Gilsenan (2011)

SECONDARY REVIEW CRITIQUE

Source: Gilsenan, E. (2011). What are the effects of music therapy on the communication of children diagnosed with autism.  University of Western Ontario.

http://uwo.ca/fhs/csd/ebp/reviews/2011-12/Gilsenan.pdf

 

Reviewer(s): pmh

 

Date:  12.30.13

 

Overall Assigned Grade:  C+ (Highest possible grade was B.)

 

Level of Evidence:  B

 

Take Away:  This critical review critiques and summarizes 9 research articles concerned with the use of music therapy to improve the communication skills of children with autism. It is difficult to generalize the findings because of the diversity of procedures, dosages, and participants.  Nevertheless, as the result of music therapy children of varying ages and varying degrees of severity of autism improved on some communication variables including turn taking, joint attention, vocalization, verbal expression, producing phrases, performance on testing instruments, singing songs, initiation, imitation, interacting, pointing, academic achievement, and attention. Only gesturing did not respond to music therapy in at least one of the reviewed sources. The author of the critical review provided several recommendations including (1) consider using music therapy to facilitate verbal communication in nonverbal children, (2) low functioning children may benefit from a combination of speech therapy and music therapy, (3) child directed procedures appear to be facilitative, (4) children with echolalia may benefit from music therapy to facilitate communication development. In addition, clinicians should consider pairing tactile  (e.g., bells or drums) and visual (i.e., pictures/object representing targeted words) when using music to teach vocabulary.

 

What type of secondary review?  Narrative Systematic Review

 

1.  Were the results valid? Yes

a.  Was the review based on a clinically sound clinical question?  Yes, but it was implied, not explicitly stated.

b.  Did the reviewer clearly describe reasonable criteria for inclusion and exclusion of literature in the review (i.e., sources)?  Yes

c.  Authors noted that they reviewed the following resources:

•  internet based databases   x

•  references from identified literature   x

d.  Did the sources involve only English language publications?  Yes

e.  Did the sources include unpublished studies? Yes

f.  Was the time frame for the publication of the sources sufficient?  Unclear. This was not described.

g.  Did the reviewers identify the level of evidence of the sources? No,  but she did identify the design.

h.  Did the reviewers describe procedures used to evaluate the validity of each of the sources? No but it was clear that these was a strategy.

i.  Was there evidence that a specific, predetermined strategy was used to evaluate the sources?  No but it was clear that these was a strategy.

j.  Did the reviewers or review teams rate the sources independently? No. There was only one reviewer

k.  Were interrater reliability data provided?  Not applicable

l.  If the reviewers provided interrater reliability data, list them: Not applicable

m.  If there were no interrater reliability data, was an alternate means to insure reliability described?  Not applicable

n.  Were assessments of sources sufficiently reliable?  Not applicable

o.  Was the information provided sufficient for the reader to undertake a replication?  Yes

p.  Did the sources that were evaluated involve a sufficient number of participants?  No

q.  Were there a sufficient number of sources?  No

2.  Description of outcome measures:

The outcome measures associated with each of the sources are

•  Outcome #1:  To improve joint attention (initiation and eye contact during attention), turn taking, gesture  (Kim et al., 2008)

•  Outcome #2:  To improve verbal, nonverbal and social communication using CARS-B Childhood Autism Rating Scale- Brazil (Gattino et al., 2011)

•  Outcome #3:  To improve on a testing instrument concerned with semantics, phonology, pragmatics, and prosody (Lim, 2010)

•  Outcome #4:  To improve prelinguistic communication—eye contact, looking and pointing at a stimulus, peer engagement, imitation of talking or singing (O’Loughlin, 2000)

•  Outcome #5:  To improve type, quality, and frequency of joint attention; social behaviors; and challenging behaviors and the PDDBI- Pervasive Developmental Disorder Behavior Inventory ( (Reitman, 2005)

•  Outcome #6:  To improve overall expressive language using ADOS Autism Diagnostic Observation Scale  (Tindell, 2009)

•  Outcome #7:  To improve social and symbolic behaviors such as eye contact, initiation of communication, and symbolic play (Wimpory et al.,1995)

•  Outcome #8:  To improve gestural, verbal, and social communication on the Rossetti Speech and Language Scale (Yeou-Cheng et al., 2006)

•  Outcome #9:  To improve receptive imitative routines  (Stephens, 2008)

 

3.  Description of results:

 

a.  What evidence-based practice (EBP) measures were used to represent the magnitude of the treatment/effect size? The author noted effect size in one review but she was not specific.

b.  Summary of the findings of the secondary review:

The author’s critical review indicated that music therapy has the potential for improving the communication skills of children with autism. The most frequently reviewed procedures involved child-directed approaches to treating communication skills but clinician directed approaches also were reviewed. The author noted that readers should consider that only 9 sources were reviewed and the reviewed sources contained an overall small number of participants and a variety of procedures and outcomes. The positive results of each of the 9 reviewed sources are

•  Outcome #1:  To improve joint attention (initiation and eye contact during attention), turn taking, gesture on the PDDBI—PDD Behavior Inventory and ESCS– Early Social Communication Scales  (Kim et al., 2008)

  – play and music therapy yielded significant change (p = 0.01)

  – music therapy resulted in significantly more changes than play therapy on the ESCS

  –  the increase in the duration of eye contact, turn taking, joint attention with eye contact, and bids for joint attention was significantly more for music therapy than for play therapy

•  Outcome #2:  To improve verbal, nonverbal and social communication using CARS-B Childhood Autism Rating Scale- Brazil (Gattino et al., 2011)

  –  subtests of the CARS-B were significantly better for music therapy compared to a control group

•  Outcome #3:  To improve on a testing instrument concerned with semantics, phonology, pragmatics, and prosody (Lim, 2010)

  – music therapy and speech therapy showed significant improvement

  – no significant difference between music and speech therapy

•  Outcome #4:  To improve prelinguistic communication—eye contact, looking and pointing at a stimulus, peer engagement, imitation of talking or singing (O’Loughlin, 2000)

  1. the 1st P group attended group therapy involving singing while pointing to pictures 2 times a week for 5 weeks. Ps were reported to improve in the following skills although no statistical support was offered for the claim:

  –  increase in vocalizations

  –  increase in singing songs

  –  increase of imitation new sounds on request

  –  increase in phrases

  –  increase in attention

  –  increase in pointing

  –  increase in joint attention

  –  increase in turn taking

 

  2.  the 2nd P group attended therapy 5 times, 3 sessions were undefined language therapy (not clear if this was group or individual therapy) and 2 groups sessions involved singing while pointing to pictures. Ps  were reported to improve in the following skills:

  –  music therapy reported significant increases in eye contact (p = .023) and looking at the stimulus (p = .014)

 

  3.  for the 3rd  P group, the C presented 10 songs representing language concepts (not clear if this was group or individual therapy, dosage not specified). C presented the songs slowly and then the P and C sang the song in unison.

  – No significant differences were reported in the outcomes.

 

  4. for the 4th  P group, the C presented songs representing language concepts to small groups in 9 sessions over 5 weeks. C presented the songs slowly and then the Ps and C sang the song in unison.

  – No significant differences were  were reported in the outcomes.

 

•  Outcome #5:  To improve type, quality, and frequency of joint attention; social behaviors; and challenging behaviors and the  PDDBI- Pervasive Developmental Disorder Behavior Inventory (Reitman, 2005)

  –  improved joint attention on the PDDBI (p = 0.01)

  –  other changes on PDDBI did not reach significance

  –  significant improvement in videotaped joint attention behaviors

•  Outcome #6:  To improve overall expressive language using ADOS– Autism Diagnostic Observation Scale (Tindell, 2009)

  –  significant improvement on ADOS for both Precision Songs curriculum and the eclectic school curriculum (p = .0003)

•  Outcome #7:  To improve social and symbolic behaviors such as eye contact, initiation of communication, and symbolic play (Wimpory et al., 1995)

  –  Report of single subject experimental design provided descriptive data only.

  –  eye contact –increased at maintenance

  –  initiation-  increased after treatment and continued to increase at maintenance

  –  number of interactions- increased after treatment and continued to increase at maintenance

 

•  Outcome #8:  To improve gestural, verbal, and social communication on the Rossetti Speech and Language Scale   (Yeou-Cheng et al., 2006)

–  Claimed but did not provide evidence that interactive musical activities using verbal and tactile stimulation provided a better outcome

•  Outcome #9:  To improve receptive imitative routines  (Stephens, 2008)

  –  Claimed but did not provide evidence that musical social milieu teaching improved receptive imitative routines.  The behaviors that improved were

  1.  spontaneous imitation of action word pairs (3 of 4 Ps)

  2.  improved motor imitation only (1 of 4 Ps)

  3.  generalization imitation  (2 of 4 Ps)

  4.  new turn-taking behaviors (2 of 4 Ps)

  5.  more appropriate academic behaviors (2 of 4 Ps)

 

c.  Were the results precise?  Unclear, the author did not provide  precision data.

d.  If confidence intervals were provided in the sources, did the reviewers consider whether evaluations would have varied if the “true” value of metrics.

Unclear. the author did not provide CI data.

e.  Were the results of individual studies clearly displayed/presented? Variable

f.  For the most part, were the results similar from source to source?  Yes. There tended to be some improvement in some variables in each of the sources.

g.  Were the results in the same direction?  Yes

h.  Did a forest plot indicate homogeneity?  Not Applicable

i.  Was heterogeneity of results explored?  No

j.  Were the findings reasonable in view of the current literature?  Yes

k.  Were negative outcomes noted?  Yes   

                                                                                                                   

4.  Were maintenance data reported?  No,for the most part. However, one of the sources (Wimpory et al., 2005) did assess follow-up 2 years after intervention. Eye contact and initiations were maintained and improved at follow-up.

 

SUMMARY OF INTERVENTION

 

Prosodic Targets:  overall prosody

Nonprosodic Targets:

•  expressive language

•  eye contact

•  gesture

•  initiation of communication

•  joint attention

•  nonverbal communication

•  performance on testing instruments

•  phonology

•  pragmatics,

•  prelinguistic communication

•  receptive imitative routines

•  semantics

•  social communication

•  symbolic behaviors

•  symbolic play

•  turn taking

•  verbal communication

Aspects of Prosody Used in Treatment of Nonprosodic Targets:   music (rhythm, intonation)

 

Description of Procedures and Supporting Data:

     Description of Source #1:  To improve joint attention (initiation and eye contact during attention), turn taking, gesture on the PDDBI—PDD Behavior Inventory and ESCS– Early Social Communication Scales  (Kim et al., 2008)

–  treatment involved Improvisational Music Therapy in which the music therapist follows the child’s interactions musically with the purpose of improving joint attention.

 

•  Evidence Supporting Source #1:

– play and music therapy yielded significant change (p = 0.01)

– music therapy resulted in significantly more changes than play therapy on the ESCS

–  the increase in the duration of eye contact, turn taking, joint attention with eye contact, and bids for joint attention was significantly more for music therapy than for play therapy

 

•  Evidence Contraindicating Source #1:

  –  small number of Ps

–  high mortality rate

–  poor interrater reliability for nonexperimenters on test instruments

–  tendency of review author to accept view that nonsignificant differences should be noted

 

     Description of Source #2:  To improve verbal, nonverbal and social communication using CARS-B Childhood Autism Rating Scale- Brazil (Gattino et al., 2011)

–  treatment involved Relational Music Therapy which is a child-centered intervention in which the music therapist shapes the P’s behaviors following the child’s actions.

•  Evidence Supporting Source #2

–  subtests of the CARS-B were significantly better for music therapy compared to a control group (not clear if all subtests were significantly different)

–  suggestion that music therapy is more effective with lower functioning children

•  Evidence Contraindicating Source #2

–  CARS-B is not an appropriate instrument for treatment outcome research

–  presentation of finding were not clear in the review

     Description of Source #3:  To improve on a testing instrument concerned with semantics, phonology, pragmatics, and prosody (Lim, 2010)

–  the music therapy involved P viewing 6 videos focusing on targeted words  (2 sessions a day for 3 days but almost double the time allotted to speech therapy)

–  the speech therapy involved the teaching of the same words as in music therapy but the procedures were not described (2 sessions a day for 3 days but almost 1/2 the time allotted to music therapy)

•  Evidence Supporting Source #3:

–  music therapy and speech therapy showed significant improvement

–  no significant difference between music and speech therapy

–  suggests that lower functioning children benefit more from music therapy than speech-language therapy

•  Evidence Contraindicating Procedure #3

–  dosage for music therapy and speech therapy were not equivalent.

–  testing instrument was nonstandard

–  tendency of review author to accept view that nonsignificant differences should be noted

–  presentation of findings were not clear in the review

 

    Description of Source #4– To improve prelinguistic communication—eye contact, looking and pointing at a stimulus, peer engagement, imitation of talking or singing (O’Loughlin, 2000)

– there were 4 treatments:

1.  Group #1 attended group therapy involving singing while pointing to pictures 2 times a week for 5 weeks.

2.  Group #2 attended therapy 5 times, 3 sessions were undefined language therapy (not clear if this was group or individual therapy) and 2 groups sessions involved singing while pointing to pictures.

  3.  For Group #3, the C presented 10 songs representing language concepts (not clear if this was group or individual therapy, dosage not specified). C presented the songs slowly and then the P and C sang the song in unison.

4.  For Group #4, the C presented songs representing language concepts to small groups in 9 sessions over 5 weeks. C presented the songs slowly and then the Ps and C sang the song in unison.

 

•  Evidence Supporting Source #4

1. the 1st P group attended group therapy involving singing while pointing to pictures 2 times a week for 5 weeks. Ps were reported to improve in the following skills although no statistical support was offered for the claim:

–  increase in vocalizations

–  increase in singing songs

–  increase of imitation new sounds on request

–  increase in phrases

–  increase in attention

–  increase in pointing

–  increase in joint attention

–  increase in turn taking

2.  the 2nd P group attended therapy 5 times, 3 sessions were undefined language therapy (not clear if this was group or individual therapy) and 2 groups sessions involved singing while pointing to pictures. Ps  were reported to improve in the following skills:

–  music therapy reported significant increases in eye contact (p = .023) and looking at the stimulus (p = .014)

 

Evidence Contraindicating Source #4

1.  For the 3rd P group, the C presented 10 songs representing language concepts (not clear if this was group or individual therapy, dosage not specified). C presented the songs slowly and then the P and C sang the song in unison.

– No significant differences were reported in the outcomes.

2.  For the 4th P group, the C presented songs representing language concepts to small groups in 9 sessions over 5 weeks. C presented the songs slowly and then the Ps and C sang the song in unison.

– No significant differences were reported in the outcomes.

  3.  Failure to define terms

4.  Tendency of review author to accept view that nonsignificant differences should be noted

 

     Description of Source #5—To improve type, quality, and frequency of joint attention; social behaviors; and challenging behaviors (Reitman, 2005)

–  Treatment involved eight 30-minute sessions administered 2 times a week.  The sessions included the following which were paired with picture stimuli:

1.  greeting song

2.  imitation task while seated

3.  playing of instruments

4.  gross motor imitation

5.  closing song

 

•  Evidence Supporting Source #5:

–  improved joint attention on the PDDBI (p = 0.01)

–  significant improvement in videotaped joint attention behaviors

–  blind evaluators

–  multiple assessments

 

•  Evidence Contraindicating Source #5:

  –  only one change on PDDBI reached significance

–  several reliability issues

–  small N

–  clarifications on the PDDBI

–  concerns about the videotaping procedures

–  tendency of Gilsenan to accept changes that do not reach significance as worth of reporting

 

     Description of Source #6— To improve overall expressive language using ADOS Autism Diagnostic Observation Scale  (Tindell, 2009)

–  The treatment involved the Precision Songs and an eclectic school curriculum.  Neither procedure was described.

 

•  Evidence Supporting Source #6:

–  significant improvement on ADOS for both Precision Songs curriculum and the eclectic school curriculum (p = .0003)

–  apparently the procedures were well defined in the original source

•  Evidence Contraindicating Source #6:

–  differences among the Ps

–  possible treatment fidelity and skill differences in teachers

–  number of teachers involved in the treatments

–  should have  used nonparametric tests for all statistical analyses

     Description of Source #7— To improve social and symbolic behaviors such as eye contact, initiation of communication, and symbolic play (Wimpory et al., 1995)

– Treatment involved the use of Music Interaction Therapy which is a child-centered intervention in which C responds to P’s action with live music to improve social interaction. Dosage for the one 3-year-old P was

1.  Baseline – 4months

2.  Treatment  with Music Interaction Therapy –7  months

3.  Unmonitored music therapy – 5 months

4.  Follow-up—2 years

 

•  Evidence Supporting Source #7:

–  eye contact –increased at maintenance

–  initiation-  increased after treatment and continued to increase at maintenance

–  number of interactions- increased after treatment and continued to increase at maintenance

–  naturalistic and frequent assessments

–  maintenance data

•  Evidence Contraindicating Source #7:

–  vague dosage in the critical review

–  report of single subject experimental design provided descriptive data only

–  concern about developmental effects

–  limited description of possibly confounding variables (parental involvement in treatment, P education)

–  small N

    Description of Source #8—To improve gestural, verbal, and social communication (Yeou-Cheng et al., 2006)

– Treatment involved child-centered interactive playgroups administered for 3 weeks that were integrated into the school curriculum. The music therapy playgroups incorporated verbal and visual support and experiences with songs and musical instruments.  The schedule included:

1.  Greeting song

2.  Communication based song such as fine motor skills (?) or gestural prompting

3.  Closing song

 

•  Evidence Supporting Source #8:

–  Claimed but did not provide evidence that interactive musical activities using verbal and tactile stimulation provided a better outcome

–  Unclear description of treatment procedures

•  Evidence Contraindicating Source #8:

–  Data not clearly presented

–  Small N

–  Procedures not clearly presented

     Description of  Source #9— To improve receptive imitative routines  (Stephens, 2008)

– Treatment involved

–  C played brief portions of Bob Marley songs

–  C demonstrated a word-motor action pair then played a segment of the Bob Marley song for 20 seconds in which P and C danced to the music.

–  C imitated P’s dancing and playing instruments and then modeled an action word pair for P to imitate

–  C prompted child to imitate, if necessary

– Procedures included

–  wait time

–  multiple modes of communication

–  generalization of school setting

 

•  Evidence Supporting Source #9:

–  Claimed but did not provide evidence that musical social milieu teaching improved receptive imitative routines.  The behaviors that improved were

1.  spontaneous imitation of action word pairs (3 of 4 Ps)

2.  improved motor imitation only (1 of 4 Ps)

3.  generalization imitation  (2 of 4 Ps)

4.  new turn-taking behaviors (2 of 4 Ps)

5.  more appropriate academic behaviors (2 of 4 Ps)

•  Evidence Contraindicating Source #9:

–  Intervention procedures and dosage were not clear in the review

–  Definition of terms needed (e.g., receptive imitative routines, more appropriate academic behaviors)

–  small N

–  weak experimental design

–  dosage of study based on time limitations rather than P performance

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