Effects of Improvisational Music Therapy vs Enhanced Standard Care on Symptom Severity Among Children With Autism Spectrum Disorder: The TIME-A Randomized Clinical Trial

Abstract

Importance: Music therapy may facilitate skills in areas affected by autism spectrum disorder (ASD), such as social interaction and communication.

Objective: To evaluate effects of improvisational music therapy on generalized social communication skills of children with ASD.

Design, setting, and participants: Assessor-blinded, randomized clinical trial, conducted in 9 countries and enrolling children aged 4 to 7 years with ASD. Children were recruited from November 2011 to November 2015, with follow-up between January 2012 and November 2016.

Interventions: Enhanced standard care (n = 182) vs enhanced standard care plus improvisational music therapy (n = 182), allocated in a 1:1 ratio. Enhanced standard care consisted of usual care as locally available plus parent counseling to discuss parents' concerns and provide information about ASD. In improvisational music therapy, trained music therapists sang or played music with each child, attuned and adapted to the child's focus of attention, to help children develop affect sharing and joint attention.

Main outcomes and measures: The primary outcome was symptom severity over 5 months, based on the Autism Diagnostic Observation Schedule (ADOS), social affect domain (range, 0-27; higher scores indicate greater severity; minimal clinically important difference, 1). Prespecified secondary outcomes included parent-rated social responsiveness. All outcomes were also assessed at 2 and 12 months.

Results: Among 364 participants randomized (mean age, 5.4 years; 83% boys), 314 (86%) completed the primary end point and 290 (80%) completed the last end point. Over 5 months, participants assigned to music therapy received a median of 19 music therapy, 3 parent counseling, and 36 other therapy sessions, compared with 3 parent counseling and 45 other therapy sessions for those assigned to enhanced standard care. From baseline to 5 months, mean ADOS social affect scores estimated by linear mixed-effects models decreased from 14.08 to 13.23 in the music therapy group and from 13.49 to 12.58 in the standard care group (mean difference, 0.06 [95% CI, -0.70 to 0.81]; P = .88), with no significant difference in improvement. Of 20 exploratory secondary outcomes, 17 showed no significant difference.

Conclusions and relevance: Among children with autism spectrum disorder, improvisational music therapy, compared with enhanced standard care, resulted in no significant difference in symptom severity based on the ADOS social affect domain over 5 months. These findings do not support the use of improvisational music therapy for symptom reduction in children with autism spectrum disorder.

Trial registration: isrctn.org Identifier: ISRCTN78923965.

Figure 1.. Flow of Participants Through the Study

Numbers assessed are based on valid data for the primary outcome. The intermediate assessment at 2 months was optional at UK sites. ASD indicates autism spectrum disorder; IQR, interquartile range. ^aRefers to migrant families unable to complete questionnaires or complete clinical interviews because of insufficient command of the country’s main language(s). ^bHigh-intensity music therapy comprised 3 music therapy sessions per week (up to 60 sessions). ^cEnhanced standard care comprised parent counseling (3 sessions) plus usual care. ^dLow-intensity music therapy comprised 1 music therapy session per week (up to 20 sessions).

Figure 2.. Effects of Interventions Over Time: Predicted Mean Values From Linear Mixed-Effects Models

Graphs illustrate the predicted values from linear mixed-effects models presented in eTables 5 and 6 in Supplement 2. Autism Diagnostic Observation Schedule (ADOS) social affect score (range of possible scores, 0-27; higher scores indicate greater severity; minimal clinically important difference, 1) over 5 months was the primary outcome. For the Social Responsiveness Scale (SRS) total, range of possible scores, 0 to 195; higher scores indicate greater severity. High-intensity music therapy comprised 3 music therapy sessions per week (up to 60 sessions); low-intensity music therapy comprised 1 music therapy session per week (up to 20 sessions).