Effectiveness of Music Therapy in Social Skill Intervention for Children With ASD/ID
Condition: Autism Spectrum Disorder; Intellectual Disability
MeSH terms: Intellectual Disability; Autism Spectrum Disorder
Study type: Interventional

Summary: 
      Autism spectrum disorder (ASD) is a developmental impairment characterized by persistent
      deficits in social communication and interactions. The prevalence figures have increased
      rapidly in recent years due to the expansion of diagnostic criteria and increased public
      awareness. The clinical presentations of ASD vary to a large extent, and approximately 56% of
      children with ASD possess below average intellectual ability (IQ < 85). The intellectual,
      verbal, and social ability in this population may greatly influence intervention outcomes.
      The social development of children with ASD and comorbid intellectual disability (ID) is not
      well understood, and how children with ASD/ID respond to social skill interventions remains
      to be investigated.

      Musical elements are a part of various behavioral interventions for ASD, however, the effects
      of music as interventions for ASD individuals have not been comprehensively examined in Hong
      Kong. The proposed study will address limited research evidence on music therapy as an
      intervention for social functioning in children with ASD with mild to borderline ID. Music
      therapy is a systematic process of intervention, wherein a therapist helps clients promote
      their health by using musical experience and relationships that develop through them. In
      particular, the investigators will examine whether using music therapy in social skill
      intervention provides additional benefits relative to non-musical intervention in a 12-week
      randomized controlled trial. Pre-treatment neural response of electroencephalograms (EEG) to
      social scenes will be used to predict the outcomes of social skill interventions, whereas EEG
      responses to music will be used to predict the effectiveness of musical social skill
      intervention. If correlation is found, then the long-term goal is to develop individualized
      intervention based on pre-treatment markers to maximize treatment efficacy.

      Aims and hypotheses:

        1. Is social skill intervention using music therapy more effective in enhancing social
           interaction than non-musical social skill training for children with ASD and
           co-occurring mild/borderline ID?

        2. Participants with enhanced neural response to social scenes relative to baseline would
           be more responsive to social skill interventions.

        3. Participants with enhanced neural response to preferred music relative to baseline would
           be more responsive to music therapy targeting social skill intervention.
    

Detailed description: 
      Autism spectrum disorder (ASD) is a developmental impairment characterized by persistent
      deficits in social communication and interactions coupled with restricted and repetitive
      patterns of behaviors. The symptoms of ASD appear in early childhood. Given that no known
      cure or effective pharmacological intervention for ASD is available, behavioral interventions
      that target autism symptoms is the main strategy to support individuals with ASD to be
      integrated into school and the society. The choice to examine music in social skill
      intervention is motivated by accruing evidence of its potential for therapeutic use for
      various clinical populations. For ASD intervention, music has been explored as a medium to
      increase social skills in the field of music therapy for some years. Children with ASD and ID
      are often described as preoccupied in their own world and may be highly passive and
      unresponsive in social situations. The low verbal ability of these children is one limitation
      to their participation given that social interactions often involve verbal exchanges. Music
      may become a conduit for children whose natural affinity to social interactions is impaired.
      Group music making and improvisations encourage initiation and turn-taking behavior in a
      non-verbal situation and may be an alternative avenue for social practice. Children with ASD
      can learn to tolerate the presence of and physical contact with other people, distinguish
      between oneself and others, and practice social behavior in music therapy group activities.

      Although these claims are supported by data, no conclusive evidence is available that music
      therapy is an effective social skill intervention for children with ASD. One hypothesis that
      has not been tested is that success in social skill interventions may depend on individual
      differences. Autistic symptoms and abilities vary widely among children with ASD, arising
      both from different developmental speeds and specific interests. Some individuals may possess
      deficits in the areas of restricted interests or repetitive behavior, which results in poor
      social skills; however, they are accepting of social interactions. The willingness to seek
      out social experiences is the foundation to social skill development because without initial
      interests in social behavior, the motivation to attend to the explicit training and modeling
      is low. In such cases of social avoidance, cultivation of social interests through other
      strategies, such as music making, may be effective. Narrowing down the types of children who
      may respond well to a particular type of intervention can facilitate timely and efficient
      treatment provision. In this study, the investigators will test quantitative
      electroencephalogram (qEEG) signals in response to music and social scenes as predictive
      measures of treatment outcomes.

      Spontaneous electrophysiological neural activities at rest or when engaged in task can be
      measured by qEEG. Spectral analysis is used to decompose qEEG signals across several minutes
      into different frequency bands, which are associated with specific functions. The most
      consistent pattern of findings in the literature is that individuals with ASD show a U-shaped
      pattern of spectral power relative to controls without ASD; that is, excessive power is
      observed at low-frequency (delta, 1-3Hz and theta, 4-7Hz) and high-frequency (beta, 13-35Hz
      and gamma, >35Hz) bands, but reduced power is detected in middle-range frequency band (alpha,
      8-12Hz). The pattern was found with wide topographic distribution, which suggested
      abnormalities across multiple brain regions. This finding was reported for children in
      different age groups and for individuals with or without comorbid ID. High-frequency bands
      have been associated with emotional responses and emotion recognition and may be linked to
      such deficits in individuals with ASD. Neural patterns that deviate from age-matched controls
      to a greater extent may suggest more severe behavioral symptoms.

      Frontal alpha asymmetry (FAA) is typically investigated in relation to emotional response and
      motivations, both in clinical and normal populations. Left-lateralized or left-dominant brain
      activity has been linked to an approach system where an individual experiences positive
      emotions and motivations. In contrast, right-lateralized frontal activity may reflect
      negative emotions and intention to withdraw. Reduced alpha power in the left frontal area of
      the scalp in individuals with ASD has also been reported. The modulation of FAA has been
      demonstrated in neurofeedback training in individuals with ASD to activate their imitation
      behaviors; so this measure is hypothesized to predict and be responsive to social skill
      interventions. High-functioning individuals with ASD show intact emotional processing when
      listening to music, although they demonstrate distinct neural patterns relative to
      neurotypical adults, which is interpreted as increased cognitive load and physiological
      arousal. Individual preference for music varies within the target group with ASD/ID and may
      predict how they respond to social skill intervention using music therapy. Although
      self-report rating scales exist for reporting music experience and preference, qEEG measures
      may be superior because they index automatic responses to musical stimuli that the target
      population of children with ASD/ID may find difficult to understand or express.

      EEG data can be collected with low-cost, commercially available products and take only 5-10
      min to set up. Children with ASD and ID are only required to sit still for a few minutes
      because no explicit task response is needed. With the relative ease of data collection, this
      procedure may be included in routine clinical check-ups. The analyses of these data can help
      researchers and clinicians to understand how neural responses in children with ASD are
      related to the clinical presentation of ASD symptoms and their social deficits. Such data may
      be further compared with those of neurotypical children to elucidate the mechanisms of social
      functioning and to improve social skill interventions. With positive validation, these neural
      markers can then be used to prescribe the type of intervention that will most likely succeed.
    

Intervention name(s): Music therapy; Behavioral-based social skill training
Intervention type(s): Other; Behavioral
Intervention description(s): Each session will follow a similar structure with a hello song, musical activities, and a goodbye song. The musical activities will vary in each session and will be mixed in later sessions to revisit and practice social skills; Each intervention session will follow a standard structure of opening greetings, social activities according to the theme of the session, and a closing activity. The activities and games will vary in each session and will be mixed in later session to revisit and practice social skills.
Other intervention name(s): game-based therapy, applied behavioral analysis
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: Single (Outcomes Assessor)
Primary purpose: Treatment