A Randomised Controlled Trial on the Effectiveness of Improvisational Music Therapy for Autistic Children Aged 7 - 11 [Autism-CHIME Trial].
Phase: NA
Conditions: Autism
Sponsor: Prof Simon Baron-Cohen

 
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IMPROVISATIONAL MUSIC THERAPY (IMT) GUIDELINES 
 
Improvisational music therapy involves the therapist and child spontaneously co-creating music 
together using singing, playing, and movement. The music therapist follows the child’s interests 
and focus of attention which aims to facilitate the child’s social communication development 
(Geretsegger et al., 2015). Crucially, improvisational music therapy is child-led and aims to 
facilitate a strong sense of personal agency and autonomy. Previous studies have identified that 
music engagement is more likely to benefit health and wellbeing when the individual has a 
greater sense of agency in the musical interaction (Howlin & Rooney, 2021; Howlin, Stapleton & 
Rooney, 2022; Saarikallio, Randall & Baltazar, 2020; Fritz et al., 2018). However, sessions will 
also often be carefully structured with improvisations weaving in and out of familiar songs or 
pre-composed music. During the improvisations, the music therapist may often create a 
balance between following and leading the child (Oldfield 2006, pp.41-91). 
The following guidelines are presented for carrying out IMT sessions with autistic children. It is 
suggested that these are applied flexibly according to the client within the therapy process. This 
treatment guide contains information on setting, musical media, goals, and basic principles for 
treatment. 
Setting 
IMT for autistic children is offered in an individual setting. The sessions will occur twice weekly 
for 30-minute sessions over a 12-week period, in addition to support as usual. The session 
might need to differ from the chosen duration to meet the needs of the child in the moment if 
necessary. While some different instruments or activities may be available from session to 
session, the general physical environment should, if possible, remain consistent and predictable 
for each individual participant. A core set of instruments will be provided and each therapist 
may also include others depending on their own preferences and their observations of each 
child. The music therapist will record the instruments played in each session in the music 
therapy log. Covers (for example a cloth sheet) will be provided to enable therapists to manage 
the visual stimulation in busy visual environments. The therapist can drape the sheet over 
objects that may be distracting for the children. 
Each session will be recorded on a video camera provided. The camera must be positioned and 
set up so that it can capture the sounds and images of both child and music therapist.  
 
 

 
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Musical Media 
All aspects of musical expression, vocal and instrumental, are used to interact with the child 
and to assess the child’s ability to interact musically and socially. Expression and behaviour that 
can be perceived in a musical way is also incorporated as a means of interaction in IMT. 
Precomposed songs or recordings of music may also be used, for example to establish a shared 
focus of attention, as a starting point for improvised music, or to provide periods of rest in 
between therapy sequences that may be more demanding for the child due to increased social 
awareness requirements. 
Goals 
The music therapist will set treatment goals that meet the child’s individual needs and specific 
competences. By choosing individualised developmental goals for each phase of the 
intervention, the therapist guides the therapy process, enables the child to gradually expand 
the child’s abilities in targeted areas of development, and is also able to evaluate progress and 
outcomes of therapy. The goals will be recorded in the child’s clinical notes, which will be 
stored onsite, according to each school’s policy.  
 
Principles 
Listed in the table below is an overview of unique and essential, essential, compatible, and 
proscribed principles in IMT for children with ASD, and their corresponding rationale, 
therapist’s attitude, activity category, and examples. The table is based both on work done by 
Geretsegger et al 2015 for the Time A RCT trial and Oldfield’s clinical experience in this field 
(Oldfield 2006, 2016). 
 
 
Principle 
Purpose/ 
Rationale 
Attitude 
Category of 
Activities 
Example/ 
Technique 
 
 
 
 
 
 
 
 
 
Use music 
making, 
including 
improvisation,  
to provide a 
holding, 
reassuring and 
predictable 
structure to the 
sessions. Often 
Provide a safe 
and reassuring 
environment to 
enable the child 
to feel at ease 
 
 
 
 
Tailor and adapt 
musical offerings 
to the child’s likes 
and dislikes and 
mood of the 
moment. Also 
make clear 
endings to a 
shared activity 
just before the 
Present musical 
structures with 
conviction and 
enthusiasm, 
while adapting to 
the needs of the 
child  
 
 
A hello song may 
initially be sung 
on the guitar but 
then move to the 
keyboard to 
follow the child’s 
interest. 
A structure may 
evolve where a 
gathering drum is 

 
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Unique and 
Essential 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
this will involve 
a “Hello song” or 
greeting activity, 
and a prepared 
musical ending 
 
 
 
 
Engage the child 
through 
providing a wide 
range of musical 
styles, 
instruments, 
interactions and 
musical games 
 
 
 
 
To improvise 
and engage with 
the child’s 
movements 
 
 
 
 
 
Facilitate 
Musical and 
Emotional 
Attunement 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
To motivate the 
child to attend, 
be present and 
interact 
 
 
 
 
 
 
 
 
To enter into 
the child’s 
world and 
provide 
motivation for 
the child to 
interact 
 
 
Increase 
opportunities 
for awareness 
of self, shared 
attention, social 
reciprocity, and 
relationship 
building 
 
 
child seems to be 
losing interest 
and needs to 
move on. 
 
 
 
 
 
To use the child’s 
particular musical 
interests to widen 
the range of 
musical 
possibilities 
available to the 
therapist and the 
child 
 
 
To watch, listen 
and be inspired by 
the child 
  
 
 
 
 
 
Follow the child’s 
focus of 
attention, 
behaviours, and 
interests; meet 
the child where 
they are musically 
and/or 
emotionally 
 
 
 
 
 
 
 
 
 
Think creatively 
about different 
ways of using 
music with each 
child 
 
 
 
 
 
 
 
To improvise 
freely around the 
child’s 
movements, also 
incorporating 
interactive dance 
and movement 
exchanges  
 
Create moments 
of musical 
attunement/ 
synchronicity 
that may develop 
into emotional 
attunement/ 
emotional 
sharing; 
incorporate the 
child’s interests 
and skills
always played in 
one corner of the 
room, and a 
shared 
improvised piano 
duet is played 
towards the end 
of the session 
 
The therapist may 
bring in an 
orchestral 
instrument such 
as the clarinet to 
create an 
improvised 
musical exchange 
with the child’s 
recorder or reed 
horn playing. 
 
The therapist may 
play the keyboard 
to accompany the 
child’s walking, 
slowing down and 
stopping, to 
match the child’s 
movements. 
 
Respond to the 
child’s utterances 
and behaviour 
using improvised 
music (e.g., by 
holding, 
mirroring, 
matching 
techniques) 

 
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Unique and 
Essential 
 
 
 
Scaffold 
Interactions 
Dynamically 
 
 
 
 
 
 
 
 
Using 
improvised 
music making to 
create a balance 
between 
following and 
initiating 
 
 
Increase 
opportunities 
for the child to 
comprehend, 
engage in, and 
initiate 
interaction 
 
 
 
 
To provide 
opportunities 
for interaction, 
adaptability and 
negotiation. 
 
 
 
 
Meet the child’s 
initiatives/ 
behaviour as 
communicatively 
intended 
 
 
 
 
 
 
To follow the 
child and enable 
the child to 
accept 
suggestions 
 
 
 
 
While following 
the child’s lead 
and musical 
ideas, form the 
child’s 
expressions into 
recognisable 
musical forms, 
patterns, or 
motifs 
 
The therapist 
moves in and out 
of following and 
initiating to 
reassure the child 
but also extend 
the child’s 
capacity to follow 
and initiate 
themselves, and 
develop 
interactive skills 
 
 
 
Apply 
improvisational 
music therapy 
techniques (e.g., 
rhythmic 
grounding, 
shaping, 
exaggerating, 
extemporising, 
frameworking) 
 
The therapist 
accompanies the 
child’s rhythmic 
drumming on the 
keyboard but 
experiments with 
slight changes of 
tempo to 
encourage joint 
listening. If the 
child loses 
interest or focus 
the therapist 
returns to the 
child’s tempo. 
Tap into Shared 
History of 
(Musical) 
Interaction 
Facilitate 
predictability/ 
feeling safe and 
secure 
Present as playful 
and reliable 
interaction 
partner fostering 
the child’s range 
of experience 
Affirm the child’s 
expression and 
actions; jointly 
create musical/ 
social motifs and 
routines 
Recognise and 
repeat the child’s 
expression and 
actions in an 
attuned way, 
giving them a 
musical form and 
value 
Facilitate 
capacity for 
flexibility/ 
ability to cope 
with change 
Create moments 
where (musical) 
expectations are 
playfully violated 
Include 
unexpected 
pauses and/or 
dynamic variation 
in improvised 
music; redirecting 
techniques 
 
 
 
 
 
Provide a Secure 
Environment 
Facilitate 
predictability/ 
feeling safe and 
secure; keep 
Present as a 
reliable and 
responsible 
Provide for 
consistency in 
therapy settings 
Maintain similar 
arrangement of 
objects in therapy 
room and 

 
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Essential 
(but not 
unique to 
IMT) 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Essential 
(but not 
unique to 
IMT) 
the child’s 
anxiety low 
interaction 
partner 
maintain some 
familiarity of 
instruments 
 
Respond to the 
child’s behaviour 
in consistent 
ways 
Avoid retreating 
from interaction 
partner into 
“observer” role 
Comment on/ 
explain 
interruptions and 
unexpected 
events 
If it is necessary 
to terminate the 
session, explain 
why you find it 
necessary to do 
so 
Build and 
Maintain a 
Positive 
Therapeutic 
Relationship 
Enable rapport 
and 
continuation of 
therapy 
Present with 
interest, respect, 
and confidence 
Understand/ 
reflect upon 
meanings of the 
child’s and the 
therapist’s 
behaviour 
Display empathy 
during (musical) 
interaction 
Follow the 
Child’s Lead 
(Non-Directive 
Approach) 
Facilitate 
intrinsic 
motivation 
Follow the child’s 
focus of 
attention, 
behaviours, and 
interests; meet 
the child where 
they are musically 
and/or 
emotionally 
Incorporate the 
child’s interests 
and motivations 
Relate to a child’s 
preference for 
numbers in 
making up a 
“number song” 
 
Keep the child’s 
anxiety low 
Match level of 
session/ 
interaction 
structure to 
child’s needs 
Allow the child to 
control certain 
aspects of the 
interaction; allow 
the child to 
functionalise the 
therapist; offer 
choices 
Set Treatment 
Goals 
Meet the 
individual 
child’s needs; 
guide and 
evaluate the 
therapy process 
Enable the child 
to reach the 
respective next 
developmental 
stage in a certain 
skill area 
Assess the child’s 
competences, 
emerging 
abilities, and 
needs; choose 
intervention 
strategies and 
techniques 
tailored to an 
If the child is 
aware of their 
own and the 
therapist’s 
(musical) actions, 
foster reciprocal 
interactions  

 
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assessed need in 
a specific area 
Facilitate 
Enjoyment 
Increase 
intrinsic 
motivation for 
interaction and 
opportunities 
for affect 
sharing 
Present with 
positive affect, 
acceptance, 
affection 
Incorporate the 
child’s interests; 
create pleasant 
and joyful 
atmosphere 
Display interest in 
the child and 
their behaviour 
and joy during 
(musical) 
interaction 
 
 
 
 
 
 
 
Compatible 
(but not 
necessary) 
Adjust Setting 
According to 
Families’ Needs, 
Clinical 
Judgement, and 
Practical 
Possibilities 
Facilitate 
generalisation 
of skills to 
everyday 
settings; 
support families 
in building safe 
relationships 
among family 
members 
Consider the 
whole range of 
settings of the 
child’s everyday 
life 
Allow for 
participation of 
parents/ 
caregivers or 
other family 
members in the 
therapy session 
 
Improvise 
together with the 
child and a family 
member in home 
environment 
Employ family 
member-
mediated 
intervention 
strategies 
Discuss with 
family members 
how they can 
employ musical 
experiences in 
interacting with 
the child; 
encourage 
parents to sing 
and vocalise 
together with 
their child