EFFECT OF MUSIC THERAPY ON SOCIAL

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EFFECT OF MUSIC THERAPY ON SOCIAL

INTERACTION AMONG CHILDREN WITH AUTISM

BY

NURUL LIYANA BINTI NURULHUDA

A dissertation submitted in fulfilment of the requirements for the Degree of Master of Human Sciences in Psychology

(Psychology)

Kulliyyah of Islamic Revealed Knowledge and human Human Sciences

International Islamic University Malaysia

OCTOBER 2018

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ABSTRACT

The purpose of this study is to compare the effect of music education on social interaction in children diagnosed with autism, between music and non-music groups in both pre- and post-intervention of the experiment. The study was conducted with 30 children with various spectrum of autism, aged between 5 to 10 years old, who participated in group music therapy for a period of 8 weeks using music, musical activities and musical instruments conducted by a music educator using a music therapy module to guide the process. The Autism Social Skills Profile (ASSP) was used for this study to measure the participants’ social interactions such as eye contact, object sharing, communication, and turn taking. Results show that the intervention group yields improvement in their social interaction skills. The outcome in combination with the observational method, provides evidence for the use of music intervention in specific areas.

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iii

ُُصَّخَلُم

ُ

ُ ثحبلا

ُ

فدهي هذه ثحبلا ةنراقملل

ينب يرثأت يقيسولما ةيميلعتلا

في تلاماعلما ةيعامتجلاا

دنع لافطلأا

نيذلا تم مهصيخشت

،دّحوتلاب ينبو

قيرف ىقيسولما يرغبو

ىقيسولما في

ةلحرلما ام لبق لخدت

ةبرجتلا امو

اهدعب . دقو تيرجأ ةساردلا

ىلع ينثلاث لافط نيذلا تم خشت دّحوتلاب مهصي

،فلتخلما مهو

نم نس 5 لىإ 10

،تاونس مهو

نيذلا اوكراش في ةعوملمجا ةلجاعلما

يقيسولماب

ةدلم 8

،عيباسأ ثيح

مدختسا عم

هذه ةعوملمجا ىقيسولما

طاشنلاو يقيسولما

تلالآا ةيقيسولما

تيلا اهمدختسي ملعم

يقيسولما مادختساب

جذونمأ ةلجاعلما يقيسولماب

هيجوتل معلا ةيل . ةفاضلإاب

لىإ

،كلذ مدختست ةمئاقلا

تاراهملل في

تلاماعلما ةيعامتجلاا

عم صاخشلأا ةيباصلما

ضربم

لافطلأا (

)

ASSP

في هذه

،ةساردلا هذه

ةمئاقلا سيقت

تايكولس تلاماعلما

،ةيعامتجلاا لثم

لصاوتلا

،يرصبلا ةكراشلماو

في

،ءايشلأا ةقلاطو

،ثيدلحا لدابتلاو

. دقو تراشأ ةجيتن

هذه

ةساردلا ّنأ لىإ

قيرف لخدتلا ةبرجتلا

ىقيسولماب نّستح نأ

تاراهم تلاماعلما

ةيعامتجلاا دنع

لافطلأا .

دكؤتو جئاتنلا هنأ عم بيلاسأ ةبقارلما

مدقت لايلد نم لجأ مادختسا لخدتلا

يقيسولما

في تلاالمجا ةنيعلما

ةلجاعملل .

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APPROVAL PAGE

I certify that I have supervised and read this study and that in my opinion, it conforms to acceptable standards of scholarly presentation and is fully adequate, in scope and quality, as a dissertation for the degree of Master of Human Sciences (Psychology)

………..

Lihanna Borhan Supervisor

I certify that I have read this study and that in my opinion it conforms to acceptable standards of scholarly presentation and is fully adequate, in scope and quality, as a dissertation for the degree of Master of Human Sciences (Psychology)

………..

Junita Nawawi Internal Examiner

This dissertation was submitted to the Department of Psychology and is accepted as a fulfilment of the requirement for the degree of Master of Human Sciences (Psychology)

………..

Shukran Abd Rahman

Head, Department of Psychology This dissertation was submitted to the Kulliyyah of Islamic Revealed Knowledge and Human Sciences and is accepted as a fulfilment of the requirement for the degree of Master of Human Sciences (Psychology)

………..

Mohammad Abdul Quayum Abdus Salam

Dean, Kulliyyah of Islamic Revealed Knowledge and Human Sciences

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DECLARATION

I hereby declare that this project paper is the result of my own investigations, except where otherwise stated. I also declare that it has not been previously or concurrently submitted as a whole for any other degrees at IIUM or other institutions.

Nurul Liyana Binti Nurulhuda

Signature ... Date ...

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INTERNATIONAL ISLAMIC UNIVERSITY MALAYSIA

DECLARATION OF COPYRIGHT AND AFFIRMATION OF FAIR USE OF UNPUBLISHED RESEARCH

EFFECT OF MUSIC THERAPY ON SOCIAL INTERACTION AMONG CHILDREN WITH AUTISM

I declare that the copyright holders of this dissertation are jointly owned by the student and IIUM.

No part of this unpublished research may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise without prior written permission of the copyright holder except as provided below

1. Any material contained in or derived from this unpublished research may be used by others in their writing with due acknowledgement.

2. IIUM or its library will have the right to make and transmit copies (print or electronic) for institutional and academic purposes.

3. The IIUM library will have the right to make, store in a retrieved system and supply copies of this unpublished research if requested by other universities and research libraries.

By signing this form, I acknowledged that I have read and understand the IIUM Intellectual Property Right and Commercialisation policy.

Affirmed by Fazillah Sulaiman

……..……….. ………..

Signature Date

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In honor of my parents for their love, encouragement, profound support, compassion, perseverance and faith in me throughout my academic life. To them, I humbly

dedicate this work.

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CHAPTER TWO: LITERATURE REVIEW ... 10

2.0 Introduction... 10

2.1 Autism and Existing Interventions ... 11

2.2 Background on Music Therapy as a Medium of Treatment ... 13

2.3 Relationship between Music Therapy and Autism ... 15

2.4 Conceptual Framework ... 17

CHAPTER THREE: METHODOLOGY ... 20

3.0 Overview... 20

3.1 Research Design ... 20

3.2 Intervention Module ... 21

3.3 Participants ... 24

3.4 Procedures... 25

3.5 Instrument ... 27

3.6 Data Analysis ... 29

3.7 Ethical Considerations ... 30

CHAPTER FOUR: FINDINGS ... 31

4.0 Overview... 31

4.1 Participants ... 31

4.2 Social Interaction ... 31

4.2.1 Major ANOVA – Total Pre-Post Intervention ... 32

4.2.2 Preliminary Analysis – Domains of Social Interaction ... 33

4.2.2.1 Eye Contact ... 33

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4.2.2.2 Object Sharing ... 35

4.2.2.3 Communication ... 36

4.2.2.4 Turn Taking ... 37

CHAPTER FIVE: DISCUSSIONS ………...… 39

5.0 Introduction... 39

5.1 Discussion on Research Questions ... 40

5.2 Effects on Eye Contact ... 41

5.3 Effects on Communication Skills ... 42

5.4 Effects on Object Sharing ... 43

5.5 Effects on Turn Taking ... 44

5.6 Research Implications ... 44

5.7 Strengths, Limitations, and Recommendations ... 45

5.8 Conclusion ... 47

REFERENCES ... 48

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CHAPTER ONE INTRODUCTION

1.0 BACKGROUND OF THE STUDY

Autism is a neurological-related disorder (Feinstein, 2010) and a developmental disorder (Belmonte et al. 2004) characterised by impairments in social functioning and reciprocation, deficits in speech and language, and unusual behaviour (Boso, Emanuele, Minazzi, Abbamonte, & Politi, 2007). A person with autism can usually be identified through their social interaction with other people, which is often described as odd.

“Idiot” is a common word used to label people with autism because their actions are considered bizarre (Feinstein, 2010).

Autism can be detected in early infancy and childhood (Smith, Segal, & Hutman, 2015) due to delayed development compared to children without autism. A person with autism can be identified via their behavioural features such as deficits in social communication and social interaction display in multiple contexts (American Psychiatric Association, 2013). Deficits can also be seen in nonverbal behaviours, ranging from poorly integrated to a lack of verbal and nonverbal communication, eye contact, body language, and facial expressions (American Psychiatric Association, 2013). They also have a deficit in developing, maintaining, and understanding relationships, indicated by difficulty in adjusting behaviour to suit various social contexts and in sharing or making friends, as well as the absence of interest in peers (American Psychiatric Association , 2013).

It is noteworthy that children with autism do not share identical symptoms. Some experience communication delay (Abram, 2014) while others experience reduced pain

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sensitivity, indifference to social conventions, epilepsy (Belmonte et al., 2004;

Dautenhahn & Werry, 2004; Feinstein, 2010; Abram, 2014), resistance to change, and lack of direct eye contact. There are also those who may have unusual repetitive play and self-stimulation (Hourigan & Hourigan, 2009). Among the aforementioned symptoms, Dautenhahn and Werry (2004) reported that the most common symptoms shared by children with autism are repetitive patterns of behaviour and resistance to change in routine. Another common symptom is difficulty in social interaction with others (Dautenhahn & Werry, 2004; Abram, 2014). They often report feeling isolated (Feinstein, 2010). Among the deficits detected, Silverman (2008) added that most children with autism have a common criterion that can be detected through their difficulty in social interaction such as the inability to understand subtle verbal communication as well as nonverbal cues such as eye contact, object sharing, and turn- taking. Although autistic children lack in several aspects compared to an average children, the most obvious deficit of a child with autism is their social interaction regardless of their levels of functioning.

The inability of autistic children to engage in social interaction may be due to their neurodevelopmental delay as compared to other non-autistic children (Shriber, 2010). One study suggests that neurodevelopmental delay refers to the regions in the autistic brain that are different in size compared to an average individual. Examples include a slightly larger amygdala and slightly smaller corpus callosum of the autistic brain (Baron-Cohen, 2017). These evidences of different sizes of regions in the brain, however, does not confirm the causal factor of autism. Another study involved the functional magnetic resonance imaging (fMRI) of the autistic brain, which sometimes detected less brain activity, indicated by the low score in socio-emotional tasks (Baron- Cohen et al., 1999). However, children with autism scored higher in analytical

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perception tasks compared to an average child (Ring et al., 1999). Yet, other fMRI studies on auditory perception test showed greater brain activity in children with autism, which could be interpreted as the hypersensitive sensory in children with autism (Samson et al., 2011). Some children with autism have sensitivity to sound in which they feel overwhelmed and could not comprehend noises around them, which may then lead to tantrums.

Interventions for children with autism have yielded different outcomes. In Malaysia, the most common approach for children with autism includes Applied Behavioural Analysis (ABA) that is practiced by The National Autism Society of Malaysia (NASOM), Early Autism Project (EAP), and Permata Kurnia, to name a few.

The ABA approach includes specific strategies for social interaction to promote positive behaviours (Lovaas, 1987; Srinivasan & Bhat, 2013).

Other therapies included integrated therapy (Dunst, Bruder, Trivet, Raab, &

McLean, 2001; Sandall, McLean, & Smith, 2000; McWilliam, 1996, 2000a, 2000b;

Wesley, 2004), the interactive environment model, which utilizes robot as a medium, (Dautenhahn & Werry, 2004; Robins, Dautenhahn, te Boekhorst, & Billard, 2005), and animal therapy (Melson, 2001; Ascione, 2005; Solomon, 2010).

The highlight of this study is to explore the possible effectiveness of music therapy on the social interaction of children with autism. Music is defined as a “process of communication among different behavioural systems: this process should be the central focus of an ecological psychology of music, involving the relations among composer, performer, and listener” (Kendall & Carterette, 1996). Music is not only a platform for entertainment as it also provides beneficial support on childhood development. According to Rimmer (2017), music has a great impact on children’s lives

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in terms of interaction as they are able to develop their communication skills. Music also enhances relationship building between a child and parent by creating a stronger bond (Rimmer, 2017) as it helps them to interact with one another, be it when singing a lullaby or listening to music over the radio in the car. This is also supported by studies on music and linguistic research; most of their literature indicate that both music and language are indistinguishable, especially during the early stages of development (McPherson & Welch, 2018).

Some studies have shown positive effects of music therapy on children with autism (Edgerton, 1994; Kern, 2004; Gold, Wigram, & Elefant, 2006; Kim et al., 2008;

Kim, Wigram, & Gold, 2009; Gattino, Longo, Leite, Faccini, & Riesgo, 2011; Abram, 2014). A vast improvement in joint visual attention was recorded in a study done by Kim et al. (2008) on children during and after music therapy compared to play session.

Kim et al. (2008) also reported a longer span of eye contact. When compared to playground interaction, Kern (2004) reported that music therapy has a higher advantage in terms of interaction between peers. Some of the children in the study hesitated to interact with one another during playtime. However, during music therapy, it did not take long for them to interact with one another. This shows that music can have an impact on interaction between peers.

Although a music therapist did not conduct the present study, the term “therapy”

will be used throughout the present study to refer to the module that is used by a music educator as it is similar to what is used by a music therapist. According to the British Association for Music Therapy (BAMT), there is no definition that restricts the use of the term “therapy” in their definition of music therapy (BAMT, 2017). In the context of Malaysia, there is no clause that “therapy” is a specific definition for a module used by a music therapist in the constitution of Malaysian Music Therapy Association (MMTA)

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(MMTA, n.d.). Thus, the term “therapy” can also be used to refer to music sessions

conducted by a music educator. Music therapy consists of several musical activities such as dancing, singing, playing musical instruments, and several other motor movements, aiming to observe the outcomes on changes in the participants’ social interaction. Thus, the present study aims to look at the effectiveness of music therapy on autistic children’s social interaction.

1.1 STATEMENT OF THE PROBLEM

The prevalence of autism is increasing over time. Parents and guardians can choose between various treatments and therapies available for children who are diagnosed with autism. The most common therapy is the Applied Behaviour Analysis (ABA) techniques. However, many are unaware of the existence of music therapy as an alternative for children with autism in improving their social interaction skills. Music has been suggested as another medium to encourage children with autism to improve their social interaction skills alongside other existing therapies.

An online survey conducted in the U.S. on treatments for children with autism showed the lowest percentage of only 34% out of 552 parents who used music therapy as a treatment method (Green, Pituch, Itchon, Choi, O’Reilly, & Sigafoos, 2006) compared to those who preferred speech therapy and ABA. Although music therapy has proven to be effective in improving numerous aspects such as eye contact, joint attention, turn taking, object sharing, (Gold, Wigram, & Elefant, 2006), improve communication skills (Gattino et al. 2011), stress management (Leardi, Pietroletti, Angeloni, Necozione, Ranalletta, & Gusto, 2007), and many more, however, parents were neither convinced nor familiar with music therapy as a medium of treatment. As

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argued by Chiang (2008), music therapy should be practised more, considering its positive outcomes.

Another factor to why music is not as popular as other therapies for treating autism is because some autistic children are hypersensitive to noise. Therefore, parents or guardians are hesitant to opt for music therapy as part of their children’s treatment, fearing that the latter’s condition might become worse. Little do they know that music therapy includes sensory integration that could develop both the cognitive and emotional adaptation responses in the brain (Berger, 2002).

From an Islamic perspective, there have been numerous debates on music’s influence on a person to sin and go astray from their iman and whether it is permissible in Islam (Reem, 2012). Nevertheless, music has proven its worth in both Islamic and secular perspectives in helping children with disabilities and their life skills. Some Muslim scholars are against the use of music in whatever means (Syed, n.d.). As narrated by Abu Huraira in Sahih Muslim (n.d.), the Prophet ﷺ said, “The bell is the musical instrument of Satan”. However, not all musical events were prohibited during the Prophet’s ﷺ time. As narrated by ‘Aisha in Sahih Al-Bukhari (n.d.), the Prophet ﷺ stopped Abu Bakr’s protest of a few women singing during the celebration of Eid.

Therefore, using music as a medium of treatment is permissible in Islam as long as it does not cause negligence and digression in faith.

The secular theories on the benefits of music are reflected in studies on the positive effect of music therapy on children with autism despite their intended outcomes (Abram, 2014; Gold, Wigram, & Elefant, 2006; Kim, Wigram, & Gold, 2009; Gattino et al., 2011; Boso et al., 2007; Edgerton, 1994).

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1.2 SIGNIFICANCE OF THE STUDY

The present study is significant in adding to the literature addressing the effectiveness of music as a non-threatening medium for autistic children to develop their social interaction skills. Children with hypersensitivity to noise could also benefit from the present study as the proposed treatment includes sensory integration, which gives music therapy the advantage to reach multiple sensory system.

On the other hand, from a parental perspective, the present study could provide an insight on how the process is done and, in turn, provide better understanding on how music therapy is effective in treating children with autism. It could also provide a new perspective on music therapy as an alternative treatment for autism.

1.3 RESEARCH QUESTIONS

Two research questions will be addressed in this study:

1. Are there any changes in social interaction during music therapy?

2. Are there any differences in the social interaction between autistic children undergoing music therapy and those who are not?

1.4 RESEARCH OBJECTIVES

There are two research objectives to be addressed in this study:

1. To track changes (if any) in the social interaction of autistic children undergoing music therapy.

2. To evaluate the effect(s) of music therapy on the social interaction of autistic children.

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8 1.5 HYPOTHESIS

For the present study, it is hypothesised that there will be an increased change in the social interaction of participants undergoing music therapy, particularly in terms of eye contact, communication, sharing, and turn-taking.

The second hypothesis predicts that participants exposed to music therapy have a statistically increased substantial improvement in social interaction compared to those who do not undergo music therapy.

1.6 CONCEPTUAL AND OPERATIONAL DEFINITIONS 1.6.1 Music Therapy

According to Nickel et al. (2005), music therapy is defined as “the therapeutic use of music and musical activities for patients suffering from somatic and mental diseases”

(p. 2). Operationally, music therapy is a medium using instrument, melody, lyrics, and songs conducted by a music educator in a process designed to facilitate and promote social interaction.

1.6.2 Social Interaction

Social interaction is conceptually defined as the process of acting and reacting to individuals around us, whereby the actions of one individual affect the other individual’s preferences (Scheinkman, 2004). Operationally, social interaction is defined as an interaction between two individuals in terms of eye contact, communication, sharing, and turn-taking. Social interaction in this study will be measured through a behaviour rating scale by the Autism Social Skills Profile (ASSP) developed by Bellini (2006).

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1.6.3 Music Educator

Music educator is operationally defined as music teachers who are able to effectively instruct on playing musical instruments to people of all ages. Music educators are also experienced in conducting music therapy on children with special needs using their own module of teaching, similar to a music therapy module.

1.6.4 Eye Contact

Eye contact is operationally defined as being able to maintain a stable eye contact while communicating with other people.

1.6.5 Communication

Communication is operationally defined as the ability to converse reciprocally when a conversation takes place.

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CHAPTER TWO LITERATURE REVIEW

2.0 INTRODUCTION

Children with autism vary on their levels of functioning, ranging from mild to severe.

Children with mild autism would need support to enhance their functioning skills. For example, a person who is able to speak but fails to engage in conversations with others will need support to help them reciprocate in the conversation (American Psychiatric Association , 2013). Children with severe autism would require highly extensive support as they may be nonverbal or have severe impairments in functioning and limited initiation in social interactions (American Psychiatric Association , 2013).

There are several other descriptions of conditions related to autism, regardless of children and adults, but there is a distinctive feature that does not associate autism with any other illnesses. Despite the lack of developmental history, autism may be observed through deficits in social interaction, retardation, linguistic abnormalities such echolalia, obsessive and repetitive behavior, and the lack of common sense (Wolff, 2004). Hyposensitivity and hypersensitivity are sometimes shown when exposed to loud or pleasant noises as well as indifference to smells.

The educational policy of “inclusion” has been advocated worldwide, enabling children with disabilities to attend mainstream schools near them. This could be a two- way recognition for both parties whereby children with disabilities are able to interact with average children and vice versa, expecting both parties to be able to cope with one another’s needs (Jordan & Jones, 1999). Despite having the abovementioned deficits, treatments are available in helping them to cope with real-world situations and blend in

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with other children of normal abilities. Articles on education and treatment of autistic children have proven that the effectiveness of behavioural adjustment could be very much improved with early intervention (Howlin, 1999; Wolff, 2004) through numerous treatments available in treating behavioural issues.

Neuroanatomical evidence shows that there is a link between music activities and brain activation (Srinivasan & Bhat, 2013), which acts as a treatment for autism and other mental chronic illnesses. Musical tasks involving auditory, visual, or motor components will lead to the co-activation of corresponding areas in the brain (Srinivasan & Bhat, 2013). It shows that musical experiences can stimulate multiple areas of the brain and promote multimodal integration. Kim and Jinah (2006) reported on neurophysiological studies that reviewed the link between music and autism, indicating that children with autism have better perception of pitch and music than an average group of children. This makes them respond better to music therapy, which increases their behavioural skills and social interaction.

According to the following studies, music therapy could be a viable option for children with autism, indirectly promoting music therapy as an alternative approach.

Before proceeding on how music therapy yields positive outcomes in treating autism, this study will focus on existing treatments and its effectiveness as an intervention for autism.

2.1 AUTISM AND EXISTING INTERVENTIONS

Some autistic children are more territorial when it comes to objects (Kim, Wigram, &

Gold, 2009), a tendency that can becomes a barrier in social interaction with other children. Some interventions can be embedded in ongoing classroom routines (Kern, 2004) such as an integrated therapy model that provides specialised therapies to be

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implemented in an autistic child’s natural context, routine, and activities (Dunst, Bruder, Trivette, Raab, & McLean, 2001; Sandall, McLean, & Smith, 2000; McWilliam, 1996, 2000a, 2000b; Wesley, 2004). One of the techniques used is the playground interaction whereby children are given toys during their playtime and they are observed for any occurrences of interaction between peers. When comparing between music therapy and playground interaction, Kern (2004) reported that music therapy has a bigger advantage in terms of interaction between peers. Some of the children in the study hesitated to interact with one another during their playtime but during music therapy, they were able to interact faster with minimal prompt than the control group.

Interactive environment is another therapy method used in treating autism (Dautenhahn & Werry, 2004). The Autonomous Robotic (AuRoRa) Project, for example, engages with interactive environment therapy that studies the possible role of mobile robots as therapeutic tools when engaging with autistic children. The AuRoRa project is based on several theories such as mindreading, social cognition, and imitation.

It focuses on the interaction between a child and a robot through eye contact, joint attention, turn-taking, reading mental states, and emotions. The result showed a positive engagement between the child and the robot in terms of eye gaze and interaction (Dautenhahn & Werry, 2004; Robins, Dautenhahn, te Boekhorst, & Billard, 2005).

Other than interactive environment therapy, interactive computer technology is another method used as a therapeutic approach in treating autism. Computers provide support in learning about social-emotional cues (Blocher, 1999). The child could match dolls with a video clip by touching and picking up the appropriate dolls. As a result, the system showed that the human-intensive, repetitive aspects of behavioural therapy techniques can be automated. Robotic and computerised therapies may generate a response imitating human interaction but the concern is the cost of robotic therapy that

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may affect the consistency of therapy session attendance. Due to the small supply in demand, the robot is not mass produced and, thus, would cost a lot more. This may limit the number of parents seeking this type of treatment for their children.

Animal therapy such as using dogs has also been introduced in treating children with autism. A study done by Solomon (2010) paired autistic children with a dog to see the social engagement, interactions, and activities between the two. It is believed that animals play a vital role in the children’s development, especially in terms of imagination, play, empathy, and morality (Melson, 2001; Ascione, 2005). It was also reported that children benefitted from the presence of a trained dog, which could boost their confidence in interacting with animals (Somolon, 2010). Although there is evidence supporting that dogs aid children in their growth development, there are a few other considerations that might need attention such as the child’s allergy towards dog fur or the dog’s illness that may affect the child (Burrows, Adams, & Millman, 2008).

Next, this study will focus on how music therapy acts as a medium of treatment.

2.2 BACKGROUND ON MUSIC THERAPY AS A MEDIUM OF TREATMENT Music therapy has been recognised, applied, and has yielded good results for participation in a wide range of healthcare and social contexts (Bunt & Stige, 2014) such as in medical, behavioural, psychodynamic, and humanistic contexts (Bunt &

Stige, 2014). Music has shown to benefit not only people with autism but also critically ill patients in coronary and surgical Intensive Care Units (ICU) that uses music therapy to increase their physiological and psychological impact (Updike, 1990). Group music therapy has proven to be effective in delaying the deterioration of cognitive function, specifically in patients with mild and moderate dementia (Chu et al., 2014).

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According to Weinberger (1998), almost the entire cerebral cortex of people who play music is active during a musical performance. This would be a desirable outcome for children with autism as they have weaker connections between brain cells that will continue to be weaker if it is not used (Abram, 2014). It is postulated that music could activate neurons in the brain and, therefore, it may be useful to strengthen the neural connections, which may result in better health and psychological outcomes for children with autism. Lim (2010) and Whipple (2004) reported that music training is an effective tool for children with high or low levels of functioning, irrespective of age group.

Music has a significant role in the development of the brain and, besides serving the element of fun in the process of enhancing skills (Weinberger, 1998), creates a safe environment for the children and enables them to develop skills simultaneously.

Exposure to music is crucial during childhood as it especially assists in language development (McPherson & Welch, 2018). Both language and music are perceived as pitch patterns that could transmit cultural meaning (Scott, 2015). Given the similarities in language and music, it is possible that they might influence one another in the acquisition of proficiency (Scott, 2015). Music therapy is also known as a noninvasive and inexpensive therapy that could reduce symptoms in mental illnesses (Chu et al., 2014).

Music therapy has often been recommended after assessments on the clients are made. It incorporates activities such as singing, dancing, listening to music, or playing instruments (Madsen, Cotter, & Madsen, 1968; Abram, 2014) as a reinforcement to modify behaviour. According to Abram (2014), the skills the clients develop throughout the sessions may be generalized to other settings, such as at home with family members, instead of only manifesting it to the therapist.

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Music therapy uses musical interaction as a means of nonverbal communication, particularly for patients who are not accessible through verbal language (Gold et al., 2004). Music could help the therapist initiate interaction and build therapeutic relationship among children with autism while, at the same time, show compliant behaviour towards the therapist (Kim et al., 2009). This indicates that music could assist in building therapeutic relationship. Not only could it could improve social interaction, it could also be a platform to express a child’s personality and feelings (Gold, Wigram,

& Elefant, 2006).

Improvisational Music Therapy (IMT) has been commonly used in most studies involving children because it is a child-centred therapy (Wigram & Gold, 2006). It helps to develop spontaneous self-expression, emotional communication, and social interaction in children with autism (Kim, Wigram, & Gold, 2008; Kim et al., 2009).

IMT uses “musical attunement”, which is a process of matching the child’s musical and non-musical expressions with a child’s pulse, movement, or expression to further generate a musical connection as well as therapeutic relationship between the child and the therapist (Kim et al., 2008). IMT yields longer occurrences of joy, emotional synchronicity and initiation of engagement behaviours in the children (Kim et al., 2009).

2.3 RELATIONSHIP BETWEEN MUSIC THERAPY AND AUTISM

Music therapy has been found to help children diagnosed with autism improve their ability in social interaction and has yielded positive outcome such as improvement in nonverbal cues, namely eye contact, sharing, and turn-taking (Abram, 2014). Evidence showed that children diagnosed with autism at an early age were seen to possess difficulties in engaging and sustaining joint attention (Gold, Wigram, & Elefant, 2006).

Joint attention refers to two individuals giving their attention to a single object

EFFECT OF MUSIC THERAPY ON SOCIAL