Journal of Music Therapy, 49(4), 2012, 430–452 G 2012 by the American Music Therapy Association

Joint Attention Responses of Children with Spectrum Disorder to Simple versus Complex Music

Amy Kalas, MM, MT-BC Downloaded from https://academic.oup.com/jmt/article/49/4/430/942992 by guest on 30 September 2021 University of Miami, United Cerebral Palsy of Miami

Background: Joint attention deficits are viewed as one of the earliest manifestations and most characteristic features of the social deficits in Disorder (ASD). Purpose: The purpose of this study was to examine the effect of simple versus complex music on joint attention of children with ASD. Method: Thirty children with a diagnosis of ASD participated in this study. Fifteen of the participants were diagnosed with severe ASD and 15 were diagnosed with mild/moderate ASD. Each participant took part in six, 10-minute individual music conditions (3 simple & 3 complex) over a 3-week period. Each condition was designed to elicit responses to joint attention. Results: Results indicated a statistically significant interaction between music modality and functioning level. Therefore, the effect of simple versus complex music was dependent on functioning level. Specifically, the Simple Music Condition was more effective in eliciting Responses to Joint Attention (RJA) for children diagnosed with severe ASD, whereas the Complex Music Condition was more effective in eliciting RJA for children diagnosed with mild/moderate ASD. Conclusions: The results of the present study indicate that for children in the severe range of functioning, music that is simple, with clear and predictable patterns, may be most effective in eliciting responses to bids for joint attention. On the contrary, for children in the mild/moderate range of functioning, music that is more complex and variable may be most effective in eliciting responses to bids for joint attention. These results demonstrate that careful manipulation of specific musical elements can help provide the optimal conditions for facilitating joint attention with children with ASD. Key words: autism; joint attention; music therapy; simple music; complex music

This research was completed in partial fulfillment of the Master of Music in Music Therapy degree at University of Miami. The author wishes to express her sincerest gratitude to Dr. Teresa Lesiuk and Dr. Shannon de l’Etoile for their support and guidance with the completion of this study and manuscript. Vol. 49, No. 4, Winter 2012 431

Impairment in social skills is one of the primary deficits in children with Autism Spectrum Disorder (ASD). Impaired social skills are manifested in lack of nonverbal communication behaviors, impairments in eye gaze and facial expressions, lack of peer relationships, lack of shared enjoyment, and lack of social Downloaded from https://academic.oup.com/jmt/article/49/4/430/942992 by guest on 30 September 2021 or emotional reciprocity (Cassel et al., 2007; Sapp, 2008). Although the diagnostic criteria for ASD also include impaired communication skills and repetitive and stereotyped patterns of behavior, deficits in social skills may be the most pervasive and difficult to overcome (American Psychiatric Association, 1994; Brownell, 2002). Joint attention deficits are viewed as one of the earliest manifestations and most characteristic features of the social deficits in ASD. The Diagnostic and Statistical Manual lists joint attention as part of the diagnostic criteria for ASD (American Psychiatric Association, 1994). Joint attention is the process of engaging another person’s attention to share in the experience of observing an object or event (Mundy & Acra, 2006). Joint attention can be divided into two categories: Responding to Joint Attention (RJA) and Initiation of Joint Attention (IJA). This study focused on Responding to Joint Attention (RJA), which involves responding to a bid for joint attention from another person by point following or gaze following (Mundy & Acra, 2006). Point following involves looking in the direction of the object or event that is being pointed to. Gaze following involves looking at the object or event of interest and then monitoring the adult’s attention. Initiation of Joint Attention (IJA) involves directing another person’s attention to an object or event by or showing. Children with ASD experience significant delays in the development of both initiating and responding to joint attention (Roeyers, VanOost, & Bothuyne, 1998). Although joint attention is a social communication behavior, it must be explained within the broader context of cognition and attention to be fully understood. Joint attention is the product of two interrelated attention-regulation systems—the anterior and posterior attention systems (Mundy, Card, & Fox, 2000; Posner & Rothbart, 2007). The anterior attention system, which controls goal-directed behavior, plays a primary role in IJA. Neuro- anatomically, this system involves the frontal eye fields, the pre- frontal association cortex, the dorsal anterior cingulate, and the 432 Journal of Music Therapy orbital prefrontal association cortex (Mundy & Acra, 2006; Mundy & Newell, 2007; Mundy & Thorp, 2006). The posterior orienting and perceptual attention system supports RJA. This system, which begins to develop in the first months of life, is controlled by the

posterior parietal association area, the superior temporal cortex, Downloaded from https://academic.oup.com/jmt/article/49/4/430/942992 by guest on 30 September 2021 and the parietal, temporal, and occipital association cortices (Mundy & Acra, 2006; Mundy & Newell, 2007; Mundy & Thorp, 2006). Because joint attention requires the ability to monitor and integrate information about the attention of self and others, it involves the coordinated activation of this distributed cortical network (Mundy & Newell, 2007). Recent research suggests that cognitive impairments in ASD are directly related to disturbances in communication between brain regions, particularly the anterior and posterior cortical connec- tions (Cherkassky, Kana, Keller, & Just, 2006). Based on these observations, joint attention deficits may be one of the earliest behavioral manifestations of atypical neural development in children with ASD (Mundy & Newell, 2007). Many interrelated factors play a role when a child is developing joint attention skills including attention regulation, imitation, and the ability to monitor self and others. These processes are involved in social attention coordination and must become fully integrated to engage in joint attention, and are often disturbed in children with ASD (Mundy et al., 2000). Joint attention deficits may also be caused by difficulties in disengaging attention; children with ASD tend to be overly focused on an object and are impaired in their ability to shift visual attention (Ibanez, Messinger, Newell, Lambert, & Sheskin, 2008; Landry & Bryson, 2004; Rincover & Ducharme, 1987; Wainwright & Bryson, 1993; 1996). This impaired disengagement may explain some of the characteristic features of ASD, including deficits in eye contact, social orienting, and joint attention (Ibanez et al., 2008). Children with ASD also have difficulties with sensory integra- tion and experience deficits in organizing sensory input. Sensory integration is the process of taking in and organizing a multitude of unorganized bits of sensory information. In a typically functioning system, the bombardment of internal and external sensory stimuli is processed in an effective manner and these bits of information are organized into cohesive whole pictures that the brain can then process (Berger, 2002). However, in children with Vol. 49, No. 4, Winter 2012 433

ASD, sensory overload is common. The sensory systems of children with ASD are receiving constant sensory information that appears to have no sequence and no temporal order. In short, there is more input than the brain can sort out, leading to a

state of sensory disorganization (Berger, 2002). Downloaded from https://academic.oup.com/jmt/article/49/4/430/942992 by guest on 30 September 2021 The deficits in joint attention that children with ASD experience may be related to difficulties they have with sensory integration and the organization of sensory input. Children with ASD may have trouble organizing the multitude of sensory input they are receiving from their environment, leading them to have difficulty shifting their focus from one object to reengage with another (Berger, 2002). Children with ASD can be taught to develop joint attention behaviors through specific interventions (Dawson & Zanolli, 2003). However, the way in which children with ASD acquire joint attention skills is different from that of children who are typically developing. Whereas the for typically-devel- oping children to attend to and engage in repeated episodes of joint attention comes from a shared affective experience, children with ASD are motivated by a desired object or activity (Corkum & Moore, 1998; Mundy, Sigman, & Kasari, 1994). Joint attention skills are usually taught to a child with ASD by encouraging them to respond to a bid for joint attention by following a pointing or gaze to a desired object (Bernier, Webb, & Dawson, 2006). A bid for joint engagement is defined as an attempt to gain the attention of another person by pointing or gazing at an object or event to share in the experience. The desired object or activity then becomes the reward for the child’s response to the bid for joint attention. Subsequently, the motivation for the continuation of joint attention behaviors revolves around the child’s level of interest in the object or activity (Bernier et al., 2006; Reitman, 2006). Music is an effective motivator for eliciting attention, particu- larly joint attention, in children with ASD (Kim, Wigram, & Gold, 2008; Reitman, 2006). Musical instruments and activities that are motivating to the child with ASD can be used as the desired object or activity that facilitates joint attention. A number of studies demonstrate that some children with ASD have musical sensitivity and a perceptual preference for music, which facilitates increased attention to musical stimuli (Blackstock, 1978; Frith, 1972; Thaut, 434 Journal of Music Therapy

1987). Because of the increased attention to musical stimuli, music- based interventions can be a motivating medium for addressing social communication behaviors such as joint attention. The favorable effects of music for children with ASD are due to specific musical elements that facilitate the perceptual organiza- Downloaded from https://academic.oup.com/jmt/article/49/4/430/942992 by guest on 30 September 2021 tion of auditory stimuli. Because children with ASD have a dysfunctional sensory system, the ordering of auditory stimuli that occurs in music helps to organize and make sense of the sensory input they are receiving (Berger, 2002; Lim, 2007; Thaut, 2008; Wigram & Gold, 2006). Musical patterns and temporal organiza- tion provide necessary structure for children with ASD. Thus, the organization of auditory information that occurs in music may focus their attentional resources, allowing them to shift focus to the object or instrument of interest and participate in joint interaction (Wigram & Gold, 2006). Studies by Reitman (2006) and Kim, Wigram, and Gold (2008) provide evidence that music-based interventions can elicit joint attention behaviors in children with ASD. However, these studies presented little information as to the type or characteristics of the music that was used. Further, little information was provided on how the music impacted joint attention behaviors. The current study contributes to the growing body of literature by providing information on what specific type of music modality (simple or complex) is most effective in obtaining the attention of children with ASD and facilitating joint interaction. In addition, as far as can be determined, no research has compared attentional response to music in children diagnosed with severe ASD versus children diagnosed with mild/moderate ASD. Because autism exists along a wide spectrum, research is needed to determine whether the functioning level of the child with ASD has an effect on joint attention behaviors during music therapy, and whether there is an interaction with music modality. These findings will inform the development of specific and effective therapeutic protocols for increasing joint attention behaviors in children diagnosed with severe ASD and children diagnosed with mild/moderate ASD. The purpose of this study was to examine the effect of simple versus complex music on joint attention of children with ASD. In this study, the following research questions were addressed for children with ASD: (a) Does the child’s level of functioning have Vol. 49, No. 4, Winter 2012 435 an effect on response to joint attention during a musical experience? (b) Does music modality, simple versus complex, have an effect on the child’s response to joint attention? (c) Does music modality interact with level of functioning? Downloaded from https://academic.oup.com/jmt/article/49/4/430/942992 by guest on 30 September 2021 Method Participants Thirty children, ages four, five, and six, with a primary diagnosis of Autism Spectrum Disorder (ASD) participated in this study. Participants were recruited from early childhood intervention programs in South Florida. Based on scores from the Childhood Autism Rating Scale (CARS), participants were separated into one of two groups: 15 of the participants were placed in the severe group and 15 were placed in the mild-moderate group (Schopler, Reichler, & Renner, 1988).

Design and Variables A23 2 repeated measures factorial design was implemented in this study to examine whether the independent variables of music modality and level of functioning had an effect on the dependent variable of RJA (Gravetter & Wallnau, 2008). The independent variable of music modality had two levels: Simple Music Condition and Complex Music Condition. The independent variable of functioning level had two levels: severe and mild/moderate. The dependent variable was RJA, measured by the number of times the child responded to a bid for joint attention by following a pointing gesture towards the object or instrument of interest. Simple music condition. Both the Simple and Complex Music Conditions were designed to facilitate joint attention in children with ASD. The Simple Music Condition (SMC) was defined as a musical intervention with a simple melody and simple musical accompaniment on keyboard. The simple melody was sung on the beat with no syncopation, had a range of no more than an octave, and moved in mostly stepwise motion with no chromatic notes. The simple accompaniment consisted of blocked chords on keyboard once every two beats. Harmonically, the simple accompaniment style used a minimum number of chord changes, typically I, IV, and V (Groene, 2001). See Figure 1 for musical notation of a song from the SMC. 436 Journal of Music Therapy Downloaded from https://academic.oup.com/jmt/article/49/4/430/942992 by guest on 30 September 2021

FIGURE 1. Notation of simple music stimuli.

Complex music condition. The Complex Music Condition (CMC) was defined as a musical intervention with a complex melody and complex musical accompaniment on keyboard. The complex melody was sung with syncopation or dotted rhythms. The complex accompaniment used the following keyboard techniques: auto accompaniment with various musical styles (i.e., boogie or salsa); an introduction pattern; and an ‘outro’ pattern as a cadence at the end of the song. Harmonically, the complex accompaniment style used more chords outside the basic I, IV, V structure. Dominant chords, 9th chords, and minor chords were added (Groene, 2001). See Figure 2 for musical notation of a song from the CMC.

Measures Early social communication scales (ESCS). The ESCS are a structured play assessment measuring non-verbal social communication Vol. 49, No. 4, Winter 2012 437 Downloaded from https://academic.oup.com/jmt/article/49/4/430/942992 by guest on 30 September 2021

FIGURE 2. Notation of complex music stimuli. skills that usually emerge in children between 8 and 30 months of age (Mundy et al., 2003). The scales are appropriate for typically developing children within this age range or for children with developmental delays whose verbal age may fall within this range. In this study, the administration and coding of the ESCS were adapted for use during musical experiences. Information from the ESCS was used to help develop six structured musical experiences comparable to the nonmusical experiences used during the original ESCS. These musical experiences were designed to elicit 438 Journal of Music Therapy responses to bids for joint attention. Information from the ESCS also served as a guideline for the design of a data collection sheet and provided a specific description of RJA to ensure accurate coding. Downloaded from https://academic.oup.com/jmt/article/49/4/430/942992 by guest on 30 September 2021 Materials The following materials were used to conduct the research study: data collection form, sheet music, Yamaha PSR-172 keyboard, REMO ocean drum, green stuffed frog, REMO gathering drum, REMO mallet, pink ball, picture book ‘‘What’s in the Jungle?’’ (Seymour, 1988), BASIC BEAT resonator bells (notes G, C, & D), SONY video camera, and tripod.

Procedure The study received approval from the Institutional Review Board of the University of the University of Miami. Subsequently, participants were recruited from early childhood intervention programs in South Florida. Each participant took part in six, 10- minute individual music conditions over a 3-week period. The researcher controlled for order effects a priori by randomly assigning children in each of the functioning groups to one of the two counterbalanced conditions (simple and complex). Of the participants with mild/moderate ASD, one-half received three sessions of the Simple Music Condition (SMC) the first week followed by a week of no treatment, followed by three sessions of the Complex Music Condition (CMC) the next week. The other half of the participants with mild/moderate ASD received three sessions of the CMC the first week, followed by a week of no treatment, followed by three sessions of the Simple Music Condition the next week. The same procedure was carried out for participants with severe ASD. The week of no treatment in between the two music conditions was to control for learning effects. While counterbalancing is intended to control for order effects a priori, to assess the adequacy of this approach the researcher ran an additional statistical test to determine whether or not order effects were present (see Inferential Analysis Results). The same music activities were used in both the SMC and CMC, the only difference being the music presentation style. The order of activities was as follows: Vol. 49, No. 4, Winter 2012 439

Monday: Ocean Drum Activity and Frog Activity; Wednesday: Gathering Drum Activity and Ball Activity; Friday: Resonator Bell Activity and Book Activity. Sample procedure — Ocean Drum Activity. The child entered the room with the therapist and was directed to sit down on the Downloaded from https://academic.oup.com/jmt/article/49/4/430/942992 by guest on 30 September 2021 therapy mat. The music therapist then placed the ocean drum between herself and the child. The music therapist sang ‘‘Listen to the Ocean Drum’’ while rocking the ocean drum back and forth with her left hand and playing the keyboard with her right hand. When the song had been sung one time, the music therapist continued playing the ocean drum with her left hand, pointed to it with her right hand, and said, ‘‘Look at the ocean drum!’’ This point and verbal direction gave the child his first opportunity to respond to a bid for joint attention by following the pointing gesture to look at the ocean drum. This procedure was repeated a total of five times, giving the child five opportunities to respond to a bid for joint attention by following the pointing gesture to the ocean drum. The procedure for the subsequent activities was the same as the Ocean Drum Activity, with the difference being the object being used to elicit joint attention and how it was manipulated. All sessions in both conditions were recorded with a video camera and stored on videotape for later analysis by the researcher and a second coder.

Data Collection Data were collected using an adapted form of the coding sheet used with the Early Social Communication Scales (Mundy et al., 2003). The Data Collection Form was used to tally frequency data on the dependent variable: Responding to Joint Attention (RJA). In each session, 10 opportunities to respond to a bid for joint attention were given to the child, five for each musical activity. The scores of the three Simple Music Conditions were added together for a total possible score of 30. The scores of the three Complex Music Conditions were added together for a total possible score of 30. Two coders watched and recorded data for the study. Training for the two coders was conducted to demonstrate what respond- ing to joint attention looks like and how to code this behavior accurately in the videos. The researcher determined that an 440 Journal of Music Therapy agreement occurred when both raters gave the same score for each musical activity. For example, if the first coder determined that in the book activity the child responded to joint attention four times and the second coder also determined that in the book activity this same child responded to joint attention four times, Downloaded from https://academic.oup.com/jmt/article/49/4/430/942992 by guest on 30 September 2021 this was an agreement. The index of concordance was calculated as percent agreement (i.e., the number of agreements divided by the total number of agreements and disagreements). Once the index of concordance reached .80 in training, the two coders began coding study material. Each coder watched the video tapes independently of each other. For study material, the index of concordance was calculated and found to be .86.

Data Analysis The average scores for the dependent variables were compared in a mixed design Analysis of Variance (ANOVA) to determine if significant differences existed. In the present study, the mixed design ANOVA was used to examine the between-subjects variable of functioning level and the within-subjects variable of music modality.

Results Descriptive Results Frequencies of participant demographics are provided in Table 1. The descriptive results, shown in Table 2, include means and standard deviations of the total RJA scores for the Simple condition, the total RJA scores for the Complex condition, and the grand total RJA scores for children diagnosed with severe ASD and children diagnosed with mild/moderate ASD. The table also includes the mean and standard deviation of the total RJA scores for all participants. The children diagnosed with severe ASD achieved their highest RJA score, 22.33, in the Simple Music Condition. The children diagnosed with mild/moderate ASD achieved their highest RJA score, 25.07, in the Complex Music Condition. The descriptive results, shown in Table 3, include means and standard deviations of the RJA scores for each musical activity for participants diagnosed with severe ASD and participants diag- nosed with mild/moderate ASD. In both the Simple and Complex Vol. 49, No. 4, Winter 2012 441

TABLE 1 Frequency of Participant Demographics

Frequency

Demographic variables Severe Mild/moderate Total Downloaded from https://academic.oup.com/jmt/article/49/4/430/942992 by guest on 30 September 2021 Gender Male 14 14 28 Female 1 1 2 Level of Functioning Severe 15 Mild/moderate 15 Age (in years) 4 448 56410 65712 Ethnicity White non-Hispanic 3 1 4 Black 2 1 3 Hispanic 10 12 22 Other (mixed ethnicity) 0 1 1 Location of Recruitment United Cerebral Palsy 8 4 12 Center for Autism and Related Disabilities 7 11 18

Music Condition, participants diagnosed with both severe and mild/moderate ASD achieved the highest mean RJA scores in the book activity.

Inferential Analysis Results The averages of the dependent variables were compared in a mixed design ANOVA to determine if significant differences existed. Prior to running the mixed design ANOVA, the effect of order was examined. The interaction of order and change over time in RJA scores was not statistically significant (F(1, 26) 5 1.56, p 5 .222). Therefore, order did not have an effect on the change of RJA over time and was not included in the following mixed ANOVA. Table 4 provides the results of the mixed design ANOVA. The interaction effect between functioning level and music modality is depicted in the form of a line graph in Figure 3. Results indicated there was a statistically significant interaction 442 Journal of Music Therapy

TABLE 2 Means and Standard Deviations of the Total Response to Joint Attention (RJA) Scores for each Music Condition

Severe Mild/moderate All participants Downloaded from https://academic.oup.com/jmt/article/49/4/430/942992 by guest on 30 September 2021 M SD M SD M SD

RJA Simple 22.33 7.21 19.40 8.66 20.87 7.97 RJA Complex 15.00 7.95 25.07 7.19 20.03 9.04 RJA Grand Total 37.33 12.64 44.47 14.07 Note. Total possible RJA score for each music condition 5 30. between music modality and level of functioning. The Simple Music Condition was more effective in eliciting responses to bids for joint attention from children diagnosed with severe ASD, whereas the Complex Music Condition was more effective in eliciting responses to bids for joint attention from children diagnosed with mild/moderate ASD. Because there was a significant interaction, a follow up analysis was run to test the significance of the simple effects. First, the

TABLE 3 Means and Standard Deviations of the Response to Joint Attention (RJA) Scores for each Musical Activity

Severe Mild/moderate

MSDM SD

Simple Music Condition Ocean Drum 3.93 1.39 3.60 1.68 Frog 2.80 1.82 2.60 1.96 Gathering Drum 3.40 1.72 2.60 1.55 Ball 3.60 1.68 2.87 1.46 Book 4.47 1.30 4.20 1.61 Resonator Bells 4.13 1.77 3.53 2.03 Total 22.33 7.21 19.40 8.66 Complex Music Condition Ocean Drum 3.07 2.05 4.00 1.85 Frog 2.00 1.60 3.93 1.53 Gathering Drum 2.47 1.69 4.27 0.80 Ball 2.33 1.84 4.40 1.45 Book 3.13 2.03 4.60 1.12 Resonator Bells 2.00 1.60 3.87 2.03 Total 15.00 7.95 25.07 7.20 Vol. 49, No. 4, Winter 2012 443

TABLE 4 Mixed Design Analysis of Variance (ANOVA)

Source SS df MS F p

Music Modality 10.417 1 10.417 0.330 0.570 Downloaded from https://academic.oup.com/jmt/article/49/4/430/942992 by guest on 30 September 2021 CARS Group 190.817 1 190.817 2.135 0.155 Modality * CARS 633.750 1 633.750 20.089 0.001 Error (Modality) 883.333 28 31.548 Error (CARS) 2502.533 28 89.376

effect of functioning level within each modality was examined. In the Simple Music Condition, there was no statistically significant difference in RJA scores between children diagnosed with severe and mild/moderate ASD (F(1) 5 1.02, p 5 .322). In the Complex Music Condition, there was a statistically significant difference in RJA scores between children diagnosed severe and mild/moderate ASD (F(1) 5 13.227, p 5 .001). The mild/ moderate group had a mean joint attention score that was 10.07 points higher than the severe group. Children diagnosed

FIGURE 3. Interaction effect between level of functioning and music modality. 444 Journal of Music Therapy with mild/moderate ASD achieved a higher RJA score (M 5 25.07) than children diagnosed with severe ASD (M 5 15.00). Second, the effect of music modality within each functioning level was examined. For children diagnosed with severe ASD,

there was a statistically significant difference in the RJA scores Downloaded from https://academic.oup.com/jmt/article/49/4/430/942992 by guest on 30 September 2021 between the Simple and Complex Conditions (F(1) 5 11.44, p 5 .004). Children diagnosed with severe ASD had a higher RJA score in the Simple Music Condition (M 5 22.33) than in the Complex Music Condition (M 5 15.00). For children diagnosed with mild/moderate ASD, there was a statistically significant difference in RJA scores between the Simple and Complex Conditions (F(1) 5 8.65, p 5 .011). Children diagnosed with mild/moderate ASD had a higher RJA score in the Complex Music Condition (M 5 25.07) than in the Simple Music Condition (M 5 19.40).

Discussion The purpose of this study was to examine the effect of simple versus complex music on joint attention of children with ASD. The first research question examined whether level of functioning of a child with ASD has an effect on RJA during a musical experience. Because the effect of functioning level on RJA was found to be dependent on music modality, simple effects were used to answer this question. Within the Simple Music Condition, there was no statistically significant difference in RJA scores between children diagnosed with severe ASD and those diagnosed with mild/moderate ASD. However, within the Complex Music Condition, there was a statistically significant difference in RJA scores between children diagnosed with severe ASD and those diagnosed with mild/moderate ASD. In the Complex Music Condition, children with mild/moderate ASD achieved a higher RJA score than those diagnosed with severe ASD. The second research question investigated whether music modality, simple versus complex, has an effect on response to joint attention of a child with ASD. Because the effect of music modality was found to be dependent on level of functioning, simple effects were used to answer this question. Within the group of children diagnosed with severe ASD, there was a statistically significant difference in RJA scores between the Simple and Complex Music Conditions. Children diagnosed with severe ASD had a higher RJA score in the Simple Music Condition than in the Vol. 49, No. 4, Winter 2012 445

Complex Music Condition. Within the group of children diagnosed with mild/moderate ASD, there was a statistically significant difference in RJA scores between the Simple and Complex Music Conditions. Children with mild/moderate ASD

had a higher score in the Complex Music Condition than in the Downloaded from https://academic.oup.com/jmt/article/49/4/430/942992 by guest on 30 September 2021 Simple Music Condition. The final question examined whether there was an interaction between music modality and a level of functioning in a child with ASD. Results indicated there was a statistically significant interaction between music modality and level of functioning. Therefore, the effect of simple versus complex music was dependent on functioning level. The Simple Music Condition was more effective in eliciting responses to bids for joint attention from children diagnosed with severe ASD, whereas the Complex Music Condition was more effective in eliciting responses to bids for joint attention from children diagnosed with mild/moderate ASD. According to the researcher’s observations, participants diag- nosed with severe ASD appeared to be overstimulated during the Complex Music Condition. The multitude of musical stimuli being presented during each song, such as the complex keyboard accompaniment pattern and complex melody, appeared to be overwhelming for some of the children diagnosed with severe ASD. The researcher observed some children holding their hands over their ears when the music started, in what appeared to be an attempt to block out the excess stimuli. These behavioral observations are supported by recent research literature stating that children with ASD, especially those in the severe range of functioning, have difficulties with sensory integration and experience deficits in organizing multifaceted sensory input (Berger, 2002). Children with severe ASD may already be hypersensitive to the multiple environmental stimuli being presented to them at any given time (i.e., the fluorescent lighting, the buzz of a fan, shelves of colorful objects, etc.). Any additional complex auditory stimuli may have been an overload to their sensory systems, leading to a state of sensory disorganization (Berger, 2002). Good Gestalts refer to the idea that pieces of information can be perceived as an organized whole. Musical stimuli are organized and perceived in patterns, which may have helped facilitate the 446 Journal of Music Therapy organization of incoming sensory input for the children with severe ASD during the Simple Music Condition (Wigram & Gold, 2006). Good Gestalts in music facilitate this perceptual organiza- tion, because the brain prefers to process information that is in a

structured form, rather than discrete bits of information (Berger, Downloaded from https://academic.oup.com/jmt/article/49/4/430/942992 by guest on 30 September 2021 2002). Good Gestalts in music provide organized sensory input for the brain and allow activation in the higher channels of cognition to take place (Lim, 2007). Researchers state that children with ASD use this organization of perceptual patterns when processing musical stimuli (Berger, 2002; Heaton, Hermelin, & Pring, 1999; Lim, 2007; Orr, Myles, & Carlson, 1998). Research suggests that the timing of stimulus presentation may be equally as important as the quality of the stimulus (Nelson, Anderson, & Gonzalez, 1984). Clearly-timed auditory information can result in perceivable input, whereas poorly-timed auditory information can results in increased disorganization. In the present study, the Simple Music Condition may have been more effective in eliciting responses to bids for joint attention in children with severe ASD, because of the clearly timed, predictable structure it provided. The even, blocked chords in the bass line accompaniment of the SMC occurred once every two beats, giving the child something predictable and repetitive that occurred over time. The melody of the SMC typically moved in a step-wise motion with few leaps and utilized quarter notes and eighth notes that occurred on the beat. The structured musical elements utilized in the SMC may have provided a sense of rhythmic and melodic predictability for the children with severe ASD. The predictability over time and organizational structure that music provides may have focused the attentional resources of the children with severe ASD, allowing them to shift attentional focus to the object or instrument of interest and participate in joint interaction (Wigram & Gold, 2006). On the contrary, the clear, predictable structure that occurred during the SMC may have been inadequate for the children mild/ moderate ASD. According to the researcher’s observations, participants diagnosed with mild/moderate ASD appeared to be uninterested during the SMC. The musical accompaniment and melody were very simple and predictable, and did not hold the attention of the children diagnosed with mild/moderate ASD for Vol. 49, No. 4, Winter 2012 447 the duration of the song. The researcher observed some children looking around the room for other interesting stimuli, rather than at the object or instrument of interest. In contrast, the CMC was more effective in eliciting responses to bids for joint attention from children diagnosed with mild/ Downloaded from https://academic.oup.com/jmt/article/49/4/430/942992 by guest on 30 September 2021 moderate ASD. These results may have been due to the sense of novelty and variety that the CMC provided. The complex auto accompaniment on the keyboard was novel and different for each song. The melody and rhythmic accompaniment of the CMC typically utilized syncopated rhythms, providing a sense of variety. These musical elements may have served to create expectations and anticipation for upcoming events for the children with mild/moderate ASD. Whereas the SMC was not stimulating enough for the children with mild/moderate ASD, the CMC provided a sense of variety and created anticipation and expectation of what was to come next. These elements may have engaged the attention of the children with mild/moderate ASD, helping them to follow the bid for joint attention towards the object or instrument of interest. The results of the present study may also be interpreted in light of the work done by Berlyne (1971a) with regard to arousal and activation. Arousal and activation states are thought to be critical functions that are related to how the brain and nervous system attend to important stimuli and interact in a meaningful way with the environment (Berlyne, 1971a). During increased states of arousal, the sensory organs and the structures through which they communicate information to the brain are given a heightened sensitivity. This heightened arousal state allows them to take in more sensory information from the external environment and the individual is better at discriminating detail in perceived stimulus patterns (Berlyne, 1971b). On the contrary, research shows that sensory pathways may be blocked or desensitized during times of unusually intense arousal. (Berlyne, 1971b). This research may help explain why the children with severe ASD in the present study were observed holding their hands over their ears during the Complex Music Condition. The multitude of musical stimuli being presented during each song in the Complex Music Condition may have been overwhelming for some of the children. Holding their hands over their ears may have been an attempt to block out the excess stimuli because they were over-aroused. 448 Journal of Music Therapy

Within the context of arousal theory, Berlyne’s Wundt curve can also help to explain the results of the present study (Berlyne, 1971b). In the Wundt curve, as perception of a stimulus reaches the optimal state of simplicity/complexity for the individual, pleasure is at the highest point. When a stimulus is perceived as Downloaded from https://academic.oup.com/jmt/article/49/4/430/942992 by guest on 30 September 2021 too simple or too complex, pleasure is at a decreased level (Berlyne, 1971b). In the case of the present study, the Simple Music Condition seemed to provide the appropriate level of simplicity/complexity for the children diagnosed with severe ASD, leading to the optimal level of arousal. They were neither under stimulated nor overstimulated during the Simple Music Condi- tion. Reaching the optimal level of arousal directed the attention of the children with severe ASD towards the object or instrument of interest, allowing them to be a part of joint engagement. In comparison, the Complex Music Condition seemed to provide the appropriate level of simplicity/complexity for the children diagnosed with mild/moderate ASD, leading to the optimal level of arousal. They were neither uninterested nor overstimulated. Reaching the optimal level of arousal facilitated the attention of the children with mild/moderate ASD towards the object or instrument of interest, allowing them to be a part of joint engagement.

Anecdotal Observations Throughout the course of this study, the researcher recorded many behavioral observations of the children with ASD. Although these participatory behaviors were not directly collected as data, they provide evidence that music is effective in directing the attention of children with ASD. The researcher noted that during the music activities many of the children shifted attention between the object or instrument of interest and the researcher’s face. Additionally, many of the children had positive affect during this shifting of attention, implying they were taking part in a shared affective experience. Further, the researcher noted that many of the children began playing the musical instrument of interest, even though they were not verbally instructed to do so. This observation implies that musical instruments are effective in obtaining the attention of children with ASD and facilitating active engagement. Finally, the researcher noted that some of the children with mild/moderate ASD began singing along with the Vol. 49, No. 4, Winter 2012 449 researcher, even though they were not verbally instructed to do so. Again, this observation implies that activities involving music and musical instruments are effective in obtaining attention the attention of children with ASD and facilitating active

engagement. Downloaded from https://academic.oup.com/jmt/article/49/4/430/942992 by guest on 30 September 2021 The researcher also noted that the book activity was most effective in maintaining the attention of the children with ASD. The results of this study indicated that in both the Simple and Complex Music Condition, participants diagnosed with both severe and mild/moderate ASD achieved the highest mean RJA scores in the book activity. These results may have been due to the fact that the book provided five different pictures—one new picture for each of the five opportunities to respond to joint attention. In the other activities, the instrument or object was the same throughout the song, whereas in the book activity, each page turn revealed a new and different picture for the child. These results may be useful when clinicians are selecting appropriate materials to hold the interest of children with ASD.

Limitations and Implications for Future Research Certain limitations existed within the scope of this research study. The first limitation of the study was that the design did not include a no-music condition. The addition of a control group would have allowed the researcher to see how the RJA of the children would have differed with no music. Conclusions could then have been made about the effectiveness of activities involving music as compared to activities not involving music in eliciting RJA. The second limitation of the study was that autism exists along a wide spectrum and the characteristics of every child on the spectrum are variable. Therefore, with the small sample size that was used, generalizing to the entire population of children with ASD is difficult. If this study is replicated, the use of a larger sample size is recommended. Another area for future research with children with ASD may be shifting attention. Researchers posit that joint attention deficits in children with ASD are caused by difficulties in disengaging attention. Children with ASD tend to be overly focused on an object and are impaired in their ability to shift attention. Therefore, future research in this area might target shifting attention, as a prerequisite behavior to joint attention. 450 Journal of Music Therapy

Conclusions The results of the present study indicate that for children in the severe range of functioning, music that is simple, with clear and predictable patterns, may be most effective in eliciting responses to bids for joint attention. The use of even, blocked chords in the Downloaded from https://academic.oup.com/jmt/article/49/4/430/942992 by guest on 30 September 2021 bass line accompaniment and a step-wise melody with even quarter notes and eighth notes that occur on the beat may provide the clearest structure and help organize the incoming informa- tion for children with severe ASD. On the contrary, for children in the mild/moderate range of functioning, music that is more complex and variable may be most effective in eliciting responses to bids for joint attention. The use of a keyboard auto accompaniment with a variety of styles inherently provides complexity in the rhythmic patterns and bass line accompaniment. In addition, the use of syncopation in the melody may be used to provide a sense of novelty for children with mild/moderate ASD and create anticipation of what is to come next. These results demonstrate that careful manipulation of specific musical elements can help provide optimal conditions for facilitating joint attention with children with ASD. Because autism exists along a wide spectrum, examining effects according to level of functioning is crucial. Each group has their own specific characteristics and needs, and the flexible nature of music makes it an effective medium for addressing these multifarious needs.

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