Patient Related Outcome Measures

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Social outcomes in children with autism spectrum

disorder: a review of music therapy outcomes

A Blythe LaGasse

To cite this article: A Blythe LaGasse (2017) Social outcomes in children with autism spectrum
disorder: a review of music therapy outcomes, Patient Related Outcome Measures, , 23-32,
DOI: 10.2147/PROM.S106267

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Social outcomes in children with autism spectrum

disorder: a review of music therapy outcomes

This article was published in the following Dove Press journal:

Patient Related Outcome Measures
20 February 2017
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A Blythe LaGasse Abstract: Autism spectrum disorder (ASD) affects approximately one in 68 children, substan-
School of Music, Theatre & Dance,
tially affecting the child’s ability to acquire social skills. The application of effective interven-
Colorado State University, Fort tions to facilitate and develop social skills is essential due to the lifelong impact that social
Collins, CO, USA skills may have on independence and functioning. Research indicates that music therapy can
improve social outcomes in children with ASD. Outcome measures are primarily assessed using
standardized nonmusical scales of social functioning from the parent or clinician perspective.
Certified music therapists may also assess musical engagement and outcomes as a part of the
individual’s profile. These measures provide an assessment of the individual’s social functioning
within the music therapy session and generalizability to nonmusical settings.
Keywords: autism spectrum disorder, music therapy, social skills

Introduction
Autism spectrum disorder (ASD) is a pervasive neurodevelopmental disorder that
affects one in 68 children.1 Core characteristics of ASD include lack of social and
communication skills, as well as repetitive and restricted behaviors.2 There is contin-
ued need for evidence-based treatment methods for children with ASD, with only 14
established practices for children and one established practice for adults according
to the National Autism Center’s National Standards Project.3 Music therapy has been
recommended as an effective treatment intervention for social interaction, verbal
communication, and socioemotional reciprocity.4 The unique stimulus of music pro-
vides an engaging way for children with ASD to interact socially and work toward
nonmusical social outcomes.

Treatment of autism
Treatment of individuals with ASD can be difficult due to the spectrum nature of
the diagnosis. Children with ASD display a range of skills in social communication
and behaviors, making individualized treatment necessary. There are three levels of
autism: Level 1 – requiring support; Level 2 – requiring substantial support; and
Level 3 – requiring very substantial support.2 Although ~44% of persons with ASD
Correspondence: A Blythe LaGasse have average intellectual ability, ~83% of persons with ASD have co-occurring devel-
School of Music, Theatre & Dance,
Colorado State University, 1778 Campus opmental, neurological, genetic, or chromosomal disabilities.1 The average medical
Delivery, Fort Collins, CO 80523, USA costs for persons with ASD are 4.1–6.2 times higher than for those without ASD, with
Tel +1 970 491 4042
Fax +1 970 491 7541
estimates of behavioral interventions costing US$40,000–60,000/year per child.1 These
Email [email protected] factors indicate that children with ASD have substantial treatment needs. Economic

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LaGasse Dovepress

factors and differences in level of diagnosis necessitate the Music therapy professionals develop music-based inter-
use of evidence-based practices and strategies that can best ventions that facilitate social, communicative, motor/sensory,
facilitate individual outcomes. emotional, cognitive, and music skills in individuals. Music
Children with ASD have difficulty with social interaction therapy services are individualized to the person’s prefer-
behaviors, including establishing and maintaining relation- ences and abilities, and these can be provided in partnership
ships, reciprocating social interaction, and communicat- with families and treatment teams.12 Music therapy can be
ing with others.2 Lack of social skills may have lifelong used with people of different socioeconomic backgrounds,
implications for children with ASD, affecting their family/ cultures, and ages and may be provided in schools, home,
community interactions, academic skills, self-worth, and music therapy clinic, or hospital.12
independence. Reports on social skills in ASD indicate that The music therapy assessment process is used to deter-
these skills are extremely difficult to learn5 and that educa- mine the individual’s current level of functioning and the
tional objectives should be focused on developing social appropriateness of music therapy as a treatment. This process
skills because they have lifelong implications.6 Therefore, involves the application of intentional and developmentally
there is a need for effective interventions targeting social appropriate music experiences.12 Following the assess-
outcomes in children with ASD who have differing levels ment, the music therapy professional designs a treatment
of functioning and abilities. plan that outlines interventions that will be used to target
Many different treatments and practices address social skills areas of need. Although there are defined protocols within
in children with ASD. The National Autism Council’s National different approaches in music therapy,13 the music therapy
Standards Report categorizes peer training, joint attention, and clinician adapts protocols to best promote the individual’s
behavioral package interventions as “established” practices for treatment needs. Furthermore, music therapy interventions
addressing social skills.3 In a review of research addressing can be combined with evidence-based strategies, including
social skills in ASD, investigators identified video modeling reinforcement, prompting, and picture schedules.12 Due to
and social skills-based group interventions as evidence-based the highly individualized treatment approach, clinicians may
practices.7,8 Chang and Locke9 found that peer-mediated address the needs of children with different levels of ASD,
interventions, in which typical peers provide a social model, including children with comorbid diagnoses.
were also promising interventions for improvising social skills.
Although the literature includes several practices and interven- Music therapy for social skills in
tions that directly or indirectly target social skills, there is no children with autism
conclusive evidence that one method of treatment is effective There is a long history of the use of music and music therapy
for developing social skills in children with ASD. Music may services to help individuals with ASD achieve nonmusical
also be used to address social skills in children with ASD and goals, including social skills.14 Clinical writings and research
research evidence has indicated that music therapy interventions on the use of music therapy show the various approaches
can successfully promote social skills.4 to treatment with music. Clinicians and researchers have
investigated the impact of music therapy from behavioral,15
Music therapy relationship-centered,16 applied behavior analysis-based,17
Music therapy is defined by the American Music Therapy family-centered,18 social communication–emotional regu-
Association as the “clinical and evidence-based use of music lation–transactional support (SCERTS) model-based,19,20
interventions to accomplish individualized goals within improvisational,21 and neurological22 approaches to facilitate
a therapeutic relationship by a credentialed professional social skills and communication. Therefore, there are many
who has completed an approved music therapy program.”10 different approaches and interventions that can be used to target
Professional music therapists hold a bachelor’s degree or social skills in music therapy. One commonality between these
higher in music therapy. Degree programs focus on musical approaches is the use of musical stimuli and musical engage-
foundations, clinical foundations, and music therapy foun- ment to provide a foundation for enhanced socialization in
dations and principles.11 The bachelor’s degree also requires children with ASD, leading to improved nonmusic social skills.
1200 hours of clinical training, inclusive of a supervised Music therapy is a unique treatment approach that uses
clinical internship. The professional credential of Music music experiences that can engage children in meaningful
Therapist–Board Certified (MT-BC) is obtained by sitting interactions with others. Many children with ASD respond
for the national board certification examination.11 positively to music experiences, making music a safe and

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Dovepress Social outcomes in ASD

structured stimulus for social engagement and the practice instrument allow for creativity. Within this experience,
of social skills. There are several reasons that musical stimuli rhythm may be held constant in order to promote the antici-
may help with developing social skills. Music has been pation and timing of musical communication, supporting the
demonstrated to activate neural networks involved in similar overall social interaction. This musical experience, wherein
musical and nonmusical tasks (eg, speech and singing both the client and therapist may be passing musical phrases back
activate the left inferior frontal gyrus)23,24 and further has the and forth, provides a means for practicing social interaction
ability to optimize target behaviors through synchronized within a structure that provides accommodations to promote
neural firings.25 Specific to persons with ASD, initial research success. For example, this experience could be completed
has demonstrated a unique attraction to musical stimuli with school-aged children with ASD who have little to no
and enhanced musical ability,26–29 with some evidence of verbal language, providing a nonverbal means for practicing
neurological reactions similar to those of a musician when social engagement, turn taking, joint attention, and other
involved in music.30 Further, adults with ASD are shown to fundamental social skills.
have intact processing of musical emotions.31 These data Music therapy interventions are indicated to have posi-
indicate that music in treatment may provide a strong basis tive effects on social skills, including increased engagement
for learning social skills that may then be generalized into a behavior,36 increased emotional engagement,37 and improved
nonmusical context. social interaction.38,39 Researchers have also indicated that
In addition to enhanced processing of music in persons music therapy can increase social greeting routines,40 joint
with ASD, the mechanisms of musical stimuli may pro- attention behaviors,21,22 peer interactions,41 communication
vide a foundation for learning social skills. The rhythmic skills,15,17,42 and cognitive social skills.43 These studies provide
and structural components of musical stimuli provide an evidence that music therapy can promote measurable changes
external cue or anchor to further help children with ASD to in the social behaviors of children with ASD.
organize, predict, and respond. A lack of neural organiza- Although music therapy interventions can promote social
tion in children with ASD may prevent children with ASD skills in individuals with ASD, there is continued need for
from appropriately responding to their environment due to larger-scale research, as many studies focused on music
difficulties with sensory overload, planning, initiation, and therapy for social skills comprise a single-subject design or
completing motor sequences.32,33 Because social skills require are case studies. Furthermore, there are unique challenges
the ability to plan, initiate, and follow through with complex to outcome measurement in music therapy. Most music
motor plans, this lack of organization could affect a person’s therapy professionals use standardized scales or published
ability to engage socially. Rhythm and music may provide a observational scales as a part of pretest and posttest measure-
unique accommodation for these deficits, as musical stimulus ment of outcomes. These scales provide information about
is highly predictable and has been widely shown to help with generalization of skills; however, they may not accurately
planning and execution of motor patterns.34,35 Structured reflect changes that are occurring within music experiences.
musical experiences can be created to specifically provide Researchers have also used observation of behaviors within
clear cues for the anticipation and planning of a response, the sessions to determine whether children with ASD dem-
thereby facilitating social interaction. Music cues can also onstrate more social interactions when engaged in musical
be used to assist with waiting/impulse control during a experiences. Social behavior has also been investigated in
social experience, with music structure outlining the social terms of musical engagement, with observational behavior
response time of the peer. Therefore, the characteristics of recording during the music therapy treatment sessions or on
the musical experience serve as a structure for completing completion of a music therapy assessment scale. In the fol-
social interactions. lowing section, the unique aspects of outcome measurement
Although musical stimuli provide a clear time-based for social skills in children with ASD are discussed.
structure, music exploration is also inherently flexible, as
musical improvisations can use different tonalities, harmo- Promoting social outcomes in
nies, melodies, phrase lengths, motives, and structure. For children with ASD
example, the use of strict structure can be provided to help Assessment
with anticipation of a back-and-forth communication, while Assessment and diagnosis of individuals with ASD rely heav-
improvisation within a certain modality (ie, major or minor ily on parental interview, cognitive/developmental assess-
key) and the use of different melodic themes on a pitched ment, observation, and a comprehensive medical evaluation.3

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Common assessments include interview assessments such as assessment has sections for social integration, communica-
the Childhood Autism Rating Scale (CARS),44 the Autism tion, stereotyped and repetitive behaviors, sensory–motor
Diagnostic Interview-Revised,45 and the Autism Diagnostic issues, and affective dysregulation (including temper tan-
Observation Schedule.46 Music therapists do not diagnose trums and aggression). The assessment has two forms – one
disorders; however, music may provide unique insights within for individuals who are verbal and one for individuals who
the assessment process for individuals with ASD. are nonverbal. One benefit of the music-based assessment
Clinical assessment in music therapy serves two func- is the feasibility of individuals completing the assessment,
tions, namely, to track the functioning level of the client which has been shown to be 95% for the MUSAD.51 The
during the course of treatment and to determine the optimal MUSAD uses specific music interactions in order to assess
selection of treatment protocols.47 Music therapy clinicians the behavioral areas and was found to have high validity and
document progress within music therapy sessions48 and reliability.50,51
also use standardized clinical assessment tools.47 By using A second music-based assessment for children with
nonmusical assessment tools that are valid and reliable, the ASD is the Individual Music-Centered Assessment Profile
music therapy clinician can determine whether the client’s for Neurodevelopmental Disorders (IMCAP-ND).52 This
functioning level is improving and whether they are meeting assessment is from a relationship-based developmental
appropriate benchmarks.47 framework, whereby the assessment rates the individual’s
One difficulty in assessing social skills in children with ability to perceive, interpret, and create music with the
ASD is that many of the nonmusical assessment tools that therapist.52 Further, this assessment is from a music-cen-
are readily available consist of subjective scales of behav- tered treatment perspective, providing insights as to how the
ior (such as the CARS). Other scales may be training or individual is functioning in music, which can better inform
time prohibitive (such as Autism Diagnostic Observation nonmusical interactions and understanding. For example,
­Schedule). Therefore, in order to determine whether gains are the individual is rated on their focus, sharing, interactions,
being made as a result of music therapy treatment, the music affect, and initiations within the musical experiences.
therapy professional may use a combination of assessment Although these musical assessments are no replacement
tools, including parent-report scales (such as the Autism for formal diagnostic procedures, the assessments may
Treatment Evaluation Checklist), clinician-based observa- be useful to help identify a person’s unique strengths and
tion scales (such as the Functional Emotional Assessment abilities within a more creative and motivating nonverbal
Scale), clinical session data documentation, interview, or form of interaction.
observation of the client across different settings. As many
music therapists are members of a larger interdisciplinary Outcomes from a parental
treatment team,48 observations from other professionals may perspective
inform the music therapist as to the generalization of skills Parent questionnaires have frequently been used to deter-
in other settings. mine the impact of music therapy treatment on children
Music therapists also use musical materials in order to with ASD. Parental questionnaires are commonly used
assess nonmusical functioning, including social skills. As in music therapy research because the participants in the
a form of alternative communication and play, assessment studies are often children who may not have verbal or
in music interactions may show social reciprocity, social cognitive skills to report on their own perceptions of their
engagement, responsiveness, and verbal/nonverbal interac- abilities. Scales used in the literature include the Social
tions.49 Because many children with ASD are attracted to Responsiveness Scale (SRS), 53 the Autism Treatment
musical stimuli, music can be used to further assess core Evaluation Checklist,54 Vineland Social–Emotional Early
characteristics of ASD.49,50 There are also two music-based Childhood Scales,55 and the Parent–Child Relationship
assessments that have been developed and tested for validity Inventory.56 Social communication has been quantified
and reliability. using the MacArthur–Bates Communicative Development
The Music-based Autism Diagnostics (MUSAD) was Inventories.57
developed specifically to assess functioning in adults with Social interaction skills have been shown to improve due
intellectual disability who may also have ASD.50 The assess- to group music therapy intervention compared to a control
ment was developed to assess the ICD-10 characteristics of group condition based on parental completion of the SRS.22
ASD, with the DSM-5 characteristics also integrated. The Significant improvements have also been indicated with the

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Dovepress Social outcomes in ASD

Vineland Social–Emotional Childhood Scales in a study of Inventory (PDD-BI),62 and the Early Social Communication
individualized family-centered music therapy (FCMT).18 Scales.63 The results of music therapy studies indicated that
Parental reports can be essential to understanding the gen- social skills for nonverbal children with ASD improved based
eralizability of learned skills; however, there is the potential on the CARS-Brazilian version (BR) scale,61 the Early Social
for parent bias, because there was no blinding of the treat- Communications Scale,21 the social subscale of PDD-BI,21 and
ment received in these studies. Despite the potential for bias, the Functional Emotional Assessment Scale.16
parental report may reflect how meaningful and relevant Observational data have also been collected and coded
treatment is to the family unit.4 in order to determine social behaviors during or after music
Parental opinion of music therapy for social and rela- therapy treatment sessions. The number of instances of
tionship outcomes has also been reported using qualitative receptive or initiated joint attention bids has been shown
research in which parents are involved in interviews and/or to increase both during22 and after music therapy interven-
focus groups. These studies indicate that music therapy inter- tions.64 Eye gaze and eye contact have also been shown to
ventions that involve the family can have a positive impact on improve during music therapy sessions using observational
the parent–child relationship in both the individual and group measures.22,65 One study also demonstrated improvements in
settings.58,59 Table 1 illustrates the range of parental-report imitation and turn taking during music therapy intervention
tools used to evaluate the effect of music therapy interven- sessions.65 Children with ASD who are engaged in music
tions from a sampling of the music therapy literature. therapy interventions have also shown improvements in joint
attention and focusing on faces outside of the music therapy
Outcomes from a clinician session.64 Table 2 illustrates the range of clinician-report tools
perspective used to evaluate the effect of music therapy interventions
Social interaction skills in music therapy treatment studies have from a sampling of the music therapy literature. Table 3
been investigated using published scales of social behavior. illustrates the use of observational measures to evaluate the
Most of these scales are completed outside of the therapeutic effect of music therapy interventions from a sampling of the
contexts as pre- and posttest measures, potentially indicating music therapy literature.
generalization of skills outside the treatment session. Further,
these scales have been completed by professionals who are Music-centered outcome measures
otherwise uninvolved with the study in order to limit researcher Although most studies on the use of music therapy for social
bias in completing these tools60 or raters who are blinded to skills in children with ASD rely on standardized or gold
the participant’s group.21,61 Scales used in the literature include standard assessments of nonmusical skills, some researchers
the CARS,44 the Pervasive Developmental Disorder Behavior have approached outcome assessment from a music-centered

Table 1 Range of parental-report tools used to evaluate the effect of music therapy interventions
Author Group/individual Design Final number of Sex Age, Parent-reported scales
participants years used
Allgood59 Group with families One group N=4 F = 2; M = 2 4–6 Interview and focus groups
Geretsegger et al80 Individual Feasibility of N = 15; high-dose treatment F = 4; M = 11 4–6 Social Responsiveness Scale
randomized (n = 4); low-dose treatment
controlled trial (n = 3); control (n = 8)
LaGasse22 Group Randomized N = 17; treatment F = 4; M = 13 6–9 Social Responsiveness Scale;
control trial (n = 9); control (n = 8) Autism Treatment Evaluation
checklist
Thompson et al18 Individual with family Randomized N = 21; treatment (n = 11); Not reported 3–6 Vineland Social–Emotional
controlled trial control (n=10) Childhood Scales (VSEEC);
Social Responsiveness Scale –
Preschool; MacArthur–Bates
Communicative Development
Inventories; The Parent–
Child Relationship Inventory
Thompson and Individual with family One group N = 11 Not reported 3–6 Interview
McFerran58
Abbreviations: F, female; M, male.

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Table 2 Range of clinician-based observation tools used to evaluate the effect of music therapy interventions
Author Group/ Design Final number of Sex Age, Clinician-based
individual participants years observation scales
Carpente16 Individual Case study N=4 F = 2; M = 2 4–8 Functional Emotional
Assessment Scale (FEAS)
Kim et al21 Individual Repeated measures N = 10 F = 0; M = 10 3–5 Early Social Communication
within subject Scales; Pervasive
design Developmental Disorder
Behavior Inventory-C
Geretsegger et al80 Individual Feasibility of N = 15; high-dose treatment F = 4; M = 11 4–6 Autism Diagnostic
randomized (n = 4); low‑dose treatment Observation Scale –
controlled trial (n = 3); control (n = 8) Social Affect
Abbreviations: F, female; M, male.

Table 3 Range of clinician-based observation tools used to evaluate the effect of music therapy interventions
Author Group/ Design Number of Sex Age, Observation measures
individual participants years
Finnigan and Individual Single case alternating N=1 F 3 Eye contact, turn taking, imitation
Starr65 treatment design
Kern and Individual Single system multiple N=4 M=4 3–5 Play/engagement and interaction
Aldridge41 baseline with peers
Kern et al40 Individual Single system N=2 M=2 3 Independent and prompted
withdrawal design responses
Kim et al21 Individual Repeated measures N = 10 M = 10 3–5 Instances of eye contact, as well as
within subject design turn-taking frequency and duration
Kim et al37 Individual Repeated measures N = 10 M = 10 3–5 Motivational responsiveness and
within subject design social responsiveness
LaGasse22 Group Randomized N = 17; treatment F = 4; M 6–9 Instances of joint attention,
controlled trial (n = 9); control (n = 8) = 13 initiating, responding, and social
eye gaze
Pasiali et al78 Individual Case study N=3 F = 1; M = 2 7–9 Behaviors observed to be different
for each child, based on needs
Vaiouli et al64 Individual Single system multiple N=3 F = 1; M = 2 5–7 Focus on faces, response to joint
baseline design attention, and initiation of joint
attention
Abbreviations: F, female; M, male.

perspective. Assessment of musical engagement and musical patterns.60 These changes were accompanied by changes in
interactions can provide information about how the child standardized scores, including scores on the Clinical Global
engages with musical stimuli and how this fits into a devel- Impression (CGI) scale and the Brief Psychiatric Rating Scale
opmental framework. (BPRS).67,68 Although music skills are not commonly tested
The Music Therapy Diagnostic Assessment (MTDA)66 in music therapy studies, changes in music skills could have
was used as a secondary outcome measure to determine implications for inclusion in music education classrooms or
engagement within music therapy sessions.18 In particular, overall engagement in music-making experiences. Table 4
this scale measured the child’s social communication and illustrates the use of musical measures to evaluate the effect
interpersonal engagement. This measure indicated a sig- of music therapy interventions from a sampling of the music
nificant positive difference for children engaged in music therapy literature.
therapy sessions.18
Music skills have also been included as a variable to Strategies for improved outcomes
determine whether engagement in music would affect musical The purpose of music therapy services is to use specific
milestones and absorption of music. One study found that musical stimuli in order to promote nonmusical skills
children with ASD who participated in 52 weekly music through music experiences. Music therapy interventions
therapy sessions increased their ability to sing melodies, play may include improvisation, precomposed music, and/
a musical scale, and reproduce simple and complex rhythmic or active music-making experiences that promote skills

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Table 4 Range of music-based tools used to evaluate the effect of music therapy interventions
Author Group/individual Design Number of participants Age, Sex Music-centered scale
years or observation
Boso et al60 Group One group N=8 23–38 F = 1; M = 7 Musical skills (playing
scales, singing melody,
and reproducing rhythm)
Kim et al21 Individual Repeated measures N = 10 3–5 M = 10 Musical synchrony
within subject design (observation)
Thompson et al18 Individual with family Randomized N = 21; treatment (n = 11); 3–6 Not reported The Music Therapy
controlled trial control (n=10) Diagnostic Assessment
Abbreviations: F, female; M, male.

including ­communication, social interaction, motor skills, practiced and learned. Improvisation in music therapy has
and cognition. Music therapy research has long focused on also been combined with general treatment models, including
social skills as one area of treatment and the unique aspects family-centered practice and the Developmental, Individual
of music interaction have been shown to help individuals difference, Relationship-based Floortime (DIRFloortime®)
with ASD to engage socially.14 Although more research is model.73
needed on the use of music therapy for social outcomes in FCMT has been applied by music therapy professionals
individuals with ASD, the extant literature shows positive to improve engagement within the community and with the
improvements in social responsiveness, communication, and child–parent relationship.18,58,59 FCMT incorporates exercises
joint attention skills. that promote parent–child relationships using music as a
Researchers have demonstrated that persons with ASD way to engage the child in the experiences. Therefore, this
often have unique attraction to music and may have enhanced approach is supporting both the parent–child relationship and
musical abilities.31,69,70 This attraction to music can be used skill development.18 The music therapist works in collabora-
to engage children with ASD in musical experiences that can tion with the parents in order to facilitate active interaction
facilitate social skills. In these experiences, engagement is with their children.74 Exercises used within an FCMT session
promoted through interactions with musical stimuli but also may include a greeting song to orient the parent and child
with the music therapist who is crafting musical stimuli that to the session, structured improvisations whereby the music
will engage the child. Peers (with ASD or neurotypical) or therapist may play a predictable harmonic structure and
parents are often involved in the sessions to promote social pause for the child to respond, structured instrument games,
skills within the family or peer group. Several types of music and/or songs with props.18 Principles of FCMT are outlined
therapy interventions and approaches have demonstrated by Thompson.74 This approach in treatment may be more
increased social engagement, including improvisational beneficial for children with ASD who are still developing
music therapy and neurological-based group music therapy. interaction skills with their families.
Improvisational music therapy has been shown to increase Child-centered and relationship-based improvisational
joint attention, social–emotional skills, social engagement, music therapy has also been shown to increase joint engage-
and nonverbal social communication. 16,21,37,71 Children ment in children with ASD.16,64,75 A full report on how music
involved in improvisational music therapy experiences are has been used within the DIRFloortime is outlined in the
actively engaging in interactive live music-making experi- case studies paper by Carpente.16 One example of music
ences. The music therapist will follow the client’s musical therapy intervention from the DIRFloortime approach is
lead, creating spontaneous music to engage musical and the two-way purposeful musical play, whereby the music
nonmusical responses.72 The music therapist can then change therapist improvises music that offers space for a response,
the music, creating music that can directly engage the clients engaging the child in a back-and-forth musical interaction.
in order to promote their therapeutic needs (such as social The spontaneous creation of music helps to first engage the
skills). In addition to overall social engagement, researchers child and then allows the child to respond to the therapist’s
have reported more instances of “joy” and “emotional syn- crafting of musical questions, thus increasing social engage-
chronicity” when children with ASD are engaged in impro- ment.16 Similar to FCMT, this approach may be best suited
visational music therapy compared to play.37 Therefore, the for children with ASD who are attracted to music making
positive and naturally engaging experience of making music and have needs in areas of social engagement and social
serves as the foundation on which the nonmusical skills are interaction skills.

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Although the specific approach in each of these afore- Music therapy interventions have also been shown to
mentioned music therapy interventions varies, the unifying improve cognitive and emotional processing skills that may
factor is the use of engaging musical experiences to help directly affect social skills. Initial evidence indicated that a
promote social engagement. Along with the musical stimuli, music therapy protocol increased selective and alternating
the interactions are at the core of each of these experiences. attention in children with neurodevelopmental disorders,
Musical engagement may be essential for the improvement of including ASD.78 Speech communication was shown to increase
social skills, as simply introducing musical materials has not in children receiving music therapy interventions, with the
been shown to increase social engagement.41 Further, simply greatest benefit for children who exhibited low verbal skills.15
presenting music in the environment has not been shown to Music therapy interventions have also been shown to improve
have an effect on engagement of children with ASD.76 There- emotional understanding,79 which may affect a person’s ability
fore, the combination of clinically selected music within a to relate to another person. Music interventions have also been
social experience is needed for increased social engagement. shown to improve motor initiation and sequencing,35 affecting
Music therapy clinicians developing musical experiences a person’s ability to initiate, sustain, or complete motor move-
for joint attention must consider many factors of the expe- ments related to social exchanges. Although more research on
rience, including the age of the clients, level of ASD, and these areas of treatment is needed, studies demonstrate initial
presenting behaviors. Unique to music therapy treatment, the evidence that music may improve skills that could directly
clinician must consider the type of music that will be used, as affect social skills in children with ASD.34,35,78
the style and/or complexity of the music may affect responses.
For example, Kalas77 found that more complex music was the Conclusion
most effective musical stimulus for eliciting joint attention Music therapy treatment may be beneficial for improving
in children with mild/moderate ASD. Conversely, children social skills in children with ASD. The unique qualities of
with severe ASD demonstrated greater joint attention with music within therapeutic interventions provide a foundation
less complex music. Therefore, the role of the music thera- for practicing social skills, including social engagement and
pist is to determine what type of music and music materials joint attention. Initial evidence supports the use of music
promotes joint attention skills and then to use those materials therapy intervention for children with ASD, with a 2014
within social experiences that provide the person with ASD Cochrane review4 indicating that music therapy interventions
the opportunities to practice joint attention. are successful for improving social interaction, verbal commu-
Musical materials and experiences have been shown to nication, initiating behavior, and social–emotional reciprocity.
be superior to nonmusical materials in the promotion of joint Although there is research support for the use of music
attention.21,22 In one study, children with ASD were engaged therapy for improving social skills in children with ASD,
in music-making experiences that promoted joint engage- more research is needed, in particular, on the impact of music
ment with a peer with ASD. Researchers coded for triadic therapy on adults with ASD. Furthermore, research is needed
joint attention that was receptive or initiated. Music therapy on the use of music therapy for children with different comor-
experiences included playing instruments, where triadic joint bidities and different levels of ASD. More research is needed
attention was between two child peers and an instrument. The on assessment tools that can appropriately capture social
music therapist provided structure using an original song that skills in music therapy interventions and the generalization
contained lyrics for the steps of joint attention to the peer and of these skills to other settings. Further, current scales have
the instrument. In this case, the instrument is a desired object only indicated parent or clinician perceptions of outcomes, as
and the reference to another person/participation in musical there are no reports of patients with ASD informing others on
play continues the engagement with an item and another their perception of outcomes due to music therapy treatment.
person in the room. The musical experience is rewarding
and can therefore be used to promote or reinforce the desired Disclosure
social skill. The researchers noted that in the play group, the The author reports no conflicts of interest in this work.
observational data indicated that the children spent more time
occupied with the tools in the room (such as game pieces) References
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