By Samata Sharma and Frank Tarazi
Over the past decade, our understanding of the brain mechanisms involved in autism has deepened. This has enabled the development of better diagnostic tools and opportunities for earlier interventions. Yet, despite the growing prevalence of autism worldwide – up to 1 in 36 children may have it – available pharmacological and behavioural interventions can only diminish some of the disruptive behaviours associated with the disease, rather than actually modify the underlying disease process itself.
Concern about the side effects of many of the medications commonly used in treatment of autism, combined with the desire to find treatments that may successfully alter the underlying neurodevelopmental abnormalities present in children with autism, has led to increased interest in using complementary and alternative medicine to discover new therapies. One such therapy with a growing evidence base is music.
Music and autism
The Cochrane Collaboration provided evidence that music therapy may help children gain improved function in the core domains of autism: social interaction, verbal communication, initiating behaviour and social-emotional reciprocity. Recent findings point to altered brain connectivity as a key feature of autism. Patients with autism may often display enhanced discrimination of, or attention to, simple stimuli (fixations on certain objects, numbers, tones and colours), along with impairment in the successful sensory integration of these simple stimuli into a more complex gestalt perceptual representation. This inability to synthesize various sensory inputs alters the ability to form the metaphors and complex cognitive representations necessary for symbolic abstraction, including grasping the nuances of language, reading body language and responding effectively to social cues.
Music has the distinct potential ability to change both the structure of the brain and the functional connectivity between regions of the cerebral cortex, allowing for greater multisensory integration across cortical and subcortical domains in earlier developmental stages. In other words, a brain exposed to music may show greater cortical activation across key areas that are otherwise less active in children with autism. It is this aberrant cortical activation and connection that is widely postulated to be the cause of the core underlying neurophysiologic aberration in autism.
Interestingly, individuals with autism often show much greater performance on tasks that involve attention to or recollection of simple sensory stimuli, when compared to healthy individuals. For example, “perfect pitch” is an auditory phenomenon that enables one to replicate or name a single tone without any external reference. It is found in individuals with autism in significantly greater numbers than in peer-matched controls.
However, when these singular pitches are linked together into a melody, autistic patients often demonstrate poorer music perception and rhythmic entrainment. Awareness of rhythm is a more complex auditory perceptual skill, and one that is necessary for the prosodic discrimination of normal speech patterns. In addition, their performance on more complex gestalt perception tasks, which underlie “big picture” thinking and social interactions, is often what is most notably affected.
Music, by activating the mirror neuron system, which is found in areas of the brain that are responsible for communication, empathy and imagination, may improve the ability of people with autism to connect socially and better understand emotions. A 2009 study utilizing music-based intervention reported that nonverbal children with autism were able to speak after undergoing auditory motor mapping training. Music has always been used as a tool to communicate artistic intent and inspire emotion, and now evidence suggests that it may also be used to heal deficits in communication.
Beyond its neuromodulatory effects on the brain, music may have even more evocative neuroplastic effects. Music not only causes the brain to activate in a certain pattern, it ultimately changes the physical structure and functional activity of certain cortical areas of the brain. This appears to occur in all individuals, which suggests a role for music not only in helping to normalize neurophysiological abnormalities, including significant improvement across clinical domains in autism, but also in promoting proadaptive cortical changes in even otherwise healthy brains.
Music has been an integral part of the human experience since the beginning of mankind. We are now beginning to see that its role may extend far beyond simply experiential. The inherent characteristics of music may allow the brain to process, interpret and respond to acoustic stimuli in ways that can improve clinical outcomes and help normalize aberrant neurophysiological responses. William Shakespeare claimed music is the food of love. We provide evidence to suggest that it may also be medicine for the mind.
Music as medicine
This potentially effective therapy has been shown to demonstrate changes in brain structure, function and behavioural interaction without the side effect profile of commonly used medication. Given its rather high benefit-to-risk ratio, we suggest the use of music as an adjunct to medication and other behavioural interventions for children with autism. As little as 15-20 minutes of exposure to music three times per week has demonstrated activation changes in the brain. More intensive 30-45 minute active music training sessions over a period of at least six to eight weeks have been shown to change the volume and density of certain brain structures involved in speech and hearing. While how this ultimately translates into clinical practice remains unknown, as longitudinal studies are sparse, a daily routine of exposure to, or training on, a musical instrument should allow for some adaptive prosocial behavioural changes.
While the greatest amount of evidence is available around classical music, all behavioural patterns require consistent practice to create sustainable change. We therefore recommend that the choice of music be left to the child and conducted for whatever extent of time the child can tolerate, up to 45 minutes a day, at least three days per week. In this way, even if clinical outcomes are not immediately apparent, the child will benefit from an experience that has shown in countless ways to have a positive and enriching effect on mood and overall well-being.
In a poetic merger of metaphor and neurophysiology, music, as a synchrony of meter and melody, invokes a symphonious response in the brain. Cortical areas activate in response to it, and over time are also altered by it. Man makes music and, in turn, music may play a role in making the mind of man.
Samata Sharma is Instructor at Harvard Medical School.
Frank Tarazi is a Professor at Harvard Medical School and Director of the Psychiatric Neuroscience Program at McLean/Massachusetts General Hospital.
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