The Autism Spectrum: A Changing Perspective

Within the world of music therapy, behavioral, social, and communication needs in autism spectrum disorder have often been the focus of research and treatment. Sensory needs have been briefly studied, but not to the level of these other goal domains. However, as the understanding of autism is constantly evolving, it is important to keep up to date with new information and understand the shift in perspective from a social-behavioral disorder to a neurological disorder with underlying sensorimotor deficits that must be addressed before significant progress can be made in other goal domains. So while we know that social skills and communication are important to work on, we are beginning to see that sensory processing and motor planning deficits may be the underlying factors contributing to the behavioral, social, and communication challenges that these individuals experience (Hardy & LaGasse, 2013).  

Sensory processing and integration deficits are present in individuals on the autism spectrum (American Psychiatric Association [APA], 2013), and manifest as sensory-seeking and sensory-avoiding behaviors (Baranek, et al., 2007; Baranek, et al., 2006). Deficits in sensory integration are more generally referred to as sensory dysfunction (Ayres, 1972). Sensory dysfunction refers to the inability to organize sensory input from the environment and one’s own body in an adaptive manner that allows one to respond to and navigate within the environment effectively. Research suggests that sensory dysfunction is prevalent in at least 70% of individuals on the spectrum (Adamson, O’Hare, & Graham, 2006; Greenspan & Wieder, 1997; Mayes & Calhoun, 1999; Tomchek & Dunn, 2007). Furthermore, study results indicate that individuals on the spectrum may present with a dysfunction in integrating proprioceptive input specifically (Blanche, Reinoso, Chang, & Bodison, 2012).

Research cites that sensory dysfunction present in individuals on the spectrum may be due to cerebellar differences (Allen & Courchegne, 2003). The cerebellum is involved in processing sensory input—including proprioceptive input— and appropriately modulating responses. However, while cerebellar differences in ASD are present, rhythmic synchronization abilities have shown to be unaffected in children and adults with cerebellar abnormalities (Molinari et al., 2005). 

As rhythm is processed within the cerebellum, and auditory feedback from the environment can be utilized to aid in proprioceptive muscular control (Thaut, Kenyon, Schauer, & McIntosh, 1999), intact rhythm processing functions can have implications on sensory integration. Furthermore, auditory and proprioceptive input may work together to optimize sensory integration.

Research illustrates that the cerebellum is cited as a primary neural structure involved in proprioception and rhythm processing, thus implying that proprioceptive input and rhythmic stimuli can be utilized to target activation within the cerebellum. The presentation of multi-sensory input—specifically, the combination of tactile and proprioceptive input—that relies on similar neural regions has resulted in heightened neural responses (Kavounoudias et al., 2008). Thus, the combination of proprioceptive input with rhythmic stimuli, both processed in similar neural regions, could enhance neural processing of such stimuli (Bruce, Desimone, & Gross, 1981; Downar et al., 2000; Kavounoudias et al., 2008; Macaluso & Driver 2001). Additional studies have suggested that combining proprioceptive and rhythmic input promotes and optimizes sensory integration by appealing to multiple perceptual channels within the cerebral cortex (Bruce, Desimone, & Gross, 1981; Downar et al., 2000;  Kavounoudias et al., 2008; Macaluso & Driver 2001; Thaut, 1984). In other words, as evidence suggests that proprioceptive input and rhythmic stimuli improve self-regulation and neural processing, these stimuli in combination may have positive effects on sensory integration.

Thus, music therapists have an integral tool to their disposal that may be the key to improving sensory integration in individuals with ASD: rhythm. Rhythmic auditory stimuli may influence how other stimuli are perceived and integrated, which can ultimately assist in one being able to modulate adaptive responses (Ayres, 1972; James et al., 1985).

 Currently, not much research exists examining the combined effects of rhythmic auditory stimuli with other sensory input to enhance sensory integration in individuals with ASD. I had the pleasure of utilizing the aforementioned research studies as a theoretical framework for my master’s thesis, which examined the effects of rhythmic proprioceptive input on sensory integration and attention in children with autism spectrum disorder. 

Two randomized groups with ASD— one receiving a protocol integrating rhythmic auditory stimuli with proprioceptive input via bouncing on a therapy ball in rhythm to music with physical assistance from the therapist (rhythmic proprioceptive input) and one receiving proprioceptive input alone without an auditory or physical cue— were compared on visual and auditory sustained and selective attention outcomes post intervention. The rhythmic proprioceptive input group performed better than the proprioceptive input group on all assessments and significantly better on visual sustained attention measures. While further research is needed to support the effects of this intervention, initial evidence supports rhythms role in conjunction with proprioceptive input to support sensory integration and attention. Rhythm may provide a structure via an organized temporal stimulus to enhance cognitive focus, create a sense of expectation, and provide an additional layer of sensory stimulation that further engages the cerebellum and enhances sensory integration (Lockhart, 2017). 

I want to make sure to emphasize that more research is needed, but preliminary evidence supports the use of rhythmic auditory stimuli to enhance sensory integration. However, that does not mean we can’t translate current evidence into music therapy practice. Utilizing what we know, music therapists can assist in sensory integration by providing interventions which incorporate multi-sensory input, and in particular, utilize rhythm as the underlying foundational framework. Within a music therapy intervention, this could involve bouncing or rolling on a therapy ball, providing deep pressure via body mapping, or utilizing any other movement or motor planning intervention combined with rhythmic auditory stimuli in the form of a metronome or appropriate live or recorded music. Rhythmic structures that are repetitive and simple, utilizing mostly binary forms and minimum syncopation, and utilize the same meter and similar tempos throughout the intervention have currently proven to be most beneficial (Hardy & LaGasse, 2013; Hardy, 2016; Kalas, 2012; Molinari, Leggio, & Thaut, 2007; Stevens & Byron, 2009; Thaut, Kenyon, Schauer, & McIntosh, 1999). 

 With all the new and ever changing autism research out there, music therapists working with this population should make sure they keep up with current research and most importantly, be thoughtful of the sensory seeking behaviors they observe in their clients on the autism spectrum. These behaviors serve a purpose, and rather than stopping a client from stemming, be creative and think of ways that you can optimize the sensory integration experience in a functional, adaptive manner.  

References

Adamson, A., O’Hare, A., & Graham, C. (2006). Impairments in sensory modulation in children with autistic spectrum disorder. British Journal of Occupational Therapy, 69, 357-364

Allen. G., & Courchesne, E. (2003). Differential effect of cerebellar abnormality on cognitive and motor functions in the cerebellum: An fMRI  study of autism. The American Journal of Psychiatry, 160(2), 262-273.

American Psychiatric Association. (2013). Autism spectrum disorder. In Diagnostic and statistical manual of mental disorder (5th ed.) (pp.50-59). Arlington, VA: American Psychiatric Association.

Ayres, A.J. (1972). Sensory integration and learning disorders. Los Angeles: Western Psychological Services. 

Baranek, G.T., Boyd, B.A., Poe, M.D., David, F.J., & Watson, L.R. (2007). Hyper-responsive sensory patterns in young children with autism,  developmental delay, and typical development. American Journal of Mental Retardation, 112, 233-245. 

Baranek, G.T., David, F.J., Poe, M.D., Stone, W.L., & Watson, L.R. (2006). Sensory experiences questionnaire: Discriminating sensory  experiences in young children with autism, developmental delays, and typical development. Journal of Child Psychology and  Psychiatry, 47, 591-601.

Blanche, E.I., Reinoso, G., Chang, M.C., & Bodison, S. (2012). Proprioceptive processing difficulties among children with autism spectrum  disorders and developmental disabilities. The American Journal of Occupational Therapy, 66(5), 621-624.

Bruce, C., Desimone, R., & Gross, C. G. (1981). Visual properties of neurons in a polysensory area in superior temporal sulcus of the macaque. Journal of  Neurophysiology, 46(2), 369–384.

Downar, J., Crawley, A. P., Mikulis, D. J., & Davis, K. D. (2000). A multimodal cortical network for the detection of changes in the sensory environment. Nature Neuroscience, 3(3), 277–283.

Greenspan, S.I., & Wieder, S. (1997). Developmental patterns and outcomes in infants and children with disorder in relating and communicating: A chart review of 200 cases of children with autism spectrum diagnoses. The Journal of Developmental and Learning Disorders, 1(1),                                              1-38.

Hardy, M.W. (2016). Guest Editorial. Music Therapy Perspective. Advance online publication. doi: 10.1093/mtp/miw008

Hardy, M.W., & LaGasse, B.A. (2013). Rhythm, movement, and autism: Using rhythmic  rehabilitation research as a model for autism. Frontiers  in Integrative Neuroscience, 7(19), 1-9.

James, M.R., Weaver, A.L., Clemens, P.D., & Plaster, G.A. (1985). Influence of paired auditory and vestibular stimulation on levels of motor skill  development in a mentally retarded population. Journal of Music Therapy, 22(1), 22-34.

Kalas, A. (2012). Joint attention responses of children with autism spectrum disorder to simple versus complex music. Journal of Music Therapy, 49(4), 430-452.

Kavounoudias, A., Roll, J.P., Anton, J.L., Nazarian, B., Roth, M., & Roll, R. (2008). Proprio-tactile integration for kinesthetic perception: An fMRI study. Neuropsychoelogia, 46, 567-575.

Lockhart, A. (2017). The effect of rhythmic proprioceptive input on attention in children with autism spectrum disorder (ASD): An exploratory  study (Master’s thesis). Retrieved from  University of Miami Scholarly Repository Database. (661). 

Macaluso, E., & Driver, J. (2001). Spatial attention and crossmodal interactions between vision and touch. Neuropsychologia, 39(12), 1304-1316.

Mayes, S.D., & Calhoun, S.L. (1999). Symptoms of autism in young children and correspondence with the DSM. Infants and Young Children, 12(2), 90-97.

Molinari, M., Leggio, M.G., Filippini, V., Gioia, M.C., Cerasa, A., & Thaut, M.H. (2005). Sensorimotor transduction of time information is preserved in subjects with cerebellar damage. Brain Research Bulletin, 67, 448-458.

Stevens, C., & Byron, T. (2009). Universals in music processing. In S. Hallam, I. Cross, & M. Thaut (Eds.) OxfordHandbook of Music Psychology (pp. 14-23). Oxford University Press. 

Thaut, M.H. (1984). A music therapy treatment model for autistic children. Music Therapy Perspectives, 1(4), 7-13.

Thaut, M.H., Kenyon, G.P., Schauer, M.L., & McIntosh, G.C. (1999). The connection between rhythmicity and brain function: Implications for therapy of movement disorders. Engineering in Medicine and Biology, 18(2), 101-108.

Tomcheck, S., & Dunn, W. (2007). Sensory processing in children with and without autism: A comparative study using the Short Sensory Profile. The American Journal of Occupational Therapy, 61(2), 190-200.