History of Music Therapy For Children With Autism

Journal of Music Therapy, 48(2), 2011, 169-207
© 2011 by the American Music Therapy Association
History of Music Therapy Treatment

Interventions for Children with Autism
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Alaine E. Reschke-Hernandez, MA, MT-Be
University of Missouri-Kansas City
The purpose of this paper is to provide a systematic review

of the history of music therapy research and treatment of
children with autism. Understanding such history is impor
tant in order to improve clinical efficacy and inform future
research. This paper includes a history of autism diagnosis,
reviews strengths and limitations of music therapy practice
with children with autism from 1940-2009, and suggests
direction for future music therapy research and clinical
practice with this population. Literature was limited to the
English language and obtained with the following search
terms: autism, autistic, (early) infantile autism, child, thera
peutic music, musical therapy, and music therapy. Table of
contents from music therapy journals were searched, and
reference lists from obtained articles were perused for
additional articles. This historical review focused primarily on
journal articles, however, books and book chapters that
appeared to hold particular historical significance were also
included.
Autistic disorder is currently one of the most prevalent

exceptionalities of childhood in the United States. From 1997 to
2007, the number of children ages 6 through 21 with autism who
received services under the Individuals with Disabilities Education
Act (IDEA) rose from 42,517 to 258,305 - a five-fold increase in
10 years (Data Accountability Center, 2009). The rise in the
prevalence of this disability has led to an analogous rise in
demand for music therapy services (Groene, 2003).
Qualitative studies and small sample quantitative studies have
suggested that music therapy is a valuable treatment option for
The author would like to acknowledge Dr. Deanna Hanson-Abromeit and Dr.
Gabriel Hernandez for their extensive support and feedback throughout the
development of this paper.
170 Journal of Music Therapy
children with autism. However, both music therapists and non

music therapists have exposed a lack of evidence to validate the
efficacy of music therapy with this clinical population (Accordino,
Comer, & Heller, 2007; Gold, Wigram, & Elefant, 2006; National
Autism Center, 2009; New York State Department of Health Early
Intervention Program, 1999; Romanczyk & Gillis, 2005; Whipple,
2004; Wigram & Gold, 2006). An analysis of historical and current
practice is valuable in spite of such criticism: it will help create a
foundation for the application of evidence-based practice
principles, promote advances in music therapy research, and
eventually lead to a wider recognition of music therapy as a valid
treatment for this population. Therefore, the objectives of this
paper are to: (a) provide a history of autism diagnosis, (b) review
historical strengths and limitations of music therapy practice with
children with autism (1940-89), (c) appraise current strengths
and limitations of music therapy treatment of children with
autism (1990 to 2009), and (d) suggest direction for future
research and clinical practice in the use of music therapy for
children with autism.
For the purpose of this paper, literature was limited to the
English language and obtained by searching PsycINFO, MEDLINE,
Cochrane Database of Systematic Reviews, Worldcat, and Coogle Scholar
databases with the following terms: autism, autistic, (early)
infantile autism, child, therapeutic music, musical therapy, and
music therapy. Table of contents from the following journals were
searched: Journal of Music Therapy, British Journal of Music Therapy,
Journal of British Music Therapy, Nordic Journal of Music Therapy,
Canadian Journal of Music Therapy, Australian Journal of Music
Therapy, Music Therapy, Music Therapy Perspectives, The Arts in
Psychotherapy. Music Therapy Today and Voices, two international
web journals, were also explored, and reference lists from
obtained articles were perused for additional articles. This
historical review focused primarily on journal articles, however,
books and book chapters that appeared to hold a particular
historical significance were also included.
History of Autism Diagnosis

Currently, autistic disorder is considered a complex neurobio
logical disability that appears by age 3, manifests as a varied
spectrum of characteristics, and lasts throughout a person's
Vol. 48, No.2, Summer 2011 171
lifetime (American Psychological Association [APA], 2000). It is

considered a pervasive developmental disorder and is character
ized by qualitative impairments in social interaction and
communication, and restricted, repetitive, stereotyped behavior,
interests, and activities (APA, 2000). These diagnostic criteria
evolved over several decades and emerged primarily from case
studies.
The term autism finds its roots in the Latin term autismus, first
introduced by Swiss psychiatrist Bleuler in 1912 to define
symptoms of peculiar fantasies in patients diagnosed with
schizophrenia (Eugen Bleuler, 2010; Harper, 2001-10). Early
use of the words autism and autistic were used to describe
hallucinations or illogical thoughts in psychiatric patients (Wells,
1919). However, the earliest clinical report on autism appeared
long before these terms were used in common practice. In 1799,
the case of a boy with clinical characteristics matching many
current criteria for an autism diagnosis was described, including
communication delays and pragmatic misuse, social awkwardness
and preference for isolation, and restricted interests (Haslam,
1809/1976).
It was not until 1943 that Kanner published a collection of case
studies of children who presented what he called early infantile
autism. These children exhibited communication deficits, sensory
sensitivities and eating difficulties, impairments in social related
ness, and an "anxiously obsessive desire for the maintenance of
sameness" (p. 245). Coincidentally in 1944, Asperger (1944/
1991), who had no knowledge of Kanner's work in the United
States due to the World War, discussed autistic psychopathy in a
Viennese publication. Asperger chose the term autism in
association with its use with schizophrenic patients to describe
the way in which they sever relations with the outside world and
noted a similar set of clinical features as those described by
Kanner. Conversely, Asperger asserted that children with autistic
psychopathy learned to speak well at a very early age, were socially
aware of others, and he spoke highly of their original ideas. These
differences later became part of the delineation between autistic
disorder and Asperger's syndrome (Wing, 1991).
Several decades passed following Kanner's seminal, 1943 article
before autism was consistently used as a diagnostic term for
children exhibiting the set of behaviors he described. Many
children matching his criteria for autism diagnosis were com

monly identified with childhood schizophrenia, child psychosis,
or mental retardation, and it was not until 1980 that autism was
added to the Diagnostic and Statistical Manual of Mental Disorders
(3rd ed.; DSM-III; APA, 1980). Eventually, autism diagnosis shifted
from this original association with these disorders to its
contemporary definition as a complex neurobiological pervasive
developmental disorder (APA, 2000).
Music Therapy for Children with Autism:

1940 through 1989
In the 1940s, early pioneers of music therapy likely worked with
children with autism in psychiatric hospitals, institutions, or
schools. During this period, the medical community in the United
States experienced a shift toward a holistic treatment philosophy,
particularly in the treatment of psychiatric disorders. Institutions
and psychiatric hospitals began to employ part-time music
therapists and music therapy volunteers while the music therapy
profession began to define itself (Davis & Gfeller, 2008). As both
autism diagnosis and the music therapy profession were simulta
neously emerging, there were no publications specifically docu
menting music therapy treatment of children with autism during
this time.
1950-74: Music Therapists Organize

A milestone in the music therapy profession occurred in 1950
with the formation of the National Association for Music Therapy
(AMTA, 1999). The Society for Music Therapy and Remedial
Music, later renamed the British Society for Music Therapy, was
subsequently founded in 1958 (British Society for Music Therapy,
2010). Various professional publications began to circulate,
including the Journal of Music Therapy (first published in 1964;
Sears, 1964) and the British Journal of Music Therapy (first
published in 1968; The Library of Congress, 2010).
Music therapists of this time period used adapted music
education, singing groups, folk dancing, and rhythm activities to
achieve various goals (Gerard, 1955; Scheerenberger, 1953).
Music was used for self-expression, socialization, rehabilitation,
psychological enrichment, and recreation in both individual and
group settings (Gerard, 1955; Gilliland, 1955; Scheerenberger,
Vol. 48, No.2, Summer 2011 173
1953; Schorsch, 1950). Harbert (1955) discussed the importance

of mainstreaming children with disabilities in music classrooms
with typical developing children. This was a novel idea for the
time, as mainstreaming did not become a standard practice until
the latter part of the 20th century (Adamek & Darrow, 2010).
Much of the literature describing the use of music with children
with autism during this early period emphasized their apparent
unusual musical ability and attraction to music (Euper, 1968;
Hollander & luhrs, 1974; Hudson, 1973; Romerhaus, 1968;
Sherwin, 1953). Sherwin categorized these musical characteristics
as "(1) an unusual interest in music, (2) a tendency to sing
differently from the average child, and (3) an oftentimes unusual
ability to reproduce familiar pieces with extraordinary accuracy"
(p. 823). He also suggested that further understanding of the
reactions of children with autism to music might illuminate a
deeper clinical understanding of the disorder (Sherwin, 1953), a
concept echoed in the 21st century (Wigram, 2000).
Nordoff and Robbins, pioneers in improvisational music
therapy for children with autism, provided an alternative
explanation for this perceived musicality. They proposed that
children with autism experienced music as a nonthreatening
medium and therefore were more likely to become engaged
in a musical experience than in other environments, parti
cularly in child-directed improvised music. Based on this
philosophy, they spent much of the 1960s developing their
Creative Music Therapy technique for children with autism and
other developmental disabilities (Nordoff, 1964; Nordoff &
Robbins, 1965, 1968).
Contemporaries of Nordoff and Robbins used improvisational
techniques to address a variety of skills. Several authors reported
using child-directed techniques to establish rapport (Goldstein,
1964; Hudson, 1973) and to encourage expressive language and
social skills (Saperston, 1973). Improvisation provided a medium
for self-expression (Saperston, 1973), allowed sensory sensitivities
to be explored (Alvin, 1969), and addressed behavior challenges
(Stevens & Clark, 1969).
Historical references indicate music therapists not only explored
improvisational techniques but also more structured techniques.
Goldstein (1964) used speech dynamics and rhythm, singing, dance,
and movement to address attention, body awareness, social skills,
and communication. She also advocated beginning a session with

familiar activities before introducing new ones to aid transitions.
Contemporary authors reported similar techniques and goals (Alvin,
1969; Euper, 1968; Hollander &Juhrs, 1974; Hudson, 1973; Kessler,
1967; Mahlberg, 1973; North, 1966; Romerhaus, 1968; Saperston,
1973; Stevens & Clark, 1969; Werbner, 1968).
The first article in the British Journal of Music Therapy to address
music therapy treatment for children with autism was published in
1969 (Alvin). In this case study, Alvin argued that establishing
communication should be the primary goal with this population.
Many other music therapists at this time agreed this was an
important domain (Goldstein, 1964; Hollander & Juhrs, 1974;
Kessler, 1967; Mahlberg, 1973; Nordoff, 1964; Nordoff & Robbins,
1965, 1968; North, 1966; Romerhaus, 1968; Saperston, 1973;
Stevens & Clark, 1969; Werbner, 1968). Alvin also advocated a
child-directed approach and achieved communication with her
clients by using a variety of live instrumental and vocal sounds,
rhythmic imitation, improvisation, and movement to recorded
music.
In spite of the pioneering by music therapists treating children
with autism through the mid-1960s, criticisms existed. "A great
deal of research needs to be done from many directions. For the
present, we have to use whatever approach has some value and
from our experience, there is no doubt, music therapy has value"
(North, 1966, p. 24). Kessler (1967) discussed the lack ofresearch
evidence for various therapeutic approaches for children with
disabilities, including autism. Stevens and Clark met this
challenge in 1969 when they published the first experimental
study on the effects of music therapy with children with autism in
the Journal of Music Therapy. It is one of only three music therapy
studies of children with autism using comparative measures from
1950 t01989.
In the 1950s, the apparent unusual musical abilities of children
with autism intrigued many music therapists. By the end of the
1960s, music therapists started delineating goals and objectives in
their publications, and articles specific to this population began
accumulating. The beginning of the 1970s encountered the
emergence of theoretically grounded music therapists working
toward a more clearly defined approach to improving the lives of
Vol. 48, No.2, Summer 2011 175
1970-82: International Growth and Domestic Division
In the 1970s and 1980s, the music therapy profession grew
internationally as music therapists continued to form organiza
tions and establish practice. Denmark instituted its first music
therapy organization (Dansk Forbund for P<edagogisk Musikter
api) in 1969 (Bonde, 2007). In 1973, German music therapists
formed the Deutschen Gesellschaft fUr Musiktherapie (Deutschen
Gesellschaft fur Musiktherapie, 2005-09). Both the Canadian
Association for Music Therapy and the Australian Music Therapy
Association were founded in 1975 (Australian Music Therapy
Association, n.d.; Canadian Association for Music Therapy, 2006),
and in 1976, the Association of Professional Music Therapists in
the United Kingdom was founded (Association of Professional
Music Therapists, 2008).
While the music therapy profession grew internationally, the
American organization divided into two separate associations in
1971: the National Association for Music Therapy and the
American Association for Music Therapy (American Music
Therapy Association, 1999). Furthermore, social and political
turbulence of the 1960s and 1970s and economic hardship of the
1980s possibly impeded music therapy growth in the United
States. As a possible aftermath of these events, only one article
regarding music therapy and children with autism was published
among the prominent music therapy journals (Journal of Music
Therapy and Britishfournal of Music Therapy) from 1975 until 1982
(Benenzon, 1976).
Creative Music Therapy

The improvisational movement gained international momen
tum when Nordoff and Robbins published Creative Music Therapy
(1977, 2007). This book introduced a theoretical foundation of
improvisational music therapy: every child has a unique, innate
capacity for musical response, expression, and engagement.
Several international case examples illustrated their approach
and delineated clinical techniques, specific musical examples, and
descriptions of child-directed musical interactions. Not only did
this provide the music therapy community with a theoretical
foundation for working with children with autism and other
disabilities, it also established standards of detailed intervention
reporting for these techniques (Nordoff & Robbins, 1977, 2007).
1982-89: Regaining Momentum
In the 1980s, music therapists in the United States began to
experience the effects of the Education for All Handicapped
Children Act, Public Law 94-142 (1975). This legislation provided
for the free and appropriate public education of children with
disabilities, although children with autism did not specifically
qualify until a revision in 1990 (Hardman, Drew, & Egan, 1999).
Internationally, music therapists formed the World Federation of
Music Therapists in 1985 (World Federation of Music Therapy,
2010), which provided international music therapists with the
momentum needed to make a more prominent impact in the
research literature with children with autism. Meanwhile, the
music therapy organizations in the United States created two new
publication journals: Music Therapy (published 1981-96) and
Music Therapy Perspectives (first published in 1982; The Library of
Congress, 2010). As a probable result of Public Law 94-142, new
publication venues, and increased international unity, articles
regarding music therapy treatment for children with autism began
to reappear.
Perhaps an early consequence of Public Law 94-142, American
authors of the early 1980s impressed the importance of using an
interdisciplinary model for success in the treatment of clients with
autism. In 1982, Bruscia partnered with a speech pathologist to
diminish echolalia using a model-cue-fade behavioral intervention
and Staum and Flowers (1984) described the generalization of skills
to a non-music environment using contingent reinforcement. Thaut
(1984) wrote an incipient protocol for music therapy's use with
children with autism. He related music therapy treatment to autism
diagnostic criteria in a developmentally based, hierarchical model
that emphasized parental cooperation and consistent therapeutic
strategies across treatment modalities. Thaut remained one of the
few authors in the United States to publish articles on music therapy
and autism for the rest ofthe 1980s (Thaut, 1987, 1988).
International music therapists focused on the sensory sensitiv
ities of children with autism in music therapy. Warwick (1984)
noted the intriguing effect of various instrument timbres on
children with autism and discussed the sensory advantages of
using the guitar in improvisational music therapy. Farmer (1985)
described similar sensory observations and noted the behavioral
responses of children with autism to vibrations. Agrotou (1988)
Vol. 48, No.2, Summer 2011 177
observed a child's apparent need for movement and loud sounds

and situated instruments at different locations in the room to
meet these needs.
The British Journal of Music Therapy published in 1989 the first
article regarding an improvisational music therapy group ap
proach for children with autism (Bryan, 1989). This music
therapist provided minimal guidance and observed the group
evolve through rhythmic and vocal imitation, reciprocal musical
conversations, and exploration of cause and effect. This article
marked the end of a chapter for international publications on
music therapy and children with autism. Although the European
Music Therapy Confederation was founded this same year
(European Music Therapy Confederation, 2005), international
music therapists experienced a deficit of publications regarding
this topic until the 21st century.
1940-89: Historical Strengths & Limitations

Trial and error categorized the period from 1940-89 as early
pioneers of music therapy challenged themselves to find
techniques that would positively impact the lives of children with
autism. Some music therapists experimented with innovative
approaches. For example, speech syllables were paired with
melodic or rhythmic patterns to improve expressive language
skills (Mahlberg, 1973; Thaut, 1984), and joint attention was
addressed by improvising on bongo drums (Warwick, 1984).
Several music therapists explored sensory sensitivities through
instrument vibrations and resonance (Agrotou, 1988; Farmer,
1985; Thaut, 1984; Warwick, 1984). Nordoff and Robbins helped
establish improvisational music therapy as one of the most
prominent contemporary techniques, completed extensive qual
itative research on the efficacy of Creative Music Therapy
(Nordoff, 1964; Nordoff & Robbins, 1965, 1968, 1977), and
established standards for documenting music therapy sessions.
A majority of music therapists modified techniques from other
fields and therapeutic approaches. Adapted music education
techniques such as folk dancing, rhythm band, Orff-Schulwerk,
instrument instruction, and music games were largely explored.
Techniques were implemented from psychology (e.g., contingent
reinforcement, behavior modification), and speech-language
pathology (e.g., sign language, oral-motor exercise). Many
authors discussed the use of non-musical techniques to achieve

therapeutic goals (e.g., visual aids).
In general, music therapists attempted a multitude of tech
niques under very broad goal areas (see Table 1). Most music
therapists addressed communication skills, particularly expressive
communication, and social skills. These goal areas reflect the early
primary domains for autistic disorder diagnosis. Next, music
therapists worked on motor and perceptual motor skills, behavior,
and cognition-all equally represented in the literature. Finally,
music therapists addressed emotional and psychological concerns,
musical ability, and sensory sensitivities. This expansive list of goal
areas reflects the trial and error of this period.
In order to provide a comparative analysis to current practice
standards, the reviewed research from 1940-89 was evaluated based
on guidelines from the Center for Evidence Based Medicine
(2009). To provide a more detailed assessment of the music therapy
literature, sub-levels were added (Davidson, et aI., 2003; Edwards,
2002; Wigram, 2002). The strict guidelines from the Coalition for
Evidence Based Policy (2010) were used to evaluate potential
randomized controlled trials. A summary of the historical research
evidence from this review is displayed in Table 2.
The 49-year research base from 1940-89 primarily consisted of
case studies, and most articles did not adequately describe the
techniques for replication. Mahlberg (1973) illustrated this
quandary: "I lacked experience and training in treating autistic
children, and found limited literature which described treatment
techniques" (p. 189). During this period, three comparative
studies using quantitative analysis were published (Stevens &
Clark, 1969; Thaut, 1987, 1988). Each of these studies employed
small sample sizes - not surprising given that autism was a
relatively new diagnostic term and the incidence was compara
tively low during this period. A detailed protocol (Thaut, 1984),
and two other qualitative articles (Kessler, 1967; Nordoff &
Robbins, 1965) were published, however, no reviews of research
or case studies containing quantitative analysis appeared.
Music Therapy for Children with Autism:

1990 through 2009
Following the period of trial and error from 1940-89, music
therapists began more focused practice with children with autism.
Vol. 48, No.2, Summer 2011 179
They aligned goals with diagnostic criteria as autism became a

well-established term. Although music therapists strived to
. improve their approach with this population, numerous criticisms
of music therapy's efficacy persisted due to the lack of strong
evidence-based support. In recent years, emphasis has been
placed on improving music therapy's clinical research base.
1990-99: American Music Therapists Expand the Depth of Practice

Public Law 94-142, the Education for All Handicapped
Children Act, has undergone multiple revisions. Perhaps the
most prominent amendment occurred in 1990 when it was
renamed the Individuals with Disabilities Education Act (IDEA),
and autism was added to the list of eligible conditions (Hardman
et aI., 1999). This amendment conceivably fueled opportunities
for music therapy employment and research. In 1990, Humpal
outlined opportunities for music therapists to serve the needs of
children, including those with autism, in early intervention
settings. The important role of music therapists and music
educators in mainstreaming support has also been discussed
(Kostka, 1993).
Many of the strategies of the 1990s were based on therapeutic
approaches from psychology and special education. Griggs-Drane
and Wheeler (1997) described the usefulness of non-music
therapy educational approaches in music therapy. Functional
assessment procedures and relevant components of the Treat
ment in Education of Autistic and Related Communication
Handicapped Children (TEACCH) method were outlined,
including the use of an individualized activity schedule, transition
objects, and alternating preferred and non-preferred activities to
decrease problematic behaviors within a session. In 1998, Starr
and Zenker summarized the methods borrowed from other
approaches and suggested that positive outcomes had been
observed with improvisational techniques, structured music
therapy, and hybrid approaches.
2000-09: Music Therapy and Autism in the 21st Century

The refrains "evidence-based" and "evidence-based medicine"
first appeared in the early 1990s (Eddy, 1990; Evidence Based
Medicine Working Group, 1992). Evidence-based medicine is
currently considered a "powerful force in today's health care
TABLE 1
A Summary of Historical Approaches in Music Therapy for Children with Autism, 1940-89
Goal Technique Citations
Communication Introduce a variety of Alvin, 1969

instruments and voice
to establish rapport and
communicate through
preferred sounds
Structured music experiences Alvin, 1969
Search for sound that Benenzon, 1976
(potentially) connects
with the child
Use an instrument/voice as Benenzon, 1976
intermediate communicative
contact with the child
Create communicative Benenzon, 1976
exchange through music
Family & child exchange Benenzon, 1976
recordings of sounds/
messages
Expressive (Techniques not specified) *Gilliland, 1955; Kessler,
language 1967
Improvisation Agrotou, 1988; Nordoff,
1964; Nordoff &
Robbins, 1965, 1968,
1977; Saperston, 1973;
Warwick, 1984;
Shared musical experience Agrotou, 1988; Nordoff &
(child-directed) Robbins, 1965, 1968,
Warwick, 1984
Short, simple songs/within Goldstein, 1964
child's comprehension
& vocal range
Rhythmic songs Goldstein, 1964
Action songs Goldstein, 1964
Transfer writing of musical North, 1966
notation to writing words
Orff-Schulwerk Hollander & luhrs, 1974
Pair expressive language/ Mahlberg, 1973;
speech syllables with Thaut, 1984
auditory pattern (melody,
rhythm) & kinesthetic cue
(e.g., name, action word)
Singing Stevens & Clark, 1969
Improvise habitual expressions Thaut, 1984
Vol. 48, No.2, Summer 2011 181
TABLE 1
Continued
Use bongo drums as a WalWick,1984

musical "bridge" to tap
out communication/
messages/emotions
Use the guitar Warwick, 1984
Hello/goodbye songs Warwick, 1984
Musical interactions using WalWick, 1984
musical attributes
Speech Oral motor exercise (e.g., Thaut, 1984; Farmer, 1985
production, wind instrument,
intonation, & breathing)
fluency Vocal improvisation with Thaut, 1984
accompaniment
Melodically shape speech Thaut, 1984; Farmer, 1985
Opposite musical attributes Thaut, 1984
(high/low, loud/soft)
Stress patterns Thaut, 1984
Resonating instruments Alvin, 1969; Farmer, 1985;
close to ears Thaut, 1984
Vocalize/sustain sounds Thaut, 1984
Singing vowels &/ or Alvin, 1969; Thaut, 1984;
consonants Farmer, 1985
Match colors, shapes, Thaut, 1984
names of musical objects
Feeling the vocal Farmer, 1985
mechanism (throat, chest,
nose, face) while singing
Awareness of vibrations Farmer, 1985
(voice, violin, autoharp,
wooden flute)
Improvisation Nordoff, 1964
Echolalia Model-cue-fade (with Bruscia, 1982
song lyrics)
Co-treatment with other Bruscia, 1982
therapies (e.g., speech/
language pathologist)
Receptive Action songs/action patterns Goldstein, 1964;
language Thaut, 1984
Orff-Schulwerk Hollander & juhrs, 1974
Use melodic/rhythmic Thaut, 1984
contour to emphasize
semantics (e.g., verbal
instructions)
TABLE 1
Continued
Identification Body part songs Romerhaus, 1968

Identification songs (objects) Werbner, 1968
Identitying musical Thaut, 1984
instrumen ts, objects,
attributes, shapes
Action songs Thaut, 1984
Choice-making Child decides activities after Warwick, 1984
hello song
. Social Skills (Technique not specified) Ellper, 1968; Romerhaus,
1968; *Schorsch, 1950
Movement or dance to Alvin, 1969; Thallt, 1984
recorded or live music
Improvisation Agrotoll, 1988; Nordoff,
1964; Nordoff &
Robbins, 1965, 1968,
Thaut, 1984; Warwick,
1984
Group improvisation/co Bryan, 1989
improvisation
Shared musical experience Agrotou, 1988; Bryan,
(child-directed) 1989; Nordoff &
Robbins, 1965, 1968,
Warwick, 1984
Circle games/music games Romerhaus, 1968; Thallt,
1984
Accordion ("face-to-face Werbner, 1968
contact")
Playing favorite songs Werbner, 1968
(group)
Connecting instrument North, 1966; Warwick,
play with the person 1984
Orff-Sch ulwerk Hollander & luhrs, 1974;
Thaut, 1984
Transition object/instrument Thaut, 1984
Listening to music Thaut, 1984
Transition from child-directed Thaut, 1984
music to therapist-directed
music
Transition from therapist Warwick, 1984
directed music to child
directed music
Musical cooperation Thaut, 1984
Vol. 48, No.2, Summer 2011 183
TABLE I
Continued
Movement/melodic imitation Thaut, 1984

Lummi sticks Thaut, 1984
Musical interactions using Thaut, 1984; WaTWick,
musical attributes 1984
Alternate playing patterns Thaut, 1984
Transition from 1: 1 MT to Thaut, 1984
group MT experience
Improvised hello/ Nordoff & Robbins, 1965
goodbye songs
Mainstreaming in Music *Harbert, 1955
Education
Imitation/ Rhythm band, rhythmic Euper, 1968
Observation activities
Appropriate & Action songs Romerhaus, 1968
active Body part songs Romerhaus, 1968
participation Circle games/music games Romerhaus, 1968
Instrument play North,1966
Transition to (Technique not specified) *Scheerenberger, 1953
adulthood/
Community
Tum taking/ Playing favorite songs Werbner, 1968
Sharing (group)
Establish rapport Child-directed music Goldstein, 1964; Nordoff &
Robbins, 1968, 1977
Rhythmic dialog Hudson, 1973
Eye contact Shared musical experience Saperston, 1973
(child-directed)
Improvisation Saperston, 1973; WalWick,
1984
Play Child-directed music Farmer, 1985
Instrument exploration Farmer, 1985
(autoharp)
Emotional & Psychological
Self expression, Singing groups *Scheerenberger, 1953
emotion, Song books *Scheerenberger, 1953
creation, Improvisation Nordoff, 1964; Nordoff &
imagination Robbins, 1965, 1968,
Thaut, 1984; WalWick,
1984
Group improvisation/ Bryan, 1989
co-improvisation
TABLE 1
Continued
Visual aids/flash cards of Thaut, 1984

moods/facial expressions
Use bongo drums as a Warwick, 1984
musical "bridge" to tap
out communication/
messages/ emotions
Relaxation (Technique not specified) *Gilliland, 1955
Listening to cello music (live) Alvin, 1969
Psychological (Technique not specified) *Schorsch,1950
enrichment
Individual worth (Technique not specified) Kessler, 1967
Playing favorite songs (group) Werbner, 1968
Development of Transition from simple Hudson, 1973
ego boundaries rhythms to complex music
Behavior Clapping with and without Mahlberg, 1973
music
Action songs, finger plays, Mahlberg, 1973
interactive songs
Playing melody bells Mahlberg, 1973
Tapping rhythmic patterns to Mahlberg, 1973
correspond with speech
syllables (nonverbal
communication)
Dancing, movement Mahlberg, 1973
Changing tempos during Mahlberg, 1973; Thaut,
movement to ensure 1984
movement patterns are
not self-stimulatory
Listening to client's choice Mahlberg, 1973
of recorded music
Improvisation Stevens & Clark, 1969;
Nordoff, 1964; Nordoff
& Robbins, 1965
Rhythmic activities to Thaut,1984
interrupt/stop
stereotyped behavior
co-improvisation
Transitions Pictures while teaching Goldstein, 1964
new songs
Familiar music to unfamiliar Goldstein, 1964
music
Transition object/instrument Thaut, 1984
Vol. 48. No.2. Summer 2011 185
TABLE 1
Continued
Decrease need Instrument play North. 1966

for sameness
Touching store Music lessons as contingent Staum & Flowers. 1984
merchandise reinforcer for appropriate
behavior
Moving away Music lessons as contingent Staum & Flowers, 1984
from therapist reinforcer for appropriate
behavior
Attention Clapping with and without Mahlberg, 1973
music
Action songs, finger plays, & Mahlberg, 1973
interactive songs
Playing melody bells Mahlberg, 1973
Listening to client's choice Mahlberg, 1973
of recorded music
Instrument play Stevens & Clark, 1969
Motor & Perceptual Orff-Schulwerk Hollander & Juhrs, 1974
Motor Accept ritualistic movements Hollander & Juhrs, 1974
& incorporate into music
application
Playing instruments Thaut,1984
(without stereotyped/
self-stimulatory behavior)
Mallets, plucking strings, Thaut,1984
playing keyboard
Rhythmic/musical Thaut, 1984
accompaniment to gross
motor movements
Perceptual motor/ (Technique not specified) Kessler, 1967;
Self concept *Scheerenberger, 1953
Singing/vocalizing to match Alvin, 1969
sound of chime bars &
other instruments
Rhythmic activities, rhythm Euper, 1968
band
Percussion instruments Goldstein, 1964; Thaut,
1984
Movement to music, Goldstein, 1964
corresponding with
actions from daily life
Orff-Schulwerk Hollander & Juhrs, 1974
Action songs Stevens & Clark, 1969;
Thaut,1984
TABLE 1
Continued
Movement with physical Thaut, 1984

contact
Imitation exercises Thaut, 1984
Body part songs Romerhaus, 1968
Orff-5chulwerk Hollander & Juhrs, 1974
Tape recorder Werbner, 1968
Playing instruments spaced Thaut, 1984
at various distances (e.g.,
resonator bells)
Musical support Warwick, 1984
Problem-solving how to Farmer, 1985
position body to playa
familiar instrument if
positioned in an unfamiliar·
way (e.g., upside down)
co-improvisation
Rehabilitation (Technique not specified) *Gilliland, 1955; Schorsch,
1950
Cognitive/Memory Imitate tones and tone Thaut, 1984
sequences
Match sound to instrument Thaut, 1984
Teach chant + body Thaut, 1984
percussion, then MT
chants while child does
body percussion, then
independent body
percussion (no chant)
Order/sequence Thaut, 1984
instrumen ts, scales, etc.
Music notation (with colors Thaut, 1984
& shapes)
Integrate music in learning Thaut, 1984
environment (e.g., alternate
task with music; learning
concepts within songs)
Categorizing Orff-Schulwerk Hollander &Juhrs, 1974
Association Orff-Schulwerk Hollander & Juhrs, 1974
Pre-academics Spelling songs Werbner, 1968
Color songs Werbner, 1968
Singing Stevens & Clark, 1969
Add/subtract by building Thaut, 1984
scales (e.g., with
resonator bells)
Colored instruments Thaut, 1984
Vol. 48, No.2, Summer 2011 187
TABLE 1
Continued
Sensory Transition object! Thaut, 1984

instrument (consider
timbre/sensory input)
Instrument exploration Farmer, 1985; Thaut, 1984
Pressure/resistance Thaut, 1984
(during movement)
Feeling instrument Farmer, 1985; Warwick,
vibrations (e.g., guitar, 1984
violin, autoharp)
"Feeling the music" Bryan, 1989
through group
improvisation/
co-improvisation
Exposure to & exploration Alvin, 1969
of variety of instrument
timbres/volumes
Musical Skills
Recreation/ Adapted music education *Gerard, 1955;
Instrument Romerhaus, 1968
instruction Folk dancing *Scheerenberger, 1953
Rhythmic activities Romerhaus, 1968;
*Scheerenberger, 1953
Orff-Schulwerk Hollander &Juhrs, 1974
Rhythm (Technique not specified) *GiIIiland, 1955
Rhythm band Euper, 1968
Structured and unstructured Alvin, 1969
improvisations
Reactions to (Technique not specified) Euper, 1968; Romerhaus,
music/ 1968
Musical ability Live relaxation music (cello) Alvin, 1969
Playing piano for child Sherwin, 1953
Singing for child Sherwin, 1953
Shared musical experience Nordoff & Robbins, 1968,
(child-directed) 1977; Warwick, 1984
Improvisation Nordoff, 1964; Nordoff &
Robbins, 1965, 1968,
1977; Warwick, 1984
Instrument play Stevens & Clark, 1969;
Warwick, 1984
Note. * Denotes historical article that is not autism-specific.
TABLE 2
Histmical Levels ofResearch Evidence in Music Therapy for Children with Autism, 1940-89
Level of evidence Citations
Level 1a:
Systematic Review" (SR) No citations met these criteria.
of Randomized
Controlled Trialsb (RCTs)
Level 1b:
RCT No citations met these criteria.
Level2a:
SR of Cohort Studies No citations met these criteria.
Level 2b:
Cohort Study< No citations met these criteria.
Low-quality RCT
Level2c:
Outcomes Research d No citations met these criteria.
Level 3a:
SR of Case Control Studies No citations met these criteria.
SR of Comparative Studies
that are not RCTs
Level3b:
Case Control Study" Stevens & Clark, 1969; Thaut, 1987, 1988
Comparative Studiel that
are not RCTs
SR of Literatureg
Level4a:
Case Seriesh No citations met these criteria.
Case Study with quantitative
data analysis
Low-quality Cohort Study
Low-quality Case Control
Study
Level4b:
Case Study without Agrotou, 1988; Alvin, 1969; Benenzon, 1976;
quantitative data Bruscia, 1982; Euper, 1968; Farmer, 1985;
analysis Goldstein, 1964; Hollander & Juhrs, 1974;
Hudson, 1973; Mahlberg, 1973; Nordoff, 1964;
Nordoff & Robbins, 1965, 1968, 1977; North,
1966; Romerhaus, 1968; Saperston, 1973;
Sherwin, 1953; Staum & Flowers, 1984;
VVarwick, 1984;VVerbner, 1968
Vol. 48, No.2, Summer 2011 189
TABLE 2
Continued
Level 4c:
Qualitative Study Kessler, 1967; Nordoff & Robbins, 1965; Thaut,
Anecdotal Study 1984 (protocol)
SUlVey Research i
Level 5:
Expert OpinioJ No citations met these criteria.
Note. a = exhaustive systematic search, objective appraisal, and summary of
literature on a specific topic with quantitative analysis (e.g., meta-analysis); b =
participants are randomly assigned to two or more groups and systematically
compared; c = identify two cohorts of individuals who received two or more
different exposures/treatments and follow for specific outcome; d = post hoc
analysis interested in quality of care, quality of life after receiving treatment; e =
post hoc analysis comparing patients who had outcome of interest to those who did
not and determine if they had the treatment of interest; f = participants in two or
more groups are compared using statistical analysis; g = exhaustive systematic
literature review with more qualitative analysis (e.g., historical research); h = post
hoc analysis of patients who had outcome of interest (no control group); i =
studies that focus more on process, investigative research, clinical wisdom (e.g.,
protocols, sUlVeys regarding current practice); j = a highly regarded expert in a
particular field or topic provides her/his opinion (Center for Evidence Based
Medicine, 2009).
environment and has grown [ ... J to prominence In the

development of clinical standards and guidelines to improve
quality of care" (Davidson, et aI., 2003, p. 162). The most recent
revision to Public Law 94-142 (2004) in the United States
mandated the use of evidence-based educational techniques
(Adamek & Darrow, 2005).
Music therapists have felt pressure to improve the level of
evidence to justify the effectiveness of their work with children
with autism. Critical conclusions of meta-analyses both by music
therapists and non-music therapists have appeared in the
literature (Accordino et aI., 2007; Gold et aI., 2006; National
Autism Center, 2009; New York State Department of Health Early
Intervention Program, 1999; Romanczyk & Gillis, 2005; Whipple,
2004; Wigram & Gold, 2006), and an international survey has
suggested a possible disconnect between clinical practice and
clinical research (Baker, Wigram, Stott, & McFerran, 2008, 2009).
To combat these CrItICIsms, the American Music Therapy

Association has recently established the Music Therapy and
Autism Task Force/Think Tank to "explore and offer recom
mendations for future directions for music therapy and autism"
(American Music Therapy Association, 2007, p. 5). Additionally,
Wigram (2002) has urged that there is potential for development,
and important alternative levels of evidence have been published.
In the past decade, music therapists have begun to pave the way
for evidence-based practice for children with autism through
clinical research models and more rigorous assessment methods.
The Rational-Scientific Mediating Model (R-SMM) and

Transformational Design Model (TDM)
The Rational-Scientific Mediating Model (R-SMM) developed
by Thaut (2000), is a systematic method of conducting high
quality research in music therapy to establish evidence-based
interventions and theoretical foundations. The researcher begins
by investigating a specific physiological, neurological, or psycho
logical response to music (Musical Response Model) and then
connects this response with an analogous nonmusical response
(Nonmusical Parallel Model). Once the researcher has deter
mined if the musical responses can be generalized to a non-music
setting, the effects of music on behavior are systematically studied
to develop an empirically supported hypothesis (Mediating
Model). Finally, the researcher studies a specific intervention or
treatment protocol that is based on the developed hypothesis
(Clinical Research Model) (Thaut, 2000).
Lim (2009) provided an example of the R-SMM applied in
research with children with autism. The author identified music
perception as a psychological response to music (Musical
Response Model) and paralleled this response to speech and
language perception, a nonmusical response (Nonmusical Paral
lel Model). This presented a logical and empirically supported
theoretical foundation that was developed to support the
empirical analysis of the use of music in speech production for
In tandem with the R-SMM, Thaut (2000) developed the
Transformational Design Model (TDM). This interdisciplinary
approach for providing evidence-based treatment aims to dispel
the use of activity-based, non-goal driven treatment. Goals and
Vol. 48, No.2, Summer 2011 191
objectives are based on client assessment and translated into

appropriate "nonmusical therapeutic exercises and stimuli"
(p. 35). Logic, creativity and strong functional musicianship,
clinical wisdom, and evidence from research (i.e., R-SMM) are
used to transform these nonmusical exercises into music therapy
applications, creating a holistic plan for generalizing skills from
therapy to reality (Thaut, 2000).
Brownell (2002) provides an example of the TDM process in his
study regarding musically adapted social stories. He defined
specific areas for intervention based on client assessment,
identified social stories as the nonmusical therapeutic exercise,
and creatively turned these into prescriptive songs. This technique
has been applied by contemporary music therapists to improve
behavior (Pasiali, 2004), self care (Kern, Wakeford, & Aldridge,
2007), promote independence in greetings (Kern, Wolery, &
Aldridge, 2007), outdoor play (Kern & Aldridge, 2006), and has
been implemented by classroom teachers trained by music
therapists to help generalize skills (Kern & Aldridge, 2006; Kern,
Wakeford, et aI., 2007; Kern, Wolery, et aI., 2007).
Assessment
Appropriate assessment has become a prominent issue for
music therapists working with children with autism. In the past
decade, Wigram (2000) has begun to illustrate the advantages of
music therapy diagnostic assessment for children with autism and
the importance of assessment in the referral and treatment
process (2002). Similar to Sherwin (1953), he has suggested that a
music therapy diagnostic evaluation could provide a unique
perspective on the strengths and needs of a child. He has also
argued the importance of including musical evidence to support
the conclusions of a music therapy assessment.
The Social Communication, Emotional Regulation, and Trans
actional Support (SCERTS) curriculum model has been explored
as an applicable intake and ongoing assessment tool in music
therapy for children with autism (Walworth, 2007). Based on a
survey, the author concluded, "music therapists are not using a
consistent assessment method with autism spectrum disorder
clients" (p. 17). The lack of a quality, universal assessment tool has
caused difficulty for music therapists trying to disseminate
treatment outcomes due to the lack of· a common language
(Walworth, Register, & Engel, 2009). Furthermore, without a

proper assessment, music therapists are in danger of activity
based, non-goal driven treatment which impacts the ability for
music therapy to be recognized as a valid evidence-based
approach by other professionals (Thaut, 2000).
1990-2009: Strengths & Limitations of Recent Approaches

The era from 1990-2009 found more focused approaches and
goal areas in comparison to earlier historical research. Likely due
to more widespread knowledge of autism diagnosis, most of the
goals addressed in the literature during this time mirrored the
diagnostic domains in the DSM-IV: social, communication, and
behavior. There was a shift to a primary concentration on social
skills, with a close secondary focus on expressive communication
skills. Behavior remained a popular goal area throughout the
history of music therapy for children with autism. Scattered
articles addressed emotional and motor skills, activities of daily
living, and pre-academics, and there was a shift away from the
musical skills of children with autism. In spite of being a common
discussion among authors who have autism (Toigo, 1992), music
therapists did not publish research related to sensory issues
during the past 2 decades.
In recent years, music therapists continued to implement many
of the techniques from the previous 4 decades, such as music
games and singing (Starr & Zenker, 1998; Woodward, 2004),
music as a reinforcement (Dellatan, 2003), and improvisation
(Donnell, 2007; Edgerton, 1994; Holck, 2004; Katagiri, 2009; Kim,
Wigram, & Gold, 2008, 2009; Woodward, 2004). The repertoire of
intervention techniques also expanded to include family-based
music therapy (Allgood, 2005; Woodward, 2004), prescriptive
songs (Brownell, 2002; Kern & Aldridge, 2006; Kern, Wakeford, et
aI., 2007; Kern, Wolery, et aI., 2007; Pasiali, 2004), and providing
clients and caregivers with music therapy tools for use outside of
music therapy (Kern & Aldridge, 2006; Kern, Wakeford, et aI.,
2007; Kern, Wolery, et aI., 2007; Starr & Zenker, 1998). Perhaps
one of the most innovative ideas from 1990-2009 was the Music
Hut, a musically adapted playground designed to encourage
socialization during outdoor play (Kern & Aldridge, 2006). A
summary of recent approaches in music therapy for children with
autism is illustrated in Table 3.
Vol. 48, No.2, Summer 2011 193
Similar to the earlier historical period, the research base from

1990-2009 primarily consisted of case studies. Most articles did
not adequately describe the techniques for replication in practice
or future research. However, music therapists in the past 2
decades challenged themselves to produce stronger research
evidence, perhaps in reaction to internal criticisms and from
professionals in other fields (Accordino et aI., 2007; Gold et aI.,
2006; National Autism Center, 2009; New York State Department
of Health Early Intervention Program, 1999; Romanczyk & Gillis,
2005; Whipple, 2004; Wigram & Gold, 2006). Recent studies
included low-quality randomized controlled trials (Kim et aI.,
2008,2009), systematic reviews of comparative studies (Gold et aI.,
2006; Whipple, 2004), and case studies with quantitative analysis
(Kern, Wakeford, et aI., 2007; Kern, Wolery, et aI., 2007; Kostka,
1993; Pasiali, 2004). Kaplan and Steele (2005) embarked on
outcomes research, a potential area for growth in future music
therapy research. A summary of the evidence from this period is
displayed in Table 4 using the same categorical structure
delineated in Table 2.
Future Implications and Conclusion

This paper provides a history of autism diagnosis and appraises
strengths and limitations of music therapy practice with children
with autism (1940-2009). Based on this information, directions
for future research and clinical practice in the use of music
therapy for children with autism can be construed. Review articles
have illustrated that this population benefits from music therapy
intervention (Gold et aI., 2006; Kaplan & Steele, 2005; Whipple,
2004); nonetheless, the level of evidence supporting its use has
been primarily case studies (see Tables 2 and 4). Comparative
studies have used exceedingly small sample sizes. Autism is no
longer considered a rare disability in the United States: one in 110
children are identified with autism, and it is more prevalent than
combined cases of childhood cancer, diabetes, and AIDS
(National Center on Birth Defects and Developmental Disabili
ties, 2010). Even if the number of available participants is small at
a music therapist's workplace, it is possible to increase the number
of children included in comparative studies through carefully
planned collaborative and multi-site research.
TABLE 3
A Summary of Recent Approaches in Music Therapy for Children with Autism, 1990-2009
Communication Music and art therapy , Hairston, 1990

incorporated in special
education classroom
developmental therapy
curriculum
Expressive Learning sign language & Buday, 1995
communication spoken vocabulary
through a story song
Improvisation Donnell, 2007; Edgerton,
1994
Musical game "Beat That Starr & Zenker, 1998
Drum" (Nordoff &
Robbins, 1991) (drum
given as a reward for
correct language skills)
Vocal improvisations in Starr & Zenker, 1998
front of a mirror (oral
motor imitation)
Words paired with sign Starr & Zenker, 1998
language
Greeting song/Goodbye Woodward, 2004
song
Song (not specific) Woodward, 2004
Receptive Improvisation Donnell, 2007
communication
Following directions Musically adapted social Brownell, 2002
stories
Social Skills Family-based group with Allgood, 2005
various structured and
unstructured
interventions
Improvisation Donnell, 2007; Edgerton,
1994; Kim et ai., 2009
Music and art therapy Hairston, 1990
education classroom
curriculum
In teraction themes Holck,2004
(improvisation)
Sharing an instrument Starr & Zenker, 1998
Greeting song/ Woodward, 2004
Goodbye song
Conducting game Woodward, 2004
Vol. 48, No.2, Summer 2011 195
TABLE 3
Continued
Morning greeting Individually composed Kern et aI., 2007

routines greeting songs
(independence) implemented by
classroom teachers
(MT trained teachers)
Family dynamics Rhythmic improvisation Woodward, 2004
Eye contact Start music when eye Starr & Zenker, 1998
contact begins; stop
music when eye
contact stops
Song (not specific) Woodward,2004
Imitation Song (not specific) Woodward, 2004
Awareness Stop & start game Woodward, 2004
Leadership Stop & start game Woodward,2004
Joint attention Family-based group Allgood, 2005
with various structured
and unstructured
interventions
Improvisation Kim et aI., 2008
Outdoor play Embedded song Kern & Aldridge, 2006
interventions
(Individually composed
& piggyback songs
implemented by
classroom teachers, MT
trained teachers)
Musical playground Kern & Aldridge, 2006
adaptation (Music Hut)
Emotional
Develop self- (Technique not specified) Woodward, 2004
confidence
Emotional Recordings of improvised Katagiri, 2009
expression & background music that
understanding represen t specific
emotion were played
during verbal
instruction about the
same emotion
Interactively sing songs Katagiri, 2009
with original lyrics
that correspond with
instruction about specific
emotions
Improvisation Kim et aI., 2009
TABLE 3
Continued
Self-expression Family-based group Allgood, 2005

with various
structured and
unstructured
interventions
Behavior Musically adapted Brownell, 2002
social stories
Improvisation Edgerton, 1994
Music and art therapy Hairston, 1990
incorporated in
special education
classroom developmental
therapy curriculum
Transitions Write a client-specific Starr & Zenker, 1998
song to increase
understanding of
what to do during a
transition (e.g., "line
up" song)
Picture flashcards paired Starr & Zenker, 1998
wi th song lyrics ~,
Record client's transition Starr & Zenker, 1998
song for him/her to
listen to during other
applicable transitions
outside of music
therapy
Exchange object! Starr & Zenker, 1998
instrument used in
first activity with object!
instrument used in next
activity
Use theme and variations Starr & Zenker, 1998
song to represen t
transition and change
within activity (e.g.,
"If You're Happy &
You Know It" keeps
changing action while
maintaining same
sentence structure)
Attention Stop & start game Woodward, 2004
Vol. 48, No.2, Summer 2011 197
TABLE 3
Continued
Inappropriate Prescriptive therapeutic Pasiali, 2004

vocalizations songs protocol
(client listens to song,
plays rhythmic
instruments to song,
then sings the song;
similar to musically
adapted social stories)
Inappropriate Prescriptive therapeutic Pasiali, 2004
use of VCR songs protocol (client
equipment listens to song, plays
rhythmic instruments
to song, then sings the
song; similar to musically
Rummaging Prescri ptive therapeutic Pasiali,2004
(for food) songs protocol (client
listens to song, plays
rhythmic instruments
to song, then sings the
song; similar to musically
Food refusal Preferred item (music) as Dellatan, 2003
a contingent reinforcer
(child had to swallow in
order to verbally request
item)
Musical behavior Improvisation Edgerton, 1994
Motor Skills
Fine motor skills Song (not specific) Woodward, 2004
Activities of Daily Living
Self-care tasks Embedded song Kern et aI., 2007
interven tions
(Individually composed &
piggyback songs
implemented by
classroom teachers, MT
trained teachers)
Pre-academics Music and art therapy Hairston, 1990
education classroom
curriculum
TABLE 4
Recent Levels of Research Evidence in Music Therapy for Children with Autism, 1990-2009
Level la:
Systematic Review" (SR) of No citations met these criteria.
Randomized Controlled
Trialsb (RCTs)
Level Ib:
RCT No citations met these criteria.
Level2a:
SR of Cohort Studies No citations met these criteria.
Level 2b:
Cohort Study" Kim et aI., 2008, 2009
Low-quality RCT
Level2c:
Outcomes Research d Kaplan & Steele, 2005
Level3a:
SR of Case Control Studies Gold et aI., 2006; Whipple, 2004
SR of Comparative Studies that are
not RCTs
Level3b:
Case Control StudyC Brownell, 2002; Buday, 1995;
Comparative Studiel that are not Edgerton, 1994; Hairston, 1990;
RCTs Katagiri, 2009
SR of Literatureg
Level4a:
Case Seriesh Kern et aI., 2007; Kostka, 1993; Pasiali,
Case Study with quantitative data 2004; Kern et aI., 2007
analysis
Low-quality Cohort Study
Low-quality Case Control Study
Level4b:
Case Study without quantitative Allgood, 2005; Dellatan, 2003;
data analysis Donnell, 2007; Griggs-Drane &
Wheeler, 1997; Kern & Aldridge, 2006;
Starr & Zenker, 1998; Wigram, 2000,
2002 (part 1); Woodward, 2004
Vol. 48, No.2, Summer 2011 199
TABLE 4
Continued
Level4c:
Qualitative Study' Accordino et aI., 2007; Baker et aI., 2008,
Anecdotal Studyi 2009 (sulVey); Holck, 2004; Lim, 2009;
SUlVey Research i Walworth, 2007 (sulVey); Walworth et
aI., 2009; Wigram, 2002 (part 2)
Level 5:
Expert OpiniOJ~ Toigo, 1992 (Temple Grandin)
Note. a = exhaustive systematic search, objective appraisal, and summary of

literature on a specific topic with quantitative analysis (e.g., meta-analysis); b =
participants are randomly assigned to two or more groups and systematically
compared; c = identity' two cohorts of individuals who received two or more
different exposures/treatments and follow for specific outcome; d = post hoc
analysis interested in quality of care, quality of life after receiving treatment; e =
post hoc analysis comparing patients who had outcome of interest to those who did
not and determine if they had the treatment of interest; f = participants in two or
more groups are compared using statistical analysis; g = exhaustive systematic
literature review with more qualitative analysis (e.g., historical research); h = post
hoc analysis of patients who had outcome of interest (no control group); i =
studies that focus more on process, investigative research, clinical wisdom (e.g.,
protocols, sUlVeys regarding current practice); j = a highly regarded expert in a
particular field or topic provides her/his opinion (Center for Evidence Based
Medicine, 2009).
According to this historical analysis, many music therapists have

continued to use many of the same or similar intervention
techniques despite a lack of research evidence and compelling
rationales to support the majority of them. Perhaps music
therapists have used clinical wisdom to inform treatment
practices. It is likely that many music therapists working with
children with autism have not engaged in clinical research or
published their work; therefore, the literature may not be
representative of current clinical practice. For example, an
international survey of music therapists revealed a disconnection
between the published literature and practice (Baker et aI., 2008).
It is also possible that music therapists are reiterating the trial and
error process of the early historical literature. Without logical,
coherent research to support a technique, the validity and
therapeutic value of it are limited (Thaut, 2000).
200 Joumal of Music Therapy
Another plausible explanation for the repetitive nature of the

past 59 years of music therapy practice with children with autism is
the lack of detail in intervention reporting. Transparent
intervention reporting provides the rationale for using an
intervention and illustrates how it was executed and by whom. It
allows readers to adequately assess the treatment intervention and
the research supporting it and to derive accurate and complete
information to replicate the study, conduct systematic reviews, or
apply the intervention in practice (Robb & Carpenter, 2009).
Music therapists ought to provide enough information in
published research, be it experimental, descriptive, or qualitative,
so that the investigated techniques can be applied successfully in
clinical practice. The ultimate purpose of music therapy research
is to benefit the client receiving treatment. By systematically
approaching focused research problems to explore the efficacy of
precise techniques and adequately documenting these techniques
in the literature, music therapists will use effective evidence-based
treatments.
Finally, music therapists should strive to discover their
potentially unique contributions to autism treatment in addition
to adapting techniques from other fields. In some cases, non
music therapy techniques are not well supported by strong
research evidence, as is the case with musically adapted social
stories (Case-Smith & Arbesman, 2008). It is important for music
therapists to learn from other disciplines, but it is also important
to validate techniques unique to music therapy (e.g., improvisa
tion). According to Clair (2000):
... the theoretical paradigms of other disciplines limit the
development of music therapy theory. To add music therapy
to a theory that was not designed to include it initially can result
in a "poor fit" or a position that remains ancillary, at best.
(p. 45)
In order for music therapy to become recognized as a valid and

effective treatment method for children with autism, future
researchers should strive to recruit larger sample sizes and
increase the number of well-designed comparative studies.
Research should be based on rigorous rationales documented in
the literature (e.g., Lim, 2009). By using systematic clinical
research models such as the R-SMM (Thaut, 2000), music
Vol. 48, No.2, Summer 2011 201
therapists can incorporate clinical wisdom and research evidence

to inform treatment practice.
This review included an exhaustive search ofjournal articles. It
excluded theses and doctoral dissertations, the subjects of which
are not well represented in journal literature. To gain larger
readership and dissemination of knowledge, these authors should
strive to publish the knowledge gained from such scholarly
pursuits. Although some publications related to music therapy
and autism may have not been included in this article, it is the
hope of the author that the material reviewed is sufficient to
provide an understanding of the evolution of music therapy for
children with autism and help draw conclusions regarding current
needs and direction for future work.
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History of Music Therapy For Children With Autism

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Journal of Music Therapy, 48(2), 2011, 169-207

© 2011 by the American Music Therapy Association

History of Music Therapy Treatment

The purpose of this paper is to provide a systematic review

Autistic disorder is currently one of the most prevalent

children with autism. However, both music therapists and non­

History of Autism Diagnosis

lifetime (American Psychological Association [APA], 2000). It is

children matching his criteria for autism diagnosis were com­

Music Therapy for Children with Autism:

1950-74: Music Therapists Organize

1953; Schorsch, 1950). Harbert (1955) discussed the importance

and communication. She also advocated beginning a session with

1970-82: International Growth and Domestic Division

Creative Music Therapy

1982-89: Regaining Momentum

observed a child's apparent need for movement and loud sounds

1940-89: Historical Strengths & Limitations

authors discussed the use of non-musical techniques to achieve

Music Therapy for Children with Autism:

They aligned goals with diagnostic criteria as autism became a

1990-99: American Music Therapists Expand the Depth of Practice

2000-09: Music Therapy and Autism in the 21st Century

Communication Introduce a variety of Alvin, 1969

Use bongo drums as a WalWick,1984

Identification Body part songs Romerhaus, 1968

Movement/melodic imitation Thaut, 1984

Visual aids/flash cards of Thaut, 1984

Decrease need Instrument play North. 1966

Movement with physical Thaut, 1984

Sensory Transition object! Thaut, 1984

environment and has grown [ ... J to prominence In the

To combat these CrItICIsms, the American Music Therapy

The Rational-Scientific Mediating Model (R-SMM) and

objectives are based on client assessment and translated into

(Walworth, Register, & Engel, 2009). Furthermore, without a

1990-2009: Strengths & Limitations of Recent Approaches

Similar to the earlier historical period, the research base from

Future Implications and Conclusion

Communication Music and art therapy , Hairston, 1990

Morning greeting Individually composed Kern et aI., 2007

Self-expression Family-based group Allgood, 2005

Goal Technique Citations

Inappropriate Prescriptive therapeutic Pasiali, 2004

Note. a = exhaustive systematic search, objective appraisal, and summary of

According to this historical analysis, many music therapists have

Another plausible explanation for the repetitive nature of the

In order for music therapy to become recognized as a valid and

therapists can incorporate clinical wisdom and research evidence

Romerhaus, B.]. (1968). Clinical experiences with hospitalized early-childhood

Wigram, T. (2000). A method of music therapy assessment for the diagnosis of

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children with autism. However, both music therapists and non

children matching his criteria for autism diagnosis were com