Geretsegger Monika, Elefant Cochavit, Mössler Karin A, Gold Christian
Department of Communication and Psychology, Faculty of Humanities, Aalborg University, Kroghstræde 6, Aalborg, Denmark, DK-9220.
Cochrane Database Syst Rev. 2014 Jun 17;2014(6):CD004381. doi: 10.1002/14651858.CD004381.pub3.
The central impairments of people with autism spectrum disorder (ASD) affect social interaction and communication. Music therapy uses musical experiences and the relationships that develop through them to enable communication and expression, thus attempting to address some of the core problems of people with ASD. The present version of this review on music therapy for ASD is an update of the original Cochrane review published in 2006.
To assess the effects of music therapy for individuals with ASD.
We searched the following databases in July 2013: CENTRAL, Ovid MEDLINE, EMBASE, LILACS, PsycINFO, CINAHL, ERIC, ASSIA, Sociological Abstracts, and Dissertation Abstracts International. We also checked the reference lists of relevant studies and contacted investigators in person.
All randomised controlled trials (RCTs) or controlled clinical trials comparing music therapy or music therapy added to standard care to 'placebo' therapy, no treatment, or standard care for individuals with ASD were considered for inclusion.
Two authors independently selected studies, assessed risk of bias, and extracted data from all included studies. We calculated the pooled standardised mean difference (SMD) and corresponding 95% confidence interval (CI) for continuous outcomes to allow the combination data from different scales and to facilitate the interpretation of effect sizes. Heterogeneity was assessed using the I² statistic. In cases of statistical heterogeneity within outcome subgroups, we examined clients' age, intensity of therapy (number and frequency of therapy sessions), and treatment approach as possible sources of heterogeneity.
We included 10 studies (165 participants) that examined the short- and medium-term effect of music therapy interventions (one week to seven months) for children with ASD. Music was superior to 'placebo' therapy or standard care with respect to the primary outcomes social interaction within the therapy context (SMD 1.06, 95% CI 0.02 to 2.10, 1 RCT, n = 10); generalised social interaction outside of the therapy context (SMD 0.71, 95% CI 0.18 to 1.25, 3 RCTs, n = 57, moderate quality evidence), non-verbal communicative skills within the therapy context (SMD 0.57, 95% CI 0.29 to 0.85, 3 RCTs, n = 30), verbal communicative skills (SMD 0.33, 95% CI 0.16 to 0.49, 6 RCTs, n = 139), initiating behaviour (SMD 0.73, 95% CI 0.36 to 1.11, 3 RCTs, n = 22, moderate quality evidence), and social-emotional reciprocity (SMD 2.28, 95% CI 0.73 to 3.83, 1 RCT, n = 10, low quality evidence). There was no statistically significant difference in non-verbal communicative skills outside of the therapy context (SMD 0.48, 95% CI -0.02 to 0.98, 3 RCTs, n = 57, low quality evidence). Music therapy was also superior to 'placebo' therapy or standard care in secondary outcome areas, including social adaptation (SMD 0.41, 95% CI 0.21 to 0.60, 4 RCTs, n = 26), joy (SMD 0.96, 95% CI 0.04 to 1.88, 1 RCT, n = 10), and quality of parent-child relationships (SMD 0.82, 95% CI 0.13 to 1.52, 2 RCTs, n = 33, moderate quality evidence). None of the included studies reported any adverse effects. The small sample sizes of the studies limit the methodological strength of these findings.
AUTHORS' CONCLUSIONS: The findings of this updated review provide evidence that music therapy may help children with ASD to improve their skills in primary outcome areas that constitute the core of the condition including social interaction, verbal communication, initiating behaviour, and social-emotional reciprocity. Music therapy may also help to enhance non-verbal communication skills within the therapy context. Furthermore, in secondary outcome areas, music therapy may contribute to increasing social adaptation skills in children with ASD and to promoting the quality of parent-child relationships. In contrast to the studies included in an earlier version of this review published in 2006, the new studies included in this update enhanced the applicability of findings to clinical practice. More research using larger samples and generalised outcome measures is needed to corroborate these findings and to examine whether the effects of music therapy are enduring. When applying the results of this review to practice, it is important to note that the application of music therapy requires specialised academic and clinical training.
自闭症谱系障碍（ASD）患者的核心障碍会影响社交互动和沟通。音乐疗法利用音乐体验以及由此发展出的关系来促进沟通和表达，从而试图解决ASD患者的一些核心问题。本版关于ASD音乐疗法的综述是2006年发表的原始Cochrane综述的更新版本。
评估音乐疗法对ASD患者的效果。
我们于2013年7月检索了以下数据库：Cochrane系统评价数据库、Ovid MEDLINE、EMBASE、拉丁美洲及加勒比地区卫生科学数据库、心理学文摘数据库、护理学与健康领域数据库、教育资源信息中心数据库、应用社会科学索引和文摘数据库、社会学文摘数据库以及国际学位论文摘要数据库。我们还查阅了相关研究的参考文献列表，并亲自联系了研究人员。
所有比较音乐疗法或添加到标准护理中的音乐疗法与“安慰剂”疗法、无治疗或ASD患者标准护理的随机对照试验（RCT）或对照临床试验均被考虑纳入。
两位作者独立选择研究、评估偏倚风险，并从所有纳入研究中提取数据。我们计算了连续结局的合并标准化均数差（SMD）及相应的95%置信区间（CI），以便合并来自不同量表的数据并便于解释效应大小。使用I²统计量评估异质性。在结局亚组内存在统计学异质性的情况下，我们检查了患者年龄、治疗强度（治疗疗程的数量和频率）以及治疗方法，将其作为可能的异质性来源。
我们纳入了10项研究（165名参与者），这些研究考察了音乐疗法干预（1周到7个月）对ASD儿童的短期和中期效果。在治疗情境中的主要结局社交互动方面，音乐疗法优于“安慰剂”疗法或标准护理（SMD 1.06，95% CI 0.02至2.10，1项RCT，n = 10）；治疗情境之外的广义社交互动（SMD 0.71，95% CI 0.18至1.25，3项RCT，n = 57，中等质量证据），治疗情境中的非言语沟通技能（SMD 0.57，95% CI 0.29至0.85，3项RCT，n = 30），言语沟通技能（SMD 0.33，95% CI 0.16至0.49，6项RCT，n = 139），发起行为（SMD 0.73，95% CI 0.36至1.11，3项RCT，n = 22，中等质量证据），以及社会情感互惠（SMD 2.28，95% CI 0.73至3.83，1项RCT，n = 10，低质量证据）。在治疗情境之外的非言语沟通技能方面无统计学显著差异（SMD 0.48，95% CI -0.02至0.98，3项RCT，n = 57，低质量证据）。在次要结局领域，音乐疗法也优于“安慰剂”疗法或标准护理，包括社会适应（SMD 0.41，95% CI 0.21至0.60，4项RCT，n = 26）、愉悦感（SMD 0.96，95% CI 0.04至1.88，1项RCT，n = 10）以及亲子关系质量（SMD 0.82，95% CI 0.13至1.52，2项RCT，n = 33，中等质量证据）。纳入的研究均未报告任何不良反应。研究的小样本量限制了这些发现的方法学强度。
本更新综述的结果提供了证据表明，音乐疗法可能有助于ASD儿童在构成该疾病核心的主要结局领域提高技能，包括社交互动、言语沟通、发起行为和社会情感互惠。音乐疗法还可能有助于增强治疗情境中的非言语沟通技能。此外，在次要结局领域，音乐疗法可能有助于提高ASD儿童的社会适应技能并促进亲子关系质量。与2006年发表的本综述早期版本中纳入的研究相比，本次更新中纳入的新研究增强了研究结果对临床实践的适用性。需要更多使用更大样本量和广义结局指标的研究来证实这些发现，并检验音乐疗法的效果是否持久。在将本综述结果应用于实践时，需要注意的是，音乐疗法的应用需要专业的学术和临床培训。
