Fostering Music Engagement of Young Children Displaying Autistic Symptoms

SoYoung Park, Suebin Lee, and Olive Zhou

Autism spectrum disorder (ASD) is a developmental disorder that can hinder one’s ability to comprehend emotions, build social skills, and respond flexibly to changes and transitions (Jadhav & Schaepper, 2021). According to the World Health Organization (2022), approximately 1% of children are diagnosed with ASD. Notably, however, many children displaying symptoms of autism do not receive a formal diagnosis during the formative early childhood years (Centers for Disease Control and Prevention, 2022). Nevertheless, the prevalence of ASD among young children has led to a focus on early identification and intervention (National Institutes of Health, 2021; U.S. Department of Health & Human Services, 2020).

One intervention that young children displaying autistic symptoms might benefit from is music therapy, particularly Improvisational Music Therapy (IMT), which has been used to address social communication, engagement, and socialemotional connections (American Music Therapy Association [AMTA], n.d.; Carpente et al., 2022; Geretsegger et al., 2012; Geretsegger et al., 2015; Kim et al., 2008; Kim et al., 2009). Specifically, the client’s music engagement, defined as therapistfacilitated involvement in the music-making process, is essential to achieving therapeutic goals in IMT, and is, to some extent, contingent on the music therapist’s skills (Aigen, 2013; Bieleninik et al., 2017; Birnbaum, 2014; Bruscia, 1988; Geretsegger, 2015; Kim et al., 2009). Yet, few studies have explored the role of IMT music therapists in fostering the music engagement of children displaying autistic symptoms.

Social Engagement and IMT

Many early signs of autism relate to difficulties with social engagement (i.e., the ability to engage, interact, or initiate social interactions; Kiely & Flacker, 2003; Thompson et al., 2013). For example, children displaying autistic symptoms typically experience difficulties in joint attention, turn-taking, understanding of social cues, and other basic social skills (Silveira-Zaldivar et al., 2021). These challenges increase the risk of developing anxiety, depression, and social isolation, and also interfere with academic attainment and relationship and employment maintenance (Silveira-Zaldivar et al., 2021). Therefore, deficits in social interactions – especially social skills and social competence – are key targets of early interventions for children displaying autistic symptoms (Landa, 2007; SilveiraZaldivar et al., 2021; Vernon et al., 2012).

Typically, training in social skills includes initiating interactions, responding, maintaining eye contact, recognizing emotions, and understanding body language (Bellini & Peters, 2008; White et al., 2006). Nevertheless, explicit social skill training has been found to produce limited beneficial outcomes for children with autism (Bellini & Peters, 2008; LaGasse, 2017; Weiss & Harris, 2001). By contrast, social skills training implicitly embedded in alternative forms of therapy, such as IMT, has been found to be more effective. In IMT, clients and therapists engage in musical dialogue, which closely mimics social communication, as clients actively participate in the process of music-making through attentive, interactive, and reciprocal musical interactions (LaGasse, 2017; Mayer-Benarous et al., 2021; Nordoff-Robbins Center for Music Therapy, n.d.). What makes IMT especially effective for children displaying symptoms of autism is its improvisational aspect. The flexibility inherent in musical features (e.g., rhythm, tempo, motion, and expression) can reflect the children’s here-and-now behaviors, allowing therapists to identify and focus on children’s individual needs (Aigen, 2001; AMTA, 2015; Pavlicevic, 2000; Sacks, 2008). This client-centered approach fosters children’s engagement in the sessions, which, in turn, helps them gain important social skills such as responsiveness, adaptability, organization, and attention (Kim et al., 2008; Kim et al, 2009; Nordoff-Robbins Center for Music Therapy, n.d.; Pavlicevic, 2000; Perkins et al., 2020).

IMT and Therapeutic Alliance Created by Music Engagement

The beneficial outcomes of music engagement in IMT are not only a result of the improvisation but also of the therapeutic alliance, which is defined as the collaborative relationship between therapist and client (Aigen, 2013; American Psychological Association., n.d.; Birnbaum, 2014; Kim et al., 2008; Lee & Kim, 2021; Pavlicevic, 2000). In IMT, the therapeutic alliance is achieved through clinicians and clients creating music collaboratively and spontaneously with various instruments to build interconnectedness (Bruscia, 1987; Carpente et al., 2022; Geretsegger et al., 2012; Pavlicevic 2000; Ritholz, 2014; Sacks, 2008). The greater the clients’ music engagement, the stronger the therapeutic alliance between the therapist and client, as music allows the client and the therapist to connect on an interpersonal level (Aigen, 2001; Pacliveciv, 2000; Sacks, 2008). Ultimately, the strength of the therapeutic alliance and the level of music engagement depend on the music therapist’s initiative and guidance (Aigen, 2013; Lee & Kim, 2021; Silverman, 2019). In other words, music therapists are responsible for encouraging and facilitating clients’ music engagement while also challenging them to meet their clinical goals. This is only possible once a strong therapeutic alliance is established, where clients feel safe being challenged by their therapists (Aigen, 2013).

Several studies highlight client empowerment as one of the ways to reach this therapeutic relationship while also challenging clients to meet their goals (Daveson, 2001; Hirsch & Meckes, 2000; Magill, 2009; Rolvsjord, 2009). Empowerment in music therapy not only comes from the music-making process itself, but also when therapists help clients recognize their potential by providing positive affirmation, respect, and hope (Rolvsjord, 2009). As therapists use music to help clients engage, they also empower clients to feel less helpless or discouraged from past negative experiences and stigmatization of their symptoms (Magill, 2009). Characterized by validating interpersonal connections and mutual music engagement between therapist and client, empowerment in music therapy sessions encourages clients’ participation and helps foster positive attitude and cognitive restructuring (Daveson, 2001). In turn, clients gain a sense of control, which can facilitate an improvement in their social skills, and, ultimately, help them meet their clinical goals (Hirsch & Meckes, 2000).

Current Study

Taken together, past research has shown that IMT is an effective intervention for young children displaying signs of autism (Kim et al., 2008; LaGasse, 2017; Reschke-Hernandez, 2011; Wigram & Gold, 2006). Although previous studies have focused on IMT for children of various ages (Bieleninik et al., 2017; Dekker et al., 2022; Geretsegger et al., 2012; Geretsegger et al., 2015; LaGasse, 2016; Mayer-Benarous et al., 2021; Mössler et al., 2020; Vasa et al., 2021; Whipple, 2004; White et al., 2007; Wigram & Gold, 2006), as of now, few studies have explored the use of IMT with preschoolers. There is also a lack of empirical research examining the benefits of IMT for young children displaying signs of autism (Geretsegger et al., 2014; Whipple, 2004). Most importantly, there has been limited focus on the perspectives of music therapists regarding the ways they support the music engagement of young children who are displaying signs of autism. To address these gaps, the current qualitative study explored the following question: How do IMT music therapists foster the music engagement of young children displaying autistic symptoms?

Participants

Method

Four music therapists, recruited via the Nordoff-Robbins Center for Music Therapy, participated in the current study. All participants had clients between the ages of two and five displaying symptoms of ASD. Two of the therapists were enrolled in graduate programs in music therapy, while the other two participants had a Master’s degree in music therapy. Each of the therapists had at least two years of experience in the field of music therapy. Three therapists were East Asian and one was multiracial. All self-identified as women, and all were in their twenties.

Procedure

Semi-structured interviews with nine open-ended questions were held with each therapist. Some key questions included “How do you recognize music engagement?” and “How important is music engagement in your music therapy sessions with your client?” (See Appendix for the full list of interview questions.) Follow-up questions were asked based on therapists’ answers during the interview. All interviews were held at the Nordoff Robbins Center for Music Therapy. Interviews ranged in length from 45 to 60 minutes and were audio-recorded.

Transcription and Coding

The audio recordings were initially transcribed using the website Trint, and were later reviewed by researchers, sentence by sentence, to avoid misinterpretation and mistranscription. Then, using grounded theory (i.e., thematic analysis), researchers independently read the transcripts to highlight key themes. The researchers then convened to review and discuss the themes. Ultimately, three common major themes were identified, with the inter-rater reliability at 80%.

Results

Three main themes demonstrating how music therapists foster music engagement for young children displaying autistic symptoms emerged from the data: the flexibility of improvised music, empowerment and creation of a safe space, and the involvement of co-therapist and parents.

Theme 1: Flexibility of Improvised Music

All four therapists described the flexibility of improvised music during IMT sessions as a critical element in supporting children’s music engagement. In contrast to pre-composed music that has strict form and structure, improvised music allowed therapists to reflect on children’s physical and emotional behaviors at the moment, by using musical elements like the chord scale and loudness. For example, when a child got distracted by the air conditioner controller in the room and rushed to observe it in detail, the therapist played the piano with an ascending scale to match the child running toward the object. Likewise, when the child stopped and looked at the air conditioner controller, the therapist paused until he rushed back, at which point the therapist resumed playing on a descending scale. In response to these improvisations, children became more musically engaged in the sessions. For example, they played with more instruments, moved or sang along with the therapist’s improvised music, and interacted with different objects in the therapy space to bidirectionally create more improvised music with the therapist. Music was also improvised to match the children’s emotional intensity. One therapist specifically mentioned using “melodic contour” (i.e., by controlling the volume or the level of pressure against the piano keys) to capture the implied emotion in children’s language and communication. For example, the therapist would play the keys softer when the child said, “This is a gift for mom” to match her tender emotions and kindness to her mother, but played the keys stronger when the child said, “I wonder where the object that I’m looking for is at” to match her frustration and irritation. In general, therapists utilized flexible musical elements like tone, pitch, and loudness to help the children engage in the session. The therapist’s attempt to match the children’s emotions through music not only helped validate their feelings but also allowed space for the children to be more musically engaged. The children added new words to the song, stomped to the beat, and played instruments to maintain or change the mood of the music, which helped them stay invested in the creation of the music. Therapists, thus, used the flexible nature of improvised music to engage the children in the sessions.

Theme 2: Creation of Safe Space and Empowerment

A second theme that emerged from the data was the importance of creating a safe space and empowering the children to make them feel confident in engaging musically. For example, one music therapist stated the following:

...There’s no right or wrong music. Every music is how they respond to that thing and that moment. So, I think music engagement is really helping them to realize — to focus on what they are doing right now at the moment instead of worrying about what the outcome will be after doing this.

Using this frame of nonjudgmental music-making, therapists were able to create a “container” of validation and acceptance for the children, freeing them from criticisms of their behaviors in the session. This increased the therapeutic alliance between the therapists and the children, allowing them to feel safe to explore a variety of issues using unfamiliar instruments to create unconventional tunes, thereby better connecting with their emotions.

Furthermore, the validation and acceptance in the therapy environment helped to foster music engagement. All four therapists reported that they encouraged musical initiative by empowering the children to gain a sense of control over their music-making, such as by giving them numerous choices of instruments, musical styles, lyrics, rhythm, and beat. One of the therapists described how her method of using the child’s own words in the improvised songs allowed the child to feel empowered, stating that “...in music, using [the client’s] own language [improvisationally] is very empowering for [her] selfdevelopment [because] she’s actually taking more independence and autonomy over the musical environment that is [hers].” Through these interactions, therapists were able to give children the confidence to take initiative, leading them to be more engaged in the music-making process.

Theme 3: Collaboration With Co-therapists and Parents

Therapists also reported that their facilitation of music engagement was often done in collaboration with co-therapists and/or the children’s parents. Three therapists highlighted the importance of collaboration between music therapists when discussing a child’s music engagement. For example, at times co-therapists contributed unique perspectives related to a child’s music engagement, based on factors such as their closer physical proximity to the child. As one co-therapist stated: [As a co-therapist] I think I have to negotiate with the primary [therapist] because the primary therapist thinks the child is a one or two [on a music engagement scale], but I don’t think so. […] For example, he sings something but it’s so easy to miss because [the primary therapist] cannot hear sometimes while playing the piano.

Importantly, the collaboration between music therapists is characterized by their joint efforts to create the most personalized session to foster and assess children’s music engagement. Moreover, two of the music therapists mentioned parents’ role in helping to foster children’s music engagement. Some therapists noted that they invited caregivers to join, especially when children demonstrated separation anxiety, and found that parents provided support and encouragement, which the therapists could then build on to foster more music engagement. For example, when parents were encouraged to not only be physically present, but to sing along and participate in the music-making, therapists were better able to encourage the children to engage with the music. Moreover, some of the therapists elicited ideas from parents, regarding topics to discuss with the children or areas to work on, which, too, resulted in a greater ability to foster children’s music engagement.

Discussion

The current study aimed to explore how IMT music therapists foster the music engagement of young children displaying autistic symptoms. Three themes emerged from interviews with music therapists: (1) the use of improvisational music as a flexible tool to encourage music engagement, (2) the importance of creating a safe therapy space to empower children during IMT sessions, and (3) working in collaboration with a cotherapist and/or a child’s parents. Each of these factors was seen as an important contributor to facilitating the music engagement of young children displaying symptoms of autism.

Findings were aligned with past research that has shown how the dynamic elements of music (e.g., volume, duration, tempo, and pitch) can be used to mirror children’s physical and emotional behaviors (Aigen, 2001; Pacliveciv, 2000). In turn, as previous work has shown (Aigen, 2001; Pacliveciv, 2000; Sacks, 2008), the fluid and communicative nature of music can foster increased music engagement and facilitate greater therapeutic relationships. Likewise, in accordance with previous literature (e.g., Kim et al, 2009; Perkins et al., 2020), results highlighted that creating a safe environment encouraged children’s music engagement during IMT sessions. Findings of the current study also demonstrated that music engagement in IMT sessions supported children’s sense of autonomy and independence. Therapists shared that children who were musically engaged were able to take control of the session by initiating the musicmaking and actively collaborating with their music therapists. Notably, one of the therapists described music engagement as a prerequisite for interaction and improvement in developing social skills — one of the main clinical goals for these children. By using what is already known about the effectiveness of music and human emotion, young clients improved their autistic symptoms and social skills through music engagement in IMT sessions. Lastly, as indicated in previous research, cotherapists’ and parents’ involvement in IMT sessions was critical for children displaying autistic symptoms (Aigen, 2013; Lee & Kim, 2021; Silverman, 2019). Importantly, the current findings showed that a collaboration between music therapists and parents helps facilitate children’s music engagement during IMT sessions, improving the therapeutic alliances and supporting social skills (Aigen, 2013; Lee & Kim, 2021; Silverman, 2019). Extending past findings, however, the current results highlighted that the client-therapist relationship was influenced by other indirect relationships, such as those between primary therapists and co-therapists. The current study showed the significance of the diverse perspectives shared by primary and co-therapists in fostering the music engagement in children displaying autistic symptoms. These findings have important implications for music therapists seeking to promote children’s music engagement as a means of fostering their social engagement skills.

Notably, the current study was exploratory in nature. Future research should build on these findings using larger sample sizes, including a greater number of music therapists, and exploring additional factors that might play a role in how music therapists foster the music engagement of young children displaying symptoms of autism (e.g., severity of symptoms, race/ethnicity of clients and therapists). Nevertheless, findings of the current study contribute to the ongoing research in the field of music therapy, and highlight how music therapists might use IMT as a therapeutic option for young children displaying autistic symptoms.

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Semi-Structured Interview Questions

Q0. Can you describe the goals of music therapy for your clients and their diagnoses?

Q1. During your sessions with your client, what do you generally notice as a common pattern that comes up during the sessions?

Q2. How do you recognize music engagement in your sessions?

Q3. How do you personally define music engagement?

Q4. How would you describe your client’s music engagement in your sessions? Q5. How important is music engagement in your music therapy sessions with your client?

Q6. How important is music engagement for your client’s personal experience with music therapy?

Q7. Do you have any previous experience with autistic clients in this age group that could be helpful for us to know about music engagement?

Q8. Is there anything else you would like to share about this topic?