Neuroscientific contributions to the development of public health policy for early intervention in Autism spectrum disorders; why music therapy matters.
Introduction;
Autism spectrum disorders (ASD) can be broadly categorized as “a group of neurodevelopmental disorders” which are “characterized by deficits in communication and socialization, along with repetitive and stereotyped behaviours” (Troyb, Knoch & Barton, 2011, p.9). Though the term was coined by Leo Kanner in 1943 (Takumi et al, 2020), in recent times, two distinct variations have presented themselves, syndromic and non-syndromic ASD. Syndromic ASD refers to cases with “a clinically defined pattern of somatic abnormalities and a neurobehavioural phenotype” which is usually accompanied by a known genetic component (Fernandez & Scherer, 2017), while the non-syndromatic variant (also known as classic or essential Autism) refers to ASD that is not accompanied by such co-morbidities and has “different developmental trajectories” with suspected genetic components (Sztainberg & Zoghbi, 2016). Although extremely well documented and frequently researched in the literature, new developments in this field are still emerging.
Policy, as it stands and where it will go;
The current model of early intervention is provided for by both the state and a number of private institutions (mostly charities and religious orders) with a “no national consistency in service provision” (Carroll, Murphy & Sixsmith, 2013). Carroll, Murphy & Sixsmith (2013) give a detailed review of the evolution of provision of disability services throughout the history of the Island of Ireland and detail how current practice is based on the Standards Framework for the Delivery of Early Intervention Disability Services (HSE, 2010c) and the Health Service Executive Reference Group Report (2009) with early intervention theory being based on the Early Start Denver Model (ESDM). Currently, a new framework is set to be developed in line with the Autism spectrum disorder bill (2017) which has recently been passed by the Seanad. This bill defines ASD as “(i) autism, (ii) Asperger’s syndrome, (iii) Rett’s syndrome, (iv) Fragile X, (v) Childhood disintegrative disorder, (vi) or any other pervasive developmental disorder prescribed by the Minister” with the first national ASD strategy to be published “no later than 2 years” after the bill has passed both houses of the Oireachtas. One of the aims of the strategy will be to
make provision for individual assessments of persons with autism spectrum disorder to be conducted by a cross-functional team of medical professionals comprising for example— (i) a psychologist, (ii) a psychiatrist, (iii) a speech and language therapist, (iv) an occupational therapist, (v) a behavioural therapist, (vi) where indicated, a social worker, and (vii) other professionals as may be deemed appropriate, so as to access the needs of the person, establish the level of ability, disability and social awareness,
And to “make provision so that the required range of services are available consistently across the State and are accessible to each person having autism spectrum disorder” (Autism spectrum disorder bill, 2017)
It is the purpose of this essay to inform policy makers on the neuroscientific evidence base for the provision of services by professional music therapists and why they should be included under “(vii) other professionals” as noted above.
The neuroscience of ASD;
One of the best known risk factors for the development of ASD is genetics although environmental influences also heavily increase the risk factor. According to Muhle et al (2018), parental age, premature birth, birth complications, medication exposure to anti-convulsants (such as valproic acid), asthma medication and possibly air pollution all contribute to risk.
With the advent of modern neuroimaging techniques, a clearer picture of the development of ASD is slowly emerging and researchers seem to agree that ASD manifests in abnormal pruning and growth of neurons (Eigsti & Shapiro, 2003, Burstein & Geva, 2021) and unusual folding in the cortical language structures of the brain (Broca’s area in particular) (Powell et al, 2012, Brun et al, 2016). Whilst various different theories have emerged over the years to explain why deficits typical of ASD occur such as the theory of mind model (Baron-Cohen, Leslie & Frith, 1985), the joint attention and social orienting model (Dawson et al, 2004), the executive function model (Rogers & Pennington, 1991), very recently there seems to be a trend towards focusing on the importance of the abnormal development of the brainstem (Delafield-Butt & Trevarthen, 2018, Dadalko & Travers, 2018, Takumi et al, 2020, Burstein & Geva, 2021).
The brainstem (as the name suggests) is located deep within the sub-cortical structures of the brain and acts as a hub region connecting many different neural structures as well as playing a vital role in breathing, swallowing, vasomotor control and the sympathetic and parasympathetic nervous systems (Joynt, 2020). Geva et al (2013) found that abnormal brainstem development lead to abnormalities in infant face to face gaze indicating dysfunctional social engagement. Various researchers have also found that sensory processing of musical elements such as pitch and language also takes place in this area (Wible et al, 2005, Krishnan et al, 2005, Bidelman et al, 2011).
Why music therapy matters;
Music therapy as been shown to benefit communication skills, social interaction, attention and motivation in children with ASD (Wigram & Gold, 2006).What follows is a short summation of the evidence base for music therapy interventions in all major affected domains of ASD (communication, socialization and motor development/sensory affect).
Communication
A qualitative study by Hernandez-Ruiz (2017) found that a six week music therapy intervention improved parents perceptions of communication with their child as well as increasing parental confidence within the ESDM model. Although inconclusive, a 2017 review by Vaiouli and Andeou suggested that music therapy “seems to promote a wide range of preverbal skills including early vocalizations”. A growing body of evidence is pointing to the relationship between music and speech, (Levitin, 2006 p.191, Koelsch 2011) driven primarily by the emergence of the field of neurologic music therapy. One such technique is that of Melodic-based communication therapy with preliminary studies indicating that it increases the prevalence of speech production in nonverbal children with ASD (Sandiford et al, 2013). The Nordoff-Robbins approach to music therapy is one of the best documented approaches to music therapy and children with developmental disorders (Gurrero et al, 2015). A 2010 study by Groß et al found that this approach to music therapy when working with children with delayed language development lead to changes in phonological memory and the understanding of sentences.
Sensory affect/motor development
Cibrian et al (2020) used neurologic music therapy techniques to improve the motor co-ordination of children with ASD in a randomised control study. Over a two month period using both NMT techniques and assistive technology (BendableSound) they found that playing tambourines improve reaction times and Bendable sound improved strengths and co-ordination. Repetitive behaviours often associated with ASD, may be caused by functional variances in the cerebellum and cerebro-cerebellar circuits (which pass through the brainstem) (D’Mello & Stoodley, 2015). Promoting neuroplasticity in order to rewire these circuits is possible using rhythmic entrainment as suggested by (Baharathi et al, 2019). Abnormalities in gait (how someone walks) are typical of ASD and although often overlooked in favour of other interventions relating to language and social skills, have a large influence on later life (joint pain and other complications) at a significant cost to the public health system (Powers, 2020). Powers also noted that NMT (specifically rhythmic auditory stimulation (RAS)) seemed to improve proprioception.
The development of socialization
Numerous studies have pointed to the use of music therapy as an effective tool to improve social interaction between parents and infants with ASD. Family-centred music therapy (FCMT) in conjunction with intensive early intervention was found to have some preliminary effects on improving social interactions (Thompson et al, 2014). Bharathi et al (2019) found significant increases in social skills scores on the TRIAD Special Skills Assessment (TSSA) and a meta-analysis by Shi et al, (2016) found that music therapy was an efficacious tool from a survey of 300 cases (160 in the experimental groups and 140 in the controls).
Conclusion
When taking the finding that individuals living with ASD have been shown to typically have normal or even superior music processing abilities (Molnar-Szakacs et al, 2009), alongside the obvious motivational and child friendly nature of music therapy based interventions it would seem obvious that music therapy interventions should play a crucial role in the development of the national autism strategy. Early intervention, in a period of high neuro-plasticity would seem to be the best place to start. By utilising the evidence based approaches of music therapy to target the key areas of socialization, communication and the sensory/motor systems, a growing body of evidence seems to suggest that these interventions are not only efficacious but could end up saving the public healthcare system money in the long term as suggested by Powers (2020). For the reasons outlined above it is hoped that the information provided for policy makers here will influence both the statutory recognition of the profession of music therapy in Ireland as well as providing a platform for its first official statutory role in the case of early intervention in Autism spectrum disorders in the up and coming national Autism strategy.
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