Behavioral therapy and music therapy for children with autism. Methods and mode of action of the two interventions

Table of contents

List of abbreviations

1 Introduction

2 Autistic disorders
2.1 History of the term "autism" – an overview
2.2 Classification according to ICD-10 and DSM-V
2.3 Forms of autistic disorders and their symptomatology
2.4 Autistic disorders and intelligence
2.5 Root cause research and the development of interventions

3 Behavioral therapy interventions for autistic disorders
3.1 Basics of Behavioral Therapy
3.2 Four selected methods of behavioral therapy
3.3 Interim conclusion

4 Music therapy interventions for autistic disorders
4.1 Basics of Music Therapy
4.2 Four selected principles of music therapy
4.3 Interim conclusion

5 Comparison of behavioral therapy and music therapy
5.1 Similarities
5.2 Differences

6 Discussion and outlook

Bibliography and source index

Bibliography

Internet sources:

Appendix:

List of abbreviations

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1 Introduction

If you look at the number of publications that have appeared on the subject of autism or autism spectrum disorder in recent years, it becomes clear that this topic is of current relevance. Especially in the field of therapy of autistic disorders, some research has been carried out in recent years and catalogues of evidence-based therapy methods have been published (cf. Bernard-Opitz 2015, p. 13). The present work deals with two selected therapy options for the treatment of autistic disorders.

Autism is one of the profound developmental disorders and is characterized by a central perception and information processing disorder. Autistic children are usually noticed at first by their self-centeredness, they live in their own world and seem to isolate themselves from everyday life. Autistic children find it difficult to understand themselves, their environment and the individuals living in them (cf. Theunissen 2014, p. 13). Autistic disorders can be counted among the most severe mental illnesses of childhood. The symptoms cause a state in which social interaction and communication is impaired and repetitive and stereotypical behaviors occur. The severity of the symptoms varies "from mentally handicapped children without language development with massive autistic symptoms to above-average gifted persons with weaker autistic symptoms with a very well developed language" (Sinzig 2011, foreword). In addition, comorbid diseases can occur to the autistic disorder, which additionally affect the autistic child. The normal development of the child is disturbed or inhibited by the aforementioned impairments. This includes, for example, language development or relationship building with other individuals. In general, all areas of development related to social learning are particularly affected. Since the cause research in the field of autistic disorders has not yet been completed, there are no therapies that promise a cure for the disorder. However, there are some ways to alleviate the symptoms of the disabled children in order to help them to lead a self-determined life within their framework. It is recommended to start the therapy as early as possible, as this is of central importance for the chances of success (cf. Remschmidt and Kamp-Becker 2008, p. 139). The children can thus be accompanied in their development from the beginning and supported in critical developmental tasks. For this reason, I refer exclusively to the treatment of autistic children in my work, although this should not give the impression that only children can be treated. There are also possibilities of therapy for adult, autistic people.

The therapy of autistic disorders is generally not a classic field of social work, but rather a field of psychiatry. Nevertheless, one also encounters autistic people in the context of the field of social work. Fields of work in which social workers¹ Meet autistic people, for example, workshops for the disabled, socio-educational day care facilities, schools with a focus on social, emotional development and learning or in dormitories for people with disabilities.

As part of my part-time job in a dormitory for people with intellectual disabilities, my attention was aroused by a young, autistic man and in this context also my interest in this topic. In my work, I would like to take a closer look at two possible intervention methods in the treatment of autistic disorders. I will explicitly present the behavioral therapy-oriented interventions and the music therapy-oriented interventions with regard to the treatment of autistic disorders on the basis of selected methods and principles. In doing so, I make no claim to the completeness of all methods and techniques used. The exemplarily selected methods and principles are only intended to illustrate the application of the different therapies. Before I go into more detail about the individual forms of therapy, I will generally present basic information on the subject of autism and define the most important forms of autism. Subsequently, as already mentioned, behavioral therapy and music therapy in application to the treatment of autistic disorders are examined and then compared with each other. I will focus on the similarities and differences of the two forms of therapy, both in the approach and the possible effects of the therapies. On the one hand, I would like to disclose the mode of action of the forms of therapy and, on the other hand, I would like to address the effect goals. In what way do the two forms of therapy work in autistic children and what effect do they have? In a final discussion, I will contribute my own statement on the various forms of therapy and go into more detail about the relevance of the topic for the profession of social work.

2 Autistic disorders

Autism, autistic disorder or autism spectrum disorder, there are now many different terms circulating that ultimately describe the same clinical picture and deal with the same topic. Due to further developments in research, however, this clinical picture is always subject to change, from a concretization and specification of certain core symptoms to a departure of the rigid view of concrete syndromes and the idea of a disease spectrum. In the following work, I will use the term autistic disorder to include all forms of autism spectrum disorder with it.

The following chapter will deal with the concept of autism and how this or the developmental disorder is defined in the diagnostic classification systems. It deals with the special symptoms of autistic disorders, as well as forms of autistic disorder. In a condensed form, reference is also made to the intelligence of autistic disorders, the cause research of the disorder and the establishment of interventions.

2.1 History of the term "autism" – an overview

The term autism is derived from the Greek word "autos" and means "self". Starting from its etymological ancestry, the term thus points to the most obvious characteristics of autistic people, their self-centeredness and departure from the surrounding environment. Autism is also referred to as a perceptual and information processing disorder "characterized by a delay and deviation in the development of social, communicative, and other skills" (Remschmidt and Kamp-Becker 2008, p. 135).

The term was first introduced in 1911 by Eugen Bleuler, a Swiss psychiatrist for a symptomatology of schizophrenic psychosis. In this context, Bleuler understood the concept of autism as a kind of basic symptom of schizophrenia, and thus described the egocentric withdrawal of his patients (cf. Poustka et al. 2008, p. 5). People with this symptomatology detach themselves from reality and retreat into a kind of internal world. Even then, Bleuler described the typical symptoms of autistic disorders, but only in relation to schizophrenic patients. Over thirty years later, Leo Kanner (1943), a child psychiatrist from the USA, and Hans Asperger (1944), a pediatrician from Austria, independently published a new explanation of autism based on Bleuler's definition. They saw autism as a mental disorder in children and adolescents, as an independent clinical picture and not as a subform of schizophrenia as in Bleuler. Kanner founded the term "early childhood autism" at that time. Asperger, on the other hand, whose research had great overlaps with that of Leo Kanner, coined the term "Asperger's syndrome" (called "autistic psychopathy" by Asperger's). Both terms are discussed in more detail in Chapter 2.3. In any case, it is clear that both Kanner and Asperger's already contained basic symptoms of today's definitions in their attempts at definition (see Myschker 2005, p. 434 and Poustka 2009, p. 332).

Today, autism is one of the "Profound Developmental Disorders" and is listed in various classification systems, such as the International Statistical Classification of Diseases and Related Health Problems (ICD) and the Diagnostic and Statistical Manual of Mental Disorders (DSM), which are discussed in more detail in the following chapter. This distinguishes between early childhood autism, atypical autism, Asperger's syndrome, Rett syndrome, other disintegrative disorders of childhood, overactive disorders with intellectual disability and movement stereotypes, other profound developmental disorders and other profound developmental disorders that are not specified (see DIMDI 2016, p. 222f.). Since 2013, the term autism spectrum disorder has also been used, which will be examined in more detail below. This term summarizes all forms of autism and basically refers to early childhood autism, atypical autism and Asperger's syndrome.

2.2 Classification according to ICD-10 and DSM-V

Several classification systems are available for the classification of autistic disorders. The two most common classification systems, the ICD and the DSM, will be presented here. The abbreviation ICD stands for "International Statistical Classification of Diseases and Related Health Problems"² and is a diagnostic classification system of medicine for diseases and health disorders issued by the World Health Organization (WHO). The ICD has rather established itself as a classification system in German-speaking countries. Since 1992, the 10th edition of the classification system has been available, which is constantly revised and updated depending on the state of research. Work is currently under way on an 11th edition, which is to be adopted in 2018. Autism is classified in icD-10 under the "Profound Developmental Disorders" and defined as follows:

"This group of disorders is characterized by qualitative deviations in mutual social interactions and communication patterns and by a limited, stereotypical, repetitive repertoire of interests and activities. These qualitative abnormalities are a fundamental functional feature of the affected child in all situations."

(DIMDI 2016, P. 222)

The "Profound Developmental Disorders" are also categorically classified into other syndromes in ICD-10. The profound developmental disorders that belong to the autism spectrum disorder are:

F84.0: Early childhood autism

F84.1: atypical autism

F84.5: Asperger's syndrome

For the diagnosis of the respective syndromes, there must be some different characteristics, which are discussed in more detail in Chapter 2.3.

A second common classification system is the DSM, which is used in psychology to classify mental disorders and is published by the American Psychiatric Association (APA). DSM stands for "Diagnostic and Statistical Manual of Mental Disorders"³ and is mainly distributed in the Anglo-American area. Since 2013 (in Germany since 2015) the DSM-V has been available as a fifth edition. In contrast to the DSM-IV, which classified autistic disorders analogously to the ICD-10 under the "Profound Developmental Disorders" and further categorically classified them into the syndromes mentioned, the subcategories of autism no longer occur in the DSM-V. Rather, the DSM-V speaks of the "autism spectrum disorder". It is assumed that autistic disorders are not different disorders that can be clearly distinguished from each other, but rather a spectrum disease with the following three core symptoms (also called symptom triads), which are also mentioned in the basic definition of profound developmental disorders in ICD-10:

- Qualitative impairment of mutual social interaction
- Qualitative impairment of communication
- Stereotype repertoire of interests and activities (cf. Theunissen 2014, p. 13f.)

The DSM-V thus dispenses with a classification of "autistic syndromes" (cf. Theunissen 2014, p. 24). The autism spectrum disorder therefore ranges "from mentally handicapped children without language development to above-average gifted persons with a very well-developed language" (Sinzig and Schmidt 2008, p. 174). Autism spectrum disorders include in particular the syndromes of early childhood autism (F 84.0), Asperger's syndrome (F 84.5) and atypical autism (F 84.1) classified according to ICD-10 (cf. Remschmidt and Kamp-Becker 2008, p. 135). In addition, the DSM-V discusses the combinations of autism spectrum disorder with leading symptoms of other mental disorders, so that "medical disease factors commonly associated with an autism spectrum disorder [..] as additional coding âIn connection with a known physical disease, genetic or environmental conditionâ [sic]" (APA 2015, p. 76). There are therefore additional codes for comorbidities, such as.B epilepsy, attention disorders or intellectual disability.

In comparison, it should be noted that the DSM-V emphasizes the continuum of autism disorder and dispenses with the designation of special syndromes in order to avoid a demarcation of terminology. Thus, it can be made clear that there are only gradual differences between the individual forms of autism. This new way of looking at autistic disorders as a spectrum disorder is currently still being strongly discussed. Since icD-10 dominates in German-speaking countries and the new approach to DSM-V of a spectrum disease has not yet fully established itself, the following work refers to the original, categorical classification of autistic disorders according to ICD-10.

2.3 Forms of autistic disorders and their symptomatology

In the following section, the three most common, profound developmental disorders, early childhood autism, Asperger's syndrome and atypical autism, will be discussed in more detail. These forms of autism, as already mentioned, belong to the autism spectrum disorder according to the DSM-V.

2.3.1 Early childhood autism (F 84.0)

The form of early childhood autism, according to ICD-10, is defined "by abnormal or impaired development that manifests itself before the age of three. It is also characterized by a characteristic pattern of abnormal functions in the following psychopathological areas: in social interaction, communication, and limited stereotypically repetitive behavior" (DIMDI 2016, p. 222). Children diagnosed with early childhood autism thus fulfill all three of the core symptoms of autism spectrum disorder mentioned. You have therefore qualitative impairments in mutual social interaction with their environment. This includes impairments in eye contact, facial expressions, posture and gestures to regulate social interactions. In other words, nonverbal behavior is restricted. These children are also unable to develop developmental relationships with their peers. They often have no friendships or no interest in other people and do not react or react negatively to approaches of others. Children with early childhood autism are unable to play fantasy or group games or engage in activities with their peers. These children do not show any initiative for social interaction on their part. Furthermore, children with early childhood autism are unable to feel socio-emotional reciprocity. They do not give comfort or let themselves be comforted. Overall, there is a lack of exchange of caresses. These children often do not stretch their arms to be taken in their arms. Physical contact with another person is often sought only for communication purposes, for example, to show this person what needs the autistic child has. So it may be that a child with early childhood autism grabs the mother's hand in the evening and leads her to his room to make it clear that he is tired and wants to be put to bed. In general, it is not or hardly possible for autistic children to understand and feel empathy and thus compassion, as they themselves are limited in their own perception. Furthermore, children with early childhood autism find it difficult to spontaneously share joy, interests or successes with others. There is no divided attention with others, which also means that the attention of others is not directed, for example, to ask the opposite person to hand over an object. In addition, the autistic children often do not show, bring or explain things that are or could be of importance to them (cf. Poustka et al. 2008, p. 54 and Theunissen 2014, p. 13).

The qualitative impairment of communication refers to a developmental disorder of spoken language, whereby there is no compensation through gestures and facial expressions. Nodding, shaking the head, interpreting to express an interest, all these gestures are not or hardly present in early childhood autism. The development of the language is either delayed or completely absent. This manifests itself, for example, in the fact that these children are relatively incapable of starting or continuing a conversation. There is no social loudness and chatting, no two-way communication and no conversations that could express interest in the other person. In addition, a stereotypical and repetitive or peculiar use of the language can be observed. This includes stereotypical vocalizations, i.e. the frequent use of the same sounds, words or phrases in constant repetition, and delayed echolalia.⁴. In addition to this subcategory, the characteristics include that those affected ask non-conformist questions and often neologisms⁵ and/or idiosyncratic language⁶ form. On top of that, children with early childhood autism have a lack of spontaneous as-if games (symbolic games) or social interaction games.⁷ to observe. In this context, no actions are spontaneously imitated and no imaginative or imitating social play takes place (cf. Poustka et al. 2008, p. 54f. and Theunissen 2014, p. 13f.).

Finally, in the definition of ICD-10, the characteristic of a limited stereotypical repetitive behavior called. Early childhood autistic people therefore deal comprehensively with stereotypical and limited interests, whereby the content of the employment and the intensity are abnormal. So it may be that autistic people can deal with one and the same thing for an enormously long time, be it for example the switching on and off of the light via a light switch. In addition, autistic people are conspicuously rigid in adhering to certain non-functional habits or rituals. This refers to repetitive behaviors, such as ritualized processes when going to bed, whereby the process is precisely structured. In this context, there is resistance to minor changes in the daily routine, as well as to changes in the personal environments of the autistic child. Constraints, rituals of action and also word rituals are the result. Furthermore, this feature includes stereotypical and repetitive motor mannerisms, i.e. complex often bizarre-looking movements of individual body parts or the whole body, which are often repeated. In autistic children, hand and finger mannerisms can often be observed, such as snapming fingers or the like. In addition, early childhood autistic people primarily deal with partial objects or non-functional elements of objects. This refers to unusual sensory interests regarding the smell, the surface texture or the smell of an object (cf. Poustka et al. 2008, p. 55 and Theunissen 2014, p. 14).

These characteristics do not all have to be given for a diagnosis of early childhood autism, but at least two characteristics from the field of social interaction must apply, as well as one characteristic each from the field of communication and repetitive, stereotypical behavior (cf. Poustka et al. 2008, p. 55f.). "In addition to these specific diagnostic features, a variety of non-specific problems often appear, such as phobias, sleep and eating disorders, outbursts of anger, and (autodestructive) aggression." (DIMDI 2016, p. 222). This form of autism is also referred to as "Kanner syndrome", "infantile autism" or "early childhood psychosis".

2.3.2 Atypical autism (F 84.1)

Atypical autism "differs from early childhood autism either by age at the onset of the disease or by the fact that the diagnostic criteria are not met in all the areas mentioned" (DIMDI 2016, p. 222). This means that abnormalities are not detectable in all psychopathological areas required for a diagnosis of autism (qualitative impairment of mutual social interaction, communication, as well as repetitive, stereotypical and ritualized behaviors). The diagnosis is made even if there are characteristic deviations in other areas. Autistic people with atypical autism do not fully meet the diagnostic criteria of early childhood autism, but show typical abnormalities of early childhood autism. The symptoms can manifest themselves before the age of three or only after the age of three. As a rule, however, this form of autism is diagnosed when the impaired or abnormal development manifests itself only after the age of three. "Atypical autism is very common in patients with severe retardance or suffering from a severe receptive disorder of speech development." (DIMDI 2016, p. 222). Atypical autism is also referred to as "atypical childhood psychosis" or "intellectual disability with autistic traits."

2.3.3 Asperger's syndrome (F 84.5)

This form of autistic disorders is also considered a mild form of autism. As with early childhood autism, Asperger's syndrome has the characteristics of qualitative deviation of mutual social interaction, as well as a limited, stereotypical repertoire of interests and activities. In contrast to early childhood autism, however, Asperger's syndrome does not have a general developmental delay or developmental delay in language and cognitive development (cf. DIMDI 2016, p. 223). Adaptive behaviour and independence must correspond to an intellectual development that can be regarded as normal in the first three years of life (cf. Poustka et al. 2008, p. 56).

The limited stereotypical repertoire of interests and activities in Asperger's autistic people is often expressed by extreme interest in special topics, such as.B timetables or telephone books, or objects such as televisions. The extreme interest in these things is often placed above the social contacts or focused in conversations as a topic of conversation. Furthermore, Asperger's syndrome is often accompanied by a striking clumsiness that can last into adolescence and adulthood (cf. DIMDI 2016, p. 223). Another term for this form of disorder is "autistic psychopathy."

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To make a diagnosis, there are many different checklists. Probably the most well-known international checklist is the Checklist for Autism in Toddlers (CHAT), prepared by Baron-Cohen et al. (1992) (cf. Poustka et al. 2008, p. 141). This checklist has been translated, expanded and modified into German. It is a comprehensive parent questionnaire with the help of which it is possible to record the early symptoms of autistic disorders at the age of 24 months. A copy of the checklist can be found in the appendix.

2.4 Autistic disorders and intelligence

The autistic disorders are mental disorders that are strikingly often associated with other mental and physical problems. These are often accompanied by an intellectual disability or an intellectual impairment. According to Poustka et al. (2008, p. 20f.) Studies in recent years suggest that the comorbidity between autistic disorders and intellectual disability is between 25 and 50%. With an intelligence quotient (IQ) of less than 50, this intellectual disability thus invariably leads to a low level of function and causes serious behavioral problems, such as compulsions, anxiety, depression and resistance to change (cf. Bölte 2011, p. 592). Thus, it can be said that a low level of intelligence is associated with difficulties, for example, in learning, in gaining social independence and practicing a profession. Therefore, the intelligence level of the autistic child in the treatment with the help of both behavioral therapy and music therapy interventions is decisive for the goal setting and therefore important to consider. Children with Asperger's syndrome usually have a normal to above-average level of intelligence and thus form the upper end of the scale of autism spectrum disorders. In contrast, the back end of the scale is early childhood autism, "since [these children] are characterized by significant intellectual disability in 75 to 80% of cases" (Goldberg and Edelson, 2006, quoted from Bernard-Opitz 2015, p. 24). In early childhood autism, a distinction is made even further between a high level of function (so-called "high functioning") and a low level of functioning (so-called "low functioning") of the affected children. This means that there are children with early childhood autism who are more likely to be limited in their intelligence, but also others who have a relatively high intelligence. Early childhood autism without an intellectual disability (IQ > 70) or at least with an average intelligence (IQ > 85) is therefore often referred to as high-functioning autism. However, this is not an official diagnostic classification, but a rather unofficial term, which is why it is not discussed in more detail here (cf. Poustka et al. 2008, p. 11).

Depending on the level of intelligence, the therapy programs differ in their approaches. In autistic children with a high level of function and intelligence, the focus is more on the development of social behavior, independence, emotional intelligence, self-control and compensation for learning disabilities. In autistic children with a low level of development, on the other hand, the focus is on establishing eye contact, simple communication, imitation and play (cf. Bernard-Opitz 2015, p. 24).

2.5 Root cause research and the development of interventions

The cause or causes of autistic disorders are still not sufficiently clarified according to the current state of knowledge. The only thing that is certain is that they cannot be explained by a cause, but that multidimensional factors are decisive. After extensive research, there is no longer any doubt that autistic disorders are based on biological pathogenesis. According to Remschmidt and Kamp-Becker (2008, p. 135 f.), the results available so far support the involvement of the following factors, as well as the possibility of an interaction between these factors:

- genetic factors
- associated physical diseases
- Brain damage or brain dysfunction
- biochemical anomalies
- neuropsychological deficits

Due to the not yet sufficiently researched causes of autistic disorders, there is still no cause-based treatment for profound developmental disorders. All forms of treatment and intervention start with the symptoms of autistic disorder. Depending on the degree of severity of the disorder, the aim is to improve social perception, communication and interaction skills, play behaviour, emotion regulation and problem-solving ability, as well as the ability to generalise (cf. Sinzig and Schmidt 2008, p.183). The main goal of the therapy ring is therefore to keep the impairment of the person concerned as low as possible or to improve it. Those affected should be given the greatest possible independence and life satisfaction, their scope for action and expression should be expanded and thus ultimately the best possible social integration should be guaranteed. In general, treatment of autistic disorder should begin as early as possible in order to accompany the development of the autistic child from the beginning. This is of the utmost importance for the prospects of success of the therapy or intervention (cf. Remschmidt and Kamp-Becker 2008, p. 139). In addition, the intervention should last as long as possible, "since the development of basic skills such as.B. the Theory of Mind⁸ - which develops in healthy children rather intuitively and "incidentally" [emphasis in the original] – in people with an autistic disease requires very long and patient, explicit guidance" (Remschmidt and Kamp-Becker 2008, p. 139).

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¹ In order to make the text easier to read, genderisation will continue to be dispensed with. When using the male spelling, however, all possible genders are equally addressed. Exceptions are some literal quotations and comparisons, which are then marked as such or are gendered.

² German.: Internationale Statistische Klassifikation der Krankheiten und verwandter Gesundheitsprobleme

³ German.: Diagnostisches und Statistisches Manual Psychischer Störungen

⁴ Echolalia refers to a compulsive re-enrolment of words and sentences that usually do not fit into the context and do not make sense or fulfill a communicative function.

⁵ Neologisms refer to new word creations, arbitrarily created new word combinations, which are usually only understandable to the autistic person himself.

⁶ Idiosyncratic language refers to a language comprehension in which the words and phrases are assigned stubborn interpretations or other distant meanings. Language differs only in meaning, but is usually still formally correct, syntax and grammar are applied correctly.

⁷ In the game, another reality is constructed, the plot deviates from the usual reality. A typical example of an as-if game is the mother-father-child game in early childhood.

⁸ In the game, another reality is constructed, the plot deviates from the usual reality. A typical example of an as-if game is the mother-father-child game in early childhood.