Introduction

Due to the severity of the problems related to autism as well as the limitations associated with the existing means of treatment, there is a need for complementary interventions (Akins, Angkustsiri, & Hansen, 2010). Additionally, more and more patients are inquiring about alternative and complementary means of treatment; thus, practitioners and parents need to be informed about these interventions and ways of integrating them into treatment. One of the alternative interventions used for treating autism has long been attracting considerable attention is the use of music therapy, which entails the use of both structured and unstructured group and individual sessions that involve listening to and/or playing music (Albornoz, 2011; Simpson & Keen, 2011). Music therapy is a potential means of treating autism because of its effectiveness in enhancing engagement, expression, joint attention, communicative skills and relationships with ones environment (Finnigan & Starr, 2010). A defining attribute associated with music therapy as an alternative intervention to autism stems from the fact it does not intimidate patients. Moreover, the majority of autistic individuals respond to music in a positive way. Such patients often have a keen response and interest in music, which makes music therapy an ideal therapeutic instrument for autistic individuals (Gattino, Riesgo, Longo, Leite, & Faccini, 2011). Albornoz (2011) describes music as a fundamental human response that spans all levels of ability and disability. The flexibility associated with music allows it to be adapted to a medium that can be used to meet the individual needs of patients. Music has been described as something that is enjoyable and motivating, providing relaxation and encouraging self-expression (Brown & Jellison, 2012). Despite such potential, little empirical research is devoted to the investigation of the outcomes associated with music therapy among autistic individuals. As a result, the proposed study seeks to investigate the question of whether music therapy can improve the condition for autistic individuals, especially the quality of life (QoL). To achieve this objective, a music therapy treatment program will be administered to individuals who have been diagnosed with autism. Their QoL will be measured before and after the program in order to determine whether any significant differences in the QoL measurements exist.

Statement of the Problem

The specific research problem that the proposed research will tackle is related to the need for additional interventions in treating autism given the limitations associated with the existing treatments as well as the severity of the problems related to autism. Currently, there are only two medications that have been approved by the United States Food and Drug Administration (FDA), which include the aripiprazole (Abilify) and Risperidone (Risperdal) (Wan, Demaine, Zipse, Norton, & Schlaug, 2010). These drugs have only been approved for their capacity to treat irritability among individuals aged between 5 and 16 years (Wan et al., 2010). As a result, there are no medications that have been proven effective for the treatment of core symptoms of autism. Off-label medications are usually recommended for the treatment of co-occurring behaviors like self-injurious behaviors, disruptive behaviors, agitation, mood, anxiety, repetitive behaviors, sleep issues, impulsivity, and inattentiveness (Simpson & Keen, 2011). These medications tend to have perceptible side effects. The use of alternative treatments for autism is becoming common, which poses the need to determine their effectiveness. In the US, the prevalence of the use of alternative and complementary treatments for autism equals to 32-87 percent, while in China such prevalence amounts to 41 percent, and in Canada the rate is 52 percent (Reschke-Hernandez, 2011). The most common reasons cited for using alternative treatments for autism include safety concerns related to taking medications and their side effects. Alternative treatments are perceived as being risk-free and capable of improving the outcomes for the autistic individuals (Else & Wheeler, 2010). The majority of referrals for alternative treatment for autism come from nurses or physicians (44 percent), and parents (16 percent) (Reichow & Volkmar, 2010). Other sources of referrals include friends and family, the Internet and books, scientific journals, and occupational therapists (Raglio, Traficante, & Oasi, 2011).

While there are several alternative interventions and therapies used for treating autism, very few presuppose empirical evidence. Moreover, there is scarce empirical evidence for alternative treatments and interventions with respect to QoL measurements, and many of them focus on success measures devoid of practical relevance and predictive validity (Gold, 2011). The existing scientific evidence for alternative approaches seems to be of less importance to practitioners and providers, but matters only to parents. Moreover, some alternative treatments are associated with risk for autistic children. Thus, due to the limitations associated with the existing treatments for autism together with the chronic and severe problems related to autism, there is a need to devise and test additional interventions for patients suffering from autism in order to determine their efficacy (Reschke-Hernandez, 2011). The proposed study seeks to address this gap in the literature. The results of the study will complement the existing scanty literature with information on the efficacy of music therapy as an alternative treatment for autism. One of the alternative approaches for autism is music therapy, which has been proven to be risk free, although its efficacy is yet to be evaluated. Thus, the primary objective of the proposed research is to investigate the effectiveness of music therapy in treating autism, especially in regard to the QoL measures. The research question that will guide the proposed design is:

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What is the effect of music therapy on the QoL outcomes for autistic individuals?

Problem Background (Literature Review)

Overview of Autism

Autism refers to a spectrum of neurological disorders typified by impairments in social communication and repetitive behaviors. People suffering from autism exhibit forms of social impairments like poor emotional and social reciprocity and lessened eye contact in the course of social interactions (Albornoz, 2011). Impairments in communication among autistic individuals are characterized by problems in sustaining and initiating conversations with others, delayed or lack of language acquisition, and using language in an idiosyncratic manner. Moreover, stereotypical and repetitive behaviors are a core symptom of autism as evidenced by manipulating objects repetitively, body twisting, and flapping hands (Brown & Jellison, 2012). Compulsive behaviors are yet another sign of autism, which typically involves the inability to adhere to fixed routines. Besides the core impairments, autistic individuals may exhibit numerous secondary impairments such as emotional and behavioral problems including self-injurious behaviors, temper tantrums, hyperactivity, depression, aggression, and anxiety. In addition, empirical evidence suggests that autism is characterized by difficulties in the modulation of sensory inputs, which is likely to manifest in the enhanced perception of visual and auditory stimuli. Other signs associated with autism include pervasive and significant motor impairments like multi-limb and dual coordination; problems with controlling posture; and gait (Gooding, 2011). Motor clumsiness and limited movement has been reported to hinder social development. To sum up, autism denotes various neurological disorders typified by both primary impairments in communication and secondary behavioral and motor impairments.

Effects of Music Therapy

Music therapy has been defined as the scientific and functional application of music by a qualified music therapist with the aim of enhancing behavioral, educational, emotional, and social development (Akins et al., 2010). Music therapy entails using musical interventions coupled with visuals in order to address the cognitive, sensory-motor, physical, communicative, psychological, social, and behavioral functioning. For autistic individuals, music therapy represents a medium of musical experiences considered non-threatening and developmentally appropriate. It is capable of eliciting positive behavioral changes and facilitating the development of skills (Procter, 2011). Because it is not an intimidating procedure, music therapy has the potential of helping autistic individuals develop social and communicative skills (Albornoz, 2011; Dimitriadis & Smeijsters, 2011). When accompanied with activities like passing a ball, playing musical instruments, or taking part in role playing music can be instrumental in fostering social interaction. Gattino et al. (2011) point out that music therapy might be utilized to facilitate the development of diverse nonmusical skills including cognitive and physical skills. Individuals having learning disabilities usually have many other problems associated with physical, sensory, and communicative impairments, as well as abnormal behavioral patterns (Gooding & Gregory, 2011). As a rule, because of these disabilities, they face considerable challenges in communicating, establishing and maintaining any form of social interaction, which results in frustration among them and those trying to understand them. Many authors agree that music is a valuable tool for autistic individuals.

The effects of musical therapy have been vastly explored in the literature. A study by Mrazova and Celec (2010) that investigated the effect of music therapy on addressing inappropriate behaviors indicated that music therapy was not only effective in teaching but also reinforcing appropriate social behavior. Similar findings have been documented in other research studies. For instance, Mateos-Moreno and Atencia-Dona (2013) used music therapy wherein music was presented together with a structured activity aimed at encouraging the development of specific non-music skills like social interaction and addressing inappropriate social patterns of behavior. The findings by Mateos-Moreno and Atencia-Dona (2013) shows that music therapy combined with a structure activity is both a therapeutic and enjoyable experience for those suffering from autism and other forms of learning disabilities. Various studies have also confirmed that music therapy in group or dyadic settings can help develop social connections (Lim & Draper, 2011; Reschke-Hernandez, 2011), which can be attributed to the fact that synchronous movements in the course of music making and rhythmic actions together with unison singing helps create a sense of unity, shared purpose, and state of cooperation. All these outcomes play a crucial role in sparking social connection between people. In addition, LaGasse (2014) showed that group music environments provide autistic children with an opportunity to learn social skills like empathy, shared affect, joint affection, social reciprocity, turn taking, and imitation. In a study by Gro?, Linden, and Ostermann (2010), it was reported that when autistic children engage in music games, they start synchronizing and imitating their social partners actions, and slowly start understanding the emotions and intentions of their partner. Some studies have reported that group singing and music making help foster positive emotions and empathy (Kern, Rivera, Chandler, & Humpal, 2013; Reichow & Volkmar, 2010), which is especially important for autistic individuals because of the problems they have when trying to understand and empathize with the emotions of others.

Music therapy has also been successfully used in enhancing a number of social skills among autistic individuals such as initiating social interactions, engagement and eye-contact (Albornoz, 2011; Simpson & Keen, 2011). A music intervention that lasted 12 weeks resulted in substantial increases in the duration and frequency of joint affection and shared positive affect when compared to a controlled group that was engaged in playing with toys (Else & Wheeler, 2010). Likewise, a seven month music intervention that entailed diverse forms of rhythmic movement games among autistic children and their mothers increased the frequency of eye contact and initiation of social interactions by the autistic children. Music therapy has also been utilized for enhancing emotional understanding among autistic children. In a study by Reichow and Volkmar, (2010), in which autistic children were taught four emotions including fear, anger, sadness, and happiness using songs and background music, it was found that the children reported most improvements in their emotional understanding when they were subjected to the background music. Studies involving children and developing adults provided evidence that music therapy is a helpful tool for facilitating the emotional and social development of people (Reichow & Volkmar, 2010; Simpson & Keen, 2011).

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Theoretical Model

The processes that take place in music improvisation might be of some help to autistic individuals in terms of developing communicative skills as well as enhancing their social interaction capacity. Musical interaction, especially musically improvisation, is often described as a form of pre-verbal and non-verbal language that allows verbal individuals to have pre-verbal experiences (Reichow & Volkmar, 2010; Simpson & Keen, 2011). It also enables non-verbal individuals to communicate without words and allows all individuals to engage with one another in a way that is more relationship-oriented and emotional compared to verbal language. Moreover, in music therapy, listening to music entails an interactive process characterized by choosing music that one considers meaningful for the individual such as associated with an issue that the individual was engaged in. In some cases, listening to music may involve reflecting upon personal issues associated with the music (Procter, 2011). For people who are able to communicate verbally, verbal reflection on the musical process is considered a crucial element of the musical therapy. The use of music therapy for treating autistic patients often takes the form of individual therapy. The justification underpinning the use of music therapy for treating people suffering from communication disorders draws upon the findings reported by such researchers as Albornoz (2011) and Simpson & Keen (2011), who refer to sound dialogues existing between infants and their mothers through musical terms. When referring to the tonal, these researchers use a number of terms like tonal movement, timber and pitch, and when explaining temporal qualities, they use terms like timing, rhythm, temp and pulse. Lim and Draper (2011) points out that young infants are very sensitive to the melodic and rhythmic aspects of maternal speech as well as the emotional tone, which is an indication that people are born with the ability to engage in the communicative musicality associated with conversation. Therefore, music is perceived as an effective medium for facilitating non-verbal social exchange for both autistic children and adults. Essential communicative behaviors like turn taking, eye contact, and joint attention are typical events that take place in active and shared music making.

In the proposed study, it is suggested that music therapy is an effective means of treating autism since this intervention helps harness the music strengths of the autistic individuals while at the same time helps alleviate their impairments. There is much evidence that proves music therapy to be an attractive option for treating autism. Firstly, musical training can help in addressing numerous core impairments associated with autism including verbal and nonverbal communication, social reciprocity and joint attention (Brown & Jellison, 2012). Moreover, musical training can help in addressing comorbidities associated with behavioral problems and poor motor performance. Secondly, autistic children tend to find music enjoyable, which can be attributed to the fact that they have a higher understanding of music compared to their normal peers. Autistic children have a more enhanced pitch perception ability in contrast to children who develop normally (Gold, 2011). Thirdly, musical therapy does not result in intimidating experiences, especially when autistic child is exploring musical instruments and the trainer intervenes by copying the actions of the child (Raglio et al., 2011). Autistic children tend to have problems with direct social engagement; as a result, musical activities that are socially embedded offer an ideal opportunity to participate in comfortable interactions with others.

Contribution of the Research

Music therapy accounts for about 12 percent of all interventions used for treating autism (Akins et al., 2010). Nevertheless, the literature review makes it clear that most of the studies assessing the effectiveness of music therapy for autism have utilized either single subject designs or small samples. In addition, most of these research studies entailed pre-post comparison of the outcomes of music therapies in the treatment group without using a control group. Therefore, the overall quality of empirical studies exploring the efficacy of music therapy for autism can be considered poor. A bulk of these studies has placed emphasis on the effectiveness of music therapy in treating communication impairments. Very few studies have been carried out to examine the effects of music therapy on behavioral, social, and emotional outcomes. It is interesting to note that no study has been conducted to explore whether music therapy enhances the QoL for autistic individuals. Based on the current available literature on music therapy, it is relatively difficult to make conclusive claims regarding the effects of music therapy on improving the QoL in individuals suffering from autism except for significant effects on communicative skills of a person. Therefore, the proposed study seeks to address this gap in the literature by adding to the scanty literature investigating the outcomes of music therapy for autistic individuals. The findings of this research will provide evidence indicating that music therapy is one of the alternative means of treatment that has a potential of helping autistic individuals in terms of the QoL through learning and developing social and communicative skills that will enable these people to live to their full potential and have productive and independent lives.

Methodology

Research Design

The research design for the proposed design is a pretest posttest design involving study and control groups. This design involves performing a pretest prior to the experimental manipulation, which is then followed by a posttest that is similar to the pretest. The choice of this design is explained by the fact that it facilitates the evaluation of the effect of an intervention by investigating the difference between the posttest and the pretest. The pretest and the posttest will be administered to both the study and control groups.

Research Hypothesis

Ha: Music therapy has a significant positive effect on the QoL for parents of autistic children

Ho: Music therapy does not have a significant positive effect on the QoL for parents of autistic children

Study Variables

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The independent variable for this study is the music therapy whereas the dependent variable is the QoL for autistic individuals. The music therapy that will be used in the proposed study is described in detail in Procedure section. The QoL refers to the wellbeing or lack of it in the life of an individual, which entails physical, social, and emotional aspects of a persons life. In the proposed study, the QoL will be measured for parents of autistic children. The QoL for parents of autistic children will be measured using the Quality of Life in Autism Questionnaire (QoLA) for caregivers and parents of children suffering from autism, which has 48 items under two subscales, with the first subscale focusing on the QoL items and the second subscale being a parent report on the extent to which the autism symptoms of the child are problematic (Khanna et al., 2011). The construct validity and concurrent validity of this instrument has been confirmed. Khanna et al. (2011) reported that an internal consistency coefficient of 0.94 for the QoLA. In terms of construct validity, Khanna et al. (2011) reported that Cohens d of 1.96. QoLA also has a good convergent validity.

Population and Sample Selection

The population for the planned study consists of autistic children. The setting for the proposed study will be an elementary school in California. The school provides special education services. Participants in the study will be selected randomly from the various grades. At a sample power of 0.25 and effect size (Cohens d) of 0.2, a sample size of 84 will be required. Participants will be randomly subjected to the treatment and included into the control groups using a computer software application for generating random sequence.

Protecting Human Rights

Participants are given a chance to enjoy numerous rights including the right not to take part in the research; the right not be harassed; the right not to be offered any inducements that are beyond the scope of participation; and the right to be contacted at times deemed reasonable. Participants also expect that the research will be conducted in compliance with the informed consent and assent. In the proposed study, a number of steps will be taken to safeguard the rights of the participants. First, participants will not be subjected to any form of discomfort or harm. Music therapy is a non-threatening intervention. Second, the anonymity, confidentiality, and privacy of participants will be guaranteed. No personal information that could be used to identify the participants personality will be collected during the research. In addition, the information collected from the research will be stored in a computer safeguarded by a password with only the researcher having access to it. This data will be destroyed one year after the research is conducted. Participation in the study will not be deliberate, wherein participants will be asked to provide an informed consent and assent in order to make an informed decision regarding participation in the research.

Procedure

Participants will be randomly subjected to the treatment and assigned to the control groups. The therapy for the control group will be toy playing whereas the treatment group will be subjected to music therapy administered by a qualified music therapist. Before administering the intervention, the QoL for participants in the treatment and control groups will be measured. All the participants in the treatment group will receive the same treatment. The music therapist will work closely with the teachers of the students when developing the music intervention and the corresponding goals that might be supported with the use of music. The music therapy sessions will be implemented thrice per week for a whole term. Posttests will be performed for both participants in the treatment and control groups.

Data Analysis

The process of data analysis will entail comparing pretest and posttest data to determine whether there are significant differences between the conditions of the treatment and control groups. A significant difference between the pretest and posttest data for the treatment group will suggest that music therapy has an effect on the QoL of autistic individuals provided that no significant differences are reported for the control group.

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