Autism spectrum disorder (ASD) is defined as a developmental disorder. It affects behaviour and communication skills. Although autism can be detected at any age, it is categorised as developmental disorder because the specific symptoms of autism spectrum disorders mainly surface during first two years of life (Manning-Courtney et al., 2013). According to the guideline created by the American Psychiatric Association the main indicators which are used in order to diagnose ASD include difficulty in communication, interaction skills with other people, repetitive behaviours or restricted interest and exhibiting other symptoms that hurts the ability of a person to function comprehensively in school, work or other areas of life (National Institute of Mental Health, 2017). Autism is categorised as spectrum disorder because there is a huge difference in the type and severity of the disease. ASD is common in all racial, economic and ethnic groups and it is a lifelong disorder. However, treatments and services can help to improve the overall ability of an individual to function normally in different areas of life, both professional and personal (Lauritsen, 2013).
There are only few medicines or pharmacological interventions elucidated so far in order to effectively handle ASD. FDA (Food and Drug Administration) has only approved two drugs for treating ASD and these are risperidone and aripiprazole. These drugs mostly used to reduce the irritability associated with ASD. However, these drugs are associated with several side-effects especially among the children who are the prime victims of ASD. Moreover other common medications like serotonin re-uptake inhibitors (SSRIs) including fluoxetine and naltrexone which are approved fro alcohol addictions or for treating depression and anxiety do not work comprehensively over all the individuals. This is the reason why special attention is given over the non-pharmacological intervention in order to effectively treat ASD. According to Narzisi et al. (2014), non-pharmacological interventions are effective in reducing behavioural complications associated with ASD. It also helps in the overall improvement of the cognitive function of the children with no visible side-effects inline pharmacological interventions. The following clinical report aims to analyze the effectives of two non-pharmacological interventions over children with ASD. At the end, the review will attempt to highlight few recommendations that will further help to streamline the interventions for ASD.
The two non-pharmacological interventions selected for this clinical report include sensory integration therapy and music therapy and target population is children between the age group of 1 to 15 years.
The search strategy is mainly directed by the search of the articles in electronic database by the use of specific keywords. The main keywords that were used to the database search include “sensory integration therapy”, “music therapy”, “autism”, autism spectrum disorder”, “non-pharmacological intervention”. The electronic databases that were use for the article search include CENTRAL, EMBASE, Ovid MEDLINE, PsycINFO, CINAHL, ASSIA, ERIC. The main inclusion criteria include research study published on or before 2013, research study conducted over children with ASD and main exclusion criteria include research study conducted before 2013 and target group is adult. According to Parahoo (2014), selecting papers which are published recently helped to increase the authenticity of research. On the basis of the literature search, 20 articles where highlight of then 10 were eliminated based on the title selection criteria and review of the abstract. Then from the remaining 10 six articles were finalised for conducting this clinical report. Finalizations of the six articles were done based on the outcome of the study and the structure of the study.
PRISMA Flow Diagram (Moher et al., 2009)
Sensory Integration therapy
Sensory integration (SI) was initially developed by A. Jean Ayres. It was developed in order to study the neurological processing of the sensory information. Sensory integrative therapy (SIT) widely used to treat intellectually challenged children since 1970s. SI mainly aims to assist children with sensory processing via exposing ASD children to sensory stimulation in an ordered and repetitive manner. The logic behind this therapy is over time, the brain will gradually adapt and will help children to process and simultaneously react to sensations in an effective way (Schaaf et al., 2014). According to Fazlio?lu and Baran (2008) SI is effective for children with autism spectrum disorders (ASD) and is regarded as third most commonly used intervention for ASD. Pfeiffer et al. (2011) conducted a study over ASD children, undergoing occupational therapy via using SI approach (OT-SI). The study showed promising gains in SIT approach comparison to the Activity Protocol group. However, Iwanaga et al. (2014) is of the opinion that although sensory integration therapy (SIT) has been widely adopted for children with ASD, its overall effectiveness is still controversial. Numerous studies have highlighted that SIT help in improvements in the sensory-motor skills, reading skills in children with learning disability and motor planning (Lang et al., 2012). However, there are no significant studies showing the significance of SIT in cognition, motor planning and motor function of the children (Iwanaga et al., 2014). Thus in order to ascertain the effectiveness of the SIT over the cognitive function, verbal skills and motor abilities of the ASD of children, Iwanaga et al. (2014) conducted a pilot study. They used Japanese version of the Miller Assessment tool for Preschoolers (JMAP) in order to detect change in the cognitive function. They mainly selected 20 children with high-functioning autism spectrum disorder (HFASD) having IQs above 70. Among 20 children, eight participated in individual SIT session and twelve participated in group therapy (GT) like communication training, social skills training, kinetic activities and children-parent play for 8 to 10 months. The result based on the scale of the JMAP taken both before and after the integration of the therapy. The statistics showed total score of JMAP and index scores except for the verbal index have increased significantly among the SIT group. While only the total scores (JMAP score) have only increased in the GT group. Moreover, SIT group showed promising improvements in the domain of co-ordination, non-verbal scores and complex index scores in comparison to the GT group. Thus showing that the SIT is effective in improving the overall cognitive function of the children with ASD in comparison to over group based interventions (Iwanaga et al., 2014). The main strength of the study is, the measurement of the cognitive development is based on the JMAP. According to Nakatsuka et al. (2013), JMAP is an authentic tool that can be effectively used to judge overall cognitive improvement. However, the study also has certain limitations. For example, the children who were selected for the study have IQ high than 70. Iwanaga et al. (2014) are of the opinion that ASD children with IQ lower than 70 suffer from significantly poor cognitive skills in comparison to IQ greater than 70. A proper randomised control trail might have made the study more authentic (Dennis et al., 2009). Another limitation of the study is its sample size (Button et al., 2013). Only 20 children were selected from the study and Button et al. (2013) are of the opinion that small sample size increases the scope of biased response. Moreover, the study is based on the previously collected data which again imposed threat over the getting biased response (Marshall et al., 2013).
In relation to the sensory processing interventions, Case-Smith, Weaver and Fristad (2015) conducted a systematic review over children with autism spectrum disorder. The review was mainly directed towards ascertain the efficacy of the sensory interventions in the domain of sensory integration therapy and sensory-based interventions over sensory processing problems. In this evidence based review, a total of 19 studies were reviewed and of them 5 examined sensory integration therapy effects and 14 were based on the interventions of sensory-based. All the selected studies highlighted sensory integration therapies as clinic-based interventions that employ sensory-rich and children oriented activities in order to improve the adaptive responses of the child towards sensory experiences. The analysis of the selected papers highlighted that the sensory-based interventions are mainly classified as class-room based interventions that employs single-sensory strategies like therapy balls, weighted vests and its influence on child's state of arousal. Sensory-based interventions mainly highlighted that they may or may not be effective if they fail to follow the recommended protocols sensory processing problems. The review also highlighted that randomised controlled trials showed positive effects for sensory integration therapy when the sample size was small. At the end, Case-Smith, Weaver and Fristad (2015) concluded that the more rigorous trails employing manual protocols are required to be reviewed in order to evaluate its effects over children with ASD. The main strength of the study, it is study plan that is systematic review approach in order to get a summarised overview of the effectiveness of the SIT. However, the main limitation of the review is it only reviewed 19 studies and thus poor sample size reduce the overall strength of the research (Faber & Fonseca, 2014).
Kashefimehr, Kayihan and Huri (2018), examined the effect of SIT on different aspects of occupational performance of the children with ASD. They selected 3 to 8 year older SD children. Short Child Occupational Profile (SCOPE) was employed in order to compare two groups of children in the domain of their sensory performance and occupational performance, SIT children (n=16) and control group (n=15). The analysis of the results highlighted significant improvement in all the SCOPE domains and SP domains with an exception of the emotional reactions and emotional or social responses. Overall their study highlighted improvement in the occupational performance upon the application of SIT over ASD children. The main strength of the study is it conducted statistical analysis in order to elucidate their results in qualitative format. The main limitation of the study, the study was not randomized and this may increase the chance of getting biased results (Harris, 2013). A detailed characteristic of the placebo and the trail group of children was also not mentioned this further hampered the quality of the study (Charan & Biswas, 2013).
Music therapy is used as an important non-pharmacological intervention for the treatment of autism spectrum disorder among the children. The importance of music therapy is, it helps to stimulate both the hemispheres of the brain and thereby helping to improve the cognitive function (Thompson, McFerran & Gold, 2014). Kim, Wigram and Gold (2009) are of the opinion that music encourages communicative behaviour and at the same time encourage structured interaction with others and thereby helping to improve the communication difficulty among the children with ASD. Music therapy can be alternatively be defined as a systematic process of non-pharmacological intervention where the therapists aims to assist the client in order to promote health via employing musical experiences and quality relationship that helps to develop dynamic force of chance (Reschke-Hernández, 2011). The central of the music therapy mainly employs free and structured improvisation like singing songs, listening to live music or pre-recorded music and vocalisation. The underlying therapy behind the affect of music therapy on the overall improvement of the verbal skills of the children is defined by Gattino et al. (2011). According to Gattino et al. (2011), listening to music therapy mainly emphasize an interactive process which encompass selecting music which is meaningful for the person and then asking the person to reflect on the experience of music. This helps to promote verbal or communication skills. Silverman (2008) thus rightly concluded that those with verbal abilities, giving verbal reflection on the music processed are considered to be an important aspect of music therapy.
Geretsegger et al. (2014) performed a review with an aim to assess the impact of music therapy over children with ASD. They conducted the literature search till 2013 July from databases like CENTRAL, EMBASE, Ovid MEDLINE, PsycINFO, CINAHL, ASSIA, ERIC. They mainly selected randomised controlled trials (RCTs) and controlled clinical trains study in order to compare the effectiveness of the music therapy over the ASD children. The review of the 10 studies highlighted that music therapy can help children with ASD in the domain of improving their overall skills in the primary outcome area and this includes social interaction, communication, reciprocity in social-emotional context and initiating behaviour. The authors also highlighted that music therapy might also proved to be helpful in enhancing non-verbal communication skills under the context of therapy. In the secondary outcome area, music therapy helping in the improvement of the social adaptation skills among the children with ASD and in promoting quality of life and well-being in parent-child relationships (Geretsegger et al., 2014). The main strength of the study is its representation and detailed layout article selection based on the inclusion and exclusion criteria. Shamseer et al. (2015) stated that in case of systematic review, a detailed illustration of the inclusion and exclusion criteria of the article selection help to increase the overall quality of the research. However, this systematic review has certain limitation like small sample size and risk bias. Only two authors were employed for the selection of the research articles and subsequent shorting of the articles based on the inclusion and exclusion criteria. According to this might increase the overall rate of the chances of performance bias (Pannucci & Wilkins, 2010).
In relation to music therapy and its affect on the children with ASD, LaGasse, (2014) conducted a randomised control trial over 17 children between the age group of 6 to 9 years. The aim of the study is to examine the effect of music therapy group intervention over the joint attention, eye gaze and interactive communication between the children with ASD. They mainly performed comparative study with music therapy group (MTG) and no-music social skills group (SSG). The children were asked to participate in ten minutes group session of 50 minutes for over a tenure of 5-week. The analysis of the social responsiveness scale (SRS), the Autism Treatment Evaluation checklist (ATEC) and video analysis of sessions highlighted that music therapy is helpful in increasing joint attention. However, there was no significant difference between the groups on the parameter of initiation of communication, response to certain questions over verbal skills and social behaviours or withdrawals (LaGasse, 2014). One of the limitations of the study is, it conducted non-blinded trail. According to Hróbjartsson et al. (2012), conducting non-blinded trial lead to the generation of biased results. However, the strength of the study is its qualitative approach and the inclusion and exclusion criteria selected for sample group selection (Mason, 2010).
Thompson, McFerran and Gold (2014) evaluated the effectiveness of family-centred music therapy in order to promote social engagement of the children with ASD. They conducted a randomised control trial over 23 children who are aged between 36 to 60 months and have severe ASD. Family-based music therapy mainly continued for 16-weeks and the change in the social engagement was measured via the help of parent-report assessment, parent interview and overall clinician observation. The analysis of the results highlighted that family based music therapy help to increase the parent-children interaction and this in turn help to increase the social interactions at home and community based interaction of the children. However, the application of music therapy showed no promising increase in the general social responsiveness and language skills of the children (Thompson, McFerran & Gold, 2014). Thus the main strength of the study is, it provided preliminary support over the family-based music therapy and its large sample size (Marshall et al., 2009). However, the study mainly used interview of the parents in order to ascertain the outcome over the children and this may lead to the generation of blinding bias (Kim et al., 2013).
Thus from the above critical analysis of the published articles based on the pharmacological interventions of SIT, it can be concluded that SIT helps in the improvement of the cognitive function of the children who have mild to moderate IQ ranging on or above 70. SIT also helped to improve the adaptive responses of the child towards executing the sensory experiences and occupational performances. Thus overall it can be summarised that the SIT which is mainly based to improve intellectual disability of the child is very effective as a non-pharmacological interventions in the domain. Another non-pharmacological intervention highlighted in this clinical report is music therapy. Critical analysis of the articles base on music therapy highlighted that music therapy helps children with ASD in the domain of verbal communication, social-emotional reciprocity and initiating behaviour. Moreover, studies like systematic review highlighted that music therapy also helps in improving social adaptation skills and thereby promoting health and well-being among parent child relationship. The improvement of the parent child relationship is also highlighted in the family based music therapies which are either procured in group or are given individually. However, the results of music therapy interventions were contrasting like one study showed effective in improvement of the social responsiveness while another study showed no promising increase in the social responsiveness apart from verbal or communication skills. Thus it can be said that further studies are required to be conducted in order to streamline the detailed outcome of music therapy and SIT.
In order to improve the overall health and well-being of the children suffering from ASD, the primary thing that is required to be worked upon is their behavioural problems. According to Lord and Jones (2013), behavioural interventions are the major source of change for children with autism spectrum disorders. Lord and Jones (2013) are of the opinion that behavioural interventions directed towards specific skills like communication approach, social interaction skills, behaviour towards others help in achieving better outcomes. Lord and Jones (2013) also highlighted that the interventions must be personalised as such bespoke intervention help to extract quality results in comparison to group-based intervention. Moreover, interventions must be procured by the direct care givers under the controlled supervision of professional nurse.
Bhat, A. N., & Srinivasan, S. (2013). A review of “music and movement” therapies for children with autism: embodied interventions for multisystem development. Frontiers in integrative neuroscience, 7, 22. https://doi.org/10.3389/fnint.2013.00022
Button, K. S., Ioannidis, J. P., Mokrysz, C., Nosek, B. A., Flint, J., Robinson, E. S., & Munafò, M. R. (2013). Power failure: why small sample size undermines the reliability of neuroscience. Nature Reviews Neuroscience, 14(5), 365.
Case-Smith, J., Weaver, L. L., & Fristad, M. A. (2015). A systematic review of sensory processing interventions for children with autism spectrum disorders. Autism, 19(2), 133-148. DOI: 10.1177/1362361313517762
Charan, J., & Biswas, T. (2013). How to calculate sample size for different study designs in medical research?. Indian journal of psychological medicine, 35(2), 121.
Dennis, M., Francis, D. J., Cirino, P. T., Schachar, R., Barnes, M. A., & Fletcher, J. M. (2009). Why IQ is not a covariate in cognitive studies of neurodevelopmental disorders. Journal of the International Neuropsychological Society, 15(3), 331-343.
Faber, J., & Fonseca, L. M. (2014). How sample size influences research outcomes. Dental press journal of orthodontics, 19(4), 27-29.
Fazlio?lu, Y., & Baran, G. (2008). A sensory integration therapy program on sensory problems for children with autism. Perceptual and Motor Skills, 106(2), 415-422.
Gattino, G. S., Riesgo, R. D. S., Longo, D., Leite, J. C. L., & Faccini, L. S. (2011). Effects of relational music therapy on communication of children with autism: a randomized controlled study. Nordic Journal of Music Therapy, 20(2), 142-154.
Geretsegger, M., Elefant, C., Mössler, K. A., & Gold, C. (2014). Music therapy for people with autism spectrum disorder. Cochrane Database Syst Rev, 6(6), CD004381. DOI: 10.1002/14651858.CD004381.pub3
Harris, K. M. (2013). The add health study: Design and accomplishments. Chapel Hill: Carolina Population Center, University of North Carolina at Chapel Hill.
Hróbjartsson, A., Thomsen, A. S. S., Emanuelsson, F., Tendal, B., Hilden, J., Boutron, I., ... & Brorson, S. (2012). Observer bias in randomised clinical trials with binary outcomes: systematic review of trials with both blinded and non-blinded outcome assessors. Bmj, 344, e1119.
Iwanaga, R., Honda, S., Nakane, H., Tanaka, K., Toeda, H., & Tanaka, G. (2014). Pilot Study: Efficacy of Sensory Integration Therapy for Japanese Children with High?Functioning Autism Spectrum Disorder. Occupational therapy international, 21(1), 4-11. doi:10.1093/jmt/thu012
Kashefimehr, B., Kayihan, H., & Huri, M. (2018). The Effect of Sensory Integration Therapy on Occupational Performance in Children With Autism. OTJR: occupation, participation and health, 38(2), 75-83.
Kim, J., Wigram, T., & Gold, C. (2009). Emotional, motivational and interpersonal responsiveness of children with autism in improvisational music therapy. Autism, 13(4), 389-409.
Kim, S. Y., Park, J. E., Lee, Y. J., Seo, H. J., Sheen, S. S., Hahn, S., ... & Son, H. J. (2013). Testing a tool for assessing the risk of bias for nonrandomized studies showed moderate reliability and promising validity. Journal of clinical epidemiology, 66(4), 408-414.
LaGasse, A. B. (2014). Effects of a music therapy group intervention on enhancing social skills in children with autism. Journal of music therapy, 51(3), 250-275. doi:10.1093/jmt/thu012
Lang, R., O’Reilly, M., Healy, O., Rispoli, M., Lydon, H., Streusand, W., ... & Didden, R. (2012). Sensory integration therapy for autism spectrum disorders: A systematic review. Research in Autism Spectrum Disorders, 6(3), 1004-1018.
Lauritsen, M. B. (2013). Autism spectrum disorders. European child & adolescent psychiatry, 22(1), 37-42.
Lord, C., & Jones, R. M. (2013). New strategies and findings for behavioral interventions in autism spectrum disorders. Annals of the New York Academy of Sciences, 1304(1), 70-76.
Manning-Courtney, P., Murray, D., Currans, K., Johnson, H., Bing, N., Kroeger-Geoppinger, K., ... & Messerschmidt, T. (2013). Autism spectrum disorders. Current problems in pediatric and adolescent health care, 43(1), 2-11. https://dx.doi.org/10.1016/j.cppeds.2012.08.001
Marshall, B., Cardon, P., Poddar, A., & Fontenot, R. (2013). Does sample size matter in qualitative research?: A review of qualitative interviews in IS research. Journal of Computer Information Systems, 54(1), 11-22.
Mason, M. (2010, August). Sample size and saturation in PhD studies using qualitative interviews. In Forum qualitative Sozialforschung/Forum: qualitative social research (Vol. 11, No. 3).
Moher D, Liberati A, Tetzlaff J, Altman DG, The PRISMA Group (2009). Preferred Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMA Statement. PLoS Med 6(7): e1000097. doi:10.1371/journal.pmed1000097
Nakatsuka, H., Shimbo, S., Watanabe, T., Yaginuma-Sakurai, K., & Ikeda, M. (2013). Applicability of food composition tables as a tool to estimate mineral and trace element intake of pre-school children in Japan: a validation study. Journal of Trace Elements in Medicine and Biology, 27(4), 339-345.
Narzisi, A., Costanza, C., Umberto, B., & Filippo, M. (2014). Non-pharmacological treatments in autism spectrum disorders: an overview on early interventions for pre-schoolers. Current clinical pharmacology, 9(1), 17-26.
National Institute of Mental Health. (2017). Autism Spectrum Disorder.Access date: 13th August 2018. Retrieved from: https://www.nimh.nih.gov/health/topics/autism-spectrum-disorders-asd/index.shtml
Pannucci, C. J., & Wilkins, E. G. (2010). Identifying and avoiding bias in research. Plastic and reconstructive surgery, 126(2), 619.
Pfeiffer, B. A., Koenig, K., Kinnealey, M., Sheppard, M., & Henderson, L. (2011). Effectiveness of sensory integration interventions in children with autism spectrum disorders: A pilot study. American Journal of Occupational Therapy, 65(1), 76-85.
Reschke-Hernández, A. E. (2011). History of music therapy treatment interventions for children with autism. Journal of Music Therapy, 48(2), 169-207.
Schaaf, R. C., Benevides, T., Mailloux, Z., Faller, P., Hunt, J., van Hooydonk, E., ... & Kelly, D. (2014). An intervention for sensory difficulties in children with autism: A randomized trial. Journal of Autism and Developmental Disorders, 44(7), 1493-1506.
Shamseer, L., Moher, D., Clarke, M., Ghersi, D., Liberati, A., Petticrew, M., ... & Stewart, L. A. (2015). Preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) 2015: elaboration and explanation. Bmj, 349, g7647.
Silverman, M. J. (2008). Nonverbal communication, music therapy, and autism: A review of literature and case example. Journal of creativity in mental health, 3(1), 3-19.
Thompson, G. A., McFerran, K. S., & Gold, C. (2014). Family?centred music therapy to promote social engagement in young children with severe autism spectrum disorder: A randomized controlled study. Child: care, health and development, 40(6), 840-852.