Autistic Spectrum Disorders (ASD) is currently a well-known and researched area majorly characterized by impairments in social and communication domains. The symptoms exhibited change from person to person making each individual unique. This fact emphasizes that the diagnostic and treatment procedures also need to be tailor made for each individual. Although it is globally a well delved area, there is paucity in many aspects in the Indian scenario. The pathogenesis of the condition is unclear but many possible explanations have been hypothesized by researchers in the field. Music Therapy (MT) is one of the intervention approaches in which various methods and techniques are modified and employed to meet the unique functional levels and needs of children with ASD. Considering the fact that music is generally a preferred component for this population, the effectiveness of using music as a medium for intervention has proven to be positive in a wide array of instances. The School of Music Therapy functioning under the Institute of Salutogenesis and Complementary Medicine of Sri Balaji Vidyapeeth University has been pioneering in the field of MT in the Indian context offering vast amounts of services to the autistic population.

• Autism; Music; Improvisational Music Therapy; Music Based Activities; Integration; Salutogenic Wellness

Jenita CR, Ramanathan M, Ananthakrishnan N (2025) Autism Spectrum Disorder and Music Therapy: A Narrative Review. J Autism Epilepsy 6(1): 1019.

Autistic Spectrum Disorders (ASD), are characterised by impairments in social communication, interaction and restricted thinking [1]. From being ill-defined, and rare childhood onset disorder, ASD has come to be a well known and researched area and is being documented as a common and heterogenous group of disorders [2]. ASD is not a disease, but a spectrum exhibiting multiple genetic as well as non-genetic causes, ranging from very mild to severe [2,3]. The term autism often represents qualitative differences and impairments in the above-mentioned domains, most often with lifelong impacts [4]. The impairments exhibited may be characterized into three different domains [3]:

• social interaction,
• language, communication and imaginative play,
• range of interests and activities.

The manifesting symptoms may change from person to person, with the most prevalent ones being verbal and non-verbal communication difficulties, repetitive actions and behaviours, and different degrees of sensitivity towards sensory inputs [5]. At least, one third of the affected children show regressions or stasis of language and social behaviours, which occurs between the ages of 1 to 2 years. The reasons for these remain unknown [4]. Delayed language acquisition and a wide range of speech deficits such as total absence of verbal output, to presence of adequate linguistic skills co-existing with the inability to effectively make use of that knowledge has been documented in individuals with ASD [6,7]. It has also been documented in literature that, up to 50% of children with ASD cease to develop functional speech [8]. Apart from these, the children have a wide range of cognitive, scholastic, learning, medical, behavioural as well as emotional deficits including insufficiency in perceiving others’ emotions, disruptions in sleep and appetite, mental health concerns such as depression, anxiety, diffused attention, self-harm behaviours as well as aggression in some cases [4]. Co-existing mental health conditions also are more prevalent when compared to their peers [9]. Over 70% of the diagnosed population meet criteria for at least one co-existing psychiatric condition such as attention deficit hyperactivity disorder and anxiety disorders and 50% of the same manifest signs of intellectual disability [4]. Features typically start presenting in early childhood, with a few of them manifesting when there is a change of situation [4]. They often result in affecting the quality of life, family dynamics, career and may lead to social vulnerability [4]. In the current scenario, the diagnosis of autism is primarily symptomatic, relying on the criteria given by the Diagnostic and Statistical Manual V [10]. Most of the information regarding ASD that are available today are the outcomes of researches conducted in the western high-income countries, as opposed to the presence of more number of cases in the low and middle income regions where the diagnosed population has only restricted access to the modern medicine [11]. Behavioural norms, culture-specific approaches, beliefs, mental health literacy and stigma towards ASD vary in different countries and regions [12]. In the Indian scenario, there is paucity at all levels right from awareness and education of professionals to the delivery of service which contributes to lack of early identification and intervention [13].

Various authors have hypothesised numerous theories in the attempt of explaining the cause of ASD and perhaps it is prevalent in individuals of every race, nation, and socioeconomic class, without following any particular pattern [14]. In the global context, the prevalence of ASD is on a relentless upsurge [15]. As of 2023, the World Health Organization has reported that 1 in every 100 children are diagnosed with ASD globally [16]. In the southern part of India, a cross-sectional study documented a prevalence rate of 6.1% with increased rates in children above the age of 3 years [17].

A complete explanation regarding the pathogenesis of ASD is still not clear and it is assumed to have multiple causatives represented by heterogenous clinical presentations [18]. In recent years, a multilineage approach has been adopted to describe the pathogenesis of ASD [11]. At present, the aetiology of ASD is still obscure with a lack of hard evidence where researchers are struggling to explain its driving abnormality [11]. Majority of the diagnosed cases of ASD are idiopathic in nature, meaning there is no well-defined and specific cause [18]. Maternal immune activation, bacterial infections and prenatal exposure to toxins are few of the several environmental factors that may contribute to idiopathic ASD [19, 20]. There is also a working relationship between the presence (and impairment) of joint attention and language development which has been established by longitudinal studies [21]. Imitation is one other quality which is a crucial precursor of language development which also lacks in the population [22].

The Theory of Mind

The impairments in emotional, social and communicative domains in the autistic population have been, attributed by researchers to dysfunctions of the human mirror neuron system [23], and communication deficits [24], and impairments in executive functioning [25], have been directed toward a lack of understanding of the ‘mind’ with relevance to the Theory of Mind [23]. One of the possible explanations as to why a large group of this population fail to acquire language may be attributed to this lack of understanding of others’ intentions and behaviours or their mind [7].

The Gut-Brain Axis

The microbiome-gut-brain axis is the relationship between the gut environment and the brain and it is being viewed as one of the important factors which is capable of modulating brain functioning and maturation but an in-depth understanding of its role as an aetiology of ASD is yet to be completely comprehended [26]. It has been found that, the microbiota composition comprised of Bacteroidetes, Firmicutes and Actinobacteria are more concentrated in children with ASD when compared to the control peers [27]. In addition to this, those diagnosed with ASD have exhibited high ratios of Faecalibacterium and Phascolarctobacterium and comparatively lower levels of Coproccocus and Bifidobacterium [27]. Children with ASD also present disaccharidase malabsorption because of reduced amounts of lactase, maltase and glucoamylase which result in an altered microbial composition, osmotic diarrhoea and bloating [28]. The possible presence of various bacterial, fungal and viral species in the gut microbiota may lead to a leaky gut in individuals diagnosed with ASD [29].

Genetic factors and biomarkers

Three genetic factors have been identified to contribute to the etiology of ASD: (1) single gene mutations in SHANK3, FMR1 or MECP2, (2) copy number variations of chromosomes such as translocations, duplications, inversions, and large deletions, and (3) accumulation of common variants leading to polygenic risk factors [18]. On the other hand, biomarkers are yet to be identified which can be utilized for screening and surveillance in the ASD population [11]. There may be production of P-cresol due to leaky gut and Clostridiaceae spp. in children with ASD and this P-cresol could serve as a possible biomarker for the condition because of its elevated amounts in the urinary and fecal samples [28]. Increased levels of short chain fatty acids (SCFAs) such as propionic acid (PPA) because of gut dysbiosis contribute to ASD as well [30].

Environmental factors

A small part of research evidences indicates dietary and environmental associations which focus on mercury and biphenyl poisoning as a potential aetiology of ASD [11]. In vitro studies have revealed that the cell lines which appeared exposed to polychlorinated biphenyls (PCBs) presented significant reductions in dopamine concentration and PCBs have also been found to be alternating with dopamine neurotransmitters [31,32]. Reactive oxygen species (ROS) being present in high levels resulting in oxidative stress has been documented as another possible mechanism underlying the presence of ASD [11]. It is also believed that the redox signalling pathway and the redox-status-sensitivity may play a significant role as co-factors in the genesis of ASD [33]. In addition to these, the signalling pathway of lipid molecules is known to be contributing towards the pathophysiology of ASD [11]. Impaired cognition, behaviour, attention which are some of the core symptoms of ASD have been directed towards an underlying molecular mechanism impacting dopaminergic neurotransmission, calcium dyshomeostasis, hypothyroidism, and oxidative stress specifically in early childhood thus manifesting as ASD specific symptoms [34].

Stem Cells

The correlation between neural stem cells (NSCs) and ASD is of focus because NSCs are present all over the central nervous system (CNS) and can differentiate into neurons, oligodendrocytes and astrocytes and the newly formed neurons play significant roles in the plasticity and functionality of the nervous system; as the aetiology of ASD is in line with altered neural maturation, this perspective is of focus in ASD research [11].

Treatment and management of ASD is currently symptomatic in nature which is effective in maximum number of cases and there are no known causative approaches or targeting therapy [11]. A major role in making a difference in the diagnosed population is played by the families, educators and direct providers, but physicians and other healthcare providers also contribute by providing necessary information regarding functional levels, in preparing the caregivers to anticipate transitions and in directing them towards other professionals and specialists when and where needed [2]. Even to this day the families of the ASD population are unfortunately devoid of guidance which may result in the formation of stereotypes and misformed speculations and beliefs [11]. Significant progress can be manifested with appropriate treatment approaches that may include behavioural therapies, scholastics, speech and language therapy, occupational therapy, social skills training and so on [18]. Provision of tailor made interventions which are suitable for each child’s developmental levels and needs is crucial in this population [35]. The available intervention approaches can aid in improving the core features of autism and must be evidence based and customised for each person’s levels and needs [4]. Researchers have also been exploring the benefits of hormonal therapies and herbal medicine to manage the symptoms of ASD [36]. With respect to the involvement and research done involving the gut-brain axis, researchers have concluded that the use of probiotics can show promising effects in the neurobehaviorual symptoms [29]. Various specific interventions have been applied in the past to improve social skills in children with ASD such as: peer-mediated strategies [37], social strategies [38], video modelling [39], and cognitive-behavioural training [40]. Early identification and intervention are crucial in ASD as most of the symptoms emerge before three years of age. It has been documented that, if a child with ASD remains completely non-verbal up to the age of 6 years, improvements in social skills as expressive language will be poor [41]. The involvement of parents in the intervention process is also crucial in various contexts. Their active participation as co-therapists is considered a best practise in some intervention approaches [42]. This practise improves the intensity of the intervention process in the therapy setting as well as at home and increases acceptance and quality of life of the family [43]. Effective communication between the healthcare professionals and the diagnosed children, their families and caregivers is also essential in the intervention process [4].

The efficient use of complementary and alternative therapeutic strategies is crucial in the management of ASD [36]. Music is a medium which can be effectively and purposefully used to nurture ‘interpersonal relatedness’ by way of a structured and systematic intervention for emotional, relational, and motivational domains [44]. In recent days, music has been evolving as a promising tool for aiding the quality of life of children with ASD [45]. Additionally, it has been documented in literature that children with ASD enjoy making and learning music [46]. Music is also known to be one of the savant abilities of children with ASD and that this population prefers listening to music, and can recognize the structure of music and melodies [47]. Recalling and reproducing long melodic phrases, being able to reproduce melodies after listening to them just once and possessing absolute pitch are some of the other musical abilities showcased by this population [48]. Though individuals with ASD have impairments in emotional processing, research shows that listening to music can stimulate intense emotions. Researchers have also emphasized that music works as a medium for children with ASD rather than being the goal itself [47]. Thus, it is established that music and music making might aid children with ASD to engage and interact with others as a result of which improvements may be observed in social, communicative and motor domains [48]. Autism research in the current scenario is focused on analysing the benefits of music on aiding social and communication skills in children with ASD. There is a belief that promising research in the future, may contribute to long-term impacts of MT on domains such as language, cognition and behaviour [45]. Earlier researchers have also studied the relationship between autism and musical capabilities [45].

The use of Improvisational MT for ASD

It is common among children with ASD to have difficulties in emotional expressions as well as reciprocity [49,50]. These deficiencies lead to impairments in communication of emotions and interpersonal skills and thus, it is crucial that any therapeutic approach provided must focus on how to develop positive emotional communication with their close others [44]. Though children and adolescents with ASD rarely engage positively in social situations, there are very few therapeutic interventions which directly affect the emotionally expressive interpersonal skills [44]. In the context of MT, therapists intend to establish meaningful therapeutic relationships with their clients via shared music making experiences which is known as joint clinical improvisation [51,52]. Improvisational MT is the interactive utilization of music with clients who are engaged to meet their therapeutic needs [53]. The improvisational method has been gaining attention and recognition as a positive approach to aid self-expression, emotional communication and social engagement for various developmental disorders, including ASD [54]. The therapist recognizes musical elements in the child’s musical and non-musical behaviours after which a predictable, supportive and empathathetic musical structure is provided to create shared musical experiences by way of non-verbal and multimodal contexts [48, 55]. Vocal improvisation in particular, incorporating vowels and consonants can aid in enhancing prosody of speech and can stimulate vocal expression [56]. Children with ASD who participated in improvisational MT for a period of ten weeks with one session per week showed positive changes in the development of communication skills as well as in social behaviour as a result of participating in the MT process [57].

Melodic Intonation Therapy and ASD

Some children with ASD share a common trait with individuals diagnosed with Broca’s aphasia: they can sing and precisely reproduce complex tunes and/or jingles [58]. Melodic Intonation Therapy (MIT) which is a form of auditory-motor mapping training (AMMT) accentuates the prosody of speech by way of slow and pitched vocalisations [59]. Music therapists have utilized an adaptation of MIT among children with ASD and have documented increased abilities to combine words and to respond to questions [60]. The adapted version of MIT involves various procedures starting from establishing a conducive & comfortable environment for the children, vocalization practices of various durations and length of speech sounds, presentation of picture stimuli alongside signs and real objects after which the phrases (or words and actions) are presented based on the MIT procedure [61]. In order to facilitate the sound-motor mapping, the music therapists make use of tuned drums which are played simultaneously when the target words or phrases are intoned during which the child gradually progresses from listening to the stimulus to singing along with the therapist to partially supported singing; repetition to producing the phrase independently [62].

Using musical instruments in MT for ASD

The effective utilization of musical instruments to engage children with ASD in musical experiences is based on the premise that music making in itself has the capacity to facilitate social communication and interaction especially in this population due to their strong inclination towards music and their positive response towards it [23]. Specifically, researchers recommend playing of musical instruments in therapy as it may be largely effective for developing social skills as well as linguistic competency in children with ASD [14]. Use of musical instruments has also been attributed to mental and psychomotor development, and cognitive growth [63].The use of simple musical instruments such as drums, cabasa and sound tubes have been used among children with ASD to increase social interaction through interactive music making [64]. Integration of playing instruments such as tambourines and maracas with background music, dancing and action imitation has been documented to increase their willingness to imitate actions and word pairs during the musical experiences making instrument playing an efficient framework for learning and development of social skills [65].A possible explanation to the positive effects of using musical instruments for children with ASD in MT can be the fact that such an activity is multimodal in nature and the mimicry and synchronisation which it stimulates [14].

Effect of MT on emotional and motivational responsiveness

The inability of the autistic population to express may result in various forms of emotional distress such as anxiety, frustration, and emotional outbursts [66]. On these lines, MT can play a potential role in providing a safe non-verbal outlet for emotional expression. When MT interventions were compared with playing with toys, significant positive effects were seen on the children’s joyful behaviour in the MT group [44]. Emotional synchronicity has also been proved to significantly serve as adjunct with MT when compared to play sessions [44]. Children who had undergone MT sessions have shown positive increase in initiation of engagement as well [44]. Researchers have also documented the benefits of MT to evoke and communicate emotions leading to development of affective skills in children with ASD [14]. Interventions engaging these children using improvisation and active participation have been observed to foster emotional connections and self-expression [67]. Music has been utilized to improve children’s abilities to encode and decode emotions as well [68].

Effect of MT in communication skills

One of the core symptoms of ASD is deficits in the social communication domain and MT has demonstrated promising results while addressing the same [69]. The use of music for improving language skills is based on the premise that there are overlaps between language and music systems in the brain and thus engaging in music making activities will play the role of an alternative medium through which the language systems can be accessed and engaged [23].Music-based interventions have shown to improve sign language and non-verbal mode of communication in children with ASD [70]. Melodic and rhythmic patterns combined with verbal instructions aid in enhancing joint attention and non-verbal social communication [71]. Singing and playing of musical instruments have proven to enhance social interactions as well as non-verbal communication skills [23].

Effect of MT on Behaviour in ASD

In the context of behavioural modification, MT can play significant roles in both facilitation of desired behaviours [72], as well as reducing undesired ones [73]. Children with ASD tend to possess behavioural issues such as the presence of stereotypic behaviours which can be reduced by employing MT [69]. Structured MT experiences have proved to reduce the manifestation of repetitive behaviours in the therapeutic setting [74]. Although there are other research evidences which do not establish positive outcomes in this domain [75]. Incorporation of music in group therapy settings can significantly improve attending behaviours in children with ASD alongside increased engagement during structured activities [76]. Individual-specific behavioural issues can be solved using targeted interventions positively by tailoring each musical experience according to each participants’ needs [77]. MT researches have also documented reductions in behavioural problems by making use of structured musical activities and for reducing stress-related aberrant behaviours [73-78].

Effect of MT on cognitive functions in ASD

MT has the potential to cause functional changes in the brain regions associated with cognitive control, emotional processing and social cognition [79]. Pioneering researchers have conducted experiments to check the effectiveness of MT on cognitive functions such as attention retention and intelligence and the results have shown significant improvements in intelligence [80].

Effect of MT on social skills in ASD

The effects of MT on social skills may vary based on the type and delivery of the MT methods employed [81]. Social skills of children with ASD such as interactions with the mother and eye contact during symbolic play has been enhanced by using MT experiences such as music-based activities and singing [82]. Use of songs which are custom made for each child (songwriting) where the lyrics are created by the therapist and set in the child’s preferred melody have proven to improve the development of social skills and reduction of undesirable behaviours in children with ASD [56]. The use of rhythm, an element of music which is used integrally in MT, has been gaining attention as an effective method to address challenges in the social skills domain employing MT experiences such as clapping and/or use of percussive instruments. Playing music during playground activities was seen to significantly enhance peer interaction in children with ASD [64]. When the effects of playing recorded music and live musical interactions were compared, the later was found to stimulate increased number of spontaneous peer interactions [64-83].

The involvement of the human mirror neuron system (MNS)

As mentioned earlier, emotional, social and communicative impairments observed in the autistic population may be attributed to dysfunctions in the MNS. Mirror neurons play a role not only in comprehension and perception of motor actions, but also in a few higher order cognitive processes [84]. As the MNS can be stimulated by multisensory stimuli, music making is one of the ways in which it can be engaged [23]. Imitation and synchronization are an integral part of music making and so it has the potential of engaging the cortical regions which overlap with those containing mirror neurons making it an efficient treatment approach for ASD [85]. AMMT can aid in the improvement of language skills through the brain regions which overlap with the MNS by way of singing, imitation and motor activity under the premise that singing, in particular, stimulates bilateral fronto-temporal networks which comprise components of the MNS [86,87].

Benefits of integrating imitation in MT for ASD

Imitation of motor movements can be effectively integrated in the intervention procedures for children with ASD due to its relationship with the MNS [88]. In the context of MT, this link has been proved in MIT where imitation of expressive speech production is involved [89].

Sri Balaji Vidyapeeth (SBV) was granted the ‘Deemed to be University’ status in the year 2008 by the University Grants Commission for setting high standards and has been functioning as a Health Sciences University since [90]. In the year 2010, a Music Medicine unit was established by the musician-clinicians of the Mahatma Gandhi Medical College and Research Institute (MGMCRI) of SBV. Later in 2013, the SBV Academy of Integrative Medicine for Holistic Individual General Health (SBV AIM HIGH) was initiated under which the Music Medicine unit operated. The Center for Music Therapy Education and Research (CMTER), an upgradation of the Music Medicine unit, was fully operative starting from January 2014 focusing on professional training in MT, patient care in clinical and community areas, and research pursuits [91]. The Institute of Salutogenesis and Complementary Medicine (ISCM) was inaugurated on the 22nd of August 2022 which has two schools under its ambit: The School of Music Therapy (SMT) and the School of Yoga Therapy (SYT). The institute strives to cross boundaries of a regular healthcare university by providing high quality education, research and clinical services via MT and YT with Salutogenesis as its focus [92].

Figure 1 Functions of the School of Music Therapy.

The School of Music Therapy (SMT), as mentioned earlier, works alongside the School of Yoga Therapy (SYT) under with Salutogenesis as the focus. The three different areas in which the school functions are (Figure 1):

• Education
• Research
• Clinical practise & community services

In a hospital context, MT is provided as part of the interdisciplinary team which collectively works towards the betterment of the client. It works at the augmentative level which is defined as a practise in which MT is provided to enhance the efforts of other treatment modalities resulting in making supportive and positive contributions to the patient’s overall treatment [93].SMT reaches various nukes and corners of the hospital, providing services in a wide array of clinical departments (Figure 2) [91]. Most of the MT experiences provided make use of live music implementing various MT methods and techniques according to the client needs and preferences. Under some circumstances, such as during an invasive,

Figure 2: Clinical services provided by SMT.

procedure, the therapists make use of recording music over headphones to distract the client from the operating room sounds. The MT experiences are offered for both the patients as well their caregivers. In the patient population, MT focuses on various non-musical objectives such as procedural support, symptomatic management, and rehabilitation. For the caregivers, it is to reduce the caregiver strain caused due to various factors. Apart from the clinical departments, SMT also conducts various community outreach programs (Figure 3), where the therapists go inside the community and provide MT based on their needs by making use of their community music [91]. The school also strives to create evidences based on the clinical and community work carried out both quantitatively and qualitatively. Various research articles have been published in esteemed journals emphasizing the need for evidence-based practises [92].

Figure 3 Community services provided by SMT.

Sri Balaji Vidyapeeth is one of the pioneering institutions in providing care for Children with Special Needs (CWSN) through Music Therapy and Yoga Therapy in order to empower them in their physical, emotional and cognitive skills [93]. The School of Music Therapy provides regular MT services for CWSN especially for children with ASD as part of clinical and community practice. The services are provided at the school premises as out-patient care and also within the schools for children with special needs in and around Pondicherry as community outreach programs. MT experiences are provided to the for enhancing various developmental skills, emotional wellbeing as well as to promote independent living. The school also provides therapeutic support to the caregivers such as parents and special educators for reduction of caregiver strain. Special training programs are conducted for the special educators and parents to use music inside the classroom and at home respectively. Various research pursuits are being taken up by the school which has resulted in one PhD research project titled “Effect of Improvisational Music Therapy on the Biopsychosocial in Children and Adolescents with Autism Spectrum Disorder” [94].

Music Therapy is now being recognized as one of the effective yet cost-efficient treatment modality which can be an integral part of the interdisciplinary team working for the better of the ASD population. Creating qualitative and quantitative evidences to document the benefits of MT for the autistic population in crucial in India. Music has the natural tendency to garner the attention of children with ASD and this has been utilized positively by music therapists to enhance various developmental and emotional domains in this population. The paucity in India at all levels such as awareness, health education, and low-cost intervention approaches are still persistent in spite of the condition being rigorously researched globally. Creation of research evidences will help improving awareness regarding early identification and intervention among parents as well as healthcare professionals. This may lead to establishment of better management strategies and significant increases in quality of life of the affected population and the caregivers. At least 12% of the treatment approaches for individuals with ASD are attributed to those using music as a medium [95]. The reason for this shall be directed towards the fact that individuals with ASD are naturally drawn towards music and it can be an easily accessible, inexpensive and a direct means of communication and interaction for this population [14].

We thank the administration of Sri Balaji Vidyapeeth Deemed to be University for the pioneering work done among children with special needs and for nurturing Music Therapy as a professional and educational field of interest. Our sincere gratitude to Prof. Ananda Balayogi Bhavanani, the Director of the Institute of Salutogenesis and Complementary Medicine and Dr Sobana R along with Dr Baishali for their support which has made the endeavours among this population possible. We would also like to extend out gratitude towards the children, their caregivers, and the authorities of the Schools of Children with Special Needs. Our final thanks to the editors of the esteemed journal for creating such platform for researchers like us to publish our work.

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