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NIHR Signal Specialist-led improvised music therapy did not improve children’s symptoms of autism

Published on 28 November 2017

doi: 10.3310/signal-000514

After five months, improvised music therapy added to enhanced usual care was no better than enhanced usual care alone for young children with an autism spectrum disorder (ASD). Clinically meaningful improvements in social and communication skills were not achieved in either group over this time. This result from a large well designed NIHR-funded international trial contrasts with an earlier systematic review of small trials that suggested beneficial effects for this specialised therapy.

Qualified music therapists provided social interactions with the children through music and singing once to three times per week. Centres in nine countries participated, including the UK. Usual care comprised a wide range of local services including communication therapies. The enhanced care was three counselling and support sessions provided to all parents in the study.

Though music itself may be useful for some children with an ASD, this specialist delivered therapy did not show any detectable benefit.

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Why was this study needed?

Autism spectrum disorders (ASDs) are lifelong neurodevelopmental conditions affecting social interaction, communication and behaviours. Around one in every 100 people in the UK have an ASD, usually diagnosed around the age of five years. ASD can have wide-reaching effects on children and their families. The estimated UK cost of supporting children combined with loss of parental earnings is more than £3 billion per year.

Although there is no cure for ASD, a variety of interventions are used to manage the condition and provide support. Music therapy aims to improve social and communication skills and is offered on the NHS.

A 2014 Cochrane review of ten studies (165 participants) suggesting positive effects of music therapy and suggested that larger-scale real-world trials were needed. This international trial recruited more than twice this number of participants, sufficient to test the effects of music therapy on young children with ASD when added to usual clinical practice.

What did this study do?

This randomised clinical trial, TIME-A, included 364 children aged four to seven years. They had a diagnosis of an autism spectrum disorder and no serious sensory disabilities. Ten centres participated from nine high-income countries including a UK arm funded by the NIHR.

Children were randomly allocated to receive one-to-one half-hour improvisational music therapy sessions for five months on top of enhanced standard care or enhanced standard care alone. Half the children receiving music therapy were invited to one session per week, and the other half to three sessions per week. Specialist music therapists used a standardised approach. Enhanced standard care comprised usual care in each country combined with three parent counselling sessions.

The study was well conducted with low drop-out. The researchers collecting and analysing data were unaware of the treatment group, which reduced bias.

What did it find?

  • At five months there was no clinically significant improvement in autism symptoms in either group. This was according to the 27 point Autism Diagnostic Observation Schedule (ADOS) social affect score, where higher numbers indicate worse symptoms. It slightly reduced from 14.08 to 13.23 in the music group and from 13.49 to 12.58 in the usual care group (mean difference [MD] 0.06, 95% confidence interval [CI] -0.70 to 0.81). A change of at least one point would be considered to be meaningful.
  • Music therapy did not have a delayed effect at seven months after the intervention period. At 12 months since baseline measures, the small but clinically significant improvement in the intervention group was the same as the improvement in the control group (MD 0.16 ADOS points, 95% CI -0.62 to 0.94).
  • There were no differences between groups according to the Social Responsiveness Scale total score which was completed by parents at five and 12 months.
  • Results did not differ for children of different ages and types of ASD, nor according to the number of music therapy sessions per week.
  • Children in the intervention group received 36 other therapy sessions, compared to 45 sessions for children in the control group. These included speech and language therapy, communication training, and sensory-motor therapies.

What does current guidance say on this issue?

The 2013 NICE guideline on autism spectrum disorders in children recommends only one type of psychosocial approach to reduce core autistic symptoms. These are social communication interventions involving play-based strategies with parents, carers or teachers. Due to the weak evidence base, there was no recommendation for music therapy.

The guideline is due to be updated in 2018.

What are the implications?

Improvisational music therapy delivered by specialist music therapists did not improve social and communication skills in children with autism spectrum disorders. Small improvements over 12 months were seen in both groups.

It is not clear whether this was due to the enhanced aspect of care – the three sessions provided to all parents in the study – or the other types of therapy sessions provided to all of the children.

It is also possible that any effect of music therapy was diluted because of the practicalities of conducting this sort of trial. For example, it might have replaced other effective components of care. Researchers report that children in music groups attended fewer other sessions and this may have led to similar improvements at 12 months despite add-on music therapy having an effect.  

Despite these concerns, it seems that this type of specialised therapy appears to have no detectable benefit.

Citation and Funding

Bieleninik L, Geretsegger H, Mossler K, et al. Effects of improvisational music therapy vs enhanced standard care on symptom severity among children with autism spectrum disorder: The TIME-A Randomized Clinical Trial. JAMA. 2017;318(6):525-35.

The UK arm of this trial was funded by the National Institute for Health Research [Health Technology Assessment Programme] (project number 12/167/95).

Bibliography

Broder-Fingert S, Feinberg E, Silverstein M. Music therapy for children with autism spectrum disorder. JAMA. 2017;318(6):523-24.

Geretsegger M, Elefant C, Mossler K, Gold C. Music therapy for people with autism spectrum disorder. Cochrane Database Syst Rev. 2014;(6):CD004381.

NHS Choices. Autism spectrum disorder: Treatment. London: Department of Health; 2016.

NICE. Autism spectrum disorder in under 19s: support and management. CG170. London: National Institute for Health and Care Excellence; 2013.

NICE. Surveillance report 2016 - Autism spectrum disorder in under 19s: recognition, referral and diagnosis (2011) NICE guideline CG128 and Autism spectrum disorder in under 19s: support and management (2013) NICE guideline CG170: Commentary on selected new evidence. London: National Institute for Health and Care Excellence; 2016.

Why was this study needed?

Autism spectrum disorders (ASDs) are lifelong neurodevelopmental conditions affecting social interaction, communication and behaviours. Around one in every 100 people in the UK have an ASD, usually diagnosed around the age of five years. ASD can have wide-reaching effects on children and their families. The estimated UK cost of supporting children combined with loss of parental earnings is more than £3 billion per year.

Although there is no cure for ASD, a variety of interventions are used to manage the condition and provide support. Music therapy aims to improve social and communication skills and is offered on the NHS.

A 2014 Cochrane review of ten studies (165 participants) suggesting positive effects of music therapy and suggested that larger-scale real-world trials were needed. This international trial recruited more than twice this number of participants, sufficient to test the effects of music therapy on young children with ASD when added to usual clinical practice.

What did this study do?

This randomised clinical trial, TIME-A, included 364 children aged four to seven years. They had a diagnosis of an autism spectrum disorder and no serious sensory disabilities. Ten centres participated from nine high-income countries including a UK arm funded by the NIHR.

Children were randomly allocated to receive one-to-one half-hour improvisational music therapy sessions for five months on top of enhanced standard care or enhanced standard care alone. Half the children receiving music therapy were invited to one session per week, and the other half to three sessions per week. Specialist music therapists used a standardised approach. Enhanced standard care comprised usual care in each country combined with three parent counselling sessions.

The study was well conducted with low drop-out. The researchers collecting and analysing data were unaware of the treatment group, which reduced bias.

What did it find?

  • At five months there was no clinically significant improvement in autism symptoms in either group. This was according to the 27 point Autism Diagnostic Observation Schedule (ADOS) social affect score, where higher numbers indicate worse symptoms. It slightly reduced from 14.08 to 13.23 in the music group and from 13.49 to 12.58 in the usual care group (mean difference [MD] 0.06, 95% confidence interval [CI] -0.70 to 0.81). A change of at least one point would be considered to be meaningful.
  • Music therapy did not have a delayed effect at seven months after the intervention period. At 12 months since baseline measures, the small but clinically significant improvement in the intervention group was the same as the improvement in the control group (MD 0.16 ADOS points, 95% CI -0.62 to 0.94).
  • There were no differences between groups according to the Social Responsiveness Scale total score which was completed by parents at five and 12 months.
  • Results did not differ for children of different ages and types of ASD, nor according to the number of music therapy sessions per week.
  • Children in the intervention group received 36 other therapy sessions, compared to 45 sessions for children in the control group. These included speech and language therapy, communication training, and sensory-motor therapies.

What does current guidance say on this issue?

The 2013 NICE guideline on autism spectrum disorders in children recommends only one type of psychosocial approach to reduce core autistic symptoms. These are social communication interventions involving play-based strategies with parents, carers or teachers. Due to the weak evidence base, there was no recommendation for music therapy.

The guideline is due to be updated in 2018.

What are the implications?

Improvisational music therapy delivered by specialist music therapists did not improve social and communication skills in children with autism spectrum disorders. Small improvements over 12 months were seen in both groups.

It is not clear whether this was due to the enhanced aspect of care – the three sessions provided to all parents in the study – or the other types of therapy sessions provided to all of the children.

It is also possible that any effect of music therapy was diluted because of the practicalities of conducting this sort of trial. For example, it might have replaced other effective components of care. Researchers report that children in music groups attended fewer other sessions and this may have led to similar improvements at 12 months despite add-on music therapy having an effect.  

Despite these concerns, it seems that this type of specialised therapy appears to have no detectable benefit.

Citation and Funding

Bieleninik L, Geretsegger H, Mossler K, et al. Effects of improvisational music therapy vs enhanced standard care on symptom severity among children with autism spectrum disorder: The TIME-A Randomized Clinical Trial. JAMA. 2017;318(6):525-35.

The UK arm of this trial was funded by the National Institute for Health Research [Health Technology Assessment Programme] (project number 12/167/95).

Bibliography

Broder-Fingert S, Feinberg E, Silverstein M. Music therapy for children with autism spectrum disorder. JAMA. 2017;318(6):523-24.

Geretsegger M, Elefant C, Mossler K, Gold C. Music therapy for people with autism spectrum disorder. Cochrane Database Syst Rev. 2014;(6):CD004381.

NHS Choices. Autism spectrum disorder: Treatment. London: Department of Health; 2016.

NICE. Autism spectrum disorder in under 19s: support and management. CG170. London: National Institute for Health and Care Excellence; 2013.

NICE. Surveillance report 2016 - Autism spectrum disorder in under 19s: recognition, referral and diagnosis (2011) NICE guideline CG128 and Autism spectrum disorder in under 19s: support and management (2013) NICE guideline CG170: Commentary on selected new evidence. London: National Institute for Health and Care Excellence; 2016.

Effects of Improvisational Music Therapy vs Enhanced Standard Care on Symptom Severity Among Children With Autism Spectrum Disorder: The TIME-A Randomized Clinical Trial

Published on 9 August 2017

Bieleninik, L.,Geretsegger, M.,Mossler, K.,Assmus, J.,Thompson, G.,Gattino, G.,Elefant, C.,Gottfried, T.,Igliozzi, R.,Muratori, F.,Suvini, F.,Kim, J.,Crawford, M. J.,Odell-Miller, H.,Oldfield, A.,Casey, O.,Finnemann, J.,Carpente, J.,Park, A. L.,Grossi, E.,Gold, C.

Jama Volume 318 , 2017

Importance: Music therapy may facilitate skills in areas affected by autism spectrum disorder (ASD), such as social interaction and communication. Objective: To evaluate effects of improvisational music therapy on generalized social communication skills of children with ASD. Design, Setting, and Participants: Assessor-blinded, randomized clinical trial, conducted in 9 countries and enrolling children aged 4 to 7 years with ASD. Children were recruited from November 2011 to November 2015, with follow-up between January 2012 and November 2016. Interventions: Enhanced standard care (n = 182) vs enhanced standard care plus improvisational music therapy (n = 182), allocated in a 1:1 ratio. Enhanced standard care consisted of usual care as locally available plus parent counseling to discuss parents' concerns and provide information about ASD. In improvisational music therapy, trained music therapists sang or played music with each child, attuned and adapted to the child's focus of attention, to help children develop affect sharing and joint attention. Main Outcomes and Measures: The primary outcome was symptom severity over 5 months, based on the Autism Diagnostic Observation Schedule (ADOS), social affect domain (range, 0-27; higher scores indicate greater severity; minimal clinically important difference, 1). Prespecified secondary outcomes included parent-rated social responsiveness. All outcomes were also assessed at 2 and 12 months. Results: Among 364 participants randomized (mean age, 5.4 years; 83% boys), 314 (86%) completed the primary end point and 290 (80%) completed the last end point. Over 5 months, participants assigned to music therapy received a median of 19 music therapy, 3 parent counseling, and 36 other therapy sessions, compared with 3 parent counseling and 45 other therapy sessions for those assigned to enhanced standard care. From baseline to 5 months, mean ADOS social affect scores estimated by linear mixed-effects models decreased from 14.08 to 13.23 in the music therapy group and from 13.49 to 12.58 in the standard care group (mean difference, 0.06 [95% CI, -0.70 to 0.81]; P = .88), with no significant difference in improvement. Of 20 exploratory secondary outcomes, 17 showed no significant difference. Conclusions and Relevance: Among children with autism spectrum disorder, improvisational music therapy, compared with enhanced standard care, resulted in no significant difference in symptom severity based on the ADOS social affect domain over 5 months. These findings do not support the use of improvisational music therapy for symptom reduction in children with autism spectrum disorder. Trial Registration: isrctn.org Identifier: ISRCTN78923965.

Improvisational music therapy is the most widely used form of music therapy in the NHS for children with autism. In the UK, more than 600 registered music therapists work with children and adults for a variety of conditions. They hold a postgraduate degree and are registered with the Health and Care Professions Council. 

The Autism Diagnostic Observation Schedule is an assessment of communication, social interaction and behaviours for diagnosis of autistic spectrum disorders (ASD) and autism. A higher score means more severe autistic symptoms, with cut-off points for ASD and for autism.

Expert commentary

This first international, multi-site study did not find music therapy statistically any more effective than enhanced standard care treatment for children with autism spectrum disorder (ASD).

However, it would be a mistake to take these findings as generalisable to music therapy treatment of children with ASD. The method of music therapy was described as ‘improvisational music therapy’, but this did not appear to take into account differences in method or technique in different countries.

A useful outcome of the study would be to encourage researchers to develop methods and assessment tools that pick up the kinds of benefits children with ASD experience, including longer-term effects post-treatment.

Dr Julie Sutton, Music Psychotherapist & Psychoanalytic Psychotherapist, Belfast HSC Trust