Article Review: Music Therapy and Communication Disorders

Article Review: “Music Improves Social and Participation Outcomes for Individuals With Communication Disorders: A Systematic Review”

Tess Vreeland

Communication is a relatively large goal domain in the field of music therapy due to its importance in activities of daily living for all people. With more recent research, the strategies and results of music with communication goals have improved and expanded. Dr. Boster and others published a research review titled “Music Improves Social and Participation Outcomes for Individuals With Communication Disorders: A Systematic Review” in 2020. The purpose of their research was to explore the effects of arts-based interventions on the socialization and participation of people with communication disorders. However, the researchers involved in this review noted that most of the studies fitting the criteria for the review used specifically music-based interventions. The structure of their review consists of explanations of communication disorders, definitions of social and participation outcomes for people with communication disorders, and an explanation of arts-based interventions targeting these goals. The researchers then outline the criteria for the articles examined which resulted in 86 articles being included in the review to cover the categories of communication disorders as follows: pediatrics with Autism Spectrum Disorder, pediatrics with developmental and acquired disabilities, adults with developmental disabilities, and adults with acquired disabilities. The conclusion consists of a discussion of the commonalities among the various study results and implications for music therapy benefiting patients with communication disorders.

The results of this review are separated by category of participants in each study. For the pediatrics with Autism Spectrum Disorder, some of the social and participation variables with positive increases include: joint attention; participation in group and peer interactions; verbal and nonverbal expression and engagement; and emotional understanding among many others. The results for the pediatric population with developmental or acquired disabilities show suggestive positive trends in variables such as frequency of verbal and nonverbal responses, engagement and participation in peer or group interactions, use of appropriate nonverbal communication, and attention to tasks among other variables. Frequency of group interactions and the understanding and expression of pragmatics were the primary positive findings in studies with adults with developmental disabilities. For adults with acquired disabilities including Alzheimer’s Disease, TBIs and Parkinson’s Disease, the primary positive trends involved frequency of verbal and nonverbal behaviors and engagement and participation in groups. 

The researchers hypothesize in the discussion section that the increase in music as a tool to aid communication disorders may be attributed to “the continued rise of music therapy as an evidence-based treatment strategy, the accessible nature of music for individuals with disabilities, and the communicative nature of music” (Boster, et. al., 2020, p. 31). The researchers highlight the meaning of the results, limitations (such as sample size) across the studies reviewed, and supported reasons why music therapy is effective in addressing communication goals. Music is an extremely accessible therapeutic medium for all ages and abilities and logistically in a variety of settings; however, the researchers note that “casual listening of music on mobile devices is not the same as music therapy that is guided or facilitated by music therapists” (Boster, et. al., 2020, p. 31). This study is important in furthering the collaboration between music therapists, speech-language pathologists, and other professionals supporting communication goals. Through reviewing and analyzing the existing research, Dr. Boster and others concluded that music-based interventions have shown to benefit individuals with communication disorders.

For the full article, please visit https://doi.org/10.1093/jmt/thaa015. 

Reference

Boster, J. B., Spitzley, A. M., Castle, T. W., Jewell, A. R., Corso, C. L., & McCarthy, J. W. (2020). Music improves social and participation outcomes for individuals with Communication Disorders: A systematic review. Journal of Music Therapy, 58(1), 12–42. https://doi.org/10.1093/jmt/thaa015

Music Therapy in the Classroom: Benefits for Students with Learning Disabilities

Approximately 33% of students receiving special education services in schools are diagnosed with a specific learning disability (National Center for Education Statistics, 2022). Music therapists working in classrooms have the tools and skills to reach students with a wide spectrum of disabilities, such as those with various SLDs. Specific learning disabilities differ with each student and discipline (e.g., reading, math, writing, etc.). Much of the research regarding music therapy and learning disabilities is related to reading skills specifically. 

Viewing reading as solely a visual experience can lead to frustration with students who struggle with reading related SLDs and teachers alike. However, the task of reading becomes more accessible when addressed as a multisensory activity. In order to read effectively, a child needs to successfully master “eye tracking, eye-hand coordination, spatial relationships and spacing, visual perception, tactile perception, organization of thought, auditory perception, self-control to sustain attention, symbolism, and rhythmic timing” (Colwell, 2002, p. 13). To address these skills, music therapists can utilize manipulatives, instruments, visuals, and rhythms and melodies contributing to the academic information. The multisensory nature of music provides opportunities to facilitate the growth of these skills, leading to improvement of overall reading ability for all students. This is especially beneficial for those with SLDs who struggle with more traditional approaches. 

Music therapy goals such as attention and memory can coincide with more specific goals for each student’s skills. Studies have shown that students receiving music therapy services had consistently lower off-task behavior when working on reading skills within the sessions than those who did not have this type of engagement (Register, et. al., 2007). Short-term memory is also a common pre-academic skill that students with SLDs must work through. Musical mnemonics, which are short musical repetitions of specific academic content, have been widely implemented in general education classrooms for students with and without specific learning disabilities to aid with memory (Gfeller, 1983, p. 188). Addressing pre-reading and functional classroom skills can facilitate more effective progress, with more individualized skills being addressed for the student with a specific learning disability.

While attention, behavior, and sensory elements of reading are broad underlying skills of learning, reading comprehension, vocabulary acquisition and knowledge, and decoding lead to different therapeutic approaches and focuses within sessions. Music has auditory, visual, and tactile structure to reinforce these concepts in an engaging way. A student receiving music therapy will likely engage in active and passive interventions that support “better discrimination for perceiving language, clearer articulation, and… positive transfers from music skills to the development of language and reading skills” (Register, et. al., 2007, p. 25). Auditory awareness is another specific skill crucial to reading comprehension. Music therapy interventions properly facilitated can address pitch, rhythm, and volume discriminations (Roskam, 1979, p. 36). These skills can transfer to crucial foundations of reading comprehension and general auditory perception and awareness.

All students are heterogeneous in their learning styles, so it is important to acknowledge and “continually consider the importance of individualized treatment planning” in these settings, as well as remain informed on increasing research concerning the best music implementation to address SLDs (Gfeller, 1984, p. 13). Music being used as a structure for academic information is valuable, but also using music as positive reinforcement and reward provides a balance that makes music therapy effective and enjoyable. One of the most important benefits of music supporting students with learning disabilities aside from the improvement of the actual academic skills is the positive association with an often frustrating task. 

-Tess Vreeland, Music Therapy Intern

References

Colwell, C. M., & Murlless, K. D. (2002). Music Activities (singing vs. chanting) as a vehicle for reading accuracy of children with learning disabilities: A pilot study. Music Therapy Perspectives, 20(1), 13–19. https://doi.org/10.1093/mtp/20.1.13.

Gfeller, K. E. (1983). Musical Mnemonics as an aid to retention with normal and learning disabled students. Journal of Music Therapy, 20(4), 179–189. https://doi.org/10.1093/jmt/20.4.179.

Gfeller, K. E. (1984). Prominent theories in learning disabilities and implications for music therapy methodology. Music Therapy Perspectives, 2(1), 9–13. https://doi.org/10.1093/mtp/2.1.9.

National Center for Education Statistics. (2022). Students With Disabilities. Condition of Education. U.S. Department of Education, Institute of Education Sciences. Retrieved August 29, 2022, from https://nces.ed.gov/programs/coe/idicator/cgg.

Register, D., Darrow, A.-A., Swedberg, O., & Standley, J. (2007). The use of music to enhance reading skills of second grade students and students with reading disabilities. Journal of Music Therapy, 44(1), 23–37. https://doi.org/10.1093/jmt/44.1.23.

Roskam, K. (1979). Music therapy as an aid for increasing auditory awareness and improving reading skill. Journal of Music Therapy, 16(1), 31–42. https://doi.org/10.1093/jmt/16.1.31.

Autism Spectrum Disorder, Gestalt Language Processing & Music Therapy

When a young child is greeted with your appreciative gesture of saying “Thank you”, they will most likely reply with, “You’re welcome” because they have heard it relayed time and time again by their surrounding adults and peers. In actuality, how long does it take in a child’s development to realize the building blocks of their reply? “You. Are. Welcome.” The shortened response is a script, or a gestalt, being an organized whole different from the summation of its parts (Merriam-Webster). The building blocks of language consist of single words, but for gestalt language processors, chunks of words are used instead. As stated before, many young children use these chunks in communication, as gestalt language processing is a normal part of human language development. However, this is seen more frequently in later years in children with Autism Spectrum Disorder (ASD) (Konyn, 2022).

Social communication with a focus in speech and language impairment is the one criterion of diagnosis in those with ASD (American Psychiatric Association, 2013) that has not changed since Dr. Leo Kanner first created the description of infantile autism in 1943 (Lim, H. A., 2010). Over the years, researchers have suggested that the capacity for pattern perception and production based on the “Gestalt style of language acquisition” has greatly influenced the language development of children with ASD (Prizant, 1987; Prizant et al., 1997). With these deficits in social communication, therapists have long searched for a form of treatment to bypass the gestalt form of language processing to a more analytic form of language processing. From a study conducted in 2010 by Hayoung A. Lim, PhD, MT-BC, NMT, both music therapy and speech therapy share nearly equal benefits when it comes to addressing a child’s language processing and verbal production.

The results of Dr. Lim’s study (2010) showed that the improvements in language processing brought on by music therapy versus speech therapy were not significant, meaning that the findings of both therapies showed similar outcomes. After being scored on the Verbal Production Evaluation Scale (VPES), 50 participants diagnosed with ASD aged 3-5 were separated into three groups: speech training, music training, and no training. After 3 days of training, the VPES posttest was administered, and it was shown that the speech and music training groups had great effects on speech production compared to the no training group. Although Dr. Hayoung listed the difference between music therapy and speech therapy, her study showed that those with music training had a 12.14 point advantage over those who were assigned speech training. A reason for this advantage towards music is a music therapy technique called developmental speech and language training through music (DSLM) that uses rhythmic cueing and pausing in order to facilitate speech through emphasizing target words. Dr. Lim explained another possible reason for the advantage of music in her earlier published article from the Music Therapy Perspectives journal (2009), stating that children with ASD are able to identify and reproduce rhythmic and melodic patterns. Through using these available strengths, music can facilitate speech and language development through DSLM, or developmental speech and language training through music.

The following case study demonstrates the effect of rhythmic emphasis on language in practice:

Patient O is an individual with ASD and is a Gestalt Language Processor receiving music therapy treatment. O has a tendency to break into long periods that he scripts that sometimes have social implications. This is seen for instance, when we sing our goodbye song. After singing, he shows the behavior of scripting, using large chunks of unanalyzed and unorganized language for around 30 seconds, listing different ways to say goodbye. To address his gestalt scripting, we used boom whackers (colored tubes that emit different notes when struck) to separate each syllable in conversational sentences. Prior to the intervention, O took 10 to 15 seconds to commit to an activity, but with the rhythmic cueing offered by the boom whackers and the music therapy intern, he was able to attain his focus and direct his attention solely to the cues, the pitches of the instruments, and the individual parts of the sentences. He was able to read 4 different sentences within 20 seconds, greatly reducing the time that O spent scripting.

-Jackson Arnold, Music Therapy Internn

Works Cited

Konyn, L. (2022, February 8). Gestalt language processing and AAC. AssistiveWare. Retrieved August 22, 2022, from https://www.assistiveware.com/blog/gestalt-language-processing-aac

Lim, H. A. (2010). Effect of "developmental speech and language training through music" on speech production in children with autism spectrum disorders. Journal of Music Therapy, 47(1), 2–26. https://doi.org/10.1093/jmt/47.1.2 

Lim, H. A. (2009). Use of music to improve speech production in children with autism spectrum disorders: Theoretical orientation. Music Therapy Perspectives, 27(2), 103–114. https://doi.org/10.1093/mtp/27.2.103

Merriam-Webster. (n.d.). Gestalt. In Merriam-Webster.com dictionary. Retrieved August 22, 2022, from https://www.merriam-webster.com/dictionary/gestalt

Prizant, B. M., 8chuler, A. L., Wetherby, A. M., & Rydell, P. (1997). Enhancing language and communication development: Language approaches. In D. Cohen & F. Volkmar (Eds.), Handbook of autism and pervasive developmental disorders (pp. 572-605). New York: John Wiley & Sons, Inc.

Prizant, B. M. (1987). Clinical implications of echolalic behavior in autism. In T. Layton (Ed.), Language and treatment of autistic and developmentally disordered children. Springfield, IL: Charles Thomas.

Music Therapy Strategies for Patients with Obsessive Compulsive Disorder (OCD)

As research develops regarding music therapy and mental health, the types of conditions that music interventions can assist with have increased. Obsessive Compulsive Disorder (OCD) is identified in The Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM–5) as having obsessions, compulsions, or both that are time consuming and not attributed to the effects of a substance, medical condition, or another mental disorder. These obsessions, defined as “recurrent thoughts, urges, or images,” and compulsions, defined as “repetitive behaviors or mental acts” such as counting, creating symmetry, cleaning, etc., can impede activities of daily living and cause other mental health conditions such as anxiety or depression (American Psychiatric Association, 2013). While there is not an abundance of research with music therapy and patients with OCD, some strategies have been effective in helping the effects of OCD in individuals. 

In order to address music therapy techniques for patients with OCD, the foundations of general counseling and therapeutic techniques must be considered. Some widely-used treatments for patients with OCD include medication such as Selective-Serotonin Reuptake Inhibitors (SSRIs) and exposure-response prevention, a method of desensitization (Abdulah, et al., 2018). However, other approaches are more applicable to the function of a music therapy session such as the cognitive-behavioral approach of restructuring thoughts to normalize the patient’s view of their condition (Salkovskis, 1999). Instead of invalidating and minimizing the client’s obsessions and compulsions, the therapist should lead the client in the “identification of key distorted beliefs and the collaborative construction of a non-threatening alternative account of their obsessional experience and preoccupations” (Salkovskis, 1999, p. 36). Cognitive-behavioral approaches have been effective in talk-therapy settings, so similar affirming and normalizing counseling techniques should be used to approach music therapy sessions with people with OCD. 

As far as specific techniques, receptive music listening has been a commonality across multiple studies with patients with OCD. Studies have found that “receptive music therapy helped reduce obsessive symptoms with comorbid anxiety and depression” (Truong, et al., 2021, p. 3). The receptive music interventions in these studies took the form of independent listening, lyric analysis, or music relaxation, and classical music was found to be the most effective genre for these types of interventions. The lyric analysis was structured by recalling obsessional thoughts, relating the lyrics to the feelings about their obsessions, and guided-imagery relaxation followed by therapeutic reflection discussion (Shirani Bidabadi, 2015). One study showed a reduction in the severity of overall OCD symptoms in individuals who listened to classical and sleep music for 50 minutes every day independently (Abdulah, et al., 2018). All of these treatments were used as adjuncts to other therapy and medication approaches. However, implementing them into sessions with patients with OCD, even if their primary goal is not related to this diagnosis, can help regulate the client so they can achieve their other goals.

Receptive music therapy approaches have been more researched with this population; however, active interventions such as “improvisational music therapy might also alleviate symptoms in OCD patients” (Truong, et al., 2021, p. 3). Allowing music improvisation within a session when someone is expressing obsessions, exhibiting compulsions, or experiencing anxiety or distress can potentially improve the outcome of the session and achievement of session goals. Providing support for patients with OCD through music therapy interventions can reduce the impact of the symptoms so the patient can resume daily and social activities more easily (Abdulah, et al., 2018). While the established techniques to implement with clients with OCD are limited due to the scarcity of research, music has a definitive impact on the symptoms related to OCD and can be implemented to improve the effectiveness of treatment. 

-Tess Vreeland, Music Therapy Intern

References

American Psychiatric Association. (2013). Obsessive-Compulsive and Related Disorders. In Diagnostic and Statistical Manual of Mental Disorders (5th ed.). 

Abdulah, D. M., Miho Alhakem, S. S., & Piro, R. S. (2018). Effects of music as an adjunctive therapy on severity of symptoms in patients with obsessive-compulsive disorder: Randomized controlled trial. Nordic Journal of Music Therapy, 28(1), 27–40. https://doi.org/10.1080/08098131.2018.1546222 

Salkovskis, P. M. (1999). Understanding and treating obsessive—compulsive disorder. Behaviour Research and Therapy, 37, 29-52.

Shirani Bidabadi, S., & Mehryar, A. (2015). Music therapy as an adjunct to standard treatment for obsessive compulsive disorder and co-morbid anxiety and depression: A randomized clinical trial. Journal of Affective Disorders, 184, 13–17. https://doi.org/10.1016/j.jad.2015.04.011 

Truong, T. P., Applewhite, B., Heiderscheit, A., & Himmerich, H. (2021). A systematic review of scientific studies and case reports on music and obsessive-compulsive disorder. International Journal of Environmental Research and Public Health, 18(22), 1-23. https://doi.org/10.3390/ijerph182211799

Music Therapy for Emotional Perception & Expression with ASD

While many goals are addressed and specific to the individual person in a music therapy session, social skills are one of the primary goal domains for people with Autism Spectrum Disorder. The Diagnostic Statistical Manual of Mental Disorders (5th ed.; DSM–5; American Psychiatric Association, 2013) lists the first diagnostic criteria as deficits in social-emotional reciprocity “ranging, for example, from abnormal social approach and failure of normal back-and-forth conversation; to reduced sharing of interests, emotions, or affect; to failure to initiate or respond to social interactions.” Within this social skills goal domain, emotional perception and expression are more specific goals that assist with socialization with peers. Research shows that music therapy is beneficial in addressing  nonverbal emotional skills, appropriate expression, and other skills within this social-emotional domain (Reschke-Hernandez, 2011).

The types of interventions to address the emotional aspect of social skills with people with ASD has shifted and expanded throughout the years with more research and practical application. Music is often used as a carrier of nonmusical information that is more engaging than spoken word. Because individuals with autism “respond more frequently and appropriately to music than to other auditory stimuli,” important social cues are more easily perceived through this mode of communication (Bownell, 2002, p. 123). This increased responsivity supports the use of music accompanying social stories to directly teach appropriate perception of emotions in relatable scenarios. Social stories have also been found to be effective in shifting behavior to prompt appropriate responses. A social story is a short, individualized text that describes an event or social situation in detail using images, printed words, and verbal explanations to provide instructions on how to appropriately respond to that situation (Brownell, 2002). The use of music to accompany these stories aids in retention of the concepts discussed because “the ability for musical recall may provide another avenue by which these students may remember and incorporate vital information” (Brownell, 2002, p. 141). 

Nonverbal communication, whether it is in the timing, facial expressions, or body language, can be an area of difficulty for people with ASD (Katagiri, 2009). Interventions that emphasize these nonverbal aspects of communication can improve the overall perception of emotions in a reciprocal conversation. The use of visual aids, flash cards of moods and facial expressions, and photographs has been found to assist with this direct explanation of the more indirect nuances of communication (Reschke-Hernandez, 2011). Drawing attention to and discussing the images and facial features associated with specific emotions can create connections and help recognize patterns for social interaction.

Researchers have also seen improvements in emotional perception through the use of correlated background music when discussing emotions or social stories attached (Katagiri, 2009). The auditory cues in the music such as tempo, dynamics, and instrumentation contribute to the understanding of the emotion being discussed. The musical delivery of the lyrics also improves the perception of the emotional meaning due to the engaging and multisensory qualities. Specifically negatively associated emotions such as anger and sadness were found to be perceived the most strongly through the use of background music interventions (Brown, 2016). 

Music has proven to be a successful method of improving emotional perception and expression in people with Autism Spectrum Disorder. Having this emotional reciprocity is important to daily living and interactions with others. Whether this is in casual social interactions with family or friends, or it is in a more formal educational or employment setting, fostering connections with others and being able to more easily express oneself benefits all people involved. Music therapists are integrating different interventions into their sessions with people working on these specific goals, and the research is growing to expand on the possibilities for finding more effective methods of connection through the medium of music.

References

American Psychiatric Association. (2013). Autism Spectrum Disorder. In Diagnostic and statistical manual of mental disorders (5th ed.). 

Brown, L. S. (2016). The influence of music on facial emotion recognition in children with autism spectrum disorder and neurotypical children. Journal of Music Therapy, 54(1), 55-79. https://doi.org/10.1093/jmt/thw017 

Brownell, M. D. (2002). Musically adapted social stories to modify behaviors in students with autism: Four case studies. Journal of Music Therapy, 39(2), 117–144. https://doi.org/10.1093/jmt/39.2.117 

Katagiri, J. (2009). The effect of background music and song texts on the emotional understanding of children with autism. Journal of Music Therapy, 46(1), 15–31. https://doi.org/10.1093/jmt/46.1.15 

Reschke-Hernandez, A. E. (2011). History of music therapy treatment interventions for children with autism. Journal of Music Therapy, 48(2), 169–207. https://doi.org/10.1093/jmt/48.2.169