Running head: MUSIC THtsRAPY AND SOCTAL SKILLS

The Elfects of Music Therapy on Social Skills in Individuals with Autism: A Meta-Analysis
Hannah L. Rux

Slippery Rock University of Pennsylvania"

A dissertation presented to The College of Graduate and Professional Sfudies, Department of
Special Education, in partial fulfillment of the requirements for the degree of Doctor
Education in Spepial Education

of

MUSIC THERAPY AND SOCIAL SKILLS

COMMI'TTI]tr MT]MBERS

Comrnittee Chair: Dr. Christopher Tarr

I)issertation Chairman I Professor of Special Education
Slippery Rock University
Committee Member: Dr. Matthew Erickson
Chairman I Associate Professor of Special Education

Slippery Rock University
Committee Member: Dr. Karen H. Larwin

University IRB Chair I Professor lResearcher I Author
Slippery Rock University

2

Docu$ign Envelope lO: 1846F818-3DC2-4D03-848F-9ElED163626S

MUSIC'II'IERAPY AND SOCIAL SKII.,I.S

Slippery Rock University of Pennsylvania
Departnrent of Special Educatiorr

.A Disscrtation Written By

l"lannah

Bachelor

of- $cience

L. Rux

in Psychology, Fairmor.rt State University, 2016

Master of Education in Speoial Education, l:airmonl. State {Jniversity, 2020

I)octor of Education in SpecialEducation, Slipper:y Roc,k University of Pennsylvania, 2023

Approved by
Do6uSigncd by:

0i[ia"n Tow €l-.8

e/2L/2023

Taru, Dissertation Committee Chair

filrlllrr,t

fficLsow

Date

9/20/2023

. Erickson, Committee Member

Date

0r. b"nn k. Wwiw
in, Comminee lvlernber

Accepted by

College of Education, Slippery Rock University of Pcnnsylvania

MUSIC THE,I(APY AND SOCTAL SKILLS

ABSTRACT'
Over the past decades, the rate of autism has increased around the world (Ghaserntabar et al.,
2015). A prolonged impairment in social skills and communication is a key feature of autism.

According to Vaiouli and Schertz (2012\joint attention is an important developmental milestone
for developing higher levels of social engagement. The delay or absence ofjoint attention is

typically seen in individuals with autism (Vaiouli & Sohertz, z0n). Civen that there is no known

teatnent or cure for autism, the focus in supporting individuals with autism is aimed toward
implementing an intervention strategy that targets the symptoms of autism (Yum et al., 2A2A).
The current investigation conducted a meta-analysis on the effects of music therapy on social

skills in individuals with autism. The analysis for this study was based on data from four
research studies providing 20 effbct size estimates. The sample within the

tbw

studies included

data from 117 participants. The sample size for the effect size analysis,was based on a sample
size of n

: 596. The four articles included in this meta-analysis produced an overall large

positive significant effect size of d :0.572 with a 95% confidence interval of 0.37 to 0.78. The
mean effect size suggests a large significant effect from music therapy across all studies.

All

studies included in this current investigation published and reported overall positive results. The

Q-statistic tests revealed siguifroant heterogeneity across all studies, with variability across the
mean effect size estimates, ranging from

d: - 0.14 to d:

1.28. Since the effect size estimates

were all positive for the published studies, it is likely that publication bias existed in the studies
used in this meta-analysis. According to Walker et al. (2008) high levels of heterogeneity can

compromise the conclusion of a meta-analysis, therefore future research is also needed to help
decrease the level of heterogeneity across studies.

MUSIC THE,RAPY AND SOCTAL SKILLS

PRT]r}.CE
This dissertation is an original, independent work that investigates the effects of music therapy
on social skills in individuals with autism.

MUSIC THE,RAPY AND SOCIAL SKILLS

6

ACKNOWLI]DGMI]NTS
I would like to take this opport'rnity to thank Dr. Christopher Thrr for continually
providing guidance and support throughout the process of this dissertation. I will forever be
grateful for your leadership, expertise, and motivational words of encouragement. Without your
guidance, support, and encowagement this dissertation would not have been possible.

Dr. Matthew Erickson, thank you for your willingness

t
join my dissertation committee.

Yow expertise in positive behavior supports and autism has added great value to my committee.
I)r. Karen Larwin thank you for your guidance and expertise in helping me complete the
analysis section of my dissertation. Without your expertise, support, and guidance in helping me
understand the statistical analysis associated with a meta-analysis, the completion of this

dissertation would not have been

possible.

,.

MUSIC THE,RAPY ANI] SOCI,AL SKILLS

DEDTCATION

I would like to dedicate this dissertation to the brave men and women that were stationed
upon the USS Cole DDG-67 on October 12,2AA0. Your bravery and dedication will never be
forgotten. Electronic Warfare Technician lst Class, Kevin Shawn Rux, uray you rest in peace

knowiug that you are loved.

I would also like to thank and dedicate this dissertation to my husband Matt. Throughout
the years, you have always been my biggest supporter! Thank you for believing in me and
always providing me with an abundance of love and encouragement. May you always know how
much I love you, then, now, and forever.

MUSIC THbRAPY AND SOCIAL SKILLS

'IABLE, O[' CON'TI]N'I'S
Chapter

I * Introduction

The Effects of Music Therapy on Social Skills in lndividuals with

Chapter 2 - Literature

Autism

Reyiew

..

Autism
BrainMechanisms

.........14
.

.... ....20

...........20

.....

.............20

Environmental Components
Genetic Components

..

.....21

....

Course and Prognosis of
Standard Treatments of

.......23

ASD

.....24

ASD

......25

The Importance of lnterpersonal and Intrapersonal Synchrony in
Interpersonal Slmchrony

ASD

.....25

...

.. ... .25
t.

Intapersonal Synchrony
The Developmental Importance

...

........27

of Social Skills in ASD

Developmental Techniques to Measure Social

............30

Skills

Vineland Social-Emotional Early Childhoctd Scales (VSEEC)
The Social Responsiveness Scale Preschool Version

.

.

for 3-Year-Olds (.SRS-P$

.

.......33

...

.......33

.....

... . ..33

The McArthur-B at es Communic atiye D eve lopment Invento ries,
Words and Gestures (1h{BCDI-W&G)

'

...

The Parent-Child Relationship Inventory

.

fCRI)

f^y,tnS/
Checklist (AfEq

The Social Skills Rating System Scale
The Autism Treatment Evaluation

The TRIAD Special Skills Assessment

(TSSA)

....33

.........33
........34
.....34

.......34

MUSIC THE,RAPY AND SOCIAL SKILLS
Social Responsiveness Scale
The

Music

fSRS/

Music Therapy Diagnostic Assessment

......34

(MTDA)

.......35

Therapy

Active and Passive Music

...........35

Therapy

..

.

.

Music Therapy for lndividuals with ASD

..

...35

......39

..

.....45

Chapter3-Methodology

............48

The lrnportance of a Meta-Analysis

Introduction.....
Inclusion

.........48

Criteria

Search Sources and Search

.

Terms

.....,..49

Databases

........50

Discovery Advanced
Evaluation of

Search

.

... . ..50

t.

Quality

..

Coding

...... . .52
......54

DevelopingCodinglnskuments.....
AreaofExpertise(a)...
.

... . ..48

.,.........54
....56

Publication Status (b)

...

....56

Location of Study (c)

..

.

......56

...
'GenderofParticipants(e),
Quality of Study (d)

Age of Participants

(0

......56

.......57

...

...........57

Level of Autism Severity of Participants (g)
Type of lntervention Strdtegy (h)

.

..

.

........57
......,...57

MUSIC THERAPY AND SOCI.AL SKILLS
Setting (i)

10

....

...,......58

Implementation Specialist

O

Length of Each Therapy Session (k)

......58

...

........58

TotalNumberofTherapySessions(l)....
Focus of measurement (m)
Social Skills Assessment Method (n)

.......59

...

Social Skills Measurement techniques

Effect Size

.....59

........59

(o)

.....59

Calculations

.......60

AggregatedScoreStudies
Basic Meta-Analysis

.......,..60

Calculation.

.....60

P-Value
Publication Bias

.....62

.

......62
t.

Chapter4-Results

...........65

Intoduction.....

........65

PrimaryModeratorsAnalysisResults
Secondary Moderators Analysis

Publication

Results.

Bias..

Conclusion
Chapter5*Discussion.
Introduction......
Moderators
Age..
Severity

.........70
.......75
......77
.........79
.....79

....."...79

........82
......92

Level.

.........g3

MUSIC THERAPY AND SOCIAL SKILLS
Intervention

Strategy.

..".....83

Sitting of Music

Therapy.

Implementation

Specialist..

Length of Therapy

,.........83
......83

Session.

Number of Music Therapy
F'ocus of

11

........84

Sessions.

.........84

Measurement....

........85

AreaofExpertise.
Skills Measurement
Location of
Implication of the

............85

Technique

..........85

Research......

..........86

Results.

.... ....86

Limitations

.....87

Recommendations for Fuflue

Research.

..

..

.....90

t.

Conclusion

......91

References

..........93

Appendices.....
Appendix A

-

Appendix B

* Inclusion

Appendix C

-

....106

IRB Approval Documentation
Criteria Data

Evaluative Method Data

-Coding

.

Sheet
Sheet

Appendix D -Evaluative Method Scoring
Appendix E

..

Rubric

. . ..

1

06

..........107
..... 108

........109
.......112

MUSIC THERAPY AND SOCIAL SKILLS

t2

LIST OF TABLES
Table

Table Description

Page

Table I

Steps in a Meta-Analysis Research Study

64

Table 2

Effect Size Estimates by Study

67

Table 3

Eflect Size Estimates by Measure Within Studies

69

Table 4

Effect Size Estimates by Age Group

70

Table 5

Effect Size Estimate by Severity Level

7t

Table 6

Effect Size Estimate by lntervention Strategy

71

Table 7

Effect Size Estimate by Setting of Music Therapy

72

Table 8

Effect Size Estimate by Implementation Specialist

72

Table 9

Effect Size Estimate by Length of Therapy Session

73

Table 10

Effect Size Estimate by Number of MT Sessions

74

Table l1

Effect Size Estimate by Focus of Measurement

74

Table 12

Effect Size Estimate by Arca of Expertise

75

Table 13

Effect Size Estimate by Skills Measurement Taken

76

Table 14

Eft'ect Size Estimate by Location of

Research

i'

76

MUSIC THERAPY AND SOCIAL SKILLS

LIST OF FIGURES
Figure Description
Figure I

Effect Size Estimate Plot by Study Measures

F'igure 2

Distribution of True Effects

13

MUSIC THHRAPY AND SOCIAL SKILLS

t4

Chapter l-Introduction
The Effects of lVlusic Therapy on Social Skills in Individuals with Autism
Autism spectrum disorder (ASD) is a disorder characterized by a prolonged impairment

in social interaction, communication, and restricted repetitive pattems of behavior across various
conditions (Ghasemtabar et al., 2015). Impairments in social interaction may include lack of eye
contact, lack of language, lack ofjoint attention, poor attention span, and limited peer relations

(Volkmar & Pauls, 2003). lmpairments in communication may include lack of pragmatic
language, lack of verbal and non-verbal language, and lack of imaginative play (Volkrnar

&

Pauls, 2003). Restricted repetitive patterns of behaviors may include abnormal preoccupations or

interest, difficulties adjusting to change, and stereotypic behaviors (Volkmar & Pauls, 2003),
Over the past couple decades, the rate of diagnostics for ASD have increased
(Gha^semtabar et al., 2015). According to Cardinal et al. (2020) over a span of seventeen years

the rate of ASD in schools, within the U.S., has increased by 430/oper year. According to Yum et

aL QAZ$ the increase in the diagnostic rate of ASD, in recent years, may be due to the evolution
of diagnostic criteria and public awareness. Given that there is no known effective treatrnent or
cure for ASD, the focus in supporting individuals with ASD is aimed toward implementing an

intervention sffategy that targets the syrnptoms of ASD (Yum et al., 2A2q.
According to Yum et al. (202A) intervention strategies should be aimed toward improving
impairments such as lack of human interaction, lack of response, lack of eye contact, lack

of

understanding sarcasm, and lack of emotional recognition. Although some individuals with ASI-f
do not comprehend social interactions, they can imitate and follow rules of social behavior (Yum

etal.,2A20). Approximately

560/o

of children diagnosed with ASD test below average (10 < 85)

on assessments that determine intellectual ability CYum et al., 2020). According to Yum et al.

MUSIC THERAPY AND SOCIAL

SKILLS

15

(2020) intervention strategies may be less effective for individuals diagnosed with severe ASD,
suggesting that an individual's level of severity may greatly affect the outcome of an

intervention.

In the past few decades, the diagnostic rate of ASD has increased around the world
(Ghasemtabar et al., 2015). According to Ghasemtabar et al. (2015) a prolonged impairment in

social skills and communication is a key feature of ASD. Past research has indicated that

individuals with ASD initiate fewer social interactions and show less empathy and/or interest in
social communication (Vaiouli

& Schertz,2Al2). According to Vaiouli and Schertz (2012) joint

attention is an important developmental milestone for developing higher levels of social
engagement. The delay or absence

ofjoint attention is typically

seen

in individuals diagnosed

with ASD (Vaiouli & Schertz, 2012\.
Joint attention refers to the ability to use signals and/or pre-symbolic communication to
gain another person's attention or interest for the purpose of direct communication or sharing

(Vaiouli & Schertz, 2012). According to Vaiouli and Schertz (2012)joint attention should
become noticeable around nine months old and should be well developed around eighteen

months. When a developmental milestone that creates a foundation for language and social
development is absent or delayed, young children are deprived from learning new skills through
reciprocal communication (Vaiouli

& Schertz,2012). Therefore, it is imperative to find an

intervention that improves social skilts in individuals diagnosed with ASD.

' Many intervention treatments have been used to improve social skills in individuals with
ASD (LaGasse, 2017). According to La(iasse (2017) video modeling and peer-mediated
interventions are considered "established" intervention practices for improviug social skills in

individuals with ASD. Although there have been several established intervention techniques that

MUSIC THHRAPY AND SOCIAL SKILLS

16

directly and indirectly target social skills in individuals with ASD, there is no evidence to
support that one method of intervention is more effective than another (LaGasse, 2017). This
may be due to the individualaed levels of severity in ASD. According to Vaiouli and Schertz
(2012) past research has suggested that music can offer an individualized child-centered
approach to intervention that promotes social development in individuals diagnosed with ASD.

Impairrnents in social interaction, corrmunication, and restricted repetitive pattems

of

behavior are often seen in individuals with ASD (Eren,2015). The cognitive pathology that
affects individuals who have ASD may cause them to experience sosial difficulties (Eren, 2015).

According to Eren (2015) music can temporarily bypass the cognitive process and target the
social and emotional challenges that individuals 'with ASD experience. Eren (2015) also noted
that a positive response to music is often seen in individuals who have ASD.

Koelsch (2009) suggested that music can automatica.lly distract. attsntion from stimuli
that cause negative reactions. Past research has deternrined, using functional neuroimaging,
music can stimulate activity in major limbic and paralimbic brain structures that help individuals

initiate, ganerate, maintain, and regulate emotions (Keolsch,2009). Eren (2015) also suggested
that music can provide opportunities to overcome social and communication difficulties for

individuals diagnosed with ASD.
GroB et al. (2010) suggested that music can also be used as a form of creative art therapy.

In the past, it has been suggested that using music to express individualized social needs can
actively support mental and psycho-physical recovery in various clinical and therapeutic
environments (GroB et a1., 2010). In addition to these environments, music therapy can be used

to develop social irnpairments (Grol} et al., 2010). According to GrolJ et al. (2010) several past
studies have illustrated the use of music therapy in the development of social skills in young

MUSIC THERAPY AND SOCIAL SKILLS

l7

children with ASD. The delay in development ofjoint attention has been identified in past
research as being a major characteristic of social deticits in individuals with ASD

(Kim et al.,

2008).
Various studies have brought forth the need tbr further research that address early
diagnosis, intervention, and future outcomes of language and social development (Kim et

a1.,

2008). AccorrJing to Kjm et al. (2008) music therapy enhances spontaneous self-expression, and
emotional and social development in individuals with ASD. Delayed speech development is
often associated with developmental delays (Grofi et al., 2010). CroB et al. (2010) suggested that
speech development is a predictor of future learning

difficulties in reading, writing, and spelling.

A developmental delay in speech is a risk factor for other cognitive and social-emotional
problems (GroB et al., 2010). GroB et al. (2010) suggests that music therapy may help enhance
speech development and communication

skills in individuals with US?.

The use of music therapy as an intervention to enhance social skills in individuals with

ASD is

a common

practice (Yum et a1., 2020). The examination of music therapy as a social

skills intervention has been inspired by significant evidence on the potential use of music as an
intervention technique to improve social skills in individuais across various severities of ASD
(Yum et al., 2A2q. Yum et al. QAZ$ suggests that passive music can be used to irnprove

familiarity and relaxation, whereas active music promotes teacher/student engagement, thereby
providing an opportunity to promote leaming through non-verbal language. Music therapy has
been comprehensively examined as a medium to increase social

skill in individuals diagnosed

with low-functioning ASD (Yum et al., 2020).
Yum et al. (2020) defined music therapy as a systematic process of intervention that
promotes

joint attention. Children with ASD are often highly passive in social situations (Yum et

MUSIC THERAPY AND SOCIAL SKILLS

18

eL,2A20). According to Yum et al. (2A2A) the low verbal ability that many individuals with ASI)
demonstrate is limited when social interactions involve verbal exchanges. However, Yum et al.

(2020) suggested that music can become a sluice for individuals whose social interactions are
impaired. Furthermore, group music therapy can be used as an intervention strategy to help

individuals with ASD learn how to interact in social situations (Ywn et al., 202q.
LaGasse (2017) noted that music therapy sessions should be individualized to each

person's needs and abilities. Past research has suggested that the use of music therapy can be
used on individuals with various socioeconomic backgrounds, cuhures,

md

ages and can be

implemented at home or in school by combining music therapy with evidence-based strategies
such as prornpting and reinforcement (LaGasse, 2017). According to LaGasse (2017) music

therapy is typically provided by a prot'essional music therapist that holds a bachelor's degree in
music therapy. Professional music therapists develop music-based interventions that promote
social communication in individuals with ASD (LaGasse, 2017).

Music therapy has been an effective intervention strategy to improve social-emotional
reciprocity and verbal and nonverbal interactions among individuals with ASD (Yum et al.,
2A2q. Yum et al. QAz$ noted that individuals with ASD can display various symptoms and
abilities depending on their developmental speeds and interests. Some individuals may have a
deficit in restricted interests or repetitive behaviors, and also be accepting of social situations
(Yum et al., 202q.In past studies, music therapy has been known to improve attention and peer
interaction in play-based settings (LaGasse, 2014). According to LaGasse QAru) music therapy
has also improved academic learning.

Music alone does not improve social behaviors, it is the presence of music within other
interventions, such as a preferred activity, that encourages positive behavioral change (LaGasse,

MUSIC THERAPY AND SOCI.AL SKILLS

19

20tq. Therefore, the willingness to participate in social interactions may build a bridge to social
skills development for individuals who have difficulty interacting in social situations (Yurn et

a1.,

2A2q.
The purpose of this study is to measure the ett'ects of music therapy on social skills in

individuals with autism. It is hypothesized that the quantitative analysis of studies that have
researched the effects of music therapy on social skills in indivieluals with autism

will reveal a

significant positive effect of music therapy on social skills in individuals with autism.

A meta-analysis will be conducted on the effects of music therapy on social skills in
individuals with ASD to investigate the following research questions:

1.

What is music therapy's impact on students identified with autism?

2.

What is the et'fect of music therapy on social skills in experimental group research design

3. What are the potential moderators of the impact of music therapy?

MUSIC THERAPY AND SOCI"AL SKILLS

20

Chapter 2 - Literature Review

Autism
Autism spectrum disorder (ASD) is defined as a developmental impairment characterized
by specific deficiencies in social communication, and restricted and repetitive pattems of
behavior (Yum el al.,2AZq. According to Azbell and Laking (2006) the abnorrnal social and
behavioral development seen in individuais with ASD is the result of a dysfunctional cenkal
nervous system. Volkmar and Pauls (2003) suggest that some sociai skills develop over time but,
even high-functioning individuals continue to display difficulties in social communication.

Volhnar and Pauls (2003) noted that

a

high rate of seizures is associated with ASD and therefore

brain involvement is strongly suggested. According to Azbell and Laking (2006), the input

stimuli received by individuals with ASD is more complex and therefore affects them dift'erently
than individuals without

ASD.
,.

Brain Mechanisms. The high rate of epilepsy and persistent neurological signs strongly
suggest brain involvement in ASD (Volkmar

&

Pauls, 2003). In postmortem studies, a range

of

abnormalities have been reported, including neuron depletion and reduced dendritic arborization

in the limbic system (Volkrnar & Pauls, 2003). These findings are of particular interest because
of the nature of social difficulties found in individuals with ASD (Volkmar & Pauls, 2003).
Vol}rnar and Pauls (2003) noted that monkeys who have lesions in their amygdala and
hippocampus have behavior similarities comparable to those seen in individuals with ASD. Past
research has suggested that social processing difl'ers between individuals

with ASD in preliontal

cortical regions (Volkmar & Pauls, 2003).

A decrease in Purkinje and granuie cells has been observed in the cerebellar cortex of
individuals with ASD (Volkmar & Pauls, 2003). According to Volkrnar and Pauls (2003) the

MUSIC THERAPY AND SOCIAL SKILLS
overall brain size

isZ-fi%

It is still unclear whether
specific areas (Vallonar

2t

greater in individuals with ASD than it is in individuals without ASD.

t}re increase in brain size is generalized across the entire brain or in

&

Pauls, 2003). Volkmar and Pauls (2003) speculated on the possibilities

related to the decline of neural pruning, but the reasoning behind the increase remains unclear.
Social processes have also been an area of focus in ASD. During activities that involve
perception of faces, Volkmar and Pauls (2003) deterrrined that the fusiform gyrus is not activated

in individuals with high-functioning autism (Asperger's Syndrome). According to Volkmar and
Pauls (2003) social deficits are not caused by the inability to process facial infomration.

Individuals with high-functioning autism often have a difficult time applying social meaning to
visual stimuli (Volkmar & Pauls, 2003). In past studies, research has shown that individuals with

ASD exhibit highly unusual patterns of visual searching when exposed to intense social
situations (Volkmar & Pauls,

2003).
i.

The specific processes on the human neural system have become a focus of interest in the
understanding of social communication and facial recognition in individuals with ASD (Volkmar

& Pauls, 2003). Different neurotransmitter systems have been researched in studies that focused
on nenrochemistry (Volkmar

& Pauls, 2003). Past research

has indicated that a high

concentration of serotonin has been observed in individuals with ASD (V
According to Volkmar and Pauls (2003) there are a variety of reported abnormalities with brain
involvement associated with ASD, but no unified theory or explanation has been reported in
studies that focus on the neurotransmitter systems in individuals

with ASD.

f,nvironmentnl Components. Over the past decade, genetic research has revealed that
neuronal junction is particularly vutnerable to genetic and environmental factors (Grabrucker,

2013). According to Grabrucker (2013)'\rnderstanding how genetic and environmental risk

MUSIC THERAPY AND SOCI"AL SKILLS

22

factors in autism converge at synapses might provide a valuable starting point for future work
towards uncovering the patho-mechanism of autism" (p. 1). ASD is a developmental disorder
that is usually diagnosed between 14-36 months old (Grabrucker, 2013). However, past research
has indicated that ASD might be present at birth, thus raising considerable interest in prenatal

environmental factors (Grabrucker, 20 1 3).
Prenatal influenza, rubella, and viral infections have been linked t due to exposure dwing fetal development (Crabnrcker, 2013), According to Grabrucker (2013)

maternal infections could affect the fetal immune system and brain because the placenta is a
source of hematopoietic stem cells that provide nutrients to the fetus during pregnancy. Zinc

deficiencies, abnormal melatonin synthesis, gestational diabetes, and other toxins have also been

linked to a higher risk of ASD (Grabrucker, 2013). Zinc is a structural component of proieins
that regulates enzymatic processes (Grabruckeg2013, p. 7). A Zinc deficiency can compromise
the inunune system and increase the possibility of infection (Grabrucker, 2013).

According to Gmbrucker (2013) two major environmental factors contribute to the
development of ASD at the synapse level. The first factor is the structural composition
synapses, which results in changes in receptor number

of

(Grabrucker,20fi). Thus, "influencing

NI\r[,DAR, AMPAR, and mGluR and affecting signaling components within the PSD"

(Crrabrucker,2Al3, p. l0). The second major environmental factor is the "p38 MAPK
(mitogen-activated protein kinase) and ERK pathway" (Grabrucker,2Al3, p. l0). According to
Crabrucker (2013) ERK regulates the synaptic delivery of AMPAR and dendritic spine

rnodifications.
ERK kinases are heavily affected by the level of Zinc within the human body
(Grabrucker, 2013). In a past study, remarkable anomalies in social behavior, which resemble

MUSIC THERAPY AND SOCIAL SKILLS

23

ASD similarities have been observed in a "EltK2 knock-out mice exhibit" (Grabrucker, 2013, p.
10). Moreover,Zinc deficiency via GPR39 changes sfructural components and a disturbance in

signaling by kina"ses leading to a disruption in LTP formation and plasticity at synapses may
converge (Grabrucker,2013). Finally, environmental factors such as immune systern

abnormalities or Zinc deficiencies can cause an imbalance of inhibition and excitation and
therefore increase the risk factor for ASD (Grabrucker, 2013).

Genetic Components. Angelrnan and Prader-Willi syndromes have drawn attention to
the genetic disposition of parental imprinting in brain development and how mutations can lead

to neurodevelopmental disorders (LaSalle, 2013). According to LaSalle (2013) artificial
reproductive technology has played a significant role in the discovery of Dupl5q syndrome
(duplications of 15qll-q13) observed in individuals with ASD. A laboratory managed by
LaSalle (2013) has observed a significant association with PCB-95 levels in the brain and

Dupi5q syndrorne, which led to the suggestion that genes and environmental factors play an
important intertrvined role in the development of ASD.
Many cases of ASD with cytogenetic duplications or deletions have been researched
(Volkmar & Pauls, 2003). According to Volkmar and Pauls (2003) a linkage disequilibrium in
GABRB3 (a marker in the gamma-aminobutyric acid receptor subunit gene), or UBE3A
(Angleman syndrome gene) is often observed in individuals with ASD. Tuberous sclerosis,
fragile X syndrome, and neurofibromatosis have also been associated with ASD (noil
&

Pauls,'2003). According to Volkmar and Pauls (2003) researchers have identified chromosomes

l6 and l7

as a gene closely associated

and neurofibrornatosis (chromosome

with the mutation of tuberous sclerosis (chromosome l6)

t7). Volkmar

association between HLA-DRB1 alleles and ASD.

and Pauls (2003) also noted a possible

MUSIC THEI{APY AND SOCIAL SKILLS

24

l'in (Volkmar & Pauls, 2003). Most diseases that have been linked directly to gene mutations are
much clearer than those of ASD (Volkmar & Pauls, 2003). Volkmar and Pauls (2003) noted that

if ASD

was a Mendelian disorder, the genes would be localized. The absence r:f consistent

significant findings suggests the possibility of multiple gene involvement in ASD (Volkmar &
Pauls, 2003). "Either many genes with
genes

stong alleles


low frequency or corlmon variants in

with weak alleles" (Volkmar & Pauls, 2003, p, 1137).
Course and Prognosis of ASD. ASD is a life-long disability with several favorable

treatment options that play a major role in the lives of individuals with ASD (Vollanar & Pauls,
2003). Past research has indioated that outcomes of ASD have improved over the years due to
case detection and intervention strategies

(Vollcrar & Pauls, 2003). In some

cases, individuals

with ASD may be able to achieve self-sufficiency in adulthood, with and without periodic
support (Volkmar & Pauls, 2003). Volkmar, Pauls, (2003) noted that the symptoms of ASD may
change with age so therefore, independence and self-help skills should be a major focus in the
treatrnent of ASD. The overall cognitive ability of an individual with ASD is a factor in

predicting social outcomes (Volkrnar & Pauls, 2003).

.

The difficulties in social interactions have been known to persist throughout childhood

(Volkmar & Pauls, 2003). Volkmar and Pauls (2003) noted that social skills taught in childhood
provide substantial social gains in adolescence. If an individual's behavior declines in
adolescence hormonal changes may be to blame (Rapin, 1997). Therefore, greater behavioral

skills are needed during these years to sustain the social and emotional demands of adolescence
(Rapin, 1997). Rapin (1997) suggests that most individuals will remain partially dependent into
adulthood, however those with adequate social skills are more likely to become self-supporting.

MUSIC THBRAPY AND SOCIAL

SKILLS

25

Rapin (1997) noted that some indivicluals make substantial gains and others decline due to
behavioral factors.

Standard'l'reatments of ASD. Over the pa-st few decades, various methods used to treat
the symptoms of ASD have been published (Volkmar & Pauis,2003). According to Volkmar and
Pauls (2003) methods typically include medications, special education services, and behavioral
therapy.

ln general, keatment goals should focus on reducing problem behaviors, and attaining

growth in communication, cognition, and self-help skills (Volkmar & Pauls,2003). According to
V
highly structured comprehensive systematic approach is needed to

treat the symptoms of ASD. Volkrnar and Pauls (2003) noted that treatment goals can vary from
person to person depending on firnctionality.

Lower-fbnctioning individuals rnay be able to develop basic leaming skills that foster
communication, as more skills are acquired a shift toward conceptual learning could be possible

(Volkmar & Pauls, 2003). Children who have not developed spoken language skills can be more
communicative through nonverbal communication means (Volkmar & Pauls, 2003). Rapin
(L997) suggests that the use of psychotropic drugs may help treat additional symptoms of ASD.

According to past research, medication such as methylphenidate has been known to rapidly
improve attention capacity in short periods of time (Rapin, 1997). Serotonergic antidepressants
are also prescribed to alter stereotypic behaviors seen in

ASD (Rapin,1997).

The Importance of Interpersonal and Intrapersonal Synchrony in ASD

' Interpersonal Synchrony. Interpersonal synchrony is "the tendency for social partners
to temporally coordinate their behavior when interacting" (Bowsher-Murray et al., 2022, p. 1).
According to Bowsher-Murray et al. (2022) interpersonal synchrony is a cortmon characteristic
of social interactions which can be in the form of a spontaneous response, a conscious effort

MUSIC THERAPY AND SOCIAL SKILLS

26

(e.g., shaking hands, high five, dance), rhythmic properties (e.g., nodding, walking), and
behavioral processes (gestures, gaztrLg, facial expression, speech). Social behaviors usually
develop shortly after birth and become more complex during infancy (Bowsher-Muray et al.,
2A22). Bowsher-Muray et al. (2022) suggested that interpersonal synchrony can positively

influence the development of self-regulation, and empathy, which in turn may promote cognitive,
social, and emotional development.

Difficulties in social interaction, communication, and building relationships are all
common characteristics of ASD (Bowsher-Muray et a1.,2022). In past studies, there has been a

particular interest in how individuals with ASD engage in interpersonal synchrony
@owsher-Murray et a1.,2A22). Evidence has indicated that individuals with ASD initiate fewer
social interactions in both spontaneous and intentional conditions (Bowsher-Murray el u1.,2022).
Past studies have found a significant correlation between low-functioning ASD and lower levels

of interpersonal synchrony (Bowsher-Murray et a1.,2022). The social siguificance

of

interpersonal synchrony may also be decreased in individuals with ASD (Bowsher-Murray et al.,
2022).

Individuals with ASD experience significant difficulties in social participation,
interacting with others, and problem solving (Vlachou

& Stawoussi, 2016). Developing

interpersonal relationships can help individuals with ASD effectively engage in and successfully
understand how to manage social situations that involve complex communication (Vlachou

&

Stawoussi, 2016). Understanding how the underlying process of interpersonal synchrony
correlates is important in understanding why interpersonal synchrony develops differently in

individuals with ASD (Bowsher-Murray et a1.,2022). Past research has indicated that
interpersonal development is decreased in individuals \ rith ASD (Bowsher-Murray et a1., 2AZD.

MUSIC THERAPY AND SOCIAL SKILLS

27

Hxperimental tasks such as pendulum swinging, chair rucking, movement improvisation, and
gazinghave been observed in individuals with low levels of interpersonal development

(Bowsher-Murray et a1.,2022). According to Bowsher-Munay etal. (2022) similar behaviors
have been observed in studies involving naturalistic environments.

A decrease in interpersonal development

has been observed in conversations between

couples in which one individual had an ASD diagnosis (Bowsher-Murray et al., 2022). High

levels of reduced spontaneous motor synchrony was also observed in adults during a partner

walk and talk task (Bowsher-Murray et aL.,2A22). According to Bowsher-Murray et al. (2A22)
there is undoubting evidence that suggests ASD is associated with reduced interpersonal
development. In sfudies that investigated intentional vs. spontaneous synchrony tasks, lower
interpersonal coherence scores were observed in groups that included at least one individual with

ASD (Bloch et al.,

2019).
,

Interpersonal synchrony increases empathy and enables succ,essful interaction and
reciprocal bonding (Bloch et al., 20i9). To successfully communicate with others, Bloch et al.
(2019) suggest developing intrapersonal skills prior to interpersonal synchrony. Intrapersonal
development is an important factor in developing interpersonal skills and therefore, atypical
synchrony of intrapersonal skills may also affect the development of interpersonal skills in

individuals with ASD (Bloch et al., 2019). From an individual perspective, non-verbal
communication such as gazing and gestures need to be coordinated with verbal output to
communicate effectively (Bloch et al., 2019).

Intrapersonal Synchrony. lntrapersonal synchrony is defined by Bloch et al. (2019)

as

"the temporal coordination of communication signals in a socially informative manner" (p"2).
According to Bloch et al. (2A19) the processing of sensory input evolves differently in

MUSIC THEITAPY AND SOCTAL SKILLS

28

individuals with ASD. In a past study that investigated perceptual stimulation, researchers
discovered that "individuals with ASD judged the presentation of two visual stimuli to be

ternporally asynchronous for smaller stimulus onset asynchronies c developed control participants" (Bloch et al., 2019,p.2).

Further evidence has also shown an advanced temporal understanding of auditory and
nisual events (tsloch et a1., 2AI\. According to tsloch et al. (2019) individuals with ASD
produce a significantly lower achievement rate for distinguishing the differences between

auditory signals, exceptional judgment, and replicating durations. A broader multisensory
temporal binding window for simultaneous discernment is also seen in individuals with ASD
compared to typically developed participants (Bloch et al.,2Al9). Bloch et al. (2019) suggest that
these findings support the belief that individuals with ASD demonstrate exceptional temporal
processing, possibly associated

with a "detail-focused, less holistic cognitive style" (p. 3).

Exceptional temporal processing is also displayed in higher level processes (Bloch et al-,
2019). Stereotypical behavioral patterns and routines compensate for the exceptional timing
functions presented in individuals with ASD (Bloch et al., 2Al9). According to Bloch et al.
(2019) individuals with ASD have a high disposition to "rely on seltstructured routines and

repetitive behavior to control bottom-up perceptual input, thereby generating experiences of
tirnelessness" (p. 3). Therefore,

it is possible that exceptional temporal processing is likely to

influence stereotypical behaviors seen in individuals with ASD (Bloch et al., 2019).

' Exceptional motor timing

has also been seen in individuals

with ASD (Bloch et al.,

2019). According to Bloch et al. (2019) "clumsiness" is a major motor production often
presented in individuals with ASD. Bloch et al. (2019) suggest that exceptional motor patterns

should be investigated across the autism spectrum as they may present as a possible diagnostic

MUSIC THHRAPY AND SOCIAL SKILLS

29

marker for ASD. In a past study designed to observe motor production variables which involved
gaming tasks and touch screens, researchers observed significantly faster movement patterns and
pressures in individuals with ASD compared to typically developed participanls (Bloch et al.,

20le).
Bloch et al. (2019) noted that other researchers have observed a significantly weaker
motor perfonnance in individuals with ASD compared to typically developed participants. Jerky

limb movements, exceptional walking patterns, increased postural sway, and atypical motor
output have been observed in individuals with ASD (Block et al., 2019). [n past studies that
focused on the motor abilities of individuals with ASD, a deficit in sensory input for motor

planning and an increased variance in motor output has been observed (Bloch et al., 2019).
Therefore, increasing evidence suggests that exceptional movement patterns influence the
development of interpersonal synchrony because social communication signals, as motor acts,
segregate from the typical production of social signals (Bloch et al., 2019).

The Autism Diagnostic Observation Schedule (ADOS) is a tool used by researchers to
measure the development of communication skills in individuals with ASD (Bloch et al., 2019).

In past studies, researchers investigated various types of gestures and their usage. During a
narrative task researchers found no differences between frequency and type of gesfure used,
however, exceptional timing of gestures correlated to speech led researchers to conclude that a
reduction in the quality of communication is a hallmark symptom of ASD (Bloch et al., 2019).

Bloch'et al. (2019) determined that "these results indicate that it is not the quantity

of

communicative signals that leads to the lmown communication difficulties but the quality
signals and how they

fit in the interactional flow" (p. 4).

of

MUSIC THERAPY AND SOCIAL SzuLLS

30

In the social a;pect Bloch et al. (2019) mentions that communication difficulties that
encompass the use of gesfures and social replication have been observed in relation to the
advanced temporal understanding of sensory events in individuals with ASD. Likewise,

according to Bloch et al. (2019) researchers also tbund a correlation between advanced temporal
understanding and the severity of symptoms associated with social communication. Therefore,
multisensory temporal binding windows coincide with interpersonal synchrony in participants

who are classified as "typically developed" but not in participants with ASD (Bloch et

a1.,

2019).

According to tsloch et al. (2019) these findings indicate a distinct association in temporal
processing and the reduction of interpersonal alignments seen in individuals with ASD.

The Developmental Importance of Social Skills in ASD
Social Skills can be defined as a complex interaction of skills used to skillfully perform
social tasks (Ghasemtabar et al., 2015; Thompson et al.,2Al3). Rankin et al. (2016) noted that
social skills are importiunt for peer acceptauce, social relationships, and academic success. White

et al. (2A07) suggested that a profound deficiency in social skills is a hallmark feature of ASD.
Social deficits are a vital source of impairment for individuals with ASD (White et a1., 2A07).

During development, social deficits become more complex during adolescence because
individuals with social impairmenLs become more aware of their social disability (White et al.,

2A0T.
In past studies, researchers have discovered that children with ASD are less likely to
initiate communication and show less sympathy and interest in those who have engaged in social
communication with them (Ghasemtabar et al., 2016). Ghasemetabar et al. (2016) noted that
social skill deficits make it difficult to establish meaningful relationships, and often result in
social isolation. White et al. (2007) suggested that social deficits may cause individuals with

3l

MUSIC THHRAPY AND SOCIAL SKILLS
ASD to suffer direct and indirect consequences resulting in loneliness and poor social support.

When combined with typical developing peers, children with ASD often experience an increase

in peer rejection and social isolation (White et al., 2AAT. Research has shown that social skill
deficits may also cause anxiety and mood disorders in adolescence (White et al., 2AA7).
The social impairments seen in individuals with ASD often involve speech, verbal
communication, and interpersonal synchrony (While et al., 2407). Problem areas may include
impairrnents in social pragmatics, dwelling on certain topics, difficulty in expressing emotions,
and

difficulty understanding sarcasm and metaphors (White et al., }AU). According to White et

al. (2007) social deficits are not caused by a lack
and the

ofsocial interest. A lack ofsocial synchrony

ability to determine when to apply the skill is the major cause of disability (White et al.,

2007). Given that children with ASD lack appropriate social skills and have tbwer opportunities

to engage in positive peer interactions, group interventions may aid in the development of social
skills in individuals with ASD (White et al., 2A0T.
Supporting individuals with ASD in their homes, schools, and communities involves
addressing each core area of impairment

(Bellini & Hopf, 2AA7). Bellini and Hopf (2007\ noted

that social skill deficits impact children with ASD at an early age and have the capacity to lead to
social anxiety, depression, and isolation. Individuals with ASD may attempt to initiate an
interaction to meet their needs or wants, however, since bilateral contribution is needed for social
interaction, initiating attempls of social interaction cannot be considered socially credible (Eren,
201 5):

In past studies, researchers have discovered that integrated and less restricted

enyironments provide unique social lsarning opportunities for individuals with ASD (Eren,
2015).

MUSIC THERAPY AND SOCIAL SKILLS

32

Individuals who display admissible sooial skills are more likely to be socially accepted by
peers, benefit

from integrated school environrnents, live more independently, and work in

a more

integrated environment (Eren, 2015). Improving social outcomes for individuals with ASD
requires a more structured intervention and carefully designed opporfunities of social
engagement

with non-exceptional peers (Eren, 2015). Therefore, selecting an intervention

designed to meet the needs
(2015) pre-existing strengths can be used to develop impaired areas. LaGasse (2017) suggested
that social skills interventions should be the main focus when addressing social behaviors

of

individuals with ASD.
According to LaGasse (2017) many treatments and practioes are available to address the
social needs of individuals with ASD, Impairments in social skills is a hallmark trait of ASD

(Rankin et a1.,2016). Social skills are an important factor in the development of peer acceptance,
relationship building, and academic success (Rankin et a1., 2016). According to the National

Autism Council's National Standards Report (2023\ practices such as peer training, joint
attention, and behavioral interventions are considered "established" intervention practices for
teaching social skills to individuals with ASD. The direct and indirect effects of social

intervention practices have been investigated in past studies. LaGasse (2017) noted that there is
no decisive evidence to suggest that one intervention strategy is more effective than another.

Intervention goals should be developed with a strong focus on social skills (Vollcnar & Pauls,
2003)..

ln past studies, music therapy has been known to improve social developmental and
behavioral skills in children with ASD (LaGasse, 2014). LaGasse (2014) suggested that music
therapy interventions may help improve attention capacity in individuals with ASD, especially in

MUSIC THERAPY AND SOCIAL SKILLS
a hands-on

JJ

environment. The use of music therapy to develop social skills in individuals with

ASD provides a directional pathway that promotes a more prominent alternative for treating the
symptoms of ASD (LaGasse, 2017). LaGasse (2017) noted that past research has indicated that
music therapy interventions have been known to promote positive social interactions in

individuals with ASD. According to Eren (2015) substantial evidence from past research has
shown that individuals with ASD have an inclination toward music. Therefore, music
interventions may provide a suitable environment that enhances social skills in individuals with

ASD (Eren,2015).
Developmental Techniques to Measure Social Skills

(i) Wneland Social-Emotional Early Childhood

Scales (VSEEC). This scale is an

88-item assessment tool that determines the level of social and emotional development in

children from birth to five years old (Thompson et al.,

2013).
,.

(ii) The Social Responsiveness Scule Preschaol

Yersion

for

3-Year-Olds (.Sfi.S-PSl. This

scale is a 65-item parent-rated diagnostic assessment that measures the social development

of

3-year-old children in natural social environments (Thompson et a1.,2013),

(rn) The MacArthur-Bates Communicative Development Inventories, Words and
Geslures (MBCDI-W&G/. This scale is an assessment designed to measure early language skills
such as vocabulary comprehension and production, and communicative gestures in children from

birth to l8 months (Thompson et al., 2013). According to Thompson et al. (2013) this scale can
also be used to assess the developmental language skills of individuals

with severe language

delays.

(iv)

The Parent-Child Relationship Inventory

QCRI). This scale is a 73-item

standardized assessment scale that measures the parent's attitude toward parenting and their child

MUSIC THtsRAPY AND SOCIAL SKILLS

34

(Thompson et al., 2013). According to Thompson et al. (2013) this standardized measure allows

for the qualitative evaluation of prescriptive comparisons of a domain.

(v) The Social Skills Rafing System Scale f,f,Slts). This scale is an assessment designed
by Gresham and Elliot, to measure social behaviors such as cooperation, assertions, self-control,
and responsibility (Ghasemtabar et al., 2015). According to Ghasemtabar et al. (2015) this
assessment consists of three specific forms (parent, teacher, student) and is designed for

tlree

periods (preschool, elementary, and secondary).

(vi) The Autism Treatment Evaluation Checklist @fEC). This scale is an assessment
designed to measure the effectiveness of new treatments on colnmunication, sociabilify,

cognitive awareness, and behavior (LaGasse,2014). According to LaGasse (2014) this
assessment is effective for monitoring the progress

of social skills in children with ASD who are

undergoing interventions. Higher functioning is determined in accordance with lower ATEC
scores (LaGasse, 2AM)-

(vii) The TRIAD Special Skills Assessment (TSSA). This scale is a criterion-based
assessment designed to measure social interactions of individuals

with ASD (Bharathi et al.,

2019). According to Bharathi et al. (2019) this assessment can be used to determine a pre-test
and.post-test rneasure.

(viii) Sacial Responsiveness Scale (SRS/. This scale is a 65-item assessment designed to
measure the level of social impairments in children ages 4-18 (LaGasse, 2014). According to
LaGasse (2014) this scale has been used to evaluate the development of social skills in

individuals with ASD.

MUSIC THERAPY AND SOCIAL SKILLS

(ix) The Music Therapy Diagnostic Assessment

35

MfD$.

This scale is an assessment

designed to measure a child's interpersonal development and social communication skills during

music therapy sessions (Thompson et al., 2013).

Music Therapy
Music therapy has been defined as the "clinical and evidence-based use of music
interventions to accomplish individualized goals within a therapeutic relationship by a
credentialed professional who has completed an approved music therapy program" (LaCasse,

2A17,p.24). According to LaGasse (2011\ music therapists must acquire a bachelor's degree in
music therapy that focuses on the principles of musical and clinical foundations of music
therapy. In addition, music therapists must also complete 1200 hours of clinical training that

includes an internship in music therapy (LaGasse, 2017). According to LaGasse (2017) a

Board-Certified Music Therapist must take a music therapist national board certification exam.
Music therapists clevelop music-based interventions that target communication, social,
emotional, and cognitive skills (LaGasse, 2017). Music therapy sessions are designed based on

individualized preferences ancl abilities (LaGasse, ZAn). According to LaGasse (2017) music
therapy sessions can be provided individually or in group sessions, and can occur in an at-home,
school, therapeutic, or corununity environment. An individual's current level of functioning can
be determined by using the Childhood Autism Rating Scale (CARS) assessment (LaGasse,

2017). LaGasse

QAIT noted that this

process involves developmentally appropriate music

experiences.

After an individual completes the CARS assessment, the music therapist will design an
appropriate treatment plan that is based on individual needs (LaGasse, 2017). Although music
therapy can have many different approaches, a protocol that addresses individualized treatment

MUSIC THERAPY AND SOCIAL SKILLS
needs is the most appropriate way to design a

keatnent plan for an individual with ASD

(LaGasse, 2Al1), Music therapy interventions combined
a

36

wilh evidence-based strategies promote

highly individualized treatment that addresses the needs of indMduals with differenl levels

of

ASD (LaGasse,2017).
Active and Passive Music Therapy
Music therapy is used as a therapeutic approach to enhance an individual's social,
physical, and emotional well-being (Bharathi et al,, 2019). Bharathi et al. (2019) suggested that
music therapy can be used as a form of comrrunication to help improve difficulties in movement,
sensing, and feeliug. Throughout most of Europe and North America, music therapy has been
used as a therapeutic practice for several years (Aldridge, 1994), Aldridge (1994) noted that

active music therapy and passive music therapy are two principal ways of applying music
therapy. Active music therapy techniques require the patient to play a musical instrument or sing,
whereas passive music therapy techniques require the patient to listen to musical recordings

(Aldridge, 1994). According to Marquez-Garcia et al. (2A21), these methods include procedures
that follow a particular technique and should be implemented accordingly.

In each approach, music is often chosen to suit the patient's individual likes or interests
(Aldridge, 1994). The effectiveness of these techniques is not fully understood (Marquez-Garcia
et aL.,2A2l). Hillecke et al. (2005) noted that music therapy can be used as an effective tool
when treating various illnesses. In past studies, music therapy

ha^s

been shown to improve the

emotional, behavioral, and social wellbeing of individuals with ASD (Marquez-Garciaetal.,
2021). After World War II, hospitals across North America incorporated the use of passive music
therapy to reduce stress and enhance the overall physical and emotional well-being of patients

(Aldridge, 1994).ln Europe, it has been suggested that using music therapy as a

MUSIC THERAPY AND SOCIAL SKILLS

37

psychotherapeutic approach can help individual's deal with intrapersonal conflicts by causing an
awakening of their emotions (Aldridge, 1994).
The effect of music on the heart and blood pressure has also been a topic of interest
throughout the years (Aldridge, 1994). ln the medical journal Lancet, researchers discovered that
music influenced blood pressure according to how much the participant appreciated music

(Aldridge, |gg4).Interest in music is an important factor that influences how

a

participant

responds to music (Aldridge, 1994).In past studies, researchers discovered that heart rate
increased or decreased, over a period of three minutes, when the participant was exposed to

music at a precise time in the cardiac cycle (Aldridge, 1994). When the participant was exposed

to music during times that was not within the cardiac cycle, no influence was observed

(Aldridge, 1994).
The effects of perceived rhythm on the respiratory pattern were.also explored, proposing
that listening to music would influence the participants respiratory pattem (Aldridge, 1994).

Aldridge (1994) noted that researchers obseryed no significant change in heart rate. However, in
participants with tachycardia and/or cardiac arrhythmias research has shown a significant
decrease in the participants

ability to perceive music when compared to healthy individuals

(Aldridge, 1994). The correlation between listening to music and changes in respiration have
also been investigated (Aldridge,1994). According to Aldridge (1994) listening to music seems

to have paradoxical and anxiolytic effects. In the past, participants have reported music to be

relaxing, however, their physiological reactions have suggested otherwise (Aldridge, 1994).
Listening to music and utilizing breathing techniques induce altemative states of
consciousness which invoke calmness and inner peace (Aldridge, 1994).In hospitals, general
anesthesia doctors have used passive music techniques to deliver a state of calmness and

MUSIC THERAPY AND SOCIAL SKILLS

38

well-being in patients who undergo various surgical procedures (Aldridge, 1994). According to
Aldridge (1994) music therapy appears to have a signiticant effect on the recovery process of
neurological disorders" Patients who have experienced temporary aphasia, music therapy has
played a significant role in the process of rehabilitation (Aldridge,1994). Music therapy has

fulfilled the rehabilitative role that involves repeated melody patterns and body movements
(Aldritlge, 1994). The singing of farniliar songs has also been found to encourage articulation
and language fluency (Aldridge, 1994). According to Aldridge (1994) the stimulation of singing

motivates the patient to communicate and promotes the activation of verbal communication.
Patients who experience dysfluencies often have ditficulties finding words. Aldridge

(1994) suggests that music therapy can activate the emotional pitch of speech (e.g., tapping,
humming, whistling). According to Aldridge (1994) music is a hmction that is distributed over
both cerebral hemispheres of the brain. Recovery from apha"sia is not

1,rrrun.r

of learning new

informatiou in the non-dominant hemisphere, but a matter of the dominant hemisphere taking
over the responsibility of language (Aldridge,1994). The non-dominant hemisphere can be
looked at as a reserve of functions in patients who experience regional failure indicating an
overall neuroplasticity (Aldridge, 1 994).
cases of elderly stroke patients, researchers have discovered that music therapy

in

combination with speech therapy significantly improves aphasia (Aldridge, 1994).In cases
coma patients, creative music therapy
are otherwise unresponsive

ha^s

of

been shown to have an inverse effect on patients who

(Aldridge, 1994). When the patient's breathing patterns are aligned

with music, stimulated changes in consciousness were observed through a coma rating scale and
clinical observations (Aldridge, 1994). Music therapy also appears to have an effective way of
engaging individuals

with special needs (Aldridge, 1994). Aldridge (1994) suggests that the

MUSIC THERAPY AND SOCIAL SKILLS

39

firnctional properties of musio exposure can arouse sensory processing in intlividuals with
disabilities by enhancing memory recall and organizing the sequence of cognitive functioning.

In past studies, researchers have emphasized the importance of music in child
developrnent (Aldridge, 1994).In the case of a child with multiple disabilities, the need for

stimulation increases by utilizing music that provides a sense of enjoyment (Aldridge, 1994)- ln
the case of newborns and infants, rnusic therapy has been used as a calmiug effect to induce
sleep and relaxation (Aldridge, 1994). Music therapy has also been used to relieve fear and

anxiety in children during the preoperative stages of surgery, and terminal illness (Aldridge,
1ee4).

Music therapy practices have been used since the early 1940's. In the early years of music
therapy intervention, music education, singing groups, and folk dancing were used to improve
socialization, self-expression, and psychological disorders (Marquez-G,arcia et a1.,2021).
Physicians and therapists used music therapy in clinical settings to help children with ASD
improve their individualized area of need (Marquez-Garcia et al., 2021). Active and passive
music therapy have been examined in past studies as facilitators of verbalization (Aldridge,
1994). According to Aldridge (1994) rnusic therapy can allow individuals without language to

communicate and develop a significant improvement in the process of treatment for individuals

with ASD.
Music Therapy for Individuals with ASD
' Behavioral and educational therapies have been known to support individuals with ASD,
but no method has been proven to address the needs of all people with ASD (Marquez-Garcia et
a1.,2021). Given the diversity within the autisrn spectrum, assistive technology and therapies

should be carefully selected to address the diverse needs of individuals with ASD

MUSIC THERAPY AND SOCIAL SKILLS
(Marquez-Garcia et a1.,2021). Marquez-Garcia et al.

40

QA2\

suggests that music therapy employs

various methods of suppoil for individuals with ASD. According to Marquez-Garcia et al. (2021)
there is a specific way each method should be executed or performed.
The history of music therapy dates back to 1940, with the first official publication in
1969 (Marquez-Garcia et al., 2421).In the earlier days of music, various activities involving

music such as music education, singing groups, and folk dancing were used to achieve social
goals (Marquez-Garcia et al., 2A2l). As the years passed, these achievements became recognized

by clinicians as a way of improving social comrnunication skills among those with ASI)
(l\4arquez-Garcia et al.,2A2l). Today, many clinicians around the world utilize music therapy

activities and techniques to improve symptoms of ASD (Marquez-Garcia et a1.,202L).
Kossyvaki and Curran (2020) suggested that activities such as music making, listening to
music, and responding to music can provide a pathway of communication for individuals with

ASD, even when spoken language is not achievable. Everyone is "born with a p:opensity for
rnusic" (Kossyvaki & Curran,202A,p. 119). According to Kossyvaki aud Curan (2020) music is
an essential human experience that everyone has engaged in before birth. During pregnancy, the

mother's voice, footsteps, and heartbeat are heard as a rhythmic sound that enables the

inclination for music at birth (Kossyvaki & Curran,2A20)- Kossyvaki and Curran QA2q referred
to rnusic to coincide with time and space making music potentially transformative.

A structured and predictable environment is preferred by individuals with ASD
(Kossyvaki & Curran, 2A2q. An interest in music is often encouraged by musical activities and

it often provides an environment that is structured and predictable (Kossyvaki & Curran, 2020).
Music has been known as a way of connecting with the world (Kossyvaki & Curran, 2020).
Kossyvaki and Curran (2020) noted that people with ASD tend to respond to music. Social

MUSIC THERAPY AND SOCIAL SKILLS

41

difficulties are corlmon in individuals with ASD, regardless of their level of functioning.
According to Kossyvaki and Curran (2020) past studies have discovered that children with ASD
have

difficulty initiating comrnunication, when communication is initiated, it is usually for

behavior regulating purposes.

Music therapy

ha^s

been u-sed for many years as an interyention strategy for children with

ASD (Thompson et al., 2013). According to Lacasse (2014) ASD affects I in 88 children in the
United States. The cause of ASD has been theorized, but no definite cause has been discovered.
Researchers are also yet to find a cure ftrr ASD, leaving many individuals with a lifetime

of

learning and social diffrculties (LaGasse, 2014). Due to the life-long impact of ASD, it is
imperative to conduct a meta-analysis to investigate evidence-based treatment methods that have
a

positive effect on social skills in individuals with ASD (LaGasse,

20lq.

ASD is a developmental impairment characterized by specific deficiencies in social
communication, and resfricted and repetitive patterns of behavior (Yuur et a1., 2020). According

to LaGasse (2014) social skills are a required ability for relationships and independence. An

inability to acquire such skills could have a lifetime effect on social outcomes for individuals
with ASD (LaGasse, 2014\. Furthermore, social skill deficits do not resolve in individuals with

nt:,without

an effective treatment method (LaGasse, 2014).ln fact, LaGasse (2014\ noted that

social skills may show less improvement than other deticits in individuals with ASD.
Over the yeurs, many fteatments have been used to address the social needs of individuals

with ASD (LaGasse, 2014).Intervention methods such as structured teaching, social skills
training, and behavioral therapies have been used as a treatment for social skill deficits (LaGasse,
zAru)- Past research has identified several interventions that target social skills in individuals

with ASD (La(iasse, 2014). LaGasse (2014) noted that research has not shown conclusive

MUSIC THERAPY AND SOCIAL SKILLS

42

evidence to support one method of treatnent over another. Most researchers agree that social

skill deficits are a hallmark sign of ASD, past research has indicated a continual need for
substantial evidence that supports effective treatments (LaGasse, 2014).

Neurological needs, identilied in individuals with ASD, should be researched firther
(LaGasse,

20lq.Individuals with ASD experience an overload of

sensory input due to neural

organizational differences (Lacasse, 2014). Some researchers suggest that individuals with ASD
choose not to interact within their environment, however, LaCasse (2014) noted that

it is not

a

matter of not wanting to interact, it's a matter of not being able to follow through or tolerate
social interaction. Social skills involve perceiving several sources of sensory input, contextual
understanding of social intentions, and successfully responding during a social interaction
(LaGasse,2014). LaGasse (2014) suggests that deficits in newal organization could affect one or
more of these elernents.
,,

Researchers agree that ASD aftbcts an individual's social and commrlnication abilities

with symptoms causing individuals to experience peer refusal and social seclusion (Bharathi et
al., 2019). In past studies, social and communication deficits have been shown to affect academic
performance, behavioq and cognitive abilities in individuals with ASD (Bharathi et al., 2019).
Bharathi et al. (2019) noted that early intervention is crucial to counterbalance the symptoms that
impact social and problem-solving proticiencies in individuals with ASD. Music therapy is a

form of communication that has the potential to address sensory, emotional, and physical deficits
(Bharathi et al.,

2A1r.

Ghasemtabar et al. (2022) believe that music-based intervention$ may have a positive

effect on individuals with ASD. In addition to reducing social impairments, music encourages
the development of hidden rnusical talents in individuals with ASD (Ghasemtabar et al,, 2022).

MUSIC THERAPY AND SOCTAL SKILLS

43

Despite the problems associated with the day-to-day processing of emotions, individuals with

ASD can perceive emotions in music equal to those who are not exceptional (Chasemtabar et a1.,
2AZD. Ghasemtabar et al. (2022) noted that music interventions are particularly effective for

individuals with ASD mostly because (1) musical training may counteract impairments in joint
attention, and social interaction, (2) musical activities may be more enjoyable due to an enhanced
understanding of emotions in music, and (3) musical activities may be less intimidating when

individuals can freely investigate different musical instruments.
Past research has shown that participation in music therapy sessions may teach

individuals with ASD how to recognize social cues and transition between one activity and
another (Ghasemtabar et a1.,2A22).Individuals with ASD often demonstrate sensory

impairments whic.h may directly affect opporfunities for social interaction (LaGasse, 2014).Pxer
et al. (2021) noted that new social skills can be acquired by focusing

ol

*

intervention that

addresses behavior and personal interests. Music therapy may provide an opportunity to

participate in social activities through music (Pater et al., }AZD. LaGasse (2014) suggested that
movement patterns in response to music may provide an opportunity to explore extemal stimuli.

According to LaGasse (2014) external cues that support engagement promote positive social
behaviors in individuals with ASD.

Music therapy has been used for many years to help individuals with ASD achieve social
goals (LaGasse, 2017). Music therapy is a unique intervention that encourages meaningful
interaotions (LaGasse,

2AlT.In

past studies, a positive response to music has encouraged

positive social engagement in individuals with ASD (LaGasse,2017). LaGasse

QAfi) noted

several reasons why music may help develop social skills in individuals with ASD. According to
LaGasse

QA|D music can activate the left inferior &ontal $mrs

and optimize targeted behaviors.

MUSIC THTIRAPY AND SOCIAL SKILLS
'Neurological reactions similar to those of

a rnusician when

44

involved in music" have been

observed in past studies (LaGasse, 2017, p.25).

LaGasse

QAfi)

noted that this data indicates that music interventions may provide a

strong foundation fbr developing social skills and possible generalization into nonmusical social
environments. The rhythmic components of music provide neural organization and response cues
that encourage individuals with ASD to appropriately respond to tJreir environrnent (LaGasse,

}ALT. LaGasse (2{JI7) suggests that

a lack of neural organization may prevent an enyironmental

response due to difficulties with "sensory overload, planning, initiation, and completing motor
sequences" (p. 25). Music rnay also accomrnodate social deficits, as

it has been shown to help

with planning and motor sequences (LaGasse, 2017).
Music therapy sessions can be created to provide specitic cues that help to initiate social
interaction, and encourage a response (LaGasse, 2017). Cues can also be used to help control
impulse response during social interaction (LaGasse, ZAn). Using structured music as an outline

for response time could create a musical experience that serves as a foundation for social
interaction (LaGasse, 2017). Past studies have concluded that music therapy can provide a
structured environment that encourages music exploration, which may help improve social

deficits in individuals with ASD (LaGasse, 2017). LaGasse (2017) noted that social interaction is
supported by the anticipation and timing of conrmunication in music.

Music therapy is appropriate to use with school-aged children who have no verbal
language skills. According to LaGasse

QA|D this method provides

a

way for individuals with

ASD to engage in social interaction. Music therapy interventions have been known to have a
positive effect on social skills in individuals with ASD (LaGasse, 2017). [n past research a
significant increase in social engagement, joint attention, peer interaction, and cognitive skills

MUSIC THERAPY AND SOCIAL SKILLS

45

have been observed in individuals with ASD (LaGasse, 2017). These studies provide
research-based evidence that music therapy can create positive social changes in individuals

with

ASD (LaGasse,20l7).
The Need for a Meta-Analysis

It has been hypothesized that music therapy interventions may improve social skills in
individuals with ASD. In past studies, music therapy interventions have been known to improve
emotional understanding and increase emotional engagement in individuals diagnosed with ASD

(Lacasse, 2014). Music therapy interventions have also been known to decrease ASD related
behaviors (LaGasse,

z}lq.

LaGasse (2014) noted that music therapy can increase

joint attention,

social gleetings, peer interaction, and cognitive social skills. Past studies have shown comparable
evidence to suggest that music is a valuable tool that can be used to improve social behaviors in

individuals with ASD (LaGa^sse,

2014).
..

Music therapy, within a group setting, has been known to improve social behaviors
amorg children with ASD (LaGasse, 2014). ln a play-based setting, music therapy has been
known to improve attention, especially when musical instruments were invoived (LaGasse,

2014).In an outdoor setting, music therapy has also been known to improve interaction in
individuals with ASD (LaGasse, 2014). LaGasse (2014) noted that children with ASD engage
better in academic group settings when music is involved. According to research,
alone that influences the change of behavior,

it is not music

it is the music paired with stnrcture, preferred

activities, and visual support that influences the change (LaGasse, 2014)"
Music therapy is a profession in which an individual uses music as an intervention to
accomplish individual physical, emotional, and social goals (Ghasemtabar et a1., 2022). Social

skills are specific behaviors that are needed to competently complete a social task (Ghasemtabar

MUSIC THE,RAPY AND SOCIAL SKILLS

46

et a1.,2022). According to Ghasemtabar et al. (2022) social skills are vitally important for
successfully interacting in social situations. Most prominent, social skills' deficits may impede
the ability to initiate and engage in social relationships, which may lead to social withdrawal and

isolation arnong those diagnosed with ASD (Ghasemtabar et al., 2022). Past studies have
suggested that music therapy is an effective method for improving social skills in individuals

with ASD (Ghasemtabar et al., TAZD.
Music therapy has brought about positive changes in social behavior (Chasemtabar et al.,
2022). Music intervention techniques have been known to harness musical talents and reduce
social impairments in individuals with ASD (Ghasemtabar et al., 2A24. Despite the problems in
processing and controlling everyday emotions, individuals with ASD can discern emotions in
music the same as non-exceptional peers (Chasemtabar et al., 2A2D.In past research, evidence
has shown that music therapy has helped individuals recognize social cues, cooperate in social

groups, and transition between activities (Ghaserntabar et a1., 2022). Although music therapy has
many approaches, focusing on indMdualized needs is prominent when designing a treatment
plan to address the social needs of individuals with ASD (LaGasse, 2017).
LaGasse

QAn) noted that music therapy interventions

are also a great way to address the

social needs of individuals with different levels of ASD. Music therapy has been used as a

therapeutic approach to enhance the physical, social, and emotional needs of individuals with

ASD (Bharathi et a1.,2019). Music therapy sessions provide an opportunity to socially interact
with peers in an environrnent that is safe and non-judgmental (Eren,2015).In past studies, real

life experiences in the safety of a musical therapeutic setting have helped individuals with ASD
to understand social interaction and communication cues (Eren, 2015). Therefore, it is prominent

MUSIC THERAPY AND SOCIAL

SKILLS

47

to conduct a Meta-Analysis on the effects of music therapy on social skills in individuals with
ASD.
F'inally, a meta-analysis can provide information that may contribute to the development

of an intervention that targets social deficits in individuals with ASD. Field and Gillet (2010)
noted that a "meta-analysis is a statistical tool for estimating the mean and variance

of

underlying population effects from a collection of empirical studies addressing ostensibly the
same research question" (p. 665). According to Field and

Gillet (2010)

a meta-analysis can

provide valuable information about the mean and variance of an underlying population's effects,
the variability in effects across studies, and information on moderator variables.

In this meta-analysis, the researcher will c research studies that involve music therapy as the independent variable and social skills

in

individuals with ASD as the dependent variable. The methodology of this meta-analysis is
discussed further in chapter three.

MUSIC THERAPY AND SOCIAL SKILLS

48

Chapter 3 - Methodotogy

Introduction
The present study conducted a meta-analysis to investigate the effects of music therapy
on social skills in individuals with autism. The researcher obtained approval trom the Slippery
Rock University lnstitutional Review Board (IRB) for the present study (See APPENDIX A for

IRB approval document). According to Field and Gillett (2010),

a meta-analysis

is a valuable

tool that can provide inforrnation on the mean and variance of underlying pcpulation effects, the

variability in effects &cross studies, and potential moderator variables. This meta-analysis
research was conducted using a six-step procedure described by Field and Gillett (2010). The

six-step procedure is as follows: (Step

l) Do a literature search, (Step 2) Decide

on inclusion

criteria, (Step 3) Calculate the efflect sizes, (Step 4) Do the basic meta-analysis, (Step 5) Do some
more advanced analysis, and (Step 6) Write it up (Field & Gillett,20l0).
The resetucher conducted this meta-analysis on the effects of music

tlerapy on social

skills in individuals with autism to investigate the following research questions:

1.

What is music therapy's impact on students identified with autism?

2. What is the effect of music therapy on social skills in experimental

group research design

studies?
.

3. What are the potential moderators of tle impact of music therapy?
Inclusion Criteria

'

The present study conducted a meta-analysis on the efl'ects of music therapy on social

skills in individuals with autism. This present study included research articles that met the

following inclusion criteria: (1) The research must be written in English, (2) The research must
be written between the years 2013 and 2023, (3) The research must include panicipants who

MUSIC THERAPY AND SOCIAL SKILLS
have been diagnosed with an Autism Specffum Disorder who were between the ages

49

of l-12, (4)

The research must include music tlerapy as the independent variable, (5) The research must

include social skills as the dependent variable, (6) The research was conducted using an
experimental group research design, (7) The research must quantitatively express the effects

of

music therapy on social skills so that the necessary data can be extracted and the effect size can
be calculated.

Search Sources and Search Terms
The researcher searched for research articles that met the inclusion criteria through

Google Scholar, and the Bailey Library at Slippery Rock University. The researcher conducted a
Discovery Advanced Searcb (Databases A-Z) through the Bailey Library using various
combinations of search terms. The researcher specifically searched through The Journal of Music
Therapy, The Journal of Child: Care, Health, and Development, The.Iournal of Advanced
Biomedical Research, and The Egtptian Journal of Neurologt, Psychiatry, and Neurosurgery.

This comprehensive search provided access to articles that met the researcher's inclusion
criteria. The present study used various combinations of the following search terms to locate
articles that met the inclusion criteria: music therapy, passive music therapy, active music
therapy, group intervention, social skills, social communication, social interaction, autism,

autism spectrum disorder, Asperger Syndrome, intellectual disabilities. After this comprehensive
search, the researcher used the Google Scholar search engine to locate additional research

articles not previously fbund in the Bailey Library's lJiscovery Advanced Search (f)atabases
A-Z).
The present study selected these search terms based on the current studies objective: This
study focuses on the effects of music therapy on social skills in individuals with autism. Bharathi

MUSIC THERAPY AND SOCIAL SKILLS

50

et al., (2019) defined the term music therapy as a healthcare practice in which music is used as a

therapeutic approach to improve social communication in an individual. The tenn autism is
defined as a newodevelopmental disorder that is characterized by a deficit in social and
communication skills (LaGasse,

z}lq.

LaGasse QAr,4) defined the term social skills as the

inability to develop the necessary skills required for relationships, independence, and vocation.
Databases. The present study located four research articles that met the researcher's

inclusion criteria. The following databases were searched to locate research articles that met the
inclusion criteria for this meta-analysis: Discovery Advanced Search (Databases A-Z),'Ihe
Journal of Music Therapy, The Journal af Child: Care, Health, and Development, The Journal
Advanced Biomedical Research, and The Egtptian Journal of Neurologt, Psychiatry, and
Neurosurgery.T1ne researcher also searched lbr research articles that met the inclusion criteria

using Google

Scholar.
r.

Discovery Advanced Search. The Discovery Advanced Search is an online search
engine that provides access to databases

A-Z in one

search.

The peer reviewed research journals that are specific to the present study are as

follows:

(l)

The

Journal of Mu,ric Therapy; (2) The Journal of Child: Care, Health, and

Dev.elapment; (3) The Journal of Advanced Biomedical Research;

$) The Egptian Journal of

Neurologt, P sychiatry, and Neurosurgery.
The

Journal of Music Therapy is a peer reviewed journal that contributes to the science

and practice of music therapy (American Music Therapy Association,2023). Tts mission is to

provide access to scholarly articles that promote the development and understanding of music
therapy interventions (American Music Therapy Association,2023). The Journal of Music
Therapy publishes various types of research, including quantitative, qualitative, mixed

af

MUSIC THERAPY AND SOCIAL SKILLS

5l

methodologies, systematic reviews, integrative reviews, meta-analysis, and meta-synthesis

(American Music Therapy Association,2023). According to the American Music Therapy
Association (2023) all research articles are selected based on their quality and contribution to
existing research.
The

Journal af Child: Care, Health, and l)evelopmenl is an international peer reviewed

journal that addresses all areas of health and childhood development (Willey, 2023). This journal
accepts both quantitative and qualitative research articles that are related to child healthcare and

development (Willey, 2023). The journal also welcomes studies that investigate the effects of
social and environmental factors on health and development (Willey, 2023). According to Willey
(2023) this journal is particularly interested in publishing articles that relate to those who are

physically, developmentally, emotionally, and socially disadvantaged.
The,Iournal of Advanced Biomedical Researcft is a multidisciplinary peer reviewed
journal that focuses on the improvement and understanding of human health and disease
(Advanced Biomedical Research, zAlD. According to Advanced Biomedical Research QAlz)
the

joumal includes articles that relate to all areas of medicine and biology, including basic

science research (e.g., anatomy, cell and molecular biology, cellular biochemistry cytology,

immunology, microbiology, pathology, pharmacology, cell and tissue), and clinical investigations
(e.g., cardiology, clinical epidemiology, endocrinology, gastroenterology, gerontology,
hematology, neuropathology, oncology, pediatrics, radiology, rheumatology, cardiovascular). The
scope also extends to the areas of interdisciplinary, multi-disciplinary, and alternative medicine

(Advanced Biomedical Research,
The

zAlD.

Egptian Journal of Neurologt, Psychiatry, and Neurosurgery is a peer reviewed,

open access journal that focuses on health, social, and ethical issues in the field of clinical

MUSIC THERAPY AND SOCIAL SKILLS

52

neurosciences, including neurology, psychiatry, and neurosurgery (Springer Open, 2021).

According to Springer Open (2023) The Egptian Journal of Neurologt, Psychiatry, and
Neurosurgerl encoruages the submission of research articles with large datasets, color
illustrations, and moving pictures. Research articles published in The Egtptian Journal

of

Neurology, Psychiafi, and Neurosurq{ery can also be located by using the search engines
EBSCO Discovery Service, Springerlink, PubMed Central, Medline, Semantic Scholar, Coogle
Scholar, ProQuest, and SCOPUS (Springer Open, 2023).

A comprehensive search of Databases A-Z (Discovery Advanced Search), I'he Journal af
Music Therapy, The Journal of Child: Care, Health, and Development, The Journal of Advanced
Biomedical Research, and The Egyptian Journal of Neurologlt, Psychiatry, and Neurosurgery
produced 115 articles that were considered for inclusion in this study. The researcher created an
inclusion criteria data sheet, inspired by the scholarly work of Tan (2018) that included all

inclusion criteria (See APPENDIX B - Inclusion Criteria Data Sheet). If the research article met
an inclusion criterion, the researcher put a check mark in the "Yes" column.

If the research article

did not meet an inclusion criterion, the researcher put a check mark in the "No" column. After
further investigation, the researcher located four research articles that met all the inclusion
criteria.

Evaluation of Quality
Articles that met the inclusion criteria were examined for quatity u.sing the Evaluative
Method (Reichow et al., 2008). The Hvaluative Method was created by Reichow et al. (2008) to
assist researchers and practitioners

in determining the most effective Evidence-Based Practice

(EBP) for individuals with autism. The instruments used in the Evaluative Method are as

MUSIC THERAPY AND SOCI.AL SKILLS
follows:

(l) rubric for evaluating

s3

the research articles rigor, (2) guidelines for evaluating the

research articles strength, (3) criteria for determining the EBP (Reichow et a1., 2008).

The inskuments described by Reichow et al. (2008) provide a standardized method for
the evaluation of interventions used for individuals with autism. According to Reichow et al.

(2008) the Evaluative Method also provides individualized ratings for each research article.

Assigning individualized ratings for each research article can assist in the evaluation of EtsP
when a combination of different research methodologies is used (Reichow et al., 2008). The
present study evaluated each research article that met the inclusion criteria using the instruments
described by Reichow et al. (2008) as the "Evaluative Methodfor Determining EBP in Autism."

Reichow et al. (2008) developed a group research design rubric to evaluate the rigor of
research articles. The rubric provided a way for the researcher to evaluate the quality

of

methodological elements of research articles (Reichow et al., 2008). The rubric included two
levels of methodological elements: primary quality indicators and seqondary quality indicators
(Reichow et al., 2008). According to Reichow et al. (2008) primary qualrty indicators
(participant characteristics, dependent measure, independent measures) are considered critical for
demonstrating the validity of a research study. The primary qirality indicators are operationally
defined using a three-temr ordinal scale: high qualify, acceptable quality, and unacceptable

quality (Reichow et a1.,2008).

Although important, secondary quality indicators (interobserver agreement, blind raters,
procedural tidelity, generalization and maintenance, social validity) are considered not necessary

for demonstrating the validity of a research study (Reichow et al., 200tt). The secondary quality
indicators are operationally defined using a dichotomous scale: evidence or no evidence
(Reichow et al., 2008). The researcher of the present study developed data sheets to evaluate

MUSIC THERAPY AND SOCIAL SKILLS

s4

group research designs, using the Evaluative Method presented by Reichow et al., (2008) (SEE

APPENDIX C for the Evaluative Method data sheet).
The guidelines for the evaluation of the research report strength provides a strategy
combining the ratings &om the rubric inlo a shength of research report ratings (Reichow et

of
aL.,

2008). According to Reichow et al. (2008) the research report is operationalized as either having
a sffong research

report strength, an adequate research report strength, or a weak research report

stength. A strong research report strength rating demonstrates solid evidence of a high-quality
research report (Reichow et al., 2008). Adequate research report strength shows strong evidence

in rnost, but not all areas (Reichow et a1., 2008). Weak research report strength indicates missing
elements or mistakes (Reichow et al., 2008). (SEE APPENDIX D for the Evaluative Method

rubric)
The reliability of the rubric has been used to evaluate field testing and communication

interventions (Reichow et a1., 2008). According to Reichow et al. (2008) each test showed high
agreement across applications and individuals. Reichow et al. (2008) stated "The high agreement
across applications and individuals support the evaluative method as a tool for reliably reviewing

autism intervention research" (p. 1316). According to Reichow et al. (2008) the validity of the
Evaluative Method was tested for concurrent validity, content validity, and face validity. The

validity of each validity type was determined by aligning the definitions of the rubric with prior
EBP definitions (Reichow et al., 2008). Further validity can be established by faining
inexperienced examiners to reliably use the rubric (Reichow et al., 2008). According to Reichow
et al., (2008) this process demonsffates good to excellent reliability and is often used to

clinical examiners on how to recognize and diagnose the presence or absence of autism.

Coding

tain

MUSIC THERAPY AND SOCIAL SKILLS

55

Developing Coding Instruments. The coding sheet and codebook in this study was
specifically designed to reflect the intervention, outcome variables, and statistical analysis. To
design a coding scheme that captures all key information, the researcher in this study thoroughly

examined each research article included in this meta-analysis. According to Brown et al. (2003)
there are four basic categories to code data:

(l)

methodological and substantive features, (2)

study quality, (3) intervention descripturs, and (4) outcome measures. Methodological and
substantive features have been identified in past studies as important variables to code in every
research synthesis (Brown et a1.,2003).

Methodological and substantive features include the source of the study, year

of

publication, and type of research design (Brown et al., 2003). According to Brown et al. (2003)
these features are coded for the purpose of relating the studies characteristics to the findings. tn

this study, the intervention categories and outcome measures were specific to the research
questions presented in this study. Variables specific to this meta-analysis study were included in

the coding sheets (SEE APPENDIX E

- Coding Sheet/Codebook). After the code sheet was

complete, the researcher of this study developed a codebook to guide the coding process.

According to Brown et al. (2003) a codebook should theoretically and operationally define each
variable to facilitate an inter-coder and intra-coder agreement. Brown et al. (2003) also noted that

"the operational definition of each category should be mutually exclusive and collectively
exhaustive" (p. 208).

. In this study, the group research study design articles were assessed according to l7
primary and secondary moderators. An excel data sheet was used to code all articles (SEE

APPENDIX E * Coding Sheet/Codebook). The following primary and secondary moderators
were chosen for this sfudy: area of expertise, source of reference, publication status, location

of

MUSIC THERAPY AND SOCIAL SzuLLS

s6

study, study design, quality, gender, age, level of severity, type of intervention skategy, setting,

implementation specialist, lenglh of each therapy session, total number of therapy sessions, focus
of measurement, social skills assessment method, and measurement technique.

Area of Expertise (a). The research articles that met the inclusion criteria for this
meta-analysis focused on music therapy and different types of social skills. This researcher
created this moderator to deterrnine whether the area of expertise influences the outcomes

music therapy on different types of social skills. The codes used for this moderator are

of

(l)

family-centered music therapy and taking turns, (2) music therapy and eye gazing, joint
attention, and communication, (3) music therapy and understanding/perspective taking ability,
responds to otlers, and maintains interaction, and (4) music therapy and social skills.

Publication Status O), The present study located four research studies that were
published in peer reviewed journals (The Journal of Mu^sic Therapy, The Journal of Child: Care,

Heakh, and Development, The Journal oJ'Advanced Biomedical Research, and The Egptian
Journal of Neurologgt, Psychiatry, and Neurosurgery.). The researcher created this moderator to
determine whether a significant difference exists in published vs. unpublished articles. The codes
used for this moderator are

(l)

published and (2) not published.

Location of Sfudy (c). A majority of research studies included in this meta-analysis were
conducted Internationally (India, Australia, Norway, Iran). There was one research study that

took place in the United States (Colorado). The researcher created this moderator to assess the
differences between studies conducted in the United States vs. Intemational. The codes used for
this moderator are (1) United States and (2) lnternational.

Quality of Study (d). The present study evaluated each research article that met the
inclusion criteria using the instruments described by Reichow et al. (2008) as the "Evaluative

MUSIC THERAPY AND SOCIAL SKILLS

57

Methodfor Determining EBP in Autism" (rubric firr evaluating the research articles rigor,
guidelines for evaluating the research articles strength, criteria for determining the EBP). The
researcher created this moderator to assess the quality of each research article. The codes (1)

strong, (2) adequate, and (3) weak in accordance with the scoring rubric of Reichow et al. (2011)
were used to assess the quality of each research article in this meta-analysis.

Gender of Participants (e). The present study chose this moderator to evaluate whether
there is a difference in the effect of music therapy on social skills between males and females.
The researcher of this study created three codes for this moderator:

(i)

Male, (2) F'emale, (3)

Male and Female.
Age of Participants (f). The present study krcated ftrur research articles that met the
inclusion criteria tbr this meta-analysis. The research articles chosen for this meta-analysis have
a combined

total of I 17 participants between the ages of I -12. The preseirt study investigated the

effect of music therapy on social skills in children who have an autism spectrum disorder and

who are between the ages of l-12. The researcher created this moderator to assess the differences
between the two age groups. The codes used in this moderator are

(l) l-6 .xd, (2) 6-12.

Level of Autism Severity of Participants (g). The researchers of the studies chosen for
this.meta-analysis used the Childhood Autism Rating Scale (CARS) or The Childhood Autism
Rating Scale Second Edition (CARS2) to assess the severity level of autism. The researcher
created this moderator to assess the differences between the participants' level of autism severity.
The researcher of this meta-analysis coded the participants' autism severity level as (l) mild, (2)
moderate, (3) severe, (4) more than one level of severity, based on the autism severity level

reported by the researchers of that study.

MUSIC THERAPY AND SOCIAL SKILLS

'Ilpe of Intervention Strategy (h). The research articles

s8
chosen for this meta-analysis

used either active music therapy, passive music therapy, or a combination of both active and
passive music therapy as an intervention strategy. Active music therapy can be defined as

actively engaging in a musical actMty by playing a musical instrument or actively participating
in song or dance. Passive music therapy can be defined as listening to rrusic in the background
while engaging in nomral activities. The researcher created this moderator to assess the
differences between active music therapy and passive music therapy. In this meta-analysis, the
researcher coded this moderator as (1) active music therapy, (2) passive music therapy, (3) active
and passive music therapy, and (777) control.

Setting (i). The studies that met the inclusion criteria for this meta-analysis conducted
their study in either a therapeutic setting, school setting, or in-home setting. Two studies were
conducted in a therapeutic setting, one study was conducted in a school setting, and one study
was conducted in an in-home setting. The researcher created this moderator to assess whether the

setting of the intervention influenced the children's social abilities. The researcher of this
meta-analysis used the following codes for this moderator: (1) therapeutic, (2) school, (3)

communiry (4) in-home, (5) more than one setting, and (777) contol.

.

Implementation Specialist (i). In past studies, music therapy

has been implemented by

various types of specialists (e.g., music therapist, school personnel, researcher). The researcher

of this meta-analysis created this moderator to determine whether different types of specialists
influenced the children's social abilities. The researcher of this meta-analysis used the fbllowing
codes for this moderator:

(l)

music therapist, (2) school personnel, (3) researcher, (4) more than

one specialist, (777\ control, and (888) not noted.

MUSIC THERAPY AND SOCIAL SKILLS

s9

Length of Each 'I'herapy Session (k). In the studies that met the inclusion criteria for
this meta-analysis, the length of each music therapy session varied. The researcher of this
meta-analysis created this moderator to determine whether the length of the music therapy
session intluenced the children's social abilities. The researcher coded this moderator as (1) 1-10

minutes, (2) 1l-20 minutes, (3) 21-30 minutes, (4) 3l-40 minutes, (5) greater than

4l

minutes,

and(777) conhol
Total Number of Therapy Sessions (l).

A11 research

articles that met the inclusion

criteria for this meta-analysis were interested in determining the effect of music therapy on social
skills in children with autism. The researcher of this meta-analysis created this moderator to
determine whether the number of music therapy sessions influenced the children's social

abilities. The researcher coded this moderator as (1) l-5 sessions, (2) 6-10 sessions, (3) 1l-20
sessions, (4)21-30 sessions, (5) greaterthan 30 sessions, and(717) control.

Focus of Measurement (m). The research articles chosen for this meta-analysis used
various categories to identi$ the social skill observed. The researcher of this rneta-analysis
created this moderator to determine how the children's soqial abilities were influenced by the

music therapy intervention. This researcher coded this moderator as (1) gives attention, (2) enters

into intentional social interaction, (3) understands and expresses emotion, (4) repetitive
behaviors, (5) interpersonal behaviors, (6) communication, (7) more than one skill, (777) control,
(888) not noted.

' Social Skills Assessment Method (n). AI1 research articles that met the inclusion criteria
for this meta-analysis measured social skills by using an indirect method. The researcher of this
study created this moderator to determine whether an indirect method of assessing social skills

MUSIC THERAPY AND SOCIAL SKILLS

60

produced different results when compared to the control group. The researcher coded this
moderator as (1) direct, (2) indirect, (3) direct and indirect, (777) control, and (888) not noted.

Social Skilts Measurement techniques (o). The research articles that met the inclusion
criteria for this meta-analysis used various techniques to measure social skills. The social skills
measurement techniques used are as follows: Social Skills Rating System fS.Sft$, Wneland

Social-Emotional Early Childhood Scales (VSEEC), Social Responsiveness Scale Preschool
Versionfor i-Yeqr Olds (SRS-PS), MacArthur-Butes Communicative Development Inventories
Words and Gestures

*

(MBCDI-WAG), Parent-Child Relationship Inventory QCRI), Music

Therapy Diagnostic Assessment (MTDA), Autism Treatment Evaluation Checklist (ATEC),

TNAD Special Skills Assessment (TSSA), and Social Response Scale f.SftS/ The researcher of
this meta-analysis created this moderator to assess whether there is a diftbrence between groups
based on the social
,s,sft,s,

skill measurement technique. The researcher coded this moderator

as

(l)

(2) vsEEC,(3) sfis-Pg (4) MBCDI-W&G, (5\ PCN, (6) MTDA, (7) ATEC,(8) rSSl, (9)

,tn^S, (10) more than one technique, {777)

control, and (88ti) not noted.

Effect Size Calculations
Aggregated Score Studics. The researcher of this study extracted the sample sizes (n),
pre and post weighted mean scores, and pre and post pooled SD scores from each research article

included in this meta-analysis. The sample size, pre and post weighted mean scores, and pre and
post pooled SD scores were used to calculate the effect size according to Cohen's d statistical

formula. Gravetter and Wallnau (2011) noted the importance of using Cohen's dto calculate the
effect size in a meta-analysis. The effect size is a quantitative measure that measures the
treatrnent effect between groups (Gravetter & Wallnau, 20l

l). According to Gravetter

and

Wallnau (2011) Cohen's d is the best method of calculating the effect size in a meta-analysis.

MUSIC THERAPY AND SOCIAL SKILLS

61

This researcher calculated the effect size using the Cohen's d method by subtracting the pre
weighted mean scores from the post weighted mean scores divided by the pre and post pooled
standard deviation scores (SEE APPENDIX E

-

Coding Sheet/Codebook).

Basic Meta-Analysis Calculation
The researcher of this study calculated the basic meta-analysis of the effects of music
therapy on social skills in individuals with autism using a random effects model described by
Schmidt and Hunter (2015). According to Hunter and Schmidt (2004) both fixed and random
effect modeis and procedures have been used in meta-analyses. However, a random effects
model and procedures are often used and more appropriate than a fixed effects rnodel to calculate
the effects size of a meta-analysis (Hunter

& Schmidt, 2000).

A tixed effects model assumes that participants from studies in a meta-analysis

are

sampled from a population in which the average effect size is fixed (Field, 2005). A random
effects model assumes that the ayerage effect size of a population randomly varies between
studies (Field, 2005). According to Field and Gillett (2010) a fixed effects model is appropriate

for situations in which a generaiization of the meta-analysis resr.rlts occurs only to the studies
included in the meta-analysis. However, wheu a generalization of the meta-analysis results in a

l*g:r

population is desired, a random effects model should be used (Field & Gillett, 2010).
According to Field (2005) the difference between the fixed and random effects size

models is the amount of statistical error Both effects size models include error, however, the
random effects size model includes additional error because it is assumed that participants are

from a diverse population with different effbct sizrs within each study (Field, 2005). According
to Hunter and Schmidt (2000) researchers often use fixed effects models more frequently than
random effects rnodels because it is "analytically easier to manage."

MUSIC THE,RAPY AND SOCIAL SKILLS

62

However, due to the assumption of a diverse population and eff€ct sizes, inadequate
results are oflen produced when a fixed effects model is used (Hunter

& Schmidt, 2000).

According to Hunter and Schmidt (2000) a Type 1 error (false positive) is seen more often in a
fixed effects model than in a random effects model. A Type 1 error occurs when statistical
calculations show a significant difference between the independent and dependent variables, but
there is no statistical difference (Cooper et a1.,2A07). F'inally, the fixed effects model can
jeopardize the accuracy of the meta-analysis results because it often produces restricted
confidence intervals (Hunter

& Schmidt,2015).

The present study used the random effects model developed by Schmidt and Hunter
(2015). This meta-analysis investigated the effects of music therapy on social skills in

individuals with autism. Wendt and Miller QAn) noted that individuals with autism are part of a
diverse population. The random effecls model differentiates effecls sizes and produces reliable

confidence intervals for diverse populations (Hunter
effects models also have less Type

I

& Schmidt, 2000). In addition, random

errors than fixed effects models (Hunter

& Schmidt,

2000).

Finally, the random effects model can result in a generalization of results to a larger population
beyond the meta-analysis (Hunter

& Schmidt, 2000). Comprehensive Meta-Analysis (CMA)

software was used in this meta-analysis to compute the basic meta-analysis using the random
effects model.

P-Value

'

The p-value test is a statistical significance test that is used in research to test whether the

null hypothesis is correct. According to Dahiru (2008) the p-value measures the probability of

a

similar result randomly occurring. The p-value does not determine the null hypothesis however,

it can suggest

as to

which hypothesis is most likely correct (Dahiru, 2008). According to Dahiru

MUSIC THHRAPY AND SOCIAL

SKILLS

63

(2008) P < .10, P < .05, and P < .01 are commonly used p-values. The present study used the
p-value P < .10 to test each moderator.

Publication Bias
Publication bias often happens when a difference between published and unpublished
studies exists (Song et a1., 2013). According to Song et al. (2013) publication bias can be

problematic because of the likelihood of researchers publishing only when acquiring positive
results. Putrlishing only when acquiring positive results

will provide misguided information to

future researchers (Song et al., 2013). Song et al. (2013) suggested various ways to measurc

publication bias. A few methods include cohort follow ups, funnel plots, published vs.
unpublished study comparison, and statistical methods.

According to Song et al. (2013) funnel plots are used more often because of the
likelihood of researchers publishing large studies regardless of their results whereas, small
studies are more

likely to be published only when their results

are positive. The present study

used the Begg and Mazumdar Rank Correlation Test. Begg and Mazumdar (1994) suggested that
an inverse correlation can test for publication bias. The rank correlation between the treatment

effect and the standard error can be computed using the Begg and Mazumdar (1994) method.
The. results

of this meta-analysis is discussed in chapter four.

&

MUSIC THERAPY AND SOCIAL SKILLS
Table

I

Steps in a Meta-Analysis Research Study

1.

Inclusion Criteria

2.

Search Sources

3.

Search Terms

4.

Calculation of Effect Size

5. Calculation of a Basic Meta-Analysis

Details
The research nrust be written in English,
(2) The research must be written between the
years 2013 and2023, (3) The research must
include participants who have been diagnosed
with an Autism Spectrum Disorder who were
between the ages of l -12, (a) The research
must include music therapy as the
independent variable, (5) The research must
include social skills as the dependent
variable, (6) The research was conducted
using an experimental group research design,
(7) The research must quantitatively express
the efl'ects ot'music therapy on social skills so
that the necessary data can be exfracted and
the effect size can be calculated.
The researcher searched for research articles
that met the inclusion criteria through Google
Scholar, and tho Bailey Library at Slippery
Rosk University. The researcher specifically
searched through The Journal of Music
Therapy, The Journal of Child: Care, Health,
and Development, The Journal aJ'Advanced
Biomedical Research, and The Egptian
Jaurnal of Neurolog,,, Psychiatry, and

(l)

The researcher used various combinations of
the following search terms to locate articles
that met the inclusion criteria: music therapy,
passive music therapy, active music therapy,
group intervention, social skills, social
communication, social interaction, autism,
autism spectrum disorder, Asperger
intellectual disabilities.
Cohen's d method was used to calculate the
effect sizes of
research desisr studies.
Random Effects Model (Schmidt, Hunter,

20t

MUSIC THTJI(APY AND SOCIAL SKILLS

6s

Chapter 4 - Results

Introduction
Using extant research, the current investigation examined music therapy's impaot on
students identified on the autisrn spectrum. Through a meta-analysis of secondary data, this

investigation sought to address the following research questions:

l.

What is music therapy's impact on students identified with autism?

2.

What is the effect of music therapy on social skills in experimental group research
design studies?

3. What are the potential moderators of the impact of music therapy?
The analysis for this investigation was based on data from four studies providing 20 effect size
estimates. The sample within the tbur studies included data
size for the effect size analysis was based on a sample af

tiom

n:Il7

participants. The sample

n: 596.
,.

A random-effects model was employed for the analysis. The studies in the analysis were
assumed to represent all potential studies. Cohen's d effect size estimate was used

for all

estimations (Borenstein,2Al9; Borenstein et a1., 2010; Borenstein et al., 2A2l; Hedges & Vevea,
1998; Higgins

& Thomas,

zA1.9). Effect size measures were calculated

with means and standard

deviations using the formula from Johnson (1989):

d:

(Ms-Mg) /

Spoor,a

considering:

Sr*uo =

l(nr-t) (s, )' + (ncD

(sc)

'l

I

(nB -nq

- 2),

where Mu is the mean for the experimental group, M" is the rnean for the control soup,

r, is the

number of participants in the experimental group, n6is the number of participants in the control

MUSIC THERAPY AND SOCIAL SKILLS

66

group,riris the standard deviation of the experimental Broup, and

sc,

is the standard deviation

of

the control group. When means and standard deviations were not available, the effect sizes were
calculated using additional formulas. In this meta-analysis, the effect size estimate for studies

providing an.F statistic were calculated using the tbllowing fbrmula (Johnson, 1989):

d=Fl(nB+ng)/@r-nd7%
Once effect sizes are calculated for individual studies, the overall effect size measure for

ali the studies combined can be calculated. According to Glass et al. (1981), this can be done by
simply calculating the mean of the individual effect size measures. However, this approach does
not take into consideration the fact that the studies vary in sample size. Hedges and Olkin (1985)
provide a formula for calculating the overall mean effect size as an unbiased weighted estimate
(i.e., weighted by sample size) of the population effect size:

d=#
f

hd

k

Fl

I wd

,!, ttat

= --[--

\r-lr
J/,\
t-1 O lAl

f,w

where the variance of d is calculated using the following formula:

2/,\

; *lo^'(a,\
\u
,1rt

Cttd t=---=
\ +/
tk

\"

*,1
Ir
\t=1 I

as

well

as the corresponding confidence

d*'

1

^2/,\

lJi]'i-'o

(d,/

[i#'

1

k

s

t'(rJ
,i -.1-

intervals using this formula:

zolzotd*)

s 6 s d+ + zoTzold*)

MUSIC THERAPY AND SOCIAL SKILLS

67

to calculate a 100(1- &) confidence interval (p. 1t 1). The overall mean effect sizes for this
meta-analysis were calculated according to the procedures recommended by Hedges and Olkin

within the Comprehen*sive Meta-Analysis,

a dedicated meta-analytic software (Borenstein et al.,

2424.
ll-lre overall mean effect size was a large positive significant effect

confidence interval of 0.37 ttl 0.78. (This was based on the guidelines of
size estimate,

d:.30

as a moderate effect size estimate, and

d:

d:

A.572 with a95o/o

d:.10

as a small effect

.50 or greater as a large effect

size estimate). The mean effcct size suggests a large significant effect from music therapy across

all the studies. The Q-statistic tests the null hypothesis that assumes all studies in the analysis
share a common effect size. The Q-value was 38.20

with

19 degrees

of freedom andp:0.006,

indicating the presence of heterogeneity. Specitically, the true effect size across all etl'ect
estimates was not the same in all of these studies. The average effect size estimate by study is
presented in Table 2.

Table 2

Effect Size Estimates by Sudy

Number

Study
Thompson et al. (2014)

of

Lower
CI

Upper
CI

0.40

0.06

0.75

Sis.
0.422

7

1.03

4.46

1.61

<0.001

52

6

0.55

a.27

0.82

<0.001

27

3

0.34

-0.i5

0.83

0.t72

.

21

Estimates
4

LaGlasse et al. (2014)

t7

Bharathi (2019)
Ghasemtabar et al. (2015)

As indicated above, LaGlasse et al. Q014) revealed the largest overall effect size estimate,
followed by Bharaithi (2019). Results were firther broken down by effect size estimates with

MUSIC THERAPY AND SOCTAL SKILLS

68

each study. Figure 1 provides a graphical representation of the effect size estimates, followed by
Table 3.

l'igure

I

Effect Size Estimate Plot by Study Measures

_!f*{l

_

Thonpson
Thunpson

E}Tggr

n.9s

tr

2

011

Thompsotr 3

0.13

Thompsou 4

CI.is

LaGlas*e

1

L.aGIas*e

l

161

,1

1)

l.a&lasse

La0las:e

0i

016

LaGlasse-l
5

tr-1_1

LaClasre 6

059

tr.aGlasse ?

I 1rl

Blraat}i

l

fi t5

Eharathi

l

0{5

Bharathi

-1

fl {ir

tsharathi.l

100

Bharathi

0

5

Btrnrathi 6
Ghasemtabar

I

ril

0::
0.12

Ghaserutab.ar! 0.91

Ghaserataba'l

Figure

I

0.11

illustrates the heterogeneity across the study measures. Since heterogeneity existed, the

effect size estimates across each level of all identified moderators were examined, and the results

of this analysis aro provided in Table 3.

MUSIC THERAPY AND SOCIAL SKILLS

69

Table 3
Effect Size Estimates by Mea.sure l{ithin Studies

narne

___Eqcus

d

Lower

Thompson I

Primary

0.98

0.46

Thompson 2

Secondary

0.21

-4.22

0.13

-0.30

Parent-Child

0.38

-0.06

LaGlasse I

Eye Gaze

2.33

1.10

LaGlasse 2

Joint Attention Child

1.61

0.51

LaGla^sse 3

Joint Attention Adult

0.03

-4.92

LaGlasse 4

Initiate Comm Adult

0.36

-0.60

LaGlasse 5

Initiate Comm Child

1.43

0.36

LaGlasse 6

Response to Comm

0.s9

-0.38

LaGlasse 7

Withdraw

1.29

a.24

Bharathi I

Social Skill Total

0.15

-0.40,

Bharathi 2

Understanding

0.45

-0.10

Bharathi 3

lnitiates Interaction

0.90

0.33

Bharathi 4

Respond to Others

1.00

0.43

Bharathi 5

Maintain Interactions

0.61

0.05

Bharathi 6

Social Skills Follow-up

4.22

-0.33

Posttest

a.n

-4.&

Ghasemtabar 2

Follow-up

0.93

0.l4

CI
1.50
0.6s
0.56
0.82
3.57
2.71
0.98
1.32
?.49
1.56
2.34
0.69
1.00
1.47
1.58
l.l7
0.77
0.87
1.73

Ghasemtabar 3

0verall

4.12

-4.42

0.67

Study

Thompson 3

Speech

Thompson 4

Ghaserntabar

Several

1

& Language

CI

Upper

Sie.

<0.00t
0.333

0.550
0.093
<0.001

0.004
0.954

0.462
0.009

0.234
0.016
A.597

0.109
0.002
0.001

0.032

0.429
0.765
0.021

0.6s4

initially identified moderators revealed no variability across the studies. Therefore, those

potential moderators were not analyzed. Those moderators included:

.

a source ofreference

.

publication status

MUSIC THERAPY AND SOCIAL SKILLS

o

study design

.

study qualify

.

gender of participants

.

social skill assessment method

70

Primary Moderators Analysis Results
Age
Age was identified as a potential moderator of the overall eft'ect size estimate of the
impact of music therapy (MT). This analysis separated students between the ages of l-6 years
and 6-12 years. The results are provided

in Table 4.

Table 4
Effbct Size Estimates by Age Group

Number
Lower Upper
Level of Studies d Limit Limit
1-6 years
4
0.40 0.06 0.75
6-12 years
16 A.64 0.39 0.90

Sis.
A.022
<0.001

As indicated above, the effect size estimate for the impact of MT for the 6-12-yearsgroup
revealed a large positive significant effect, whereas the effect size estimate for the I -6 years
group revealed a moderate positive significant efl'ect. The two levels were fbund to be

significantly different, p <.00

1.

The severity of the student's disability was also examined. The available data provided

two levels of severity (r.e., severe, multiple levels). The results are provided in Table 5.

MUSIC THERAPY AND SOCIAL SKILLS
'Iable

7t

5

E/fect Size Estirnate by Severity Le.vel

of
Lower Upper
Limit Limit
Studies d
4
0.40 0.06 0.75

Number
Level
Severe

Multiple Levels of

Severity 16

0.64 0.39

0.9

Sis.

0.022
<0.001

As indicated, the ellbct size estirnate tbr the impact of MT was higher for the multiple levels

of

severity tlan the severe level. Results also indicate that the two levels were significantly
different, p <.001.

Intervention strategy was also examined, with trvo levels being found in the extant
research (i.e., active, active

&

passive). The results of this analysis are provided in Table 6.

Table 6
E/fect Size Estimate by Intervention Strategt

Number of
Level
Studies d
Active
11
0.70
Active & Passive I
0.49

Lower Upper
Limit Limit
0.35 1.06
0.25 A.72

Sis.
<0.001
<0.001

As indicated above, the effect size estimate for the irnpact of MT was greater for the active
interventions than the active & passive interventions. Results also indicate that the two levels
were significantly different, p <.001

.

The setting of the MT was examined fbr three levels: therapeutic, school, and in-home.
The rcsults are prescnted in Table 7.

MUSIC THERAPY AND SOCIAL SKILLS

72

Table 7
Effect Size Estimate by Setting of Music Therapy

Level

Studies d

Therapeutic

l0

School

6

Limit

0.78
0.s5
0.40

ln-Home

0.34

t.23

0.001

0.27

0,82

<0.001

0.06

a.7s

0.022

As indicated above, the most significant impact of MT was revealed in the therapeutic setting,
followed by the school setting, and then in-home. Results also indicate that the tlree levels were
signilicantly different, p <.00 1.
The impact of the MT based on who was implementing the therapy was also examined.
The three levels of implementation specialist representecl in the extant i"sear"h included: music
therapist, researcher, and more than one specialist. The results of this analysis are presented in
Table 8.

Table 8

Effict

Size Estimate by Implementation Specialist

Level

Lower

Number

of

Studies

d

Limit

Upper

Limit

Sie.

Music Therapist

t1

0.70

0.3s

r.06

<0.001

Researcher

3

0.34

-0.15

0.83

0.t72

More than one

6

0.55

0.27

0.82

<0.001

MUSIC THERAPY AND SOCIAL SKILLS

73

As indicated above, the greatest impact of MT was revealed when the implementation specialist
was a music therapist, followed by more than one specialist conducting the implementation.
Results also suggest that the three levels differed significantly,

p <.001.

The length of the therapy on the impact of the MT was analyzed. The research provided
three different lengths of therapy sessions: 21-30 minutes,

i1-40 minutes,

xd 4I minutes or

rnore. These results zre provided in Table 9.

'lhble 9
Elfect Size Estimate by Length of Therapy Session

Number

Lower Upper
Level
Studies d
Limit Limit
2l -30 minutes
3
0.34 -0.15 0.83
of

Sis.

A.fi2
t.

3L - 40

4l

minutes

minutes or

more

10

0.48

0.27

0.69

<0.001

7

L.03

0.46

1.6i

<0.001

Results indicate that the longest sessions (41 minutes or more) resulted in the grcatest impact.

Resulls also indicate that the three levels were signifrcantly different, p <.001.
The number of MT sessions was examined. Students were reported to attend one to five
sessions, six to ten sessions, or 30 ar more sessions. These results are presented

in Table

10.

MUSIC THERAPY AND SOCIAL SKILLS

74

Table 10
E/fect Size Estimate by Number of MT Sessions

1-5 Sessions

7

Lower Upper
d
Limit Limit
0.97 0.58 1.37

6-10 Sessions

7

0.36

0.17

0.56

<0.001

Sessions 6

0.54

0.31

017

<0.001

level

30 or more

Number
of Studies

Sie.
<0.001

As indicated above, the greatest impact of MT was revealed for the students attending one
sessions, followed by

to

/ive

jA or more se.ssrons. Results also suggest that the three levels were

significantly different, p <.001.
The impact on

Ml

based on the focus of measurement, was analyzed across five possible

actions by the student (i.e-, attention, initiate communication, respond tro communication, speech

& language, andwithdraw). The results of these analyses

are presented in Table 11.

Table 1l
Etfect Size Estimate by Focus of Measurement

Level

Lower Upper
Limit Limit

Sis.

l.Os

a.fi

t.94

0.019

Communication 3

0.88

0.41

1.35

<0.001

Cornmunication 4

0.57

0.28

0.85

<0.001

I

0.13

-0.30

0.56

0.550

|

1,.29 A,24

2.34

0.016

Respond to
Speech

d

4

Attention
Initiate

Number
of Studies

&

Language

Withdraw

MUSIC THERAPY AND SOCIAL SKILLS

75

As indicated above, MT had the greatest impact on withdraw, followed by attentior and initiate
communication. All the estirnated efl'ect size estimates of MT were revealed to be large except
for the speech and language levels. Results also indicate that the five levels were significantly

different,p <.001.
Secondary Moderators Analysis Results
Three potential secondary moderators were examined. Three different levels represented

the area of expertise of the MT administrator. The results of this analysis are provided in Table

t2.

Table 12
Effect Size Estimate by Area of Expertise

Number

Family-Centered Music Therapy and Taking Turns

4

Lower Upper
"
d Limit Limit
0,38 o.ts 0.6

Music Therapy, Eye Gazing, Joint Attention, and
Communication

7

0.97 0.58 1.37

0.001

Music therapy, understanding/perspective taking
ebililarclponds to others, and maintains interaction

9

0.48 0.29 0.68

0.001

of
Level

Studies

As indicated above, the largest etfbct size estimate was lbtrnd with music therapy, eye gazing,

joint attention, and communicadoz.

Results also suggest that the tl:ree levels were significantly

different, p <.001.
The skill measurernent taken was also identified as a secondary moderator. The extant
research provided three potential measures: SS-RS, f^S&4, awJ multiple measures. The results for

this analysis are provided in Table 13.

Sie.
0.001

MUSIC THERAPY AND SOCIAL SKILLS

76

Table 13
E/fect Size Estimate by Skills Measurement Technique

Number

Level

of
Studies d

ssRS
TSSA

3
6
Multiple Measures li

0.34
0.55
0.70

Lower
Limit

-0.15
0.27
0.35

Upper

Limit

0.83
0.82
1.06

Sie.

0.172
<0.001
<0.001

As indicated above, studies using multiple measures reported the largest estimated elTect size
estimate, followed by the TSSA. Results also indicate that the three levels were significantly

different, p <.001.

Lastly, the location of the research study (i.e., damestic, tnternationa[) was analyzed for
any differences across estimated effect size estimates. The results of this analysis are provided in
Table 14.

Table 14
Elfect Size Estimate by Location of Research

Level

Domestic

of
Studies d

Number

7

Intemational 13

Lowff
Limit

Upper

Limit

Sie.

1.03 0.46

1.61

<0.001

0.45 0.26

A.64

<0.001

MUSIC THERAPY AND SOCTAL SKILLS

77

As indicated above, the results reveal that domeslic studies reported large positive significant
effect size estimates overall, while international studies reported a moderate to large effect size
estimate. Results also indicate that the two levels were significantly different, p <.001.

Publication Bies
A1l studies in the current investigation were published and reported an overall positive
result. As indicated above, the Q-statistic showed that heterogeneity existed across the studies,

with variability across the mean effect size estimates, ranging from d : -.14 to

d:

1.28 (a range

of 1.42). f igure 2 illustates the true mean effect size estimates of the studies included in the
current investi gation.

Figure 2
Distribution nf True Effects

Negative Eftect

-2,00

sitive Effe*t

-0.50

u.u u

0.$0

1.0[

1.$0

As indicated above, the mean eftbct size was .57 with a95o/o confidence interval of .36 to .78.
So, while there was variability in the individual effect size estimates, the diskibution size estimates \ryas all positive for the published studies. Therefore,
bias exists.

it is likely that publication

MUSIC THERAPY AND SOCIAL SKILLS

78

Conclusion
This meta-analysis examined the existing research on music therapy with students

identified on the autism speckum. Based on the available research, the overall result revealed a
significant positive effect of music therapy on students with autism therapy. Additionally, the
results reveal statistically significant heterogeneity across the identified studies and the different

effect size measures examined within those studies. All the potential primary moderators,

including the age of students, the severity level of diagnosis, MT intervention strategy, setting of
MT, administrator of MT, length of session, number of sessions, and focus of behavior being
measured, were significant and positive. Secondary moderators, iucluding the administrator's
area of expertise, the sfudy's location, and the mea^surement of the skills used, were also found to
be

positive and significant. Since all tbw studies were published aud reported positive results,

publication bias is likely. These results and their implications are discussed in Chapter Five.

MUSIC THERAPY AND SOCI,AL SKILLS

79

Chapter 5 - Discussion

Introduction
Autism spectrurn disorder (ASD) is a life-long disability characterized by developmental
deficits in social communication, and restricted and repetitive patterns of behavior (Volhnar &
Pauls, 2003; Yum el a1.,202A). [t has been suggested

t]at social

and behavioral impairments in

individuals with ASD are a result of a debilitated central nervous system (Azbell & Laking,
2A0q. The high rate of epilepsy and tenacious neurological involvement has strongly suggested
brain involvement in individuals with ASD (Volkmar & Pauls, 2003). A range of neurological
abnormalities such as neuron depletion and reduced dendritic arborization in the limbic system
have been reported in past studies (Volkmar

&

Pauls, 2003).

Social processes have also been reported as an area of tbcus in individuals with ASD,

applying social meaning to visual stimuli is often observed as a very difficult task (Volkmar &
Pauls,2003). According to Volkrnar and Pauls

Qll3)this may

be due to the hiehly unusual

pattern of visual searching individuals with ASD demonskate when exposed to social

interaction. Social diffrculties experienced by individuals with ASD are known to persist
throughout a lifetime (Volkmar & Pauls, 2003). According to Vollanar and Pauls (2003) social

skills taught during childhood and adolescence may provide substantial social gains to support
independent living during adulthood. These findings are of interest because of the nature

of

social diffrculties found in individuals with ASD (Vollanar & Pauls, 2003).
. Social skills have been defined as a complex interaction of skills used to perform social
tasks (Ghasemtabar et al., 2Al5; Thompson et al.,

z}n).ln

past studies, it has been suggested

that a profound deficiency in social skills is a primary feature of ASD (White et al., 20A7). Social

deficits often involve speech, verbal communication, and interpersonal synchrony (White et al.,

MUSIC THERAPY AND SOCIAL SKILLS

80

2A07). Problem areas may also include dwelling on a particular subject, lack of emotional
expression, and lack of understanding sarcasm and metaphors (White et al., 20A7). According to

White et al. (2007) the major cause of disability is not a lack of social interest, but the lack of

ability to determine when to apply the skill is the major cause of social impairment.
Treatnents that address social deficits are aimed toward minimizing social impairments

in individuals with ASD (Rankin et a1., 2016). The National Autism Council's National
Standards Report QA23) suggests using an intervention practice that focuses on the development

of social skills in individuals with ASD. In past studies, music has created a foundation for social
interaction, and provided a structured environment that promotes social development in

individuals with ASD (LaGasse, 2017). According to past research, rnusic therapy interventions
have been known to improve attention, and promote social development in individuals with ASD

Music therapy (MT) is a music based intervention that targets cornnunication skills
according to individualized needs, preferences, and abilities (LaGasse,ZAfi). According to
Chasemtabar et al.

QA24 music is a valuable tool that can be used to develop social behaviors

and reduce social impairrnents in individuals with ASD. In past studies, researchers have
accentuated the importance of

MT in childhood development (Aldridge,1994). Calming effects

and reduced l'eelings of fear and anxiety have been reported (Aldridge, 1994).

In the early 1940's, music education, singing groups, and folk dancing were used to
improve socialization, and sell'-expression (Marquez-Garcia et a1.,2021). As the years passed,
clinicians began to recognize music as a way of improving social skills in individuals with ASD
(Marquez-Garcia et al.,2A2l). Today, many clinicians use MT as an alternative intervention

MUSIC THERAPY AND SOCIAL SKILLS

8l

treatment ftlr ASD (Marquez-Garcia et a1.,202L). According to LaGasse QAn) there are several
reasons why MT improves socialization skills in individuals with ASD.

In past studies, the rhythmic component of music has been known to encourage neural
organization and appropriate response cues (LaGasse, 2017). According to LaGasse (2017) using
structured music as an outline for response time could create a foundation for positive social
interaction. Furthermore, MT may also provide a way for individuals who are non-verbal to
engage in social interaction (LaGasse, 2017).

A significant

increase in social engagement,

joint

attention, and peer interaction has been observed in past studies (Lacasse, 2017).
Over the years, MT has brought about positive changes in social behavior (Ghasemtabar

et a1.,2022). Evidence from past studies have shown that MT can help individuals recognize
social cues, cooperate in social groups, and transition between activities (Ghasemtabar et al.,

2424. Despite the many approaches to Mt focu^sing on individualized needs is prominent for
successfully designing a keatment plan to address the physical, social, and emotional needs

of

individuals with ASD (La(iasse, ZAn). These studies provide research-based evidence that MT
can create positive social changes in individuals with ASD.

The current study combined the results of 4 research studies that met the following

inclusion criteria: the research is written in English, the research is published between the years
2A13-2023, the research includes

MT

as the independent

variable, the research includes social

skills as the dependent variable, the research includes participants who have a medical diagnosis

of autism and who are between the ages of I -l 2, the research was conducted using aggregated
data or a group research design that includes a functional analysis, the research quantitatively
expressed the effects of

MT on social skills

effect size can be calculated.

so that the necessary data can be extracted and the

MUSIC THERAPY AND SOCIAL SKILLS

82

The 4 articles were analyzed according to 17 primary and secondary moderators. The

following primary and secondary moderators were initially evaluated for use in this study: area
of expertise, source of reference, publication status, location of study, study design, quality,
gender, age,level of severity, t1rye of intervention strategy, setting, implementation specialist,

length of each therapy session, total number of therapy sessions, focus of mea^surement, social

skills assessment method, and measurement technique. Since several initiaily identified
rnoderators revealed no variability across studies, those moderators were not analyzed. Those

moderators included: source of reference, publication status, study design, sfudy quality, gender,
and social

skill

assessment.

The overall mean effect size had a large positive significant effect
confidence interval of 0.37 to 0.78. (This was based on the guidelines of
size estimato,

d:.30

as a moderate effect size estimate, and d

:

d:0.572 with a 95%

d:.10

as a small effect

.50 or greater as a large effect

size estimate). The mean effect size suggests a large significant effect &om

MT across all the

studies. The Q-statistic tests the null hypothesis that assumes all studies in the analysis share a

common ef[ect size. The Q-value was 38.20 with 19 degrees of freedom and p: 0.006,

indicating the presence of heterogeneity. Specifically, the true effect size across all effect
estimates was not the same in all studies.

Moderators
Age. This moderator was separated into the following age groups:

1-6

years, and

6- t

2

years..The results of this moderator indicated that the effect size estimate fbr the impact of MT

for the 6-12 years level showed a large positive significant effect size
estimate for the

(d:

0.64). The effect size

l-6 years level showed a moderate positive significant effect size (d: 0.40). The

two levels within this moderator were found to be significantly different (p < 0.001).

MUSIC THERAPY AND SOCIAL SKILLS

83

Severity Level. This moderator was separated into the following levels of severity:
severe,

and,

multiple levels of severity . The results of this moderator indicated that the effect size

estimate for the impact of
size

(d:

MT for the severe level showed a moderate positive significant effect

0.40). The effect size estimate for multiple levels of severity showed a large positive

significant effect srze (d:0.64). These results also indicate that the two levels were significantly
different (D < 0.001).

Intervention Strategy. This moderator was examined using the following two levels:
active, and active & passive. The results of this moderator indicated that the effect size estimate

for the impact of MT was higher for the active interventions (r/ : 0.70) than the active & passive
interventions

(d:

0.49). The effect size estimate for the active interventions showed a large

positive significant effect, whereas the active & passive interventions showed a moderate
positive significant eflect. The results also indicated that the fwo lsvels.were significantly
different (p < 0.001).

Sitting of Music Therapy. This moderator was examined for the following three levels:
therapeutic, school, and in-home. The results of this moderator indicated that the effect size
estimate for the impact of

MT for both the therapeutic

positive significant effect size (d: 0.78;

d:

and school settings showed a large

0.55), whereas the effect size estimate for the

in-home setting showed a moderate positive significant effect size

(d:

0.40). According to the

results, the therapeutic level revealed the most significant impact of MT, followed by the school
setting, and then the in-hame setting.

Implementation Specialist. This moderator was examined for the following levels of
implementation specialists: nzsic therapist, researcher, and more than one specialist. The results

of this moderator indicated that the effect size estimate for the impact of MT for the music

MUSIC THERAPY AND SOCIAL SKILLS

84

therapist, and the more than ore specialist levels revealed a large positive significant effect size

(d:

0.70;

d:

0.55). The effect size estimate for the researcher level revealed a moderate

positive significant effect stze (d:0.34). The greatest impact of MT was revealed when the
implementation specialist was a music therapist, followed by more than one specialist, and then
the researcher The results of this moderator also indicated that the three levels are significantly

different (p < 0.001).

Length of Therapy Session. This moderator was examined using the following levels:
21-30 minutes,3l-40 minutes, and,4l minutes or more. The results of this moderator indicated
that the effect size estimate for the impact of MT for the 21-30 minutes, and the 3t-40 minutes
sessions revealed a moderate positive significant effect size

effect size estimate for the
slze (d

:

I .03).

4l

(d:0.34; d:0.48),

whereas t}re

minutes or more session revealed a large positive significant effect

According to the results, the

4

I minutas or more session revealed the most

significant impact of MT, followed by the 3I-40 minutes session, and then the 2l-30 minutes
session. The results also indicate that the three levels were significantly different (p < 0.001).

Number of Music Therapy Sessions. This moderator was examined using following
levels: 1 to 5 sessions, 6-10 sessions,and 30 or more sessions. The results of this moderator
indicated that the effect size estimate for the impact of MT for the 30 or more sessio,ns, and the
6-10 sessio,ns revealed a moderate positive significant effect size
size estimate for

(d:0.54;

d:

the 1-5 sessions revealed a large positive significant effect size

According to the results,

l-5

sessions revealed the most significant impact of

A36'). The effect

(d:

Ml

0.97).

fbllowed by

30 or more sessions, and then 6-10 sessions. The results also indicate that the three levels were

significantly different (p < 0.001).

MUSIC THERAPY AND SOCIAL SKILLS
.B'ocus

8s

of Measurement This moderator was examined using the following levels:

attention, initiate communication, respond to communication, speech & language, and withdraw,
The results of thi^s moderator indicated that the effect size estimate for the impact of MT for

attention, initiate cornmunication, respond to communication, andwithdraw revealed alarge

positivesignificanteffectsize(d=1.05;d=0.88; d=A.57 d:1.29).Theeffectsizeestimate
for speech & language revealed a small positive significant effect size

(d:

0.13). Aocording to

the results, withdraw revealed the most significant impact of MT, followed by attention, initiate

communication, respond to communication, and then speech & language" The results also
indicate that the five levels were significantly different (p < 0.001).

Area of Expertise. This moderator was examined using the following levels:
farnily-centered music therapy and taking turns, m*sic therapy, eye gazing, joint attentions, and
communication, and music therapy, understanding/perspective tahing ability, responding ta
others, and maintaining interaction.The results of this moderator indisated that the effect size
estimate for the iurpact of

MT far music therapy,

revealed a large positive siguificant effect size

eye gazing,

(d:

joint attention, and communication

A.97)-

The effect size estimate for family-centered music therapy and taking turns, and music
therapy, understanding/perspective taking ability, responding to others, and maintaining

interaction revealed a moderate positive significant effect size

(d:

0.38;

d:0.48).

The largest

effect size estimate was found in the music therapy, eye gazing, joint attention, and

comtnunicationlevel, followed by the music therapy, understanding/perspective taking ability,
responds to athers, and maintains interaclion level, and then the.family-centered music therapy

and taking turns level. The results also indicated that the levels were significantly different (p <
0.001).

MUSIC THERAPY AND SOCIAL SKILLS

86

Skills Measurement'Ilechnique. This m
,S^SflS,

TSSA, and multiple tneasures. The results of this moderator indicated that the effect size estimate

for the impact of MT far multiple measures revealed a large positive significant effect srze (d:
0.70). The effect size estimate for the

^9Sft.S,

and

LS,514

measures revealed a moderate positive

significant ef[ect stze (d = 0.0.34; d = 0.55). The largest effect size estimate was found in the
multiple measures level, followed by the TSSA, and then the

^S,S/iS

levels. The results also

indicated that the three levels were significantly different (p < 0.001).

Location of Research. This moderator examined the following levels: domestic,

and.

international.The results of this moderator indicated that the effect size estimate for the impact
of MT for the domestic level revealed a large positive significant effect size

(d:

1.03). The

effect size estimate for the internationallevel revealed a moderate positive significant effect size

(d:

0.45). The largest effect size estimate was found in the domestic level, followed by the

international level.The results also indicated that the two leveis were significantly different (p <
0.001).

Implication of the Results
According to Cihasemtabar et al. (2020) music therapy has brought about positive
changes in social behavior. Music intervention techniques have also been known to harness

musical talents and reduce social impairments in iudividuals with ASD (Ghasemtabar et

a1.,

2022). Despite the problems in processiag and controlling everyday emotions, indMduals with

ASf) can discern emotions in music the same as non-exceptional peers (Ghasemtabar et al.,
2022). Past research has also revealed that music therapy can help individuals recognize social
cues, cooperate

in social groups, and transition between activities (Ghasemtabar et al., 2022).

MUSIC THERAPY AND SOCIAL SKILLS

87

LaGasse (2017) noted that music therapy interventions are a great way to address the

social needs of individuals with different levels of ASD. According to Bharathi et al. (2019)
music therapy has been used as a therapeutic approach to enhance the physical, social, and
emotional needs of individuals with ASD. Music therapy sessions can provide an opportunity fbr

individuals with ASD to socially interact with peers in an environment that is safe and
non-judgmental (Eren,20l5). According to Lacasse (20L7) music alone does not impmve social
behaviors, it is the presence of music within another intervention that encourages positive
change.

In this current study, it was hypothesized that the quantitative analysis of studies that
havs researched the effects of music therapy on social skills in individuals with ASD
a

will reveal

positive significant effect of music therapy on individuals with ASD. Past research has

demonstrated that music therapy interventions have improved social skills in individuals with
t.

ASD regardless of whether the intervention specialist utilized active or passive music therapy.
The overall result of this crurent study revealed a positive significant effect of music
therapy on social skills in individuals with ASD. All primary (age, severity level, intervention
strategy, setting, implementation specialist, length of session, number of sessions, and focus

of

measurement) and secondary (area of expertise, study location, and skills measurement

technique) moderators used in this study were found to be positive and significant.
This meta-analysis also reveals statistically significant heterogeneity across all studies
and the diflbrent effect size measures examined

within those studies. The Q-statistic showed

variability across the mean effect size estimates (d = - 0.14 to d : I .2ll). Even though there was
variability within the individual effect size estimates, the distribution of effect size estimates
were all positive for the published studies and therefore, it is likely that publication bias existed.

MUSIC THHRAPY AND SOCIAL SKILLS

88

Limitations
A meta-analysis is

a valuable

analytical tool that can provide information on the mean

and variance of underlying population effects, the variability in effects across studies, and

potential moderator variables (Field & Gillett, 2010). The main purpose of a meta-analysis is to
summarize the results of multiple studies, analyze the differences between studies, and increase
the accuracy of the effect size estimates (Walker et al., 2008). According to Walker et al. (2008),
there are a few critical issues in a meta-analysis that need to be addressed, including publication
bias, the identification and selection of studies, the heterogeneity of results, and the availability

of data.
Publication bias happens when research is published based on the studies findings
(Walker et al., 2008). According to Walker et al. (2008) database searches are unlikely to
produce a representative sample because studies that show positive outcomes are more likely to
be published than studies that do not. Walker et al. (2008) suggested that publication bias occurs
because publishers favor positive studies that create catching headlines and recognition.

ln

a

recent study, researchers found that9To/o of studies that showed positive results were published

vs l2oh of studies that showed negative results (Walker et al., 2008). Researchers also found that

*0..o unpublished studies are excluded in an analysis, the positive effects of the study may
increase up

to

690/o

(Walker et a1., 2008).

According to Walker et al. (2008) important steps should also be taken when identifoing
relevant studies to include in a meta-analysis" First, a cornplete set of keywords should be used
when searching a database for inclusion articles (Walker et al., 2008). The search engine you use

for searching articles is also important because using multiple search engines can help increase
the number of studies found (Walker et al., 2008). This step

will help locate a long list of studies

MUSIC THERAPY AND SOCIAL SKILLS

89

that may or may not tre directly relevant to the meta-analysis (Walker et al., 2008). When
selecting articles, the list should also be subject to clearly defined inclusion criteria (Walker et
al., 2008). This step will help reduce differences among studies, and improve the quality of the
research study (Walker et a1., 2008).

According to Walker et al. (2008) the funnel plot technique can be used to detect the
possibility of biases in the identification and selection phases. ln a funnel plot, the effect size is
"plotted on the horizontal axis against standard error, or sample size on the vertical axis" (Walker
et

a1.,2008,p.434).lf no bias exists, the graph will have

a symmetrical funnel shape, whereas

when the graph shows lack of symmetry, negative studies are missing (Walker et al., 200S).
However, it is important to keep in mind that firnnel plots can sometimes be misleading.

According to Walker et al. (2008) a lack of symmetry can also be caused by heterogeneity.
Heterogeneity refers to the degree of variance in the results ofa research study (Walker
et a1., 2008). Walker et al. (2008) noted that the forest plot is an effective tool to determine the

level of heterogeneity. A forest plot estimates the effect of each study, and creates a line that
represents a confidence interval (Walker et al., 2008). When the confidence intervals overlap, the
effects are similar, and therefore the level of heterogeneity is low (Walker et a1.,2008). At the

point of no effect, the forest plot also includes a reference line (Walker et al., 2008). When the
effects lie on opposite sides of the refbrence line, the level of heterogeneity is high (Walker et al.,
2008). According to Walker et al. (2008) high levels of heterogeneity can compromise the
conclusion of a meta-analysis.
The availability of data within a research study is also important. Most research articles
include a sunmary of results which may include the mean, standard deviation, confidence

interval, t-test,

P, and

Cohen's d. According to Walker et al. (2008) when this information is

MUSIC THERAPY AND SOCIAL SKILLS

90

lacking within a research article it can severely limit the results of a meta-analysis. In this current
study, the availability of data was lacking in several research articles that were considered for

inclusion in this meta-analysis. The research articles that were lacking infonnation were
excluded from this meta-analysis.

Recommendations for F-uture Research
The use of music therapy as an intervention for improving social skills in individuals with

ASD has been a corlmon practice for many years (Yum et al., 2A2q. A comprehensive search of
the literature produced several articles that were considered for inclusion in this meta-analysis,
however only four articles met the inclusion criteria. Due to the small number of studies included

in this meta-analysis, several initially identified moderators were not analyzed due to no

variability across studies. It is evident that future research is needed to better understand the
effects of music therapy on social skills in individuals with ASD. Specifically, more research is
needed to provide future researchers

with the data required to analyze the initially ictentified

moderators excluded from this meta-analysis.

A few studies included in this meta-analysis also wanant further investigation. Bharathi
et al. (2019) investigated the effects of music therapy on social skills in children with ASD. The

study was designed using a pre-test/post-test/follow-up method. Fifty-four children were
assigned into two groupsr active and passive @harathi et al., 2019).

A limitation to their study

was that the participants were selected from only one city, and the age of the children with ASD
was limited to 6-12 year olds (Bharathi et al., 2019). Therefbre, it has been suggested that more
research is needed among various populations, age groups, and severity levels (Bharathi et

20rr.

a1.,

MUSIC THERAPY AND SOCIAL SKILLS

9l

Thompson et al. (2013) investigated the effects of family centered music therapy on
social skills in children with ASD. The study was a parallel randornized trial that included
twenty-three children with severe ASD (Thompson et a1.,2013). A limitation to their study was
that their study had a small sample size. According to Thompson et al. (2013) the small sample
size "limited the study's power to detect effects other than on the primary outcome where the

effect was very latge" (p. 847). Therefore, it has been suggested that larger studies are needed to
detennine the effectiveness of the intervention (Thompson et al., 2013).
F'inally, Ghasemtabar et a[. QAZD investigated the effects of music therapy on improving
social skills in children with ASD. Chasemtabar et al. QA22) designed a clinical trial study that
included pre-tesUpost-test/follow-up data. A limitation to their study was that their study was

limited to the community of Tehran city, and the study's sample size was limited to children who
are between the ages of 7-12 (Ghasemtabar et a1.,2A22). Therefore,

it has been suggested that

more research is needed to investigate otler samples with different demographic characteristics
(Ghasemtabar et al., TAZD.

Conclusion
The current study conducted a meta-analysis on the effects of music therapy on social

skills in individuals with ASD. The analysis for this study was based on data from four research
studies providing 20 effect size estimates. The sarnple within the four studies included data from
I 17 participants. The sample size for the effect size analysis was based on a sample size af

n:

596. The four articles included in this meta-analysis produced an overall large positive

significant effect size of

d:0572

with

a 95% confidence

interval of 0.37 to 0.78. The mean

effect size suggests a large significant effect from music therapy across all studies.

MUSIC THERAPY AND SOCIAL SKILLS

92

All studies included in this current investigati
and reported overall positive

results. The Q-statistic tests revealed significant heterogeneity across all studies,
across the mean effect size estimates, ranging from

d:

- 0.14 to

d:

with variability

1.28. tt is evident that there

is variability in the individual efl'ect size estimates, however the effect size estimates were all

positive for the published studies. Therefore, it is likely that publication bias existed in the
studies used in this meta-analysis. F-urthermore, according to Walker et al. (2008) high levels

of

heterogenerty can compromise the conclusion of a meta-analysis, therefore future research is also

neededto help decrease the level ofheterogeneity across studies.

Music therapy interventions have been known to improve emotional understanding and
increase emotional engagement in individuals with ASD (LaGasse, 2014). Music therapy

interventions have also been known to decrease ASD related behaviors and increase joint
attention, social greetings, peer interaction, and cognitive social skilts (LaGasse, 2014). The
results of this meta-analysis revealed that music therapy is an effective intervention treatrnent for

improving social skills in individuals with ASD. All primary moderators, including the age of
students, the severity level of diagnosis,

Ml

MT intervention

sh-ategy, setting of

MT, administrator of

length of session, number of sessions, and focus of behavior beiug measured, were

significant and positive. All secondary moderators, including the adminiskator's area

of

expertise, the study's location, and the measurement of the skills used, were also found to be
positive and significant.

MUSIC THERAPY AND SOCIAL SKILLS

93

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106

Appendices
Appendix A

-

IRB Approval Documentatioa

TO:

Dr. Christopher Tarr, Special Education

FROM:

Michael Holmstrup, Ph.D., Chairperson Institutional Review Board (IRB)

DAIE:

May 1,2A23

RE:

Protocol Approved

Protocol #: 2A% -090-88-A
Protocol Title: The Effects of Music Therapy on Social Skilts in Individuals with

Autism- A Meta-Analysis

The Institutional Review Board

[RB) of Slippery Rock University

has conducted an
t.

administrative rer.iew of the above-referenced protocol under the "exempt" category.

You may begin your project as of May 1,2023. Your protocol

will automatically

close on

April

34,2024, unless you request, in writing, to keep it open.

Please contact the IRB Office by phone at(724)738-4846 or via e-mail at irb@sru.edu should

your protocol change in any way.

MUSIC THERAPY AND SOCIAL SKILLS
Appendix B

-

rc1
Inclusion Criteria Data Sheet

Inclusion Criteria Data Sheet
Date:

Article Reference:

Criteria
The research is written in English.
The research is written between
the years 2013 and 2023.
The research includes parlicipants
who have been diagnosed with an
autism spectrum disorder, and
who were between the ages of

1-t2.
The research includes music
therapy as the independent
variable .
The research includes social skills
as the dependent variable.
The research was conducted using
aggregated data or a group
research desigu that includes a
functional analysis.
Thb research quantitatively
expressed the effects of music
therapy on social skills so that the
necessary data can be extracted,
and the effect size can be
calculated.

Met Inclusion Criteria:

Yes

No

MUSIC THERAPY AND SOCIAL SKILLS
Appendix C

108

- Evaluative Method Data Sheet

Quality of the Evaluative Method for Group Research Data Sheet
Author(s):
Article Title:
Year:

Primary Quality
Indicators
Participant
Characteristics
Independent Variable
Comparison
Condition
Deoendent Variable
Link Between
Research Question
and Data Analvsis
Use of Statistical

High
Qualitv

Acceptable
Quality

Unacceptable Quality

Tests

Secondary Quality

Evidence

No Evidenco

Indicators
Random Assicnment
lnterobserver Agreement
Blind Raters
Fidelitv

Attrition
Generalization
Effect Size
Social Validitv

Stons

Comments:

The Overall Streneth of the Research Reoort:
Adequate

Weak

MUSIC THERAPY AND SOCIAL SzuLLS
Appendix D

-

109

Evaluative Method Scoring Rubric

Quality of the Evaluative Method for Group Research Rubric
Primary Qualify
Indicators
Participant
Characteristics

High
Oualitv
(l) Age and geirder
are provided for all
participates,
(2) diagnostic
information is
provided for all
participants with
autism,
(3) information on the
characteristics of the
interventionist is
provided (Reichow et

Iudependent Variable

Comparison
Condition

al..2008).
Details about the
treatment are
provided and
replicable (Reichow
et a1.,2008).

The quality of the
conditions for the
comparison group are
replicable (Reichow
et a1.,2008).

Acceptable
Oualitv
An acceptable rating
is given to a study
that met two out of
three criterions.

An acceptable rating
is given to a study
that provides
adequate detail about
the independent ''
variable but excludes
specific detail.
An acceptable rating
is given to a study
tJrat provides an
adequate description
of the conditions for
the comparison
grouD.

Dependent Variable

The quality of the
dependent measure is

Link Between
Research Question
and Data Analvsis

(1) operational, (2)
replicable, (3) shows
a transparent link to
the dependent
variable, (4) collected
at appropriate times
(Reichow et a1.,
2008).
Data analysis is
strongly linked to the
research question(s)

An acceptable rating
is given to a study
that met three out
four criterions.

of

An acceptable rating
is given to a study in
which the data

Unacceptable Quality

An unacceptable
rating is given to

a

study that met less
than two criterions.

An unacceptable
rating is given to a
study that does not
provide adequate
details about the
independent variable.

An unacceptable
ratrng is given to a
study that does not
provide an adequate
description of the
conditions for the
comparison grouo.
An unacceptable
rating is given to a
study that rneets less
than three criterions.

An unacceptable
rating is given to a
study in which the

ll0

MUSIC THERAPY AND SOCIAL SKILLS
using correct units of
measure on all
variables (Reichow et
aI.,2008).

analysis is adequately
linked to the research
question(s) and uses
adequately correct
units of measure ort
all variables.

measure on all

An acccptable rating
is given to a study in
which the statistical

An unacceptable
rating is given to a
study in which the

measuro revealed an
adequate statistical
analysis with an
adequate power and

statistical measure
does not reveal an
adequate statistical
analysis, power, and
sample size.

data analysis does not

adequately link the
research question(s)
and does oot use

correct units

of

variables.
Use of Statistical
Tests

Each statistical
measure showed
proper statistical
analyses with
adequate power and
sample size (Reichow
et al., 2008).

sample size.
Secondary Quality

lndicators
Random Assignment

Interob scrver Agreement

Blind Raters

Fidelity

Attrition

Generalization

Effect Size

Evidence

A random assignment
procedure was used to assigu
participants to groups
(Reichow et aI.,2008).
IOA was collected across all
participants, raters, and
conditions with good reliability
(k > .60) (Reichow et al.,
2008).
Raters are blind to the
participants' treatmsnt
condition (Reichow et al.,
2008).
Fidelity of the procedure or
treatment is continually
evaluated across participants
and conditions (Reichow et al.,
2008).
Articulation is comparable
across conditions (Reichow et
a1..2008).
Generalization and/or
maintenance were evaluated
after collection of the final
outcome measure (Reichow et
al..2008).
Eflect sizes are described for
7 5o/o of the outcome moasures

No Evidsnce

MUSIC THERAPY AND SOCIAL SKILLS

lll

and are equal or greater than
-40 (Reichow et al,, 2008).
The research study contains the

Social Validity

following:
(1) dependent variables are
socially valued,
(2) intervention was time and
cost effective,
(3) comparisons are observed
between, individuals with and
without disabilities,
(a) the behavior change is
clinically signifi cant,
(5) results were socially
acceptable,

(6) independent variables are
manipulated by people who
had contact with the
participant,
(7) the context of the study
occurred naturally (Reichow et
aI..2008).

fhe Overall
Stons
All primary quality
indicators received high
quality ratings and
revealed evidence of fow
or more secondary quality
indicators (Reichow et a1.,
2008).

Streneth of the Research Report:
Adequate
Weak
Four or more primary quality
Less them four primary quality
indicators received high
indicators received high quality
quality ratings and revealed
ratings and revealed evidence of
evidence of two secondary
less than two secondary quality
qualrty indicators (Reichow et
indicators (Reich aI.,2008).
2008).

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