Source:
Wan,
C. & Schlaug, G. Neural pathways
for language in autism: the potential for music-based treatments. Future Neurology, 2010, 5(6), pp797-805
Summary:
In
this special report, the authors present the clinical potential of a new
experimental music-based therapy, termed Auditory Motor Mapping Training (AMMT).
This novel therapy is considered a viable tool to facilitate expressive
language in non-verbal individuals with autism, as well as in possible
strengthening of the underlying neural connections.
The
authors first describe the core diagnostic features of Autism Spectrum
Disorders (ASD), highlighting the language deficits and impaired communication
skills, which can be persistent. Subsequently, it is explained how these
deficits have been studied using structural and functional imaging and
neurophysiological techniques. Studies have reported structural differences in
language-related regions between individuals with
autism and controls, although with some inconsistency across these investigations.
Nevertheless, the authors argue that these differences could be partly
attributed to the complexity of the disorder, which may have different
etiologies and intrinsic heterogeneity in linguistic abilities among
individuals with autism.
After
describing language processing in typically developing individuals and
structural abnormalities in autism, the authors emphasize the possible
existence of aberrant long-range connectivity in this disorder. They outline
which anatomical pathways could be affected, such as the arcuate fasciculum
(AF), the extreme capsule (EmC) and the uncinate fasciculus (UF). Therefore,
both the language areas (Broca and Wernicke´s regions) and the neural
connections between them might be abnormal, impaired or underdeveloped. It is explained
how connectivity across brain regions have been examined through functional and
structural imaging techniques, using functional Magnetic Resonance Imaging
(fMRI) and Diffusion Tensor Imaging (DTI), respectively. As an example, the authors mention
recent published studies using DTI tractography, which reported abnormalities
in the corpus callosum and in frontal lobe tracts, such as the arcuate
fasciculus (AF) in autistic children.
In
addition, Wan and Schlaug present research in which music making and intensive
musical training produced plastic changes in the brain (particularly, an
increased number and volume of fibers of the AF). They suggest that a music-based
intervention can also be used in autism, to engage and strengthen the
connections between frontal and temporal regions bilaterally, and thus facilitating
expressive language in nonverbal individuals.
Finally,
the authors present AMMT as an innovative intervention with clinical potential
in autism and characterize its three main components including singing, motor
activity (using a set of tuned drums to engage both hands) and imitation.
Reflections:
The presented article by Wan and Schlaug conducted
in the Music and Neuroimaging Laboratory at Harvard University provides deeper insight
into the role of music therapy in the treatment of children with autism. Several
questions crossed my mind while reading this article, such as: why music
therapy is not common in clinical settings and how this field can be further developed?
The
potential advantage of music interventions in autism is not a new finding. Many
studies have previously reported the musical strengths of the individuals with
autism, such as their superior music perception abilities and enjoyment in
musical activities, such as singing or playing an instrument. Furthermore,
musical stimuli have been shown to activate brain regions associated with the
processing of emotions, emphasizing the therapeutic potential of musical
activities in this disorder. A year after publishing the aforementioned article,
they published a sequel entitled “Auditory-Motor Mapping Training as an
Intervention to Facilitate Speech Output in Non-Verbal Children with Autism: A
Proof of Concept Study” in which they reported reliable improvements in
participant´s expressive language using auditory-motor mapping training.
However,
most of the studies referring to efficacy on music therapy in autism have been
anecdotal reports of single cases, lacking
empirical support. Recently, a Cochrane review (2014) assessed the effects of
music therapy for individuals with ASD. Only 10 out of 431 studies found in
this field met the inclusion criteria, as relevant randomized controlled trials
(RCTs) or controlled clinical trials (CCTs). The presented results provided evidence
that music therapy may assist children with ASD to improve their skills in
social interaction, verbal communication, initiating behavior, and
social-emotional reciprocity.
For
future studies, music therapists and researchers are required to carry out
empirical investigations with larger samples sizes, controlled paradigms with
longer periods of observation, statistical analysis to test the significance of
improvements, proper follow- up and observations outside of therapy sessions. Nevertheless,
studies will still have many sources of heterogeneity (e.g. patient´s age,
intensity of therapy and type of treatment approaches) and limitations.
Although
some animal models have been used for understanding the basic perceptual
mechanisms in music processing, these models seem to be useless when it comes
to study the effectiveness of music therapy in facilitating speech output.
A
more robust approach would be the use of imaging techniques to investigate the structural
and functional differences of the neural network, prior and after the music
therapy, as well as during some follow-up period.
In
conclusion, music-based therapies in autism have been underutilized and poorly
studied. More empirical research and interdisciplinary collaboration are needed
to reveal the strengths and weaknesses of this field. Moreover, the development
of these innovative interventions will not only bring advancement of knowledge,
but will also directly benefit individuals, their families and society.
References:
Wan
C, Bazen L, Baars R, Libenson A, Lauryn Zipse, Zuk J, Norton A, Sclaug, G.
“Auditory-motor mapping training as an intervention to facilitate Speech Output
in non-verbal children with autism: A proof of concept study”, PLos ONE,
6, 2011, 1-7.
Geretsegger
M, Elefant C, Mössler KA, Gold C. “Music therapy for people with autism spectrum
disorder”, Cochrane Database of Systematic Reviews, 2014, Issue 6. Art.
No.:CD004381. DOI: 10.1002/14651858. CD004381.pub3.
2 comments:
You’re right - there is a need for further empirical research in this area, as highlighted by the Cochrane review. Another Cochrane review examining the effects of music therapy with patients who had acquired brain injuries yielded only seven studies that could be included, and of these seven, only two were determined to have low risk of bias (two by M. Thaut et al. involving rhythmic entrainment). You wonder why music therapy is not more common in clinical settings, and this could be an answer. As you report, most of the studies to date have been single case studies lacking empirical support. So far there just hasn’t been sufficient evidence-based research to satisfy the medical community. It is unfortunate, because there are so many benefits to be gained. The work of Wan & Schlaug is a step in the right direction, and yes, there has to be interdisciplinary collaboration. It would be helpful to have a music therapist as part of the research team in designing and implementing interventions, as music therapists would be able to provide perspective based on their clinical practice. I feel confident that in the next few years, with the help of research incorporating input from stakeholders as well as neuroimaging techniques, significant new understandings will emerge that will help guide practice, and improve the lives of persons with autism and their families.
I have had both success and failure when working with ASD students in the music classroom. For some students music is an escape, a joy, an opportunity to express oneself creatively and to contribute as part of a larger collaborative ensemble. There is certainly a great deal of experiential and narrative studies that show the profound impact that music can have on individuals in the autism spectrum. But music research is lacking in this area and it leaves a big gap in teacher training in differentiated classrooms. Thanks for this piece, it provides me with some references that will inform my own research!
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