birmingham autism seminar october 2009

Prof. Tony Wigram - Birmingham Autism Seminar October 2009

The social value and structure of music for ASD: Research,

diagnostic assessment and intervention

TONY WIGRAM PhDAalborg University, Denmark

Harper House Children’s ServiceHertfordshire Partnership NHS Trust


“YOU’RE GOING TO HAVE TO GIVE UP YOUR ASSUMPTIONS ABOUT SHARED MEANINGS”

“…EACH OF US WHO LEARNS TO TALK TO YOU,… MANAGES TO FUNCTION AT ALL IN

YOUR SOCIETY, …MANAGES TO REACH OUT AND MAKE A CONNECTION WITH YOU, IS

OPERATING IN ALIEN TERRITORY, MAKING CONTACT WITH ALIEN BEINGS. WE SPEND OUR ENTIRE LIVES DOING THIS, AND THEN

YOU TELL US WE CAN’T RELATE”JIM SINCLAIR


“SOCIAL SKILLS MAY BE DEFINED AS THE ABILITY TO UNDERSTAND OTHERS BEHAVIOUR AND RELATE TO THEM

ACCORDINGLY”(Pam Yates, 1992)

“IT IS THE INTERPRETATIONS OF OTHERS BEHAVIOUR THAT GUIDE OUR ACTIONS, NOT

THE BEHAVIOUR ITSELF”(Rita Jordan, 1998)


STRUCTURE IN MUSIC

Music contains a significant degree of structure, which can be applied in therapy

• Rhythmic structure

• Melodic structure

• Harmonic structure

• Phrasing

• Dynamics


Children and adults with autism

• Change, especially unpredictable change is very difficult, and provokes anxiety responses

• They often don’t understand what is required or expected of them

• You can’t explain – verbal language is often also not understood

• Predictable structures, for example in music, help

• When they can understand the structure, they can then participate in, and use the structure


The developmental problem of social interaction

• Normal babies: biologically primed to lay an active role in social interaction: Inherent timing = turn-taking dialogues

• Autistic baby: Neurological dysfunction interferes with coding and understanding messages (e.g. language, facial expression

• RECEIVES CONFUSED MESSAGES• RETREATS FROM SOCIAL INTERACTION• MESSAGES CONTINUE• DEVELOPS “CUTTING OUT” MECHANISMS• DEVELOPS OBSESSIONS AND RITUALS (to establish self

understood order)• DOES NOT EXPERIENCE NORMAL PRE-VERBAL

CONVERSATIONAL ECHANGE• DOES NOT MOVE ON INTO SOCIAL INTERACTION AND

NORMAL MLANGUAGE DEVELOPMENT


3 TYPES OF THERAPEUTIC TECHNIQUE USED IN MUSIC THERAPY THAT PROVIDES

STRUCTURE AND PROMOTES SOCIAL ENGAGEMENT

• MATCHING - EMPATHIC

• FRAMEWORKING – DIRECTIVE

• DIALOGUING - ELICITING


MATCHING

• ”Improvising music that is compatable, matches or fits in with the client’s style of playing maintaining the same tempo, dynamic, texture, quality and complexity of the musical elements.”

• Particularly important when engaging with ASD to establish an understood and shared level of social engagement. Matching is the starting point to build that relationship


FRAMEWORKING

• Providing a clear musical framework for the improvised material of a client, or group of clients, in order to create or develop a specific type of musical structure.” (Wigram 2000)

• Particularly helpful with ASD, where their creation of sounds may not be musically ‘intentional’ – a framework places their sounds inside an understandable musical context, and relates them to the therapist


DIALOGUING• - a process where therapist and client/clients

communicate through their musical play.

• Turn-taking dialogs: making music together where the therapist or clients) in a variety of ways, musical or gestural, can cue each other to take turns.

• Continuous ‘Free-floating’ dialogs: making music in a continuous musical dialogic exchange – a free-floating dialogue. Here participants (therapists) and clients)) play more or less continuously and simultaneously.

• Particularly important for ASD as Dialoguing skills are fundamental in communication


Expectations for Music therapy intervention

• Social interaction, social communication joint attention, initiation of engagement

• Music works as a social language

• Structuring interaction and dialogue through using musical structure

• Interest, motivation, initiating engagement

• Socially empathic engagement


Example 2 – AssessmentSam

• 5 years old

• Repetitive, echolalic language

• Preoccupied with the toilet

• Poor interpersonal engagement

• Assessment for diagnosis (ASD), but also for strengths and difficulties


Music therapy findings Musical Perspectives

• Initial engagement autonomous• Picks up tempi and musical style very quickly• Takes control of the music – decides when to

stop• Follows melodic, rhythmic and then harmonic

patterns from piano• Picks up and takes over musical dialogue• Loses interest – then re-engages


Edgerton (1994)

• participants:– 11 autistic children, severely to mildly impaired– Age range 6 to 9 years

• intervention:– improvisational music therapy– weekly 30-minute sessions over 10 weeks– “reversal” in 6th session using structured pre-

composed music instead of improvisation


Edgerton (cont.)

• Outcome measures:– Scale developed by the author of

Communicative Responses and Acts by the child based on items from numerous rating scales for musical communicativeness, autism and communication skills

– 107 items: 91 musical and 16 non-musical– 69 defined as communicative responses, 38

defined as communicative acts


Mean Scores for group

– change from first to last session significant (p < .01)

(graph by CLE, reproduced from JMT)


Edgerton: effect size & conclusion

• effect size:first session to last session:d = 4.56 (95% CI 3.11 to 6.01)

• conclusion:communicative behaviour of children with ASD improves during MT

• Edgerton, C. (1994). The effect of improvisational music therapy on the communicative behaviors of autistic children. Journal of Music Therapy, 21, 31-62.


Two outcome investigationsAmelia Oldfield PhD

Child development Centre, Addenbrookes HospitalCroft Children's Unit, Cambridge

• Music therapy with children with autistic spectrum disorder and their parents

• Music Therapy Diagnostic Assessments


Oldfield Study 1: General Description

• 10 children and their mothers received weekly individual music therapy sessions at the Child Development Centre, Cambridge, for 24 weeks

• Mothers (and two fathers) involved both in treatment and investigation


Main findings

• Nine out of the ten dyads achieved some or all of individual aims set out before treatment began.

• Music therapy seemed to be particularly effective at increasing the children’s levels of engagement. With a number of children, as the levels of engagement increased, the amount of continuous (engagement avoiding) playing and music making decreased.

• Music therapy was also good at increasing some of the children’s use of words and reducing echolalic speech or vocalisations.


Oldfield Study 2: Music Therapy Diagnostic Assessment (MTDA) and

Autism Diagnostic Observation Schedule (ADOS) study: Design

• Over a period of two years 30 children attending the Croft children’s Unit and receiving the ADOS and the MTDA were investigated

• A scoring system for the MTDA, similar to the already existing ADOS scoring system was devised


Comparison between ADOS and MTDA testsSimilarities Differences

• Both last 30 to 45 minutes

• Both focus on interactions through play and verbal interactions

• Both interested in process of play rather than assessing skills

• Children asked to make up stories in both tests

• MTDA more child led than ADOS

• Content of MTDA varied more than content of ADOS

• Child met MTDA tester twice rather than once (MTDA done over two weeks although only second session scored)

• ADOS more verbal than MTDA


ResultsThe two assessments showed 72 % agreement between

diagnostic categories, indicating that the MTDA was providing similar information to a recognised and established diagnostic

tool.

MTDA and ADOS agreements and disagreements

Agree72%

Disagree28%


Video Example 2 - Joel

• 7 year old boy suspected with ASD• No use of non-verbal behaviour to regulate social

interaction• Does not use direct eye contact• Bad at relating to other people – and other children• Does not share enjoyment• Lack of socially imitative play• Stereotypic, ritualistic behaviour


Joel’s responses in Music therapy

• Joel matches tempo and rhythm• Joel starts to reference me by looking • Clear evidence of awareness and attention• Joel watches and plays WITH me• Feels and plays the timing in the music• Joel breaks his own ritualised playing

patterns (up and down the black notes)


EXPECTATIONS OF THERAPY:

In the area of CommunicationActivating intersubjective behavioursSpontaneous initiation of contactDevelopment of meaningful gestures and signsDevelopment of communicative vocalisationEmergence of language in songs


In the area of Social development:

Motivated interactionShared and understood experiencesRelationship building skillsTolerance of changeEntrained responsesFlexibility


In the area of Emotional needs:Developed and Increased sense of selfEmpathic synchronicity – shared emotionsContainment of emotional expressionEmergence of insight and self-esteem

In the area of Cognitive development:Development of awareness, attention and concentration Development of organisational skillsDevelopment of memory


EVIDENCE BASED PRACTICEMusic Therapy in Autism Spectrum Disorder and Developmental Disability

Type of Evidence

Edgerton 1994 Evidence based Clinician ObservedOldfield 2005 Evidence based and Clinician ObservedKim 2006 Evidence based RCT

Walworth 2007 Clinician observedKern and Aldridge 2006 Case seriesBuday 1995 Case study randomised crossoverBrownell 2001 Case studies quasi RCTFarmer 2003 RCTHairston 1990 Clinician observedThaut 1988 Experimental studyGold et al 2003 RCTWhipple 2004 Meta review)


Music Therapy for Autistic Spectrum Disorder: A Cochrane Review

Christian Gold, PhD Bergen University, NorwayTony Wigram PhD, Aalborg University, DenmarkCochavit Elefant PhD, David Yellin College, Israel


Description of included studies

• 3 included studies

• all from USA

• N = 24 (21 male), age 2-9

• structured MT (songs, sung stories), more receptive than active

• versus „placebo“ therapy(similar therapy without music)

• short-term (1-4 weeks)


Communicative skills - gestural

Review: Music therapy for autistic spectrum disorderComparison: 01 Music therapy vs. "placebo" therapy Outcome: 01 Communicative skills: gestural

Study SMD (fixed) Weight SMD (fixed)or sub-category SMD (SE) 95% CI % 95% CI

Buday 1995 0.4756 (0.1504) 95.77 0.48 [0.18, 0.77] Farmer 2003 1.1676 (0.7159) 4.23 1.17 [-0.24, 2.57]

Total (95% CI) 100.00 0.50 [0.22, 0.79]Test for heterogeneity: Chi² = 0.89, df = 1 (P = 0.34), I² = 0%Test for overall effect: Z = 3.43 (P = 0.0006)

-4 -2 0 2 4

Favours "placebo" Favours MT


Communicative skills - verbal

Review: Music therapy for autistic spectrum disorderComparison: 01 Music therapy vs. "placebo" therapy Outcome: 02 Communicative skills: verbal

Study SMD (fixed) Weight SMD (fixed)or sub-category SMD (SE) 95% CI % 95% CI

Buday 1995 0.3471 (0.1097) 97.42 0.35 [0.13, 0.56] Farmer 2003 0.8066 (0.6736) 2.58 0.81 [-0.51, 2.13]

Total (95% CI) 100.00 0.36 [0.15, 0.57]Test for heterogeneity: Chi² = 0.45, df = 1 (P = 0.50), I² = 0%Test for overall effect: Z = 3.32 (P = 0.0009)

-4 -2 0 2 4

Favours "placebo" Favours MT


Findings

• MT may help children with ASD to improve communicative skills both gestural (p= .0006) and verbal (p=.0009)

• whether these effects are persistent remains to be shown

• for clinical practice:– MT is a promising option to help children with ASD

improve some of their core problems


Therapeutic interventions

Highest ‘success’ rate for any intervention: about 50%

• no single therapy helps everyone• no single therapy helps everything• hard to know who will benefit from what

What helps?• early intervention• intense intervention• structure and predictability• increasing ‘attention’ to others• building up motivation


Joint attention in improvisational music therapy with autistic

children

Jinah Kim

Supervisor: Tony Wigram

Aalborg University


Research Questions• 1. Do children show observable and measurable changes in

joint attention behaviour in response to improvisational music therapy?

• 2. Are there any observable musical features in improvisational music therapy that characterize the engagement and maintenance of joint attention of the child and the therapist both within and across cases?

• 3. Treatment manual related questions; were the therapists able to follow the direction of the manual? Was it possible to apply the instruction of the manual to autistic children as it was described?


Hypothesis; musical attunement and its effects on joint attention skills in children

with ASD• Musical attunement will open and maintain

the communicative channel with the child. The child’s ability in joint attention will increase positively over time and musical attunement will play a role in improving joint attention behaviour of the child with ASD. Joint attention behaviour may be better in music therapy condition than free play condition.


Research Design

• A controlled study: repeated measures, between conditions and within subjects design; 12 improvisational music therapy sessions vs.

12 free play sessions with toys. Children were randomly assigned to receive either music therapy first followed by play, or vice versa

• Two sub-conditions:“undirected vs. more directed parts”

• Systematic, semi-flexible treatment manual • Paticipants:10 children (all male), age 3 to 6

years old with clear diagnosis of autism


VIDEO EXAMPLE – ’K’

• Age: 3.03• Cognitive level: Moderate developmental Disability• Korean Childhood Autism Rating Scale (KCARS): 32.5 • Social Maturity Scale (SMS): 54.6• Psyco Educational Profile (PEP): 68.5• Non-verbal, hyperactive.• Toy Play: With Bulldozer; pushes therapist’s hand away;

plays with functions of bulldozer. • Muic Therapy: Playing on drum and cymbal –

spontaneous eye contact, smiling, affective exchanges


Dependent measures

• There were 3 pre, in-between, and post measurements

1) The Early Social Communication Scales (ESCS)

2) The Pervasive Developmental Disorder Behavior Inventory(PDDBI)

3) The Mother Play Intervention Profile(MPIP) • Analysis of sampled DVD excerpt from

sessions (Music Therapy vs. Free Play)


ESCS – joint attention and social interaction 8

10

12

14

16

18

20

22

Time point

ES

CS

-Jo

int A

tten

tion

1 2 3

56

78

9

Time point

ES

CS

-So

cia

l In

tera

ctio

n

1 2 3


The results of repeated measures ANOVA

• PDDBI :Effects over time significant (p<.0001), but group, condition and group * time are not.

• ESCS : Time (p=.0193) Time*group=.0179) • Effect size of ESCS results: - comparing scores after music therapy with after free

play (ignoring the sequence) found a medium effect (d =.57 with 95% Confidence Intervals (CI) ranging from 0.23-0.92)

- comparing scores based on the change scores between data points (i.e. change during music therapy versus change during free play) yields an effect size of d = .95 (95% CI ranging from 0.15 – 1.76), a larger significant effect. These two effect sizes were significant (p < 0.05)


Analysis of sampled video data

• 1) What are the differences in … over the four sampled sessions (1,4,8,12) when comparing:

① undirected music therapy vs. directed music therapy ② undirected free play vs. directed free play ③ directed music therapy vs. directed free play ④ undirected music therapy vs. undirected free play ⑤ directed music therapy vs. undirected free play ⑥ undirected music therapy vs. directed free play


Inter-observer reliability

Dependent variable Agreement ICC

• Eye contact frequency 0.96• Joy frequency 0.91• Emotional synchronicity 0.90 • Initiation of engagement by the child 0.93• Musical synchronicity frequency 0.96• Turn-taking frequency 0.94• Initiation of interaction 0.86• Imitation 0.69


Analysis of sampled video data 2

• The four sampled sessions were 1,4,8,12, and minutes 4-7 from the first 15 minutes (undirected section) and minutes 19-22 from the second 15 minutes (directed section) were selected for analysis:

• CODING OF BEHAVIOURS UNDERTAKEN SECOND BYSECOND.Repeated measures ANOVA to find significant differences

• BOX POLTS: Each box plot represents the pooled results. The bold line is the median value. The tiny balls are ‘outliers’ – scores that lie outside the range.

①


Selected session analysis findings; music therapy vs. free play

Eye contact Duration a significant effect (p<.0001) was found comparing the music therapy condition with free

play

MT play

02

04

06

0

Condition

Eye

co

nta

ct d

ura

tion


Joy Duration (smiling & laughing during the interaction) A highly significant effect was

found comparing the music therapy condition with free play (p<.0001), session – 1st, 4th, 8th, 12th (p= .0007) and session part – unstructured and structured (p= .0034)

1.MT 4.MT 8.MT 12.MT 1.play 4.play 8.play 12.play

020

4060

8010

0

First part of session (unstructured)

Session number and condition

Joy

du

ratio

n


020

4060

8010

0

Second part of session (structured)


Joy

du

ratio

n


Initiation of engagement by child with autism

condition (p<.0001), session (p= .0010) and session part (p= .0292).


05

1015

20

First part of session (unstructured)


Initi

atio

n o

f en

ga

ge

me

nt f

req

ue

ncy


05

1015

20

Second part of session (structured)


Initi

atio

n o

f en

ga

ge

me

nt f

req

ue

ncy


Turn-taking duration condition (p<.0001) and session part (p= .0370).

MT.1 play.1 MT.2 play.2

05

01

00

15

02

00

Condition and session part

Tu

rn-t

aki

ng

du

ratio

n


Research Autism UK Website

• Music Therapy submission by Tony Wigram, Christian Gold & Amelia Oldfield

• Evaluations by Prof. Tony Charman (UCL); Prof. Patricia Howlin (St. George’s Medical School & Prof. Dido Green (Guy’s Hospital)

• Music Therapy graded with two ticks based on the research evidence: 2 ticks represents Strong Positive Evidence of effect.


Quality rating Very strong, positive evidence•2 or more Grade A studies or •1 Grade A study and 3 or more Grade B studies The majority of these studies show significant positive effects Strong, positive evidence2 or more Grade B studiesThe majority of these studies show significant positive effects Limited, positive evidence•At least 1 Grade B study or •2 or more Grade C (cases series) studies,


Some negative evidence•At least 1 Grade B study or •2 or more Grade C (cases series) studies case series studies showing no significant effects Strong negative evidence.•1 Grade A study or •2 or more Grade B studies The majority of these studies show no significant effects. Very strong negative evidence.•More than 1 Grade A study showing no significant positive effects or •3 or more Grade B studies showing no significant positive effects or •1 Grade A study plus more than 2 Grade B studies showing no significant effects.


Hazard ratings

Limited evidence of harmful effects.Any Grade D studies indicating adverse/harmful effects

Strong evidence of harmful effects.Any Grade C studies indicating adverse/harmful effects

Very strong evidence of harmful effects.Any Grade A or B studies indicating adverse/harmful effects


1, 2 & 3 tick interventions

• 1 Tick: TEACCH; Social Stories, Gluton free Casein free diet, Milieu training, Visual Schedule

• 2 Ticks: CBT; Music Therapy, Anti Depressants (also 3 Hazards); Melatonin

• 3 Ticks: Early Intensive Behavioural Intervention (LOVAAS); Olonzapine; PECS; Risperidone (also 3 Hazards)


• References:

• Gold, C., Wigram, T., & Elefant, C. (2006). Music therapy for autistic spectrum disorder (Cochrane Review), The Cochrane Library, Issue 2, 2006. Chichester, UK: John Wiley & Sons, Ltd.www.thecochranelibrary.com

• Wigram, T & Gold, C. (2006) Title: Research evidence and clinical applicability of Music Therapy for Autism Spectrum Disorder Child Care: Health and development 32, 5, 535-542

• Edgerton, C. (1994). The effect of improvisational music therapy on the communicative behaviors of autistic children. Journal of Music Therapy, 21, 31-62.

• Oldfield, A (2006) Interactive Music Therapy in Child and Family Psychiatry. London, Philadelphia: Jessica Kingsley Publishers

• Holck, U (2002) ‘Kommunikalsk’ Samspil I Musikterapi: Kvalitative videoanalyse af musikalske og gestiske interaktioner med børn med betydelige funktionsnedsættelser, herunder børn med autism. Aalborg Universitet.

• Wigram, T., Nygaard Pedersen, I., & Bonde, L.O. (2002) A Comprehensive Guide to Music Therapy. Theory, Clinical Practice, Research and Training. London: Jessica Kingsley Publications.

• Wigram, T. (2002) Indications in Music Therapy: Evidence from assessment that can identify the expectations of music therapy as a treatment for Autistic Spectrum Disorder (ASD): meeting the challenge of Evidence Based Practice. British Journal of Music Therapy 16, (1) 11-28.

• Wigram, T (2004) Improvisation: Methods and Techniques for Music Therapy Clinicians, Educators, and Students. London, Philadelphia: Jessica Kingsley Publishers.

http://www.thecochranelibrary.com/


Thank you for your attention to my presentation

Thank you for support fromAalborg UniversityAnglia Ruskin UniversityAAU Humanistisk FakultetHarper House Children’s Service: UKNHSAutism DenmarkJinah Kim & Korean Research FoundationMusic Therapy Charity, UK

birmingham autism seminar october 2009

Health & Medicine

music music

structure of music

initiation of engagement

social skills

musical dialogue

musical style

social interaction messages

musical communicativeness