Ali Swoish
Autism Spectrum Disorder (ASD) is a complex neurodevelopmental disability that impacts cognitive, social, and sensory development (e.g., Crane, 2015; Kanner, 1943; LaGasse, 2017). Children diagnosed with ASD tend to withdraw from physical or social contact, and demonstrate a limited capacity to understand social cues (e.g., Edgerton, 1994; Kim, Wigram, & Gold, 2008; Lim, 2009). In fact, children with ASD have particular trouble developing joint attention and turn-taking behaviors — two non-verbal communication skills integral in establishing and maintaining relationships (Crane, 2015; Harril & Jones, 2009; LaGasse, 2017; Spiro & Himberg, 2016). As early as six months (Pasiali, LaGasse & Penn, 2014; Spiro & Himberg, 2016; Wigram & Gold, 2006), children with ASD have difficulty exhibiting joint attention, or the ability to directly engage and share an experience with another individual through the use of eye contact, pointing, listening, and sustained concentration (Crane, 2015; Kim et al., 2008; Spiro & Himberg, 2016; Vaiouli et al., 2015). Likewise, children with ASD have difficulty understanding the reciprocal flow and social timing involved in turn-taking (i.e., an interaction in which two or more people initiate and respond to one another in a time-sensitive, back-and-forth manner; Kim et al., 2008; LaGasse, 2016; Simpson & Keen, 2011; Spiro & Himberg, 2016). Given that joint attention and turn-taking are crucial for the later acquisition of more complex social skills such as sharing and symbolic play (Baron-Cohen, 1987; Spiro & Himberg, 2016; Wimpory et al., 1995), researchers have sought avenues to support the joint attention and turn-taking abilities of children on the Autism spectrum.
One such method that research has shown to be effective in engaging and socially stimulating children with ASD is Improvisational Music Therapy (e.g., Aigen, 1991; Carpente, 2014; Kim et al., 2008; Nordoff & Robbins, 1977). In Improvisational Music Therapy, also known as Creative Music Therapy, therapists and clients use multiple instruments to create music and improvise with one another (Aigen, 2001; Nordoff & Robbins, 1977; Wigram & Gold, 2006). Research has acknowledged that the creative act of music making offers children with ASD an alternative form of self-expression, social engagement, and communication that increases their ability to initiate joint attention and turn-taking behaviors (Carpente, 2014; LaGasse, 2017; Spiro & Himberg, 2016; Wigram & Gold, 2006; Vaiouli, Grimmet, & Ruich, 2015). Given recent interest in music as an alternative method for supporting the development of social skills among children with ASD, this brief literature review addresses the following question: How does Improvisational Music Therapy affect the joint attention and turn-taking skills of children diagnosed with Autism Spectrum Disorder?
Joint Attention
Recent research suggests that Improvisational Music Therapy can support the acquisition of joint attention skills such as sharing eye contact and maintaining concentration on individuals or instruments for extended periods of time (Gold et al., 2006; Kim et al., 2008; Pasiali et al., 2014; Wigram & Gold, 2006). During Improvisational Music Therapy sessions, the child learns how to focus on one instrument or rhythmic pattern at a time while temporarily ignoring other instruments or patterns being played by the therapist (LaGasse, 2016; Pasiali et al., 2014; Vaiouli et al., 2015). The therapist supports the child’s ability to maintain sustained concentration by encouraging children to match the beat of the music, create their own rhythms, and to beat drums and play piano or guitar chords at a steady tempo for minutes at a time (Edgerton, 1994; Spiro & Himberg, 2016; Wigram & Gold, 2006). These tasks require children with ASD to engage in joint attention with the therapist by acknowledging them with their eyes and ears (Kim et al., 2008; Simpson & Keen, 2011; Spiro & Himberg, 2016). As eye contact, listening, and concentration become more frequent or elongated in Improvisational Music Therapy sessions, children with ASD begin to develop a predictable, structured understanding of how to listen and respond to musical stimuli (Kim et al., 2006; Spiro & Himberg, 2016; Vaiouli et al., 2015). This form of musical scaffolding grows in complexity as the sessions continue over time, allowing for the development of attention sharing, concentration, and active listening skills that generalize to real world social situations (Edgerton, 1994; Gold et al., 2006; Kim et al., 2008; Pasiali et al., 2014; Spiro & Himberg, 2016; Wigram & Gold, 2006).
In addition, research suggests that the Improvisational Music Therapy technique of musical attunement, in which the therapist matches the child’s expressions and emotions with the music during sessions, is associated with improvements in spatial awareness (Edgerton, 1994; Gold et al., 2006; Kim et al., 2008) — a key component of joint attention. By listening to the child’s spontaneous musical input and matching their musical rhythm and melodies, Improvisational Music Therapists bring the child’s awareness outside of themselves and toward other people or instruments in the room (Kim et al., 2008; Wigram & Gold, 2006). An increased sense of spatial awareness, in turn, allows the child to feel more comfortable in maintaining direct eye contact and concentration during a session (Edgerton, 1994; Kim et al., 2008). Therefore, by creating an interactive means of connection through music, Improvisational Music Therapy aids children with ASD in obtaining the joint attention behaviors necessary to focus, concentrate, and maintain eye contact throughout the session, and subsequently in other environments (Edgerton, 1994; Kim et al., 2008; Wigram & Gold, 2006).
Turn-taking
Research suggests that Improvisational Music Therapy can also support children’s acquisition of turn-taking skills, by providing rhythmic and structured musical activities that act as building blocks for understanding social timing and interpersonal communication (Harril & Jones, 2009; Spiro & Himberg, 2016; Vaiouli et al., 2015; Wimpory et al., 1995). During music therapy sessions, therapists first guide children with ASD through repeated musical rhythms and phrases in order to create a structured format for communication (Kim et al., 2006; LaGasse, 2016). While playing instruments, the child learns to look towards the therapist and listen to the structured melodies and rhythms being created (Aigen, 2001; Gold et al., 2006; Kim et al., 2008; Spiro & Himberg, 2016). Over time, the repetition of listening, responding, and initiating behaviors during music therapy sessions provides the child with a predictable sense of which phrase will come next in the improvisation, wherein both child and therapist can pause and re-enter the phrase in a back and forth manner (Harril & Jones, 2009; Spiro, 2016; Wimpory et al., 1995).
As such, this improvised form of communication allows for practice in both receptive and expressive communication skills as the child gains the ability to intently listen to what the therapist is playing and thoughtfully respond in his or her own way (Simpson & Keen, 2011;Wigram & Gold, 2006). This back-and-forth music making offers an opportunity for children with ASD to practice a musical conversation of listening, planning, and executing (Carpente, 2014; Spiro & Himberg, 2016; Wimpory et al., 1995; Vaiouli et al., 2015). These turn-taking skills often generalize to other environments, helping them to develop the interactive capacities necessary for play (Baron-Cohen, 1987; Harril & Jones, 2009; Wigram & Gold, 2006; Wimpory et al., 1995).
Conclusion
Overall, current research suggests that Improvisational Music Therapy supports the development of joint attention and turn-taking skills in children diagnosed with ASD, thus providing them with a better understanding of how to adequately interpret and actively respond to social stimuli. However, research has yet to delineate which therapist techniques are most effective in impacting the joint attention and turn-taking behaviors of children with ASD. Furthermore, the extant research has studied children on the Autism spectrum as an aggregate, without taking into consideration the deficits and level of functioning specific to each child. Future research should therefore delineate whether the effects of Improvisational Music Therapy may differ between verbal and nonverbal children, as well as across existing levels of joint attention and turn-taking skills, in order to understand how to better support children with ASD by individually tailoring music therapy programs.
References
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Aigen, K. S. (2001). Popular musical styles in Nordoff-Robbins clinical improvisation. Music Therapy Perspectives, 19(1), 31-44.
Baron-Cohen, S. (1987). Autism and symbolic play. British Journal of Developmental Psychology, 5, 139-148.
Carpente, J. A. (2014). Individual music-centered assessment profile for neurodevelopmental disorders (IMCAP- ND): New developments in music-centered evaluation. Music Therapy Perspectives, 32(1), 56-60.
Crane, H. (2015). Music therapy and the treatment of children diagnosed with Autism Spectrum Disorder. Lucerna, 10, 110-120.
Edgerton, C. L. (1994). The effect of Improvisational Music Therapy on the communicative behaviors of Autistic children. Journal of Music Therapy, 31(1), 31-62.
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Kanner, L. (1943). Autistic disturbances of affective contact. Nervous Child, 2, 217-250.
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(9), 1758-1766.
LaGasse, B. (2017). Social outcomes in children with Autism Spectrum Disorder: A review of music therapy outcomes. Patient Related Outcome Measures, 8, 23- 32.
Lim, H. A. (2009). Use of music to improve speech production in children with Autism Spectrum Disorders: Theoretical orientation. Music Therapy Perspectives, 27(2), 103-114.
Nordoff, P., & Robbins, C. (1977). Creative music therapy. New York, NY: John Day.
Pasiali, V., LaGasse, A. B., & Penn, S. L. (2014). The effect of musical attention control training (MACT) on attention skills of adolescents with neurodevelopmental delays: A pilot study. Journal of Music Therapy, 51(4), 333-354.