Music Therapy and Early Start Denver Model to

Teach Social Communication Strategies to Parents of

Preschoolers with ASD: A Feasibility Study
EUGENIA HERNANDEZ-RUIZ, MME, MT-BC University of Kansas

ABSTRACT:  Parents of young children diagnosed with or at risk of Consistent with the recommendation of involving parents in
Autism Spectrum Disorder face extended waiting times for treatment early intervention, the present author investigated the feasibil-
and/or intensive treatment schedules that may be prohibitively expen- ity (limited-efficacy, acceptability, and adaptation) of a music
sive for the families. Parent coaching and parent-mediated therapy
are available alternatives within well-researched relationship-based
therapy program, based on the Early Start Denver Model
behavioral models such as the Early Start Denver Model (ESDM), and (ESDM) and the Parent-Early Start Denver Model (P-ESDM),
parent-mediated ESDM (P-ESDM). This project investigated feasibility which teaches parents behavioral strategies to enhance their
measures (limited-efficacy, acceptability, and adaptation) of a six-week children’s social communication. The Early Start Denver
music therapy program anchored in the P-ESDM to coach parents in Model is a psychoeducational model with demonstrated effi-
behavioral strategies that could enhance their children’s social interac- cacy in the treatment of young children with ASD (Dawson
tions. Three parent-child dyads participated in group sessions. Parents
et  al., 2010; Estes et  al., 2014, 2015; Rogers, Dawson, &
found this modality developmentally, culturally, and age appropriate.
They also seemed more comfortable in their parenting skills. Parents Vismara, 2012).
considered that their children improved in social skills due to their
participation. These preliminary results indicate that parents can learn
Early Start Denver Model Description
the principles of the ESDM within a music-based intervention, and The Early Start Denver Model integrates applied behavioral
that the ESDM and P-ESDM might provide music therapists with a analysis (ABA) principles with a developmental, relationship-
well-researched theoretical framework for their practice. based approach to create a comprehensive, manualized, and
Keywords: parent-mediated, autism, social communication, music- structured intervention for children with ASD symptoms aged
based intervention, feasibility 12 to 48 months (Rogers & Dawson, 2010). This model pro-
motes a child-centered, responsive style that embeds behav-
ioral teaching objectives within the child’s play and interests
Autism Spectrum Disorder (ASD) is mainly defined by dif- (Rogers, Dawson, & Vismara, 2012; Rogers et  al., 2012).
ficulties in social interaction and communication (American The creators of the ESDM incorporated ABA theory, which
Psychiatric Association, 2013). Behavioral components of states that behaviors have antecedents and consequences,
social communication include joint attention, nonverbal com- that adults can influence child behavior through modifying
munication, shared affect, and imitation, which are the founda- the latter, and that children with ASD will learn and change
tion of more complex social interactions (Lord, 2010). Children behaviors, even if their neurobiological profile requires adap-
with ASD show variable levels of impairment in these behav- tation of teaching techniques (Rogers & Dawson, 2010). On
iors, sometimes starting in infancy (Chiang, Soon, Lin, & Rogers, the other hand, the authors infused the model with a develop-
2008; Lord, 2010). In fact, current recommendations in the aut- mental perspective, with an understanding of how very young
ism field include intervention as soon as the first signs of devel- children learn. Child-centered approaches, play strategies,
opmental difficulties are noticed, and before formal diagnosis, Pivotal Response Training (Koegel, Koegel, Harrower, & Carter,
as a way to offset the social communication deficit cascade 1999), and Positive Behavior Support (Powell, Dunlap, & Fox,
of the first years of life (Ozonoff et  al., 2015; Zwaigenbaum 2006) became critical components of the model (Rogers &
et al., 2015). However, parents of young children diagnosed or Dawson, 2010). Recently, researchers have identified this
at risk of Autism Spectrum Disorders often face extended wait- type of intervention as Naturalistic Developmental Behavioral
ing times for treatment and/or intensive treatment schedules Interventions (NDBI; Bradshaw, Steiner, Gengoux, &
that may be prohibitively expensive for the families (Braddock Koegel, 2015).
& Twyman, 2014). Providing parents with skills and know- Treatment with the ESDM model is supported by the ESDM
ledge that improve their everyday interactions with their young Curriculum Checklist, a published developmental scale that
children with Autism Spectrum Disorders seems a reasonable assesses children’s strengths and needs with an emphasis in
and cost-effective complement to treatment (Oono, Honey, & social communication behaviors (Rogers & Dawson, 2009).
McConachie, 2013; Zwaigenbaum et al., 2015). It supports the professional in creating an individualized and
developmental trajectory for treatment. Treatment duration
varies according to individual needs, but is normally struc-
tured in 12-week periods. Treatment goals and objectives
are designed, reassessed, and modified as needed every 12
© American Music Therapy Association 2017. All rights reserved.
For permissions, please e-mail: journals.permissions@oup.com weeks (Rogers & Dawson, 2010). Parents are included in
10.1093/mtp/mix018 therapist-delivered services to ensure generalization of skills
1

Downloaded from https://academic.oup.com/mtp/advance-article-abstract/doi/10.1093/mtp/mix018/4747142

by University of Florida user
on 24 January 2018
 2 Music Therapy Perspectives

in everyday life. In a randomized controlled trial (RCT) of this with each strategy in the order presented before moving to
comprehensive intervention, toddlers showed meaningful the next. However, given that some parents may start treat-
improvements in cognitive ability, adaptive ability, and reduc- ment with considerable skills in one area, the sequence can
tion of ASD symptoms, compared to a community treatment be altered to accommodate parent and child needs (Rogers &
group (Dawson et al., 2010). Vismara, 2015).
In its original model, therapists, trained and certified in the “Step into the spotlight” and orientation to the activ-
ESDM, provided the intervention in individual settings, within ity.  Parents are encouraged to provide enough enjoyment and
an intensive 20-hour-per-week schedule (Dawson et al., 2010). stimulation to orient the child to the reinforcement that par-
However, more recent developments have incorporated par- ents can provide (i.e., “stepping into the spotlight”). Once the
ent-coaching and parent-mediated therapy, group daycare, child is oriented to the parent, the latter uses responsive par-
and community settings, as effective alternatives to treatment enting skills to follow his/her child’s lead, which most children
(Rogers, Estes, et al., 2012; Vivanti et al., 2014). One of these find reinforcing. These skills include listening actively, helping
elaborations is the adaptation to a parent-led intervention, the child attain his/her goals, imitating him/her, and narrat-
the Parent-based ESDM (P-ESDM), where the principles of ing ongoing activities. This reinforcing exchange is the precur-
the ESDM are taught to the parents in a manualized approach sor of more elaborate social interactions (Rogers, Dawson, &
(Rogers, Dawson, & Vismara, 2012; Rogers & Vismara, 2015). Vismara, 2012).
In the P-ESDM, the parents receive weekly or bimonthly “Find the smile!”. Compared to typical children, most
sessions with a certified ESDM therapist that coaches the par- children with autism find social interaction less reward-
ents in vivo on the implementation of the behavioral strategies ing than object play (Dawson, Osterling, Rinaldi, Carver, &
with their child (Rogers, Dawson, & Vismara, 2012). Parents McPartland, 2001). Therefore, making activities more engag-
then implement the strategies in their everyday interactions ing (i.e., finding the smile) is a prerequisite for children
with their children. Treatment goals are negotiated by the pro- with ASD to engage in successful social exchanges (Rogers,
fessional and parent according to child and parental needs Dawson, & Vismara, 2012). The social-sensory routines
at the beginning of treatment, and are also revised every 12 (SSRs), a specific contribution of this model to the ASD field,
weeks (Rogers & Vismara, 2015). The ESDM therapist coaches are reinforcing simple games (finger play, songs, roughhous-
the parent without eliciting typical ABA format (i.e., without ing, physical actions) without objects that engage and regu-
trying to transform the parents into ABA therapists). The par- late the child with ASD.
ents remain affectionate play partners, but with a clear under- “Talking bodies”. Most children with ASD have distinct
standing of the behaviors they need to teach their children difficulty in noticing, interpreting, and showing conventional
(Estes et al., 2015; Rogers & Vismara, 2015). nonverbal gestures (Gordon & Watson, 2015). However,
One RCT comparing a P-ESDM group with a community repeated practice in everyday routines, strategies such as posi-
treatment group showed similar gains in sensitive parent- tioning (parent in front of the child), and direct teaching of
ing skills and child distal developmental outcomes (i.e., those gestures can significantly increase a child’s nonverbal
overall functioning assessed through standardized tests communication (Dawson et al., 2010).
such as ADOS and Vineland) (Rogers, Estes, et  al., 2012). “It takes two to tango.”  Appropriate social interactions are
However, the children in the P-ESDM group showed these based on back-and-forth exchanges set by explicit or implicit
increases with approximately half the intervention hours turn-taking (e.g., Estevanovic & Eperäkylä, 2015). Under this
(12 one-hour coaching sessions with parents, and no ESDM concept, parents are taught to create joint activities by “setting
direct services to children). Further, parents in the P-ESDM a theme,” elaborating, and closing the activity. By building on
group showed significantly higher parent-therapist alliance the previous strategies, the parent can modify any play or eve-
(Rogers, Estes, et  al., 2012), and they did not report an ryday activity into a joint activity. This structure promotes lan-
increase in stress (Estes et al., 2014). Given that the period guage, adaptive skills, and cognitive development (Dawson
of diagnosis and start of treatment is a particularly stress- et al., 2010).
ful time, the lack of increase in these parents’ stress could Transitions and closure.  Some children with ASD have diffi-
indicate better adjustment to the challenges of the diagno- culty transitioning into and out of activities (Lequia, Wilkerson,
sis (Estes et al., 2014). In a long-term follow-up study, the Kim, & Lyons, 2015). Clear transition strategies that help
children maintained gains in intellectual abilities, adaptive them disengage from the activity help manage arousal lev-
behaviors, symptom severity, and challenging behaviors, els, provide closure, and sustain pleasant interactions (Rogers
significantly different from the community group (Estes & Dawson, 2010; Rogers & Vismara, 2015). Clear cues for
et al., 2015) transitioning also support the understanding of expectations
within a joint activity, an area of difficulty for individuals with
Parent-Based Early Start Denver Model (P-ESDM) Principles autism (Baron-Cohen, 1995).
Rogers, Dawson, and Vismara (2012) presented the basic
principles of the Early Start Denver Model to parents through Music Therapy and ASD
easy concepts and memorable phrases (e.g., “step into the spot- Researchers have found that music therapy is an effective
light”), which are preserved in this description of the model. psycho-educational therapy for ASD (Geretsegger, Elefant,
These principles refer to focus of attention (“step into the spot- Mossler, & Gold, 2014). In a Cochrane review of music
light”), motivation (“find the smile”), nonverbal communica- therapy for ASD, Geretsegger and collaborators (2014) con-
tion and imitation (“talking bodies”), joint attention (“it takes cluded that music-based interventions had a moderate to
two to tango”), and transitions and closure. Rogers, Dawson, large effect size on social interaction and nonverbal com-
and Vismara (2012) recommend that parents feel comfortable munication skills of individuals with ASD. Two studies (Kim,
Downloaded from https://academic.oup.com/mtp/advance-article-abstract/doi/10.1093/mtp/mix018/4747142
by University of Florida user
on 24 January 2018
 Music Therapy and P-ESDM for ASD: A Feasibility Study 3

Wigram, & Gold, 2008; Thompson, McFerran, & Gold, 2014) (EIBI) showed that incorporating parents in treatment had
also showed a large effect on quality of family relationships, moderate to high positive effects in the intellectual, language,
but high attrition in one of them (Kim et al., 2008) indicates and adaptive skills of young children (Strauss, Mancini, SPC
the need of caution when interpreting these results. Although Group, & Fava, 2013). Both a recent systematic review and a
more research is needed, with larger numbers of participants meta-analysis of non-music-based interventions for this popu-
and long-term assessments of results, the potential of music lation support this assertion (Oono et al., 2013; Zwaigenbaum
therapy to increase social communication skills of children et  al., 2015). Contrastingly, few authors have studied the
with autism is clear (Geretsegger et  al., 2014). Three basic effect of music-based interventions from a family perspective.
constructs included in the Early Start Denver Model have also However, those studies have shown favorable results. These
been investigated separately in previous music therapy stud- findings include being a highly accepted therapy, with high
ies: joint attention, responsive interactions, and family-cen- satisfaction levels among participants (Williams, Berhelsen,
tered perspective. Nicholson, Walker, & Abad, 2012); promoting an “even play-
Joint attention and clear expectations.  Joint attention is the ing field” where each family member participates as much as
ability to attend to another person’s focus of attention, and is she/he can (Allgood, 2005, p. 98); becoming part of the pleas-
a foundational skill for communication and social interaction. urable family routines; and allowing the parents to feel com-
Music-based interventions have shown a larger effect on initi- fortable in social situations with their children (as opposed to
ating joint attention and receptive joint attention, compared to other social situations) (Allgood, 2005).
play or spoken language (Kim et al., 2008; Paul et al., 2015). In an innovative model, Thompson, McFerran, and Gold
A  music-based intervention might create an effective bridge (2014) found positive results when families participated in
for joint attention and shared activity (Benavides & Orrego, Family-Centred Music Therapy (FCMT). A small RCT (N = 23)
2010). To support joint engagement, music therapists create and further qualitative assessments of the FCMT program
pleasurable, structured activities where objects (instruments) showed strengthened parent-child interactions, and improved
are shared in a social way (Kalas, 2012). Furthermore, under- parental perceptions of their children, compared to non-music
standing others’ expectations is a critical component of par- early intervention groups (Thompson et al., 2014; Thompson &
ticipating in a joint activity (Baron-Cohen, 1995). Transition McFerran, 2015). Music therapy with a family perspective,
songs and closure cues within music activities (such as strong where the activities allow each member’s participation “from
cadences, fading out of the music) within a session might sup- where he is,” with clear expectations and pleasurable experi-
port the child with ASD in this process (Juhnke, 2015). ences, seems an ideal context to support parent-child inter-
Mutually Responsive Orientation.  Similar to the ESDM, actions and relationships (Schwartzberg & Silverman, 2017;
the Mutually Responsive Orientation (MRO) framework pro- Thompson et al., 2014; Williams et al., 2012).
motes “a positive, mutually binding, and cooperative relation- Furthermore, involving parents and caregivers in music
ship between the parent and the child” (Aksan, Kochanska, & therapy activities seems to promote skill learning, generali-
Ortmann, 2006, p.  833) and was used by Pasiali (2012) in zation, and maintenance. Within a music therapy university
a music therapy study with developmentally at-risk children. clinic, where parents were encouraged to observe and par-
MRO is identified by four factors: coordinated routines, har- ticipate, the parents valued the unique multisensory approach
monious communication, mutual cooperation, and emotional of music-based interventions for their children with ASD, and
ambience (emotionally positive interactions) (Aksan et  al., observed generalization of their child’s skills to other set-
2006). In Pasiali’s study (2012) with four vulnerable families tings (Schwartzberg & Silverman, 2017). Importantly, parents
with a history of maternal depression and at-risk children, the spontaneously implemented the strategies outside the therapy
results of an intervention under this construct were encourag- setting. To support this interest, Schwartzberg and Silverman
ing. The hello and good-bye routines (common in the music (2017) recommend that music therapists assess parents’ com-
therapy sessions), as well as the flexibility of the music therapy fort, and educate them in the adaptation of strategies in the
session, facilitated the development of coordinated routines. home setting, while integrating “evidence-based approaches
The therapist’s actions (e.g., modeling musical interactions) from within and outside of the music therapy profession”
and bidirectional parent/child actions facilitated harmonious (p. 109).
communication. Mutual cooperation was achieved in several Closely related to parental involvement is parental self-
situations. The parents seemed more willing and capable of efficacy. Parents with high levels of self-efficacy are more
scaffolding the activity to meet the children’s abilities, and prone to involve their children in activities that promote their
of redirecting the children’s attention to the most meaning- development (Thompson & McFerran, 2015). Furthermore,
ful stimuli (the music). Meanwhile, the children consistently parental competence supports parental sensitivity to chil-
sought comfort from their parents, sought nonverbal approval dren’s needs, which is crucial to attain social engagement
of their actions (by engaging in eye contact), and initiated (Pasiali, 2012). By becoming a play partner, meeting the
cooperative activities (such as cleaning up instruments) child “where he is” with regard to his skills and mood, and
(Pasiali, 2012). The parents’ enjoyment and children’s joyful achieving a subtle negotiation between the therapist, the
participation contributed to a positive emotional environment. child, and her-/himself, the parent can complement and
Pasiali (2012) concluded that music therapy provided “a con- enhance the professional’s therapeutic efforts (Thompson &
text that promoted mutually responsive parent-child interac- McFerran, 2015). Further, a family-centered perspective
tions” (p. 329). addresses parental mental health concerns, such as paren-
Family-centered perspective.  Within the ASD field, a com- tal distress, which might impact parental perceptions of the
prehensive analysis of Early Intensive Behavioral Interventions child’s skills (Thompson & McFerran, 2015; Williams et al.,

Downloaded from https://academic.oup.com/mtp/advance-article-abstract/doi/10.1093/mtp/mix018/4747142

by University of Florida user
on 24 January 2018
 4 Music Therapy Perspectives

2012). These perceptions, in turn, can shape children’s skill father participating in three of them, and the mother in seven
acquisition and performance (Kirby, 2016). (10 out of 12, for a total participation of 83.3%). The mother
Notwithstanding these efforts, research on parent-mediated in this dyad completed both the pretests and posttest without
music therapy as a viable treatment for Autism Spectrum consulting her spouse. The child’s sibling (a 9-year-old boy)
Disorders is scarce. Undoubtedly, some effective constructs also participated in one of the sessions. For the second dyad
(such as the MRO and family-centered perspective) have (P2), the mother brought her other two children (aged 4 years
been incorporated into music therapy programs with parents and 4 months, respectively) to all the sessions they attended
(Pasiali, 2012; Schwartzberg & Silverman, 2017; Thompson (eight out of 12, 66% of the sessions). Although she was ini-
et  al., 2014). However, the incorporation of well-studied tially asked to avoid bringing the other children so she could
behavioral and developmental principles of change in a concentrate in her child with ASD, she was accommodated
coherent, research-based parent-coaching model, such as the given the difficulty in finding appropriate care for her other
ESDM and P-ESDM, is essentially absent. The P-ESDM can children. In session nine, both parents in this dyad came to
provide a strong theoretical framework and tested strategies the session. The father mainly observed the session. For the
that are congruent with music therapy goals and techniques third dyad (P3), only the mother participated in the study, and
for parents and children with ASD (Geretsegger et al., 2014). she attended 100% of the sessions. She spontaneously shared
Specific feasibility information regarding adaptation of this that she was taking anti-anxiety medication and antidepres-
model to a music-based intervention, and acceptability of the sants (for reasons unrelated to her child’s diagnosis). The
intervention (e.g., whether parents believe these interventions effect of this medication on her participation and responses is
to be helpful, culturally sensitive, and developmentally appro- unknown. None of the participants had previous knowledge
priate), is needed. Therefore, the purpose of this study was to or experience with the ESDM. None of the children received
investigate the feasibility (limited efficacy, acceptability, and any medication, and none of them initiated another therapeu-
adaptation measures) of a music therapy program anchored in tic or school program throughout the duration of this study.
the P-ESDM, which coaches parents in behavioral strategies Other demographic variables that could impact the results
that enhance their children’s social interactions. The specific (age, gender, educational level of parents, and other therapies)
research questions were: are reported in Table 1.

1) Do parents feel more competent in their parental role Measures

after experiencing the music therapy sessions (parental Parental Sense of Competence.  To address the first research
sense of competence)? (Limited efficacy) question, whether parents feel more competent after experi-
2) Is the parent’s perception of her/his child’s social skills encing the music-based intervention, the Parenting Sense of
modified by their participation in a short music therapy Competence Scale (PSOC; Gilmore & Cuskelly, 2009) was
program? (Limited efficacy) implemented. This test is a 17-item scale that measures the
3) Does the parent’s mental health impact her/his sense of parent’s satisfaction with his/her way of being a parent, and
competence? (Limited efficacy) his/her self-efficacy in the parental role. It takes an average
4) Do the parents find this mode of learning strategies for of eight minutes to complete. A higher overall score indicates
their children adequate, engaging, and appropriate? a positive parental experience, with a maximum of 102. Its
(Acceptability and adaptation) internal consistency is acceptable, within a range of .75 to
5) Is it possible to include the ESDM within a music-based .88, as reported in several studies (Johnston & Mash, 1989;
intervention? (Adaptation) Lovejoy, Verda, & Hays, 1997; and Ohan et al., 2000, as cited
in Gilmore & Cuskelly, 2009).
Method Social Responsiveness Scale-2.  For the second research
question, the parents indicated their perception of their child’s
Design ability to respond socially with the Social Responsiveness
This feasibility study, with a convenience sample recruited Scale-2 (SRS-2), Preschool Module (Constantino & Gruber,
from two early intervention programs, included pretest-post- 2012). This scale identifies the presence and severity of social
test measures of limited efficacy of the intervention: paren- impairments in people with Autism Spectrum Disorders, and
tal sense of competence, parental perception of child’s social is organized into five subscales (awareness, cognition, com-
skills, and parental distress, as well as posttest measures of munication, motor, and restrictive and repetitive behaviors—
acceptability (Final Survey). Participants’ comments (elicited RRB). Higher total scores indicate increased ASD severity, and
as “other comments” in the Final Survey, and spontaneous are separated into four ranges: normal < 59; mild, 60 to 65;
comments) and researcher’s field notes informed the study as moderate, 66 to 75; and severe, 76 or higher. Its internal con-
measures of acceptability and adaptation of the Parent-ESDM. sistency (alpha) was .88 for parent report and .93 for teacher
report (Greaves-Lord et  al., 2012, in Constantino & Gruber,
Participants 2012). It has a short implementation time (15 minutes).
Three parent-child dyads participated. Child participants K-6 Scale. For the third research question, parental mental
were two boys and one girl, with ages between 2.5 and health was measured as a possible moderator of the interven-
3 years. One of the children had been formally diagnosed with tion using the K-6 Scale (K-10 and K-6, Harvard Medical School,
ASD. The other two were undergoing diagnostic testing during 2005; Kessler et al., 2003). This screening tool, redesigned for
the research project (but the diagnosis was confirmed after the the US National Health Interview Survey-NIHS (Centers for
conclusion of the research project in both cases). In the first Disease Control and Prevention [CDC], 2011), is a Likert-type
dyad (P1), both parents came in different sessions, with the scale of six questions that detects psychological “distress” in the
Downloaded from https://academic.oup.com/mtp/advance-article-abstract/doi/10.1093/mtp/mix018/4747142
by University of Florida user
on 24 January 2018
 Music Therapy and P-ESDM for ASD: A Feasibility Study 5

Table 1
Demographic information

P1 P2 P3
Mother Age 41 31 39
Race/ethnicity/nationality White/Russian Filipino-American Caucasian
Married Status Married Married Married
Highest educational 2nd year PhD Master’s 3rd year PhD
degree
Child Age 3 2.5 2.5
Gender Female Male Male
Number of siblings 1 2 0
Age of siblings 9 yrs. a) 4 yrs. N/A
b) 4 mos.
Birth order 2nd 2nd 1st
Other therapies OT, Early intervention ABA, Early intervention once/
once/week Music therapy week

past 30 days (Kessler et al., 2003). A score equal to 13 or higher a Bluetooth speaker, and a MacAir computer to reproduce
indicates severe distress, whereas a score of 5 to 12 indicates recorded music.
moderate distress in need of intervention (Prochaska, Sung, Music selection.  The researcher selected the music con-
Max, Shi, & Ong, 2012). This test has shown good psychomet- sidering the following criteria: 1) low level of difficulty and
ric properties: sensitivity 0.36 (0.08), specificity 0.96 (.02), and high level of familiarity so parents felt comfortable singing and
internal consistency 0.89 (Kessler et al., 2003). It can be admin- using the songs during the session and at home; 2) develop-
istered in an average of three minutes, by any health provider, mentally appropriate, that is, taken from available literature
or can be answered by the patient him-/herself (CDC, 2011). of young children’s music, with narrow vocal ranges, repeti-
Final Survey.  The Final Survey addressed the fourth tive structures, short phrases, and child-oriented, simple lyrics
research question (acceptability) through a 10-question ad (e.g., “Five Green and Speckled Frogs”); 3) easily supported by
hoc survey that explored parents’ perception of interest and visual stimuli since most children with ASD are visual learners;
enjoyment (questions 1, 6, and 8), perceived difficulty (ques- 4) action songs (those that are accompanied by gross or fine
tions 2 and 3), usefulness (questions 4 and 5), cultural sensi- motor movements) that lend themselves to creating sensory-
tivity (question 7), developmental appropriateness (question social routines (SSR); and 5) evidence-based, given that some
9), and parental competence (question 10). Participants of the songs were used as part of a research-based curriculum
expressed their opinions through a Likert-type scale with for early intervention (Walworth, 2013), even though the pro-
anchors of 1 (completely disagree) to 5 (completely agree), cedures in this study were different and designed to incorpo-
with the opportunity to provide written comments at the end. rate the principles of the Early Start Denver Model (see Music
Questions 2, 3, 6, and 8 were reverse scored (see Online Resources, in Online Supplement B—Song Distribution &
Supplement A–Final Survey). Reference List).
Field notes.  To determine the feasibility of adapting the
ESDM within a music-based intervention, a log of clinical Interventionist Qualifications
observations was kept as field notes. The music therapist wrote The interventionist was the researcher, a PhD music ther-
the most salient events and impressions of the session immedi- apy student, with a master’s degree in music therapy, board-
ately after its conclusion from her own recollections. She used certified (MT-BC), also certified in the Early Start Denver
these notes to adjust her coaching to observed parental needs Model (University of California–Davis). The researcher has
(e.g., increasing prompting to the mother in P1, who seemed a Professional Concentration in ASD (UC–Davis), an Autism
to require more guidance). She reviewed them at the end of Research Training–Summer Program (McGill University), a
the project in search of meaningful patterns. These accounts Graduate Diploma in ASD (Instituto Politecnico Nacional/
were then conceptually organized and analyzed around the Clinica Mexicana de Autismo, A.C.), and extensive on-the-job
ESDM principles (“stepping into the spotlight,” “finding the training, as well as 12  years of clinical experience with this
smile,” etc.), as reported in the Results section. population.

Setting and Materials Procedure

Setting and equipment.  The sessions were conducted in a Program duration.  Two evaluation sessions (pretest and
large, well-lit room commonly used as a music therapy clinic. posttest) and ten 30-minute biweekly group sessions (i.e.,
Equipment included small percussion instruments (chiquitas, six-week program) constituted this program. In an RCT
maracas, jingle bells, sleigh bells, rhythm sticks, small hand of ­parent-ESDM, Rogers, Estes, and collaborators (2012)
drums, rainbow drums, castanets, wood blocks, and trian- found that parents achieved treatment fidelity by the eight
gles), a guitar (played only by the music therapist), scarves, or ninth session. Therefore,  10  sessions were considered
handmade visuals, a board to attach visuals, seating mats, ­sufficient. Also, the study exceeded the minimum dosage for

Downloaded from https://academic.oup.com/mtp/advance-article-abstract/doi/10.1093/mtp/mix018/4747142

by University of Florida user
on 24 January 2018
 6 Music Therapy Perspectives

family music-based interventions (six sessions; see Williams dyad, and between dyads, in an attempt to identify a com-
et al., 2012). On the other hand, the length of the program was mon response pattern. The researcher’s field notes of the ses-
compacted to six weeks (instead of the customary 12 weeks in sion process, participants’ spontaneous comments, and Final
ESDM) because several families expressed their preference of Surveys were analyzed regarding the parents’ success in learn-
a shorter time frame during recruitment. ing the principles (adaptation), their opinions of the interven-
Recruitment.  A convenience sample was recruited from tion (acceptability), and their consistency with the quantitative
volunteers at a university research/treatment center and a measures (limited efficacy and adaptation).
community early intervention state-funded service center
through flyers and word of mouth. The researcher was a PhD Results
student at the university and supervised a music therapy Parental Sense of Competence
practicum at the university autism center, but was not pre-
To answer the first question, “Do parents feel more com-
viously involved in treatment with any of the families. The
petent in their parental role after experiencing the music
Institutional Review Board (IRB) provided approval, and par-
therapy sessions?,” the mothers completed the Parental Sense
ents signed an informed consent for themselves and for their
of Competence Scale (PSOC; see Gilmore & Cuskelly, 2009).
child before participating in the sessions. Given the age and
P1 and P2 showed a perception of higher competence (see
communication difficulties of the children, no minor assent
Table  3). Interestingly, the mother in P3 showed a small
was requested.
decrease in her score, but she also commented “feeling more
Pretest.  Session 1: Parents provided written informed con-
secure” and “feeling happier” in her relationship with her
sent and responded to the demographic questions, PSOC,
child during the last session. This incongruence is evident
SRS-2 Preschool module, and K-6. Only parents were present
across measures and will be addressed in the discussion.
in this session. Given that this study was focused on paren-
tal learning of ESDM strategies within a group setting, and Parental Perception of Child’s Social Skills
not individualized child outcomes, the ESDM Curriculum
To address the second question, “Is the parent’s perception
Checklist (Roger & Dawson, 2009) for programming was not
of her/his child’s social skills modified by their participation
used. Child assessment was informally performed through par-
in a short music therapy program?,” the mothers filled out the
ent interview in this first session (asking a few questions about
SRS-2, Preschool module (Constantino & Gruber, 2012) as
child abilities, disruptive behaviors, preferences, and musical
a pretest and posttest measure (see Table  3 for results). The
taste), and direct observation during the treatment sessions.
mother in P1 responded within the limits of a normal score
Adaptations to each child’s abilities were provided through
in both instances. However, in the pretest, the score was
individualized verbal prompting to parents.
just within the limit of a normal range, with a considerable
Treatment.  Sessions 2–11: Thirty-minute music therapy
decrease at posttest. The mother considered that the area
sessions were provided to parents and children in a group
most affected was communication. The mother in P2 scored
setting. Table  2 shows the detailed structure of the session
her child in the severe range in both the pretest and post-
and its correspondence with the ESDM principles previ-
test. However, the posttest showed a considerable reduction
ously described. Online Supplement B (Song Distribution &
since the last score was the boundary between the severe and
Reference List) shows the distribution and repetition of
moderate ranges. The mother considered that the areas mostly
these songs during the 10 treatment sessions. Based on
affected were cognition and restricted interests and repetitive
Pasiali (2012) and the ESDM and P-ESDM manual (Rogers &
behaviors (RRB).
Dawson, 2010), the following behavioral strategies were
The mother in the P3 dyad scored both the pretest and
implemented to support interactions within and between
posttest within the severe range, with a slight increase in the
dyads: 1)  verbally supporting parents and children to try
posttest. According to this mother, her child’s greatest impair-
new activities; 2)  giving descriptive and pertinent verbal
ment was the RRB. As with the PSOC, this mother’s comments
reinforcement; 3)  modeling playful and joyful actions and
seemed inconsistent with her scoring during posttest. During
interactions; 4) shaping and reinforcing any response, free-
the last session, she mentioned that “I see a completely differ-
ing the parents from the need of “doing things right”; 5) pro-
ent boy since we started music therapy; he is saying good-bye
moting nonverbal communication (eye contact, physical
to everybody [his first word ever pronounced, which hap-
contact, smiles) through appropriate positioning of people
pened during one of the MT sessions], looking at us, he is ask-
and objects; 6) promoting the construction of “coordinated
ing us to play and sing the songs, he is very smiley and social,
routines” through repeating the songs (identically or slightly
and he said bye-bye to a little girl the other day.”
varied); 7) promoting interaction through guided sharing of
musical instruments; 8)  creating activities for turn-taking
and social-sensory routines; and 9) supporting and reinforc- Parental Mental Health and Its Impact on Parental Sense of
ing spontaneous interactions of the dyad. Competence
Posttest.  Session 12: parental responses to the PSOC, SSR- To answer the third research question, “Does the parent’s pre-
2, K-6, and Final Survey. vious mental health impact her/his sense of competence?,” the
mothers responded to the K-6 scale (Kessler et al., 2003), which
Data Analysis screens for “distress” (see Table  3). The mother in P1 scored
Given the small sample size, statistical analyses were not within the no-distress range for the pretest and posttest, but the
appropriate. The data for the quantitative measures were ana- mothers in P2 and P3 showed a reduction from the moderate-
lyzed by comparing the pretest and posttest scores for each distress range in the pretest to no distress in the posttest.

Downloaded from https://academic.oup.com/mtp/advance-article-abstract/doi/10.1093/mtp/mix018/4747142

by University of Florida user
on 24 January 2018
 Table 2

on 24 January 2018
Session sections, target behaviors, and procedures

Target behavior

by University of Florida user

Session Section Intervention Child Adult ESDM principle Procedure

Hello Song When I Meet a New Wave/say hello Capture child’s Orient, “Step into the In the first three sessions, participants sat in a
Friend (Batey, J., in attention and say hello spotlight”: becoming semicircle with the child in front of the parent.
Walworth, 2013)* child’s main focus of As sessions progressed, the MT encouraged
attention the parents to sit face-to-face with their child
to promote imitation. MT sang the song with
guitar, including each participant’s name in
the song one at a time. Adult participants were
encouraged to sing along, and children were
encouraged to wave to the person named.
Songs with Visuals Five Little Ducks** Follow Make sure the child is “Step into the spotlight” The MT presented a clear visual with five
instruction/ attending and and “Find the smile”: ducklings and a “mommy” duck on a black
Do action with prompt his/ engagement in object play cardboard in the center of the semicircle. The
Music Therapy and P-ESDM for ASD: A Feasibility Study

visual her response ducklings were taken off the board as the song
indicated. The music was presented a capella.
After the second session, children took turns
taking the ducklings off. Parents encouraged
responses by singing, pointing to the board, and
helping take the visual off the board.
Funga A La Feeya** Children and parents sat in a circle and held
a colored stretch band. The MT sang the

Downloaded from https://academic.oup.com/mtp/advance-article-abstract/doi/10.1093/mtp/mix018/4747142

song while providing directions regarding the
movement of the band. The parents helped the
children hold on to the band and perform the
movements.
Itsy Bitsy Spider** The MT presented pictures of a spider, a
waterspout, a sun, and a cloud with rain on a
black cardboard. These were moved according
to the lyrics. The music was presented a
capella. After the second session, children took
turns moving the visual. Parents encouraged
responses by singing, making hand movements,
and pointing to the board.
Birdie Beat (Avirett, J., in The MT provided a visual of a small bird to
Walworth, 2013) each parent. They were asked to attain child’s
attention and then do the movements according
to the chant.
7
 8
Table 2
Continued

on 24 January 2018
Target behavior
Session Section Intervention Child Adult ESDM principle Procedure

by University of Florida user

5 Green & Speckled The MT presented pictures of five green and
Frogs** speckled frogs and a log on a black board. The
frogs were taken away according to the lyrics.
The music was presented a capella. After the
second session with this song, children took
turns moving the visual. Parents encouraged
responses by singing and pointing to the board.
They also took turns presenting the song to the
group.
Oh, Where Has Follow Make sure the “Step into the spotlight” The MT presented pictures of a dog and a scarf
My Little Dog Gone?** instruction/ child is attending and and “Find the smile”: for each parent. The parents hid the picture of
Do action with prompt his/her engagement in object play the dog under the scarf and asked the child to
visual (cont.) response (cont.) (cont.) look for it with gestures and lyrics. The music
was presented a capella. If the child was
successful, the parent was encouraged to find
new hiding spots with/without the scarf around
the room.
Five Little Monkeys** The MT presented pictures of five little monkeys
and a bed. These were moved according to
the lyrics. The children took turns moving the
visual. Parents encouraged responses by singing
and pointing to the board. By the last session,

Downloaded from https://academic.oup.com/mtp/advance-article-abstract/doi/10.1093/mtp/mix018/4747142

they presented the activity to the whole group.
The music was presented a capella.
Movements The Ants Go Do movements Model behaviors and “Talking bodies”: Participants were asked to sit down in a circle.
and Actions Marching** through prompt movement imitation and nonverbal The MT started the song and “marched” around
imitating adult communication the circle. The end of the verse was modified
to say: “and they all go marching down to play
with a friend.” As she said that, she invited one
of the parent-child dyads to stand up and walk
around the circle. The song was continued until
all dyads were “marching” (walking) around in
a circle. The music was presented a capella.
Music Therapy Perspectives
 Table 2

on 24 January 2018
Continued

Target behavior

by University of Florida user

Session Section Intervention Child Adult ESDM principle Procedure
The Body Language This song asks for different movements in the
(Sandler, S., in verse. The participants were invited to stand up
Walworth, 2013*) and make the movements as indicated by the
song. The lyrics were modified to incorporate
new movements. The music was presented with
guitar and singing.
If You’re Happy and You This song asks for different movements in the
Know It** verse. The participants were invited to sit down
and make the movements as indicated by the
song. The lyrics were modified to incorporate
new movements. After the second session using
this song, children were asked to propose new
Music Therapy and P-ESDM for ASD: A Feasibility Study

movements. Parents were asked to help if the

child could not make up a movement. The
music was presented with guitar and singing.
Make Rainbows (Fulton, The dyads received a scarf for each person
2015)* and were told to find a spot in the room. The
MT sang and played the song with guitar. The
1,2,3 Play Do movements Model behaviors and “Talking bodies”:
parents were asked to model the behaviors
(Rushing, J., in through prompt movement imitation and nonverbal
(moving the scarf, and then putting it in the
Walworth, 2013)* imitating adult (cont.) communication (cont.)

Downloaded from https://academic.oup.com/mtp/advance-article-abstract/doi/10.1093/mtp/mix018/4747142

floor to simulate a “puddle” and jumping on it).
(cont.)
The participants were invited to sit and play
their small percussion instrument as indicated
by the song (fast, slow, high, low). The lyrics
were modified to incorporate new patterns. The
music was presented with guitar and singing.
This song served as the transition for the guided
improvisation (see next section).
9
 10

on 24 January 2018
Table 2

by University of Florida user

Continued

Target behavior
Session Section Intervention Child Adult ESDM principle Procedure
Guided Improvisation Bongo Jam Imitate actions Create and elaborate “It takes two to tango”: Participants were provided a range of small
(Guilmartin, 2014)* with instruments activity by imitating elaboration of joint activity percussion instruments. The parents were asked
and propose child and proposing to involve their children in playing. The MT
Bongo Rock
others playing patterns walked around modeling or giving short verbal
(Epps, 2008)*
prompts to the parents on how to engage the
children. The main strategy was to instruct
the parents to imitate their child, and then
introduce slight changes to promote imitation
from the child. The music was presented
through a Bluetooth speaker placed beside the
circle of participants.
Music-Assisted Hush Little Baby** Calm down and Create a comfortable Self-regulation and closure Parents were asked to “cuddle with their child”
Relaxation Twinkle, Twinkle Little orient to end of relaxing environment for by sitting in a semicircle with their child on
Star** the session down regulation their lap. As the sessions progressed, they were
How Will You Grow? encouraged to sing, and to have their children
(Avirett, J., in Walworth, facing them to promote joint attention. The
2013)* music was provided through singing and guitar

Downloaded from https://academic.oup.com/mtp/advance-article-abstract/doi/10.1093/mtp/mix018/4747142

(finger-picking style).
Good-Bye Song It’s Time to Go** Wave, say Model waving good-bye Closure The song was presented two or three times with
good-bye sign language for “time,” “to go,” “wave good-
bye,” and “say.” Parents were encouraged to ask
for child’s participation through imitation.
*A reference list for the music resources is provided in Online Supplement B—Song Distribution & Reference List.
** Public domain.
Music Therapy Perspectives
 Music Therapy and P-ESDM for ASD: A Feasibility Study 11

Table 3 different degrees of difficulty in being their child’s focus of

Results of quantitative measures (PSOC, SRS-2, K-6) attention. Two of the children (P1 and P2) ran around the
room, climbed on the chairs, and had great difficulty focusing
PSOC SRS-2 K-6 on the interventions. The third one (P3) clung to her mother
and cried most of the session. For P1, the mother remained
Parent Pretest Posttest Pretest Posttest Pretest Posttest
passive without attempting to engage or orient her child to the
P1 92 99 59 47 7 6 session. Being able to redirect their child’s attention was a skill
P2 81 86 90 76 14 9 that the mothers needed to work on if they were going to be
P3 79 75 78 81 12 9 successful in teaching other skills to their children. Therefore,
Note: In the PSOC, higher numbers indicate better outcome (increased the therapist encouraged the mothers, particularly in the P1
parental sense of competence). In the SRS-2 and K-6, lower numbers dyad, to be more active by giving the child clear antecedents
indicate better outcome (less functional impairment and less distress, and specific and immediate reinforcements contingent to their
respectively). behavior (“Ask her to come no more than twice, and then help
her do it”; “You can tell her ‘great job sitting’ when she does”;
Acceptability of the Intervention “Find an instrument that he likes and show it to him”), which
Regarding acceptability of the intervention, the mothers are well-known ABA principles (Cooper, Heron, & Heward,
responded to a Final Survey that addressed parents’ perception 2007), but within a play- and child-centered perspective.
of interest and enjoyment, perceived difficulty, usefulness, cul- Further coaching was provided with in-the-moment prompts
tural sensitivity, developmental appropriateness, and parental such as “make sure she is looking at you,” “put the instrument
competence. All three participants completely agreed when in front of your eyes, so she looks at you,” “now do what he
asked about their enjoyment of the program, willingness to is doing,” “she wants to bang the drum, do it with her,” etc.
sign up again, usefulness, culture appropriateness, age appro- By the tenth session, all three mothers maintained their child’s
priateness, and parental competence (questions 1, 4, 5, 7, 9, attention throughout, in a playful, nonrestrictive way, and led
and 10, respectively). One of the mothers (P3) considered the the group in at least one song with visuals, while orienting
sessions difficult for her child (moderately agree), while the their child to the activity.
others did not (question 2). Two of the participants (P2 and “Find the smile.” The mothers had substantial difficulty
P3) moderately disagreed with the assertion “my child was engaging their children in the activity and finding the appropri-
not engaged in the session” (question 8), while P1 completely ate motivators. The most effective strategy used to motivate the
disagreed. All three participants completely disagreed when children was observing the children’s behaviors and imitating
asked whether they were overwhelmed by the demands of the them, instead of asking the child to imitate the adult. Once the
session or felt bored (questions 3 and 6, respectively). adults “found the smile,” they were coached to continue that
Written comments (elicited in the survey as “other com- activity until the child showed subtle behaviors of disengage-
ments”) are reproduced in their entirety here. The mother ment, such as looking away, taking another object, etc. At that
in P2 wrote: “We enjoyed this music therapy experience. point, the parents were asked to immediately follow the child’s
I  believe my son would have engaged more with a slightly gaze/nonverbal behavior to find the new interest and re-engage
larger group (5–6 children). However, [my son] loved the the child. Eventually, all parents were coached to introduce
physical and musical interactions and shared enjoyment for modifications (“variations”) to their child’s behavior. As a group,
marching around with other kids during the singsongs. My by the end of the sessions, all children showed clear preferences
only suggestion would be to incorporate even more types of toward specific songs, initiated communication to request those
hands-on manipulatives like a parachute or bubbles or pup- activities, and interacted with the other children (e.g., by follow-
pets to help with visual learning. Thank you for this oppor- ing each other, jumping imitatively, or sharing instruments).
tunity.” The mother in P3, in contrast with her responses in Talking bodies.  Children with ASD have difficulty interpret-
the PSOC and SRS-2, but consistent with other spontaneous ing nonverbal communication and imitating actions (Vivanti,
comments, wrote: “We loved this class! [My son] has made so Nadig, Ozonoff, & Rogers, 2008). In this group, participants
much progress since starting the class that I barely recognize showed a lack of understanding of gestures (such as when
him. I wish there were many more music therapy classes. This asked to sit down) during the first two sessions. The parents
class has been so good for both of us.” The mother in P1 did were coached to exaggerate their gestures while being con-
not offer any extra comments in writing, but she also verbal- sistent and contingent (i.e., repeating gestures until they got a
ized an interest to continue music therapy sessions. Based on response, and reinforcing accordingly). Moreover, the parents
these responses, the music therapy program seemed culturally were instructed to imitate the children’s spontaneous move-
and age appropriate, tailored to their skill level, interesting, ments. Once the child realized that he was being imitated,
and supportive of parent-child interaction and development. and enjoyed the “imitation game,” the parent introduced brief
modifications to the movement. By the end of the program, all
Adaptation of ESDM in a Music-Based Intervention (Field the parents engaged their children in imitation of movements
Notes) with music and props.
The evidence regarding the adaptation of the ESDM within It takes two to tango.  During the first session, the moth-
a music-based intervention is presented through field notes, ers were unsuccessful in creating joint activities with instru-
participants’ comments, and therapist’s observations. The ments and recorded music. Children were very interested in
accounts are organized around the ESDM principles. the instruments but would not allow their mothers to partici-
“Stepping into the spotlight” and orientation to the pate in their play. The mothers made several communication
activity.  During the first few sessions, the mothers had bids (placing her instrument near to her child’s, saying “look”)
Downloaded from https://academic.oup.com/mtp/advance-article-abstract/doi/10.1093/mtp/mix018/4747142
by University of Florida user
on 24 January 2018
 12 Music Therapy Perspectives

or direct requests (“play like me”), which were all ignored sensitized her to her own child’s needs, and motivated her to
by the children. Throughout the sessions, the mothers (and score him higher in the SRS-2 (more severe impairment), and
father) received coaching and modeling to observe their child, herself lower in the PSOC (less competent), during the post-
and follow her/his interest by taking an identical instrument test. On the other hand, this awareness of difficulties did not
and imitating the child’s actions. Once the child noticed and seem to limit her enthusiasm and appreciation of the music
enjoyed such interactions (which happened very quickly), the therapy program. Her spontaneous and unsolicited comments
parents were coached to modify the rhythmic pattern slightly seem a good measure of the acceptability of the program.
and encourage their child to imitate. By the tenth session, all Regarding the second research question (parental percep-
mothers had successfully encouraged their child to imitate tion of child’s social skills), it is noteworthy that such a short
them at least once. The mother in the P1 dyad was notably program (10 music therapy sessions) seemed to have a notice-
successful in creating a musical call-and-response of at least able impact on these mothers’ perceptions. Two of them (P2
three back-and-forth exchanges. and P3) showed an important decrease in the SRS-2 (12 and
Transitions and closure. Children had different levels of 14 points, respectively). Since it is unlikely that a six-week,
ability to self-regulate and sit for a quiet activity. For P1, the one-hour-per-week program had this type of effect on the
child could remain in the mother’s lap if the mother held her. children’s actual skills, the difference may be attributed to the
For the P2 dyad, the child had the most difficulty sitting during mothers’ perception of the skills. Even though the mother in
the closing activity, particularly during the first three sessions P3 rated her child as more affected by ASD at posttest, this
they attended. In this case, the mother was coached to find difference could be considered as increased awareness and
a comfortable position for him (which she discovered meant objectivity. This change in perception is important, consider-
lying down on the floor, with his feet on her lap) and to sing ing that parental perceptions can shape children’s skill acqui-
to him while making eye contact. The child remained in this sition, as reviewed in the introduction (Kirby, 2016).
position for the closing intervention in the last session. For With regard to the third question, “general mental health”
the third dyad, P3, the child tended to sit and hug his mother as a moderator of the mothers’ perception of her competence
tightly, avoiding eye contact with anyone else. His mother and her child’s social skills, the K-6 showed a decrease in
was coached to accept his self-regulatory strategy and provide scores for all participants. For P2 and P3, this reduction meant
rhythmic patting on his back while she sang to him. By the decreasing from moderate distress, to no distress. Researchers
end of the last session, the child was sitting on his mother’s lap have concluded that parental distress can have a major impact
and was alternating his gaze between his mother and other on parental reports of quality of life (including social skills)
participants. of a child with a disability (Davis, Mackinnon, & Waters,
2012). By presumably being in a calmer state, the mothers
Discussion might have appraised their own and their child’s performance
The purpose of this study was to investigate the feasibil- more objectively, without interference from anxious or other
ity (limited efficacy, acceptability, and adaptation measures) competing emotions. However, given the limited control of
of a music therapy program anchored in the ESDM, which extraneous variables in this study and small sample size, it is
coaches parents in behavioral strategies that enhance their not possible to credit the observed changes to this interven-
children’s social interaction. Regarding the first question, tion. On the other hand, the presence of moderate distress in
two of the mothers seemed to feel more competent in their the pretest of two of the three participants, and their change
parenting skills after participating in this program. The dif- in the posttest, supports the idea of investigating distress as a
ference in scores, however, was small. Their scores indicate moderator in larger, more controlled studies.
that these mothers had a considerably high sense of efficacy, Related to the acceptability of the intervention (fourth ques-
which might be less amenable to change through interven- tion), all mothers considered the intervention to be culturally
tion. Another possible explanation is that the PSOC might and developmentally appropriate, enjoyable, and promoting
not be sensitive to a short-term intervention such as the one a successful interaction within the dyads and between chil-
introduced in this study. Most items on this scale are worded dren. All families expressed, in verbal or written form, their
to reflect “the general experience of parenting” (Gilmore & desire to continue in a music therapy program. At least two of
Cuskelly, 2009). Another measure that elicits responses spe- them provided specific examples of how the intervention had
cific to the child with ASD, and/or that evaluates a shorter time generalized to their everyday life (e.g., “he is asking us to play
frame (e.g., a six-week program), might yield more substantial and sing the songs; he is very smiley and social, and he said
results. bye-bye to a little girl the other day”). Given the difficulty and
Noticeably, the mother in the P3 dyad showed a decrease importance of skill generalization of children with ASD, these
in her parental sense of competence, as self-reported with the outcomes are particularly valuable.
PSOC. She also showed a slight increase in her perception of The therapist’s field notes, and the participants’ comments
her child’s social difficulties (SRS-2). However, these results and Final Surveys, showed that adaptation of the ESDM
are incongruent with her verbal report of meaningful gains within a music-based intervention is feasible (fifth research
(e.g., “I see a completely different boy since we started music question). Parents learned the basic principles of the model
therapy…he is very smiley and social, and he said bye-bye to (“stepping into the spotlight,” “finding the smile,” imitating,
a little girl the other day”). This child did not participate in any etc.) in a non-challenging, effortless way. With specific hands-
other child program, and the mother had very limited experi- on prompting, and very brief discussions, they modified their
ence with young children, as reported by herself. The inter- behavior to accommodate their children’s needs. Positive child
action with other children with similar diagnoses might have outcomes observed during the sessions included increased

Downloaded from https://academic.oup.com/mtp/advance-article-abstract/doi/10.1093/mtp/mix018/4747142

by University of Florida user
on 24 January 2018
 Music Therapy and P-ESDM for ASD: A Feasibility Study 13

communication (babbling, first words, spontaneous naming Another consideration would be to implement the fidelity
and pointing), and spontaneous interactions within dyads measures of the ESDM (Rogers & Dawson, 2010) as part of the
(e.g., engaging in reciprocal musical exchanges with her outcome measures, coupled with behavioral data to compare
mother; lying quietly for three to four minutes while making the customary play-based ESDM parent-coaching sessions,
eye contact with his mother, and babbling communicatively) with a music-based ESDM parent-coaching session. Inclusion
and between children (imitation, lending of instruments, and of more objective measures of parent and child outcomes, and
following each other during play). of the effect of parent learning on child outcomes, would sup-
port the evaluation of efficacy. Finally, single-subject designs
Limitations could investigate the effect of music as a mediator of outcomes.
History (other variables concomitant with this intervention), as
well as selection and sample size (since it is a small convenience Conclusion
sample), are threats to the validity of this study, particularly to its Consistent with Schwartzberg and Sullivan’s (2017) recom-
limited-efficacy measures. However, the focus of this study was mendation to incorporate evidence-based approaches from
the acceptability and adaptation of a non-music model within within and outside the music therapy profession, and with
a music-based intervention, which, arguably, are not equally current recommendations to include parents in the treatment
impacted by history and sample size. The author considers that of children with ASD (e.g., Zwaigenbaum et  al., 2015), this
those limitations do not preclude the value of these findings. feasibility study addressed the limited efficacy, acceptability,
Another possible limitation is the fact that all the quanti- and adaptation of the P-ESDM (Rogers, Dawson, & Vismara,
tative measures are self-reports, and these are commonly 2012) to a music-based parent-coaching intervention. Parental
considered to have a high potential for bias. However, from reports and therapist observations of three participating dyads
a family-centered perspective, and within a feasibility study, seem to indicate that using music to teach parents the behav-
parents’ perceptions are considered essential to the under- ioral strategies of this model is culturally and developmentally
standing of the problem and of the effect of the intervention; acceptable, and that it supports joyful and effective interac-
therefore, a “biased” self-report is not considered a hindrance tions. Initial evidence of successful parent learning also sup-
but enrichment to understanding. Including other measures ports this adaptation. Further research should include more
and evaluators, such as behavioral observations and trained objective measures of efficacy and direct child outcomes.
observers, could provide a more balanced perspective. The development of a conceptual framework, an intervention
manual, and mechanistic research that explores the specific
Clinical Implications role of music in this intervention are also needed.
The Early Start Denver Model is a well-researched model
that seems feasible within music-based interventions. The ses- Supplementary Material
sion materials (Table  2), as well as the behavioral strategies Supplementary material is available at Music Therapy
described in the Method section (Procedure), are intended to Perspectives online.
provide the clinician with a step-by-step approach to incorp-
orate P-ESDM principles in a music therapy session. Even if
clinicians do not have access to sessions with parent-child
dyads, they could include ESDM principles in their practice References
by following the strategies recommended here (becoming the Aksan, N., Kochanska, G., & Ortmann, M. R. (2006). Mutually responsive orien-
focus of attention, eliciting enjoyment, imitating the child, tation between parents and their young children: Toward methodological
incorporating sensory-social routines, etc.). On the other advances in the science of relationships. Developmental Psychology, 42, 833–
hand, since certification in the ESDM is available and required 848. doi:10.1037/0012-1649.42.5.833
to be an ESDM therapist, further exploration of the model is Allgood, N. (2005). Parents’ perceptions of family-based group music therapy for
advised for the interested clinician. children with Autism Spectrum Disorders. Music Therapy Perspectives, 23(2),
92–99. doi:10.1093/mtp/23.2.92
American Psychiatric Association. (2013). Diagnostic and statistical manual of
Future Research
mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.
One of the greatest strengths of this study is that it shows doi:10.1176/appi.books.9780890425596.dsm01
promising results within a very economical (two 30-minute Baron-Cohen, S. (1995). Mindblindedness: An essay in on autism and theory of
sessions per week), socially valid, and age-appropriate inter- mind. Cambridge, MA: MIT Press.
Benavides, H., & Orrego, P. (2010). Assessing the development of joint attention
vention. On the other hand, a parent-coaching model did
skills through an intervention based on musical practices in a child with aut-
not seem optimal when performed in a group, even if some ism spectrum disorder. Psicoperspectiva–Individuo y Sociedad, 9(2), 224–252.
music-based studies did show positive results with this set- doi:10.2225/PSICOPERSPECTIVAS-VOL9-ISSUE2-FULLTEXT-10
ting (Williams et  al., 2012). In contrast with Williams and Braddock, B., & Twyman, K. (2014). Access to treatment for toddlers with
colleagues (2012), this study was anchored in an interven- Autism Spectrum Disorders. Clinical Pediatrics, 53(3), 225–229.
tion model that has very specific and delineated interven- doi:10.1177/0009922814521284
tion strategies. Teaching the parents these specific strategies Bradshaw, J., Steiner, A. M., Gengoux, G., & Koegel, L. K. (2015). Feasibility and
effectiveness of very early intervention for infants at-risk for autism spectrum
requires in-the-moment prompting that is difficult to achieve
disorder: A systematic review. Journal of Autism and Developmental Disorders,
when negotiating the needs of several dyads who might be in 45(3), 778–794. doi:10.1007/s10803-014-2235-2
very different situations and levels of ability. Therefore, it is Centers for Disease Control and Prevention (2011). Mental illness surveillance among
recommended that future studies and intervention programs adults in the US. Morbidity and Mortality Weekly Report, 60 (Supplement), 1–
consider individual parent coaching. 30. Retrieved from: https://stacks.cdc.gov/view/cdc/31627 (January 27, 2016).

Downloaded from https://academic.oup.com/mtp/advance-article-abstract/doi/10.1093/mtp/mix018/4747142

by University of Florida user
on 24 January 2018
 14 Music Therapy Perspectives

Chiang, C., Soong, W., Lin, T., & Rogers, S. J. (2008). Nonverbal communication Oono, I., Honey, E., & McConachie, H. (2013). Parent-mediated early intervention for
skills in young children with autism. Journal of Autism and Developmental young children with Autism Spectrum Disorders (ASD). The Cochrane Database
Disorders, 38(10), 1898–1906. doi:10.1007/s10803-008-0586-2 of Systematic Reviews, 4, CD009774. doi:10.1002/14651858.CD009774.pub2
Constantino, J. N., & Gruber, C. P. (2012). Social Responsiveness Scale (2nd ed.) Ozonoff, S., Young, G., Landa, R., Brian, J., Bryson, S., Charman, T., …Iosif, A.
(SRS-2) [Manual]. Torrance, CA: Western Psychological Services. (2015). Diagnostic stability in young children at risk for autism spectrum dis-
Cooper, J., Heron, T. E., & Heward, W. L. (2007). Applied behavior analysis (2nd ed.). order: A baby siblings research consortium study. Journal of Child Psychology
Upper Saddle River, NJ: Pearson/Merrill-Prentice Hall. and Psychiatry, 56(9), 988–998. doi:10.1111/jcpp.12421
Davis, E., Mackinnon, A., & Waters, E. (2012). Parent proxy-reported qual- Pasiali, V. (2012). Supporting parent-child interactions: Music therapy as an interven-
ity of life for children with cerebral palsy: Is it related to parental psycho- tion for promoting mutually responsive orientation. Journal of Music Therapy,
social distress? Child: Care, Health and Development, 38(4), 553–560. 49(3), 303–334. doi:10.1093/jmt/49.3.303
doi:10.1111/j.1365-2214.2011.01267.x Paul, A., Esharda, M., Emenon, S., Earora, I., Ekansal, N., Earora, K., & Singh, N. C.
Dawson, G., Osterling, J., Rinaldi, J., Carver, L., & McPartland, J. (2001). Brief report: (2015). The effect of sung speech on socio-communicative responsiveness in
Recognition memory and stimulus-reward associations: Indirect support for the children with Autism Spectrum Disorders. Frontiers in Human Neuroscience, 9,
role of ventromedial prefrontal dysfunction in autism. Journal of Autism and 1–9. doi.org/10.3389/fnhum.2015.00555
Developmental Disorders, 31(3), 337–341. doi:10.1023/A:1010751404865 Powell, D., Dunlap, G., & Fox, L. (2006). Prevention and intervention for the chal-
Dawson, G., Rogers, S., Munson, J., Smith, M., Winter, J., Greenson, J., Donaldson, lenging behaviors of toddlers and preschoolers. Infants and Young Children,
A., & Varley, J. (2010). Randomized controlled trial of an intervention for tod- 19, 19–35.
dlers with autism: The Early Start Denver Model. Pediatrics, 125(1), e17–e23. Prochaska, J. J., Sung, H.-Y., Max, W., Shi, Y., & Ong, M. (2012). Validity study of
doi:10.1542/peds.2009-0958 the K6 Scale as a measure of moderate mental distress based on mental health
Estes, A., Munson, J., Rogers, S. J., Greenson, J., Winter, J., & Dawson, G. (2015). treatment need and utilization. International Journal of Methods in Psychiatric
Long-term outcomes of early intervention in 6-year-old children with autism Research, 21(2), 88–97. doi.org/10.1002/mpr.1349.
spectrum disorder. Journal of the American Academy of Child & Adolescent Rogers, S. J., & Dawson, G. (2009). Early Start Denver Model Curriculum Checklist
Psychiatry, 54(7), 580–587. doi:10.1016/j.jaac.2015.04.005 for young children with autism. New York: Guilford Press.
Estes, A., Vismara, L., Mercado, C., Fitzpatrick, A., Elder, L., Greenson, J., … Rogers, Rogers, S. J., & Dawson, G. (2010). Early Start Denver Model for young children with
S. (2014). The impact of parent-delivered intervention on parents of very young autism. New York: Guilford Press.
children with autism. Journal of Autism and Developmental Disorders, 44(2), Rogers, S. J., & Vismara, L. (2015, 6-25-2105 Version). Coaching parents in ESDM
353–365. doi:10.1007/s10803-013-1874-z (Unpublished document, PDF provided by authors).
Estevanovic, M., & Eperäkylä, A. (2015). Experience sharing, emotional reciprocity, Rogers, S. J., Dawson, G., & Vismara, L. A. (2012). An Early Start for your child with
and turn-taking. Frontiers in Psychology, 6. doi:10.3389/fpsyg.2015.00450 autism. New York: Guilford Press.
Geretsegger, M., Elefant, C., Mossler, K. A., & Gold, C. (2014). Music therapy for Rogers, S. J., Estes, A., Lord, C., Vismara, L., Winter, J., Fitzpatrick, A., …Dawson, G.
people with autism spectrum disorder. Cochrane Database Systematic Reviews, (2012). Effects of a brief Early Start Denver Model (ESDM)–based parent inter-
6, Cd004381. doi:10.1002/14651858.CD004381.pub3 vention on toddlers at risk for Autism Spectrum Disorders: A randomized con-
Gilmore, L., & Cuskelly, M. (2009). Factor structure of the Parenting Sense trolled trial. Journal of the American Academy of Child & Adolescent Psychiatry,
of Competence scale using a normative sample. Child: Care, Health & 51(10), 1052–1065. doi:10.1016/j.jaac.2012.08.003
Development, 35(1), 48–55. doi:10.1111/j.1365-2214.2008.00867.x Schwartzberg, E., & Silverman, M. (2017). Parent perceptions of music therapy in
Gordon, R., & Watson, G. (2015). Brief report: Gestures in children at risk for Autism an on-campus clinic for children with Autism Spectrum Disorder. Musicae
Spectrum Disorders. Journal of Autism and Developmental Disorders, 45(7), Scientiae, 21(1), 98–112. doi:10.1177/1029864916644420
2267–2273. doi:10.1007/s10803-015-2390-0 Strauss, K., Mancini, F., Fava, L. & SPC Group, (2013). Parent inclusion in early inten-
Juhnke, A. G. (2015). The effect of a transition song on the length of transitions sive behavior interventions for young children with ASD: A synthesis of meta-
among children with autism spectrum disorder (Unpublished Master’s Thesis). analyses from 2009 to 2011. Research in Developmental Disabilities, 34(9),
University of Kansas, Lawrence, KS. 2967–2985. doi:10.1016/j.ridd.2013.06.007
K-10 and K6. (2005). Harvard Medical School. Retrieved from: http://www.hcp.med. Thompson, G., & McFerran, K. S. (2015). “We’ve got a special connection”:
harvard.edu/ncs/k6_scales.php (September 2015). Qualitative analysis of descriptions of change in the parent-child relationship
Kalas, A. (2012). Joint attention responses of children with Autism Spectrum Disorder by mothers of young children with autism spectrum disorder. Nordic Journal of
to simple versus complex music. Journal of Music Therapy, 49(4), 430–452. Music Therapy, 24(1), 3–26. doi:10.1080/08098131.2013.858762
doi:10.1093/jmt/49.4.430 Thompson, G., McFerran, K., & Gold, C. (2014). Family-centred music therapy to
Kessler, R., Barker, P., Colpe, L., Epstein, J., Gfroerer, J., Hiripi, E., … Zaslavsky, A. promote social engagement in young children with severe autism spectrum dis-
(2003). Screening for serious mental illness in the general population. Archives order: A randomized controlled study. Child: Care, Health and Development,
of General Psychiatry, 60(2), 184–89. 40(6), 840–852. doi:10.1111/cch.12121
Kim, J., Wigram, T., & Gold, C. (2008). The effects of improvisational music therapy Vivanti, G., Nadig, A., Ozonoff, S., & Rogers, S. J. (2008). What do children with aut-
on joint attention behaviors in autistic children: A randomized controlled trial. ism attend to during imitation tasks? Journal of Experimental Child Psychology,
Journal of Autism and Developmental Disorders, 38, 1758–1766. doi:10.1007/ 101(3), 186–205. doi:10.1016/j.jecp.2008.04.008
s10803-008-0566-6 Vivanti, G., Paynter, J., Duncan, E., Fothergill, H., Dissanayake, C., & Rogers, S.
Kirby, A. V. (2016). Parent expectations mediate outcomes for young adults J. (2014). Effectiveness and feasibility of the Early Start Denver Model imple-
with Autism Spectrum Disorder. Journal of Autism and Developmental mented in a group-based community childcare setting. Journal of Autism and
Disorders, 46(5), 1643–1655. doi:10.1007/s10803-015-2691-3. doi:10.1001/ Developmental Disorders, 44(12), 3140–3153. doi:10.1007/s10803-014-2168-9
archpsyc.60.2.184 Walworth, D. (2013). Bright Start Music: A developmental program for music ther-
Koegel, L. K., Koegel, R. L., Harrower, J. K., & Carter, C. M. (1999). Pivotal response apists, parents and teachers of young children. Silver Spring, MD: American
intervention 1: Overview of approach. Journal of the Association for Persons Music Therapy Association.
with Severe Handicaps, 24, 174–185. Williams, K. E., Berhelsen, D., Nicholson, J. M., Walker, S., & Abad, V. (2012). The effect-
Lequia, J., Wilkerson, K. L., Kim, S., & Lyons, G. L. (2015). Improving transition iveness of a short-term group music therapy intervention for parents who have a child
behaviors in students with Autism Spectrum Disorders: A  comprehensive with a disability. Journal of Music Therapy 49(1), 23–44. doi:10.1093/jmt/49.1.23
evaluation of interventions in educational settings. Journal of Positive Behavior Zwaigenbaum, L., Bauman, M., Choueiri, R., Kasari, C., Carter, A., Granpeesheh,
Interventions, 17(3), 146–158. doi:10.1177/1098300714548799 D., …Natowicz, M. (2015). Early intervention for children with autism spectrum
Lord, C. (2010). Autism: From research to practice. American Psychologist, 65(8), disorder under 3  years of age: Recommendations for practice and research.
815–826. doi:10.1037/0003-066X.65.8.815 Pediatrics, 136(4), s60–s81. doi:10.1542/peds.2014-3667E.

Downloaded from https://academic.oup.com/mtp/advance-article-abstract/doi/10.1093/mtp/mix018/4747142

by University of Florida user
on 24 January 2018