapy at New York University’s Steinhardt School, we have been engaging children on the spectrum in music therapy since 1989.
Recently a team of International researchers published a clinical trial examining the effectiveness of improvisational music therapy in reducing symptoms for children with autism (http://jamanetwork.com/journals/jama/article-abstract/2647867). Though the findings were disappointing, the path to validating that improvisation is a bona fide evidence-based treatment for children on the spectrum has clearly begun. Early outcomes studies on recognized treatment modalities often fail to find treatment effects. Early outcome studies in all health fields are typically one-size-fits-all treatment that proceed under the assumption that all therapists, all patients/clients and all therapeutic relationships are created equally. These studies seldom find positive results because the gains of successful therapeutic relationships are negated by the unsuccessful ones. Given that fact, the finding in this study is not unusual. Second generation studies are more able to answer the question: “What treatment-specific benefits occur for which groups of patients under what conditions?”
To take the next step in the research process to establish improvisation as an evidence-based treatment intervention, music therapy researchers need to look carefully at this first generation study to understand the results. From the vantage point of years of clinical experience utilizing improvisation in the tradition of Paul Nordoff and Clive Robbins, who are considered the founding fathers of improvisational music therapy for children on the spectrum, here is my detailed perspective.
Despite its scope and strong experimental design, there were clear limitations with the study which the authors themselves acknowledge. A diagnostic tool (ADOS) was used as the outcome measure rather than an instrument that measures change in functioning or quality of life outcomes. Though the clinical interventions of the therapist were described in this study (synchronizing, mirroring, grounding), there was no discussion of how these interventions were created musically. It is impossible to assess the quality of the music created by the therapist and how effective the musical experience was in engaging the participants in this study.
The ability to listen and respond musically with sensitivity and clinical intention is a specialized skill set. It takes time and experience for music therapists to learn to improvise effectively in clinical sessions. The therapists who participated in the study varied greatly in their years of experience and training. No information was given regarding the quality of the music making or improvisational abilities of the therapists, nor specific training in improvisation, the amount of time they had already been utilizing improvisation in their practice, previous experience working with autistic children, or what kind of supervisory supports they were receiving before becoming part of the treatment team.
The authors of the study also point out study limitations in looking solely at symptom reduction. We agree with the authors that symptom reduction may not be a sensitive or appropriate outcome measure. Functional abilities are more important than reduction of symptom severity and the authors point out that this study only addresses the latter. It was a serious omission that functional gains and improved quality of life were not measured.
There were other limitations as well. The children varied greatly in terms of functioning, particularly around expressive language and cognitive abilities. It is possible that baseline symptom level was related to treatment response. For example, it is possible that children with intact speech or higher levels of cognitive functioning responded differently to the intervention than children with limited speech, or limited cognitive functioning. Subgroup analyses are essential in investigating response to autism treatments, given the heterogeneity of the population. One-size-fits all approaches are particularly limited in autism spectrum research.
Another problem related to controlling the intervention was the different numbers of sessions participants received, and that participants missed. It appears as if half of the scheduled music therapy sessions were not given. In fact, there was no discussion at all of the impact of missed sessions as a clinical variable.
The authors do acknowledge that the lack of consistency and implementation between different music therapists in different locations might have had an effect on the overall measurement of the music therapy intervention. It also acknowledges the total length of the study (5 months) as probably being too short.
The problem of testing a low-quality behavioral intervention in a large, well-designed outcome study which is not then followed by second generation studies can have major negative impacts on a field. This was the case in the ADHD literature, when in 1999 The Multimodal Study tested stimulant medication against a weak behavioral intervention. Because stimulant medication outperformed the limited behavioral intervention, and because second generation large clinical trial studies did not follow, the field was influenced for decades in believing medication was a superior treatment. It is vital that second generation studies are fielded to provide a more in-depth perspective on high-quality interventions.
The most problematic element of the study under discussion was the lack of therapy process measures. Engagement is a key ingredient for the success of any therapy. Research shows that the more engaged a client is, the more benefits he or she is likely to achieve. We know from clinical experience that increased musical engagement results in increased attention, awareness, responsiveness, organization, and flexibility in music therapy participants.
Yet this study did not measure musical engagement. It did not determine how many of the participants became significantly more engaged with music making in the sessions. We do not know how clients became more engaged. We do not know how much their level of engagement increased. It could be that some participants did become more engaged and some did not. Gains by those who did become more engaged and benefitted from the intervention may not have been detected when combined in the overall analysis with those that did not. Without looking at engagement, the researchers undertaking this study were, in our view, taking a black box approach to the intervention that they were investigating.
To summarize, we do not know anything about the quality of the musical and improvisational skill of the therapists, the quality of the music making interventions of the therapists, how many clients showed increased engagement with the music making, and whether those clients who did show increased engagement in music making made functional or quality of life gains outside in other settings. We do not even know if clients who increased engagement with music making showed reduced symptoms.
To address the need for a sensitive empirical therapy process measure, we are working at the Nordoff-Robbins Center to develop an empirically-validated process measure. Process measure data is needed to answer the question of what gains in musical engagement can be realistically expected for what groups under what conditions. This in turn drives research design; for example, treatment conditions need to be at the quality and duration of time needed to allow gains to emerge.
From our perspective, we want to know which groups of children on the spectrum increase their social connection with the primary people in their lives – family members, teachers, peers – when they increase their engagement with music during treatment in Nordoff-Robbins music therapy. This is the next step that needs to be researched, and we need to construct the best method to measure this.
Paul Nordoff and Clive Robbins are recognized as pioneers of the clinical intervention and study of improvisation (Nordoff and Robbins 2007) in clinical music therapy. Broadly speaking, they focused on the fundamental research question “How are the therapist and client engaged in music making?” In their holistic case studies, they asked and found a variety of answers to the question “How does increased musical engagement lead to overall improvement in the child’s life?” Their core question and findings continue to provide the foundation of our ongoing research at the Center.
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