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Effectiveness of Floor-time therapy in comparison to Floor Time Therapy Adjunct to Music Therapy in the Children with Autism

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Indian Journal of Health Social Work

Effectiveness of Floor-time therapy in comparison to Floor Time
Therapy Adjunct to Music Therapy in the Children with Autism
Spectrum Disorder

Manasi Rani Panda1 , S. Haque Nizamie2, Narendra Kumar Singh3

1Psychiatric Social Worker, Department of Psychiatric Social Work, S.C.B. Medical College, Cuttack, Odisha, 2Ex -Professor of Psychiatry, Central Institute of Psychiatry, Kanke, Ranchi, Jharkhand, 3Psychiatric Social Worker, Department of Psychiatric Social Work, Central Institute of Psychiatry, Kanke, Ranchi, Jharkhand.

Correspondence: Manasi Rani Panda, e-mail id: pandamanasi1@gmail.com

ABSTRACT

Background: Autism Spectrum Disorders (ASD) is a group of neurological disorders characterized by impaired social communication and interaction as well as the presence of stereotyped behaviours and interest. The Floortime Therapy (FT) has been evolved around the principles of DIR (Developmental, Individual-differences, Relationship-based model) i.e. an intervention that is used to promote an individual’s development through a respectful, playful, joyful, and engaging process and music has also been studied to be an adjunctive therapy in numerous psychological problems and combined use of music and FT would fetch better results for children with ASD. There is paucity of studies on the impact of combined therapy in children and adolescents with ASD. Aim: The present study intended to see the effective comparison between FT and FT adjunct to Music Therapy in ASD. Method: Ten children diagnosed with ASD, as per ICD-10 DCR criteria were selected in the study through purposive sampling method and allocation of treatment was done. Those two groups of children were appropriately matched as per their age and clinical condition. Measures like ‘Socio-demographic and Clinical Data Sheet’, ‘Childhood Autism Rating Scale (CARS)’ & ‘Indian Scale for Assessment of Autism (ISAA) were used for data collection. Results:  There was significant change in the scores of CARS and ISAA, over treatment from baseline to middle, baseline to post and middle to post in both groups i.e. FT and FT adjunct to Music Therapy. Conclusion:  Adjunctive use of Music Therapy with DIR Model (e.g. FT) can hasten the improvement process in ASD as compared to single use of Floor-time therapy.

Keywords: Autism spectrum disorder, floortime therapy (FT), music therapy.

 

INTRODUCTION

Autism Spectrum Disorders (ASD) is a group of neurological disorders characterized by social communication impairments as well as the presence of stereotyped behaviours and interest (APA, 2000). Although precise neurobiological mechanisms have not yet been established, it is clear that Autism Spectrum Disorders (ASD: henceforth it will be spelt as ASD) reflect the operation of factors in the developing brain. The Autism Spectrum Disorders occur along with IDD and language disorder in many cases. Even though there are strong and consistent commonalities, especially in social deficits, there is no single behaviour that is always typical of autism or any of the autistic spectrum disorders and no behaviour that would automatically exclude an individual child from diagnosis of ASD (Lord & Gee, 2001). Autism is the current global health crisis, which is not bounded by any margins and also does not distinguish between any nationality, ethnicity or social status.  It’s high time that the world begins to recognize the scope of this problem and acts internationally and locally to improve the lives of the growing number of individuals and families affected by this devastating disorder (Kopetz & Endowed, 2012).

Theory of mind signifies the deficit in empathy towards other people’s feelings and ideas. They could seldom connect with the surrounding and their inability to consider other people perspective leads to significant social and communicative challenges (Richard, 2000; Baron-Cohen, 2000). The Connectivity Theory has demonstrated decreased connectivity in the central nervous system in autism. It is clinically reasonable to assume that individuals with autism have poorly developed connections between separate brain circuitries. The Default Network Theory of the brain have long been shown to be dysfunctional or even damaged in autism (Klin et al., 1995).

Developmental Individual-difference Relationship-based model (DIR) was derived from over years of study and research about child development from the various fields. Floortime is the heart of the DIR model and it plays an important component on comprehensive programme for infants, adolescents and their families with a variety of developmental challenges including autism spectrum disorders. DIR model on FT was created by child psychiatrists Stanley Greenspan and Serena Wieder. The theory of DIR was initially described by Greenspan and was further developed over the next 20 years. FT focussed on the interest of child needs and how to respond to the child interest. It creates parent-child connections and brings out a child’s creativity and curiosity (Greenspan &Wieder, 1999).

FT takes place in a calm environment based at home or in a professional setting. Parents were encouraged to use this approach in their daily lives to expand their child’s circles of communication and strengths. The parents were asked to play with the child on the floor for at least 20 minutes or more which leads to associate them in their child’s world. Their shared world later helps the child to master each of his functional, emotional and developmental capacities. Following a child’s lead, interests and natural desires actually encourages the child to allow the parents into their emotional life. FT is also applicable to children with moderate to severe forms of developmental delays and it helps the child master the first stage of shared attention. Developmental capacities seek to measure changes in an individual’s ability to form warm intimate and trusting relationships. The capacity to initiate intentional actions and social engagement leads to spontaneous communication. Because of the wide range of individual differences in children with autism and the many unique relationships within families, it is necessary for parents to have the information and options to make informed choices about the type of services their child will receive. FT has a solid base of empirical evidence, and is widely used for children of all ages and abilities (Anderson, 2008).

Music therapy has been defined as a systematic process where the therapist helps the client to promote health, using musical experience and the relationship that develop through them. It is also perceived a type of therapeutic intervention where musical interaction in addition to verbal interaction used as a mean of interaction and expression of feelings (Gold et al., 2005). Though music therapy consists of music, the therapy covers a much larger definition and techniques or activities. In the physical therapy setting, dancing and moving to the music are activities that boost strength, balance as well as moods. Soft music playing in the background of a therapeutic session is one of the more positive and practical music therapy activities (Wigram, 2004).

Research studies and clinical reports have shown that music created spontaneously and creatively through structured and flexible improvisation attracts the attention and provokes engagement in children with ASD, and promotes the development of reciprocal, interactive communication and play. Data seems to suggest that active music therapy sessions could be of aid in improving autistic symptoms such as gestural and communication skills (Wigram & Gold, 2006).

In recent years, there has been a great effort to meet rising need and demand for innovative and therapeutic services that can give children with ASD the best chance to develop intellectually on a social basis, to discover their talents and to cope with their challenges. Among the effective and existing treatment options for individual with special needs are both FT and Music Therapy. There are many researcher applied music as a basic part in FT and it creates a great interest in between children (Wolfberg, 2009). The music Therapies combined with the DIR model creates a unique and comprehensive approach that accomplishes these tasks. The blend of a child-centered focus along with creative and expressive modalities brings together a dynamic and integrative model that children thrive on. Music Therapy can help children with sensory issues. Dr. John Carpente, a music therapist has incorporated the DIR model into his work as well. He states that the therapist’s task is to improvise music built around the child’s responses, reactions, responses, and/or movements to engage him or her in a musical experience that will facilitate (musical) relatedness, communication, socialization, and awareness (Carpente, 2009). FT based music therapy that involves the implementation of interactive music within the FT (Carpente & Gasse, 2015). Music therapy pioneers Nordoff and Robbins (1977), described their work with Edward, a young boy with autism: Personal and musical conditions, combined to make it possible for him to participate in sustained two-way communication. Researchers highlight varied music therapy treatment approaches, such as applied behaviour analysis, social stories and FT combined with improvisational music therapy and strategies such as collaborative consultation and family-centered practice (Kern &Humpal, 2012).

AIM & OBJECTIVES

The present research intends to see the impact of Music Therapy (Classical Instrumental Hindustani Ragas) in children with ASD, as an adjunct to FT.

The present study has the following objectives:

  • To find out the impact of FT on children with ASD.
  • To know the impact of Music Therapy on children with ASD.

METHODOLOGY

In this study, two different forms of therapy (FT and Music Therapy) – this implies that one group gets only FT and another group gets FT adjunct to Music Therapy) were applied and compared on two groups of children with same type of condition (ASD). Those two groups of children were appropriately matched as per their age and clinical condition. The study was conducted at the Department of Erna Hoch Center for Child and Adolescent Psychiatry (CCAP), Central Institute of Psychiatry, Kanke, Ranchi. The study sample consisted of 10 children (age range in between five to fifteen) with diagnosis of ASD, as per ICD-10 DCR criteria. Patients were selected through purposive sampling method and allocation of treatment (FT vs. FT adjunct to Music Therapy) was done on the selected samples by using the ‘odd-even formula’. Selected 10 children were assigned with digits and children with odd numbered digits were selected for FT adjunct to Music Therapy and children with even numbered digit were selected for only FT.

Tools Used

  • Socio-Demographic and Clinical Data Sheet
  • Childhood Autism Rating Scale (Schopler et. al,1980)
  • Indian Scale for Assessment of Autism (Patra & Arun, 2011)
  • Indian instrumental classical music viz. Raga Pilu and Raga Khamaj

 Analysis

Statistical package for social science version 22.0 was applied for analysis of the data. Descriptive statistics were used to describe the various sample characteristics. Distribution of socio-demographic variables across two groups of participants was done by using Chi square/fisher-exact test for categorical variables and Mann-Whitney test for continuation variable. For further understanding of difference within the group and locate the changes at different phase of measurement and intervention Friedman and Wilcoxon sign rank test was applied for the CARS and ISAA. To see the percentage change on CARS and ISAA, Mann-Whitney test was applied.To compare the impact of FT and FT adjunct to Music Therapy on children with ASD.

RESULTS


Table 1 shows the comparison of the socio-demographic characteristics of children with ASD participants.
The sample selected for study consisted of 80% of males and 20% female. About 60% samples belongs
to joint family and 30% of participants have family history of various mental illness. Among those who
participated, 50% were from urban habitat, 20% were from semi-urban and 30% were from rural area.
The result also show that 20% of sample belongs to lower socio-economic status, 30% belongs to middle
socio-economic status and 50% belongs to higher socio-economic status. Out of all the participants 80%
were Hindu, 10% Muslim and 10% belongs to other category of religion. Almost 60% of them had
associated with IDD. Majority of the participants’ mothers were unemployed (80%) whereas fathers were
employed (90%) in the selected sample, out of them 80% were government employees.

Table 2: explains socio-demographic and clinical profile of continuum variable by using Mann- Whitney test. The mean rank age of the respondents were found higher (6.30) in FT group as
compared to mean rank (4.70) of FT adjunct to music therapy group. The mean rank of family
monthly income was found (5.00 & 6.00) similar in both the groups i.e. FT adjunct to music therapy
group and FT group. However mean rank of the fathers education was found (5.00) in FT adjunct to
music therapy group and (6.00) FT group. The mean rank of the mother’s education was found
(5.60) in FT adjunct to music therapy group and FT group (5.40). The mean rank score of VSMS was
found higher (6.70) in FT group as compared to FT adjunct to Music Therapy group (4.30). Results
also indicated that the mean rank score of DST was found higher (7.10) FT group than FT adjunct to
music therapy group (3.90). However no significant difference was found with regard to age of
respondents, monthly family income, and education of father, education of mother, number of
family member, number of sibling, position of respondent among sibling in the both groups.

DISCUSSION 

The current study was conducted to see whether the combination of FT and Music Therapy is effective or FT alone is affective in the children with Autism Spectrum Disorders. The teaching strategies and support used for intervention were, play-materials, toffees, and other learning materials etc. which were based on the child’s need and interest and according to the recommendation from previous evidence based interventions. The common target was to involve them in play with parents, according to their interest and to explore their interest area, over a period of 24 training sessions, spread over six weeks inside the play room of Child and Adolescent Psychiatry Department of the aforesaid institute. Outcome measures were obtained to assess the improvement on the basis of observation, frequency recording of problem behaviour for every predefined target, frequency change in problem behaviour within the specific time of each individuals, mid and post assessment using CARS and ISAA scores under various domains of individuals. To assess the overall improvement of three levels of intervention, Friedman chi-square test was used and to compare in between two groups, Mann-Whitney Test was used to get significant difference of intervention. 

The two groups were compared in important socio-demographic variables like, age, sex, habitat, family type and family history of psychiatric illness. The study comprised of male and female ratio of 5:0 in Group One and 3:2 in Group Two. Though, the present study was carried out on only 10 children, male preponderance was seen even in this tiny population. Past studies also stated that ASD is diagnosed as four times more in boys than girls and female population may be prone to have fewer chances to have autism genetically or under diagnosed (Bryson & Smith, 1998; Fombonne, 1999; Kim et al., 2011; Frazier et al., 2014). Studies revealed that levels of severity of autistic traits for patients with pervasive developmental disorder not otherwise specified were found in 1.4% of boys and 0.3% of girls which suggested specific mechanisms by which females may be relatively protected from vulnerability to autistic traits. One possibility could be the diagnostic gender bias among professional meaning that girls who meet criteria for ASD are at disproportionate risk of not receiving a clinical diagnosis as recognizing autism is difficult in girls than boys (Loomes R, Hull L, Mandy WP, 2017). Another possibility may be that given the existing gender discrimination in a country like India, male children are given more importance than females and are taken to hospital with a hope for complete recovery. In present study parents could able to recognize the initial symptoms of ASD in their child in an average by the age of three However the average age of all participants is 7.4 years. Indian parents’ initial symptom recognition in children who were eventually diagnosed with ASD was at a range of 6 to 10 months later than families in the West as compared to the parents in west (Daley TC, 2004; Desai, 2012). One reason could be the lack of awareness among the Indian parents regarding ASD and its manifestation. The current study indicates that the 50 % have a co-morbidity of IDD. Previous Studies also reported that autism have co-morbidity of IDD in 20%-70% of the cases (Dawson G, 2008) and 25%-75% according to Balte and Poustka (2002). In this study 50% of the cases belongs to higher socio-economic background, where early descriptive studies conducted in individual with autism found a preponderance of parent from high social class background, as defined by their education, occupation or intellectual level (Treffert DA, 1970). One possibility could be according to investigator of early eighties, that high social class bias in diagnostic services and treatment in the clinic population from which participants were drawn (Schopler E, Andrews CE, Strupp K., 1979). However present study also revealed that near about 60% cases belong to joint family, which revealed that there is no such dominance of nuclear family as studied before in literature. Present study shows that 60% of the children had mild delay in developmental milestones and 60% also mild delay in socio adaptive functioning. Studies reported that individual with autism have more problem in adaptive behaviour than their cognitive functions (Tomanik et al., 2007).

Intervention

Family members of a child with autism face various challenges and adjustment difficulties as compared to normal family, due to the child’s behavioural problems (Greeff &Walt, 2010). So the primary goal of treatment is to reduce the symptoms of maladaptive behaviour, promoting socialization and educating and supporting the families. Children with ASD differ from one another in the ways they engage, relate, and communicate and in the ways they respond to sensations, and plan and sequence their actions. These differences mean that and intervention is designed keeping in view each child’s unique style, rhythm and mood, an intervention that must also consider the home setting. The social play of children with ASD is substantially limited, lacking joint attention, creativity, and pretend scenarios. Greenspan and Wieder (1997) described absent joyful interactions and engagement that reflects interest in and attachment to others. Greenspan’s Floortime intervention utilizes play to focus on the individual differences and interest of the child. The active involvement of caregiver is essential throughout the process. This model enables to construct a holistic assessment and intervention program that incorporates the child’s and family’s unique developmental profile that addresses these core deficits (Hess, 2013). Floortime has a solid base of empirical evidence, and is widely used for children of all ages and abilities (Anderson, 2008).
 
Result of present study suggested that there was an increase in active involvement in play activity when the children were allowed to play freely. They were also more likely to respond to therapist’s verbal responses. Gradually in this process they started taking initiative for their play and started initiating social signals like greeting the therapist while entering the play room, holding therapist’s hand while playing. Similar improvement was seen in a study undertaken by Greenspan and Weider which showed that a majority of the children learned to relate and engage with warmth, trust and intimacy, were able to interact, read and respond to social signals and a subgroup of children developed the capacity for imaginative play, creative use of language and reflective thinking (Greenspan & Wieder, 1997)
 
Initially in the play sessions though children were didn’t show any interest in play activities, gradually they involved in some particular games and tried to play with that same game in different style. For example in case study five, child was interested in marbles, so once he was holding the marbles, then he started counting, also he used those marbles a time as ball and rolling that from one side to another side etc. In case study three, child was involved in some play activity towards the last week, though he was initially reluctant but later respond to other children partially. Further, few children with high functioning autism displayed more empathetic behaviour towards others. The same kind of result was suggested in a follow-up study of 16 children diagnosed with (ASD) was conducted by Wieder and Greenspan in 2005, to determine if children with ASD could overcome the core deficits in social behavior and become empathetic and reflective with floor time intervention, which revealed that with the Floortime approach, a subgroup of children with ASD can become empathetic, creative, and reflective, with healthy peer relationships and solid academic skills.
A rationale for the use of music therapy for individuals with communication disorders is based on the findings from infancy researchers described sound dialogues between mothers and infants using “musical” terms. When describing tonal qualities researchers use the terms pitch, timbre and tonal movement, and when describing temporal qualities they speak of pulse, tempo, rhythm, and timing (Bonde and Wigram, 2002). Trevarthen describes the sensitivity of very young infants to the rhythmic and melodic dimensions of maternal speech, and to its emotional tone, as demonstrating that we are born ready to engage with the ’communicative musicality’ of conversation, and this premise allows music to act as an effective medium for engaging in non-verbal social exchange for children and adults with autism spectrum disorder (Trevarthen, 1999).
 
Music with rapid fire orchestral rhythms has to increase the participation and alertness and manage anger; and music without rhythms to induce relaxation; and repeated rhythms to regulate the emotions. The active/improvisational form of music therapy techniques can be more useful in severely disturbed patients and that more receptive approaches can be of better efficacy in milder conditions (Nizamie & Tikka, 2014) Music Therapy can help children with sensory issues. Dr. John Carpente, a music therapist has incorporated the DIR/Floortime model into his work as well. He states that the therapist’s task is to improvise music built around the child’s responses, reactions, responses and movements to engage him or her in a musical experience that will facilitate (musical) relatedness, communication, socialization, and awareness (Carpente, 2009). FT based music therapy that involves the implementation of interactive music within the FT (Carpente & Gasse, 2014). Present study there is a significant difference between the two groups. Within the behavioural model, there is little or no consideration of a child’s internal mental states; while in FTP, CoC are encouraged during purposeful activities so that the child links his or her behaviour to intention rather than learning by rote and reinforcement (Greenspan &Wieder, 1999).
 
SUMMARY AND CONCLUSION
 
Behavioural and developmental approaches is the concept of following the child’s lead, this is especially relevant within the current trends in the research pertaining to evidence-based practice in regards to interventions with children with Autism Spectrum Disorder (ASD).In present study it can be concluded that FT leads to significant improvement in the problem behaviour of children with autism. However this study concludes that FT therapy was given adjunctively with music therapy are more effective than FT therapy for the treatment of the children with Autism Spectrum Disorders and music therapy leads to musical reflection of their emotional state and on the index study.
 
LIMITATIONS & FUTURE DIRECTIONS
 
In present study the sample size was small hence results cannot be generalized. Most of the children were having co morbid of IDD and there were very few female participants. Larger sample can be taken with longer duration of sessions further. In future, follow up should be included to see the actual effect of improvement when child go to his/her real environment.
 
IMPLICATIONS
 
Autism spectrum disorders are chronic conditions that require ongoing medical and Clinical intervention. There is a growing body of evidence that supports the efficacy of certain interventions in ameliorating symptoms and enhancing functioning, but much remains to be learned. The present study gives an idea that adjunctive music therapy and interactive play therapy is useful for children with autism and therefore it can be used as a standard treatment in professional centres in our country. Health care professionals are in a position to provide important longitudinal medical care and to support and educate families and guide them to empirically supported interventions for their children.
 
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15 thoughts on “Effectiveness of Floor-time therapy in comparison to Floor Time Therapy Adjunct to Music Therapy in the Children with Autism”

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