School of Occupational Therapy
Touro University Nevada
OCCT 643 Systematic Reviews in Occupational Therapy CRITIC!!" ##RIS$% TO#IC &CT'
(ocused )uestion* %oes music therapy intervention help improve sociali+ation and communication s,ills in children with autism spectrum disorders-
#repared .y*
Kelsey Puliafico & Jennifer Unck
%ate Review Completed* Octo/er 0th1 25
Clinical Scenario*
Autism spectrum disorders disorders (ASD) comprise a range of developmental disabilities disabilities According to t!e "enters for Disease "ontrol and Prevention# appro$imately % in ' c!ildren in t!e United States are affected by ASD ("enter for Disease "ontrol and Prevention "D"# *+%*) ,ndividuals diagnosed -it! ASD !ave significant limitations in communication and social interaction skills (Autism Society# nd) Symptoms of ASD usually appear during early development and may include reluctance to make eye contact -it! ot!ers# inability to e$press needs or -ants# difficulty recogni.ing social cues# and displaying repetitive be!av iors (Autism Speaks# *+%/) Due to t!ese limitations# individuals diagnosed -it! ASD !ave difficulty -it! occupational performance in a variety of areas A fe- of t!ese occupations oc cupations include play# education# and social participation (American 0ccupational 0 ccupational 1!erapy Association A01A# A01A# *+%2) ,n t!e 0ccupational 1!erapy Practice 3rame-ork (01P3)# some social interaction skills t!at are re4uired for participation in t!ose various occupations are listed under t!e area of performance skills A fe- of t!e social interactions skills t!at are impacted in individuals -it! ASD include speec! production# regulation of be!aviors# emotional e$pression# and timely responses to social cues (A01A# (A01A# *+%2) Play is one of t!e main occupations of young c!ildren ,nteracting -it! ot!ers during play re4uires some level of 5oint attention and social interaction Joint attention re4uires s!aring attention -it! anot!er person -!ile engaging in an e$perience (Kalas# *+%*)
1rouble -it! 5oint attention is a commonly seen deficit in t!e early stages of ASD 6ecause c!ildren -it! ASD are unable to respond to or initiate 5oint attention t!is is seen as one of t!e most significant deficits to social interaction (Kalas# *+%*) 3or e$ample# c!ildren -it! ASD may not initiate conversation or engage in play -it! peers at sc!ool -!ic! limits t!eir social interaction "ommunication difficulties affect a significant number of c!ildren -it! ASD 7ore specifically# 8+9/+: of c!ildren -it! ASD never gain useful speec! (Pickett et al *++; )
esearc! supports a variety of interventions to !elp improve sociali.ation and communication skills in c!ildren -it! ASD 7usic t!erapy is one area of researc! t!at !as been considered and !as provided some effective results "!ildren -it! ASD usually need structured guidance for appropriate interaction (1revart!en# "# Aitkin# K# Papoudi# D# & >obarts# J# %;;) 1!e various structures in music# suc! as r!yt!ms# patterns# and tempo# act as a good medium for teac!ing c!ildren -it! ASD about t!ese appropriate skills (?igram & @old# *++) o-ever# study limitations -arrant furt!er researc! to validate t!e use of music t!erapy for ASD
Summary of ey (indin7s*
Summary of
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Parent perception of c!ild=s social interaction skills -as positive follo-ing music intervention (
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>esearc! s!o-ed improvements in social engagement# social be!aviors and emotional understanding after music t!erapy in c!ildren -it! ASD (
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,ndividuals -it! Autism s!o- affinity for music tasks due to increased activation in specific brain areas related to music (
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7usic t!erapy may be an effective tool for speec! production and verbali.ation in c!ildren -it! ASD ((
7usic t!erapy !elped increase 5oint attention skills in c!ildren -it! ASD (
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All iesgo#
Summary of
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7ore researc! -it! larger sample si.e and inclusion of control group is needed to support t!e use of music intervention in c!ildren -it! ASD (Kalas# *+%*#
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Simple music is more effective on 5oint attention for lo-er functioning ASD and comple$ music is more effective on 5oint attention for !ig!er functioning (Kalas# *+%*#
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7usic t!erapy is effective in directing and obtaining attention of c!ildren -it! ASD needed for interpersonal responsiveness (Kalas# *+%*# < evel ,C Kim# ?igram & @old# *++;#
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,mprovisational music t!erapy promotes positive emotional e$pression in c!ildren -it! ASD (Kim# ?igram & @old# *++;#
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Eo
Contri/utions of )ualitative Studies*
Eo 4ualitative studies -ere appraised
.ottom !ine for Occupational Therapy #ractice*
Clinical and community-based practice of OT: 1!e researc! supports t!e use of music interventions to improve communication and sociali.ation skills in c!ildren -it! ASD in a variety of settings (ie !ome !ealt!# sc!ool9based# outpatient clinics# and community settings) 1!roug!out all of t!e researc! studies conducted music interventions proved to be a motivating factor to promote sociali.ation and communication skills "lient and family9centered music t!erapy interventions !ad positive effects on overall outcomes Alt!oug! t!e researc! supports t!e use of music interventions# t!ese strategies s!ould be implemented in collaboration -it! ot!er interventions due to not enoug! statistical significance to support music t!erapy interventions on t!eir o-n Program development: 1!e variety of music based interventions utili.ed in t!e researc! could be used as a guide for ne program development ,ncorporating c!ild9led interactions -it!in intervention sessions proved to be an effective strategy for promoting improvements in sociali.ation and communication skills (Kim ?igram & @old# *++;) 1!is premise s!ould be co nsidered -!en developing a ne program so t!at c!ildren are able to feel more engaged 1!erapist s!ould take into consideration t!e level of stimulation t!at is most effective for t!e client=s functional level -!en developing programs (Kalas# *+%*) Societal Needs: Due to stigma and stereotypes associated -it! ASD# t!ese individuals need to develop effective communication and sociali.ation skills to interact appropriately in society and advocate for t!emselves ?it!out t!e ability to effectively communicate# c!ildren -it! ASD -ill !ave difficulty conveying t!eir t!oug!ts# feelings and needs 1!e increasing prevalence of ASD diagnosis supports t!e development of pertinent interventions to meet t!e needs of individuals -it! ASD 6ased on t!e researc!# music t!erapy interventions could be a viable option Healthcare delivery and policy: 6ased on t!e researc!# music t!erapy interventions s!ould be utili.ed in con5unction -it! ot!er interventions due to t!e specificity of certain targeted deficits in communication and sociali.ation 1!e ma5ority of studies revie-ed !ad small sample si.es and t!erefore results -ere not generali.able 6ecause of t!is# more researc! s!ould be conducted in t!e area of music interventions for communication and sociali.ation prior to -riting strict protocols for its use Education and training of OT students: Discussion of benefits of music t!erapy intervention for c!ildren -it! ASD s!ould be introduced in entry9level occupational t!erapy (01) curriculum# !o-ever# an entire course on t!e sub5ect is not necessary 1raining could be provided on t!e various types of music t!erapy intervention t!at are available 0verall# more researc! s!ould be done to determine t!e effectiveness of music t!erapy for c!ildren -it! ASD to make it a more substantial topic of interest in t!e field of 01
efinement! revision! and advancement of factual "no#ledge or theory: 1!is researc! supports music t!erapy intervention for positive outcomes in c!ildren -it! ASD ,t -as found t!at music -as a motivating factor for c!ildren -it! ASD and !ad positive effects on parent9c!ild relations!ips (1!ompson# 7c3erran# & @old# *+%8) 0ne study found t!e need for various levels of stimulation (e$ simple vs comple$ music) in intervention based on t!e functional level of t!e c!ild -it! ASD (Kalas# *+%*) arious researc! studies support t!e t!eory t!at music interventions are effective at fostering communication and sociali.ation skills in c!ildren -it! ASD suc! as 5oint attention# speec! production and emotional understanding (1!ompson# 7c3erran & @old# *+%8C Sandiford# 7ainess & Da!er# *+%*C iesgo#
Review #rocess*
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P,"0 4uestion -as developed based on a topic from A01A=s >esearc! 0pportunities 1ables9 Participation in Performing Arts Programs to >educe Fmotional Problems
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,nitial P,"0 4uestion GDo c!ildren -it! emotional problems -!o engage in performing arts !ave a reduction in symptoms associated -it! t!ose emotional problemsHI
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,nitial P,"0 4uestion -as too broad for researc! capacity so it -as narro-ed do-n to GDoes music t!erapy intervention !elp improve sociali.ation and communication skills in c!ildren -it! autism spectrum disordersHI
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P,"0 4uestion -as approved by t!e course instructor
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A compre!ensive literature revie- of t!e topic -as performed using key terms
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,nclusione$clusion criteria -ere establis!ed
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Articles obtained t!roug! t!e literature revie- -ere furt!er e$amined to determine if t!ey met inclusione$clusion criteria
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%+ articles met inclusione$clusion criteria
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7et!odological 4uality of eac! article -as assessed using t!e 7c7aster University "ritical >evie- 3orms 9 uantitative Studies
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?ork -as peer revie-ed
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>evie-ed articles -ere analy.ed in an evidence table
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1!e evidence table -as revie-ed by t!e course instructor
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3urt!er summari.ed in critically appraised topic ("A1)
#rocedures for the Selection and appraisal of articles*
,nclusion "riteriaB
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Articles -ritten in Fnglis!
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Articles publis!ed bet-een *++/9*+%/
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Participants age +9*% years
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Diagnosis of ASD
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,nterventions -it! music t!erapy
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,ntervention outcomes of sociali.ation and communication skills
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Peer revie-ed 5ournals
F$clusion "riteriaB
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Articles in language ot!er t!an Fnglis!
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Articles publis!ed before *++/
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Diagnosis ot!er t!an ASD
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,nterventions not utili.ing music t!erapy
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,nterventions -it! outcomes t!at do not include co mmunication and sociali.ation skills
Systematic >evie-s
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Search Strategies:
Cate7ories Patient"lient Population ,ntervention 0utcomes
ey Search Terms "!ildren -it! autism# autism# ASD# autism spectrum disorders 7usic t!erapy# music# music intervention# occupational t!erapy Social skills# communication# communication skills# sociali.ation# sociali.ation skills# social interaction# interaction# verbal skills
%ata/ases and Sites Searched ",EA<# Pro4uest ealt! & 7edical "omplete# @oogle# @oogle Sc!olar# !and9searc!ing
Quality Control/Peer Review Process:
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3ocus 4uestion revie-ed and approved by course instructor
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"ompre!ensive literature searc! including databases and !and9searc! -ere completed
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All appraised articles -ere peer revie-ed and discussed for feedb ack
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"ritical revie-s and evidence tables -ere revie-ed and approved by course instructor
Results of Search* Summary of Study Designs of Articles Selected for Appraisal:
!evel of $vidence ,
,, ,,,
Study %esi7n89ethodolo7y of Selected rticles
Systematic revie-s# meta9analysis# randomi.ed controlled trials 1-o groups# nonrandomi.ed studies (eg# co!ort# case9control) 0ne group# nonrandomi.ed (eg# before and after#
Num/er of rticles Selected /
% *
pretest# and posttest) , Descriptive studies t!at include analysis of outcomes (single sub5ect design# case series) "ase reports and e$pert opinion# -!ic! include narrative literature revie-s and consensus statements 0t!er ualitative Studies 101A
* + + %+
Small sample si.e (1!ompson# 7c3erran# & @old# *+%8 C Sandiford# 7ainess# & Da!er# *+%*C iesgo#
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Use of parent report assessments# Parents non blinded may cause bias# Use of one t!erapist limits generali.ability of findings (1!ompson# 7c3erran# & @old# *+%8)
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,nconsistency among parent report# 0b5ective measures to gauge progress# >anges in functional and be!avioral levels bet-een participants#
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Duration of t!e training videos# alidity of t!e PFS (
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S!ort duration of intervention# Eeed more acc urate tools for outcome assessment (@attino# do Santos >iesgo#
Small sample si.eC results could not be generali.ed to ot!er populations (Kim# ?igram# & @old# *++')
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Small sample si.e (Katagiri# *++;C
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Eo specific or valid outcome measures# Diverse ages and verbal abilities# 1ime frame for t!e treatment -as too s!ort# Eo assessment data revealing if t!ey -ere
able to transfer skills into social interaction in real life (Katagiri# *++;) •
Division of t!e training conditions by t!e target -ords rat!er t!an b y participant groups# Different formats used for pre and post9tests# ,t -as assumed t!at t!ere -ould be no carryover or period effects bet-een eac! condition (
Small sample si.e (Kalas# *+%*C Kim# ?igram# & @old# *++;)
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Eo pre or posttests (Kalas# *+%*C Kim# ?igram# & @old# *++;)
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Eo control group or randomi.ation of participants (Kalas# *+%*C Kim# ?igram# & @old# *++;)
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Eo formal outcome measure (Kalas# *+%*) ig! number of dropouts (Kim# ?igram# & @old# *++;)
Eo
rticles Selected for ppraisal*
@attino# @ S# dos Santon >iesgo# >#
attention be!aviors in autistic c!ildrenB a randomi.ed controlled study $ournal of utism and .evelopmental .isorders! /0! %L/'9%L doiB %+%++Ls%+'+89++'9+/9 Kim# J# ?igram# 1# & @old# " (*++;) Fmotional# motivational and interpersonal responsiveness of c!ildren -it! autism in improvisational music t!erapy %usic Therapy and utism! 1/* 2) 8';92+; doiB%+%%LL%8*8%8+;%+/+
Other References*
American 0ccupational 1!erapy Association (*+%2) 0ccupational t!erap y practice frame-orkB Domain and process# (8rd ed) merican $ournal of Occupational Therapy! ,0 (Suppl%)# S%NS2' !ttpBd$doiorg%+/+%2a5ot*+%2'*++ Autism Society (nd) bout autism >etrieved from !ttpB---autism9societyorg-!at9is Autism Speaks (*+%/) .S%-2 .iagnostic Criteria4 >etrieved from !ttpsB---autismspeaksorg-!at9autismdiagnosisdsm9/9diagnostic9criteria "enters for Disease "ontrol and Prevention (*+%/) utism Spectrum .isorder *S.+4 >etrieved from !ttpB---cdcgovncbdddautismdata!tml Pickett# F# Pullara# 0# 0=@rady# J# @ordon# 6 (*++;) Speec! ac4uisition in o lder nonverbal individuals -it! autismB A revie- of features# met!ods# and prognosis Cognitive and 5ehavioral Neurology! &&(%)# %9** 1revant!en# "# Aitkin# K# Papoudi# D# & >obarts# J# (eds) (%;;) Children #ith utism: .iagnosis and 6ntervention to %eet Their Needs4 Jessica Kingsley Publis!ers#
