The Therapeutic Relationship As Outcome Predictor in Music Therapy with Children with Autism

Background: Shaping sensory perceptions, regulating affective dynamics, or joining attention are abilities that enable human beings to relate. Children with an autism spectrum condition (ASC) can face challenges in all of these areas. However, their bodily and emotional expressions form and inform relational abilities. By creating music that is embodied and attuned to the child’s relational resources, therapists might effectively strengthen the child’s social skills on a generalized level.

Objectives: The aim of the present study was to examine whether a therapeutic relationship, in which the therapist is attuned to the child’s expression and behavior, predicts generalized changes in social skills in children with ASC.

Methods: This predictor study included music therapy sessions from 48 children from 7 countries worldwide who were between 4 and 7 years of age and diagnosed with ASC. Improvisational music therapy was provided weekly over a period of 5 months. Generalized interaction skills were measured using the Autism Diagnostic Observation Schedule (ADOS) and the Social Responsiveness Scale (SRS) questionnaire at baseline, 5 and 12 months. The therapeutic relationship was assessed using the evaluation tool for Assessing the Quality of Relationship (AQR). Associations between the therapeutic relationship and generalized outcomes have been analyzed using a linear mixed effect model.

Results: This study found significant interaction effects between the therapeutic relationship and generalized changes in social skills in children with ASC. A symptom reduction as measured with the Autism Diagnostic Observation Schedule (ADOS) was found after 12 months (B = -3.89; CI = -7.51, - 0.26; p = 0.0399), if a relationship was developed in which the therapist was emotionally and musically attuned to the child’s affective and relational needs. ADOS subgroup analysis showed a significant decrease of symptoms especially in the area of language and communication (B = -1.79; CI = -3.46, -0.12; p = 0.0402). Also problems in social responsiveness decreased more over the course of 5 months as measured with the SRS (B = -23.46; CI = -45.63, -1.29; p = 0.0426). However, this effect waned after 12 months.

Conclusions: These results emphasize a therapeutic relationship, in which the therapist attunes to the child’s expressions musically and emotionally, as important mechanism of change. These results might challenge a behavioristic paradigm in autism treatment focusing on training strategies rather than relational factors such as affect attunement as intervention strategy to improve social skills.